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Aneurysm and av fistula

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Aneurysm and av fistula

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Aneurysm and av fistula

  1. 1. Aneurysm and AVFAneurysm and AVF Dr Sumer yadav MCh - plastic surgeon sumeryadav2004@gmail.com
  2. 2. AneurysmAneurysm An aneurysm is a distention of an artery brought by a weakening/ destruction of the arterial wall. An aneurysm is a balloon-like bulge in an artery. sumeryadav2004@gmail.com
  3. 3. Types of AneurysmsTypes of Aneurysms False ◦ Due to traumatic breach in the wall ◦ The sac made up from the compressed surrounding tissue True ◦ Dilatation involving all layers of the wall sumeryadav2004@gmail.com
  4. 4. Types of AneurysmsTypes of Aneurysms types of aneurysms: 1. Aortic aneurysm - There are two types of aortic aneurysm - Abdominal aortic aneurysm and - Thoracic aortic aneurysm 2. Cerebral aneurysm - occurs in an artery in the brain. 3. Others: Peripheral Aneurysm sumeryadav2004@gmail.com
  5. 5. sumeryadav2004@gmail.com
  6. 6. Abdominal Aortic Aneurysms An aneurysm that occurs in the abdominal portion of the aorta is called an abdominal aortic aneurysm (AAA). Most aortic aneurysms are AAAs. Thoracic Aortic Aneurysms An aneurysm that occurs in the chest portion of the aorta (above the diaphragm) is called a thoracic aortic aneurysm (TAA). sumeryadav2004@gmail.com
  7. 7. Brain Aneurysms Aneurysms in the arteries of the brain are called cereberal aneurysms or brain aneurysms. Brain aneurysms also are called berry aneurysms because they're often the size of a small berry. sumeryadav2004@gmail.com
  8. 8. Peripheral Aneurysms ◦ Aneurysms that occur in arteries other than the aorta and the brain arteries are called peripheral aneurysms. ◦ Common locations for peripheral aneurysms include the popliteal, femoral and carotid arteries. sumeryadav2004@gmail.com
  9. 9. Causes:Causes: Abdominal aortic aneurysm causes:  Atherosclerosis Smoking Hypertension - Vasculitis (infection in the aorta) - Cocaine use Genetic factors sumeryadav2004@gmail.com
  10. 10. CausesCauses 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 sumeryadav2004@gmail.com
  11. 11. Thoracic aortic aneurysm causes:  About 1 in 4 aortic aneurysms occur in the thoracic area of the aorta (higher up in the chest). Causes are the same as with aortic aneurysms, plus the following below: Marfan Syndrome - this is a genetic disorder of the connective tissue; it is a much less common cause of aortic aneurysm.  Previous aorta injury Traumatic injury - cause by a vehicle accident or a bad fall. sumeryadav2004@gmail.com
  12. 12. Brain (cerebral) aneurysm causes: Weakness in the artery wall (usually present since birth) Hypertension Arteriosclerosis (plaques of cholestrol, platelets, fibrin, and other substance form on the arterial wall) Most cerebral aneurysms develop at the forks or branches in arteries because the walls in these sections are weaker. They most commonly form at the base of the brain - but can form anywhere in the brain.  sumeryadav2004@gmail.com
  13. 13. Clinical manifestation:Clinical manifestation: Abdominal Aortic Aneurysms A throbbing feeling in the abdomen Deep pain in back or the side of the abdomen Steady, gnawing pain in the abdomen that lasts for hours or days If an AAA ruptures, symptoms may include : Sudden, severe pain in lower abdomen and back; Nausea and vomiting; Constipation Problems with urination Clammy, sweaty skin Light-headedness Rapid heart rate when standing up Shock sumeryadav2004@gmail.com
  14. 14. Thoracic Aortic Aneurysms Pain in jaw, neck, back, or chest  Coughing and/or hoarseness Shortness of breath and/or trouble breathing or swallowing Loss of voice If a TAA ruptures or dissects Sudden, severe, sharp or stabbing pain starting in the upper back and moving down into the abdomen. Pain in chest and arms, and pt. can quickly go into shock. sumeryadav2004@gmail.com
  15. 15. Cerebral (brain) aneurysm symptoms The following symptoms may be experienced before a cerebral aneurysm ruptures: Very severe headache that occurs suddenly Nausea Vomiting Eyesight problems Seizures (fits) Loss of consciousness Confusion A drooping eyelid Stiff neck Light sensitivity If the cerebral aneurism bursts it will cause bleeding in the brain and a hemorrhagic stroke - it can also cause intracranial hematoma sumeryadav2004@gmail.com
