periphral vascular disease 2

5/28/2018 Periphral Vascular Disease 2

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Prof. Sami Asfar 1

Arterial Aneurysms

Sami AsfarM.B.,Ch.,B., M.D.(UK), FRCSEd, FACS

Professor and Chairman,

Departments of Surgery, Faculty of Medicine, Kuwait University

and Mubarak Al-Kabeer HospitalLiver Vascular SurgeryThis tafree3 includes every thing


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Prof. Sami Asfar 2

Objectives: To Learn:

Types of aneurysms

Clinical presentation of aneurysms Principles of management

Arterial Aneurysms

Outcome:

To be able: Recognize patients suffering from aneurysms

Timely referral of such patients to the vascular surgeon


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Prof. Sami Asfar 3

Internal Carotid

Subclavian

Thoracic

Innominate

Renal/Splenic

Iliac

Abdominal

Popliteal

Femoral

Shape


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Prof. Sami Asfar 4

Arterial Aneurysms

Site of vascular suturePuncture or trauma

Definition: Abnormal widening of a blood vessel

1.5 X diameter of the vessel proximal to the

dilatation

Types:True:here the ful l thickness of the wallis involved including (in tima, media, and adventi tia

)

False:

here it i s a puncture that cause

bleeding acuamil ated in one side the by time fibrosis

occur and i t become pulsating) and so it is called :

Pseudo-aneurysm

or

Pulsating Haemotoma


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Prof. Sami Asfar 5

AAA (Abdominal Aorti c Aneuri sm)

Incidence: General population . 1-5%

> 65 years age . 3-5%

> 70 years age .10%

M : F ...4 : 1 (most common female)

Risk Factors: Atherosclerosis 95% ( most impo.)

Hypertension ... 40%

Smoking

Age Males

Family history (1st degree relative)


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Prof. Sami Asfar 6

Pathogenesis of AAA

Atheromatous degeneration of intima

Neutrophils release

Elastase & Metalloproteinase cause

Loss of ELASTINin the media of Aortic wall

Compensatory expansion of adventitial layer

(Newman et al J Vasc Surg 1994)


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Prof. Sami Asfar 7

Intramural Haematomaall aneur isms have in tramur al thrombus

the thrombus break down the atheroma and then blood wi ll collect inside and give in tramural atheroma or so call ed

haematoma

Breakdown of atheromatous plaque

Splitting of the media with formation of Intramural haematoma


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Prof. Sami Asfar8

Associated Biochemical Conditions

Alpha-1-antitrypsin deficiency

Type III collagen synthesis disorders Fibrillin synthesis disorders

Elastin disorders


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Prof. Sami Asfar9

AAA

Life expectancy: of age-matched controls

Most deaths are due to:

Coronary artery disease

Ruptured AAA

Concomitant Abdominal Pathology (other pathologies can happenwith the AAA)

Asymptomatic G.B. calculi:5-20%

Colon cancer: 4-5%

Avoid concomitant aortic surgery


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Prof. Sami Asfar10

Natural History of AAA

Expansion: 0.2-0.8 cm/year Rupture:

Risk of rupture Size of the aneurysm The size of aneurysm is measur ed by its anterior -poster ior diameter

Laplace Law: T=Pxr

T: Tension on the wallP: Intraluminal pressure

r: Radius of the sac (diameter)

Aneurysm Size Risk of Rupture

5 cm 5% in 5 yrs (we do not operate itbecause there is a small chance to rupture)

5.5 cm 5% per yr cumulativewe operate it because it wil l rupture soon (25% in 5 yrs)


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Prof. Sami Asfar11

Abdominal Aortic Aneurysm

AAA

Presentation:

Asymptomatic:

Symptomatic:Distal embolisation:

Limb ischaemia, Blue toes

Back, abdominal pain:

Leaking aneurysm patient wi ll have tachycardia

Ruptured aneurysm patient wi ll be in shock

Incidental:

