1. Arterial aneurysms are a permanent localized dilatation of an artery over its normal diameter. They are caused by degenerative diseases like atherosclerosis that damage the artery wall. 2. Abdominal aortic aneurysms (AAA) specifically are 4 times more common in males. They are usually asymptomatic but can cause pain or rupture. Elective repair is recommended when AAA exceeds 5.5cm in diameter. 3. Ruptured AAA has a high mortality rate of 50% even with emergency surgery, so preventative repair of larger aneurysms is important to avoid rupture.

1. Arterial AneurysmsArterial Aneurysms

2. DefinitionDefinition
Permanent localized dilatation of thePermanent localized dilatation of the
affected artery over the normal diameteraffected artery over the normal diameter
~~ 50%50% ArteriomegalyArteriomegaly
~~ 100%100% AneurysmsAneurysms
As the age increases, arteries becomeAs the age increases, arteries become
stiffer, wider (aneurysm) and longerstiffer, wider (aneurysm) and longer
(tortousity)(tortousity)

3. AetiologyAetiology
Most by degenerative disease (atherosclerosis)Most by degenerative disease (atherosclerosis)
Structural weakness & Haemodynamic forcesStructural weakness & Haemodynamic forces
– Damage to, and loss of intimaDamage to, and loss of intima
– Reduction in the elastin and collagen content of theReduction in the elastin and collagen content of the
mediamedia
– Collagen; tensile strength, adventitiaCollagen; tensile strength, adventitia
– Elastin; recoil capacity, mediaElastin; recoil capacity, media
Risk factorsRisk factors
– smoking, hypertension, hypercholesterolaemiasmoking, hypertension, hypercholesterolaemia

4. AetiologyAetiology
Laplace’s lowLaplace’s low
(Tension varies directly with radius when(Tension varies directly with radius when
pressure is constant)pressure is constant)
– For every increase in the radius there is aFor every increase in the radius there is a
large increase in tension, leading to furtherlarge increase in tension, leading to further
enlargement of the aneurysmenlargement of the aneurysm

5. Rare causes of aneurysmsRare causes of aneurysms
CongenitalCongenital
– Marfan’s syndromeMarfan’s syndrome((misfolding of themisfolding of the
protein fibrillin-1)protein fibrillin-1), Berry aneurysms, Berry aneurysms
Post-stenoticPost-stenotic
– Coarctation of the aorta, Cervical rib, Popliteal arteryCoarctation of the aorta, Cervical rib, Popliteal artery
entrapment syndromeentrapment syndrome
TraumaticTraumatic
– Gunshot, stab wounds, arterial puncturesGunshot, stab wounds, arterial punctures
InflammatoryInflammatory
– Takayaso’s diseaseTakayaso’s disease(( is a form of largeis a form of large
vessel granulomatous vasculitis with massive intimal fibrosis andvessel granulomatous vasculitis with massive intimal fibrosis and
vascular narrowingvascular narrowing, Behcet’s disease, Behcet’s disease ((is a rare immune-is a rare immune-
mediated small-vessel systemic vasculitis that often presentsmediated small-vessel systemic vasculitis that often presents
with mucous membrane ulceration and ocular problems.with mucous membrane ulceration and ocular problems.

6. Rare causes of aneurysmsRare causes of aneurysms
MycoticMycotic
– Bacterial endocarditis, syphilisBacterial endocarditis, syphilis
Pregnancy associatedPregnancy associated
– Splenic, cerebral, aortic, renal, iliac &Splenic, cerebral, aortic, renal, iliac &
coronarycoronary

7. Classification of aneurysmsClassification of aneurysms
WallWall
■■ TrueTrue
■■ FalseFalse
MorphologyMorphology
■■ Fusiform,Saccular,DissectingFusiform,Saccular,Dissecting
AetiologyAetiology
■■ Atheromatous, Collagen disease,Traumatic,Atheromatous, Collagen disease,Traumatic,
Mycotic (bacterial rather than fungal)Mycotic (bacterial rather than fungal)

