The document outlines a seminar presentation on aneurysms. It discusses the introduction, historical aspects, classification, abdominal aortic aneurysm, surgical management, and recent advances related to aneurysms. The presentation covers the definition, etiology, location, morphology, and pathogenesis of different types of aneurysms. It provides details on abdominal aortic aneurysms including risk factors, natural progression, clinical presentation, diagnosis using imaging modalities like ultrasound and CT, and treatment.
3. SEMINAR PLAN
INTRODUCTION
HISTORICAL ASPECT
CLASSIFICATION
ABDOMINAL AORTIC ANEURYSM
SURGICAL MANAGEMENT
VIDEOS
PERIPHERAL ANEURYSM/ OTHER TYPES
RECENT ADVANCES
STUDIES/ONGOING RESEARCH WORK
REFERENCES/
4. INTRODUCTION
The term ANEURYSM is derived from the Greek
word ANEURYSMA meaning “ a widening”
An ANEURYSM is defined as a permanent
localized dilation of artery having at least a 50 %
increase in diameter compared with the expected
normal diameter.
Normal arterial diameter is dependent on
age,gender,body size and other factors.
5. An Aneurysm is defined as a localized dilation at
least 50 % larger than an adjacent normal portion of
the same artery.
ECTASIA- Arterial dilation less than 50% above
normal
ARTERIOMEGALY– Diffuse arterial enlargement
involving several arterial segments with an increase
in diameter greater than 50% above normal.
6. HSTORICAL PERSPECTIVE
2000 B.C – PAPYRUS – Description of traumatic
aneurysms of the peripheral arteries.
131 A.D – GALEN -- Defined an aneurysms as a
localized pulsatile swelling that disappeared on
pressure.
1793 A.D – JOHN HUNTER -- Operated for a
pulsatile mass in popliteal fossa.
7. HISTORICAL ASPECT
1950 A.D – ALEXIS CARREL/ DeBakey and
Cooley – Demonstrated a segment of aorta can be
replaced by another artery or vein.
1953 A.D – BAHNSON– First successful
repair of ruptured aortic aneurysm.
1954 A.D – ETHEREDGE– Repair of
thoracoabdominal aneurysm .
1991A.D -- PARODI – Revolutionary minimally
invasive endovascular approach.
8. Types of Arteries
Elastic arteries – the largest arteries
Diameters range from 2.5 cm to 1 cm
Includes the aorta and its major branches
Sometimes called conducting arteries
High elastin content dampens surge of blood
pressure
Figure 19.2a
15. True/false aneurysm
Aneurysm focal dialation greater than 1.5
times normal diameter
True aneurysm contains all layers of arterial wall.
False aneurysm dialation covered by thick
fibrinous capsule.
16. PSEUDOANEURYSM
Injury to wall of vessel allows blood to escape from vessel into
adjacent tissue
Extravasated blood coagulates and becomes a mass along side the
vessel
This mass of blood (hematoma) gives the impression that there is
an aneurysm
25. BASED ON MORPHOLOGY
Saccular aneurysm
Fusiform aneurysm
Dissecting aneurysm
Cylindroid aneurysm
Berry aneurysm
26. BASED ON MORPHOLOGY
FUSIFORM
SYMMETRICAL CIRCUMFERENTIAL
ENLARGEMENT INVOLVING ALL
LAYERS OF THE ARTERY WALL.
SACCULAR
ANEURYSMAL DEGENERATION
AFFECTING ONLY PART OF THE
ARTERIAL CIRCUMFERENCE.
30. AAA INCIDENCE
2% TO 5% OF ALL MEN OVER 60 YRS
15,000 DEATHS PER YEAR IN USA
COMMON IN MEN ABOVE 60YRS
PEAK OF 5.09% AT 80 YRS IN MEN
PEAK OF 4.5% AT 90 YRS IN WOMEN
GREATER - FIRST DEGREE RELATIVES
TALLER INDIVIDUALS
31.
