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.

2. ANEURYSMS
PRESENTED by---Dr.JYOTINDRA SINGH
MODERATOR– Dr. A. BHASKARAN

3. SEMINAR PLAN
 INTRODUCTION
 HISTORICAL ASPECT
 CLASSIFICATION
 ABDOMINAL AORTIC ANEURYSM
 SURGICAL MANAGEMENT
 VIDEOS
 PERIPHERAL ANEURYSM/ OTHER TYPES
 RECENT ADVANCES
 STUDIES/ONGOING RESEARCH WORK
 REFERENCES/

4. INTRODUCTION
 The term ANEURYSM is derived from the Greek
word ANEURYSMA meaning “ a widening”
 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.
 Normal arterial diameter is dependent on
age,gender,body size and other factors.

5.  An Aneurysm is defined as a localized dilation at
least 50 % larger than an adjacent normal portion of
the same artery.
 ECTASIA- Arterial dilation less than 50% above
normal
ARTERIOMEGALY– Diffuse arterial enlargement
involving several arterial segments with an increase
in diameter greater than 50% above normal.

6. HSTORICAL PERSPECTIVE
 2000 B.C – PAPYRUS – Description of traumatic
aneurysms of the peripheral arteries.
 131 A.D – GALEN -- Defined an aneurysms as a
localized pulsatile swelling that disappeared on
pressure.
 1793 A.D – JOHN HUNTER -- Operated for a
pulsatile mass in popliteal fossa.

7. HISTORICAL ASPECT
1950 A.D – ALEXIS CARREL/ DeBakey and
Cooley – Demonstrated a segment of aorta can be
replaced by another artery or vein.
 1953 A.D – BAHNSON– First successful
repair of ruptured aortic aneurysm.
 1954 A.D – ETHEREDGE– Repair of
thoracoabdominal aneurysm .
 1991A.D -- PARODI – Revolutionary minimally
invasive endovascular approach.

8. Types of Arteries
 Elastic arteries – the largest arteries
 Diameters range from 2.5 cm to 1 cm
 Includes the aorta and its major branches
 Sometimes called conducting arteries
 High elastin content dampens surge of blood
pressure
Figure 19.2a

9. 9
Arterial microstructure

10. 10
Arterial microstructure
Intima Endothelial cells

11. 11
Arterial microstructure
Media Smooth muscle cells, collagen & elastin

12. 12
Arterial microstructure
Adventitia Collagen fibers

14. CLASSIFICATION
 ETIOLOGY
 LOCATION
 MORPHOLOGY
 TRUE/FALSE

15. True/false aneurysm
 Aneurysm focal dialation greater than 1.5
times normal diameter
 True aneurysm contains all layers of arterial wall.
 False aneurysm dialation covered by thick
fibrinous capsule.

16. PSEUDOANEURYSM
 Injury to wall of vessel allows blood to escape from vessel into
adjacent tissue
 Extravasated blood coagulates and becomes a mass along side the
vessel
 This mass of blood (hematoma) gives the impression that there is
an aneurysm

17. Axilla –Pseudoaneurysm, stab wound severed brachial artery
Brachial artery
Pseudoaneurysm with
blood clotAxillary fat

18. BASED ON ETIOLOGY
CONGENITAL
 IDIOPATHIC
 TUBEROUS SCLEROSIS
 TURNER’S SYNDROME
 MENKE’S SYNDROME
CONNECTIVE TISSUE DISORDER
 MARFAN’S SYNDROME
 EHLERS-DANLOS SYNDROME
 CYSTIC MEDIAL NECROSIS
 BERRY ( CEREBRAL)

19. ETIOLOGICAL CLASSIFICATION
 DEGENERATIVE
 Non Specific( atherosclerosis )
 Fibromuscular dysplasia
 INFECTIOUS
 BACTERIAL
 FUNGAL
 SYPHILIS

20. ETIOLOGICAL CLASSIFICATION
 INFLAMMAORY- Arteritis
 Takayasu’s disease
 Behcet’s disease
 Kawasaki disease
 PAN
 Giant cell arteritis
 SLE
 Periarterial ( pancreatitis )

