Aneurysm

introduction
An aneurysm is a permanent localized dilation,
stretching or ballooning of an artery to
around 50% increase in the size.
Incidence:
 Aneurysms occur in men more often than in

women, and their incidence increases with

age.
Definition
 According to American heart association and
an aneurysm occurs when part of an artery
wall weakness allowing it to widen
abnormally or weakness, allowing it to widen
abnormally or balloon out
 In other words

An aneurysm is a localized sac or dilation

formed at a week point in the wall of the
aorta
Abdominal aortic aneurysm may be caused by:
 damage to the artery wall by metalloproteinase,

 infection

 congenital weakening of the connective tissue

component of the artery wall.

 fungal (mycotic) infections

 trauma

 smoking and male gender are stronger risk factors

 inflammatory aortitis

 infections aortitis (HIV infection, syphilis)

CLASSIFICATION
I. The layer of vessel wall involved :
 True aneurysms
 False aneurysms

II. Based up on morphology

Fusiform aneurysm
Sacular aneurysm
Dissecting aneurysm
Cylindrical aneurysm
Berry aneurysm
Classification
III. Based on location
 Aortic aneurysm
 Cerebral aneurysm
 Peripheral aneurysm

IV. Based on pathological mechanism

 Atherosclerotic aneurysms
 Syphilitic aneurysms
 Mycotic aneurysms
I.The layers of vessel wall involved
True aneurysms:Is one in which the wall of the
artery forms the aneurysm, with at least one
vessel layer still intact.
A true aneurysm is one that involve all three
layers of the wall of an artery
It can be further subdivided into
 Fusiform
 Saccular
False aneurysms or pseudo aneurysm:
 Is not an aneurysm, but a disruption of 1 to 2

layers of the arterial wall resulting in bleeding

that is contained by surrounding structures
(results from the development of a sac
around a hematoma, that maintains a
communication with the lumen of an artery
whose wall has been ruptured or penetrated).
False aneurysms may result from
 trauma or infection.
 after peripheral artery bypass graft surgery at

the site of the graft – to – artery anastomosis.

 arterial leakage after removal of cannulas

such as upper or lower extremity arterial

catheters and intra aortic balloon pump
devices.
Based on morphology
a.Fusiform aneurysm:
 It is circumferential and relatively uniform in

shape. (bilateral out pouching).

 Fusiform aneurysms bulges all the sides of a

blood vessel. The result is an elongated, tubular,

or spindle like swelling.
b.Saccular aneurysms:
 It bulges only on one side and it looks like sac,

they are spherical in shape and involve only a

portion of the vessel wall, they very in size and
filled with partially or fully by thrombus
c.Dissecting aneurysms:
 Is an aneurysm is an aneurysms that occurs

with a tear in the artery wall that separates

the 3 layers of the wall, rather than
ballooning out the entire wall. It is also
called pseudo aneurysm
 Is not a true aneurysm, but rather is a

hematoma in the arterial wall that

separates the layers of the arterial wall.
 Patients may have an aneurysm in more

than one location. The growth rate of

aneurysms is unpredictable, but the larger
the aneurysm, the greater the risk of
rupture
d. Cylindrical aneurysm
 aneurysm that occurs along the length of the vessels. It
is rare type of aneurysm.
e. Berry aneurysm
 A berry aneurysm which looks like a berry on a narrow
stem , is most common types of brain aneurysms. They
make up 90%of all brain aneurysm according to standford
health care . Berry aneurysm tend to appear at the base of
the brain where the major blood vessels meet ,also known
as the circle of willis.
when a berry aneurysm . Ruptures ,blood form the
artery moves into the brain causing subarachnoid
haemorrhage
Based on location
1.Aortic Aneurysm
The aorta is the large artey that begins at the
left vertical of the heart it passes through the
chest and abdominal cavities .The normal diameter
of the aorta in between 2 and 3 centimeter [cm]
but can bulge to beyond 5cm with an aneurysm .
The most common aneurysm of the aorta is an
abdominal aortic aneurysm[AAA] This occurs in the
part of the aorta that runs through the abdomen.
and Thoracic aortic aneurysm (TAA)part of the
aorta running through the chest.
 Abdominal aortic aneurysm
 Thoracic aortic aneurysm
Abdominal Aortic aneurysms:
 Are often asymptomatic and frequently detected on