32. NORMAL SIZE OF INFRARENAL
AORTA
Age
SEX 40 40 – 49 50 – 59 60 - 69 70 avg
Male 2.1 2.2 2.3 2.3 2.4 2.3
Female 1.7 1.8 1.9 2.0 2.0 1.9
33. Risk Factors
Familial History
20% of patients with AA have 1st Degree relative
Connective tissue disease
Marfans
Ehlers-Danlos
Atherosclerosis (90%)
Smoking
Hyperlipidemia
Diabetes
Gender
Males > Females
Age
38. ANATOMICAL
GRADUAL TAPERING OF AORTA
REDUCTION of ELASTIC LAMELLAE
in DISTAL AORTA
REDUCTION /ABSENCE OF NUTRIENT
ARTERIES IN INFRARENAL AORTA
39. 39
Wall stress is force exerted on the wall
The aneurysm wall weakens
The Biomechanical Perspective
Hypothesis AAA rupture is a failure of the aneurismal
wall, when wall stresses exceeds wall strength
40. 40
The Biomechanical Perspective
Wall stress is force exerted on the wall
The aneurysm wall weakens and expands
Until it ruptures
Hypothesis AAA rupture is a failure of the aneurismal
wall, when wall stresses exceeds wall strength
41. Biochemical
ELASTIN and ELASTOLYTIC PROTEASE
ELASTIN – produced in soluble form pro-
elastin
in media of the arteries
insoluble
elastic recoil ability
half-life is 70 years
ELASTIN depletion occurs early in AAA
caused by serine protease
MMP
42. BIOCHEMICAL
COLLAGEN and COLLAGENOLYTIC PROTEASES
STRUCTURAL UNIT IS TROPOCOLLAGEN
AORTIC COLLAGEN IS CONCENTRATED IN THE
ADVENTITIA
HAS MULTIPLE CROSS LINKS
INSOLUBLE
DEGENERATION OF COLLAGEN OCCURS IN AAA :
caused by TIMP, MMP-3 and MMP-9
44. POSSIBLE AAA PATHOGENIC MECHANISM
AAA
Degradation Of Elastin & Collagen
MMP Production
(especially MMP-9 & MMP-1)
Induction Of MMP activators
Secretion Of Cytokin
Chronic Inf. Response
(AIM, AILs)
Acute Inf. Response
(PMN,AIM,AILs)
Fragmentation of ELASTIN (EDP)
Vascular Event ( Genetic, Autoimmune, Etc )
45. AAA Sequelae
Natural history
• gradual and/or sporadic expansion
• accumulation of mural thrombus
Complications
• rupture
• thromboembolic events
• compression of adjacent structures
46. Progression of a AAA
Pathological changes cause the aorta wall to
• become thinner
• bulge
• tear
• rupture
47. AAA RUPTURE & SURVIVAL
5 year rupture rate
7.0cm or more 75%
6.0cm to 7.0cm 35%
5.0cm to 6.0cm 25%
SURVIVAL
> 6.0CM 5YR SURVIVAL 6%
< 6.0CM 5YR SURVIVAL 47.8%
48. AAA: risk of rupture
Simplifed estimates based on various studies
Tan W Abdominal Aortic Aneurysm Rupture www.emedicine.com
0
Risk of rupture for untreated aneurysm within 5 years (%)
10
70
60
40
50
30
20
80
25%
35%
75%
Aneurysm size
5-5.9cm 6-6.9cm ≥7cm
49. CLINICAL PRESENTATION
AAA are asymptommatic before rupture in 75%
Abdominal palpation may show a pulsatile
abdominal mass.
Vague abdominal and back discomfort.
Large aneurysms – GI symptoms– early satiety and
vomitting.
Inflammatory aneurysms- pain /fever /ureteral
obstruction
52. DIAGNOSIS
PHYSICAL EXAMINATION
-- Detection of expansile pulsation
-- unreliable about 50%-- false negative
-- large hypogastric aneurysm palpated on
rectal examination
INVESTIGATIONS
-- X- RAY
-- USG
-- CT/MRI / MR ANGIOGRAPHY
-- ARTERIOGRAPHY
53. Sensitivity of physical exam
Lederle. JAMA 1999;281:77-82.
Aneurysm
diameter
Sensitivity
3.0-3.9 cm 29%
4.0-4.9 cm 50%
≥ 5.0 cm 76%
Pooled analysis of 15 studies
54. X - RAY
LUMBAR SPINE RADIOGRAPH
Characteristic of
EGGSHELL PATTERN
of CALCIFICATION
55. USG
Ultrasound is most useful and least expensive
mode of diagnosis.
Measuring transverse aneurysmal diameter.
