Aneurysms
❖ Definition: An aneurysm is a localized dilatation of an artery, at least 1.5
times its normal given diameter to form a sac.
❖ Classification: Aneurysms can be classified according to:
➢ Structure:
o True aneurysm: where, the wall is formed of the 3 layers of the dilated
artery; intima, media, and adventitia.
o False aneurysm is a hematoma communicating with the lumen of an
artery through a small puncture tear in its wall. Thus, the wall of the
false aneurysm is formed by the fibrous wall of the hematoma.
➢ Site:
o Central: meant for aortic aneurysm which commonly involve the
abdominal aorta.
o Peripheral: the commonest is the popliteal aneurysm.
o Visceral: the commonest is splenic, renal, coeliac, and superior
mesenteric artery.
o Carotid: rare but quite problematic if left untreated
➢ Etio-pathological:
o Degenerative (atherosclerotic): the most common and it is due to
structural change of the arterial wall resulting in its weakness.
o Infected: it is to describe a localized infection of the arterial wall; the
most vivid example is the mycotic aneurysm secondary to infected
embolus showering from infected cardiac valve’s vegetation
complicating bacterial endocarditis or infection of preexisting
aneurysm
o Collagen diseases: like Behcet’s disease, Marfan syndrome and
Ehler’s Danlos syndrome due to defective collagen synthesis
o Traumatic: all starts as a small puncture wound that initially seal by a
clot with contained perivascular hematoma. Later the clot dissolve
with communication set between the vessel lumen and the inner cavity
of the previous hematoma contained within its fibrous capsule (false
aneurysm). Could occur either:
▪ Iatrogenic: following a percutaneous arterial access for example
cardiac catheterization
▪ Inadvertent Intravenous Drug Abusers: due to mistakenly
puncturing the artery during recreational drug injection
▪ Penetrating trauma: sharp puncture penetrating trauma e.g., knife
tip
o Congenital: due to inborn event resulting in aneurysm which is usually
saccular e.g., Berry’s aneurysm of the circle of Willis that would lead to
subarachnoid hemorrhage upon rupture, visceral aneurysms like splenic,
coeliac, and renal.
❖ Complications:
➢ Rupture is the most serious complication. It can produce fatal hemorrhage.
➢ Distal Ischemia: due to either:
o Thrombosis and total occlusion of the aneurysm as in case of popliteal
aneurysm.
o Detachment of fragments of the mural thrombus from within the
aneurysm can cause distal embolization. A common example is the
occurrence of gangrene in one of the digits due to distal emboli from
subclavian aneurysm which develops in patients with thoracic outlet
syndrome.
➢ Infection may lead to rupture and secondary hemorrhage and/or sepsis
syndrome and septic shock
➢ Compression on adjacent structures as the aneurysm gets bigger e.g:
o Vein…. may cause obstruction or even thrombosis.
o Nerve may cause motor or sensory affection.
o Bone may also be eroded as commonly seen in lumbar vertebra due
abdominal aortic aneurysm
➢ Penetration into adjacent structure like a vein or a viscus producing a
fistula e.g AortoCaval and AortoEnteric Fistulae.
❖ Clinical features:
➢ Asymptomatic: most of the central aneurysms are asymptomatic
aneurysms, e.g., the abdominal aorta. They are accidentally discovered
at clinical examination or imaging study that is done for another reason.
➢ Pulsating Swelling.
➢ Symptoms due to compression on adjacent structures.
➢ LOCAL signs of aneurysm:
o A swelling that lies along the line of an artery and can be moved across
the line of the artery but not along it.
o The swelling exhibits expansile pulsations (expansile means expansion
in all directions
o Proximal pressure on the main artery results in diminution or
disappearance of the pulsations.
o Distal compression on the main artery causes the aneurysm to increase
in size and to become tenser.
o A systolic thrill may be felt and a systolic bruit may be heard.
❖ Differential diagnosis:
➢ Swelling overlying an artery may elicit transmitted arterial pulsations.
Pressure on the proximal artery does not change the size of the swelling.
If the swelling can be moved away from the artery, the pulsations would
disappear.
➢ Vascular tumour as an osteosarcoma or metastases may pulsate.
➢ Abscess
➢ Arterio-Venous Fistula
❖ Investigations:
1. Duplex scanning is very useful
2. CT angiography is very accurate in diagnosis
3. Magnetic Resonance Angiography MRA which might replace CT
angiography in case of renal impairment.