21. ETIOLOGICAL CLASSIFICATION
POST- DISSECTION
 IDIOPATHIC
 CYSTIC MEDIAL NECROSIS
 TRAUMA

POST-STENOTIC
 THORACIC OUTLET SYNDROME
 COARCTATION

22. ETIOLOGICAL CLASSIFICATION
 PSEUDOANEURAYSM
 TRAUMA
 ANASTOMOTIC DISRUPTION

MISCELLANEOUS
PREGNANCY- ASSOCIATED
INFLAMMATORY ABDOMINAL AORTIC

23. BASED ON LOCATION
 LOCATION FRQNCY
 ABDOMINAL AORTA 65%
 THORACIC AORTA 19%
 AA + ILIAC 13%
 THORACOABDOMINAL 2%
 ISOLATED ILIAC 1%

24. LOCATION-PERIPHERAL
 LOCATION FREQUENCY
 POPLITEAL 70%
 FEMORAL together make upto 90%
 CAROTID 4 %
 SUBCLAVIAN 2%
 CEREBRAL 2%
 SPLENIC 1%
 MESENTRIC 0.5%
 RENAL 0.5%

25. BASED ON MORPHOLOGY
 Saccular aneurysm
 Fusiform aneurysm
 Dissecting aneurysm
 Cylindroid aneurysm
 Berry aneurysm

26. BASED ON MORPHOLOGY
 FUSIFORM
SYMMETRICAL CIRCUMFERENTIAL
ENLARGEMENT INVOLVING ALL
LAYERS OF THE ARTERY WALL.
SACCULAR
ANEURYSMAL DEGENERATION
AFFECTING ONLY PART OF THE
ARTERIAL CIRCUMFERENCE.

27. ABDOMINAL AORTIC ANEURYSM

28. Types of AAA
 Morphological classification
• fusiform aneurysms
• saccular aneurysms
• dissecting aneurysms
• pseudo-aneurysms
 Segments involved
• thoracic
• thoraco-abdominal
• abdominal
• main branches of the aorta
• iliac arteries

29. 29
http://nusselt.me.cmu.edu/amongrad/summaries/AAAs.html
Abdominal Aortic Aneurysms (AAA)
2cm - 3cm
3cm - 10cm+

30. AAA INCIDENCE
 2% TO 5% OF ALL MEN OVER 60 YRS
 15,000 DEATHS PER YEAR IN USA
 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

32. NORMAL SIZE OF INFRARENAL
AORTA
Age
SEX 40 40 – 49 50 – 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
 Familial History
20% of patients with AA have 1st Degree relative
 Connective tissue disease
 Marfans
 Ehlers-Danlos
 Atherosclerosis (90%)
 Smoking
 Hyperlipidemia
 Diabetes
 Gender
 Males > Females
 Age

34. Marfans Syndrome
 KKKK
 PATIENTS HAVE DEFECT IN THE
FIBRILLIN STRUCTURE.

35. Ehlers-Danlos
 Ehlers – Danlos have defect in pro-collagen
type 3

36. Atherosclerotic Abdominal Aortic Aneurysm
Aneurysm with
thrombus
Kidney
Kidney
Aorta

37. PATHOGENESIS of AAA
ANATOMICAL
MECHANICAL
GENETICS
MOLECULAR BIOLOGY
BIOCHEMICAL
IMMUNOLOGICAL

38. ANATOMICAL
GRADUAL TAPERING OF AORTA
REDUCTION of ELASTIC LAMELLAE
in DISTAL AORTA
REDUCTION /ABSENCE OF NUTRIENT
ARTERIES IN INFRARENAL AORTA

39. 39
 Wall stress is force exerted on the wall
 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
 Wall stress is force exerted on the wall
 The aneurysm wall weakens and expands
 Until it ruptures
Hypothesis AAA rupture is a failure of the aneurismal
wall, when wall stresses exceeds wall strength

41. Biochemical
 ELASTIN and ELASTOLYTIC PROTEASE
 ELASTIN – produced in soluble form pro-
elastin
in media of the arteries
insoluble
elastic recoil ability
half-life is 70 years
 ELASTIN depletion occurs early in AAA
caused by serine protease
MMP

42. BIOCHEMICAL
 COLLAGEN and COLLAGENOLYTIC PROTEASES
 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

43. 43
Mechanical properties of arteries
Roach, M.R. et al, Can. J. Biochem. & Physiol., 35: 181-190 (1957).