8. ClassificationClassification
FalseFalse
is when there is a breach inis when there is a breach in
the vessel wall such that bloodthe vessel wall such that blood
leaks through the wall but isleaks through the wall but is
contained by the adventitia orcontained by the adventitia or
surrounding perivascular softsurrounding perivascular soft
tissuetissue..
TrueTrue
– Dilatation involving allDilatation involving all
layers of the walllayers of the wall

9. FusiformFusiform
– Spindle-shapedSpindle-shaped
involving wholeinvolving whole
circumferencecircumference
SaccularSaccular
– Small segment of wallSmall segment of wall
ballooning due toballooning due to
localized weaknesslocalized weakness

10. Incidence- atheroscleroticIncidence- atherosclerotic
>90% affecting abdominal aorta>90% affecting abdominal aorta
Infra-renal segment inInfra-renal segment in ~~95%95%
Male : Female ratioMale : Female ratio 4:14:1
More common in western countriesMore common in western countries
5% over 50s, 15% over 80s5% over 50s, 15% over 80s
Associated with iliac aneurysms in 30%Associated with iliac aneurysms in 30%
Associated with popliteal aneurysms in 10%Associated with popliteal aneurysms in 10%

11. Classification of Thoracic Aortic AneurysmClassification of Thoracic Aortic Aneurysm

13. Anatomy of the abdominal aortaAnatomy of the abdominal aorta
Begins at T12, Ends at L4Begins at T12, Ends at L4
Anterior relationsAnterior relations
– Splenic vein, pancreas, duodenumSplenic vein, pancreas, duodenum
RightRight
– Cisterna chyli, IVC, azygos veinCisterna chyli, IVC, azygos vein
LeftLeft
– Sympathetic trunkSympathetic trunk
Surface anatomySurface anatomy
– Just above transpyloric plane in the mid line to a pointJust above transpyloric plane in the mid line to a point
left to the midline on the supracristal planeleft to the midline on the supracristal plane

14. branches of the abdominal aortabranches of the abdominal aorta
Paired visceral branchesPaired visceral branches
– Suprarenal, renal, gonadalSuprarenal, renal, gonadal
Unpaired visceral branchesUnpaired visceral branches
– Coeliac, SMA, IMACoeliac, SMA, IMA
Paired abdominal wall branchesPaired abdominal wall branches
– Subcostal, inferior phrenic,lumberSubcostal, inferior phrenic,lumber

15. Clinical features of AAAClinical features of AAA
Asymptomatic in 75%Asymptomatic in 75%
– Incidentally discovered during clinical exam.orIncidentally discovered during clinical exam.or
radiographic investigationradiographic investigation
PainPain
– Central abdominal radiating to the backCentral abdominal radiating to the back
– Chronic due to stretching the vessel wall orChronic due to stretching the vessel wall or
compression/erosion of surroundingcompression/erosion of surrounding
structuresstructures
– Acute pain due to ruptureAcute pain due to rupture

16. Clinical features of AAAClinical features of AAA
RuptureRupture
– Risk of rupture ~ aneurysm sizeRisk of rupture ~ aneurysm size
– Retroperitoneal 80%, back pain, stableRetroperitoneal 80%, back pain, stable
– Intraperitoneal 20%, abdo/back/falnk pain,Intraperitoneal 20%, abdo/back/falnk pain,
shockshock
– 5-year rupture rate 0% in AAA <5cm5-year rupture rate 0% in AAA <5cm
– 5-year rupture rate 25% in AAA >5cm5-year rupture rate 25% in AAA >5cm
Risk of rupture can be predicted byRisk of rupture can be predicted by
– High diastolic BP, COADHigh diastolic BP, COAD

17. Complications of AAAComplications of AAA
Fistulation, rareFistulation, rare
– Gut, IVC, left renal veinGut, IVC, left renal vein
Thrombosis, rareThrombosis, rare
– Acute lower limb ischaemiaAcute lower limb ischaemia
Distal embolismDistal embolism
– Acute ischaemia to small distal areas (trashAcute ischaemia to small distal areas (trash
foot)foot)
Distal obliterationDistal obliteration
– Claudication, rest pain, gangreneClaudication, rest pain, gangrene