routine physical examination or coincidentally when

the patient is examined for an unrelated problem.
(e.g.: abdominal x-ray, USG, CT Scan etc).
 On physical examination, a pulsatile mass in the

periumbilical area slightly to the left of the midline

may be detected. Bruits may be auscultated with a
stethoscope placed over the aneurysm. Physical
findings may be more difficult to detect in obese
individuals.
Clinical manifestation
-Only about 40% of the patients with abdominal
aortic aneurysms have symptons.
-some patients complain that they can feel thin
heart beating in their abdominal man or
abdominal thrombbing
-is associated with thrombus ,included or smaller
distal occlusion .may result from emboli
- Small cholesterol ,platelet ,or fibrin emboli may
lodge in the interosseous or digital arteries,
causing cyanosis and molting of the toe
CLINICAL MANIFESTATION
Thoracic aorta aneurysms:
 Are often asymptomatic ,when symptoms are present,

the most common manifestation is deep, diffuse chest

pain that may extend to the inter scapular area.
 Aneurysms located in the ascending aorta and the

aortic arch can produce angina from disruption of

blood flow to the coronary arteries and hoarseness as
a result of pressure on the recurrent laryngeal nerve.
Pressure on the esophagus can cause dysphagia.
 If the aneurysm presses on the superior vena cava,

decreased venous return can result in distended neck

veins and edema of the head and arms.
2.Cerebral /intracranial aneurysm
Is an abnormal localized dialation of the wall
of a cerebral artery due to congenital absence of
the muscle layer of the vessel.
Aneurysms usually occur at a bifurcation of an
artery or major branches of the circle of willis
Clinical manifestation :
severe head ache
nausea, vomitting
vision and speech impairment
meningeal sign
Grading of aneurysm
Hunt – Hess scale
 0-unruptured : asymptomatic discovery
 I- Asymptomatic : minimal headache with

slight nuchal rigidity.

 II-Moderate to sever headache, nuchal

rigidity, no neurological deficit other than CN

deficit.
 III- drowsiness, confusion, or mild focal

deficit (eg.hemiparesis) or combination of

these findings.
 IV – stupor, moderate to sever deficit,
possibly early decerebrate rigidity and
vegetative disturbances.
 V – deep coma, decerebrate rigidity,

moribund appearance.
 peripheral aneurysms
 AN aneurysm can also occur in peripheral
artery .types of peripheral aneurysm include;-
a] popliteal anuerysm
An aneurysm happens behind the knee , it is
most common peripheral aneurysm
Complications
-emboli :-severe ischemia of sudden onset
-thrombosis:-ischemia ulceration of toes
b]Splenic artery aneurysm
This type of aneurysm occur near
the spleen
site
Most common one in the main trunk
of spleen artery,usually solitary and one
saccular
C]Mesenteric artery aneurysm
This affects the artery that tranports
blood to the intestines
D]Femoral artery aneurysm
This femoral artery in the groin
E]Caroid artery aneurysm
This occurs in the neck
F] Visceral aneurysm
This is a bulge of the arteries that supply
blood to the bowel or kidney
Based on pathological mechanism
A] Atherosclerotic aneurysm
- Atherosclerotic Aneurysm are aneurysm
caused by atherosclerotic and typically occur
in the abdominal aorta
-Inflammation associated with
atheroscelerosis leads to
destruction ,thinking and thus weakening of
vascular wall,specifically the tunica
media ,which leads to aneurymal dilation of
the vessels
B]Syhilitic aneurysm
Sphilitic Aneurysm as arise during
tertiary ayphilis due to chronic
inflammation in the tunica adventitia of
large elastic arteries ,particularly the
aorta ischemia of thr tunica
media .combined with further syphilitie
inversion into the tunica media
itself .results in medial destruction and
weakening ,ultimately causing dilation
and aneurysm formation
C.MYCOTIC ANEURYSM : Resulting from
weakening of the arterial wall by microbial
infection.
ETIOLOGY
The exact cause is unknown.
Recent evidence includes:
 Atherosclerosis
 Hypertension
 Aortic aneurysms may involve the aortic arch,

