1) The document discusses aortoiliac aneurysms, including definitions, epidemiology, risk factors, rupture risk, associated aneurysms, pathophysiology, diagnosis, imaging, decision making for treatment, medical management, and indications for intervention.
2) Key risk factors for aneurysm rupture include diameter greater than 5.5 cm, female sex, smoking, and saccular aneurysm morphology. Imaging recommendations include ultrasound screening and CT or MRI for diagnosis.
3) Treatment is generally recommended for aneurysms greater than 5.5 cm in men or 5 cm in women, or those showing rapid growth. Immediate repair is indicated for ruptured aneurysms.
Aneurysms of splanchnic and visceral arteriesTapish Sahu
This document provides information on aneurysms of splanchnic and visceral arteries. It discusses their definition, epidemiology, etiology, clinical presentation, treatment principles, and management approaches for different types of aneurysms including splenic artery aneurysms. The key points are that splanchnic artery aneurysms are rare but lethal, various treatment modalities exist including open surgery, endovascular techniques, and observation depending on the specific aneurysm characteristics and patient factors.
This document discusses penetrating aortic ulcers (PAUs), which are focal ulcerative lesions in the aortic wall. PAUs have unknown causes but are often associated with atherosclerosis. They can progress to pseudoaneurysms or ruptured aneurysms. Symptomatic PAUs usually require intervention to prevent rupture, while asymptomatic cases may be monitored. Computed tomography is the primary diagnostic tool and endovascular stent grafting is now usually the preferred treatment approach over open surgery due to lower risks, though complications can still occur.
Acute mesenteric arterial disease can result from occlusion of the mesenteric arteries or veins, reducing or stopping blood flow to the intestines. It has high morbidity and mortality rates of 60-70% despite aggressive treatment. Diagnosis involves clinical evaluation, lab tests, CT angiography and mesenteric angiography. Treatment depends on the severity and includes resuscitation, antibiotics, surgery to remove dead bowel and restore blood flow, and endovascular procedures in some cases. Prompt diagnosis and treatment is needed to prevent intestinal infarction and improve outcomes.
1. Autogenous vein grafts have histological properties that make them less than ideal as vascular conduits compared to arteries, such as a lack of vasa vasorum and compliance mismatch.
2. Prosthetic grafts are more standardized but have higher risk of thrombosis and intimal hyperplasia. Various modifications aim to improve patency such as heparin bonding and venous adjuncts.
3. Surveillance of vascular grafts with duplex ultrasound is important to detect failing grafts which can be treated with thrombectomy or new bypass to preserve limb.
The document discusses intimal hyperplasia, which is the abnormal proliferation of smooth muscle cells within the innermost layer of arteries. It describes the pathophysiology, stages, and response to different types of arterial injury. Intimal hyperplasia is a major contributor to restenosis and graft failure. The document outlines the key stages following arterial injury, including platelet activation, thrombosis, leukocyte migration, and smooth muscle cell proliferation. It also discusses the response of veins, prosthetic grafts, and dialysis access sites to injury and techniques to reduce intimal hyperplasia.
Aneurysms of upper and lower extremities + aneurysmsTapish Sahu
The document discusses aneurysms of the upper and lower extremity arteries. It defines an aneurysm as a permanent localized dilation of an artery with at least a 50% increase in diameter compared to normal. The most commonly affected vessel is the abdominal aorta. The document discusses the classification, presentation, diagnosis and treatment options for various types of peripheral artery aneurysms including femoral, popliteal, profunda femoris and persistent sciatic artery aneurysms. Treatment involves open or endovascular surgical repair depending on the location and size of the aneurysm.
Graft thrombosis is a major cause of failed arterial bypass surgery. Several techniques can be used to assess grafts intraoperatively, including inspection, palpation, arteriography, ultrasonography, angioscopy, and intravascular ultrasonography. Early graft failure within 30 days is often due to technical errors, while late failure over 30 days is usually caused by atherosclerosis or intimal hyperplasia. Treatment depends on the timing and cause of failure. Early failures may be treated with thrombectomy or thrombolysis, while late failures respond better to thrombolysis or open revision. The optimal conduit depends on patient and graft factors. Close surveillance after treatment is important to monitor for recurrent stenosis.
Vascular surgery patients are at high risk for postoperative complications due to complex surgeries and preexisting health issues. The safest environment is determined by medical comorbidities, surgery risks, and ability to maintain homeostasis. High-risk patients are admitted to the ICU or step-down unit. Hemodynamic monitoring guides resuscitation through indicators like blood pressure, CVP, urine output, and lactate levels. Central lines and arterial lines are used for monitoring and access but carry risks if improperly placed. Postoperative complications include hypertension, hypotension, arrhythmias, myocardial infarction, and pulmonary issues treated through medication, pacing, or ventilation.
Aneurysms of splanchnic and visceral arteriesTapish Sahu
This document provides information on aneurysms of splanchnic and visceral arteries. It discusses their definition, epidemiology, etiology, clinical presentation, treatment principles, and management approaches for different types of aneurysms including splenic artery aneurysms. The key points are that splanchnic artery aneurysms are rare but lethal, various treatment modalities exist including open surgery, endovascular techniques, and observation depending on the specific aneurysm characteristics and patient factors.
This document discusses penetrating aortic ulcers (PAUs), which are focal ulcerative lesions in the aortic wall. PAUs have unknown causes but are often associated with atherosclerosis. They can progress to pseudoaneurysms or ruptured aneurysms. Symptomatic PAUs usually require intervention to prevent rupture, while asymptomatic cases may be monitored. Computed tomography is the primary diagnostic tool and endovascular stent grafting is now usually the preferred treatment approach over open surgery due to lower risks, though complications can still occur.
Acute mesenteric arterial disease can result from occlusion of the mesenteric arteries or veins, reducing or stopping blood flow to the intestines. It has high morbidity and mortality rates of 60-70% despite aggressive treatment. Diagnosis involves clinical evaluation, lab tests, CT angiography and mesenteric angiography. Treatment depends on the severity and includes resuscitation, antibiotics, surgery to remove dead bowel and restore blood flow, and endovascular procedures in some cases. Prompt diagnosis and treatment is needed to prevent intestinal infarction and improve outcomes.
1. Autogenous vein grafts have histological properties that make them less than ideal as vascular conduits compared to arteries, such as a lack of vasa vasorum and compliance mismatch.
2. Prosthetic grafts are more standardized but have higher risk of thrombosis and intimal hyperplasia. Various modifications aim to improve patency such as heparin bonding and venous adjuncts.
3. Surveillance of vascular grafts with duplex ultrasound is important to detect failing grafts which can be treated with thrombectomy or new bypass to preserve limb.
The document discusses intimal hyperplasia, which is the abnormal proliferation of smooth muscle cells within the innermost layer of arteries. It describes the pathophysiology, stages, and response to different types of arterial injury. Intimal hyperplasia is a major contributor to restenosis and graft failure. The document outlines the key stages following arterial injury, including platelet activation, thrombosis, leukocyte migration, and smooth muscle cell proliferation. It also discusses the response of veins, prosthetic grafts, and dialysis access sites to injury and techniques to reduce intimal hyperplasia.
