AORTIC ANEURYSM

DEFINITION
An aneurysm is a localized sac or dilation formed at a weak point in the wall of the aorta. Because of the high pressure in the arterial system, aneurysms can enlarge, producing complications by compressing surrounding structures

CLASSIFICATION

 A fusiform aneurysm is a diffuse dilation that involves the entire circumference of the arterial segment. A saccular aneurysm is a distinct, localized out pouching of the artery wall. A dissecting aneurysm is created when blood separates the layers of an artery wall, forming a cavity between them. A false aneurysm (pseudoaneurysm) occurs when the clot and connective tissue are outside the arterial.

ABDOMINAL AORTIC ANEURYSMS

 1. Approximately 36.5 abdominal aortic aneurysms are diagnosed per 100,000 individuals. Abdominal aneurysms are most common in individuals older than 50 years of age. They are more common in men than women, with ratios of 2:1. Three fourth of true aortic aneurysm occur in abdomen and one fourth in the thoracic aorta The average mortality rate for persons undergoing elective abdominal aneurysm repair is 4 to 5 percent.

INCIDENCE

 Rupture of abdominal aortic aneurysm is the 15th most common cause of death for men in the United States. Fifty percent of all persons whose aneurysms rupture before they can be transported into the operating room will die. For persons who undergo emergency surgical repair mortality rate is also high, around 54 percent.

 Atherosclerosis Uncontrolled hypertension inherited or congenital syndromes, such as Marfan syndrome or Ehlers-Danlos syndrome. Infection Tobacco use Anastomotic (postarteriotomy) and graft aneurysms Blunt or sharp trauma, including operative trauma, can damage the aortic wall.

ETIOLOGY

 Most commonly, atherosclerotic plaque collects on the intimal surface of the aorta. This plaque formation will cause degenerative changes in the media The destruction of the medial layer of a segment of the aorta leads to loss of elasticity, weakening Dilation of the aorta

PATHOPHYSIOLOGY

CLINICAL MANIFESTATION
THORACIC AORTIC ANEURYSMS Pulse and BP difference in upper extremities Pain and pressure symptoms Constant pain because of pressure Intermittent and neuralgic pain Dyspnea, Abnormal pulsation apparent on chest

 Hoarseness, voice weakness, or complete aphonia, Dysphagia Dilated superficial veins on chest Cyanosis Distended neck veins and edema of the head and leg

CONTINUED..

ABDOMINAL ANEURYSM
Asymptomatic Abdominal pain is most common, either persistent or intermittent often localized in middle or lower abdomen to the left of midline Lower back pain Feeling of an abdominal pulsating mass Thrill, auscultated as a bruit

 Hypertension Distal variability of BP, pressure in arm greater than thigh Thrombi may form and and then embolize,traveling to other arteries and causing ischemia to affected limb If rupture, will present with hypotension and/or hypovolemic shock

CONTINUED

DIAGNOSTIC EVALUATION Health history Physical examination Abdominal ultrasound Arteriography X-ray Computed tomography

COMPLICATIONS Fatal hemorrhage Myocardial ischemia Stroke Paraplegia due to interruption of anterior spinal artery Abdominal ischemia

Continued.
Graft occlusion Graft infections Acute renal failure Lower extremity ischemia Death

PROGNOSIS
With early diagnosis and treatment the prognosis is good When the aneurysm ruptures survival rate drops dramatically to below 50 percent

COLLABORATIVE CARE
Early treatment and detection is imperative If aneurysm is larger than 5-6cm or increasing aneurysm by 0.5 cm over a six month period surgical repair is the treatment For individuals with small aneurysm less than 4cm conservative therapy is initiated Coronary and carotid artery should be assessed for atherosclerotic disease

OPEN SUGERY
1. Incising the diseased segment of the aorta; 2. Removing intraluminal thrombus or plaque; 3. Inserting a synthetic graft (dacron or polytetrafluoroethylene), which is sutured to the normal aorta proximal and distal to the aneurysm; and 4. Suturing the native aortic wall around the graft so that it will act as a protective cover If the iliac arteries are also aneurysmal, the entire diseased segment is replaced with a bifurcation graft.