Screening /Surveillance/ follow up after
endovascular repair.
• Best used to assess
progression of AAA
size
• Average expansion of
0.4cm/year
Longitudinal Section of 2cm Aorta
56. Inconsistent in
visualization of
Renal and iliac arteries.
They are less useful
in demonstrating
Accessory Renal
Arteries.
Cant detect Rupture.
57. Sensitivity of ultrasound
Ranges from 82% to 99%
Approx 100% in cases with a
pulsatile mass
In a small proportion of
patients, visualization of the
aorta inadequate due to obesity,
bowel gas, or periaortic disease
Quill. Surg Clin North Am 1989;69:713-20.
59. CT Imaging
Precise test – provides good
images of aorta,aortic
lumen,branch vessels and
adjacent retroperitoneal
structures.
Shows size and extent of
aneurysm and relation to renal
and iliac arteries.
SPIRAL CT – 3 dimensional
image.
67. MRI/ MR ANGIOGRAPHY
Use of contrast agents have made it possible to
produce high quality images of aorta.
Useful for planning and follow up of endovascular
repair.
Less sensitive than CT scan in identifying accessory
renal arteries.
69. SELECTION OF PATIENTS
When the maximal diameter of aneurysm reaches
5.5 cm – risk of rupture increases
-- aneurysm repair indicated.
Patient with evidence of rapid expansion,tenderness
in the region of aneurysm ,back or abdominal pain –
urgent repair.
Patient with significant coronary disease– referred
for coronary revascularization before surgical repair.
Anatomy of aneurysm determines– type of repair.
70. Contraindications for surgery for AAA
Age > 85
Cardiac Class iii -- iv angina
LVEF <30%
MI or CHF ( within 30days)
severe valvular disease/LV aneurysm
Renal S.Creatinine >3.0 mgs%
Hepatic Biopsy proven cirrhosis with ascitis
Abdomen Diffuse retroperitoneal Fibrosis
71. OPEN SURGERY
TRANS ABDOMINAL EXPOSURE
when exposure of rt renal artery is required
when need for access to intra abdominal organ
when access to right iliac system required
RETRO PERITONEAL EXPOSURE
extensive peritoneal adhesions
need for suprarenal exposure
Advantage – short duration of ileus/ less pulmonary
complications/ shorter stay in ICU
73. STEPS OF PROCEDURE
INCISION
EXPOSURE OF AORTA
PREPARATION OF NECK OF ANEURYSM
EXPOSURE OF ILIAC ARTERIES
SITE OF DISTAL CLAMPING
OPENING OF AORTA/ INCISION EXTENDED
INSERTION OF GRAFT
CHECKING THE PATENCY OF GRAFT
CLOSURE OF SAC
80. Open surgical repair (OSR): drawbacks
Significant incision in the abdomen
30–90 minute cross-clamp
Up to 4-hour procedure
1–2 days intensive care
7–14 days hospitalization
4–6 weeks recovery time
81. Complications –AAA Surgery
Early :
Myocardial ischemia
Mild Renal failure
Postoperative Pneumonia
Paralytic Ileus
Colonic ischemia
Distal Embolisation
PARAPLEGIA
Post operative sexual dysfunction
82. Complication -- AAA Surgery
Late :
Anastamotic Pseudoaneurysms
Aortoenteric Fistula
Graft Occlusion
Graft Infection
83. Recent advance - AAA
ENDOVASCULAR REPAIR
TRANSLUMINAL PLACEMENT OF A GRAFT WITHIN
THE ANEURYSM THAT COMPLETELY EXCLUDES
THE SAC FROM GENERAL CIRCULATION
85. Benefits
Theoretical
Reduced complications and mortality
Decreased hospitalization
Decreased cost
Realized
Same number of complications but different types
Less systemic complications, same mortality
Shorter respiratory support
Decreased ICU and hospital stay
Decreased blood loss
Cost??