Aneurysms of upper and lower extremities + aneurysmsTapish Sahu
The document discusses aneurysms of the upper and lower extremity arteries. It defines an aneurysm as a permanent localized dilation of an artery with at least a 50% increase in diameter compared to normal. The most commonly affected vessel is the abdominal aorta. The document discusses the classification, presentation, diagnosis and treatment options for various types of peripheral artery aneurysms including femoral, popliteal, profunda femoris and persistent sciatic artery aneurysms. Treatment involves open or endovascular surgical repair depending on the location and size of the aneurysm.
Graft thrombosis is a major cause of failed arterial bypass surgery. Several techniques can be used to assess grafts intraoperatively, including inspection, palpation, arteriography, ultrasonography, angioscopy, and intravascular ultrasonography. Early graft failure within 30 days is often due to technical errors, while late failure over 30 days is usually caused by atherosclerosis or intimal hyperplasia. Treatment depends on the timing and cause of failure. Early failures may be treated with thrombectomy or thrombolysis, while late failures respond better to thrombolysis or open revision. The optimal conduit depends on patient and graft factors. Close surveillance after treatment is important to monitor for recurrent stenosis.
Vascular surgery patients are at high risk for postoperative complications due to complex surgeries and preexisting health issues. The safest environment is determined by medical comorbidities, surgery risks, and ability to maintain homeostasis. High-risk patients are admitted to the ICU or step-down unit. Hemodynamic monitoring guides resuscitation through indicators like blood pressure, CVP, urine output, and lactate levels. Central lines and arterial lines are used for monitoring and access but carry risks if improperly placed. Postoperative complications include hypertension, hypotension, arrhythmias, myocardial infarction, and pulmonary issues treated through medication, pacing, or ventilation.
1. Vascular surgery patients present unique challenges due to multiple comorbidities. Anesthesia aims to provide analgesia, amnesia, and muscle relaxation while minimizing physiologic stress.
2. Regional techniques like epidurals combined with light general anesthesia result in better outcomes for aortic and infrainguinal surgery compared to general anesthesia alone by reducing sympathetic activation.
3. Strict intraoperative monitoring of vital signs, oxygenation, ventilation, and neurologic function is important due to the physiologic perturbations of vascular surgery. Tight glycemic control and maintenance of normothermia and hemostasis also impact outcomes.
Preoperative evaluation and management of vascular surgery patients is important to minimize complications. It includes assessing cardiac, pulmonary, renal, and diabetic status through history, exams, labs, and testing. Patients found to be high-risk may require optimization like smoking cessation or glucose control prior to elective surgery. During surgery, prophylaxis against DVT is recommended according to patient risk factors. Postoperative care focuses on glycemic control and resuming medications appropriately.
Upper extremity arterial disease can be caused by large vessel occlusive diseases like atherosclerosis or embolism, or small vessel diseases like autoimmune disorders. Symptoms range from Raynaud's phenomenon to acute ischemia with pain and pallor. Evaluation involves vascular exams, imaging like ultrasound and angiography. Treatment depends on severity and includes medications for vasospasm, endovascular interventions for stenoses, or open surgery for severe occlusions.
This document discusses vascular access during cardiac catheterization. It covers various access sites including femoral, radial, brachial and ulnar arteries as well as internal jugular, subclavian and femoral veins. Potential complications of vascular access like hematoma, pseudoaneurysm, retroperitoneal hemorrhage and arteriovenous fistula are described. Risk factors, diagnosis and management of these complications are provided. Prevention strategies to avoid vascular access complications are also mentioned.
Molecular imaging techniques such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) can help diagnose and monitor various vascular diseases. PET provides better resolution than SPECT but is more expensive. Tracers like 18-FDG are used to detect vascular inflammation. Molecular imaging helps assess atherosclerosis, aortic diseases, vasculitis, and vascular graft infections. Intravascular ultrasound (IVUS) provides high resolution imaging of blood vessels and plaque morphology. It helps with vascular interventions, aneurysm treatment, and diagnosing various aortic and venous conditions. Both molecular imaging and IVUS provide additional information to angiography with benefits for treatment planning and monitoring.
presentation will give a idea about management of thoracoabdominal aortic aneurysm, including detail of investigation and treatment options available today.
This document discusses hybrid approaches for treating thoracoabdominal aneurysms and aortic arch disease. It describes using endovascular stent grafts in combination with open surgical debranching of visceral arteries. The conclusions state that hybrid procedures may have lower early morbidity than open surgery while providing similar long-term survival outcomes, making them a safer alternative for high-risk patients.
1. Acute limb ischemia (ALI) occurs due to sudden deterioration of arterial blood supply to the limb. The main causes are thrombosis from atherosclerosis or embolism from cardiac sources.
2. ALI is clinically evaluated and classified into 3 classes based on severity of symptoms. Treatment depends on the class and involves early heparinization, catheter-directed thrombolysis, percutaneous thrombectomy, or surgical thrombectomy/bypass.
3. For less severe class I and IIA ALI, endovascular options like catheter-directed thrombolysis or pharmacomechanical thrombectomy are preferred to rapidly restore blood flow while minimizing risks. More severe class III ALI often requires emergency surgical intervention or
Acute SMV thrombosis was described in a document that discussed:
1. It remains a life-threatening condition with high mortality despite advances in treatment.
2. It most commonly involves the superior mesenteric vein and is usually secondary to conditions that increase risk of thrombosis.
3. Presentation can be non-specific with abdominal pain but imaging such as CT can clearly identify thrombosis.
The document discusses various techniques for coronary artery bypass grafting (CABG), including conventional on-pump CABG using cardioplegic arrest and cardiopulmonary bypass (CPB), and minimally invasive techniques like off-pump CABG (OPCAB) and mid-cabinal CABG (MIDCAB) without use of CPB. It summarizes the technical concepts of different graft conduits, procedures like MIDCAB using stabilization devices, and clinical trials comparing on-pump CABG to off-pump techniques. The largest trial found no difference in major cardiovascular outcomes between on-pump and off-pump CABG, though off-pump was associated with less bleeding, transfusions, and acute kidney injury
This document discusses complications that can occur during percutaneous coronary intervention (PCI) procedures. It notes that while PCI has over a 90% success rate, complications still occur in 1-5% of cases. It identifies several factors that can increase the risk of complications, such as advanced age, urgent procedures, and comorbidities like heart failure or diabetes. The document categorizes types of potential complications and discusses some in more depth, such as vascular access complications, dissections, and perforations. It also examines angiographic and technical factors that can influence complications, as well as indications for emergency cardiac surgery following PCI.
1. AAA can be defined as an abdominal aortic diameter of 3 cm or greater in either the anterior-posterior or transverse plane. Risk factors include male sex, smoking history, and family history of AAA.
2. Screening for AAA is recommended for men aged 65 years or older with a single ultrasound scan. Men aged 60 or older with a family history of AAA in a sibling or parent should also be screened.
3. Elective repair of AAA is recommended when the diameter reaches 5.5 cm for men. Repair may be considered at smaller sizes between 4.5-5.4 cm for younger, low-risk patients. Ruptured AAA requires emergent open surgical repair.
This document discusses aortic dissection and provides information on the condition. It begins with an introduction to the author and their background and credentials. The rest of the document defines aortic dissection, discusses its pathogenesis, risk factors, classification systems, clinical presentation, diagnostic challenges, treatment options including medical, surgical and endovascular approaches, complications, and recommendations. It provides detailed information on acute type A and type B aortic dissections, including extended surgical repair techniques for type A dissections.
