ANEURYSM DISEASE Flashcards
complications of an untreated aneurysm?
- Rupture
- Dissection
- Embolism of material distally
- Thrombosis of the Aneurysm
- Aorto-enteric Fistula
Etiologies of Aneurysms?
- ATHEROSCLEROSIS • Most occur in the 6th & 7th decade of life
- Often associated with: – C.A.D. – Hypertension – Cerebral Vascular Disease – Renal Impairment – Diabetes – C.O.P.D.
- Syphilis – Is a late Complication of – Previously most common cause
- Cystic Medial Necrosis – Marfan’s Syndrome – Small percentage of aneurysms
- Ehlers-DanlosSyndrome – Loss of Elastic Fibers
- Trauma
Risk factors for aneurysms?
- Age (increases with age, 60-80)
- Gender (incidence greater in males)
- Family History (15% familial)
- Atherosclerosis
- Hypertension
- Smoking
- plus: other atherosclerotic associated risk factor
Aneurysm classifications are based on?
•Location •Type •Pathology
Locations of aneurysms?
Aortic Locations: • Sinus of Valsalva • Ascending Aorta • Transverse Aortic Arch • Descending Thoracic Aorta • Thoraco-Abdominal Aorta • Abdominal Aorta – Infra-renal = 90%
• Iliac Artery • Femoral Artery • Popliteal Artery • Carotid Artery • Mesenteric Arteries – Splenic
What is a fusaform aneurysm?
• Ovoid configuration
Involves the Entire Circumference of the artery
TRUE: • Fusiform shape - usually • Has all the elements of the vessel wall • Localized Dilation of the Artery • Weakening of the whole wall of the artery
What is a saccular aneurysm?
Aneurysmal Defect is confined to a portion of the circumference of the arterial wall, the remainder is uninvolved
What is a pseudo-aneurysm?
FALSE (Pseudo-aneurysm) • Does not include all the layers/elements of the arterial wall • Adventiais Usually Intact • Frequently due to TRAUMA • “Hematoma” • Can be due to instrumentation of an artery – Surgery or Percutaneous
Explain a dissecting aneurysm?
DISSECTING: • False Lumen • The histological layers of the arterial wall are separated by blood entering through an intimal tear • There is Progressive Extension of the False Lumen Proximally and/or Distally
What is a mycotic aneurysm?
• InfectedAneurysm – Bacterial – Fungal • Tuberculosis – Syphilitic • Infected Pseudo-aneurysm • Dissection • Embolization • Fistula
What is a sinus of valsalva aneurysm?
• Uncommon • Male >Female • Average age 31 • Etiology – Usually congenital weakness – Bacterial Endocarditis – Tuberculosis – Syphilis • Rupture – into Right Ventricle or Atrium
What are the symptoms of the sinus of valsalva aneurysm?
• Pain –Angina like –Right upper quadrant • Nausea / Vomiting • Dyspnea • Feeling of Constriction
Findings of a sinus of valsalva aneurysm?
• Often found incidentally at heart catheterization or on C.T. Scan • Asymptomatic (usually) unless Rupture • Murmur +/– Partial obstruction of Pulmonary outflow tract – If concurrent aortic valve disease • C.H.F. • Wide Pulse Pressure • Death
what is an ascending throacic aneurysm? its etiologies?
- Fusiform • Associated Hypertension 90% • There may be concomitant atherosclerotic occlusive disease in other areas • 50% of thoracic aneurysms
- 6th and 7th decade of life –can be earlier • Male > Female • Atherosclerosis • Syphilis –Most common cause in the Past –May be saccular
Symptoms of an ascending thoracic aneurysm?
• Pain +/• Usually secondary to Compression, Distortion or Erosion of surrounding structures • Rupture • May become quite large without symptoms • Dyspnea – Compression of trachea or bronchus
Pain: • May be Acute if Sudden Rupture or Dissection • Mild if Gradual expansion • Radiate – Neck, back, shoulder or abdomen • If pain is increasing it is an Ominous sign
Findings of an ascending thoracic aneurysm?
- Palpable only if extends above the supra-sternal notch - rare
- Tracheal Deviation
- Murmur – Aortic Valve Insufficiency (AVI) – Aortic Valve Stenosis (AVS)
- Heart Failure – AVI
- Hoarseness – Stretch on Vagus or Recurrent Laryngeal Nerve • Left vocal cord paralysis
- Dysphagia - Compression of Esophagus
- Embolic findings/symptoms
- Sudden Death – Shock – Cardiac Tamponade
Evaluation of ascending thoracic aneurysm?
- CXR – Widened Mediastinum – Calcification
- C.T. scan
- MRA
- Echocardiography
- Arteriography – Lumen may appear normal if laminated thrombus
Acute treatment of Ascending thoracic aneurysm?
Medically Stabilize: • Control Blood Pressure – Beta Blocker - control cardiac contractility • Propranolol - Inderal® (historical) • Esmolol - Brevibloc® • Labetalol - Normadyne® – After-load Reduction - reduce hypertension • Sodium Nitroprusside - Nipride® • Labetalol - Normadyne®
Surgery for Ascending thoracic aneurysm?
Surgery: • Mediansternotomy • Extracorporal Bypass • Interposition Graft • Patch Graft • Valve conduit if aortic valve involved
A descending thoracic aneurysm can be which types? most commonly?