86. ENDOVASCULAR REPAIR
( EVAR )
DISADVANTAGES
CUSTOMISED FOR EACH PATIENT
FOLLOW UP IS CRUCIAL
LONG TERM IMPLICATIONS AWAITED
ENDOLEAK 14 – 20 %
CONTRAST INDUCED NEPHROPATHY
HIGH COST
87. Anatomic Criteria
Proximal neck length >15mm
diameter <28mm
Tube graft: distal cuff length >10mm
diameter <28mm
Iliac artery diameter >7mm and < 15mm
Minimal to moderate tortuosity
No mural thrombus at attachment sites
Minimal calcification
No associated mesenteric occlusive disease
102. Complications of EAAA repair
1) Injuries to arteries of access – Iliac/ Supra Renal
2) Embolization - micro – Renal Failure
distal – Ischemia
3) Procedure related
Groin hematoma, wound infection
POST IMPLANT SYNDROME
4) Device related
Migration, detachment, rupture, stenosis, kinking,
endoleak
103. Endoleaks
Coined by White, et al, 1996
Leak around proximal or distal attachment sites
Persistent flow in aneurysm sac
Incomplete exclusion
Rates
0 to 44%
Risks
Expansion
Rupture
104. Endoleak Classification
Type I—perigraft
Persistent flow at proximal or distal attachment
sites
Type II—retrograde flow from side branches
Inferior mesenteric or lumbar arteries
Subgroup A: inflow only; B: in and outflow
Type III—graft defect
Type IV—graft porosity
Primary or secondary
105. RUPTURED AAA
With increasing age of the population–
INCIDENCE increasing to 30/ 100,000 patients.
There is a increase in proteolytic activity in aortic
wall
C/f – PAIN – abdominal/ back
FAINTING/ VOMITING
FINDINGS – MASS
TENDERNESS
BP < 80 mm Hg
Hematocrit < 38%
WBC > 10,000/ microletre
108. AAA Basics: Mortality
15,000 lives per year taken due to rupture
(13th leading cause of death)
• 40% of 5.5-6cm
AAAs will rupture
in 5 years
• Average survival if
untreated is 17
months
109. Rupture outcomes
Mortality rate can be as high as 80%[1]
More than one third of rupture cases die outside the
hospital
Ruptured AAA
1. Adam. J Vasc Surg 1999;30:922-8.
2. Thomas. Br J Surg Aug 1988
110. AAA - RUPTURE- Treatment
A) EMERGENCY SURGERY
:: First successful repair of a ruptured AAA was by Cooley
and DeBakey in 1954
:: More than 98% of ruptures occur below the renal arteries.
:: Exploration -- through MIDLINE incision
IF aorta approached at infra renal level– it should be clamped
PROXIMAL CONTROL– At the level of diaphragm
111. ABDOMINAL AORTIC RUPTURE
OTHER METHODS
Compression at diaphragm
Placement of aortic balloon
catheters
Foley catheters via puncture of
the aneurysm
112. AORTIC DISSECTION
Aortic dissection is characterized by separation of
the aortic wall layers by extraluminal blood that
usually enters the aortic wall through an intimal
tear.
ACUTE– IF patients are seen within 14 days
CHRONIC– IF they are seen beyond 14 days
associated with HYPERTENSION
MALE > FEMALE
113.
114. DeBakey Classification
Type I – involves the ascending aorta and variable
extent on the descending thoracic or
thoracoabdominal aorta.
Type II – limited to the ascending aorta.
Type III – involving the descending thoracic aorta
without III a or with III b extension to the abdominal
aorta.
116. SURGICAL TECHNIQUES
1) GRAFT REPLACEMENT
removing the most threatening area
closing the entry site of dissection
reestablishing blood flow in distal aorta
2) AORTOPLASTY
suture of intimal tear at entry site
3) FENESTRATION
creating a large reentry from the false lumen
into the true lumen.
117. THORACO ABDOMINAL AORTIC ANEURYSM
Aneurysms that involve the thoracic and abdominal
aorta or those aneurysms including the visceral
aortic segments .
Etiology– degenerative– 80%
sequelae of chronic dissection– 20%
c/f-- sudden development of severe pain– back
/epigastric/flank pain
others– hoarseness/cough
hemoptysis/dysphagia lusoria
118. Crawford classification
Type I – involves Descending thoracic aorta and
abdominal aorta proximal to renal arteries.
Type II – Most of DTA + AA distal to renal
arteries
Type III – Involves aorta distal to renal arteries.
Type IV – Involves all or most of the abdominal
aorta including the paravisceral segment.
119. (MYCOTIC ANEURYSMS)
“Infected aneurysm" has gradually replaced the original
designation "mycotic aneurysm”
Saccular aneurysms are seen most commonly .