1. Femoral pseudoaneurysms are defects in the femoral artery wall that allow blood to leak between the layers of the arterial wall. They are usually caused by complications from catheterization procedures.
2. Ultrasound is used to diagnose femoral pseudoaneurysms by detecting swirling blood flow within a sac connected to the artery.
3. Small, asymptomatic pseudoaneurysms may be monitored, as many will close on their own. Treatment options for problematic pseudoaneurysms include ultrasound-guided compression, thrombin injection under ultrasound-guidance, or surgery.
- The document discusses reasons for failure of thoracic endovascular aortic repair (TEVAR) and outcomes of secondary surgical interventions.
- The main reasons for TEVAR failure identified are type I endoleaks, persistent false lumen perfusion in chronic dissection, retrograde dissection, and graft infection.
- Most secondary surgical interventions involved total arch replacement or descending aorta replacement to address failures. Outcomes were mixed, with 13.5% mortality and many requiring additional operations later. Proper patient and graft selection can help reduce the need for open conversion after TEVAR failure.
Anaesthetic management of Abdominal aortic aneurysmsAbhijit Nair
Anesthesia management for abdominal aortic aneurysm (AAA) repair requires careful hemodynamic control. The aortic cross-clamp can cause significant cardiac stress and changes in preload, afterload, and ejection fraction. Agents are needed to manage blood pressure rises during clamping and potential hypotension after removal. Postoperative care focuses on pain control to prevent increases in myocardial oxygen demand, and monitoring for potential renal insufficiency.
Endovascular repair of thoracic and abdominal aortic aneurysmsApollo Hospitals
Endovascular repair of thoracic and abdominal aortic aneurysms has significantly reduced mortality and morbidity compared to open surgery. It involves placing stent grafts using catheters to exclude aneurysms from blood flow. Proper patient selection based on aneurysm anatomy and vessel access is important for success. Follow up imaging is needed to monitor for complications like endoleaks. Mid-term results show endovascular repair provides good outcomes with 85% survival at 18-24 months for thoracic aneurysms. It has emerged as an alternative to open surgical repair for properly selected abdominal aortic aneurysm cases.
The document defines no-reflow as inadequate myocardial perfusion through a coronary circulation segment without mechanical vessel obstruction. No-reflow occurs in 30% of patients after reperfusion for myocardial infarction and is associated with worse outcomes. It results from microvascular obstruction from distal embolization, ischemic injury, and reperfusion injury. Diagnosis involves assessing TIMI flow, myocardial blush grade, and imaging techniques. Prevention focuses on reducing embolization using thrombectomy or filters while treatment involves vasodilators like adenosine, verapamil, and glycoprotein IIb/IIIa inhibitors.
- Abdominal aortic aneurysm (AAA) is a localized dilatation of the abdominal aorta exceeding normal diameter of 3 cm. It is more common in males over 65 years of age and smokers.
- Risk factors include atherosclerosis, family history, hypertension, and connective tissue disorders. The weakened vessel wall leads to proteolytic degradation and rupture risk increases with size over 5 cm.
- Screening with ultrasound is recommended for high risk groups. CT/MRI further characterize anatomy and complications like thrombosis. Surveillance intervals are based on size. Elective open or endovascular repair is indicated over 5.5/5 cm or rapid growth. Medical management focuses on slowing progression.
Presentation about the hazards and potential complications that could happen in any cardiac or peripheral catheterization procedure and how to avoid them
Thoracoabdominal aortic aneurysms (TAAAs) involve the thoracic and abdominal aorta. They account for 10% of aortic aneurysms and are challenging for anesthesiologists due to risks of paraplegia, renal failure, and other complications during surgery. Pre-operative evaluation of cardiac, pulmonary, and renal function is important for risk assessment and stratification. Proper management and optimization of any co-morbidities is also key to achieving a good surgical outcome.
1. Vascular surgery patients present unique challenges due to multiple comorbidities. Anesthesia aims to provide analgesia, amnesia, and muscle relaxation while minimizing physiologic stress.
2. Regional techniques like epidurals combined with light general anesthesia result in better outcomes for aortic and infrainguinal surgery compared to general anesthesia alone by reducing sympathetic activation.
3. Strict intraoperative monitoring of vital signs, oxygenation, ventilation, and neurologic function is important due to the physiologic perturbations of vascular surgery. Tight glycemic control and maintenance of normothermia and hemostasis also impact outcomes.
Preoperative evaluation and management of vascular surgery patients is important to minimize complications. It includes assessing cardiac, pulmonary, renal, and diabetic status through history, exams, labs, and testing. Patients found to be high-risk may require optimization like smoking cessation or glucose control prior to elective surgery. During surgery, prophylaxis against DVT is recommended according to patient risk factors. Postoperative care focuses on glycemic control and resuming medications appropriately.
Upper extremity arterial disease can be caused by large vessel occlusive diseases like atherosclerosis or embolism, or small vessel diseases like autoimmune disorders. Symptoms range from Raynaud's phenomenon to acute ischemia with pain and pallor. Evaluation involves vascular exams, imaging like ultrasound and angiography. Treatment depends on severity and includes medications for vasospasm, endovascular interventions for stenoses, or open surgery for severe occlusions.
This document discusses vascular access during cardiac catheterization. It covers various access sites including femoral, radial, brachial and ulnar arteries as well as internal jugular, subclavian and femoral veins. Potential complications of vascular access like hematoma, pseudoaneurysm, retroperitoneal hemorrhage and arteriovenous fistula are described. Risk factors, diagnosis and management of these complications are provided. Prevention strategies to avoid vascular access complications are also mentioned.
Molecular imaging techniques such as positron emission tomography (PET) and single photon emission computed tomography (SPECT) can help diagnose and monitor various vascular diseases. PET provides better resolution than SPECT but is more expensive. Tracers like 18-FDG are used to detect vascular inflammation. Molecular imaging helps assess atherosclerosis, aortic diseases, vasculitis, and vascular graft infections. Intravascular ultrasound (IVUS) provides high resolution imaging of blood vessels and plaque morphology. It helps with vascular interventions, aneurysm treatment, and diagnosing various aortic and venous conditions. Both molecular imaging and IVUS provide additional information to angiography with benefits for treatment planning and monitoring.
presentation will give a idea about management of thoracoabdominal aortic aneurysm, including detail of investigation and treatment options available today.
This document discusses hybrid approaches for treating thoracoabdominal aneurysms and aortic arch disease. It describes using endovascular stent grafts in combination with open surgical debranching of visceral arteries. The conclusions state that hybrid procedures may have lower early morbidity than open surgery while providing similar long-term survival outcomes, making them a safer alternative for high-risk patients.
1. Acute limb ischemia (ALI) occurs due to sudden deterioration of arterial blood supply to the limb. The main causes are thrombosis from atherosclerosis or embolism from cardiac sources.
2. ALI is clinically evaluated and classified into 3 classes based on severity of symptoms. Treatment depends on the class and involves early heparinization, catheter-directed thrombolysis, percutaneous thrombectomy, or surgical thrombectomy/bypass.
3. For less severe class I and IIA ALI, endovascular options like catheter-directed thrombolysis or pharmacomechanical thrombectomy are preferred to rapidly restore blood flow while minimizing risks. More severe class III ALI often requires emergency surgical intervention or
Acute SMV thrombosis was described in a document that discussed:
1. It remains a life-threatening condition with high mortality despite advances in treatment.
2. It most commonly involves the superior mesenteric vein and is usually secondary to conditions that increase risk of thrombosis.
