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Aortic Aneurysms

Aortic Aneurysms. Mark A. Farber, MD. Aortic Aneurysms Incidence. 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%.

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Aortic Aneurysms

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  1. Aortic Aneurysms Mark A. Farber, MD

  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%

  3. Aortic AneurysmsDefinition • Pseudoaneurysm • True Aneurysm

  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

  5. Aortic AneurysmsAssociated Aneurysms • Iliac - 41% • Femoro-popliteal - 15% • Pts with unilateral popliteal aneurysms-->8% AAA • Pts with bilateral popliteal aneurysms--> 30%-50% AAA

  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

  7. Aortic AneurysmsEtiology • Atherosclerosis • Cystic Medial Necrosis • Dissection • Ehlers-Danlos Syndrome • Syphilis • Familial Associated • Lysyl Oxidase deficiency

  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

  9. Aortic AneurysmsEtiology Multifactorial

  10. Aortic AneurysmsPhysics • Laplace’s Law T = P x R T - Tension P - Pressure R - Radius

  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

  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

  13. Ruptured AneurysmThumbnail Sketch • 60-70 y/o who presents with c/o abd pain, hypotension and a pulsatile abdominal mass

  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

  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

  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

  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

  18. Aortic AneurysmsMRA • Now widely available • More expensive than CT • No contrast agent required • Spacial resolution less than CT

  19. Aortic AneurysmsRisks • Complications of AAA • Thrombosis • Distal embolization • Rupture 23.4% of aneurysms 4-5 cm will rupture

  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.

  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

  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)

  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

  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

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