Discussion about different types of Aneurysm, details about Abdominal aorta aneurysm and brief discussion about some important peripheral aneurysms. Includes approach to different forms of Abdominal aortic aneurysm, its management and complications related to the surgery.

1. ANEURYSM
DR. BIPUL
THAKUR
1

2. INTRODUCTION
• The term ANEURYSM is derived from the Greek word ANEURYSMA
meaning “ a widening”.
• Normal arterial diameter is dependent on age , gender, body size
and other factors.
• 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%
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3. 3

4. CLASSIFICATION
True/False Aneurysm
 True aneurysm : contains all layers of arterial wall.
 False aneurysm :dilation covered by thick fibrinous capsule.
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5. 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
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6. 6

7. BASED ON LOCATION
LOCATION FREQUENCY
• ABDOMINAL AORTA 65%
• THORACIC AORTA 19%
• AA + ILIAC 13%
• THORACOABDOMINAL 2%
• ISOLATED ILIAC 1%
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8. 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%
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9. BASED ON MORPHOLOGY
 FUSIFORM:
SYMMETRICAL CIRCUMFERENTIAL ENLARGEMENT INVOLVING
ALL LAYERS OF THE ARTERY WALL.
 SACCULAR:
ANEURYSMAL DEGENERATION AFFECTING ONLY PART OF THE
ARTERIAL CIRCUMFERENCE.
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11. ABDOMINAL AORTIC ANEURYSM
 INCIDENCE: 2% TO 5% OF ALL MEN OVER 60 YRS
 COMMON IN MEN ABOVE 60YRS
PEAK OF 5% AT 80 YRS IN MEN
PEAK OF 4.5% AT 90 YRS IN WOMEN
 GREATER - FIRST DEGREE RELATIVES
TALLER INDIVIDUAL
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12. Risk Factors
 Atherosclerosis (90%)
-Smoking
-Hyperlipidemia
- Diabetes
 Gender
- Males > Females
 Age
 Familial History
- 20% of patients with AA have 1st Degree relative
 Connective tissue disease
- Marfan Syndrome- defect in Fibrillin structure
- Ehlers-Danlos - defect in pro-collagen type 3
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14. 14

15. AAA Sequelae
 Natural history :
- gradual and/or sporadic expansion
- accumulation of mural thrombus
 Complications
- rupture
- thromboembolic events
- compression of adjacent structures
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16. Progression of AAA
 Pathological changes cause the aorta wall to
- become thinner
- bulge
- rupture
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17. AAA ANNUAL RUPTURE RISK 17
American Association for Vascular Surgery and Society for
Vascular Surgery

18.  Risk of rupture of an abdominal aortic aneurysm
(AAA) over time according to the first measurement
of aneurysm diameter in 1792 men and 465 women.
The risk of rupture increased markedly in aneurysms
larger than 5.5 cm in diameter
18
Powell, JT, Greenhalgh, RM, N Engl J Med 2003; 348:1895

19. CLINICAL PRESENTATION
AAA are asymptomatic before rupture in 75%
 Abdominal palpation may show a pulsatile abdominal mass.
 Vague abdominal and back discomfort.
 Large aneurysms – GI symptoms– early satiety and vomiting.
 Inflammatory aneurysms- pain /fever /ureteral obstruction
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20. CLINICAL PRESENTATION
 AAA RUPTURE
 Syncope
 Back abdominal 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 ecchymosis
- Hematemesis, melena, hematochezia (aortic-enteric fistula)
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21. 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
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22. X-RAY
 Lumbar Spine Radiograph:
Egg shell Pattern of Calcification
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23. USG
 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
 Can’t detect Rupture.
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24. 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.
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26. MRI/ MR ANGIOGRAPHY
 Useful for planning and follow up of endovascular repair.
 Less sensitive than CT scan in identifying accessory renal
arteries.
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27. 27
Chaikof EL, Dalman RL, Eskandari MK, et al. The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm. J Vasc
Surg 2018; 67:2.