- Fusiform –Most
- Saccular –Rare
- Mycotic –Bacterial –Syphilis
what is a descending thoracic aneurysm?
- 40% of Thoracic aneurysms
- Expand slowly - rarely rupture
- 6th thru 8th decade
- Majority begin just distal to the Left Subclavian artery • Length –Localized to… –Full length of the Aorta
Etiologies of descending thoracic aneurysm?
- Atherosclerosis
- May be associated with Trauma – at left subclavian artery (ductus arteriosum)
- Hypertension
- Cystic Medial Necrosis
- Syphilis - rare
Symptoms of a descending thoracic aneurysm?
- Usually Asymptomatic
- Pain can be the first symptom
- Compression symptoms – Stridor – Cough – Dyspnea – Hoarseness – Erosion
- Hemoptysis
Findings of a descending thoracic aneurysm?
- Often diagnosed on Routine CXR – Calcification
- Usually no specific physical findings
- Bruit ?
- Reduced Left Arm BP if Subclavian artery is involved
- Evidence of Dissection – Asymmetric pulses
Evaluation of a descending thoracic aneurysm?
- Chest x-ray
- T.E.E.
- C.T. Scan / C.T.A.
- MRA
- Arteriography
Treatment of descending thoracic aneurysm?
- Medical - acute –Control of Blood pressure –Negative Inotropy
- Surgery –Bypass –Shunt –Clamp, Cut, Sew
What is a thoraco abdominal aneurysm ?
- Less common
- Etiology – Atherosclerosis (most)
- Symptoms – Vague
- Often Diagnosed Incidental to other evaluation
- Treatment (Complex) –Surgery - Often Staged –Endovascular
what is a infra-renal abdominal aortic aneuryms?
- 90% - 95% aneurysms are below the Renal Arteries
- Aorta is normally < 3 cm (non-pathologic)
- 60 - 70 years old
- Male > Female (5:1)
- May involve one or both Iliac Arteries
- Dubois – 1951, repaired with Homograft
Etiologies of infra-renal abdominal aortic aneuryms
• Atherosclerosis • Associated –HTN –Diabetes • Infectious –Rare –Gram positive (more common) • Ehlers Danlos syndrome
Symptoms of infra-renal abdominal aortic aneuryms?
- Typically Asymptomatic till Rupture
- Pain –Pain of Rupture may be the First Symptom
- May begin weeks or months before rupture –Abdominal Pain –Back Pain –Radiated Pain – Flank / Groin / Chest
- Pulsating sensation
- Sense of Fullness
- Compression symptoms –Intestine –Ureter –Bladder
- GI Bleeding- fistula
- Inferior Vena Cava – Erosion, Rare <1%
findings of a infra-renal abdominal aortic aneurysm?
- Palpable Aneurysm –Pulsatile –“Expansatile”
- Findings of Thrombosis
- Thrill / Bruit
- Pulses Distally - normal (+/- if PAD)
- Shock
Rupture of an infra-renal abdominal aortic aneurysm?
- History of AAA
- 75% Retroperitoneal
- 25% Intraperitoneal –Rapid Exsanguination
- Pain
- Pulsatile Mass
- Hypotension
Evaluation of infra-renal abdominal aortic aneurysm?
- CT scan: • Excellent study • Shows Rupture • Now more convenient to obtain than in the past
- Back X-ray
- Ultrasound of Abdominal –Gallbladder evaluation
- Screening tests
- Etc.
Arteriogram: • Not for Diagnosis of aneurysm • May (+/-) help to evaluates Anatomy in preparation for repair • Risks
Ultrasound: • Bedside • Sensitive • Specific • Excellent to follow the Status of the Aneurysm • Bowel gas may interfere with evaluation
treatment upon observation of an infra-renal abdominal aortic aneurysm?
Observation: • Conservative Management • Must weight risk of Rupture vs. Repair – May be a difficult call • Frequent Surveillance – Ultrasound – CT Scan (if U/S is not suitable) – Every 4 – 12 months
Elective repair of an infra-renal abdominal aortic aneurysm?
- 3 cm?, 4 cm?, 5 cm? or 6 cm?
- Double the size of the Native Aorta – Usually compared to the supra-renal dimension
- When patients health may afford the best opportunity • Surgery – open abdominal repair
- Endovascular approach – percutaneous
- Elective repair - 1% - 5% mortality
Emergency repair of an infra-renal abdominal aortic aneurysm?
• Differential Diagnosis – Need to consider what else it could be
- Resuscitate – Fluids – Blood products (transfusion)
- Surgery / (EVAR) – Emergency: 50% mortality (vs. <5% for elective)
Femoral aneurysms?
• FEMORAL –Frequently Pseudoaneurysms –Associated with instrumentation of the vessel
Popliteal aneurysms?
POPLITEAL –May be associated with A.A.A. –Initial presentation may be Embolic –May present with pain
Mesenteric aneurysms?
MESENTERIC –Splenic most common
Symptoms of an aortic dissection? Diagnostic test? Mortality?
- Symptoms – Pain • Sharp tearing pain (50%) • Migratory pain (15%) – Neuro-symptoms – can be transitory – Beware of Chest Pain, Neurologic Symptoms and Limb changes!
- CXR – is suspicious 65% of the time
- Mortality is 1-2% per hour • 75% dead in 2 weeks