18. InvestigationInvestigation
CXR, PFTCXR, PFT
ECG, EchoECG, Echo
ESRESR
U&EsU&Es
USSUSS
Spiral CT with contrastSpiral CT with contrast
ArteriographyArteriography

19. CT ScanCT Scan Spiral CTSpiral CT

20. AngiographyAngiography

21. Indications for operation of AAAIndications for operation of AAA
AsymptomaticAsymptomatic
■■ Aneurysm > 55 mm in APAneurysm > 55 mm in AP
■■ Patient fit for surgeryPatient fit for surgery
■■ Indications for endoluminal are the sameIndications for endoluminal are the same
SymptomaticSymptomatic
painful or tenderpainful or tender
distal embolisationdistal embolisation

22. Management of AAAManagement of AAA
Elective repair for AAA >6cmElective repair for AAA >6cm
– Mortality 5%Mortality 5%
Urgent repair for AAA <6cmUrgent repair for AAA <6cm
– Developed back painDeveloped back pain
– Rate of growth >0.5cm / 6 monthRate of growth >0.5cm / 6 month
Emergency repair for ruptured AAAEmergency repair for ruptured AAA
– Mortality 50%Mortality 50%

23. Elective surgical repairElective surgical repair
6-unit X-matched blood6-unit X-matched blood
Mid line or transverse incisionMid line or transverse incision
Aneurysm neck defined and controlledAneurysm neck defined and controlled
Control of normal vessels distal to AAAControl of normal vessels distal to AAA
Systemic heparinization, 5000IUSystemic heparinization, 5000IU
AAA sac opened and thrombus removedAAA sac opened and thrombus removed
Back bleeding from lumber arteries controlled byBack bleeding from lumber arteries controlled by
suturessutures
Inlay tube or trouser synthetic graftInlay tube or trouser synthetic graft
Closure of aneurysm sac over graftClosure of aneurysm sac over graft

25. Emergency surgical repairEmergency surgical repair
Unstable patient, no investigationUnstable patient, no investigation
Stable patient, USS/spiral CTStable patient, USS/spiral CT
10-unit of x-matched blood10-unit of x-matched blood
Urinary catheter & 2 large-bore i.v. linesUrinary catheter & 2 large-bore i.v. lines
Resustation to systolic BPResustation to systolic BP ~100mmHg~100mmHg
Crash anaesthetic inductionCrash anaesthetic induction
No heparinizationNo heparinization
Rapid entrance to abdomen & neck controlRapid entrance to abdomen & neck control
– If difficult, supra-renal clamp for short periodIf difficult, supra-renal clamp for short period

26. Complications of aortic surgeryComplications of aortic surgery
Haemorrhage, DICHaemorrhage, DIC
CVACVA
Colonic ischaemia spinal cord ischaemiaColonic ischaemia spinal cord ischaemia
Aorto-enteric fistulaAorto-enteric fistula
Graft thrombosisGraft thrombosis
Myocardial ischaemiaMyocardial ischaemia
Renal failure, ARDS, MODSRenal failure, ARDS, MODS
False anastomotic aneurysmFalse anastomotic aneurysm
Distal embolism (trash foot)Distal embolism (trash foot)

27. Endovascular repair of AAAEndovascular repair of AAA
Patient unfit for surgical repairPatient unfit for surgical repair
– severe cardio-pulmonary co-morbidities, hours shoesevere cardio-pulmonary co-morbidities, hours shoe
kidney, Inflammatory AAA, hostile abdo.kidney, Inflammatory AAA, hostile abdo.
Anatomical suitabilityAnatomical suitability
– Neck diameter & lengthNeck diameter & length
– Iliac arteries diameter & tortousityIliac arteries diameter & tortousity
MorbidityMorbidity
– Endoleak, migration, kink, thrombosisEndoleak, migration, kink, thrombosis
MortalityMortality ~5%~5%
Flow-up & durabilityFlow-up & durability

