The document outlines a seminar presentation on aneurysms. It discusses the introduction, historical aspects, classification, abdominal aortic aneurysm, surgical management, and recent advances related to aneurysms. The presentation covers the definition, etiology, location, morphology, and pathogenesis of different types of aneurysms. It provides details on abdominal aortic aneurysms including risk factors, natural progression, clinical presentation, diagnosis using imaging modalities like ultrasound and CT, and treatment.
3. SEMINAR PLAN
īŽ INTRODUCTION
īŽ HISTORICAL ASPECT
īŽ CLASSIFICATION
īŽ ABDOMINAL AORTIC ANEURYSM
īŽ SURGICAL MANAGEMENT
īŽ VIDEOS
īŽ PERIPHERAL ANEURYSM/ OTHER TYPES
īŽ RECENT ADVANCES
īŽ STUDIES/ONGOING RESEARCH WORK
īŽ REFERENCES/
4. INTRODUCTION
īŽ The term ANEURYSM is derived from the Greek
word ANEURYSMA meaning â a wideningâ
īŽ An ANEURYSM is defined as a permanent
localized dilation of artery having at least a 50 %
increase in diameter compared with the expected
normal diameter.
īŽ Normal arterial diameter is dependent on
age,gender,body size and other factors.
5. īŽ An Aneurysm is defined as a localized dilation at
least 50 % larger than an adjacent normal portion of
the same artery.
īŽ ECTASIA- Arterial dilation less than 50% above
normal
ARTERIOMEGALYâ Diffuse arterial enlargement
involving several arterial segments with an increase
in diameter greater than 50% above normal.
6. HSTORICAL PERSPECTIVE
īŽ 2000 B.C â PAPYRUS â Description of traumatic
aneurysms of the peripheral arteries.
īŽ 131 A.D â GALEN -- Defined an aneurysms as a
localized pulsatile swelling that disappeared on
pressure.
īŽ 1793 A.D â JOHN HUNTER -- Operated for a
pulsatile mass in popliteal fossa.
7. HISTORICAL ASPECT
1950 A.D â ALEXIS CARREL/ DeBakey and
Cooley â Demonstrated a segment of aorta can be
replaced by another artery or vein.
īŽ 1953 A.D â BAHNSONâ First successful
repair of ruptured aortic aneurysm.
īŽ 1954 A.D â ETHEREDGEâ Repair of
thoracoabdominal aneurysm .
īŽ 1991A.D -- PARODI â Revolutionary minimally
invasive endovascular approach.
8. Types of Arteries
īŽ Elastic arteries â the largest arteries
īŽ Diameters range from 2.5 cm to 1 cm
īŽ Includes the aorta and its major branches
īŽ Sometimes called conducting arteries
īŽ High elastin content dampens surge of blood
pressure
Figure 19.2a
15. True/false aneurysm
īŽ Aneurysm focal dialation greater than 1.5
times normal diameter
īŽ True aneurysm contains all layers of arterial wall.
īŽ False aneurysm dialation covered by thick
fibrinous capsule.
16. PSEUDOANEURYSM
īŽ Injury to wall of vessel allows blood to escape from vessel into
adjacent tissue
īŽ Extravasated blood coagulates and becomes a mass along side the
vessel
īŽ This mass of blood (hematoma) gives the impression that there is
an aneurysm
25. BASED ON MORPHOLOGY
īŽ Saccular aneurysm
īŽ Fusiform aneurysm
īŽ Dissecting aneurysm
īŽ Cylindroid aneurysm
īŽ Berry aneurysm
26. BASED ON MORPHOLOGY
īŽ FUSIFORM
SYMMETRICAL CIRCUMFERENTIAL
ENLARGEMENT INVOLVING ALL
LAYERS OF THE ARTERY WALL.
SACCULAR
ANEURYSMAL DEGENERATION
AFFECTING ONLY PART OF THE
ARTERIAL CIRCUMFERENCE.
30. AAA INCIDENCE
īŽ 2% TO 5% OF ALL MEN OVER 60 YRS
īŽ 15,000 DEATHS PER YEAR IN USA
īŽ COMMON IN MEN ABOVE 60YRS
PEAK OF 5.09% AT 80 YRS IN MEN
PEAK OF 4.5% AT 90 YRS IN WOMEN
GREATER - FIRST DEGREE RELATIVES
TALLER INDIVIDUALS
31.
