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
seg-ment.
• A saccular aneurysm is a distinct, localized out-
pouching of the artery wall.
• A dissecting aneurysm is created when blood
sepa-rates 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
 INCICENCE
• 1. Approximately 36.5 abdominal aortic
aneurysms are diagnosed per 100,000 individuals.
• Abdominal aneurysms are most common in
individu-als 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.
• 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.
 ETIOLOGY
• 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.
 PATHOPHYSIOLOGY
• 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
 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
 CONTINUED……..
• Hoarseness, voice weakness, or complete
aphonia,
• Dysphagia
• Dilated superficial veins on chest
• Cyanosis
• Distended neck veins and edema of the head
and leg
• Decreased venous drainage
• Ipsilateral dilatation of pupils
 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
 CONTINUED……
• 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
 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
• Impotence
• 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
SURGICAL THERAPY
 OPEN SUGERY
1. Incising the diseased seg-ment 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.
 NURSING DIAGNOSIS
• Ineffective Tissue Perfusion related to
aneurysm or aneurysm rupture or dissection
• Risk for Infection related presence of
prosthetic vascular graft and invasive lines
• Acute Pain related to pressure of aneurysm
on nerves and postoperatively
•
 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
com-monly 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
classifi-cation
• 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 extend in the opposite direction,
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
diaphor-esis.
• 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
dissec-tion.
• Typically, the pain is localized to either the front or the
back of the chest.
• The pain may migrate along the direction of the
dis-section.
• 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
• CT scan
• Transesophageal echocardiogram (TEE)- A
transesophageal echocardiogram (TEE) can
identify dissections that are closest to the aortic
root
• Angiogram
• Magnetic resonance imaging (MRI)
 COMPLICATION
• Cardiac tamponade-Hypotension, narrowed
pulse pressure, distended neck veins, muffled
heart sounds and pulsus paradoxus
• Haemmorhage
• Ischemia
• Death
 NURSING MANAGEMENT
• Bed rest
• Pain relief with narcotics Control of blood
pressure
• trimethaphan (Arfonad)
• sodium nitroprusside (Nipride) Control of
myocardial contractility
• propranolol (Inderal)
• labetalol (Normodyne) Aortic resection and
repair
 Continued…
• Type A dissections usually are repaired
surgically
• Type B dissections often are managed
medically
 SURGICAL TREATMENT
• 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 management
• Aortic replacement,
• Fenestration of the intimal flap
• Extra-anatomic bypass
 NURSING MANAGEMENT
• Provide semi fowlers position-to maintain bp that
maintains vital organ perfusion
• Narcotics and tranquilezers should be administered
• Continous iv infusion of antihypertensive agents
• Should check for increasing pain, peripheral pulses
• The physician is also notified of persistent
coughing,sneezing, vomiting, or systolic blood pressure
above 180 mm Hg because of the increased risk for
hemorrhage
• Fluids are important to maintain blood flow through
the arterial repair site and to assist the kidneys with
excreting intravenous contrast agent and other
medications used during the procedure