Arterial Aneurysms

Sami Asfar
M.B.,Ch.,B., M.D.(UK), FRCSEd, FACS
Professor and Chairman, Departments of Surgery, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Hospital

Liver & Vascular Surgery

This tafree3 includes every thing

Prof. Sami Asfar

Arterial Aneurysms
Objectives:
To Learn: Types of aneurysms Clinical presentation of aneurysms Principles of management

Outcome:
To be able: Recognize patients suffering from aneurysms Timely referral of such patients to the vascular surgeon
Prof. Sami Asfar

Internal Carotid Innominate Subclavian Thoracic

Shape

Renal/Splenic Abdominal Iliac Femoral

Popliteal

Prof. Sami Asfar

Arterial Aneurysms
Definition:
Abnormal widening of a blood vessel
1.5 X diameter of the vessel proximal to the dilatation

Types:
True: here the full thickness of the wall
is involved including (intima, media, and adventitia )

False: here it is a puncture that cause

bleeding acuamilated in one side the by time fibrosis occur and it become pulsating) and so it is called :

Pseudo-aneurysm or Pulsating Haemotoma

Prof. Sami Asfar

Puncture or trauma

Site of vascular suture

AAA (Abdominal Aortic Aneurism)

Incidence:
General population . 1-5% > 65 years age . 3-5% > 70 years age . 10% M : F ... 4 : 1 (most common female)

Risk Factors:
Atherosclerosis 95% ( most impo.) Hypertension ... 40% Smoking Age Males Family history (1st degree relative)

Prof. Sami Asfar

Pathogenesis of AAA
Atheromatous degeneration of intima Neutrophils release Elastase & Metalloproteinase cause Loss of ELASTIN in the media of Aortic wall Compensatory expansion of adventitial layer
(Newman et al J Vasc Surg 1994)

Prof. Sami Asfar

Intramural Haematoma
all aneurisms have intramural thrombus the thrombus break down the atheroma and then blood will collect inside and give intramural atheroma or so called haematoma

Breakdown of atheromatous plaque

Splitting of the media with formation of Intramural haematoma

Prof. Sami Asfar

Associated Biochemical Conditions

Alpha-1-antitrypsin deficiency Type III collagen synthesis disorders Fibrillin synthesis disorders Elastin disorders

Prof. Sami Asfar

AAA
Life expectancy: of age-matched controls Most deaths are due to:
Coronary artery disease Ruptured AAA

Concomitant Abdominal Pathology (other pathologies can happen

with the AAA)

Asymptomatic G.B. calculi:5-20% Colon cancer: 4-5% Avoid concomitant aortic surgery
Prof. Sami Asfar

Natural History of AAA

Expansion: Rupture:
0.2-0.8 cm/year

Risk of rupture Size of the aneurysm

The size of aneurysm is measured by its anterior-posterior diameter

Laplace Law:

T=Pxr
T: Tension on the wall P: Intraluminal pressure r: Radius of the sac (diameter)

Aneurysm Size
5 cm
because there is a small chance to rupture)

Risk of Rupture
5% in 5 yrs (we do not operate it
5% per yr cumulative
10

5.5 cm
we operate because it will rupture soon Prof. Sami it Asfar

(25% in 5 yrs)

Abdominal Aortic Aneurysm AAA

Presentation:
Asymptomatic: Incidental:
Clinical examination, U/S, CT-Scan

Symptomatic:
Distal embolisation: Limb ischaemia, Blue toes Back, abdominal pain: Leaking aneurysm patient will have tachycardia Ruptured aneurysm patient will be in shock

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Diagnosis of AAA
Clinical: 95% accurate (expansile pulsation ) U/S: (best then CT SCAN) 95% accurate (reliable size measurement)
means pulsation in all directions

Plain X-Ray: Calcified aortic wall

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Diagnosis of AAA

Spiral CT, MRA:

Most accurate

Angiography:
Misleading
because it outlines the lumen only So we do not do it for aneurysms

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Indications for Repair of AAA

Asymptomatic > 5.5 cm diameter ( if the patiant is

asymptomatic but the size is big, bigger than 5.5 cm)

Symptomatic Rapidly expanding in 6-12 months by U/S Ruptured or Leak

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AAA + Abdominal/Back pain What do think about??

