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Published on : Mar 14, 2014
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Slide 1 - Aortic Aneurysms Mark A. Farber, MD
Slide 2 - Aortic AneurysmsIncidence 30-60/1000 Increasing incidence over past 3 decades Incidence of AAA Autopsy 1.5-3.0% U/S Screening 3.2% Pts with CAD 5.0% Pts with PVD 10.0% Pts with femoral and pop.aneurysms 50.0%
Slide 3 - Aortic AneurysmsDefinition Pseudoaneurysm True Aneurysm
Slide 4 - Definitions Aneurysm - Increase in diameter of 50% (1.5x) its normal diameter – Focal region Ectasia - Diffuse dilatation of an artery with increase in diameter >50% Arteriomegaly - Diffuse enlargement of an artery, but not lg. Enough to meet criteria for an aneurysm
Slide 5 - Aortic AneurysmsAssociated Aneurysms Iliac - 41% Femoro-popliteal - 15% Pts with unilateral popliteal aneurysms-->8% AAA Pts with bilateral popliteal aneurysms--> 30%-50% AAA
Slide 6 - Aortic AneurysmsAssociated Medical Conditions Carotid Artery Stenosis - 10% have AAA Smoker:Nonsmoker - 8:1 Male:Female - 4:1 HTN - 40% of pts with AAA have HTN
Slide 7 - Aortic AneurysmsEtiology Atherosclerosis Cystic Medial Necrosis Dissection Ehlers-Danlos Syndrome Syphilis Familial Associated Lysyl Oxidase deficiency
Slide 8 - Aortic AneurysmsEtiology Decrease in elastin and collagen in arterial wall Elastin becomes fragmented-->arterial elongation and dilatation Increase in the collagenase and elastase activity
Slide 9 - Aortic AneurysmsEtiology Multifactorial
Slide 10 - Aortic AneurysmsPhysics Laplace’s Law T = P x R T - Tension P - Pressure R - Radius
Slide 11 - Aortic AneurysmsClinical Presentation Asymptomatic - 70-75% Symptoms: Early satiety, N,V Abd., Flank, or Back pain 1/3 of pts experience abd. And flank pain Abrupt onset of pain -->Rupture or expansion of aneurysm
Slide 12 - Aortic AneurysmsRuptured Aneurysms Small tear-> pain, followed by frank rupture Usually occurs postero-laterally Can rupture in Vena Cava creating Aorto-Caval Fistula Occasionally can rupture anterior - usually fatal
Slide 13 - Ruptured AneurysmThumbnail Sketch 60-70 y/o who presents with c/o abd pain, hypotension and a pulsatile abdominal mass
Slide 14 - Aortic AneurysmsDiagnosis Physical Exam: If <5cm in diameter, then cannot be detected by routine physical exam Radiographs: Calcified wall. Can determine size in 2/3 Cannot rule out and AAA
Slide 15 - Aortic AneurysmsDiagnosis 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
Slide 16 - Aortic AneurysmsDiagnosis 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
Slide 17 - Aortic AneurysmsCT 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
Slide 18 - Aortic AneurysmsMRA Now widely available More expensive than CT No contrast agent required Spacial resolution less than CT
Slide 19 - Aortic AneurysmsRisks Complications of AAA Thrombosis Distal embolization Rupture 23.4% of aneurysms 4-5 cm will rupture
Slide 20 - Aortic AneurysmsRupture Risks Patients with COPD and HTN have increased risk of rupture Rate of enlargement: 0.5 cm/ year Survival 50% die prior to reaching hospital, and an additional 24% prior to repair.
Slide 21 - Aortic AneurysmsTreatment Risks Mortality 0.9 - 5% with current surgical techniques Morbidity 5-10% usually associated with cardiac events Endovascular Techniques are significantly reducing morbidity and mortality associated with repair
Slide 22 - Aortic AneurysmsIndications for Treatment Presence of an infrarenal aneurysm > 5cm without associated co-morbid medical conditions Repair smaller aneurysms if rate of enlargement is greater than expected Repair all symptomatic aneurysms If co-morbid conditions exist wait until risk of repair and rupture are equal (approx. 6 cm)
Slide 23 - Aortic AneurysmsTreatment-Surgical Standard Surgical Repair Replace diseased aorta with artificial artery Requires 7 day hospital stay Recovery time 3-6 months Proven method with good long term results
Slide 24 - Aortic AneurysmsTreatment - Endovascular Repair through an incision in the groin with expandable prosthesis under fluoroscopic guidance Requires both surgical and radiological assistance Significantly reduced m+m Long tern result unknown Hospital stay 2 days, Recovery time 1-2 weeks