Clinical examination, U/S, CT-Scan


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Prof. Sami Asfar12

Diagnosis of AAA

Clinical: 95% accurate (expansile pulsation means pulsation in all directions) U/S: (best then CT SCAN) 95% accurate (reliable size measurement)

Plain X-Ray: Calcified aortic wall


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Prof. Sami Asfar13

Diagnosis of AAA

Spiral CT, MRA:Most accurate

Angiography:

Misleading because it outl ines the lumen only So we do not do it for aneurysms


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Prof. Sami Asfar14

Indications for Repair of AAA

Asymptomatic > 5.5 cm diameter ( i f the patiant isasymptomatic but the size is big, bigger than 5.5 cm)

SymptomaticRapidly expanding in 6-12 months by U/S

Ruptured or Leak


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Prof. Sami Asfar

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Urgent SurgeryResuscitation in Operating Room

Why? Cause thi patient is bleedingso you are wasting the blood

AAA + Abdominal/Back pain

What do think about??

? Rupture ? Leak

If the patient is StableIf the patient isUnstable

(Low BP/Shock)

U/S, CT-Scan

Leaking Aneurysm

Resuscitation in ICU & Prepare for Surgery


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Prof. Sami Asfar

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Elective Surgery for AAA(Preoperative Assessment) you should prepare and do

- Anaesthesia Consultation

- Chest X-ray

- Cardiac Function Tests:

ECG

Echocardiogram (Ejection Fraction, Ventricular Function)

Stress Tests: Treadmill, Thallium Scan

? Cardiac Catheterisation

- Pulmonary Function Tests

- Bowel Preparation: 4 Liters Go-Lytely


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Prof. Sami Asfar

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Elective Surgery for AAA(Preoperative Assessment)

Ejection Fraction < 50% I ncreased Risk of death in thesurgery

(Cambria et al J Vasc Surg 1992)

Preoperative management of cardiac abnormalities

improves 5-year survival by 10-20%

10% AAA patients require cardiac revascularisationbecause there is a chance to develop i nfarcti on dur ing or after the surgery

(Johnstone KW J Vasc Surg 1994)


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Prof. Sami Asfar

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Surgery for AAAPostoperative Mortality

Type of Surgery Mortality

Elective < 5%

Ruptured > 50%

Cardiac events are responsible for:69% Early Death after aor tic aneurysm is done

44% Late Death after aort ic aneurysm is do ne


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Prof. Sami Asfar

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Complications of AAA Surgery

Renal Failure: Elective 2% Rupture 21%

Ischaemic Colitis: 6%

Acute Limb Ischaemia

Trash foot

Graft infection: 1%

Neurogenic Impotence you could damage nerves dur ing sur gery

Spinal Cord Ischaemia: seen i n thoraco-abdominal sugery

Artery of Adamkiewicz T8, L1-L4 (if thi s artery i s thrombosed or damaged you get spinalcord ischaemia)

1:400 AAA repair

1:5000 Aorto-iliac disease


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Prof. Sami Asfar

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Infected Aortic Graft

REMM BER: NO OTHER SURGERIES ARE DONE AT THE SAME TI ME WHEN WE DO AORTIC SURGERY TO

AVOID I NFECTION OF THE GRAFT.

1% after Aortic Repair (months-years) > 50% Mortality

Organisms: Staph aureus

E. coli (Lorentzen et al Surgery 1985)

Presentation:

Fever, malaiseAbdomen & back pain

Septic emboli to legs

Groin abscess

Aorto-enter ic Fi stula (most of the time it i s between the duodenum)CAUSES: Recurrent upper GI bleed

Treatment:

Graft ExcisionExtra-anatomical By-pass (Axillo-Bifemoral)


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Prof. Sami Asfar

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Screening for AAA

U/S Screening of people > 60 years age

every 6-12 months

Decreased the incidence of Rupture by 85%(Scott et al Br J Surg 1995)


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Prof. Sami Asfar

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Small (< 5.5 cm) AAAWE DO NOT OPERATE I T CUASE THE COMPLI CATIONS AFTER THE OPERATION ARE BAD AND EARLY surgery is

