CTVS 61 Aortic aneurysm

  1. What is aneurysm?
    Aneurysms is defined as an increase in size of more than 50% above the normal arterial diameter.
  2. True and false aneurysm?
    • True aneurysms involve all three layers of the vessel wall.
    • False aneurysm or pseudoaneurysm describes a focal defect in the artery with an associated collection of blood contained by adventitia and periarterial tissue; it may be degenerative, infectious, or traumatic in etiology.
  3. Enlist the indications of surgery in aortic aneurysm (AA).
    What are the principle involved in surgical management?  [TU 2055] 

    Risk factors for AAA?
    • Age
    • Male gender
    • Concurrent aneurysms
    • Family history
    • Tobacco use
    • Hypertension
    • Hyperlipidemia
    • Height
    • Female gender, black race, and diabetes appear to be protective.
  4. Describe clinical features of AA aneurysm.  [TU 2066]
    • ●Asymptomatic – The majority of patients are asymptomatic
    • ●Symptomatic but not ruptured – Symptomatic - The development of symptoms may be a sign that AAA configuration is rapidly expanding, has become large enough to compress surrounding structures, or is an inflammatory or infectious aneurysm. Patients with symptomatic AAA most commonly present with abdominal, back, or flank pain, which may or may not be associated with AAA rupture. AAA can also present with other clinical manifestations, such as limb ischemia . 
    • ●Symptomatic and ruptured –   The classic presentation of severe pain, hypotension, and a pulsatile abdominal mass occurs in about 50 percent of patients.
  5. Diagnosis of AAA?
    • Physical examination as a palpable pulsatile mass, most commonly supraumbilical and in the midline.
    • USG - not ideal method, fail to detect upto 50% of aneurysm ruptures.
    • CECT with CT angiography - provides anatomic information; it detects vessel calcification, thrombus, and concurrent arterial occlusive disease and permits
    • multiplanar and three-dimensional reconstruction and analysis for operative planning
  6. Screening in AAA?
    Society for Vascular Surgery Clinical Practice Council recommends further screening intervals as follows:

    • <2.6 cm:= no further screening recommended
    • 2.6-2.9 cm: reexamination at 5 years
    • 3-3.4 cm: reexamination at 3 years
    • 3.5-4.4 cm: reexamination at 12 months
    • 4.5-5.4 cm: reexamination at 6 months
  7. What are the management options of AAA. [TU 2066]

    Medical treatment of AAA
    To decrease progression of AAA - 

    • Anti platelettherapy using aspirin
    • Beta blockers
    • Statins,

    Smoking cessation.
  8. Indications for surgery in aortic aneurysm. What are the principles involved in surgical management? Enumerate the complications following surgery. [TU 2055] 

    Indications of surgical repair?
    • Aneurysms > 5.5 cm in maximal diameter
    • > 5 mm of growth in 6 months or more than 1 cm in a year
    • Aneurysms with a saccular rather than the typical fusiform anatomy
  9. Open Techniques of surgical repair?
    Open aneurysm repair involves replacement of the diseased aortic segment with a tube or bifurcated prosthetic graft through a midline abdominal or retroperitoneal incision. Approach to open repair can be either Transperitoneal or Retroperitoneal. 

    Transperitoneal repair through a midline laparotomy incision isthe most widely used approach to the usual infrarenal aneurysm and offers a rapid exposure, excellent access to renal and iliac vessels, and the ability to fully examine the  abdominal contents.

    The retroperitoneal approach is thought, by some, to reducephysiologic stress on the patient and to result in fewer postoperative pulmonary complications as well as a reduction of postoperative ileus.

    Given the need for lifelong surveillance with endovascular repair, younger patients with low operative risk may benefit more from open surgical repair, whereas older patients and those with high operative risk may benefit more from endovascular repair, provided their aortoiliac anatomy is appropriate
  10. Operative steps?
  11. What is EVAR?
    • Endovascular aneurysm repair (EVAR) is a type of endovascular surgery used to treat pathology of the aorta, most commonly an abdominal aortic aneurysm (AAA).
    • When used to treat thoracic aortic disease, the procedure is then specifically termed TEVAR (thoracic endovascular aortic/aneurysm repair).

    EVAR is performed by inserting graft components folded and compressed within a delivery sheath through the lumen of an access vessel, usually the common femoral artery. Upon deployment, the endograft expands, contacting the aortic wall proximally and iliac vessels distally to exclude the aortic aneurysm sac from aortic blood flow and pressure. 

    Compared with open AAA repair, EVAR is associated with a significant reduction in perioperative mortality, primarily because EVAR does not require operative exposure of the aorta or aortic clamping.

    In 2003, EVAR surpassed open aortic surgery as the most common technique for repair of AAA, and in 2010, EVAR accounted for 78% of all intact AAA repair in the United States. 

    Once the patient is anesthetized, endovascular aneurysm repair is accomplished through an orderly sequence that includes gaining vascular access, placement of arterial guidewires and sheaths, imaging to confirm aortoiliac anatomy, main body deployment, gate cannulation (bifurcated graft), iliac limb deployment, graft ballooning, and completion imaging.

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  12. Complications following surgical repair of AAA? [TU 2055]
    Complications of EVAR -

    • A) Endograft complications - 
    • Access site complications
    • Percutaneous access
    • Endoleak
    • Device migration
    • Separation of components
    • Limb kinking and occlusion
    • Endograft infection

    • B) Systemic complications -
    • Cardiopulmonary complications
    • Intravenous contrast complications
    • - Contrast-induced nephropathy
    • - Allergy

    • c) Ischemic complications
    • - Renal ischemia
    • - Intestinal ischemia
    • - Extremity ischemia
    • - Pelvic ischemia
    • - Spinal ischemia

    • d) Other 
    • Abdominal compartment syndrome
    • Postimplantation syndrome
Card Set
CTVS 61 Aortic aneurysm
Aortic aneurysm