Aneurysm and AV fistula

1. ANEURYSMS, AVF, ARTERITIS &
RAYNAUD’S DISEASE

2. TABLE OF CONTENTS
• Aneurysms
• Risk factors
• management
 Thoraco-abdominal aneurysms
 Abdominal aneurysms
 Peripheral aneurysms
 Dissecting aneurysms
 Mycotic aneurysms
• Arteriovenous fistula; Congenital and acquired
• Arteritis; Buerger’s disease and other types of arteritis
• Raynaud’s Disease

3. ANEURYSMS
• It is an abnormal permanent dilatation of
localised segment of arterial system.
• When there is a >50% increase in the expected
diameter of the vessel. Below 50% is termed as
ectatic
• Atherosclerosis which is the most common
(90%) facilitating cause of aneurysm is due to
destruction and loss of stability of tunica media.

4. Classification of aneurysms
• Wall
 True (three layers: intima, media, adventitia)
 False (single layer of fibrous tissue e.g aneurysm
following trauma)
• Morphology
 Fusiform
 Saccular
• Aetiology
 Atheromatous
 Mycotic (bacterial rather than fungal)

5.  Collagen disease like Marfan‘s syndrome, polyarteritis
nodosa, Ehler-Danos syndrome.
 Traumatic
 Congenital:
 Berry aneurysm; cirsoid aneurysm; congenital AV fistula.
• Sites; Thoracic, abdominal, and peripheral (iliac, femoral,
popliteal, visceral, carotid or subclavian), cerebral ‘berry’
aneurysms.
 The most common is true, fusiform, atherosclerotic, aortic
aneurysms.

7. Risk factors
• Atherosclerosis
• Hypertension
• Smoking and alcohol
• Connective tissues diseases e.g ehlers danlos
syndrome[ defective type 3 collagen synthesis]
• Congenital defects e.g marfan syndrome
• Infections e.g syphillis
• Mutations e.g TGF-beta receptor mutations
• Diabetes

8. Clinical Features of Aneurysms
• Symptoms relate to the vessel affected and the tissue
it supplies and result from compressions of
surrounding structures, thrombosis, rupture, or
release of emboli and erosions
• Compressions-Distal oedema due to venous
compression, altered sensation due to compression of
nerves.
• Erosion into bones, joints, trachea or oesophagus.
• Aneurysm with thrombosis can throw an embolus
causing gangrene of toes, digits, extending often
proximally also.

9. • On local exam
• Swelling at the site which is pulsatile
(expansile), smooth, soft, warm,
compressible, with thrill on palpation and
bruit on auscultation.
• Swelling reduces in size when pressed
proximally.

10. Investigations
• Imaging studies; Doppler study, duplex scan,
angiogram, DSA(Digital Subtraction
Angiography).
• Tests relevant for the cause, like blood sugar,
lipid profile,
• Echocardiography

11. Differential Diagnosis
• Pyogenic abscess: Abscess has to be always
confirmed by aspiration; especially in axilla,
popliteal region, groin.
• Vascular tumours.
• Pulsating tumours: Sarcomas, pulsating
secondaries.
• Pseudocyst of pancreas mimics aortic
aneurysm.
• AV fistula

12. management
• Medical management
To minimize the rate of expansion and rupture.
Smoking cessation
Control of BP to minimize wall stress that
contribute to expansion and rupture
• Reconstruction of artery using arterial grafts.
• Arterial endoaneurysmorrhaphy—MATAS. It is
done usually for peripheral saccular aneurysm.
• Therapeutic embolisation.
• Clipping the vessel under guidance (e.g. cranial
aneurysms).

14. Thoraco-abdominal Aneurysms
• Often asymptomatic. Different clinical features to
thoracic aortic dissection (acute chest pain
(angina/MI), back pain, acute aortic regurgitation,
or cardiac failure).
• Diagnosed by widened mediastinum on CXR or
on CT/MRI. Rupture has high mortality and rare
without prior symptoms.
• Elective surgery has up to 20% mortality and risk
of paraplegia; 10% require dialysis after surgery.
Endovascular stenting is a potential future
treatment of choice due to high surgical risks.

