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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