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
• gradual and/or sporadic expansion
• accumulation of mural thrombus
Complications
• rupture
• thromboembolic events
• compression of adjacent structures

46. Progression of a AAA
 Pathological changes cause the aorta wall to
• become thinner
• bulge
• tear
• 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 ≥7cm

49. CLINICAL PRESENTATION
AAA are asymptommatic before rupture in 75%
 Abdominal palpation may show a pulsatile
abdominal mass.
 Vague abdominal and back discomfort.
 Large aneurysms – GI symptoms– early satiety and
vomitting.
 Inflammatory aneurysms- pain /fever /ureteral
obstruction

50. Clinical Presentation
 AAA-- RUPTURE
 Syncope
 Back abdomnial pain
 Shock
 Sudden death (rupture)
 Ripping or tearing pain
 Atypical pain (groin, flank., hip, bladder )
 Nausea vomiting tenesmus
 Cullen sign periumbilical ecchymosis
 Grey-Turner sign flank eccyhmosis
 Hematemesis melena hematochezia
(aorticenteric fistula)

51. Clinical Presentation
 Thoracic Aneurysms
 Dysphagia
 SOB
 Neurologic symptoms (Horners Syndrome)
 Dissecting Aneurysms
 Intrascapular pain (Descending aorta 63%)
 Anterior chest pain (Ascending aorta 70%)
 Change in Pattern
 Stroke
 Paraplegia
 Pericardial Tamponade
 Diaphoresis

52. DIAGNOSIS
PHYSICAL EXAMINATION
 -- Detection of expansile pulsation
 -- unreliable about 50%-- false negative
 -- large hypogastric aneurysm palpated on
rectal examination
 INVESTIGATIONS
 -- X- RAY
 -- USG
 -- CT/MRI / MR ANGIOGRAPHY
 -- 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%
≥ 5.0 cm 76%
Pooled analysis of 15 studies

54. X - RAY
 LUMBAR SPINE RADIOGRAPH
Characteristic of
EGGSHELL PATTERN
of CALCIFICATION

55. USG
 Ultrasound is most useful and least expensive
mode of diagnosis.
 Measuring transverse aneurysmal diameter.
 Screening /Surveillance/ follow up after
endovascular repair.
• Best used to assess
progression of AAA
size
• Average expansion of
0.4cm/year
Longitudinal Section of 2cm Aorta

56.  Inconsistent in
visualization of
Renal and iliac arteries.
They are less useful
in demonstrating
Accessory Renal
Arteries.
Cant detect Rupture.

57. Sensitivity of ultrasound
Ranges from 82% to 99%
Approx 100% in cases with a
pulsatile mass
In 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.

58. Ultrasound screening
5
20
8
29
9
27
0
5
10
15
20
25
30
Number
Emergency Ops Ruptured
aneurysms
AAA deaths
Screened Control
Lindholdt. BMJ 2005;330:750.
Controlled screening trial of men age 65 to 73
ITT analysis n=6333 screened, n=6306 control
P=0.002
P=0.001 P=0.003

59. CT Imaging
 Precise test – provides good
images of aorta,aortic
lumen,branch vessels and
adjacent retroperitoneal
structures.
 Shows size and extent of
aneurysm and relation to renal
and iliac arteries.
 SPIRAL CT – 3 dimensional
image.

61. 61
Lumen
Thrombus
Calcification
Inferior
Vena Cava
Spinal
Column
Psoas
Muscle
A CT Slice

65. CT ANGIO - AAA

66. CT ANGIO - AAA

67. MRI/ MR ANGIOGRAPHY
 Use of contrast agents have made it possible to
produce high quality images of aorta.
 Useful for planning and follow up of endovascular
repair.
 Less sensitive than CT scan in identifying accessory
renal arteries.

