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Aneurysms; The Bubble Burst

Aneurysms; The Bubble Burst. Mr JV Smyth Vascular Surgery. ‘Atherosclerotic’ Mycotic Inflammatory Connective tissue disorder False. Simple Ureteric compression AV fistula Aortoenteric fistula Rupture Thrombosis/Embolism. Aortic/iliac Popliteal Visceral Intracerebral. Asymptomatic

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Aneurysms; The Bubble Burst

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  1. Aneurysms; The Bubble Burst Mr JV Smyth Vascular Surgery

  2. ‘Atherosclerotic’ Mycotic Inflammatory Connective tissue disorder False Simple Ureteric compression AV fistula Aortoenteric fistula Rupture Thrombosis/Embolism Aortic/iliac Popliteal Visceral Intracerebral Asymptomatic Back pain Tenderness Limb ischaemia Threshold for surgery Fusiform Saccular

  3. The Paradigm Abdominal aortic aneurysm Asymptomatic Atherosclerosis Fusiform Infrarenal Principal risk is rupture

  4. Aneurysms • Males 4:1 • 60’s and upward • Hypertensive smokers • Family history of AAA • 1 in 25 random 65yr males • 1 in 6 65 yr HT male smokers with FH • Usually incidental finding during Ix for something else

  5. SCREENING • Common condition • Significant outcome if not diagnosed • Effective intervention • At-risk population subgroup • Widely available test • Safe, sensitive and specific • Economic (QALY) • National AAA screening programme recently announced

  6. Mortality

  7. Open repair • Replace aneurysmal segment • GA, laparotomy, aortic XC • Mortality 5-7% • 90% cardiac • Occasional respiratory/renal failure/PE • Patient selection • Echo, stress test • PFTs

  8. Maximum transverse diameter Normal aorta < 2.5cm Ectasia < 3.5cm Small AAA < 4.5cm Large AAA >5.5cm Rupture is exponentially associated with MTD ~1% Annual risk at 4cm ~ 7% Annual risk at 6cm ~30% annual risk at 8cm

  9. Endovascular repair • Reline aorta rather than replace • Dependent on radial force of stents for fixation rather than sutures • Modular system • Bilateral groin incisions (or punctures) • Avoids laparotomy, XC • Mortality 1.9% (EVAR 1 trial)

  10. Why not everyone ? EARLY ENDOLEAKS

  11. Endoleak Types • I around aortic or iliac landing zones • II from lumbars or IMA • III between graft components • IV loss of graft integrity

  12. Anatomical suitability • Infrarenal neck, common iliac arteries • Length • Shape • Angulation • Thrombus • Iliac access • Tortuosity • Calibre

  13. Oversizing • Suprarenal uncovered stent • Barbs • More flexible devices • Repositioning capability • Low profile delivery system • Custom made prosthesis

  14. Complex EVAR • Iliac conduit • Carotid access • Iliac bifurcation device • Aorto-uniiliac and cross over • IIA embolisation • Fenestrated • Branched • Chimney

  15. Why not everyone ? LATE ENDOLEAKS

  16. Long term FU • Device integrity • Conformational change • Reinterventions proportional to time

  17. Ruptured AAA • Lower back pain, hypotension, abdo mass • Most never get to hospital • Overall mortality 95% • Postoperative mortality ~50% • Get large IV lines in • Call vascular surgeons • Permissive hypotension, analgesia • Send blood for XM, FBC, clotting, U&E

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