Leukocytosis and an Elevated erythrocyte sedimentation
rate (in 73% of the cases)
weight loss
The aneurysm is palpable in 50 to 60% of the cases and
almost always tender
.
The onset is insidious, and a low-grade fever may be present
for several months before diagnosis .
120. Management
Infected aortic aneurysms are treated with intravenous
antibiotics and surgical excision.
Antibiotic therapy must be continued postoperatively for at
least 6 weeks.
The standard surgical approach involves
1.Resection of the infected aneurysm and
infected retroperitoneal tissue
2.Restoration of distal perfusion by placement of an extra-
anatomical bypass graft tunneled through unaffected tissue
planes to avoid placing a graft in a contaminated region.
121. SYPHILITIC ANEURYSM
Seen in tertiary stage of syphilis with
obliterative endarteritis of vasa vasorum
and aortitis
Roughening of intima: “Tree barking”
Involves the thoracic aorta
Complications include rupture, aortic
insufficiency, and narrowing of coronary
ostia
123. BERRY ANEURYSM
Involve cerebral arteries at bifurcations
Probably arise at congenital points of
weakness in wall
Can rupture and result in subarachnoid
hemorrhage
Clinically may see headache, stiff neck
(meningeal irritation) and death
124. HIV RELATED ANEURYSM
Often MULTIPLE/ and at unusual sites
occur at–COMMON CAROTID
SUPERFICIAL FEMORAL ARTERY
ABDOMINAL AORTA
MICROSCOPICALLY
HIV VASCULOPATHY are typical of a
LEUKOCYTOCLASTIC vasculitis that affects
vasa vasorum
RECONSTRUCTION – AUTOGENOUS GRAFT
if available
126. FEMORAL ANEURYSM
Common peripheral aneurysm
Incidence- 7.39 / 1OOOOO Population
TRUE aneurysm- Non specific etiology
FALSE aneurysm - anastomotic/traumatic
catheter-induced/infected
TYPE 1 – Limited to Common Femoral Artery
TYPE 2 – Involving orifice of Profunda Femoris
artery
127. Femoral aneurysm
Asymptommatic with pulsatile mass
Local pain – pressure on ajacent nerve
Limb edema/venous distention- venous compression
Lower extremity ischemia with intermittent
claudication/rest pain/gangrene
COMPLICATIONS – THROMBOSIS
RUPTURE
EMBOLIZATION
128. OPERATIVE MANAGEMENT
TYPE 1 ANEURYSM
INTERPOSITION GRAFT OF DACRON
e PTFE
TYPE 2 ANEURYSM
INTERPOSITION GRAFT TO SFA/ PFA with
reimplantation of the other artery.
SYNDACTYLIZATION- Suturing of
Superficial and Profunda femoris arteries together to
form a common lumen
129. POPLITEAL ANEURYSM
Is commonest ( 70% )
65% bilateral with 25% associated with AAA
Etiology related to chronic flexion/extension
Associated aneurysms – other leg, femoral, aortic
131. C/f -- Swelling in popliteal region which is
smooth,soft,pulsatile,well localised,warm
compressible,often with thrill and bruit.
-- thrombosis and emboli can cause distal
gangrene
-- rupture :: torrential haemorrhage
Rx --- ANEURYSMORRHAPHY
Repair with arterial graft using PTFE,dacron
ENDOLUMINAL STENTING
132. UPPER EXTREMITY ANEURYSM
SUBCLAVIAN ARTERY ANEURYSM
Over 60 yrs – More common in men
Etiology– Degenerative
Thoracic outlet obstruction
Trauma
c/f -- Chest/neck/shoulder pain
neurological dysfunction- brachial plexus
hoarseness—Rt. Recurrent laryngeal nerve
Respiratory insufficiency- trachea
Hemoptysis– lung apex erosion.
133. SUBCLAVIAN- AXILLARY ANEURYSM
POST STENOTIC DILATATION--- OUTLET OBSTRUCTION
Younger patients/females/ right side more common
Associated with CERVICAL RIBS
Associated with Raynauds phenomenon.
ARTERIOGRAPHY – To assess the degree of post
stenotic dilation of the subclavian artery.