15. Crawford classification of Thoraco-
abdominal aortic aneurysm
• Type I; left subclavian A to renal A
• Type II; left subclavian A to aortic bifurcation
• Type III; mid-descending aorta to aortic
bifurcation
• Type IV; upper abdominal aorta and all or
none of the infrarenal

16. Thoracic aortic aneurysm andChest X-
ray showing aortic aneurysm

17. Abdominal Aneurysm
• Abdominal aortic aneurysm is the most common aortic
aneurysm.
• Splenic artery aneurysm is the 2nd most common type.
• Incidence is 2%. It is more common in males.
• Transverse diameter of aorta in an aneurysm should be
3 cm or more.
• Common in elderly; common in males (4:1); chance of
getting aneurysm in genetically related first degree
relatives is 10 times more.
• Common in smokers (8:1with nonsmokers); in 55% of
patients Chlamydia pneumoniae is identified.

18. Abdominal aortic aneurysm
• Most common large vessel aneurysm. 95%
associated with atheromatous degeneration and
95% occur below renal arteries. 15% extend
down to involve the origins of the common iliac
arteries.
• 5-10% are ‘inflammatory’
• Most are asymptomatic; 40% are detected
incidentally (clinical examination, ultrasound,
AXR).
• Mycotic aneurysms are rare, but have a high
rupture rate.

19. • Risk of rupture and mortality increases with
increasing aneurysm diameter.
• Surgical intervention is indicated for:
AP diameter >5.5cm in fit individuals.
Rapid increase in diameter on serial
surveillance scans, e.g. >0.5cm in 6 months.
• Regular ultrasonographic assessment is
indicated for asymptomatic aneurysms <55
mm in diameter.

20. Classification
• Classification I
Infrarenal—most common (95%).
Suprarenal—5%. Isolated suprarenal type is
rare; it is usually associated with thoracic and or
infrarenal types.
• ™
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Classification II
Asymptomatic.
Symptomatic.
Symptomatic ruptured.

21. Asymptomatic Type
• It is found incidentally either on clinical
examination or on angiography or on
ultrasound.
• Repair is required if diameter is over 5.5 cm
on ultrasound.
• It is identified during routine abdominal
palpation or while assessing or operating for
some other abdominal conditions.

22. Symptomatic without Rupture (Clinical
features/presentations)
• It presents as back pain, abdominal pain, mass
abdomen (smooth, soft, nonmobile, not moving
with respiration, above the umbilicus, pulsatile)
• Common in males (4:1); common in smokers.
• GIT, urinary, venous symptoms can also occur
• In infrarenal type upper border is clearly felt.
• Lower limb ischaemia and embolic episodes can
occur.
• Being a retroperitoneal mass back pain is
common

23. • 5% present as inflammatory aneurysm adherent to
ureters, left renal vein, inferior vena cava and
duodenum. Expanding aneurysm blocks lymphatics
causing inflammation and fibrosis
• Aortocaval fistula, presents as high output cardiac
failure with continuous bruit in abdomen and severe
lower limb ischaemia.
• Aortoenteric fistula is due to erosion of aneurysm
into 4th part of duodenum presenting as GI bleed,
malaena, shock.

24. Investigation
• Blood urea, serum creatinine.
• US (neck of the aneurysm, dimensions and relation to
renal arteries are difficult to assess), aortogram, DSA, CT
scan (most precise). US is an effective screening tool.
Screening is done in cardiovascular patients in men (60–
85 years), in women (60–85 years); men and women
above 50 years with family history; annually in
asymptomatic AAA with 4.0–4.5 cm size, with size >4.5
cm once in every 6 months.
• CT angiogram, MR angiogram.
• Blood sugar, lipid profile, other relevant investigations
like ECG, echocardiography, cardiac and pulmonary
assessment.

25. • Full blood count, electrolytes, liver function
tests, coagulation tests and blood lipid
estimation should be performed.

27. Spiral computed tomogram
showing an infrarenal aaa

28. Complications of abdominal aortic
aneurysm
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Rupture, infection
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Thrombosis, embolism
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Distal ischaemia/gangrene
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Aortocaval fistula formation
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Aortoenteric fistula
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Erosion of vertebra
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Spinal cord ischaemia when thrombosis
develops

29. Surgical Treatment
• Indications for surgery
Asymptomatic aneurysm more than 5.5 cm.
Growth rate more than 0.5 cm/year.
Painful, tender aneurysm.
Thrombosed aneurysm, aneurysm with distal
emboli.