28. 28

29. Treatment options
 OPEN SURGERY (OSR)
 Endovascular Aneurysm Repair (EVAR)
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30. Indications
 The AAA diameter is greater than 5.5 cm in diameter in men. In
women, it might be considered from a smaller diameter (5.0 cm)
 The patient with AAA is symptomatic
 The AAA is rapidly expanding (more than 1 cm/year) irrespective of
the absolute diameter
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31. 31

32. Complications –AAA Surgery
• Early :
- Myocardial ischemia
- Renal failure
-Postoperative Pneumonia
-Paralytic Ileus
-Colonic ischemia
-Distal Embolisation
-Paraplegia
• Late :
-Anastomotic Pseudoaneurysms
-Aorto-enteric Fistula
-Graft Occlusion
-Graft Infection
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33. ENDOVASCULAR REPAIR
 TRANSLUMINAL PLACEMENT OF A GRAFT WITHIN THE
ANEURYSM THAT COMPLETELY EXCLUDES THE SAC
FROM GENERAL CIRCULATION
 INTRODUCTED BY PARODI IN 1990
 SUCCESS RATE 98 %
 CONVERTION RATE 12 %
 OVERALL HOSPITAL MORTALITY < 2.5 %
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34. 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
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35. DISADVANTAGES
 CUSTOMISED FOR EACH PATIENT
 FOLLOW UP IS CRUCIAL
 LONG TERM IMPLICATIONS AWAITED
 ENDOLEAK 14 – 20 %
 CONTRAST INDUCED NEPHROPATHY
 HIGH COST
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38. Complications of EAAA repair
 Injuries to arteries of access – Iliac/ Supra Renal
 Embolization - micro – Renal Failure
- distal – Ischemia
 Procedure related: Groin hematoma, wound infection, Post-
implantation syndrome
 Device related : Migration, detachment, rupture, stenosis, kinking,
endoleak
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39. Endoleaks
 Leak around proximal or distal attachment sites
 Persistent flow in aneurysm sac
 Risks :
- Expansion
-Rupture
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40. 40
Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting standards for endovascular aortic aneurysm repair. J
Vasc Surg 2002; 35:1048

41. RUPTURED AAA
 anteriorly into the peritoneal cavity (20%) or postero-laterally into
the retroperitoneal space (80%) causing Retroperitoneal hematoma
 Less than 50% of patients with rupture survive to reach hospital.
C/F:
 “Classic triad:”
-Severe abdominal pain -Hypotension -Pulsatile mass
 Less common symptoms:
-Groin/flank pain, hematuria, groin hernia all secondary to
increased intra-abdominal pressure
- Congestive Heart Failure with JVD and abdominal bruit if patient
has ruptured into the Vena Cava
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42. Rupture outcomes
 Operative mortality: 50%
 Combined Mortality(Community + Hospital) : 80-90 %
 More than one third of rupture cases die outside the hospital
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43. 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
• OTHER METHODS : Compression at diaphragm
Placement of aortic balloon catheters
Foley catheters via puncture of the aneurysm
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44. THORACO ABDOMINAL AORTIC
 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
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45. 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
Para visceral segment.
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46. 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
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47. PERIPHERAL ANEURYSM
 FEMORAL ARTERY ANEURYSM
 POPLITEAL ARTERY ANEURYSM
 TIBIAL ARTERY ANEURYSM
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48. 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
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49. Femoral aneurysm
 Asymptomatic with pulsatile mass
 Local pain – pressure on adjacent nerve
 Limb edema/venous distention- venous compression
 Lower extremity ischemia with intermittent claudication /rest
pain/gangrene
 COMPLICATIONS -THROMBOSIS
- RUPTURE
- EMBOLIZATION
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50. OPERATIVE MANAGEMENT
 TYPE 1 ANEURYSM:
- INTERPOSITION GRAFT OF DACRON
- e PTFE
 TYPE 2 ANEURYSM:
-INTERPOSITION GRAFT TO SFA/ PFA with re-implantation
of the other artery.
- SYNDACTYLIZATION- Suturing of Superficial and Profunda
femoris arteries together to form a common lumen
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51. POPLITEAL ANEURYSM
 commonest ( 70% )
 65% bilateral with 25% associated with AAA
 Etiology related to chronic flexion/extension
 Associated aneurysms – other leg, femoral, aortic
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52.  Clinical features-
-Swelling in popliteal region which is smooth, soft ,
pulsatile , well localized, warm compressible , often with thrill and
bruit.
- thrombosis and emboli can cause distal gangrene
- rupture : torrential hemorrhage
 Treatment- ANEURYSMORRHAPHY- Repair with arterial graft using
PTFE, dacron
- ENDOLUMINAL STENTING
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53.  National Institute for Health and Care Excellence (NICE) in the UK
published guidelines in 2020 recommending open surgical repair
unless contraindicated, reserving EVAR for high-risk patients or
those with a hostile abdomen.
 This compares to the European Society for Vascular Surgery 2019
guidelines, which recommend EVAR as the first-line treatment
option with open surgical repair to be considered for patients with
long life expectancy.
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54. THANK YOU
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