68. Treatment options
Endovascular stent grafting( EVAR)OPEN SURGERY( OSR)

69. SELECTION OF PATIENTS
 When the maximal diameter of aneurysm reaches
5.5 cm – risk of rupture increases
-- aneurysm repair indicated.
 Patient with evidence of rapid expansion,tenderness
in the region of aneurysm ,back or abdominal pain –
urgent repair.
 Patient with significant coronary disease– referred
for coronary revascularization before surgical repair.
 Anatomy of aneurysm determines– type of repair.

70. Contraindications for surgery for AAA
 Age > 85
 Cardiac Class iii -- iv angina
LVEF <30%
MI or CHF ( within 30days)
severe valvular disease/LV aneurysm
 Renal S.Creatinine >3.0 mgs%
 Hepatic Biopsy proven cirrhosis with ascitis
 Abdomen Diffuse retroperitoneal Fibrosis

71. OPEN SURGERY
 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
 RETRO PERITONEAL EXPOSURE
extensive peritoneal adhesions
need for suprarenal exposure
Advantage – short duration of ileus/ less pulmonary
complications/ shorter stay in ICU

72. VIDEO GRAPHIC
 OPEN SURGICAL
REPAIR

73. STEPS OF PROCEDURE
 INCISION
 EXPOSURE OF AORTA
 PREPARATION OF NECK OF ANEURYSM
 EXPOSURE OF ILIAC ARTERIES
 SITE OF DISTAL CLAMPING
 OPENING OF AORTA/ INCISION EXTENDED
 INSERTION OF GRAFT
 CHECKING THE PATENCY OF GRAFT
 CLOSURE OF SAC

79. AAA - REPAIR

80. Open surgical repair (OSR): drawbacks
 Significant incision in the abdomen
 30–90 minute cross-clamp
 Up to 4-hour procedure
1–2 days intensive care
7–14 days hospitalization
4–6 weeks recovery time

81. Complications –AAA Surgery
 Early :
Myocardial ischemia
Mild Renal failure
Postoperative Pneumonia
Paralytic Ileus
Colonic ischemia
Distal Embolisation
PARAPLEGIA
Post operative sexual dysfunction

82. Complication -- AAA Surgery
 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

84. ENDOVASCULAR REPAIR
( EVAR )
 INTRODUCTED BY PARODI IN 1990
 SUCCESS RATE 98 %
 CONVERTION RATE 12 %
 OVERALLL HOSPITAL MORTALITY <
2.5 %

85. Benefits
 Theoretical
 Reduced complications and mortality
 Decreased hospitalization
 Decreased cost
 Realized
 Same number of complications but different types
 Less systemic complications, same mortality
 Shorter respiratory support
 Decreased ICU and hospital stay
 Decreased blood loss
 Cost??

86. ENDOVASCULAR REPAIR
( EVAR )
 DISADVANTAGES
 CUSTOMISED FOR EACH PATIENT
 FOLLOW UP IS CRUCIAL
 LONG TERM IMPLICATIONS AWAITED
 ENDOLEAK 14 – 20 %
 CONTRAST INDUCED NEPHROPATHY
 HIGH COST

87. Anatomic Criteria
 Proximal neck length >15mm
diameter <28mm
 Tube graft: distal cuff length >10mm
diameter <28mm
 Iliac artery diameter >7mm and < 15mm
 Minimal to moderate tortuosity
 No mural thrombus at attachment sites
 Minimal calcification
 No associated mesenteric occlusive disease

88. ENDOVASCULAR REPAIR
EVAR

96. Preoperative angiogram Postoperative angiogram
®
AAA repair with stent graft

98. Tube Endograft Placement
Katzen, et al

99. Uniiliac Endograft Placement
Semba, et al

100. Bifurcated Endograft
Placement
Katzen, et al

102. Complications of EAAA repair
1) Injuries to arteries of access – Iliac/ Supra Renal
2) Embolization - micro – Renal Failure
distal – Ischemia
3) Procedure related
Groin hematoma, wound infection
POST IMPLANT SYNDROME
4) Device related
 Migration, detachment, rupture, stenosis, kinking,
endoleak

103. Endoleaks
 Coined by White, et al, 1996
 Leak around proximal or distal attachment sites
 Persistent flow in aneurysm sac
 Incomplete exclusion
 Rates
 0 to 44%
 Risks
 Expansion
 Rupture