? Rupture ? Leak

If the patient isUnstable

(Low BP/Shock)

If the patient is Stable

U/S, CT-Scan Urgent Surgery

Resuscitation in Operating Room Why? Cause thi patient is bleeding so you are wasting the blood

Leaking Aneurysm
Resuscitation in ICU & Prepare for Surgery

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Elective Surgery for AAA

(Preoperative Assessment) you should prepare and do - Anaesthesia Consultation - Chest X-ray - Cardiac Function Tests:
ECG Echocardiogram (Ejection Fraction, Ventricular Function) Stress Tests: Treadmill, Thallium Scan ? Cardiac Catheterisation

- Pulmonary Function Tests - Bowel Preparation: 4 Liters Go-Lytely

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Elective Surgery for AAA

(Preoperative Assessment)

Ejection Fraction < 50%

surgery

Increased Risk of death in the

(Cambria et al J Vasc Surg 1992)

Preoperative management of cardiac abnormalities improves 5-year survival by 10-20% 10% AAA patients require cardiac revascularisation
because there is a chance to develop infarction during or after the surgery (Johnstone KW J Vasc Surg 1994)

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Surgery for AAA

Postoperative Mortality

Type of Surgery Elective Ruptured

Mortality < 5% > 50%

Cardiac events are responsible for:

69% Early Death after aortic aneurysm is done 44% Late Death after aortic aneurysm is done

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Complications of AAA Surgery

Renal Failure:
Elective 2% Rupture 21%

Ischaemic Colitis: 6% Acute Limb Ischaemia Trash foot Graft infection: 1% Neurogenic Impotence you could damage nerves during surgery Spinal Cord Ischaemia: seen in thoraco-abdominal sugery
Artery of Adamkiewicz T8, L1-L4 (if this artery is thrombosed or damaged you get spinal
cord ischaemia)

1:400 AAA repair 1:5000 Aorto-iliac disease

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Infected Aortic Graft

Presentation:
Fever, malaise Abdomen & back pain Septic emboli to legs Groin abscess Aorto-enteric Fistula (most of the time it is between the duodenum)CAUSES: Recurrent upper GI bleed

Treatment:
Graft Excision Extra-anatomical By-pass (Axillo-Bifemoral)
REMMBER: NO OTHER SURGERIES ARE DONE AT THE SAME TIME WHEN WE DO AORTIC SURGERY TO AVOID INFECTION OF THE GRAFT

1% after Aortic Repair (months-years)

> 50% Mortality Organisms:
Staph aureus E. coli
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(Lorentzen et al Surgery 1985)

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Screening for AAA

U/S Screening of people > 60 years age every 6-12 months

Decreased the incidence of Rupture by 85%

(Scott et al Br J Surg 1995)

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Small (< 5.5 cm) AAA

WE DO NOT OPERATE IT CUASE THE COMPLICATIONS AFTER THE OPERATION ARE BAD AND EARLY surgery is NOT associated with any long-term survival advantage

U.K. Small Aneurysm Trial:

U/S Surveillance is safe Early surgery is NOT associated with any long-term survival advantage (Lancet 1998;352:1619-55)

Predictors of increased risk of rupture:

Chronic obstructive pulmonary disease Systolic hypertension Increased pulse pressure (Crenenwett et al Surgery 1985)

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Medical Management of Small AAA

INSTEADE OF HAVING A SURGERY WE GIVE THE PATIENT WITH SMALL AAA THE FOLLOWING:

Propranolol:
Increases tensile strength of aortic connective tissue Reduction in expansion rate of aneurysm
(Gadowski et al J as Surg 1994)

Doxycycline:
Potent metalloproteinase inhibitor Very effective (DONE ON animal studies ONELY)
(Petrinee et al J Vasc Surg 1996)

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Inflammatory Aortic Aneurysm

5-10% of AAA Pathology: we do not know the cause it is an inflammatory process
Marked thickening of the media & adventitia of the aneurysm wall
(AAA: the media is thin)

Dense retroperitoneal inflammatory fibrotic reaction incorporating:

Duodenum, IVC, Lt Renal vein, Ureters

Presentation:
Pain with No rupture Ureteric obstruction: 3-4% Weight loss: 5% High ESR (50-100 mm/1st hr)

Treatment:
Prof. Sami Asfar

Same as AAA

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Endovascular Repair of AAA

this comes recently without major surgery

Transfemoral placement of intraluminal prosthetic graft Stent graft into the infrarenal aorta Less morbidity and immediate postprocedure mortality

Require suitable length of normal calibre aorta below renal arteries for graft fixation
Initially it was thought that 40% of AAA are suitable

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Endovascular Repair of AAA

EVAR-1 & EVAR-2 Most recent results of two randomized studies:
Only reduced in-hospital mortality to 1.2% from 3.8% which is excellent Overall survival after 4 yrs NOT significant Re-intervention 5% a year because of endoleaks 1% a year incidence of rupture 33% more cost than normal major surgery (F/U with repeat CT-scans) Did not improve health related quality of life
(Lancet 2005;365:2156-2158)

