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08-23-10 Abdominal Aortic Aneurysm

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08-23-10 Abdominal Aortic Aneurysm

  1. 1. 08-23-10 Abdominal Aortic Aneurysm & Carotid Surgery (D’Amato) – Outline Abdominal Aortic Aneurysm  Focal dilatation of a blood vessel to at least50% greater than its normal size o True aneurysm: primary dilatation of the artery includingall vessel wall layers o Falseaneurysm(pseudoaneurysm): disruption of the vessel wall,does not includeall layers of the wall and may actually bea pulsatilehematoma not contained by the artery wall butby a fibrous capsule o Falseaneurysms of the femoral artery secondary to catheterization: most common aneurysm o Infrarenal abdominal aneurysms (AAA): most common true aneurysm  Found in 2% elderly malepopulation  5% w CAD and 50% w femoral or popliteal aneurysms  S/S: most asymptomatic, 80% present as palpablepulsatileabdominal mass in midabdomen justabove and to the left of the umbilicus.  Natural Hx: most continue to expand and will eventually rupture.  Size is best determinant of rupture risk o 5.5-6cm w/in 5yrs  Diagnosis o Imaging  Xray: cheap, may show calcifications,notideal for suspected AAA  US: cheap, good for identification of vessel sizes,wall weaknesses  CT: GOLD STANDARD, good for identification of vessel sizes,thrombus,extent of inflammation,rupture  Con: radiation,cost  MRI: shows rate of flow, no radiation  Con: expensive as crap  Arteriography: best for determination of proximal,distal extent  Con: underestimates thrombus size  Treatment o Surveillance  <5 cm  Annual US o Surgery  Indications  Symptomatic  >0.5 cm increasein a year  Total size >5 cm  Open  Process o Aorta and common iliacsareclamped  Plaqueis removed  Graft is sutured to proximal segment  Graft is sutured to distal segment  Aneurysm wall is sutured around graft.  Benefits o Good overall prognosisfollowingrepair  Long term results are excellent  Graft failurerateis lowand falseaneurysmformation is rare  Risks o M/M duringprocedure is relatively high o 2-4% death rate o 5-10% complication rateincl.bleeding,renal failure,MI,graft infection,limb loss,bowel ischemia and erectiledysfunction.  Endovascular
  2. 2.  Selection criteria o Asymptomatic  >5cm, or increasein sizeby 0.5cm in last 6 months o Symptomatic  Size not factor  At least1.5cm distal to renal arteries(proximal landingzone) w/o significantcalcification or thrombus,and similarly a distal landingzone of at least2.5cm. o  Benefits: o not necessary to perform open-chest or open-abdominal aneurysm surgery. o reduces the recovery time by several days. o patients can return home and return to normal activities within 4 to 6 weeks. o avoids complications of open surgical procedure,especially useful for pts with multipleco-morbities  Risks: o small,butsignificant,risk of aneurysmrupture that is slightly higher than that of open-surgery aneurysmrepair o blood leakages around the stent graft o blockageof the flow of blood through the stent graft o movement of the stent graft from its original siteof placement o fracture of the stent graft o infection o Arteriography must be used o Potential for leaks near or atthe graft o Life-long monitoringrequired  Tidbits o Requires aorta proximal to aneurysm to be cylindrical for atleast 1.5cm. o Endograft repair is more expensive than open repair in spiteof the lower peri-procedural morbidity. The devices are expensive ($10,000- 15,000), and there is further cost due to the extended follow-up with imagingstudies to identify graft movement or leak Cerebrovascular Vascular Disease  Diagnosis o Carotid bruits  At angle of mandible  Caused by turbulent flow  Heart murmurs- bil.,lower neck  Bruits not reliable indicators of severe carotid artery disease (only 35% pts. w bruits have significantdisease)  Bruits aremore predictive of MI than of stroke o Motor &/or sensory w or w/o mental changes may be seen  Transientischemic attack (TIA)  Abrupt onset-5mins.  Resolves w/in 1 hour  Symptoms o Motor deficit- contralateral o Sensory deficit- contralateral o Aphasia –expressiveor global
  3. 3.  Amaurosis Fugax –transientmonocular blindness d/tembolus in opthalmic artery  Hollenhorstplaques-small,brightflecks in retina  Acute,unstable neuro deficits – stroke in evolution  Completed stroke - >24hrs.  Vertebrobasilar disease  Reduction of flow in vertebral and basilar areas  Drop attacks,clumsiness and variety of sensory phenomenon  Vertigo, diplopia,dysphagia,or dysequilibriumoccurringindividually israrely due to vertebrobasilar disease.  Treatment o Focuses on preventing strokes and TIA’s by removing the sourceof atheroemboli or, less commonly, by improvingblood flow. o Medical Tx.  Warfarin –embolus from heart  Aspirin  Ticlopidine–not candidates for surgery  Control arrythmias o Carotid Angioplasty,Stenting (CAS)  Indications  High risk pts o Recurrent stenosis o Severe co-morbidities o Surgically hostileneck  High carotid lesion  Prior surgery  Radiation  Risks  Similar to Sx o Carotid endarterectomy (CEA) is the primary operation  Indications  Asymptomatic Carotid Stenosis o High-grade stenosis - 80-90%occlusion o Patients at risk for stroke  Plaqueulceration  Plaquestricture  Plaqueechogenicity  Symptomatic Carotid Stenosis o Degree is relative  Risks  Acute myocardial infarction  Perioperativestroke  Graft closure  Cranial nervedysfunction  Contraindications  Severe neurologic deficitfollowinga cerebral infarction  Complete occlusion of carotid with stroke  Concurrent medical illnessthatwould significantly limitthe patient’s life expectancy Studies o NASCET/ACAS  Sx > conservativetreatment for high grade stenosis  Depends on the surgeon
  4. 4.  Complication rateshould be: o <5% in symptomatic pts o <2% in asymptomatic pts o SAPPHIRE study  >80% asymptomatic and >50% symptomatic stenosis profiles were randomized  30-day death and complic ratefavored stenting  3-year follow-up  No difference between angioplasty and stenting o CREST study  Early results indicatethat stenting has a higher morbidity in patients over 80 years of age  Carotid Revascularization Endarterectomy vs. Stenting Trials

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