thoracic aorta, and /or abdominal aorta.

 ¾ of true aortic aneurysms occur in the

abdominal aorta (below the level of the renal

arteries) and ¼ in the thoracic aorta. Popliteal
artery aneurysms rank third in frequency.
 Syphillis
 Marfan syndrome
 Penetrating or blunt trauma
 Older age (60)
 Male sex
 Family history of aneurysmal disease
 Hyperlipidemia
 Obesity
 Diabetes
PATHOPHYSIOLOGY
The most common etiology of aneurysms of the
descending and abdominal aorta is
atherosclerosis.
loss of elasticity, weakening and aortic dilation

degenerative changes in the media (middle layer

of the arterial wall)

atherosclerotic plaque deposition beneath the

intima (the innermost layer of the arterial wall)

As the aneurysm expands the wall tension

increases
Further weakening of vessel walls

If not treated : ruptre

Clinical manifestation
 Constant pain in abdomen, chest, lower back
or groin area.
 Sudden severe headache, nausea, vomiting,

visual disturbance, loss of consciousness

 Lower abdominal, back and / or groin pain
 Easily palpated (felt ) pulsation of the artery

located in the groin area , knee.

 Pain in the leg, sores or the feet /lower legs.
Diagnostic studies:

1.Chest x-rays: Done in demonstrating the

media stinal silhouette and any abnormal
widening of the thoracic aorta.
2.Plain x–ray of the abdomen: May show
calcification within the wall of AAAs.
3.ECG:May be performed to rule out evidence
of MI because some persons with thoracic
aneurysms have symptoms suggestive of
angina.
4.Echocardiography: Assists in the diagnosis
of aortic valve insufficiency related to
ascending aortic dilation.
5.USG :Useful in screening for
aneurysms and to serially monitor
aneurysm size.

6.CT scan: Is the most accurate test to

determine the anterior – to – posterior
length, the cross – sectional diameter,
and the presence of thrombus in the
aneurysm
7.MRI : May be used to diagnose and assess
the location and severity of aneurysms.

8.Angiography: Provides information about the

involvement of intestinal, renal or distal
vessels. It is also useful if a suprarenal or
thoracoabdominal aneurysm is suspected.
Complications
 Fetal hemorrhage
 Myocardial ischemia
 Paraplegia due to interruption of anterior

spinal artery
 Abdominal ischemia
 Graft infection
 Graft occlusion
 Acute renal failure
 impotence
MANAGEMENT
The goal of management is
 To prevent the aneurysm from rupturing
◦ Once an aneurysm is suspected, studies are
performed to determine its exact size and location.
◦ A careful review of all body systems is necessary to
identify any coexisting disorders, especially of the
lungs, heart or kidney because they may influence
the patient’s surgical risk.
◦ If carotid and /or coronary artery obstructions are
present they may need to be corrected before the
aneurysm is repaired.
◦ For individuals with small aneurysms (<4 cm),
conservative therapy is initiated, which consists of
risk factor modification, decreasing blood pressure
and monitoring aneurysm size every 6 months
using, MRI and CT scan (5.5 cm is the threshold for
repair).
SURGICAL MANGEMENT
Surgical intervention may occur earlier in
 Younger low – risk patients
 If the aneurysm is expending rapidly ( 0.5cm

diameter increase over a 6 month period)

 In a patient who is symptomatic
 If the risk of rupture is high.
1. Aneurysm Repair: Surgical repair is recommended for all
aneurysms greater than 6cm wide.