Abdominal aortic aneurysm (AAA)
This is the most frequent site of aneurysms. It affects the aorta below the
origin of the renal arteries in 95% of cases. It may extend to affect the iliac arteries.
Rarely does it extend upwards to involve variable distance of the suprarenal
abdominal aorta or the thoracic aorta in which case it is called a thoraco-abdominal
aortic aneurysm. The most serious natural fate is rupture. Risk of rupture is
exponentially related to the aneurysm transverse diameter where a significant risk is
observed when the diameter at or exceed 5 cm in female and 5.5 cm in male patients.
❖ Etiology:
Atherosclerosis induced degenerative wall changes is the commonest cause
and is responsible for 95% of AAAS.
❖ Clinical features:
➢ Asymptomatic aneurysms: In 75% of patients the AAA is discovered
accidentally during a routine abdominal examination (as a pulsatile epigastric
mass) or during ultrasonography or CT scan performed for some other reason.
➢ Pain is the commonest symptom. As A.A.A. gradually enlarges and impinges
on surrounding structures causing vague abdominal pain. Back and flank pain
results from vertebral compression. Large aneurysms can even erode the spine
and cause severe back pain, in absence of rupture, these patients may be
wrongly diagnosed as having lumbar disc prolapse.
➢ Symptoms of rupture. The classic triad of AAA rupture is sudden severe Pain,
a pulsatile abdominal Mass and Shock. However, sometimes one or more of
the components of the triad are absent or delayed in a patient with rupture.
❖ Investigations:
Imaging studies:
➢ Ultrasonography. If AAA is clinically suspected, ultrasonography is
the screening test of choice to document or to rule out the presence of
an aneurysm. It is rapid, inexpensive, non-invasive, and accurate.
➢ C.T scan If repair of AAA is decided, CT scan provides data that are
important for surgery especially if endovascular repair is considered.
➢ Magnetic resonance angiography MRA: is a good alternative to CT
scan but is costly yet it is the preferred imaging modality in those
patients with renal impairment.
➢ Direct aortography it would provide information about the aortic
branches and their relation to the aneurysm, however those data are
readily available using CT. So direct aortography is not used for
diagnostic purposes whenever aneurysm is suspected.
Preoperative Investigations:
o CBC and Coagulation profile.
o Kidney functions.
o Liver Functions.
o ECG, Echocardiography
Treatment:
➢ Screening Program:
o Ultrasonography to all high-risk individuals like age above 60,
hypertensives, Ist degree relative of known AAA cases.
➢ Conservative management:
o Aneurysms with less than critical transverse diameter (5 cm in
female and 5.5 cm in males) are not offered intervention yet with
proper control of their risk factors e.g., hypertension and
smoking.
o Interval ultrasound measurement
➢ Elective intervention:
o Indications:
• Symptomatic AAA regardless of the size
• Asymptomatic AAA either:
◼ Reaching the critical diameter (5.5 cm)
◼ Or increasing diameter on follow up ultrasonography (½ cm
every 6 months)
◼ Or aneurysm discovered accidently prior to abdominal
transplant proceduree.g., liver or kidney
➢ Urgent Intervention: Patients presenting with symptoms of acute expansion
(acute onset of severe abdominal pain referred to back with absence of signs
of rupture or leakage on Contrast CT)
➢ Immediate Intervention: Patients with diagnosis of either rupture or
leaking
◼ Immediate transfer to the operating room
◼ No time should be lost in surgical ward or ICU admission
Techniques of AAA repair:
Depending upon the patient’s fitness for surgery and suitable abdominal conditions
they might be offered one of the following:
❖ Open Abdominal Aortic repair:
In patients with good general condition and acceptable cardiopulmonary
functions without a previous history of major abdominal surgery or peritonitis, the
standard treatment is trans-peritoneal open repair by excluding the aneurysm and
implanting a synthetic graft
❖ Endovascular repair of AAA :
In patients of either high risk for anesthesia or open surgery or with
previous major abdominal surgery or with gastrointestinal or less common other
abdominal malignancy with good survival potential might be offered the
endovascular therapy if certain anatomical conditions of the aorta, aneurysm and
bilateral iliac artery are fulfilled.