32. NORMAL SIZE OF INFRARENAL
AORTA
Age
SEX 40 40 â 49 50 â 59 60 - 69 70 avg
Male 2.1 2.2 2.3 2.3 2.4 2.3
Female 1.7 1.8 1.9 2.0 2.0 1.9
33. Risk Factors
īŽ Familial History
20% of patients with AA have 1st Degree relative
īŽ Connective tissue disease
īŽ Marfans
īŽ Ehlers-Danlos
īŽ Atherosclerosis (90%)
īŽ Smoking
īŽ Hyperlipidemia
īŽ Diabetes
īŽ Gender
īŽ Males > Females
īŽ Age
38. ANATOMICAL
GRADUAL TAPERING OF AORTA
REDUCTION of ELASTIC LAMELLAE
in DISTAL AORTA
REDUCTION /ABSENCE OF NUTRIENT
ARTERIES IN INFRARENAL AORTA
39. 39
īŽ Wall stress is force exerted on the wall
īŽ The aneurysm wall weakens
The Biomechanical Perspective
Hypothesis AAA rupture is a failure of the aneurismal
wall, when wall stresses exceeds wall strength
40. 40
The Biomechanical Perspective
īŽ Wall stress is force exerted on the wall
īŽ The aneurysm wall weakens and expands
īŽ Until it ruptures
Hypothesis AAA rupture is a failure of the aneurismal
wall, when wall stresses exceeds wall strength
41. Biochemical
īŽ ELASTIN and ELASTOLYTIC PROTEASE
īŽ ELASTIN â produced in soluble form pro-
elastin
in media of the arteries
insoluble
elastic recoil ability
half-life is 70 years
īŽ ELASTIN depletion occurs early in AAA
caused by serine protease
MMP
42. BIOCHEMICAL
īŽ COLLAGEN and COLLAGENOLYTIC PROTEASES
īŽ STRUCTURAL UNIT IS TROPOCOLLAGEN
AORTIC COLLAGEN IS CONCENTRATED IN THE
ADVENTITIA
HAS MULTIPLE CROSS LINKS
INSOLUBLE
DEGENERATION OF COLLAGEN OCCURS IN AAA :
caused by TIMP, MMP-3 and MMP-9
44. POSSIBLE AAA PATHOGENIC MECHANISM
AAA
Degradation Of Elastin & Collagen
MMP Production
(especially MMP-9 & MMP-1)
Induction Of MMP activators
Secretion Of Cytokin
Chronic Inf. Response
(AIM, AILs)
Acute Inf. Response
(PMN,AIM,AILs)
Fragmentation of ELASTIN (EDP)
Vascular Event ( Genetic, Autoimmune, Etc )
45. AAA Sequelae
Natural history
âĸ gradual and/or sporadic expansion
âĸ accumulation of mural thrombus
Complications
âĸ rupture
âĸ thromboembolic events
âĸ compression of adjacent structures
46. Progression of a AAA
īŽ Pathological changes cause the aorta wall to
âĸ become thinner
âĸ bulge
âĸ tear
âĸ rupture
47. AAA RUPTURE & SURVIVAL
5 year rupture rate
7.0cm or more 75%
6.0cm to 7.0cm 35%
5.0cm to 6.0cm 25%
SURVIVAL
> 6.0CM 5YR SURVIVAL 6%
< 6.0CM 5YR SURVIVAL 47.8%
48. AAA: risk of rupture
Simplifed estimates based on various studies
Tan W Abdominal Aortic Aneurysm Rupture www.emedicine.com
0
Risk of rupture for untreated aneurysm within 5 years (%)
10
70
60
40
50
30
20
80
25%
35%
75%
Aneurysm size
5-5.9cm 6-6.9cm âĨ7cm
49. CLINICAL PRESENTATION
AAA are asymptommatic before rupture in 75%
īŽ Abdominal palpation may show a pulsatile
abdominal mass.
īŽ Vague abdominal and back discomfort.