 The surgical technique involves:

 The aneurysm is exposed, the aorta is clamped just above
the below the aneurysm to stop the flow of blood.
 Incising the diseased segment (thoracic or AAA) of the aorta
and removing intraluminal thrombus or plague.
 Inserting a synthetic graft (Dacron or poly tetrafluroethylene
(PTFE)), which is sutured to the normal aorta proximal and
distal to the aneurysm
 Suturing the native aortic wall around the graft so that it will
act as a protective cover.
2. Endovascular Graft Procedures:
 Minimally invasive endovascular grafting in an

alternative to conventional surgical repair of

AAAs. The endovascular technique involves
the placement of a suture less aortic graft
into the abdominal aorta inside the aneurysm
via a femoral artery cut down.
3. Clipping the aneurysm
4. Wrapping the aneurysm
5. Coiling the aneurysm
6. Endovascular graft procedure
Nursing Management:

Nursing assessment
 A thorough history and physical assessment

should be performed. The patient should be

monitored for indications of aneurysm
rupture such as diaphoresis, paleness,
weakness, tachycardia, hypotension,
abdominal, back, groin or periumbilical pain,
changes in level of consciousness or a
pulsating abdominal mass.
Nursing implementation:
 Health promotion
 The patient should be encouraged to reduce

cardiovascular risk factors, including BP

control, smoking cessation increasing
physical activity and maintaining normal body
weight and serum lipid levels.
Acute intervention:
 Pre operative assessment must include

detection of concurrent coronary artery

disease and cerebrovascular disease.
 Assess all peripheral pulses for baseline

comparison post operatively.

 Preoperative preparations are same like any

other major surgeries including bowel

preparation, NPO after midnight, IV
antibiotics immediately before surgery.
Post operative care:
 Post operatively patients typically go to an ICU

for close monitoring. If the thorax is entered

during surgery, chest tubes will be in place.
 In addition to maintaining adequate respiratory

function, fluid and electrolyte balance, pain

control the nurse must monitor graft potency
and renal perfusion, dysrhythmias, infections,
neurologic complications etc.
1. Risk for hemorrhage related to risk of bleeding
at the graft site
Interventions:
 Monitor for increase in pulse rate, decrease in BP,

clammy skin, anxiety, restlessness, decreasing

levels of consciousness, pallor, cyanosis, thirst,
oliguria (urine output less than 0.5 ml/kg/hour),
increase in abdominal girth, increased chest tube
output greater than 100ml/hour for 3 hours and
back pain (retroperitoneal bleeding).
 Monitor CVP, left atrial pressure.
2. Risk for impaired gas exchange related to ineffective
cough secondary to pain from large incision.
Interventions:
 Assess lung sounds every 1 to 2 hours. Report any

adventitious sounds.
 Adequately oxygenate the client
 Monitor oxygen saturation continuously

 After extubation, assist with coughing by using

incentive spirometry, provide splinting pillows before

coughing, encouraging ambulation and adequate
analgesia.
3. Risk for ineffective tissue perfusion related to
temporary decrease in blood supply during surgery.
Interventions:
 Assess dorsalis pedis and posterior tibial pulses every

hour for 24 hours.

 Report any change in pulse quality or absent pulses.

 Assess dorsiflexion and plantiflexion and sensation.

(pins and needles sensation) every hour for 24 hours

 Inspect lower extremities for mottling, cyanosis,

coolness or numbness every 4 hours

Medical management of TAA
 Beta blockers: atenolol (tenormia)
metorodol
carvedilol
 Angiotensin receptor blocker :

losartan
valsartan
Irbesartan
End