Suitable for high risk patients who have suitable anatomic conditions (Aortic neck below renal arteries).
(Lancet 2005;365:2156-2158)

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Other Arterial Aneurysms

Iliac artery aneurysm Splenic artery aneurysm Renal artery aneurysm Femoral artery aneurysm Popliteal artery aneurysm Mycotic aneurysms

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Iliac Artery Aneurysm

Rarely isolated Usually extension of AAA Pulsatile mass palpable by PR examination Rupture into sigmoid colon:
Lower G.I. Bleed

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Splenic Artery Aneurysm 1% of population F:M 4:1 Causes:

Fibromuscular dysplasia Portal hypertension: 10% Multiparity Pancreatitis: pseudo-aneurysm

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Splenic Artery Aneurysm

Presentation
Incidental:
Plain X-ray: Signet ring calcification in 70% U/S, CT-Scan

Rupture:
Intra-peritoneal bleeding: shock Stomach: Upper GI bleeding Double rupture phenomenon (lesser sac then peritoneum) Mortality: 25%

Abdominal pain:
Epigastric & left upper quadrant
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Splenic Artery Aneurysm Rate of Rupture

Asymptomatic nonpregnant: 2% First discovered during pregnancy: 95%
Maternal Mortality 75%
(Angelakis Obst Gyn 1993)

Treatment:
Endovascular embolisation
For women in child-bearing age

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Renal Artery Aneurysm

Rare: 0.1% population Saccular < 1.5 cm Incidental Rupture is uncommon except in pregnancy Associated with:
Medial fibroplasia Polyarteritis nodosa: Multiple microaneurysms

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Management of Renal Artery Aneurysm

Indications
Symptomatic + > 2 cm diameter Child-bearing age

Surgery
Vein patch:
Saphenous vein graft

Internal iliac artery graft Ex-vivo repair

Percutaneous Embolisation
After one year

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Popliteal Artery Aneurysm

most common after AAA

Most common peripheral artery aneurysm Popliteal artery > 2 cm diameter Bilateral: 50% so when you diagnose it in one side most probably you have another one at the other side Associated with AAA: 40% Aetiology: Atherosclerosis Popliteal artery entrapment: Poststenotic dilatation

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Popliteal Artery Aneurysm

Clinical Presentation
50% Symptomatic: Distal ischaemia:
Most common and serious presentation Distal embolisation Acute thrombosis of aneurysm

Rupture: 4%
Compression of popliteal nerve or vein

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Popliteal Artery Aneurysm

Diagnosis:
U/S, MRA, CT-Scan Angiography

Treatment:
Proximal & distal ligation Femoro-popliteal bypass

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Popliteal Artery Aneurysm

Prognosis:
Depends on the patients presentation

Asymptomatic patients:
5-yr graft patency Limb salvage 80% 98%

Ischaemic symptoms:
65% 5-yr graft patency 20% amputation

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Mycotic Aneurysms
Bacterial infection of the arterial wall Usually saccular In atypical locations Lack calcification of the wall

Organisms:
o Staph species o Salmonella species o Streptococcus species 30% 10% 10%

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Mycotic Aneurysms
Presentation:
Fever, Leukocytosis Rapidly enlarging, warm, tender pulsatile mass Septic emboli Deeply seated:
PUO Rupture: Shock

Blood culture: +ve only 50%

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Mycotic Aneurysms
Affected Arteries:
Aorta 40% Peripheral arteries 35% Visceral arteries 20%
(Brown et al J Vasc Surg 1985)

Treatment:
Antibiotics Depending on the site:
Excision or bypass

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Thoraco-Abdominal & Dissecting Aneurysms

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Aortic Dissection DeBakey Classification

Type I:
Ascending, Descending & Abdominal Aorta

Type II:
Ascending Aorta

Type IIIa:
Descending Aorta

Type IIIb:
Descending & Abdominal Aorta

Marfans Syndrome Ehlers-Danlos Syndrome Takayasus aortitis

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Prof. Sami Asfar

Aortic Dissection
1. Intimal tear
Entrance
False Lumen

Exit

True Lumen

4. Double channel Aorta 2. Blood under pressure dissects the media 3. Splitting of media (intimomedial flap)
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Thoraco-Abdominal Aneurysms (TAAA) Crawford Classification

Type I:
Descending & Abdominal Aorta Not involving the Renal arteries

Type II:
Thoracic & Abdominal Aorta

Type III:
Distal Thoracic & Abdominal Aorta

Type IV:
All or most of Abdominal Aorta

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