īŽ Large aneurysms â GI symptomsâ early satiety and
vomitting.
īŽ Inflammatory aneurysms- pain /fever /ureteral
obstruction
52. DIAGNOSIS
PHYSICAL EXAMINATION
īŽ -- Detection of expansile pulsation
īŽ -- unreliable about 50%-- false negative
īŽ -- large hypogastric aneurysm palpated on
rectal examination
īŽ INVESTIGATIONS
īŽ -- X- RAY
īŽ -- USG
īŽ -- CT/MRI / MR ANGIOGRAPHY
īŽ -- ARTERIOGRAPHY
53. Sensitivity of physical exam
Lederle. JAMA 1999;281:77-82.
Aneurysm
diameter
Sensitivity
3.0-3.9 cm 29%
4.0-4.9 cm 50%
âĨ 5.0 cm 76%
Pooled analysis of 15 studies
54. X - RAY
īŽ LUMBAR SPINE RADIOGRAPH
Characteristic of
EGGSHELL PATTERN
of CALCIFICATION
55. USG
īŽ Ultrasound is most useful and least expensive
mode of diagnosis.
īŽ Measuring transverse aneurysmal diameter.
īŽ Screening /Surveillance/ follow up after
endovascular repair.
âĸ Best used to assess
progression of AAA
size
âĸ Average expansion of
0.4cm/year
Longitudinal Section of 2cm Aorta
56. īŽ Inconsistent in
visualization of
Renal and iliac arteries.
They are less useful
in demonstrating
Accessory Renal
Arteries.
Cant detect Rupture.
57. Sensitivity of ultrasound
īŽRanges from 82% to 99%
īŽApprox 100% in cases with a
pulsatile mass
īŽIn a small proportion of
patients, visualization of the
aorta inadequate due to obesity,
bowel gas, or periaortic disease
Quill. Surg Clin North Am 1989;69:713-20.
59. CT Imaging
īŽ Precise test â provides good
images of aorta,aortic
lumen,branch vessels and
adjacent retroperitoneal
structures.
īŽ Shows size and extent of
aneurysm and relation to renal
and iliac arteries.
īŽ SPIRAL CT â 3 dimensional
image.
67. MRI/ MR ANGIOGRAPHY
īŽ Use of contrast agents have made it possible to
produce high quality images of aorta.
īŽ Useful for planning and follow up of endovascular
repair.
īŽ Less sensitive than CT scan in identifying accessory
renal arteries.
69. SELECTION OF PATIENTS
īŽ When the maximal diameter of aneurysm reaches
5.5 cm â risk of rupture increases
-- aneurysm repair indicated.
īŽ Patient with evidence of rapid expansion,tenderness
in the region of aneurysm ,back or abdominal pain â
urgent repair.
īŽ Patient with significant coronary diseaseâ referred
for coronary revascularization before surgical repair.
īŽ Anatomy of aneurysm determinesâ type of repair.
