Aneurysm, Dissection

1. Aneurysm, Dissection

2. Aneurysm • Aneurysm: localized dilation of the vessels or the heart • May occur at any site, most important is aorta and ventricles. • True aneurysm is bounded by vessel wall • False aneurysm: extravascular hematoma with communication to vascular space (Pulsating hematoma)

5. Aneurysm • Congenital or acquired • Aortic aneurysm: • Causes: • Atherosclerosis • Cystic medial degeneration • Others: trauma, congenital (berry aneurysm), infections (mycotic aneurysm, syphilis), Vasculitis

6. Aneurysm • Mycotic aneurysm (infection) • Route of infections • Embolization of infections • Extension of adjacent infection • Circulating organisms

7. Aneurysm • Saccular aneurysm: localized bulging of vessel • Fusiform aneurysm: long segment of the vessel is involved.

8. Aortic Aneurysm • Atherosclerosis is the most common cause • Common in abdominal aorta: Abdominal Aortic Aneurysm (AAA) • May occur at other sites: thoracic aorta, common iliac artery…. • AAA is usually below the level of renal arteries and above aortic bifurcation

9. Aortic Aneurysm • AAA can be saccular or fusiform • Atherosclerosis – weak media – aneurysm – thrombosis. • Mycotic AAA: atherosclerosis with infection, bacteria: Salmonella

10. Aortic Aneurysm • Pathogenesis: • Genetic Predisposition • >50 years • M>F • Marfan syndrome • Genetic defects in structural proteins • Atherosclerosis

12. Aortic Aneurysm • Complications: • Rupture with massive hemorrhage • 2% in <4 cm aneurysm • 5-10% in >5 cm aneurysm • Occlusion of vessels: renal artery, mesenteric, iliac • Embolism • Compression of other structures: eg. ureters

13. Aortic Aneurysm • Presentation of AAA: • Abdominal mass: pulsating • Any of the complications

14. Aortic Aneurysm • Presentation of Thoracic aneurysm • Respiratory difficulties • Difficulty in swallowing • Cough • Chest pain • Heart disease: valvular disease, Ischemic heart disease • Syphilitic aneurysm

15. Aortic Dissection

16. Aortic Dissection • Dissection is hematoma within the vessel wall with dissection of blood between layers of the media (muscle layer) • Can rupture resulting in massive hemorrhage

18. Aortic Dissection • Two groups of patients: • Men 40-60 years with hypertension • Young with connective tissue disorder eg. Marfan syndrome • Others: iatrogenic, Pregnancy • Dissection is unusual in severe atherosclerosis

19. Aortic Dissection • How does is happen? • Intimal tear usually within 10 cm of the aortic valve • Dissection of blood into aortic wall • Dissection can extend proximally or distally usually between the middle and outer third of the muscle layer • Dissection can rupture outside the vessel • Or can open inside to the vascular space resulting in Chronic dissection

20. Aortic Dissection • Pathology: • Cystic medial degeneration • Degeneration of the muscle • Deposition of plasma proteins and collagen • Fragmentation of elastic fibers

21. Aortic Dissection • Types: • Type A: • Common, dangerous • Proximal Ascending aorta: DeBakey type I • Ascending and Descending thoracic aorta: DeBakey type II • Type B: • Distal to subclavian artery • DeBakey type III

22. Aortic Dissection • Presentation: • Sudden Severe pain: anterior chest radiating to the back then moving downward • Complications: • Rupture • Cardiac tamponade • Occlusion of vessels: coronary, mesenteric, renal….

23. Berry Aneurysm

24. Arteriovenous Fistula • Communication between arterial and venous circulation • Causes: • Developmental • Trauma/repair • Rupture of vessels • Aneurysm • Inflammatory process • surgical

26. Arteriovenous Fistula • If small: not significant • If large can cause heart failure • May rupture resulting in hemorrhage

27. Varicose Veins

28. Varicose Veins • Abnormal dilated, tortuous veins • Due to prolonged increase in pressure • Common in superficial veins of legs • Occupational relation: Long stand, long automobile and airplane rides • Common: 15-20% of general population • More in >50 years, obese women • Familial tendency

30. Varicose Veins • Valve deformity, thrombosis • Pathology: Thickening and thinning of the vessel walls, degeneration, calcification, muscle hypertrophy (Phlebosclerosis)

31. Varicose Veins • Presentation: • Venous stasis, congestion, edema, pain, thrombosis • Skin atrophy, ulcers, poor healing • Esophageal varices • Hemorrhoides

32. Thrombophlebitis and Phlebothrombosis • Thrombophlebitis is venous thrombosis • Phebothrombosis is inflammation of veins • Predisposing factors for thrombosis: • Heart failure, neoplasia, obesity, post operative, prolonged bed rest, genetic hypercoagulability

33. Thrombophlebitis and Phlebothrombosis • Presentation: • DVT: edema, cyanosis, dilated superficial veins, tenderness, swelling, pain (Homan sign) • Others: veins in skull, dura, pelvic veins • Trousseau sign

34. Vascular Neoplasm

35. Vascular Neoplasm • Benign • Borderline • Malignant

36. Hemangioma • Common in infants, children • Skin, mucosa, subcutaneous tissue • Capillary hemangioma • Cavernous hemangioma

38. Vascular Ectasia • Nevous Flammeus: birth mark • Spider Telangiectasia: in cirrhosis, pregnancy

39. Kaposi Sarcoma • Chronic: classic • Old men, multiple red-purple skin plaques in lower extremities • Slow growing • Endemic (African) KS • Children in Africa • Localized/generalized lymphadenopathy • Transplant-Associated KS • AIDS-Associated KS • ¼ of AIDS patients, male, Homosexual

40. Kaposi Sarcoma • Pathology • Patch • Plaque • Nodular • Cause: associated with Human Herpes Virus type 8 (HHV8)

42. Angiosarcoma • Malignant vascular neoplasm • Sporadic • Secondary: radiation, lymphedema • Arise in any site: common in skin, soft tissue, breast, liver

43. Coarctation of Aorta