Cardiothoracic
Dr. Abdulameer
Surgery
“Aneurysms”
Dr.Abdulameer
Lecture
#2
Total Lec: 31
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Aneurysms
It is a dilatation of the arterial wall of at least 50% increase over normal arterial
diameter .
Classification
Aneurysms may be classified by
1. Type.
2. Morphology.
True
False
3. Location.
Aortic Aneurysm:
What is an aortic aneurysm ?
An aortic aneurysm is a bulge in a section of the aorta {greater than 50
percent of the normal diameter (width)}
Aneurysms can form in any section of the aorta, but they are most
common in the belly area .
Abdominal aortic aneurysm .
Thoracic aortic aneurysm
RISK FACTORS
Age.
Smoking
Family history .{first degree relative}
Other aneurysm.
Genetics.
HPN.
Occlusive disease
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Male Gender
Alcohol
Infections
Aortic coarctation.
Symptoms:
Most aneurysms are asymptomatic when discovered (60-80%)and
become symptomatic when expanding or ruptured
symptoms may begin to occur if the aneurysm gets bigger and puts
pressure on surrounding organs.
Abdominal aortic aneurysm:
(AAAs) is true aneurysms commonly involve the infrarenal aorta. aortic
diameter >3 cm = AAA.
An AAA of any size can rupture, but those >5 cm are more likely to rupture.
size is the most important factor in determining rupture risk
The most common location of rupture retroperitoneum
Rupture is associated with an 80–90% overall mortality
The most common symptoms of abdominal aortic aneurysm include:
1. General abdominal pain or discomfort.
2. A pulsating sensation in the abdomen.
3. A "cold foot" or a black or blue painful toe can happen if an abdominal aortic
aneurysm produce a blood clot that breaks off and blocks blood flow to the legs
or feet.
4. Fever or weight loss, if it is an inflammatory aortic aneurysm.
EXAM
■
Vital signs may be surprisingly normal.
■ Hypotension and shock if rupture with
significant blood loss
■ Abdominal tenderness, distension, or
pulsatile abdominal mass [75% above
umbilicus]
■ Evidence for retroperitoneal hematoma
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■ Periumbilical ecchymosis (Cullen’s sign)
■ Flank ecchymosis (Grey-Turner’s sign)
■ Massive GI bleed if rupture into GI tract
(aortoenteric fistula)
■ High-output heart failure if rupture into vena cava
(aortocaval fistula)
Thoracic aortic aneurysm:
1. Chest pain.
2. Back pain.
3. A cough or shortness of breath.
4. Hoarseness.
5. Difficulty or pain while swallowing.
If an aortic aneurysm bursts
,
or ruptures, there is:
o
Sudden severe pain.
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o
Extreme drop in blood pressure and signs of shock.
o
Without immediate treatment, death occurs.
Diagnosis of Aortic Aneurysm:
1. Aortic aneurysms are often discovered during a routine physical examination.
2. X-ray
3. ultrasound
4. Echocardiogram
5. Transesophageal echocardiogram
6. CT Angiogram
7. Magnetic resonance angiogram.
8. Angiogram
Plain Abdominal X-ray
Ultrasonogram Arteriogram
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CT Scan
Treatment of Aortic Aneurysm:
1. Medical treatment:
Small aneurysms rarely rupture and are usually treated by control the high
blood pressure usually by (Beta-blockers).
More exercise.
Eat a heart-healthy diet.
Stop smoking.
Medicines to lower high cholesterol.
If you don't have surgery, you will have routine
ultrasound tests to see if the
aneurysm is getting bigger.
2. Surgical repair of aortic
aneurysms:
Thoracic or abdominal aortic aneurysms that
are:
Large, causing symptoms
Rapidly getting bigger
Are considered at risk of rupturing. Surgery is
usually recommended if any one
of these factors is present.
People
who are at significant risk from surgery
may elect to use medical management or
another
technique such as a stent graft procedure.
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INTRA OP
:
incision
.
Exposure
.
Clamping
.