70. Contraindications for surgery for AAA
īŽ Age > 85
īŽ Cardiac Class iii -- iv angina
LVEF <30%
MI or CHF ( within 30days)
severe valvular disease/LV aneurysm
īŽ Renal S.Creatinine >3.0 mgs%
īŽ Hepatic Biopsy proven cirrhosis with ascitis
īŽ Abdomen Diffuse retroperitoneal Fibrosis
71. OPEN SURGERY
īŽ TRANS ABDOMINAL EXPOSURE
when exposure of rt renal artery is required
when need for access to intra abdominal organ
when access to right iliac system required
īŽ RETRO PERITONEAL EXPOSURE
extensive peritoneal adhesions
need for suprarenal exposure
Advantage â short duration of ileus/ less pulmonary
complications/ shorter stay in ICU
73. STEPS OF PROCEDURE
īŽ INCISION
īŽ EXPOSURE OF AORTA
īŽ PREPARATION OF NECK OF ANEURYSM
īŽ EXPOSURE OF ILIAC ARTERIES
īŽ SITE OF DISTAL CLAMPING
īŽ OPENING OF AORTA/ INCISION EXTENDED
īŽ INSERTION OF GRAFT
īŽ CHECKING THE PATENCY OF GRAFT
īŽ CLOSURE OF SAC
80. Open surgical repair (OSR): drawbacks
īŽ Significant incision in the abdomen
īŽ 30â90 minute cross-clamp
īŽ Up to 4-hour procedure
1â2 days intensive care
7â14 days hospitalization
4â6 weeks recovery time
81. Complications âAAA Surgery
īŽ Early :
Myocardial ischemia
Mild Renal failure
Postoperative Pneumonia
Paralytic Ileus
Colonic ischemia
Distal Embolisation
PARAPLEGIA
Post operative sexual dysfunction
82. Complication -- AAA Surgery
īŽ Late :
Anastamotic Pseudoaneurysms
Aortoenteric Fistula
Graft Occlusion
Graft Infection
83. Recent advance - AAA
ENDOVASCULAR REPAIR
TRANSLUMINAL PLACEMENT OF A GRAFT WITHIN
THE ANEURYSM THAT COMPLETELY EXCLUDES
THE SAC FROM GENERAL CIRCULATION
85. Benefits
īŽ Theoretical
īŽ Reduced complications and mortality
īŽ Decreased hospitalization
īŽ Decreased cost
īŽ Realized
īŽ Same number of complications but different types
īŽ Less systemic complications, same mortality
īŽ Shorter respiratory support
īŽ Decreased ICU and hospital stay
īŽ Decreased blood loss
īŽ Cost??
86. ENDOVASCULAR REPAIR
( EVAR )
īŽ DISADVANTAGES
īŽ CUSTOMISED FOR EACH PATIENT
īŽ FOLLOW UP IS CRUCIAL
īŽ LONG TERM IMPLICATIONS AWAITED
īŽ ENDOLEAK 14 â 20 %
īŽ CONTRAST INDUCED NEPHROPATHY
īŽ HIGH COST
87. Anatomic Criteria
īŽ Proximal neck length >15mm
diameter <28mm
īŽ Tube graft: distal cuff length >10mm
diameter <28mm
īŽ Iliac artery diameter >7mm and < 15mm
īŽ Minimal to moderate tortuosity
īŽ No mural thrombus at attachment sites
īŽ Minimal calcification
īŽ No associated mesenteric occlusive disease
102. Complications of EAAA repair
1) Injuries to arteries of access â Iliac/ Supra Renal
2) Embolization - micro â Renal Failure
distal â Ischemia
3) Procedure related
Groin hematoma, wound infection
POST IMPLANT SYNDROME
4) Device related
īŽ Migration, detachment, rupture, stenosis, kinking,
endoleak
103. Endoleaks
īŽ Coined by White, et al, 1996
īŽ Leak around proximal or distal attachment sites
īŽ Persistent flow in aneurysm sac
īŽ Incomplete exclusion
īŽ Rates
īŽ 0 to 44%
īŽ Risks
īŽ Expansion
īŽ Rupture
104. Endoleak Classification
īŽ Type Iâperigraft
īŽ Persistent flow at proximal or distal attachment
sites
īŽ Type IIâretrograde flow from side branches
īŽ Inferior mesenteric or lumbar arteries
īŽ Subgroup A: inflow only; B: in and outflow
īŽ Type IIIâgraft defect
īŽ Type IVâgraft porosity
īŽ Primary or secondary
105. RUPTURED AAA
īŽ With increasing age of the populationâ
INCIDENCE increasing to 30/ 100,000 patients.
īŽ There is a increase in proteolytic activity in aortic
wall
īŽ C/f â PAIN â abdominal/ back
FAINTING/ VOMITING
īŽ FINDINGS â MASS
TENDERNESS
BP < 80 mm Hg
Hematocrit < 38%
WBC > 10,000/ microletre
108. AAA Basics: Mortality
īŽ 15,000 lives per year taken due to rupture
(13th leading cause of death)
âĸ 40% of 5.5-6cm
AAAs will rupture
in 5 years
âĸ Average survival if
untreated is 17
months
109. Rupture outcomes
īŽMortality rate can be as high as 80%[1]
īŽMore than one third of rupture cases die outside the
hospital
Ruptured AAA
1. Adam. J Vasc Surg 1999;30:922-8.
2. Thomas. Br J Surg Aug 1988
110. AAA - RUPTURE- Treatment
A) EMERGENCY SURGERY
:: First successful repair of a ruptured AAA was by Cooley
and DeBakey in 1954
:: More than 98% of ruptures occur below the renal arteries.