30. Open surgical repair
• It is called as endo-aneurysmorrhaphy with
intraluminal graft placement. It is done under
GA with epidural support.
• Knitted Dacron graft after preclotting or woven
Dacron graft or ePTFE tube graft is used. Graft
is anastomosed above and below using
polypropylene sutures (4 zero). Inferior
mesenteric artery can be reimplanted. Graft is
covered with aneurysmal sac.

31. • Minimal incision aortic surgery (MIAS) is
done in thin individual with midline
abdominal incision 12 cm in length with its 9
cm part above the umbilicus

33. Endovascular aneurysm repair (EVAR)
• It is endoluminal stent graft placement into
the aneurysmal segment of aorta using
interventional radiology with Seldinger’s
technique approach through femoral artery.
• Dacron or ePTFE with integral metallic stent
for support and firm attachment is used as
stent/endovascular prosthesis

35. Ruptured abdominal aortic aneurysm
• Risk of rupture is 1%, if diameter is within 5.5 cm
in size. Risk increases to 20% once the diameter =
7 cm.
• It may be anterior rupture (20%) into the free
peritoneal cavity causing severe shock and
death very early; or posterior rupture (80%) with
formation of retroperitoneal haematoma of
large size causing severe back pain, hypotension,
shock, absence of femoral pulses and with a
palpable mass in the abdomen.

36. • Symptoms
 Severe/sudden onset epigastric and/or back/loin pain.
 History of sudden ‘collapse’, often with transient
hypotension.
 May have history of AAA under surveillance.
• Signs
 Cardinal signs are unexplained rapid onset hypotension,
pain, and sweating.
 A pulsatile abdominal mass is not always easy to feel
(due to pain and abdominal wall rigidity).

37. Management of ruptured abdominal
aortic aneurysm
• Early diagnosis (abdominal/back pain, pulsatile
mass, shock)
• Immediate resuscitation (oxygen, intravenous
replacement therapy, central line)
• Maintain systolic pressure, but not >100 mmHg,
consider permissive hypotension
• Urinary catheter
• Cross-match six units of blood
• Rapid transfer to the operating theatre

38. • Post-operative care
 Transfer to ICU.
Normalize core temperature.
Correct clotting and maintain Hb >10g/dL.
Adequate analgesia and accurate fluid
balance.
Attention to cardiac/renal/pulmonary
dysfunction.

39. Complications of surgery
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MI is the most common cardiac complication in
perioperative and in first 2 days of postoperative
period
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Haemorrhage and haemodynamic complications
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Renal failure—is most common noncardiac
complication
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Colonic ischaemia
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Sexual dysfunction
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Aortoduodenal fistula
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Aortovenacaval fistula

40. • ™
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Spinal cord ischaemia—paraplegia
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Paralytic ileus
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Distal thromboembolism—blue toe syndrome
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DVT
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Graft leak, graft thrombosis, graft failure
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Anastomotic disruption, pseudoaneurysm formation
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Prosthetic infection/migration
• Abdominal compartment syndrome.
• Death (overall up to 50% of operated cases).

41. Peripheral Aneurysms
• Popliteal type is the most common one.
Peripheral aneurysms occur in descending order
of frequency in popliteal, femoral, subclavian,
axillary and carotid arteries.
• Expansile pulsation which is confirmed using two
finger placement with thrill and bruit is typical.
Infection, thrombosis make it less pulsatile
mimicking an abscess.
• Erosion into adjacent bone and skin, rupture are
known to occur.
• Distal emboli may lead into digital gangrene.

42. Popliteal aneurysm
• Is most common (70%).
• 65% are bilateral.
• 25% cases are associated with abdominal aortic
aneurysm.
• 75% cause complications in 5 years.
• Presentations;
Swelling in popliteal region which is smooth,
soft, pulsatile, well-localised, warm,
compressible, often with thrill and bruit.

43. • Treatment;
Aneurysmorrhaphy.
Repair with arterial graft using PTFE, Dacron.
Endoluminal stenting.