Incising the diseased segment of the aorta

1. insertion of synthetic graft

3.suturing native aortic wall over synthetic graft

ENDOVASCULAR GRAFTING
Endovascular grafting involves the transluminal placement and attachment of a sutureless aortic graft prosthesis across an aneurysm

COMPLICATIONS OF ENDOVASCULAR GRAFTING

bleeding, hematoma, wound infection at the femoral insertion site; distal ischemia or embolization; dissection or perforation of the aorta;

CONTINUED.
Graft thrombosis; graft infection; break of the attachment system; Graft migration; proximal or distal graft leaks; delayed rupture Bowel ischemia.

PATIENT EDUCATION AND HEALTH MAINTENANCE Instruct patient about medications to control BP and the importance of taking them. Discuss disease process and signs and symptoms of expanding aneurysm or impending rupture, For postsurgical patients, discuss warning signs of postoperative complications (fever, inflammation of operative site, bleeding, and swelling).

CONTINUED..
Encourage adequate balanced intake for wound healing. Encourage patient to maintain an exercise schedule postoperatively. Instruct patient that due to use of a prosthetic graft to repair the aneurysm, he will require prophylactic antibiotic use for invasive procedures, including routine dental examinations and dental cleaning

EVALUATION: EXPECTED OUTCOMES

TISSUE COLOR, SENSATION, AND TEMPERATURE NORMAL; NONTENDER, NONSWOLLEN, AND INTACT NO SIGNS OF INFECTION REPORTS CONTROL OF PAIN WITH MEDICATION

AORTIC DISSECTION

DEFINITION
Aortic dissection, occurring most commonly in the thoracic aorta, is the result of a tear in the intimal (innermost lining of the arterial wall) that allows blood to enter between the intima and media, thus creating a false lumen

CLASSIFICATION
Type A dissections Include types I and II of DeBakey's classification Involve the ascending aorta or the ascending and descending aorta Are the most common and lethal type Require immediate surgicaL treatment

CONTINUED.
Type B dissections Do not involve the ascending aorta Begin distal to the subclavian artery and extend downward into the descending and abdominal aorta Are also known as type III of DeBakey's classification often initially treated with medical therapy

INCIDENCE
They are three times more common in men than in women most commonly in the 50- to 70-year-old age group Approximately 60,000 cases are diagnosed each year in the United States.

ETIOLOGY
Marfan syndrome Congenital heart disease A history of hypertension Pregnancy Trauma Iatrogenic injuries Atherosclerosis

Continued
A rupture may occur through adventitia or into the lumen through the intima, Allows blood to reenter the main channel Resulting in chronic dissection or occlusion of branches of the aorta. As the heart contracts, each systolic pulsation causes increased pressure on the damaged area, which further increases the dissection

 The dissection of the aorta may progress backward in the direction of the heart, obstructing the openings to the coronary arteries or producing hemopericardium (effusion of blood into the pericardial sac) or aortic insufficiency, it may progress forward , causing occlusion of the arteries supplying the gastrointestinal tract, kidney, spinal cord, and legs

 Sudden onset of pain that is described as severe and tearing. The pain is typically associated with diaphoresis. The typical patient with acute aortic dissection usually has sudden, severe pain in the anterior part of the chest or intra scapular pain radiating down the spine into the abdomen or legs Location of the pain depends on the site of the dissection. Typically, the pain is localized to either the front or the back of the chest. The pain may migrate along the direction of the dissection.

Cardiac tamponade Hypertension or hypotension Absence of peripheral pulses Aortic regurgitation from damage to the aortic valve Pulmonary edema Neurologic findings are due to dissection of major arteries. Carotid artery obstruction produces hemiplegia or hemi anesthesia. Spinal cord ischemia can cause paraplegia. Compression of adjacent structures

DIAGNOSTIC EVALUATION
Health history and physical examination ECG-Left hypertrophy Chest x-ray angio CT scan 64 Transesophageal echocardiogram (TEE) Angiogram Magnetic resonance imaging (MRI)

COMPLICATION
Cardiac tamponade-Hypotension, narrowed pulse pressure, distended neck veins, muffled heart sounds and pulsus paradoxus Haemmorhage Ischemia Death

 Type A dissections usually are repaired surgically Type B dissections often are managed medically

 Surgical treatment is indicated in several circumstances: (1) location of dissection in ascending aorta, (2) development of ischemic complication, (3) poor response to medical management with continued pain, (4) aneurysmal degeneration (5) in selected Stanford type B patients

SURGICAL TREATMENT

Surgical management
Aortic replacement, Fenestration of the intimal flap Extra-anatomic bypass