:: Exploration -- through MIDLINE incision
IF aorta approached at infra renal levelâ it should be clamped
PROXIMAL CONTROLâ At the level of diaphragm
111. ABDOMINAL AORTIC RUPTURE
īŽ OTHER METHODS
īŽ Compression at diaphragm
īŽ Placement of aortic balloon
catheters
īŽ Foley catheters via puncture of
the aneurysm
112. AORTIC DISSECTION
īŽ Aortic dissection is characterized by separation of
the aortic wall layers by extraluminal blood that
usually enters the aortic wall through an intimal
tear.
īŽ ACUTEâ IF patients are seen within 14 days
īŽ CHRONICâ IF they are seen beyond 14 days
associated with HYPERTENSION
MALE > FEMALE
113.
114. DeBakey Classification
īŽ Type I â involves the ascending aorta and variable
extent on the descending thoracic or
thoracoabdominal aorta.
īŽ Type II â limited to the ascending aorta.
īŽ Type III â involving the descending thoracic aorta
without III a or with III b extension to the abdominal
aorta.
116. SURGICAL TECHNIQUES
1) GRAFT REPLACEMENT
removing the most threatening area
closing the entry site of dissection
reestablishing blood flow in distal aorta
2) AORTOPLASTY
suture of intimal tear at entry site
3) FENESTRATION
creating a large reentry from the false lumen
into the true lumen.
117. THORACO ABDOMINAL AORTIC ANEURYSM
īŽ Aneurysms that involve the thoracic and abdominal
aorta or those aneurysms including the visceral
aortic segments .
īŽ Etiologyâ degenerativeâ 80%
īŽ sequelae of chronic dissectionâ 20%
īŽ c/f-- sudden development of severe painâ back
/epigastric/flank pain
īŽ othersâ hoarseness/cough
hemoptysis/dysphagia lusoria
118. Crawford classification
īŽ Type I â involves Descending thoracic aorta and
abdominal aorta proximal to renal arteries.
īŽ Type II â Most of DTA + AA distal to renal
arteries
īŽ Type III â Involves aorta distal to renal arteries.
īŽ Type IV â Involves all or most of the abdominal
aorta including the paravisceral segment.
119. (MYCOTIC ANEURYSMS)
âInfected aneurysm" has gradually replaced the original
designation "mycotic aneurysmâ
Saccular aneurysms are seen most commonly .
Leukocytosis and an Elevated erythrocyte sedimentation
rate (in 73% of the cases)
weight loss
The aneurysm is palpable in 50 to 60% of the cases and
almost always tender
.
The onset is insidious, and a low-grade fever may be present
for several months before diagnosis .
120. Management
īŽ Infected aortic aneurysms are treated with intravenous
antibiotics and surgical excision.
īŽ Antibiotic therapy must be continued postoperatively for at
least 6 weeks.
īŽ The standard surgical approach involves
1.Resection of the infected aneurysm and
infected retroperitoneal tissue
2.Restoration of distal perfusion by placement of an extra-
anatomical bypass graft tunneled through unaffected tissue
planes to avoid placing a graft in a contaminated region.