IMA ligation
.
opening
the wall
.
Prosthetic
graft
What are
the factors that increase the Complications
If the evaluation of the heart indicates significant heart disease, we should do
coronary artery bypass surgery (CABG )or coronary angioplasty prior to repairing
an aortic aneurysm .
This is because coronary artery disease is the most important underlying factor
contributing to complications ,such as Heart attack.
Others
Stroke
.
Kidney
disease
.
Chronic
lung disease
.
Cirrhosis
of the liver
.
Smoking
High blood pressure
Ruptured
aneurysm
:
It is not an option to wait
until an aneurysm has ruptured before
surgery is done. Most people who have a
ruptured aortic aneurysm die
.
POST
OP
COMPLICATIONS
Death
8.1
-
5
%
in elective
MI - 2-5%
CVA
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Renal insufficiency
Colonic ischemia .
Spinal cord ischemia
Haemorrhage, DIC
LATE COMPLICATION
Aortoenteric fistula
Retrograde ejaculation.
Infected graft .
Groin infection < 5%.
Incisional hernia - 10-20%
Bowel obstruction
Amputation , Blue toe syndrome
Lymphocele in groin 2%
False anastomotic aneurysm
Graft thrombosis
3. Endovascular aortic
aneurysms repair:
Some aortic aneurysms can be repaired without traditional surgery, using
endovascular aortic repair.
A tube called a stent graft is inserted through an artery in the groin. The stent
graft makes a bridge between the healthy parts of the aorta (above and below
the aneurysm).
Diameter and length of the
proximal neck of the aneurysm
.
Tortuosity of the aorta
Anatomy of the iliac
arteries
.
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Endovascular AAA Repair
Less invasive alternative
treatment that is associated
with:
Reduced morbidity
Reduced blood loss
Shorter hospital stay
Earlier return to function n
Drawbacks:
Limited long-term data
More intense patient follow-up
Recovery Time
Up and Walking that evening
Majority go home within 24-48 hours
Regular Diet the Same Day
Minimum if any ICU Stay
complications
Local hematoma or bleeding
Infection
Incomplete repair
leakage
Placement of an endovascular stent graft
in an aortic aneurysm. In figure A, a
catheter is inserted into an artery in the
groin (upper thigh).It is then threaded
up to the abdominal aorta, and the stent
graft is released from the catheter. In
figure B, the stent graft allows blood to
flow through the aneurysm
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Peripheral aneurysm:
- Aneurysms that occur in arteries other than the aorta (and not in the brain) are
called peripheral aneurysms.
- Common locations for peripheral aneurysms include popliteal artery, femoral
artery, and the carotid artery.
- Peripheral aneurysms are not as likely to rupture as aortic aneurysms, but blood
clots can form in peripheral aneurysms. If a blood clot breaks away from the
aneurysm, it can block blood flow through the artery.
Signs and symptoms of peripheral aneurysm
:
may include:
1. A pulsating lump that can be felt in the neck, arm, or leg.
2. Leg or arm pain, or cramping with exercise.
3. If a peripheral aneurysm is large, it can press on a nearby nerve or vein and cause
pain, numbness, or swelling.
4. Gangrene.
5. An aneurysm in the neck can block the artery to the brain and cause a stroke.
Diagnostic tests and procedures:
o
Physical examination
o
Doppler.
o
CT scan.
o
MRA.
o
Angiography.
Treatment:
- Some aneurysms, mainly small ones that are not causing pain, can be treated with
"watchful waiting".
- Others need to be treated to prevent growth and complications.
- The goals of treatment are to:
Prevent the aneurysm from growing.
Prevent or reverse damage to other body structures.
Prevent or treat a rupture.
To allow participation in normal daily activities.
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How can an aneurysm be prevented?
The best way to prevent an aneurysm is to avoid the risk factors that increase the
changes of developing one. To do this, you can:
- Stop smoking.
- Control high blood pressure.
- Control high cholesterol.
- Get regular physical activity.
- Limit alcohol.
AYA…