aortic aneurysms dilshan udayasiri. some anatomy ascending aorta arch of the aorta descending aorta...

Aortic AneurysmsDilshan Udayasiri

Some Anatomyascending aorta

arch of the aorta

descending aorta

abdominal aorta

Layers of the aorta

Types of aneurysmsShape

Saccular Fusiform

Ruptured

Causes

Degenerative

Dissecting

LocationThoracic (25%)•Ascending (60%)•Aortic Arch - includes brachiocephalic arteries (10%•Descending (40%)•Thoracoabdominal (10%)Abdominal (75%)

Percentage 60% 10-15 % 25-30 %

Type DeBakey I DeBakey II DeBakey III

Stanford A Stanford B

  Proximal Distal

Risk Factors•Hypertension

•Hypercholesterolaemia

•Smoking

•Age (rare before 60)

•Genetic (Marfans, Ehlers-Danlos syndrome)

•Bicuspid Aortic Valve

• Inflammatory/infectious - eg Giant Cell Arteritis

Symptoms• Incidental

• Pain - tearing, radiating to back

• Heart failure - due to AR

• Thromboembolic (stroke, painful/parathesia of limbs)

• Hoarseness of voice (compression of recurrent laryngeal nerve )

• Can mimic other acute disorders (AMI, renal colic, pancreatitis)

Signs

• obs

• lack of peripheral pulses

• Pulsatile mass and tender abdomen

• Murmur

• Decreased BS and dullness to percussion

• Signs of heart failure

• Neurologic signs (Horner’s Syndrome - compression of cervical sympathetic ganglion)

Investigations

Treatment

•Watchful Waiting + medical

•Percutaneous or open intervention

Watchful Waiting• Tight blood pressure control (MAP between 60 -

75)

• beta blocker favourable unless contraindicated

• persistent hypertension, check kidneys

• cease smoking

• treat hypercholesterolaemia

• Screening

• 6 months after initial scan then every 12 months unless symptomatic or increased rate of expansion or if size is 4.5cm - 5.5cm.

Indications for surgery

•HD unstable

•symptomatic

•diameter ≥ 5.5cm

•rate of growth ≥ 1.0cm/year

Endovascular repairIndications

High perioperative risk pt’s

Other Benefitsshorter ICU stayShorter Hospital StayQuicker return to normal functionIncreased surviability in the short term

ComplicationsEndoleak (Type 1-4)Device MigrationInfectionHaematomaStrokeAMIDeath

Surgery• Incision depends on location

• Median sternotomy - arch

• left thoracomtomy - descending

• left thoracotomy extending across costal margin for retroperitoneal approach - thoracoabdominal

• Abdominal incision - AAA

ConsiderationsDistal perfusioncerebral protectionRenal DysfunctionStaged procedure