121. SYPHILITIC ANEURYSM
īŽ Seen in tertiary stage of syphilis with
obliterative endarteritis of vasa vasorum
and aortitis
īŽ Roughening of intima: âTree barkingâ
īŽ Involves the thoracic aorta
īŽ Complications include rupture, aortic
insufficiency, and narrowing of coronary
ostia
123. BERRY ANEURYSM
īŽ Involve cerebral arteries at bifurcations
īŽ Probably arise at congenital points of
weakness in wall
īŽ Can rupture and result in subarachnoid
hemorrhage
īŽ Clinically may see headache, stiff neck
(meningeal irritation) and death
124. HIV RELATED ANEURYSM
īŽ Often MULTIPLE/ and at unusual sites
occur atâCOMMON CAROTID
SUPERFICIAL FEMORAL ARTERY
ABDOMINAL AORTA
īŽ MICROSCOPICALLY
HIV VASCULOPATHY are typical of a
LEUKOCYTOCLASTIC vasculitis that affects
vasa vasorum
īŽ RECONSTRUCTION â AUTOGENOUS GRAFT
if available
126. FEMORAL ANEURYSM
īŽ Common peripheral aneurysm
īŽ Incidence- 7.39 / 1OOOOO Population
īŽ TRUE aneurysm- Non specific etiology
īŽ FALSE aneurysm - anastomotic/traumatic
catheter-induced/infected
īŽ TYPE 1 â Limited to Common Femoral Artery
īŽ TYPE 2 â Involving orifice of Profunda Femoris
artery
127. Femoral aneurysm
īŽ Asymptommatic with pulsatile mass
īŽ Local pain â pressure on ajacent nerve
īŽ Limb edema/venous distention- venous compression
īŽ Lower extremity ischemia with intermittent
claudication/rest pain/gangrene
īŽ COMPLICATIONS â THROMBOSIS
RUPTURE
EMBOLIZATION
128. OPERATIVE MANAGEMENT
īŽ TYPE 1 ANEURYSM
īŽ INTERPOSITION GRAFT OF DACRON
īŽ e PTFE
īŽ TYPE 2 ANEURYSM
īŽ INTERPOSITION GRAFT TO SFA/ PFA with
reimplantation of the other artery.
īŽ SYNDACTYLIZATION- Suturing of
Superficial and Profunda femoris arteries together to
form a common lumen
129. POPLITEAL ANEURYSM
īŽ Is commonest ( 70% )
īŽ 65% bilateral with 25% associated with AAA
īŽ Etiology related to chronic flexion/extension
īŽ Associated aneurysms â other leg, femoral, aortic
131. īŽ C/f -- Swelling in popliteal region which is
smooth,soft,pulsatile,well localised,warm
compressible,often with thrill and bruit.
īŽ -- thrombosis and emboli can cause distal
gangrene
īŽ -- rupture :: torrential haemorrhage
īŽ Rx --- ANEURYSMORRHAPHY
īŽ Repair with arterial graft using PTFE,dacron
īŽ ENDOLUMINAL STENTING
132. UPPER EXTREMITY ANEURYSM
īŽ SUBCLAVIAN ARTERY ANEURYSM
Over 60 yrs â More common in men
īŽ Etiologyâ Degenerative
īŽ Thoracic outlet obstruction
īŽ Trauma
īŽ c/f -- Chest/neck/shoulder pain
īŽ neurological dysfunction- brachial plexus
īŽ hoarsenessâRt. Recurrent laryngeal nerve
īŽ Respiratory insufficiency- trachea
īŽ Hemoptysisâ lung apex erosion.
133. SUBCLAVIAN- AXILLARY ANEURYSM
īŽ POST STENOTIC DILATATION--- OUTLET OBSTRUCTION
īŽ Younger patients/females/ right side more common
īŽ Associated with CERVICAL RIBS
īŽ Associated with Raynauds phenomenon.
īŽ ARTERIOGRAPHY â To assess the degree of post
īŽ stenotic dilation of the subclavian artery.
īŽ Rxâsignificant dilationâ CERVICAL RIB removal
īŽ vascular reconstructionâ mobilization with end
to end anastomosis with or without short
interposition vein or prosthetic graft.
134. KOMMERELLâS DIVERTICULUM
īŽ ABERRANT RIGHT SUBCLAVIAN ARTERY
īŽ Most common congenital abnormality of aortic arch
īŽ Dysphagia lusoriaâ esophagus compressed against
postr. Trachea
īŽ Rx â propensity to cause symptom and lethal rupture
â
RESECTION OF ANEURYSMAL ARTERY
WITH VASCULAR RECONSTRUCTION
135. HYPOTHENAR HAMMER SYNDROME
īŽ Seen in men younger than 50 years age.