NOT associated with any long-term survival advantage

U.K. Small Aneurysm Trial:

U/S Surveillance is safe

Early surgery is NOT associated with any long-term

survival advantage (Lancet 1998;352:1619-55)

Predictors of increased risk of rupture:

Chronic obstructive pulmonary disease

Systolic hypertension

Increased pulse pressure (Crenenwett et al Surgery 1985)


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Prof. Sami Asfar

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Medical Management of Small AAAINSTEADE OF HAVING A SURGERY WE GIVE THE PATIENT WITH SMALL AAA THE FOLLOWING:

Propranolol:

Doxycycline:

Increases tensile strength of aortic connective tissue

Reduction in expansion rate of aneurysm(Gadowski et al J as Surg 1994)

Potent metalloproteinase inhibitor

Very effective (DONE ON animal studies ONELY)

(Petrinee et al J Vasc Surg 1996)


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Prof. Sami Asfar

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Inflammatory Aortic Aneurysm

5-10% of AAA Pathology: we do not know the cause it is an inf lammatory process

Marked thickening of the media & adventitia of the aneurysm wall

(AAA: the media is thin)

Dense retroperitoneal inflammatory fibrotic reaction incorporating:

Duodenum, IVC, Lt Renal vein, Ureters

Presentation:Pain with No rupture

Ureteric obstruction: 3-4%

Weight loss: 5%H igh ESR (50-100 mm/1st hr)

Treatment: Same as AAA


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Prof. Sami Asfar

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Endovascular Repair of AAAthi s comes recentl y without major surgery

Transfemoral placement of intraluminal

prosthetic graft Stent graft into the

infrarenal aorta

Less morbidity and immediate post-

procedure mortality Require suitable length of normal

calibre aorta below renal arteries for

graft fixation

Initially it was thought that 40% ofAAA are suitable


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Prof. Sami Asfar

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Endovascular Repair of AAA

EVAR-1 & EVAR-2

Most recent results of two randomized studies: Only reduced in-hospital mortality to 1.2% from 3.8%

which is excel lent

Overall survival after 4 yrs NOT significant

Re-intervention 5% a year because of endoleaks

1% a year incidence of rupture

33% more cost than normal major surgery(F/U with repeat CT-scans)

Did not improve health related quality of life

(Lancet 2005;365:2156-2158)

Suitable for high risk patients who have suitable anatomic

conditions (Aortic neck below renal arteries).

(Lancet 2005;365:2156-2158)


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Prof. Sami Asfar

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Other Arterial Aneurysms

Iliac artery aneurysm

Splenic artery aneurysm

Renal artery aneurysm Femoral artery aneurysm

Popliteal artery aneurysm

Mycotic aneurysms


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Prof. Sami Asfar

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Iliac Artery Aneurysm

Rarely isolated

Usually extension of AAA

Pulsatile mass palpable by PR examination

Rupture into sigmoid colon: Lower G.I . Bleed


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Prof. Sami Asfar 29

Splenic Artery Aneurysm

1% of population

F:M 4:1

Causes: Fibromuscular dysplasia

Portal hypertension: 10%

Multiparity

Pancreatitis: pseudo-aneurysm


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Prof. Sami Asfar 30


Presentation Incidental:

Plain X-ray: Signet ring calcification in 70%

U/S, CT-Scan

Rupture: Intra-peritoneal bleeding: shock

Stomach: Upper GI bleeding

Double rupture phenomenon

(lesser sac then peritoneum)

Mortality: 25%

Abdominal pain:

Epigastric & left upper quadrant
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Prof. Sami Asfar 31


Rate of RuptureAsymptomatic nonpregnant: 2%

First discovered during pregnancy: 95%

Maternal Mortali ty 75%(Angelakis Obst Gyn 1993)