  16. 16. Risk factors:Risk factors:  Male gender - Men are more likely than women to have aortic aneurysms.  Age - Abdominal aortic aneurysms are more likely to occur in people who are aged 65 or older.  Smoking - Smoking can damage and weaken the walls of the aorta.  Family history - People who have family histories of aortic aneurysms are at higher risk for the condition, and they may have aneurysms before the age of 65.  History of aneurysms in the arteries of the legs.  Certain diseases and conditions that weaken the walls of the aorta. Such as high BP and atherosclerosis  Having a bicuspid aortic valve - can raise the risk of having a thoracic aortic aneurysm. A bicuspid aortic valve has two leaflets instead of the typical three.  Car accidents or trauma - also can injure the arteries and increase the risk for aneurysms. sumeryadav2004@gmail.com
  17. 17. Diagnostic test:Diagnostic test: sumeryadav2004@gmail.com
  18. 18. Aortic AneurysmsAortic Aneurysms DiagnosisDiagnosis Arteriography: ◦ Cannot determine aneurysm size because of mural thrombus ◦ Indications for obtaining arteriography  Suspicion of visceral ischemia  Occlusive disease of iliac and femoral arteries  Severe HTN, or impair renal function  ? Horseshoe Kidney  Suprarenal of TAAA component  Femoro-Popliteal Aneurysms sumeryadav2004@gmail.com
  19. 19. Aortic AneurysmsAortic Aneurysms DiagnosisDiagnosis Ultrasound ◦ Establishes diagnosis easily ◦ Accurately measures infrarenal diameter ◦ Difficult to visualize thoracic or suprarenal aneurysms ◦ Difficult to establish relationship to renal arteries ◦ Technician dependent ◦ Widely available, quick, no risk, cheap sumeryadav2004@gmail.com
  20. 20. Aortic AneurysmsAortic Aneurysms CT ScanCT Scan Very reliable and reproducible Can image entire aorta Can visualize relation ship to visceral vessels Longer to obtain and is more costly than U/S Most useful Requires contrast agent - renal toxicity sumeryadav2004@gmail.com
  21. 21. Aortic AneurysmsAortic Aneurysms MRAMRA Now widely available More expensive than CT No contrast agent required Spacial resolution less than CT sumeryadav2004@gmail.com
  22. 22. Management:Management: The goals of management may include: Preventing the aneurysm from growing Preventing or reversing damage to other body structures Preventing or treating a rupture or dissection Allowing the pt. to continue doing their normal daily activities sumeryadav2004@gmail.com
  23. 23. Medical management:Medical management: In aortic aneurysm: Medicines are used to lower blood pressure, relax blood vessels, and lower the risk that the aneurysm will rupture (burst). Beta blockers and calcium channel blockers are the medicines most commonly used. sumeryadav2004@gmail.com
  24. 24. Cerebral aneurysm treatmentsCerebral aneurysm treatments It help to relieve symptoms as well as managing complications:  Painkillers - usually for headaches.  Calcium channel blockers - these stop calcium for entering cells of the blood vessel walls. They reduce the amount of widening and narrowing of blood vessels; often a complication of a ruptured aneurysm.  A vassopressor - this is an injected drug which raises blood pressure; widens blood vessels which have remained stubbornly narrowed. The aim is to prevent stroke.  Anti-seizure drugs - seizures may occur after an aneurysm has ruptures. Examples include levetiracetam (Keppra), phenytoin (Dilantin, Phenytek, others) and valproic acid sumeryadav2004@gmail.com
  25. 25. A ventricular catheter - this can reduce the pressure on the brain caused by hydrocephalus (excess cerebrospinal fluid). The catheter, which is placed in the spaces filled with fluid inside the brain, drains the excess liquid into an external bag. It may be necessary to place a shunt system - a shunt (flexible silicone rubber tube) and a valve. The shunt system is a drainage channel that starts in the brain and ends in the patient's abdominal cavity. Rehabilitation therapy - sometimes a subarachnoid hemorrhage causes brain damage, resulting in impaired speech and bodily movements. Rehabilitation therapy helps the patient relearn vital skills. sumeryadav2004@gmail.com
  26. 26. Surgical management:Surgical management: The two main types of surgery to repair aortic aneurysms are: 1. Open Abdominal or Open Chest Repair  In aortic aneurysms, open abdominal or open chest repair. This surgery involves a major incision (cut) in the abdomen or chest.  General anesthesia is used during this procedure. During the surgery, the aneurysm is removed. Then, the section of aorta is replaced with a graft made of material such as Dacronor Teflon 2. Endovascular Repair  In endovascular repair, the aneurysm isn't removed. Instead, a graft is inserted into the aorta to strengthen it.  The surgeon first inserts a catheter into an artery in the groin (upper thigh) and threads it to the aneurysm. Then, using an x ray to see the artery, the surgeon threads the graft (also called a stent graft) into the aorta to the aneurysm.  The graft is then expanded inside the aorta and fastened in place to form a stable channel for blood flow. The graft reinforces the weakened section of the aorta. This helps prevent the aneurysm from rupturing. sumeryadav2004@gmail.com