īŽ ULNAR artery and nerveâ enter hand by traversing
īŽ GUYONâS CANAL
īŽ TRAUMA â MURAL degeneration
īŽ damage to Intimaâ THROMBOSIS
īŽ damage to MEDIAâ TRUE ANEURYSM
īŽ C/fâ pain,cold sensation,paresthesias,cyanosis and
mottling of digits.
īŽ 4th and 5th digit involved
136. īŽ THUMB not involvedâ RADIAL BLOOD supply
īŽ RAYNAUDâS PHENOMENON- not seen
īŽ -- UNILATERAL
īŽ -- THUMB NOT INVOLVED
īŽ ABSENCE OF CLASSIC TRIPHASIC CHANGE
īŽ surgical therapy
īŽ -- cervicodorsal sympathectomy
īŽ -- excision of ulnar artery aneurysm with ligation
of ulnar artery and aneurysmectomy with
microsurgical reconstruction of ulnar artery by
reanastomosis or interposition vein graft.
139. 139
What is the Current Clinical
Procedure?
There is a danger with using
diameter for surgical decision
Find AAA in the
population
By Accident
Ultrasound
screening
(in the future)
âWatchful waitingâ
Surgical
repair for
aneurysms īŗ
5.5 cm max
diameter
140. 140
Why is Using Max Diameter a Problem?
Fillinger et al, Journal of Vascular Surgery April 2003 p726
īŽ Both AAAs have max diameters of 5.5cm
īŽ âAâ ruptured after 18 months of this scan
īŽ âBâ is still under observation after more than 3 years
īŽ Max stress of âAâ is more than twice that of âBâ
īŽ Small Aneurysms are known to rupture
A B
141. 141
How to Obtain Wall Stress
Fluid Model
âĸFlow Patterns
âĸWall Shear Stress
Structural Model
âĸWall Movement
âĸWall stress
Combined Fluid Structure Model
âĸRealistic wall shear stress and wall stress
Computer Tomography (CT) Scan
Blood Properties Wall Properties
144. EAAA in 2009
īŽ There are many new grafts available, now they
are âSecond Generationâ
īŽ Data from EUROSTAR (4000+ patients)
īŽ Newer grafts have better 3-year mortality
īŽ Fewer secondary interventions
īŽ Fewer conversions of open repair
īŽ Fewer graft rupture
īŽ Shorter hospital stay
Torella et. al. 2004
145. AneuRx
īŽ Medtronic
īŽ Modular bifurcated with
extension cuffs
īŽ Graftâthin walled
polyester
īŽ Stentâouter self
expanding Nitinol stents
īŽ Deliveryâ25F
introducer sheath
īŽ Mechanical deployment
handle
May, et al
146. ONGOING STUDIES
īŽ Wall stress could be a potential tool to replace
maximum diameter.
īŽ RETROPERITONEAL APPROACH
operative mortality â 12 % compared to 35%
with transperitoneal approach.
īŽ SPINAL CORD ISCHEMIC COMPLICATIONS
pre operative CSF removal
pre operative angiography- identify dominant
SPINAL ARTERY
147. TAKE HOME MESSAGE
īŽ Increased screening and follow up has reduced
mortality with aneurysms.
īŽ Now not the size but the wall stress is important
indicator for rupture aneurysm.
īŽ Endograft AAA repair is still a developing field with
promise- 2nd generation grafts have reduced
operative complications.
īŽ For open surgeries retroperitoneal approach has its
own advantage.
īŽ Radiologist and surgeons need better understanding
to deal with aneurysms for its a team work.
148. REFERENCES
īŽ BAILEY AND LOVE
īŽ SCHWARTZ
īŽ SABISTON
īŽ RUTHERFORD BOOK OF VASCULAR
SURGERY
īŽ INDIAN JOURNAL OF SURGERY
īŽ AMERICAN JOURNAL OF SURGERY
īŽ RECENT ADVANCES BY â TAYLOR
īŽ RECENT ADVANCES BY- RL GUPTA
īŽ SURGICAL ANATOMY ATLAS
149. NEWS FLASH!
īŽ Diabetics were actually protected from
AAA!
īŽ Odds ratio of 0.52 (0.45-0.61)
īŽ Patients with DVT were also protected
īŽ Odds ratio of 0.67 (0.53-0.84)