3. Presentation can be non-specific with abdominal pain but imaging such as CT can clearly identify thrombosis.
The document discusses various techniques for coronary artery bypass grafting (CABG), including conventional on-pump CABG using cardioplegic arrest and cardiopulmonary bypass (CPB), and minimally invasive techniques like off-pump CABG (OPCAB) and mid-cabinal CABG (MIDCAB) without use of CPB. It summarizes the technical concepts of different graft conduits, procedures like MIDCAB using stabilization devices, and clinical trials comparing on-pump CABG to off-pump techniques. The largest trial found no difference in major cardiovascular outcomes between on-pump and off-pump CABG, though off-pump was associated with less bleeding, transfusions, and acute kidney injury
This document discusses complications that can occur during percutaneous coronary intervention (PCI) procedures. It notes that while PCI has over a 90% success rate, complications still occur in 1-5% of cases. It identifies several factors that can increase the risk of complications, such as advanced age, urgent procedures, and comorbidities like heart failure or diabetes. The document categorizes types of potential complications and discusses some in more depth, such as vascular access complications, dissections, and perforations. It also examines angiographic and technical factors that can influence complications, as well as indications for emergency cardiac surgery following PCI.
1. AAA can be defined as an abdominal aortic diameter of 3 cm or greater in either the anterior-posterior or transverse plane. Risk factors include male sex, smoking history, and family history of AAA.
2. Screening for AAA is recommended for men aged 65 years or older with a single ultrasound scan. Men aged 60 or older with a family history of AAA in a sibling or parent should also be screened.
3. Elective repair of AAA is recommended when the diameter reaches 5.5 cm for men. Repair may be considered at smaller sizes between 4.5-5.4 cm for younger, low-risk patients. Ruptured AAA requires emergent open surgical repair.
This document discusses aortic dissection and provides information on the condition. It begins with an introduction to the author and their background and credentials. The rest of the document defines aortic dissection, discusses its pathogenesis, risk factors, classification systems, clinical presentation, diagnostic challenges, treatment options including medical, surgical and endovascular approaches, complications, and recommendations. It provides detailed information on acute type A and type B aortic dissections, including extended surgical repair techniques for type A dissections.
1. Femoral pseudoaneurysms are defects in the femoral artery wall that allow blood to leak between the layers of the arterial wall. They are usually caused by complications from catheterization procedures.
2. Ultrasound is used to diagnose femoral pseudoaneurysms by detecting swirling blood flow within a sac connected to the artery.
3. Small, asymptomatic pseudoaneurysms may be monitored, as many will close on their own. Treatment options for problematic pseudoaneurysms include ultrasound-guided compression, thrombin injection under ultrasound-guidance, or surgery.
- The document discusses reasons for failure of thoracic endovascular aortic repair (TEVAR) and outcomes of secondary surgical interventions.
- The main reasons for TEVAR failure identified are type I endoleaks, persistent false lumen perfusion in chronic dissection, retrograde dissection, and graft infection.
- Most secondary surgical interventions involved total arch replacement or descending aorta replacement to address failures. Outcomes were mixed, with 13.5% mortality and many requiring additional operations later. Proper patient and graft selection can help reduce the need for open conversion after TEVAR failure.
Anaesthetic management of Abdominal aortic aneurysmsAbhijit Nair
Anesthesia management for abdominal aortic aneurysm (AAA) repair requires careful hemodynamic control. The aortic cross-clamp can cause significant cardiac stress and changes in preload, afterload, and ejection fraction. Agents are needed to manage blood pressure rises during clamping and potential hypotension after removal. Postoperative care focuses on pain control to prevent increases in myocardial oxygen demand, and monitoring for potential renal insufficiency.
Endovascular repair of thoracic and abdominal aortic aneurysmsApollo Hospitals
Endovascular repair of thoracic and abdominal aortic aneurysms has significantly reduced mortality and morbidity compared to open surgery. It involves placing stent grafts using catheters to exclude aneurysms from blood flow. Proper patient selection based on aneurysm anatomy and vessel access is important for success. Follow up imaging is needed to monitor for complications like endoleaks. Mid-term results show endovascular repair provides good outcomes with 85% survival at 18-24 months for thoracic aneurysms. It has emerged as an alternative to open surgical repair for properly selected abdominal aortic aneurysm cases.
The document defines no-reflow as inadequate myocardial perfusion through a coronary circulation segment without mechanical vessel obstruction. No-reflow occurs in 30% of patients after reperfusion for myocardial infarction and is associated with worse outcomes. It results from microvascular obstruction from distal embolization, ischemic injury, and reperfusion injury. Diagnosis involves assessing TIMI flow, myocardial blush grade, and imaging techniques. Prevention focuses on reducing embolization using thrombectomy or filters while treatment involves vasodilators like adenosine, verapamil, and glycoprotein IIb/IIIa inhibitors.
- Abdominal aortic aneurysm (AAA) is a localized dilatation of the abdominal aorta exceeding normal diameter of 3 cm. It is more common in males over 65 years of age and smokers.
- Risk factors include atherosclerosis, family history, hypertension, and connective tissue disorders. The weakened vessel wall leads to proteolytic degradation and rupture risk increases with size over 5 cm.
- Screening with ultrasound is recommended for high risk groups. CT/MRI further characterize anatomy and complications like thrombosis. Surveillance intervals are based on size. Elective open or endovascular repair is indicated over 5.5/5 cm or rapid growth. Medical management focuses on slowing progression.
Presentation about the hazards and potential complications that could happen in any cardiac or peripheral catheterization procedure and how to avoid them
Thoracoabdominal aortic aneurysms (TAAAs) involve the thoracic and abdominal aorta. They account for 10% of aortic aneurysms and are challenging for anesthesiologists due to risks of paraplegia, renal failure, and other complications during surgery. Pre-operative evaluation of cardiac, pulmonary, and renal function is important for risk assessment and stratification. Proper management and optimization of any co-morbidities is also key to achieving a good surgical outcome.
The document discusses liver trauma, including:
- Liver injuries occur in approximately 5% of trauma admissions and the liver's anatomy makes it susceptible to injury.
- Comprehensive knowledge of hepatic anatomy is essential to managing liver injuries, including understanding the liver's lobes, vasculature, and ligamentous attachments.
- Liver injuries are classified based on their severity; while most stable patients can now be managed non-operatively, unstable or higher grade injuries may require surgery or other interventions.
- Diagnosis involves tools like ultrasound, CT scans, and diagnostic peritoneal lavage to identify injuries and guide management approaches.
Non cardiac surgery in cardiac patients moTamer Taha
This document discusses guidelines for evaluating and managing cardiac risk in patients undergoing non-cardiac surgery. It outlines factors that increase surgical risk like prolonged stress and changes in thrombotic factors. Complication rates are reported to be 7-11% with 0.8-1.5% mortality depending on precautions. Up to 42% of complications are cardiac related. It provides recommendations on pre-operative testing and risk stratification using indices. Risk reduction strategies discussed include use of beta-blockers, statins, and revascularization. Perioperative management of antiplatelets and anticoagulants is also covered.