  27. 27. Brain aneurysms:Brain aneurysms: Brain aneurysms have two options if the aneurysm has ruptured: Surgical clipping - the aneurysm is closed off. The surgeon removes a section of the skull to get to the aneurysm and finds the blood vessel that feeds it. A tiny metal clip is placed on the neck of the aneurysm to block off the blood flow to it. Endovascular Repair sumeryadav2004@gmail.com
  28. 28. Endovascular RepairEndovascular Repair sumeryadav2004@gmail.com
  29. 29. PreventionPrevention A large percentage of aneurysms are caused by arteriosclerosis. The following steps will help prevent the development of arteriosclerosis and aneurysms: Quit smoking Keep blood pressure under control Keep blood cholesterol levels under control Eat a healthy, well balanced diet, rich in fruit and vegetables, unrefined carbohydrate, dietary fiber, good quality fats, and lean protein Keep bodyweight within the ideal limits for height Get at least 7 hours of good quality sleep each night Keep yourself physically active (check with your doctor that this is OK for you) sumeryadav2004@gmail.com
  30. 30. ComplicationsComplications Haemorrhage leading to shock and even death Myocardial ischemia Stroke Paraplegia due to interruption of anterior spinal artery Abdominal ischemia Graft occlusion Graft infection Acute renal failure Lower extremity ischemia sumeryadav2004@gmail.com
  31. 31. AVFAVF sumeryadav2004@gmail.com
  32. 32. What are Arterio-VenousWhat are Arterio-Venous fistulae?fistulae? • Surgically created “end to side” shunts which allow dialysis. • Lower arm (radio-cephalic) better than upper arm (brachio-cephalic, brachio- basilic, brachio-brachial). • Native better than grafts (PTFE, bovine ureter) sumeryadav2004@gmail.com
  33. 33. AnatomyAnatomy sumeryadav2004@gmail.com
  34. 34. sumeryadav2004@gmail.com
  35. 35. sumeryadav2004@gmail.com
  36. 36. sumeryadav2004@gmail.com
  37. 37. Typical AV FistulaTypical AV Fistula “Arterial” needle “Venous” needle Thrill sumeryadav2004@gmail.com
  38. 38. Typical AV FistulaTypical AV Fistula Arterial pressure Venous pressure sumeryadav2004@gmail.com
  39. 39. Fistula MaturationFistula Maturation Definition: Process by which a fistula becomes suitable for cannulation (ie, develops adequate flow, wall thickness, and diameter) Rule of 6’s: In general, a mature fistula should: ◦ Be a minimum of 6 mm in diameter with discernible margins when a tourniquet is in place ◦ Be less than 6 mm deep ◦ Have a blood flow greater than 600 mL/min ◦ Be evaluated for nonmaturation 4–6 weeks after surgical creation if it does not meet the above criteria National Kidney Foundation. Am J Kidney Dis. 2006;48(suppl 1):S1-S322.sumeryadav2004@gmail.com
  40. 40. Problems with fistulaeProblems with fistulae • Poor development • Difficulty needling • Inadequate dialysis – Low flow rates – Recirculation • High pressures and prolonged bleeding • Thrombosis • Almost all due to stenoses which are recurrent sumeryadav2004@gmail.com
  41. 41. Flat AV Fistula: peri-anastomoticFlat AV Fistula: peri-anastomotic stenosisstenosis “Arterial” needle “Venous” needle Weak thrill sumeryadav2004@gmail.com
  42. 42. Pulsatile AV Fistula: stenosis awayPulsatile AV Fistula: stenosis away from anastomosisfrom anastomosis Flat Remote Thrill Pulsatile and high pressure sumeryadav2004@gmail.com
  43. 43. Recirculation “Arterial” needle “Venous” needle Thrill sumeryadav2004@gmail.com
  44. 44. Treatment optionsTreatment options • Angioplasty – Standard balloon angioplasty – High pressure balloon – Cutting or scoring balloon • Surgery • Refashion anastomosis • Patch stenosis • Higher fistula • Whichever way, get on with it. sumeryadav2004@gmail.com
  45. 45. Balloon angioplastyBalloon angioplasty • Big enough – Tendency to use too small balloons • High or ultra high pressure – Standard RBP of 15Atm @8mm • Inflation handle (obviously). • Long inflation times as recoil common. • Rupture uncommon but be prepared sumeryadav2004@gmail.com
  46. 46. Rupture managementRupture management • Not that frequent to have major rupture (1- 2%). • Tamponade with long low pressure inflation • Covered stent as bail out • Associated with subsequent loss of fistula sumeryadav2004@gmail.com
  47. 47. ConclusionConclusion • AV fistulas are simple to understand. – History and examination are diagnostic. • Most problems are due to stenosis. • Angioplasty is highly successful if done right. • Stenoses recur so you will get to know the patients well. sumeryadav2004@gmail.com
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