29. Inflammatory AAAInflammatory AAA
Marked fibrosis of the aneurysm wall extending to theMarked fibrosis of the aneurysm wall extending to the
surrounding structuressurrounding structures
It involve the anterior and lateral aspects onlyIt involve the anterior and lateral aspects only
It associated with inflammatory cell infiltrate of T- , B-It associated with inflammatory cell infiltrate of T- , B-
lymphocytes & plasma cellslymphocytes & plasma cells
The fibrosis may compress the ureters leading to renalThe fibrosis may compress the ureters leading to renal
failurefailure
Rupture is less common and usually posteriorRupture is less common and usually posterior
Pt. presents with abdo. pain, weight loss, raised ESRPt. presents with abdo. pain, weight loss, raised ESR
Difficult surgery, therefore conservative/endovascularDifficult surgery, therefore conservative/endovascular

30. popliteal aneurysmspopliteal aneurysms
Second most common site of atheroscleroticSecond most common site of atherosclerotic
aneurysms (70 % peripheral, 2/3 B/L)aneurysms (70 % peripheral, 2/3 B/L)
C/FC/F
– pulsatile swellingpulsatile swelling
– aneurysm thrombosisaneurysm thrombosis oror distaldistal emboliemboli
USS/CT/Arteriography to confirm diagnosisUSS/CT/Arteriography to confirm diagnosis
40% of pts with PA aneurysms have an AAA40% of pts with PA aneurysms have an AAA

31. IndicationIndication
– ComplicationComplication
– Asymptomatic Size > 25 mmAsymptomatic Size > 25 mm
RxRx
– Surgical repair, resection/ligation and veinSurgical repair, resection/ligation and vein
bypassbypass

32. Femoral aneurysmsFemoral aneurysms
Can occur in isolation but usually part ofCan occur in isolation but usually part of
generalized arteriomegalygeneralized arteriomegaly
Often symptomless and rarely ruptureOften symptomless and rarely rupture
Distal emboli & thrombosis may occurDistal emboli & thrombosis may occur
Surgical repair by using vein or synthetic graftSurgical repair by using vein or synthetic graft

33. Splenic aneurysmsSplenic aneurysms
Male : female 1 : 4Male : female 1 : 4
It present in child bearing periodIt present in child bearing period
Usually symptomless unless rupturedUsually symptomless unless ruptured
Rupture rate 25% in the third trimesterRupture rate 25% in the third trimester
Surgical treatment is indicated if theSurgical treatment is indicated if the
aneurysm diameter >3cm or patient isaneurysm diameter >3cm or patient is
pregnantpregnant

34. 1- AAA1- AAA
A- is 4 time more common in malesA- is 4 time more common in males
B- incidence is falling in western countriesB- incidence is falling in western countries
C- may safely observed if asymptomatic andC- may safely observed if asymptomatic and
>5.5cm in diameter>5.5cm in diameter
D- is rarely amenable to endoluminal stentingD- is rarely amenable to endoluminal stenting
E- is less common than popliteal aneurysmsE- is less common than popliteal aneurysms

35. 2- AAA2- AAA
A- may cause embolisation to lower limbsA- may cause embolisation to lower limbs
B- is more common in malesB- is more common in males
C- can almost always be treated byC- can almost always be treated by
endovascular stentingendovascular stenting
D- can be detected by screeningD- can be detected by screening
E- should be operated upon when it is 5.5 cmE- should be operated upon when it is 5.5 cm
longlong

36. 3- AAA3- AAA
A- typically rupture at 4cm diameterA- typically rupture at 4cm diameter
B- extends above the renal artery in 20% ofB- extends above the renal artery in 20% of
casescases
C- is invariably visible on abdominal X-rayC- is invariably visible on abdominal X-ray
D- is associated with coronary artery diseaseD- is associated with coronary artery disease
E- has an association with smokingE- has an association with smoking

37. answersanswers
1- A1- A
2- ABD2- ABD
3- DE3- DE