Treatment: Endovascular embolisation

For women in chil d-bearing age


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Prof. Sami Asfar 32

Renal Artery Aneurysm

Rare: 0.1% population

Saccular < 1.5 cm

Incidental

Rupture is uncommon except in pregnancy Associated with:

Medial fibroplasia

Polyarteritis nodosa:

Multiple microaneurysms
http://www.scvir.org/members/caseclub/0698/0698_02/0698_022.html


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Prof. Sami Asfar 33

Management of Renal Artery Aneurysm

Indications Symptomatic + > 2 cm diameter

Child-bearing age

Surgery

Vein patch:

Saphenous vein graft

Internal iliac artery graft

Ex-vivo repair

Percutaneous Embolisation

Af ter one year
http://www.scvir.org/members/caseclub/0698/0698_02/0698_025.htmlhttp://www.scvir.org/members/caseclub/0698/0698_02/0698_024.html


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Prof. Sami Asfar 34

Popliteal Artery Aneurysmmost common after AAA

Most common peripheral artery aneurysm

Popliteal artery > 2 cm diameter

Bilateral: 50% so when you diagnose it in one side most probably you have another one at the other side

Associated with AAA: 40%

Aetiology:

- Atherosclerosis

- Popliteal artery entrapment: Poststenotic dilatation


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Prof. Sami Asfar 35

Popliteal Artery Aneurysm

Clinical Presentation

50% Symptomatic:Distal ischaemia:

Most common and serious presentationDistal embolisation

Acute thrombosis of aneurysm

Rupture: 4%

Compression of popliteal nerve or vein


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Prof. Sami Asfar 36


Diagnosis: U/S, MRA, CT-Scan

Angiography

Treatment: Proximal & distal ligation

Femoro-popliteal bypass


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Prof. Sami Asfar 37


Prognosis:

Depends on the patients presentation

Asymptomatic patients:

5-yr graft patency 80% Limb salvage 98%

Ischaemic symptoms:

65% 5-yr graft patency

20% amputation


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Prof. Sami Asfar 38

Mycotic Aneurysms

Bacterial infection of the arterial wall

Usually saccular

In atypical locations

Lack calcification of the wall

Organisms:

o Staph species 30%

o Salmonella species 10%

o Streptococcus species 10%


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Prof. Sami Asfar 39

Mycotic Aneurysms

Presentation:

Fever, Leukocytosis

Rapidly enlarging, warm, tender pulsatile mass

Septic emboli

Deeply seated:

PUO

Rupture: Shock

Blood culture: +ve only 50%


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Prof. Sami Asfar 40

Mycotic Aneurysms

Affected Arteries: Aorta 40%

Peripheral arteries 35%

Visceral arteries 20% (Brown et al J Vasc Surg 1985)

Treatment: Antibiotics

Depending on the site:

Excision or bypass


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Prof. Sami Asfar 41

Thoraco-Abdominal & Dissecting Aneurysms


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Prof. Sami Asfar 42

Aortic Dissection

DeBakey Classification

Type I:Ascending, Descending & Abdominal Aorta

Type II:

Ascending Aorta

Type IIIa:Descending Aorta

Type IIIb:Descending & Abdominal Aorta Marfans Syndrome

Ehlers-Danlos Syndrome

Takayasus aortitis


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Prof. Sami Asfar 43

Aortic Dissection

1. Intimal tear

Entrance

Exit

2. Blood under pressure dissects the media

3. Splitting of media (intimomedial flap)

4. Double channel Aorta

True Lumen

False Lumen


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Prof. Sami Asfar 44

Thoraco-Abdominal Aneurysms (TAAA)

Crawford Classification

Type I:Descending & Abdominal Aorta

Not involving the Renal arteries

Type II:Thoracic & Abdominal Aorta

Type III:Distal Thoracic & Abdominal Aorta

Type IV:All or most of Abdominal Aorta

periphral vascular disease 2

Documents

sami asfar9aaa life

years age

risk of rupture size

aaa asymptomatic

size of aneurysm

aneurysms timely referral

cmyear rupture

agematched controls