44. Carotid artery aneurysm
• Incidence is less than 4% of peripheral aneurysms.
• Most common site: Common carotid artery bulb,
often extends into the internal carotid artery.
• Causes;
 Atherosclerosis, trauma.
 Syphilis, Marfan’s syndrome.
 Ehler-Danlos syndrome.
 Congenital.

45. • Clinical Features;
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10% bilateral.
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Swelling in the neck at the level of the thyroid cartilage,
below the angle of mandible.
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Pulsatile (expansile pulsation).
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Smooth, soft, nontender, horizontally mobile.
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Bruit felt.
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Neurological features due to embolic episodes (50%).
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Hoarseness of voice.
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Horner’s syndrome.
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Dysphagia.
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Swelling extending into the tonsillar bed.

46. • Differential Diagnosis;
Carotid body tumour.
Neurofibroma arising from the vagus.
Abscess in neck.
• Complications
Rupture.
Thrombosis.
Hemiplegia.

47. • Investigations
Doppler of neck, carotid angiogram.
DSA, CT angiogram.
• Treatment
Reconstruction of the artery using vascular
graft.
Ligation of the bulb as a life-saving procedure,
but results in hemiplegia.
Intravascular stents.

48. Femoral aneurysm
• True aneurysm of the femoral artery is
uncommon.
• Mostly asymptomatic pulsatile groin swelling or
pain. May present with lower limb ischaemia.
• Over half are associated with abdominal or
popliteal aneurysms.
• Large aneurysms should be repaired.
• False aneurysm occurs after arterial surgery at
this site.

49. • Treatment
reanastomosis of the bypass in the groin under
suitable antibiotic cover.
excision of the infected graft and insertion of a
further bypass routed around the infected area.
For false aneurysms caused by femoral artery
puncture, thrombin injection under ultrasound
guidance may be successful and avoids surgery

50. Iliac aneurysm
• This usually occurs in conjunction with aortic
aneurysm
• Mostly common iliac and asymptomatic.
• Rarely palpable and rupture may be missed
as acute abdomen or renal colic.
• Open surgery usually involves an inlay graft,
but some iliac aneurysms may be suitable for
endovascular repair.

51. Dissecting Aneurysm
• It is the dissection of media of the aorta after
splitting through intima creating a channel in the
media of the vessel wall.
• Causes
Hypertension (It is associated in 80% of dissecting
aneurysms).
Cystic medial necrosis.
Marfan’s syndrome and collagen diseases.
Trauma.
Weakening of the elastic layers of the media due to
shear forces

52. • Features
It is always seen in thoracic aorta, common in
ascending aorta (70%).
It can occur in aortic arch or thoracic descending
aorta.
This dissected aortic channel gets lined by
endothelium, often reopens distally into the
aorta causing double-barrelled aorta which, in
fact, prevents complications.
It is commonly associated with aortic
insufficiency

53. • I. Classification (DeBakey’s)
Type I: Dissection begins in ascending aorta
extends into descending thoracic aorta (70%)
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Type II: Dissection originates in ascending aorta
and extends only up to the origin of the major
vessels. It is safer type with less complications
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Type III: Dissection begins in the descending
thoracic aorta beyond the origin of the left
subclavian artery

54. • II. Stanford classification
Proximal—includes DeBakey’s Type I and II
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Distal—includes DeBakey’s Type III
• III. Dissecting aneurysm can be:
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Acute
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Chronic
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Healed dissecting aneurysm which
communicates distally again to aorta as double
barrelled aorta

56. • Clinical Features
Pain in the chest, back which is excruciating.
Features of ischaemia due to blockage of
different vessels.
• Investigations
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Chest X-ray shows mediastinal widening
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Arterial Doppler
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Angiogram

57. • Complications
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Acute: Rupture into the pericardium or pleura—
dangerous type
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Chronic: Blockage of coronary vessels and major vessels
like carotid and subclavian arteries with aortic
insufficiency
• Treatment
 Antihypertensives.
 Surgery: Using Dacron graft reconstruction of aorta has
to be done with cardiopulmonary bypass.

