AORTIC ANEURYSMS

Dr. Santosh Mathew MS.,MCh.,FIACS

Consultant Cardiac Surgeon
Ahalya Hospital, Mussafah.
AORTIC ANEURYSM
• Aortic aneurysm is a general term for an
enlargement (dilatation) of the aorta greater than 1.5
times normal size.
• Cause of an aneurysm is multifactorial.
• End Result is an underlying weakness in the wall of
the aorta at that location
• According to Law of Laplace all aneurysms expand
till rupture. ( T=PxR)
 CAUSES OF AORTIC ANEURYSM
GENETIC CONDITIONS
• Marfan syndrome (FBN1 mutation)
• Ehlers-Danlos syndrome type IV (COL3A1
mutation)
• Loeys-Dietz syndrome (TGFBR1 and TGFBR2
mutations)
• Turner syndrome (45,X karyotype)
• Polycystic kidney disease
• Noonan syndrome
MARFAN’S SYNDROME
EHLER-DANLOS SYNDROME
 CAUSES OF AORTIC ANEURYSM

• Hypertension
• Dyslipidemia – Atherosclerosis
• Vasculitis
• Microbial infections - syphilis, staph aureus
• Autoimmune – Kawasaki disease
• Cocaine, Amphitamine
• Post stenotic aneurysm
• Aortic Trauma
INFLUENCE OF AORTIC SIZE ON , LIFETIME INCIDENCE OF
RUPTURE/DISSECTION OF AORTIC ANEURYSM.
(Plot for the ascending aorta is shown in the upper panel and for the
descending aorta in the lower panel)
EPIDEMIOLOGY OF AORTIC ANEURYSMS
• 1% - 2% of population harbor aneurysms in their
aorta
• 10% prevalence in older age groups
• Most aneurysms go undetected until rupture
• Mortality from ruptured aneurysms is as high as
90%
• 15000 individuals die every year because of rupture
of aortic aneurysms in US
• Aneurysms run in families ( 1° relatives x 12 times)
 PATHOLOGY OF AORTIC ANEURYSMS
• Intimal atheroscleosis
• Decrease in the number of smooth muscle cells in
the aortic media layer (medial atrophy)
• Fragmentation of elastic lamina
• Signs of local chronic inflammation of aortic wall
• Neovascularisation
• Intraluminal thrombus
SYPHILITIC AORTIC ANEURYSM
SIGNS & SYMPTOMS OF AORTIC
ANEURYSMS
• Most intact aortic aneurysms do not produce
symptoms
• As they enlarge, symptoms such as
abdominal pain and back pain may develop
• Compression of nerve roots may cause leg
pain or numbness
SIGNS & SYMPTOMS OF AORTIC
ANEURYSMS
• Pain in an aneurysm is a sign of
impending rupture
• when rupture occurs massive internal
haemorrhage results, unless treated
immediately, shock and death can occur
within minutes.
ENDO ANEURYSMORRAPHY IS THE GOLD
STANDARD FOR ANEURYSM REPAIR
ENDOVASCULAR STENT GRAFT
 ASCENDING AORTIC ANEURYSM WITH
SEVERE AR IN A PATIENT WITH MARFAN
SYNDROME
 CASE PRESENTATIONS
1
• 48 year old male • Brought in shock to A/E BP
• 71/53, left hemiparesis
Known Hypertensive for >3 yrs
stopped medication • UMN facial palsy (L)
• Feeling unwell for few days • Resuscitated with i.v. fluids
• Sudden onset severe chest pain • Peripheral pulses feeble. radial
and loss of consciousness pulse L < R
• Systolic murmur
INVESTIGATIONS

ECG Chest X - ray

ECHOCARDIOGRAM
• Pericardial Effusion, Tamponade Physiology
• Concentric LVH
• Good LV function No WMA
• Dilated ascending aorta (5cm) with dissection
and thrombus in the false lumen with turbulent
flow
• Aortic Valve Normal
CT SCAN
PRE OP CT SCAN
PROFOUND HYPOTHERMIA & TOTAL
CIRCULATORY ARREST
• At 15°C Heart Lung Machine was stopped and
all the blood from the patient was drained into
the oxygenator reservoir
• Hypothermia was maintained by cooling
blankets and ice packs around the head
• Distal anastomosis of the aortic arch with the
dacron graft
• Heart Lung Machine was restarted by pumping
blood into the aorta through the femoral artery
CASE PRESENTATIONS
2
CASE PRESENTATIONS
3
 ABDOMINAL AORTIC ANEURYSM
• Risk of rupture is related to diameter
• Once the aneurysm reaches about 5 cm high risk
for rupture
• Fusiform aneurysms are considered less rupture
prone than saccular
• Present as large pulsatile mass above the
umbilicus
• Bruit may be heard from the turbulent flow in the
aneurysm
 ABDOMINAL AORTIC ANEURYSM

• Rupture may be the first hint of AAA

• Once aneurysm has ruptured it presents with
classic symptoms of abdominal pain which is
severe, constant and radiating to the back , with
flank ecchymosis
• Diagnosis confirmed by bedside ultrasound.
Free fluid in abdomen may indicate rupture
• Contrast enhanced Ctscanis the best to diagnose
AAA and guide treatment options
FLANK ECCHYMOSIS
 CASE PRESENTATIONS
4

• 29 year old male staff nurse from Phillipines

• Referred with huge suprarenal abdominal
aortic aneurysm 10.8 cm in diameter, 21.3cm
in length extending from below the level of
coeliac artery with involvement of superior
mesenteric artery origin, renal arteries,
inferior mesenteric artery and reaches
inferiorly at the level of aortic bifurcation
POST OPERATIVE PROBLEMS
• Renal Failure
• Transient Hepatic Failure
• Transient pancreatic dysfunction
• Bowel motility problems

Discharged on 20 th POD on haemodialysis

His kidney’s recovered almost completely after 3 months. He
started producing 3000 ml urine per day serum creatinine
remained stable at 170 and dialysis was stopped.
 CONCLUSIONS
• Early detection of AAA is life saving as it may be asymptomatic till
rupture ( Ultrasound abdomen for all > 65 years)
• If there is a family history of aortic aneurysm there is 10 times more
chance of developing it.
• Hypertension should be controlled with appropriate medication
• Pain in presence of an aneurysm indicates rupture
• Ascending aorta >6 cm, Descending >7 cm and abdominal aorta >5
cm warrants urgent surgical repair
• Endovascular stents are appropriate in selective cases. Longterm
results are uncertain.
If you are offered one of the following tests free, which
one you will select
a. MRI of brain
b. Coronary Angiogram
c. Ultrasound Abdomen
d. Echocardiogram
e. PET scan
Thank You