Rx—significant dilation– CERVICAL RIB removal
vascular reconstruction– mobilization with end
to end anastomosis with or without short
interposition vein or prosthetic graft.
134. KOMMERELL’S DIVERTICULUM
ABERRANT RIGHT SUBCLAVIAN ARTERY
Most common congenital abnormality of aortic arch
Dysphagia lusoria– esophagus compressed against
postr. Trachea
Rx – propensity to cause symptom and lethal rupture
↓
RESECTION OF ANEURYSMAL ARTERY
WITH VASCULAR RECONSTRUCTION
135. HYPOTHENAR HAMMER SYNDROME
Seen in men younger than 50 years age.
ULNAR artery and nerve– enter hand by traversing
GUYON’S CANAL
TRAUMA – MURAL degeneration
damage to Intima– THROMBOSIS
damage to MEDIA– TRUE ANEURYSM
C/f– pain,cold sensation,paresthesias,cyanosis and
mottling of digits.
4th and 5th digit involved
136. THUMB not involved– RADIAL BLOOD supply
RAYNAUD’S PHENOMENON- not seen
-- UNILATERAL
-- THUMB NOT INVOLVED
ABSENCE OF CLASSIC TRIPHASIC CHANGE
surgical therapy
-- cervicodorsal sympathectomy
-- excision of ulnar artery aneurysm with ligation
of ulnar artery and aneurysmectomy with
microsurgical reconstruction of ulnar artery by
reanastomosis or interposition vein graft.
139. 139
What is the Current Clinical
Procedure?
There is a danger with using
diameter for surgical decision
Find AAA in the
population
By Accident
Ultrasound
screening
(in the future)
“Watchful waiting”
Surgical
repair for
aneurysms
5.5 cm max
diameter
140. 140
Why is Using Max Diameter a Problem?
Fillinger et al, Journal of Vascular Surgery April 2003 p726
Both AAAs have max diameters of 5.5cm
“A” ruptured after 18 months of this scan
“B” is still under observation after more than 3 years
Max stress of “A” is more than twice that of “B”
Small Aneurysms are known to rupture
A B
141. 141
How to Obtain Wall Stress
Fluid Model
•Flow Patterns
•Wall Shear Stress
Structural Model
•Wall Movement
•Wall stress
Combined Fluid Structure Model
•Realistic wall shear stress and wall stress
Computer Tomography (CT) Scan
Blood Properties Wall Properties
144. EAAA in 2009
There are many new grafts available, now they
are ‘Second Generation’
Data from EUROSTAR (4000+ patients)
Newer grafts have better 3-year mortality
Fewer secondary interventions
Fewer conversions of open repair
Fewer graft rupture
Shorter hospital stay
Torella et. al. 2004
145. AneuRx
Medtronic
Modular bifurcated with
extension cuffs
Graft—thin walled
polyester
Stent—outer self
expanding Nitinol stents
Delivery—25F
introducer sheath
Mechanical deployment
handle
May, et al
146. ONGOING STUDIES
Wall stress could be a potential tool to replace
maximum diameter.
RETROPERITONEAL APPROACH
operative mortality – 12 % compared to 35%
with transperitoneal approach.
SPINAL CORD ISCHEMIC COMPLICATIONS
pre operative CSF removal
pre operative angiography- identify dominant
SPINAL ARTERY
147. TAKE HOME MESSAGE
Increased screening and follow up has reduced
mortality with aneurysms.
Now not the size but the wall stress is important
indicator for rupture aneurysm.
Endograft AAA repair is still a developing field with
promise- 2nd generation grafts have reduced
operative complications.
For open surgeries retroperitoneal approach has its
own advantage.
Radiologist and surgeons need better understanding
to deal with aneurysms for its a team work.
148. REFERENCES
BAILEY AND LOVE
SCHWARTZ
SABISTON
RUTHERFORD BOOK OF VASCULAR
SURGERY
INDIAN JOURNAL OF SURGERY
AMERICAN JOURNAL OF SURGERY
RECENT ADVANCES BY – TAYLOR
RECENT ADVANCES BY- RL GUPTA
SURGICAL ANATOMY ATLAS
149. NEWS FLASH!
Diabetics were actually protected from
AAA!
Odds ratio of 0.52 (0.45-0.61)
Patients with DVT were also protected
Odds ratio of 0.67 (0.53-0.84)