The document discusses arterial aneurysms, defining them as abnormal dilations of blood vessels and classifying them based on morphological and locational characteristics. It highlights abdominal aortic aneurysms (AAA) as common in older males, often caused by atherosclerosis, and outlines diagnosis and management strategies, including imaging techniques and surgical options. Complications from aneurysms and their repair, such as bleeding and cardiac events, are also detailed.

1. DR JOEL ARUDCHELVAM
CONSULTANTVASCULAR ANDTRANSPLANT SURGEON

2. Arterial aneurysms
 Abnormal focal dilatation of a vessel of more
than 50 percent of its normal diameter
 Abdominal aorta more than 3 cms – normal
diameter is about 2 cms
 Ectasia - A focal dilatation between normal
size and 50%
 Arteriomegaly - diffuse dilatation of arteries

3. Types of aneurysm
Based on wall characteristics
True – all layers of the vessel wall is involved
False – all layers are not involved
 Wall is formed by organized haematoma and
center has flow
 Occur following vascular trauma and vessel wall
infection (Mycotic).

4. FALSE
ANEURYSM

5. Types of aneurysm
 Based on morphology
 Fusiform
 Saccular – spherical and only involves part of
vessel wall.

6. Types of aneurysm
 Based on location
 Aortic
 Femoral
 Popliteal
 Ect

7. Aneurysms -Causes
 Wall weakening
 Atherosclerosis and weakening of vessel wall –
commonest cause
 Trauma – false aneurysms
 Infection - tuberculosis, and others(mycotic)
 Collagen vascular disease – Marfan’s, Ehlers-
danlos
 Congenital weakness – e.g.berry
 Familial

8. Investigations
 Imaging
 Duplex scan
 Confirm the aneurysm
 Size
 CT Scan + Angiography
 Site
 Size
 Proximal and distal circulation
 Surrounding tissues
 infection

9. Management
Depends on
 Symptoms
 Size
 Complications
 Skin threat
 Infection
 Type of artery
 End artery – organ ischaemia
 Non essential artery (with collaterals) – radial /Ulnar, Tibial
etc
 True / false

10. Management

11. Abdominal Aortic
Aneurysm (AAA)
 Common in males (1:4)
 White men
 Prevalence increases with age
 5%–7% of the population older than 60 years

12. AAA
Classification
•Suprarenal
• Above the level of
renal arteries
•Juxta renal
• within 1cm of renal
arteries
•Infra renal
• Below the level of renal
arteries

13. Abdominal Aortic Aneurysm
(AAA)
Causes
Atherosclerosis and weakening of vessel wall –
commonest cause
Cystic medial necrosis
Aortitis - Syphilis
Collagen vascular disease – Marfan’s, Ehlers-
danlos
Infection – tuberculosis
Familial

14. Presentation
Incidental finding – Asymptomatic
Self-felt lump
Symptomatic – pain due to
 erosion of vertebrae
 Infection
 rapid expansion -0.5 cm/ year
Complications
 Rupture
 Thrombosis
 Embolism – blue toe syndrome
Screening

15. Examination
• Expansile mass
• Aortic – above umbilicus
• Aorto – iliac - below
umbilicus
•Can / cannot feel upper
margin - suprarenal

16. Imaging
 USS Abdomen – helps to confirm the
diagnosis and useful in follow-up and
screening.

17. CT scan of abdomen and pelvis
with CT Aortogram
 Exact diameter of
aneurysm (maximum)
 The extent (supra/infra
renal, Aortic, Aorto iliac)
 length and angulation of
neck
 helps to plan the
intervention – surgical/
endovascular
 To detect leak

18. CT scan of abdomen and
pelvis with CT Aortogram

19. Management
 Indication for intervention include
 Diameter more than 5.5cms
 Symptomatic
 Complicated

20. Aortic Aneurysms
 Laplace’s Law
T = P x R
T - Tension
P - Pressure
R - Radius

21. Diameter and risk of rupture

22. Smaller Aneurysms

23. Aortic Aneurysms
surgery Risks
 Mortality
 About 5% with surgery
 Morbidity
 5-10% associated with cardiac events
 Endovascular Techniques are significantly
reduce

24. Interventional options
 Surgical – inlay repair with synthetic vascular
grafts (PTFE, Polyester)
 Endo Vascular Aneurysm Repair (EVAR) – for
patient who are unfit for open repair

25. AAA repair – inlay
technique

26. AAA repair – inlay
technique

27. Surgical complications
Peri-operative
Bleeding
Coagulopathy
Aortic clamping
 Increased cardiac load
 Visceral/ organ ischaemia
 Renal dysfunction
 visceral ischemia
 spinal cord ischemia/injury - The artery of Adamkiewicz
 lower extremity ischemia/emboli

28.  Aortic clamp release
 Hypotension
 Reperfusion effects
 Late
 Aorto enteric fistula
Surgical complications

29. Endo Vascular Aneurysm Repair
EVAR
First introduced by Parodi et al. in 1991

30. Endo Vascular Aneurysm Repair
EVAR
 Anatomical requirements
 Length, angulation of infrarenal neck
 > 60° neck angulation – 70% complication
 Minimum length - 10 mm
 Iliac artery diameter
 To accommodate device (7 mm)
 To allow device to seal (1.5 cm)
 Absence of thrombus at aortic neck
 Thrombus does not allow good neck seal

31. Open vs. EVAR
Study Patients
Follow up
(yrs)
30d
Mortality
Mayo Clinic AAA
(Open)
307 36 5
Canadian AAA
(Open)
680 6 5.4
AneuRx I–III
(EVAR)
1192 4 1.9
EUROSTAR
(EVAR)
2955 4 1.7

32. Complication of EVAR
Device related
Graft migration
Endoleak
Procedure related
Dissection
Malpositioning
Renal failure
Thromboembolisation
Ischemic colitis

33. Systemic complications of
EVAR:
 Congestive heart failure
 Renal failure

34. leaking aortic aneurysm
 Sudden onset pain
 Back, abdominal
 Collapse / faintishness

35. Investigations
 Known patient with aortic aneurysm and
haemodynamic instability
 Immediate intervention
 If resuscitated
 CT scan

36. Investigations
 CT scan of abdomen and pelvis with CT
Aortogram

37. Management of leaking AAA
 Resuscitation and preparation - parallel
 Grouping and DT - transfuse to keep the blood pressure just enough to
keep vital organs perfused
 Prepare for emergency surgery
 inform surgeon
 Anaesthetist
 theatre
 ICU
 Explain the risk of surgery to the patient and the relatives and consent

38. Management of leaking AAA
 Surgical intervention is similar to non ruptured
aneurysm repair
 In actively bleeding patient
 proximal aorta is clamped first
 Transfusion
 surgery

39. Follow up
 Diameter less than 4.5 cms – yearly USS
 Diameter above – 6 monthly USS
 Treat the associated conditions

40. Thank
You