58. • Indications for surgery
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Progressive disease
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Significant ischaemia
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Impending rupture
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Type A aortic dissection

59. Mycotic Aneurysms
• Common bacteria are gram-positive organisms
like Staphylococcus aureus (most common) and
Streptococcus.
• Common aetiology is bacterial endocarditis but
could be any infective site.
• Common vessels involved are aorta, visceral,
head and neck and intracranial.
• Commonly it is saccular, multilobed, with a
narrow neck

60. • Patient presents with fever, toxaemia and
tender pulsatile mass if it is in the periphery.
• Investigations: Leucocytosis. Positive blood
culture, MR or CT angiogram are relevant.
• Treatment
Broad-spectrum antibiotics
Resection of aneurysm; debridement and
drainage of the infected aneurysm with
adequate blood transfusions.

61. Extra-anatomic bypass through uninfected
tissue planes to avoid contamination of the
graft.
Long-term antibiotic therapy is necessary.
It has got 25% mortality.

62. ARTERIO VENOUS FISTULA
• Communication between an artery and a vein
(or veins) may be either a congenital
malformation or the result of trauma.
• Arteriovenous fistulae for haemodialysis access
are also created surgically.
• The structural effect of arterial blood flow on
the veins is characteristic; they become dilated,
tortuous and thick walled (arterialised).

63. • The physiological effect, if the fistula is big
enough, is an increase in cardiac output. In
extreme circumstances, this can cause left
ventricular enlargement and even cardiac
failure.

64. Congenital Arteriovenous
Malformation
(Fistula)
• Sites
Limbs, either part or whole of the limb is
involved. It may be localised to toes or fingers.
Lungs.
Brain—in circle of Willis.
Other organs like bowel, liver.

65. Clinical Features
• Structural changes in the limb:
 Limb is lengthened due to increase in blood flow since
developmental period.
 Limb girth is also increased.
 Limb is warm.
 Continuous thrill and continuous machinery murmur
all over the lesion.
 Dilated arterialised varicose veins are seen due to
increased blood flow and also due to valvular
incompetence.
 Often there is bone erosion or extension of AVF into
the bone as such.

67. • Physiological changes
Because of the hyperdynamic circulation, there
is increased cardiac output and so often
congestive cardiac failure.
• Investigations
Angiogram—MR angiogram is ideal.
Doppler study.
X-ray of the part.
ECG, echocardiography.

68. • Complications
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Haemorrhage
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Thrombosis
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Cardiac failure (CCF)
• Treatment
Conservative—sclerotherapy, compression,
avoiding injury.
Indications for intervention

69.  Absolute: Haemorrhage, ischaemia, CCF.
 Relative: Pain, functional disability, cosmesis, limb
asymmetry.
 Emergency: Torrential bleeding usually after trauma
(example— road traffic accidents).
 Interventions;
 Surgical ligation of feeding vessels and complete excision
of the lesion.
 Therapeutic embolisation/preoperative embolisation
hasten the proper surgical excision.
 In emergency bleeding, adequate transfusion of blood,
tourniquet usage, intraoperative embolisation and then
excision of entire lesion is done

70. Acquired Arteriovenous Fistula (AVF)
• Causes
Trauma (most common cause):Femoral
region,Popliteal region, Brachial region, Wrist,
Aorta—vena caval, Abdomen.It may be following
road traffic accidents, penetrating wounds, cock-
fight injury (common in South India).
After surgical intervention of major vessels.
Therapeutic: For renal dialysis. It is done to have
easy and adequate venous access for long time
haemodialysis. Common sites are wrist, brachial,
and femoral region.

71. • Investigations
Doppler, angiogram.
ECG, echocardiography.
• Treatment
Excision of fistula and reconstruction of artery
and vein with graft. Done in early stages—
larger vessels. Venous or Dacron graft is used.

72. In emergency situation, quadruple ligation,
i.e. both artery and vein above and below are
ligated without touching the fistula and sac
Therapeutic embolisation may be tried.

73. Reconstruction of AV fistula
using graft.
Quadruple ligation of AV fistula. Hunter’s
ligation

74. ARTERITIS
Thromboangiitis obliterans (Buerger’s
disease)
• This is characterised by occlusive disease of small-
and mediumsized arteries (plantar, tibial, radial,
etc.), thrombophlebitis of the superficial or deep
veins, and Raynaud’s syndrome
• It occurs in male smokers, usually under the age of
30 years. Often, only one or two of the three
manifestations are present.
• Histologically, there are inflammatory changes in
the walls of arteries and veins, leading to
thrombosis.