This document discusses infrainguinal arterial procedures, focusing on femoropopliteal bypass surgery. It begins with an overview of preoperative testing and imaging, including duplex scanning, MRI angiography, CT angiography, and conventional angiography. The key steps of an above-the-knee femoropopliteal bypass are then described in detail, including harvesting the great saphenous vein, exposing the femoral artery, and exposing the popliteal artery distally. The bypass is performed by anastomosing the vein graft proximally to the femoral artery and distally to the popliteal artery above the knee. Precise surgical technique is important for successful bypass outcomes.
1. Abdominal aortic aneurysm (AAA) is defined as a dilation of the aorta greater than 30 mm or 1.5 times the normal diameter. AAA is usually asymptomatic and detected incidentally on imaging.
2. Treatment options for AAA include open surgical repair for aneurysms over 5.5 cm, those growing rapidly, or with anatomy unsuitable for endovascular repair. Endovascular aneurysm repair (EVAR) has become more common due to shorter recovery.
3. Complications of AAA include endoleak, graft failure, infection, and rupture, with rupture having a high mortality rate. Postoperative surveillance with imaging is important to monitor for complications.
- Abdominal aortic aneurysms (AAAs) are dilations of the abdominal aorta that increase the risk of rupture. AAAs are typically repaired surgically either through open or endovascular procedures.
- AAAs are caused by degradation of elastic and connective tissues in the aortic wall from factors such as smoking, genetics, and atherosclerosis. Left untreated, AAAs gradually enlarge and have a high risk of fatal rupture.
- Clinical diagnosis involves abdominal examination for a pulsatile mass and imaging tests. Treatment depends on AAA size and involves surgery once a threshold diameter is reached to prevent rupture. Emergency surgery is needed for ruptured AAAs.
This document provides guidelines for pre-operative evaluation and risk assessment. It discusses evaluating patients' medication use, medical conditions, functional status, and surgery-specific risk. Key factors that increase cardiac risk include recent heart attack, heart failure, diabetes, and poor functional status. Testing may be warranted for intermediate-high risk surgery or patients with a predicted >1% risk of major cardiac events. Continuation of most medications is reasonable. Statins, aspirin, and beta-blockers in selected patients can reduce risk. Timing of elective surgery depends on prior stenting or heart attack. The goal is to identify and optimize modifiable risks to reduce complications.
Tavi,Transcatheter Aortic Valve Replacement, TAVI,TAVR,Dr.Hasan Mahmud
Transcatheter aortic valve implantation (TAVI) has been developed as an alternative to surgical aortic valve replacement for high-risk patients. TAVI involves threading a collapsible valve through blood vessels and implanting it to replace the diseased valve. Over 30,000 high-risk patients with severe aortic stenosis have undergone TAVI, based on evidence from studies showing it is safer than surgery for this group. TAVI indications may expand as longer-term data on outcomes becomes available and the procedure requires a multidisciplinary team approach and dedicated training.
Preop evaluation of cardiac patient postd=ed for non cardiac surgery Rajesh Munigial
This document discusses pre-operative evaluation and preparation of cardiac patients for non-cardiac surgeries. It outlines that patients with coronary artery disease undergoing non-cardiac surgery are at increased risk of complications. A thorough pre-operative evaluation including history, physical exam, diagnostic tests, and knowledge of the planned surgery is important to assess risk factors and develop a management plan. Tests like ECG, stress testing, echocardiogram and in some cases angiography help evaluate cardiac status. Medical optimization including management of angina, heart failure, diabetes, etc. can help reduce perioperative risk. Timing of surgery depends on the clinical status and risk of delay. Intraoperative management focuses on preventing ischemia.
Spectrum Of Ct Findings In Rupture And Impendinging Rupture Of AAAXiu Srithammasit
This document discusses CT imaging findings of ruptured and impending rupture of abdominal aortic aneurysms. CT is the preferred imaging method for evaluating acute aortic syndrome due to its speed and availability. Findings indicative of rupture include retroperitoneal hematoma adjacent to the AAA and active extravasation of contrast. Findings predictive of impending rupture are large aneurysm size, lack of circumferential thrombus, discontinuity of wall calcifications, and the hyperattenuating crescent sign. Infected, inflammatory, and fistula-related aneurysms are also described.
This document provides an overview of carotid occlusive disease and its treatment. It discusses the pathophysiology and risk factors of atherosclerosis and how it leads to carotid stenosis. For symptomatic patients, carotid endarterectomy is recommended for >70% stenosis to prevent stroke. Asymptomatic patients may benefit from carotid endarterectomy for >60% stenosis. Medical management focuses on controlling risk factors like hypertension, diabetes, and dyslipidemia. Antiplatelet drugs like aspirin are also used. Carotid artery stenting is an alternative to endarterectomy for high-risk patients. Clinical trials have established the benefits and guidelines for treatment of symptomatic and asymptomatic carotid stenosis.
Surgical management of valvular heart diseaseSaurabh Potdar
This document discusses the surgical management of valvular heart disease. It covers general considerations for valve disease etiology and diagnosis. It describes the different types of prosthetic valves including mechanical and bioprosthetic options. It provides details on the surgical treatment of specific valve diseases like aortic stenosis, aortic regurgitation, and choices for valve replacement or repair. Surgical intervention is usually recommended for severe symptomatic valve disease and aims to improve hemodynamics and clinical outcomes, though risks vary based on patient factors.
Seminar on treatment of renal artery stenosisAbid_Kuchay
Renal artery stenosis (RAS) can cause hypertension, renal dysfunction, and other issues. The main causes are atherosclerosis (over 90% of cases) and fibromuscular dysplasia. Diagnostic evaluations include duplex ultrasonography, CT angiography, MRI, and invasive angiography. Treatment depends on the cause, with percutaneous angioplasty often used for fibromuscular dysplasia and medical management preferred for atherosclerotic RAS due to risks of intervention and lack of clear benefit shown in clinical trials. Revascularization may be considered for severe, unilateral atherosclerotic RAS but has not been shown to improve outcomes compared to medical management.
1) The document discusses considerations for perioperative management of patients undergoing thoracic endovascular aortic repair (TEVAR). It covers preoperative optimization, indications for TEVAR, neurological management including cerebrospinal fluid drainage and risks of stroke and spinal cord injury, hemodynamic management, and respiratory care.
2) Key aspects of management include preoperative optimization of comorbidities, use of cerebrospinal fluid drainage in high risk patients, maintaining adequate blood pressure and perfusion pressure postoperatively to prevent spinal cord injury, and lung-protective ventilation.
3) Complications of TEVAR like stroke, spinal cord injury, and paraplegia require multidisciplinary care including interventions to optimize
This document provides information on abdominal aortic aneurysms (AAA). It defines AAA as a dilation of the abdominal aorta to 3 cm or more. AAAs can be classified based on their shape (fusiform or saccular) and location (infrarenal, juxtarenal, pararenal). Risk factors include atherosclerosis and smoking. Screening is recommended for men over 65 and those with a family history. Elective repair is indicated for asymptomatic AAAs over 5.5 cm or those expanding rapidly. Treatment options include open surgery, endovascular aneurysm repair, or medical management.
Carotid vascular disease is a leading cause of stroke in the US. Treatment options include carotid endarterectomy (CEA) surgery and nonsurgical carotid revascularization using angioplasty and stenting. Studies have shown conflicting results comparing the two approaches. CEA is generally recommended but angioplasty and stenting may be better for high-risk surgical patients or those with significant comorbidities. More research is still needed to refine treatment recommendations.
