Arterial Aneurysms

Vascular Surgery Course For MRCS

Military Academy, Thursday 18.08.05
 Definition
Permanent localized dilatation of the
affected artery over the normal diameter
~ 50% Arteriomegaly
~ 100% Aneurysms

As the age increases, arteries become

stiffer, wider (aneurysm) and longer
(tortousity)
 Aetiology
Most aneurysms are caused by degenerative
disease affecting the vessel (atherosclerosis)
Structural weakness & Haemodynamic forces
Damage to, and loss of intima
Reduction in the elastin and collagen content of the
media
Collagen; tensile strength, adventitia
Elastin; recoil capacity, media
Risk factors
smoking, hypertension, hypercholesterolaemia
 Aetiology
Laplaces low
(Tension varies directly with radius when
pressure is constant)

For every increase in the radius there is a

large increase in tension, leading to further
enlargement of the aneurysm
 Rare causes of aneurysms
Congenital
Marfans syndrome, Berry aneurysms
Post-stenotic
Coarctation of the aorta, Cervical rib, Popliteal
artery entrapment syndrome
Traumatic
Gunshot, stab wounds, arterial punctures
Inflammatory
Takayasos disease, Behcets disease
 Rare causes of aneurysms
Mycotic
Bacterial endocarditis, syphilis
Pregnancy associated
Splenic, cerebral, aortic, renal, iliac &
coronary
 Classification
False Fusiform
Due to traumatic Spindle-shaped
breach in the wall involving whole
The sac made up from circumference
the compressed Saccular
surrounding tissue Small segment of wall
True ballooning due to
Dilatation involving all localized weakness
layers of the wall
 Incidence- atherosclerotic

>90% affecting abdominal aorta

Infra-renal segment in ~95%
Male : Female ratio 4:1
More common in western countries
5% over 50s, 15% over 80s
Associated with iliac aneurysms in 30%
Associated with popliteal aneurysms in 10%
Anatomy of the abdominal aorta
Begins at T12, Ends at L4
Anterior relations
Splenic vein, pancreas, duodenum
Right
Cisterna chyli, IVC, azygos vein
Left
Sympathetic trunk
Surface anatomy
Just above transpyloric plane in the mid line to a point
left to the midline on the supracristal plane
branches of the abdominal aorta
Paired visceral branches
Suprarenal, renal, gonadal
Unpaired visceral branches
Coeliac, SMA, IMA
Paired abdominal wall branches
Subcostal, inferior phrenic,lumber
 Clinical features of AAA
Asymptomatic in 75%
Incidentally discovered during clinical exam.or
radiographic investigation
Pain
Central abdominal radiating to the back
Chronic due to stretching the vessel wall or
compression/erosion of surrounding
structures
Acute pain due to rupture
 Clinical features of AAA
Rupture
Risk of rupture correlate with aneurysm size
Retroperitoneal, back pain, stable
Intraperitoneal, abdo/back/falnk pain, shock
5-year rupture rate 0% in AAA <5cm
5-year rupture rate 25% in AAA >5cm
Risk of rupture can be predicted by
High diastolic BP, COAD
 Complications of AAA
Fistulation, rare
Gut, IVC, left renal vein
Thrombosis, rare
Acute lower limb ischaemia
Distal embolism
Acute ischaemia to small distal areas (trash
foot)
Distal obliteration
Claudication, rest pain, gangrene
 Investigation
CXR, PFT
ECG, Echo
ESR
U&Es
USS
Spiral CT with contrast
Arteriography
 Management of AAA
Elective repair for AAA >6cm
Mortality 5%
Urgent repair for AAA <6cm
Developed back pain
Rate of growth >0.5cm / 6 month
Emergency repair for ruptured AAA
Mortality 50%
 Elective surgical repair
6-unit X-matched blood
Mid line or transverse incision
Aneurysm neck defined and controlled
Control of normal vessels distal to AAA
Systemic heparinization, 5000IU
AAA sac opened and thrombus removed
Back bleeding from lumber arteries controlled by
sutures
Inlay tube or trouser synthetic graft
Closure of aneurysm sac over graft
 Emergency surgical repair
Unstable patient, no investigation
Stable patient, USS/spiral CT
10-unit of x-matched blood
Urinary catheter & 2 large-bore i.v. lines
Resustation to systolic BP ~100mmHg
Crash anaesthetic induction
No heparinization
Rapid entrance to abdomen & neck control
If difficult, supra-renal clamp for short period
 Complications of aortic surgery
Haemorrhage, DIC
CVA
Colonic ischaemia spinal cord ischaemia
Aorto-enteric fistula
Graft thrombosis
Myocardial ischaemia
Renal failure, ARDS, MODS
False anastomotic aneurysm
Distal embolism (trash foot)
 Endovascular repair of AAA
Patient unfit for surgical repair
severe cardio-pulmonary co-morbidities, hours shoe
kidney, Inflammatory AAA, hostile abdo.
Anatomical suitability
Neck diameter & length
Iliac arteries diameter & tortousity
Morbidity
Endoleak, migration, kink, thrombosis
Mortality ~5%
Flow-up & durability
 Inflammatory AAA
Marked fibrosis of the aneurysm wall extending to the
surrounding structures
It involve the anterior and lateral aspects only
It associated with inflammatory cell infiltrate of T- , B-
lymphocytes & plasma cells
The fibrosis may compress the ureters leading to renal
failure
Rupture is less common and usually posterior
Pt. presents with abdo. pain, weight loss, raised ESR
Difficult surgery, therefore conservative/endovascular
 popliteal aneurysms
Second most common site of atherosclerotic
aneurysms
Occasionally, present with pulsatile swelling
Commonly, aneurysm thrombosis or distal
emboli leading to peripheral ischaemia
USS/CT/Arteriography to confirm diagnosis
Surgical repair, resection/ligation and vein
bypass
40% of pts with PA aneurysms have an AAA
 Femoral aneurysms
Can occur in isolation but usually part of
generalized arteriomegaly
Often symptomless and rarely rupture
Distal emboli & thrombosis may occur
Surgical repair by using vein or synthetic graft
 Splenic aneurysms
Male : female 1 : 4
It present in child bearing period
Usually symptomless unless ruptured
Rupture rate 25% in the third trimester
Surgical treatment is indicated if the
aneurysm diameter >3cm or patient is
pregnant
 1- AAA
A- is 4 time more common in males
B- incidence is falling in western countries
C- may safely observed if asymptomatic and
>5.5cm in diameter
D- is rarely amenable to endoluminal stenting
E- is less common than popliteal aneurysms
 2- AAA
A- may cause embolisation to lower limbs
B- is more common in males
C- can almost always be treated by
endovascular stenting
D- can be detected by screening
E- should be operated upon when it is 5.5 cm
long
 3- AAA
A- typically rupture at 4cm diameter
B- extends above the renal artery in 20% of
cases
C- is invariably visible on abdominal X-ray
D- is associated with coronary artery disease
E- has an association with smoking
 answers
1- A
2- ABD
3- DE