104. Endoleak Classification
 Type I—perigraft
 Persistent flow at proximal or distal attachment
sites
 Type II—retrograde flow from side branches
 Inferior mesenteric or lumbar arteries
 Subgroup A: inflow only; B: in and outflow
 Type III—graft defect
 Type IV—graft porosity
 Primary or secondary

105. RUPTURED AAA
 With increasing age of the population–
INCIDENCE increasing to 30/ 100,000 patients.
 There is a increase in proteolytic activity in aortic
wall
 C/f – PAIN – abdominal/ back
FAINTING/ VOMITING
 FINDINGS – MASS
TENDERNESS
BP < 80 mm Hg
Hematocrit < 38%
WBC > 10,000/ microletre

106. ABDOMINAL AORTIC ANEURYSM

107. ABDOMINAL AORTIC ANEURYSM
WITH FATAL RUPTURE

108. AAA Basics: Mortality
 15,000 lives per year taken due to rupture
(13th leading cause of death)
• 40% of 5.5-6cm
AAAs will rupture
in 5 years
• Average survival if
untreated is 17
months

109. Rupture outcomes
Mortality rate can be as high as 80%[1]
More 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 level– it should be clamped
PROXIMAL CONTROL– At the level of diaphragm

111. ABDOMINAL AORTIC RUPTURE
 OTHER METHODS
 Compression at diaphragm
 Placement of aortic balloon
catheters
 Foley catheters via puncture of
the aneurysm

112. AORTIC DISSECTION
 Aortic dissection is characterized by separation of
the aortic wall layers by extraluminal blood that
usually enters the aortic wall through an intimal
tear.
 ACUTE– IF patients are seen within 14 days
 CHRONIC– IF they are seen beyond 14 days
associated with HYPERTENSION
MALE > FEMALE

114. DeBakey Classification
 Type I – involves the ascending aorta and variable
extent on the descending thoracic or
thoracoabdominal aorta.
 Type II – limited to the ascending aorta.
 Type III – involving the descending thoracic aorta
without III a or with III b extension to the abdominal
aorta.

115. Ascending Aorta – Dissecting Aneurysm
Dissection
Aortic Valve
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
 Aneurysms that involve the thoracic and abdominal
aorta or those aneurysms including the visceral
aortic segments .
 Etiology– degenerative– 80%
 sequelae of chronic dissection– 20%
 c/f-- sudden development of severe pain– back
/epigastric/flank pain
 others– hoarseness/cough
hemoptysis/dysphagia lusoria

118. Crawford classification
 Type I – involves Descending thoracic aorta and
abdominal aorta proximal to renal arteries.
 Type II – Most of DTA + AA distal to renal
arteries
 Type III – Involves aorta distal to renal arteries.
 Type IV – Involves all or most of the abdominal
aorta including the paravisceral segment.

119. (MYCOTIC ANEURYSMS)
“Infected aneurysm" has gradually replaced the original
designation "mycotic aneurysm”
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
 Infected aortic aneurysms are treated with intravenous
antibiotics and surgical excision.
 Antibiotic therapy must be continued postoperatively for at
least 6 weeks.
 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
 Seen in tertiary stage of syphilis with
obliterative endarteritis of vasa vasorum
and aortitis
 Roughening of intima: “Tree barking”
 Involves the thoracic aorta
 Complications include rupture, aortic
insufficiency, and narrowing of coronary
ostia

122. Syphilitic Aneurysm – Ascending Arch of Aorta
Aneurysm
Aortic Valve

123. BERRY ANEURYSM
 Involve cerebral arteries at bifurcations
 Probably arise at congenital points of
weakness in wall
 Can rupture and result in subarachnoid
hemorrhage
 Clinically may see headache, stiff neck
(meningeal irritation) and death

124. HIV RELATED ANEURYSM
 Often MULTIPLE/ and at unusual sites
occur at–COMMON CAROTID
SUPERFICIAL FEMORAL ARTERY
ABDOMINAL AORTA
 MICROSCOPICALLY
HIV VASCULOPATHY are typical of a
LEUKOCYTOCLASTIC vasculitis that affects
vasa vasorum
 RECONSTRUCTION – AUTOGENOUS GRAFT
if available