Anesthetic Management of Abdominal Surgery.pptxTadesseFenta1
This document outlines an anesthesia course for abdominal and genitourinary surgery. The course aims to enable anesthetists to safely manage anesthesia for patients undergoing abdominal, gastrointestinal, hepatobiliary, anal, and genitourinary surgeries. It covers preoperative evaluation, risks associated with abdominal surgery, anesthetic techniques for different procedures, postoperative complications, and management of patients with hepatic or cardiovascular disease. The course assessments include assignments, quizzes, and a final written exam.
1. Arterial aneurysms most commonly occur in the abdominal aorta and can be caused by degenerative processes, infections, trauma, or genetic conditions.
2. Abdominal aortic aneurysms are the most prevalent type of aneurysm in the United States and rupture of aneurysms is a serious complication.
3. Aneurysms can be classified by their morphology (fusiform vs. saccular), etiology (degenerative, inflammatory, infectious), and location (aortic, iliac, femoral, etc.). Management depends on the type and severity of the individual aneurysm.
This document discusses antiplatelet agents used for cardiovascular disease. It describes the mechanisms of action, indications, dosing, side effects, and perioperative management of various antiplatelet drugs including aspirin, clopidogrel, ticlopidore, ticagrelor, prasugrel, cangrelor, abciximab, eptifibatide, tirofiban, dipyridamole, vorapaxar, and atopaxar. It also discusses the use of antiplatelet therapy for primary and secondary prevention of cardiovascular events such as cardiovascular death, stroke, and myocardial infarction, as well as for peripheral artery disease.
The document discusses normal coagulation, coagulopathies, and hemorrhage. It begins by introducing coagulation as a defense mechanism to maintain circulatory system integrity during vascular injury. Coagulation involves thrombin generation, fibrin clot formation, and fibrin clot dissolution through a balance of procoagulant, anticoagulant, and fibrinolytic factors. The mechanisms of hemostasis include vasoconstriction, platelet activation and aggregation, coagulation, and fibrinolysis. The major components and processes of coagulation are then described, including vitamin K-dependent proteins, fibrinolysis proteins, the roles of endothelium and platelets, the coagulation cascade, and tests to monitor blood coagulation.
The document summarizes several cases of hypercoagulable states and deep vein thrombosis (DVT). It describes three cases: 1) A 36-year-old with recurrent DVT who presented with abdominal pain and bleeding, 2) A 33-year-old man with sudden dyspnea and chest pain along with leg edema, and 3) A 21-year-old woman referred for contraceptive evaluation given her family history of thrombosis. It then reviews hypercoagulable states, including definitions and classifications of congenital and acquired causes. Specific conditions discussed in detail include deficiencies of antithrombin, protein C, and protein S; factor V Leiden; prothrombin gene mutation; antiphosph
CT, MRI, and angiography are important imaging modalities in vascular surgery. CT was developed in the 1970s and provides detailed cross-sectional images using x-rays. It is now widely used to evaluate vascular conditions like aneurysms, arterial blockages, and venous diseases. CT angiography with intravenous contrast allows visualization of blood vessels. While very useful, CT does expose patients to radiation. Other limitations include beam hardening artifacts from dense tissues and partial volume effects.
This document discusses radiation safety in vascular and endovascular procedures. It defines key terms like absorbed dose, equivalent dose, and effective dose. It describes the biological effects of radiation as either deterministic or stochastic. It provides guidance on minimizing radiation exposure for patients and operators during diagnostic imaging and endovascular interventions through techniques like collimation, distance, barriers, and monitoring dose. The goal is to justify and optimize radiation use to provide benefit while limiting harm.
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This document discusses various familial risk factors for atherosclerosis, including familial hypercholesterolemia, hypertension, diabetes, and obesity. It describes the genetics and mechanisms underlying each condition, such as mutations in LDLR, ApoB, and PCSK9 genes for familial hypercholesterolemia. Environmental and epigenetic factors that interact with genetic risks to influence atherosclerosis are also reviewed. The document provides guidelines for diagnosing each familial condition based on clinical criteria such as LDL levels and family history of premature cardiovascular disease.
Less commonly considered causes of atherosclerosisTapish Sahu
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This document discusses the relationship between smoking and atherosclerotic risk. It summarizes several studies that find smoking significantly increases the risk of peripheral artery disease and negatively impacts inflammation levels and vascular health. Multiple trials also found smoking cessation can reduce atherosclerotic progression and improve outcomes for those with peripheral artery disease. Studies highlighted include the ARIC study, MESA trial, ACS-NSQIP database, and University of California Davis Registry, all of which linked smoking to higher risk of peripheral artery disease and poorer prognosis.
This document discusses hyperlipidemia and its role in atherosclerosis. It covers several hypotheses for the pathogenesis of atherosclerosis relating to the accumulation of lipids in the arterial wall. It also summarizes guidelines from expert panels for screening and managing lipid disorders to reduce cardiovascular risk, such as targeting LDL-C levels. Newer drug classes are mentioned for treating hyperlipidemia, including PCSK9 inhibitors, with statins remaining the first-line treatment due to their efficacy and safety profile based on clinical trial evidence.
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This document provides an overview of lymphatic pathophysiology. It discusses the embryological development, anatomy, and physiology of the lymphatic system. Regarding pathology, it describes lymphedema as an imbalance between lymph uptake and transport capacity. Primary lymphedema is caused by genetic disorders or developmental anomalies, while secondary lymphedema can result from damage to the lymphatic vessels from trauma, infection, surgery, radiation therapy, or malignancy. Complications of lymphedema include adipogenesis, fibrosis, infection, and in rare cases, lymphatic tumors. Lymphangioscintigraphy is currently the gold standard imaging method for evaluating the lymphatic system.
1. Venous pathophysiology involves a complex interplay between genetic, environmental, and acquired factors that can disrupt the normal balance between procoagulant and anticoagulant mechanisms in the veins.
2. The venous endothelium plays a critical role in homeostasis by maintaining an anticoagulant state, but this can be damaged by various disease processes, promoting thrombosis.
3. Abnormal venous biomechanics and valve incompetence, as seen in varicose veins and post-thrombotic syndrome, can lead to ambulatory venous hypertension from impaired flow and reflux of blood in the veins.
This document discusses arteriogenesis and angiogenesis for treating peripheral arterial disease. It defines various types of neovascularization including vasculogenesis, arteriogenesis, and angiogenesis. Arteriogenesis involves growth and remodeling of preexisting collateral vessels, while angiogenesis is the formation of new capillaries from existing blood vessels in response to ischemia. Gene and protein therapies for promoting neovascularization have shown limited benefits, while cell-based therapies using endothelial progenitor cells and bone marrow mononuclear cells have demonstrated more promising results. The goals of therapy for critical limb ischemia are to relieve pain, heal ulcers, prevent amputation, and improve quality of life.
This document discusses the basic principles of arterial hemodynamics and its clinical application in arterial disease. It covers topics such as fluid pressure and energy, Bernoulli's principle, fluid energy losses due to viscosity and inertia, vascular resistance, blood flow patterns, the effects of stenosis, collateral circulation, and the impact of exercise therapy, vasodilators, sympathectomy, vascular steal, and gravity on arterial hemodynamics and blood flow.