75. • Treatment
is total abstinence from smoking,
which arrests, but does not reverse, the
disease.
Established arterial occlusions are treated as
for atheromatous disease
amputations may eventually be required.

76. Other types of arteritis
• Arteritis occurs in association with many
connective tissue disorders, e.g. rheumatoid
arthritis, systemic lupus erythematosus and
polyarteritis nodosa.
• This is usually the province of the specialist
physician, but the surgeon may be called on to
carry out minor amputations. Sympathectomy
has previously been used, but is usually
ineffective.

77. • Temporal arteritis is a disease in which localised
infiltration with inflammatory and giant cells leads to
arterial occlusion, ischaemic headache and tender,
palpable, pulseless (thrombosed) arteries in the scalp.
Irreversible blindness occurs if the ophthalmic artery
becomes occluded.
• The surgeon may be required to perform a temporal
artery biopsy, but this should not delay immediate
steroid therapy to arrest and reverse the process before
the ophthalmic artery is involved.
• The length of the biposy should be at least 1 cm.

78. • Takayasu’s disease is an arteritis that obstructs
major arteries, particularly the large vessels
coming off the aortic arch. It usually pursues a
relentless course.Idiopathic.
• It is common in young females (85%); common
in Japan; commonly subclavian artery is
involved (85%); involves all layers of arteries of
upper limb and neck; often bilateral. It remains
unnoticed for long time.

79. • Features
 Fever, myalgia, arthralgia, upper limb claudication.
 Absence pulses in upper limb/limbs, neck;
hypertension.
 Fainting on turning the neck or change in position;
atrophy of face.
 Thrill/bruit along major arteries of upper limb and neck
are the features.
 Optic nerve atrophy without papilloedema.
 Weakness and paraesthesia of upper limb.

80.  Cerebral softening, convulsions, hemiplegia can occur.
 Occasionally it can be life-threatening. Myocardial
infarction;embolism, ischaemia are other complications.
 DSA; MR angiography and Doppler are the investigations.
• Treatment
 To suppress immunity prednisolone 50 mg/day and
cyclophosphamide daily is given.
 Vascular reconstruction.

81. RAYNAUD’S DISEASE
• This idiopathic condition usually occurs in young
women and affects the hands more than the
feet.
• There is abnormal sensitivity in the arteriolar
response to cold.
• These vessels constrict and the digits (usually the
fingers) turn white and become incapable of fine
movements.
• The capillaries then dilate and fill with slowly
flowing deoxygenated blood, resulting in the
digits becoming swollen and dusky.

82. • As the attack passes off, the arterioles relax,
oxygenated blood returns into the dilated
capillaries and the digits become red.
• Thus, the condition is recognised by the
characteristic sequence of blanching, dusky
cyanosis and red engorgement, often
accompanied by pain.

83. • Treatment of Raynaud’s disease
protection from cold and avoidance of pulp and
nailbed infection.
Calcium antagonists, such as nifedipine, may
also have a role to play and electrically heated
gloves can be useful in winter.
Sympathectomy has been used in the past, but
it is either ineffective or its effects are short-
lived.

84. Raynaud’s syndrome
• The term ‘Raynaud’s syndrome’ is most often
used for a peripheral vasospasm in
atherosclerosis, thoracic outlet syndrome, carpal
tunnel syndrome, systemic lupus erythematosus
or rheumatoid arthritis.
• The clinical features areas for Raynaud’s disease,
but they may be much more aggressive.
• Raynaud’s syndrome may also follow the use of
vibrating tools like pneumatic road drills, chain
saws, wood cutting, and is known as ‘vibration
white finger’.

85. • Treatment is directed primarily at the underlying
condition
• The syndrome when secondary to collagen
disease leads frequently to necrosis of digits and
multiple amputations.
• Sympathectomy yields disappointing results and
is not recommended.
• Nifedipine, steroids and vasospastic antagonists
may all have a role in treatment.
• Patients with vibration white finger should avoid
vibrating tools.

86. REFERENCES
• Bailey & Love’s, “Short Practice of Surgery, 26th
Edition”
• SRB’s, “Manual of Surgery, 5th Edition”
• Oxford Handbook of Clinical Surgery, 4th
Edition