125. PERIPHERAL ANEURYSM
 FEMORAL ARTERY ANEURYSM
 POPLITEAL ARTERY ANEURYSM
 TIBIAL ARTERY ANEURYSM
 UPPER EXTREMITY
 SUBCLAVIAN ARTERY ANEURYSM
 SUBCLAVIAN-AXILLARY ARTERY ANEURYSM
 KOMMERELL’S DIVERTICULUM
 AXILLARY ARTERY ANEURYSM
 HYPOTHENAR HAMMER SYNDROME

126. FEMORAL ANEURYSM
 Common peripheral aneurysm
 Incidence- 7.39 / 1OOOOO Population
 TRUE aneurysm- Non specific etiology
 FALSE aneurysm - anastomotic/traumatic
catheter-induced/infected
 TYPE 1 – Limited to Common Femoral Artery
 TYPE 2 – Involving orifice of Profunda Femoris
artery

127. Femoral aneurysm
 Asymptommatic with pulsatile mass
 Local pain – pressure on ajacent nerve
 Limb edema/venous distention- venous compression
 Lower extremity ischemia with intermittent
claudication/rest pain/gangrene
 COMPLICATIONS – THROMBOSIS
RUPTURE
EMBOLIZATION

128. OPERATIVE MANAGEMENT
 TYPE 1 ANEURYSM
 INTERPOSITION GRAFT OF DACRON
 e PTFE
 TYPE 2 ANEURYSM
 INTERPOSITION GRAFT TO SFA/ PFA with
reimplantation of the other artery.
 SYNDACTYLIZATION- Suturing of
Superficial and Profunda femoris arteries together to
form a common lumen

129. POPLITEAL ANEURYSM
 Is commonest ( 70% )
 65% bilateral with 25% associated with AAA
 Etiology related to chronic flexion/extension
 Associated aneurysms – other leg, femoral, aortic

130. 1. Popliteal Artery
2. Anterior Tibial Artery
3. Fibular Artery
4. Posterior Tibial Artery

131.  C/f -- Swelling in popliteal region which is
smooth,soft,pulsatile,well localised,warm
compressible,often with thrill and bruit.
 -- thrombosis and emboli can cause distal
gangrene
 -- rupture :: torrential haemorrhage
 Rx --- ANEURYSMORRHAPHY
 Repair with arterial graft using PTFE,dacron
 ENDOLUMINAL STENTING

132. UPPER EXTREMITY ANEURYSM
 SUBCLAVIAN ARTERY ANEURYSM
Over 60 yrs – More common in men
 Etiology– Degenerative
 Thoracic outlet obstruction
 Trauma
 c/f -- Chest/neck/shoulder pain
 neurological dysfunction- brachial plexus
 hoarseness—Rt. Recurrent laryngeal nerve
 Respiratory insufficiency- trachea
 Hemoptysis– lung apex erosion.

133. SUBCLAVIAN- AXILLARY ANEURYSM
 POST STENOTIC DILATATION--- OUTLET OBSTRUCTION
 Younger patients/females/ right side more common
 Associated with CERVICAL RIBS
 Associated with Raynauds phenomenon.
 ARTERIOGRAPHY – To assess the degree of post
 stenotic dilation of the subclavian artery.
 Rx—significant dilation– CERVICAL RIB removal
 vascular reconstruction– mobilization with end
to end anastomosis with or without short
interposition vein or prosthetic graft.

134. KOMMERELL’S DIVERTICULUM
 ABERRANT RIGHT SUBCLAVIAN ARTERY
 Most common congenital abnormality of aortic arch
 Dysphagia lusoria– esophagus compressed against
postr. Trachea
 Rx – propensity to cause symptom and lethal rupture
↓
RESECTION OF ANEURYSMAL ARTERY
WITH VASCULAR RECONSTRUCTION

135. HYPOTHENAR HAMMER SYNDROME
 Seen in men younger than 50 years age.
 ULNAR artery and nerve– enter hand by traversing
 GUYON’S CANAL
 TRAUMA – MURAL degeneration
 damage to Intima– THROMBOSIS
 damage to MEDIA– TRUE ANEURYSM
 C/f– pain,cold sensation,paresthesias,cyanosis and
mottling of digits.
 4th and 5th digit involved

136.  THUMB not involved– RADIAL BLOOD supply
 RAYNAUD’S PHENOMENON- not seen
 -- UNILATERAL
 -- THUMB NOT INVOLVED
 ABSENCE OF CLASSIC TRIPHASIC CHANGE
 surgical therapy
 -- cervicodorsal sympathectomy
 -- excision of ulnar artery aneurysm with ligation
of ulnar artery and aneurysmectomy with
microsurgical reconstruction of ulnar artery by
reanastomosis or interposition vein graft.