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Computer in pharmaceutical research and development-Mpharm(Pharmaceutics)MuskanShingari
Statistics- Statistics is the science of collecting, organizing, presenting, analyzing and interpreting numerical data to assist in making more effective decisions.
A statistics is a measure which is used to estimate the population parameter
Parameters-It is used to describe the properties of an entire population.
Examples-Measures of central tendency Dispersion, Variance, Standard Deviation (SD), Absolute Error, Mean Absolute Error (MAE), Eigen Value
Know the difference between Endodontics and Orthodontics.Gokuldas Hospital
Your smile is beautiful.
Let’s be honest. Maintaining that beautiful smile is not an easy task. It is more than brushing and flossing. Sometimes, you might encounter dental issues that need special dental care. These issues can range anywhere from misalignment of the jaw to pain in the root of teeth.
Giloy in Ayurveda - Classical Categorization and SynonymsPlanet Ayurveda
Giloy, also known as Guduchi or Amrita in classical Ayurvedic texts, is a revered herb renowned for its myriad health benefits. It is categorized as a Rasayana, meaning it has rejuvenating properties that enhance vitality and longevity. Giloy is celebrated for its ability to boost the immune system, detoxify the body, and promote overall wellness. Its anti-inflammatory, antipyretic, and antioxidant properties make it a staple in managing conditions like fever, diabetes, and stress. The versatility and efficacy of Giloy in supporting health naturally highlight its importance in Ayurveda. At Planet Ayurveda, we provide a comprehensive range of health services and 100% herbal supplements that harness the power of natural ingredients like Giloy. Our products are globally available and affordable, ensuring that everyone can benefit from the ancient wisdom of Ayurveda. If you or your loved ones are dealing with health issues, contact Planet Ayurveda at 01725214040 to book an online video consultation with our professional doctors. Let us help you achieve optimal health and wellness naturally.
Pictorial and detailed description of patellar instability with sign and symptoms and how to diagnose , what investigations you should go with and how to approach with treatment options . I have presented this slide in my 2nd year junior residency in orthopedics at LLRM medical college Meerut and got good reviews for it
After getting it read you will definitely understand the topic.
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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PGx Analysis in VarSeq: A User’s PerspectiveGolden Helix
Since our release of the PGx capabilities in VarSeq, we’ve had a few months to gather some insights from various use cases. Some users approach PGx workflows by means of array genotyping or what seems to be a growing trend of adding the star allele calling to the existing NGS pipeline for whole genome data. Luckily, both approaches are supported with the VarSeq software platform. The genotyping method being used will also dictate what the scope of the tertiary analysis will be. For example, are your PGx reports a standalone pipeline or would your lab’s goal be to handle a dual-purpose workflow and report on PGx + Diagnostic findings.
The purpose of this webcast is to:
Discuss and demonstrate the approaches with array and NGS genotyping methods for star allele calling to prep for downstream analysis.
Following genotyping, explore alternative tertiary workflow concepts in VarSeq to handle PGx reporting.
Moreover, we will include insights users will need to consider when validating their PGx workflow for all possible star alleles and options you have for automating your PGx analysis for large number of samples. Please join us for a session dedicated to the application of star allele genotyping and subsequent PGx workflows in our VarSeq software.
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Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
2. Definitions
A true arterial aneurysm is defined as an increase to 1.5
times the normal arterial diameter with involvement of
all three anatomic layers.
In the infra renal abdominal aorta, an aneurysm is
traditionally defined as a diameter greater than 3 cm or
more than 50% larger than a normal proximal segment
measured in either anteroposterior or transverse
dimension in a plane perpendicular to the longitudinal
axis of the aorta.
3. Epidemiology & risk factors
Age
Smoking
Atherosclerotic disease
Hypertension, male gender, hypercholesterolemia,
family history
Negative risk factors include female sex, African
American race, and diabetes.
4.
5.
6. Rupture Risk
Risk of rupture most occurring in patients with an AAA
diameter of 5 to 5.5 cm.
The risk of rupture was independently associated with
female sex, larger initial AAA diameter, smoking, lower
FEV1, and higher mean blood pressure.
Saccular aneurysm morphology appears to portend an
increased risk of rupture compared with fusiform
aneurysms
CTA can also indicate an increased risk of rupture,
including the presence of a dissection, mural thrombus,
or a dissection of the peripheral calcification of the
aneurysm sac
7. AAA DIAMETER IN CM RISK OF RUPTURE (%)
3-3.9 0.3
4-4.9 0.5-1.5
5-5.9 1-11
6-6.9 11-22
>7 >30
8. Associated Aneurysms
The involvement of adjacent arterial segments is not
uncommon in infrarenal AAAs, with 5% to 15%
extending to the juxta- or suprarenal aorta and 10% to
25% involving the iliac arteries.
Synchronous lesions of the thoracic aorta (12%) and
femoral or popliteal artery (14% among male patients)
are also common
9. Iliac artery aneurysms occur most frequently in the
common iliac artery (CIA) (70%), typically in conjunction
with an AAA.
The largest published series of common iliac artery
aneurysms (CIAAs) reports that 86% of patients with
CIA aneurysms presented with concurrent or previously
treated AAAs
12. In the thoracic aorta, the media contains 55 to 60
lamellar units, with adventitial vasavasora penetrating
the vascular zone of the outer layers, whereas there are
28 to 32 lamellar units in the abdominal aortic media.
This makes the abdominal aorta relatively avascular
compared with the more proximal aorta, relying more on
the transintimal diffusion of oxygen and nutrients
Biomechanical stress of aortic bifurcation
13. Pathogenesis of Abdominal Aortic Aneurysms” identified
four mechanisms relevant to AAA formation:
1.proteolytic degradation of aortic wall connective tissue
2 inflammation and immune responses
3.biomechanical wall stress
4 .molecular genetics.
14.
15. Diagnosis
History
Patients with AAAs are typically asymptomatic.
Those who are symptomatic and previously
undiagnosed often present with diffuse nonspecific
abdominal and/or lower back pain.
Patients may also state that they can feel pulsations in
their abdomen. Those who are thin may state that they
can see a pulsatile mass in their abdomen
16. Physical Examination
An AAA may be detected on physical examination as a
palpable pulsatile (expansile) mass, most commonly
supra umbilical and in the midline
The location, however, may be variable, as aortic
tortuosity can result in a lateral and/or infra umbilical
location
17. Physical examination
Recommendation Level of
recommendation
Quality of
evidence
In patients with a suspected or known AAA, we recommend
performing physical examination that includes an assessment
of femoral and popliteal arteries. In patients with a popliteal or
femoral artery aneurysm, we recommend evaluation for an
AAA.
1 A
18. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
In patients with active cardiac conditions, including unstable
angina, decompensated heart failure, severe vulvular disease, and
significant arrythmia, we recommend cardiology consultation before
endovascular aneurysm repair (EVAR) or open surgical repair
(OSR).
1 B
In patients with significant clinical risk factors, such as coronary
artery disease, congestive heart failure, cerebrovascular disease,
diabetes mellitus, chronic renal insufficiency, and unknown or poor
functional capacity (metabolic equivalent [MET] < 4), who are to
undergo OSR or EVAR, we suggest noninvasive stress testing.
2 B
We recommend a preoperative resting 12-lead electrocardiogram
(ECG) in all patients undergoing EVAR or
OSR within 30 days of planned treatment.