137. SPLANCHNIC ANEURYSM
 22 % present as clinical emergencies
 high resolution CT, MRA,USG-more recognition
 SPLENIC ARTERY ANEURYSM -- 60 %
 HEPATIC ARTERY ANEURYSM -- 20 %
 SUPERIOR MESENTRIC ARTERY -- 5.5%
 CELIAC ARTERY ANEURYSM -- 4%
 GASTRIC/GASTROEPIPLOIC -- 4%
 INTESTINAL -- 3%
 PANCREATIC -- 2%
 GASTRODUODENAL -- 1.5%

138.  RECENT ADVANCES

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)
“Watchful waiting”
Surgical
repair for
aneurysms 
5.5 cm max
diameter

140. 140
Why is Using Max Diameter a Problem?
Fillinger et al, Journal of Vascular Surgery April 2003 p726
 Both AAAs have max diameters of 5.5cm
 “A” ruptured after 18 months of this scan
 “B” is still under observation after more than 3 years
 Max stress of “A” is more than twice that of “B”
 Small Aneurysms are known to rupture
A B

141. 141
How to Obtain Wall Stress
Fluid Model
•Flow Patterns
•Wall Shear Stress
Structural Model
•Wall Movement
•Wall stress
Combined Fluid Structure Model
•Realistic wall shear stress and wall stress
Computer Tomography (CT) Scan
Blood Properties Wall Properties

142. 142
Results: Visualisation of Maximum
Wall Stress

143. 143
Results: Wall Shear Stress at Systolic Peak

144. EAAA in 2009
 There are many new grafts available, now they
are ‘Second Generation’
 Data from EUROSTAR (4000+ patients)
 Newer grafts have better 3-year mortality
 Fewer secondary interventions
 Fewer conversions of open repair
 Fewer graft rupture
 Shorter hospital stay
Torella et. al. 2004

145. AneuRx
 Medtronic
 Modular bifurcated with
extension cuffs
 Graft—thin walled
polyester
 Stent—outer self
expanding Nitinol stents
 Delivery—25F
introducer sheath
 Mechanical deployment
handle
May, et al

146. ONGOING STUDIES
 Wall stress could be a potential tool to replace
maximum diameter.
 RETROPERITONEAL APPROACH
operative mortality – 12 % compared to 35%
with transperitoneal approach.
 SPINAL CORD ISCHEMIC COMPLICATIONS
pre operative CSF removal
pre operative angiography- identify dominant
SPINAL ARTERY

147. TAKE HOME MESSAGE
 Increased screening and follow up has reduced
mortality with aneurysms.
 Now not the size but the wall stress is important
indicator for rupture aneurysm.
 Endograft AAA repair is still a developing field with
promise- 2nd generation grafts have reduced
operative complications.
 For open surgeries retroperitoneal approach has its
own advantage.
 Radiologist and surgeons need better understanding
to deal with aneurysms for its a team work.

148. REFERENCES
 BAILEY AND LOVE
 SCHWARTZ
 SABISTON
 RUTHERFORD BOOK OF VASCULAR
SURGERY
 INDIAN JOURNAL OF SURGERY
 AMERICAN JOURNAL OF SURGERY
 RECENT ADVANCES BY – TAYLOR
 RECENT ADVANCES BY- RL GUPTA
 SURGICAL ANATOMY ATLAS

149. NEWS FLASH!
 Diabetics were actually protected from
AAA!
 Odds ratio of 0.52 (0.45-0.61)
 Patients with DVT were also protected
 Odds ratio of 0.67 (0.53-0.84)

150. HELLO– ANY QUESTIONS