1 B
We recommend echocardiography before planned operative repair
in patients with dyspnea of unknown origin or worsening dyspnea
1 A
19. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
In patients with a drug-eluting coronary stent requiring open aneurysm
repair, we recommend discontinuation of P2Y12 platelet receptor inhibitor
therapy 10 days preoperatively with continuation of aspirin. The P2Y12
inhibitor should be restarted as soon as possible after surgery. The relative
risks and benefits of perioperative bleeding and stent thrombosis shouldbe
discussed with the patient.
1 B
We suggest continuation of beta blocker therapy during theperioperative
period if it is part of an established medical regimen.
2 B
If a decision was made to start beta blocker therapy (because of the
presence of multiple risk factors, such as coronary artery disease, renal
insufficiency, and diabetes), we suggest initiation well in advance of surgery
to allow sufficient time to assess safety andtolerability.
2 B
We suggest preoperative pulmonary function studies, including room air
arterial blood gas determinations, in patients with a history of symptomatic
chronic obstructive pulmonary disease (COPD), long-standing tobacco use,
or inability to climb one flight of stairs.
2 C
We recommend smoking cessation for at least 2 weeks beforeaneurysm
repair.
1 C
We suggest administration of pulmonary bronchodilators for at least2
weeks before aneurysm repair in patients with a history of COPD or
abnormal results of pulmonary functiontesting.
2 C
20. Assessment of medical comorbidities
Recommendation Level of
recommendation
Quality of
evidence
We suggest holding angiotensin-converting enzyme (ACE) inhibitors and
angiotensin receptor antagonists on the morning of surgery andrestarting
these agents after the procedure once euvolemia has beenachieved.
2 C
We recommend preoperative hydration in non dialysis dependent
patients with renal insufficiency before aneurysmrepair.
1 A
We recommend preprocedure and postprocedure hydration with normal
saline or 5% dextrose/sodium bicarbonate for patients at increased risk
of contrast-induced nephropathy (CIN) undergoing EVAR
1 A
We recommend holding metformin at the time of administration of
contrast material among patients with an estimated glomerular filtration
rate (eGFR) of <60 mL/min or up to 48 hours before administration of
contrast material if the eGFR is <45 mL/min.
1 C
We recommend restarting metformin no sooner than 48 hours after
administration of contrast material as long as renal function has remained
stable (<25% increase in creatinine concentration abovebaseline).
1 C
We recommend perioperative transfusion of packed red blood cells if the
hemoglobin level is <7 g/dL
1 B
We suggest hematologic assessment if the preoperative platelet countis
<150,000/μL.
2 C
22. Computed Tomography
Computed tomography (CT) provides excellent imaging
of AAAs with greater reproducibility of diameter
measurements than US.
CT particularly with the adjunctive use of iodinated
contrast to perform a CT angiogram (CTA), provides a
wealth of anatomic information, including defects in
vessel calcification, thrombus, and concurrent arterial
occlusive disease.
CTA also permits invaluable multiplanar and three-
dimensional reconstruction and analysis for operative
planning
23. Drawbacks associated with CTA include substantial
exposure to radiation, particularly in the setting of serial
examinations, and the use of iodinated contrast media is
problematic in a population with a high incidence of
associated kidney disease
24. Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) and magnetic
resonance angiography (MRA) are, like CT, quite
sensitive in the detection of AAAs Unlike CT, MRI does
not demonstrate aortic wall calcification, which may be
quite important in operative planning
MRA utilizes gadolinium, which has been associated
with the development of nephrogenic systemic fibrosis in
patients with a low GFR.
25. Aneurysm imaging
Recommendation
Level of
recommendation
Quality of
evidence
We recommend using ultrasound, when feasible, as the preferred
imaging modality for aneurysm screening and surveillance.
1 A
We suggest that the maximum aneurysm diameter derived from
computed tomography (CT) imaging should be based on an outer
wall to outer wall measurement perpendicular to the path of the
aorta.
Ungraded
Good Practice Statement
We recommend a one-time ultrasound screening forAAAs in men
or women 65 to 75 years of age with a history of tobaccouse.
1 A
We suggest ultrasound screening for AAA in first degree relatives of
patients who present with an AAA. Screening should be performed
in first-degree relatives who are between 65 and 75 years of age or
in those older than 75 years and in goodhealth.
2 C
We suggest a one-time ultrasound screening forAAAs in men or
women older than 75 years with a history of tobacco use and in
otherwise good health who have not previously received a
screening ultrasound examination.
2 C
26. Aneurysm imaging
Recommendation
Level of
recommendation
Quality of
evidence
If initial ultrasound screening identified an aortic diameter >2.5cm
but <3 cm, we suggest rescreening after 10years.
2 C
We suggest surveillance imaging at 3-year intervals for patients
with an AAA between 3.0 and 3.9cm.
2 C
We suggest surveillance imaging at 12-month intervals for patients
with an AAA of 4.0 to 4.9 cm indiameter.
2 C
We suggest surveillance imaging at 6-month intervals for patients
with an AAA between 5.0 and 5.4 cm indiameter. 2 C
We recommend a CT scan to evaluate patients thought tohave
AAA presenting with recent-onset abdominal or back pain,
particularly in the presence of a pulsatile epigastric mass or
significant risk factors forAAA.
1 B
27. The decision to treat
Recommendation
Level of
recommendation
Quality of
evidence
We suggest referral to a vascular surgeon at the time ofinitial
diagnosis of an aortic aneurysm.
Ungraded
Good Practice Statement
We recommend repair for the patient who presents with an
AAA and abdominal or back pain that is likely to beattributed
to the aneurysm.
1 C
We recommend elective repair for the patient at low or
acceptable surgical risk with a fusiformAAA that is greater or
equal to 5.5 cm.
1 A
We suggest elective repair for the patient who presents with a
saccular aneurysm.
2 C
We suggest repair in women with AAA between 5.0 cm and
5.4 cm in maximum diameter.
2 B
In patients with a small aneurysm (4.0-5.4 cm) whowill
require chemotherapy, radiation therapy, or solid organ
transplantation, we suggest a shared decision-making
approach to decide about treatmentoptions
2 C
28. Medical management during the
period of AAA surveillance
Recommendation
Level of
recommendation
Quality of
evidence
We recommend smoking cessation to reduce the risk ofAAA growth
and rupture.
1 B
We suggest not administering statins, doxycycline, roxithromycin,
ACE inhibitors, or angiotensin receptor blockers for the sole purpose
of reducing the risk of AAAexpansion and rupture.
2 C
We suggest not administering beta blocker therapy for thesole
purpose of reducing the risk of AAA expansionand rupture. 1 B
29. Indications for Intervention
In general, the size criterion for elective repair is 5.5 cm
for men and 5 cm for women or a 12-month growth rate
of equal to or greater than 10 mm in both sexes.
Both the UK small aneurysm trial and the ADAM trial
documented that surveillance of aneurysms between 4
and 5.5 cm is safe with compliant patients
Additional indications for elective or early intervention
included saccular aneurysms, dissection of mural
thrombus, or fracture of saccular calcification.
30.
31. Timing for intervention
Recommendation
Level of
recommendation
Quality of
evidence
We recommend immediate repair for patients who present witha
ruptured aneurysm. 1 A
Should repair of a symptomatic AAA be delayed to optimize
coexisting medical conditions, we recommend that the patient be
monitored in an intensive care unit
(ICU) setting with blood products available.
1 C