Aortic Aneurysm

SGD B2
outline
Introduction Sign & Symptom Prognosis

Definition Diagnose Complication

Epidemiology Differential Diagnose Case

Etiology Management

Risk Factor Prevention

Pathophysiology Prevention
INTRODUCTION
Aneurysm is an abnormal bulge in the wall of an artery
Aneurysm 15.000 deaths yearly, 10th leading causes
Atherosklerosis plaque formation and rupture can
increase the risk of aneurysm
In this presentation we would like to elaborate more
about the cause, sign & symptoms, diagnosis,
treatment, and prevention
Definition
 AAA
 A maximum dilatation or widening of the abdominal (infrarenal)
aortic diameter of 3.0 cm or more or 1.5 times from expected
normal diameter to compensate for individual variation of the
adjacent aorta

 AAA: abdominal and thoracoabdominal

In the abdomen --> association with renal arteries
- infrarenal (85%)
- pararenal with involvement of 1 or both
renal arteries
- suprarenal

 Common iliac arteries are often involved

Infrarenal AAA
TAA
Epidemiology

AAA Older patients (65-80 years) --> 2.2%

Prevalence : men 4-8% and women 1-2%
Prevalence Aortic aneurysm is increased,

But AAA is
From 15,000 to 13,000 deaths yearly
decreased In 2000 --> 10th leading cause of death in USA

TAA - 6 cases per 100,000 person-years

Etiology
RISK FACTORS
 PATOPHYSIOLOGY
Abdominal Aortic Aneurysm
Elastin

MEDIAL THINNING
DECREASE OF ELASTIN AND INTIMAL
THICKENING

Proteolysis, metalloproteinases, and inlammation

INCREASE OF
INCREASE OF
CONCENTRATION OF
CONCENTRATION OF
PROTEOLYTIC
THE INHIBITOR
ENZYMES
PATOPHYSIOLOGY

INCREASED
METALLOPROTEINASE
S
DEGRADATION OF
ELASTIN AND
COLLAGEN
DECREASED
INHIBITIOR ACTIVITY

IMMUNOREACTIVE INCREASE OF
PROTEIN MORE IN FREQUENCY OF
ABDOMINAL AORTA ANEURYSM
PATOPHYSIOLOGY
 PATOPHYSIOLOGY
Thoracic Aortic Aneurysm

INCREASE OF SPECIFIC DEGRADATION OF

ENZYMES STRUCTURAL PROTEIN

WEAKENING OF THE
• ELASTIC FIBER
AORTIC WALL, LOSS
FRAGMENTATION
OF ELASTICITY, AND
• DEGENERATION OF
CONSEQUENT
MEDIA
DILATATION
 PATOPHYSIOLOGY
– Law of Laplace
“The wall tension is proportional to the pressure times the
radius of the arterial conduit.”

T=PXR
PATOPHYSIOLOGY

TENSION PRESSURE INCREASING

INCREASED INCREASE RADIUS

INCREASE THE RISK OF RUPTURE

Sign and Symptom
How to diagnose ?
Thoracic Aortic Aneurysm
Chest X-Ray
• Abnormal aortic sillhouette
• Mediastinal mass 
diffuse widening
mediastinum
• Enlargement aortic knob
• Tracheal deviation
• Change in aortic contour
Aortography
Preoperative evaluation 
define location an extent of
aneurysm
Replaced by CT and MRI
CT Scan
Contrast-enhanced
observe the morphology,
pattern, distribution of
thrombus and calcification,
and visualization of dissection
and intimal flap.
 CT Scan

Descending thoracic Ascending thoracic

aortic aneurysm aortic aneurysm
MRI
Best assessment of
true size, lumen and
vessel well, observing
excellent vessel
anatomy and
surrounding structure.
Least renal toxicity,
but time consuming
and not for unstable
patient.
CT Angiography
Good for imaging tortuous thoracic aorta
Reconstruct axial images to 3D
Accurate diameter
MR Angiography
Multiple planes 3D with
Gadollinium Contrast
Accurate diameter, shows
blood flow, not visualize
adventitia well
 Transthoracic Echocardiogram
Demonstration of aortic
enlargement
May find severe
atherosclerosis, mildly
enlarged aorta, eccentric
thickening of one wall, and
echogenicity consistent
with thrombus
Good for unstable px,
operator-dependent
How to diagnose ?
Abdominal Aortic Aneurysm
Abdominal Aortic Aneurysm
Abdominal Examination
USG (most common used)
Contrast enhanced CT or MRI
CT Angiography
MR Angiography
Differential Diagnose
Abdominal Aortic Aneurysm
Differential diagnose
Thoracic Aortic Aneurysm
 management
Abdominal Aortic Aneurysm

Rupture ?
Unruptured Risk check
Non-rupture ?

Rupture Emergency

The risk :
management
Abdominal Aortic Aneurysm
Open
Surgery
Endovascula
r Surgery
management
Thoracic Aortic Aneurysm
  Recommendations
Ascending Surgery is indicated in patients who have aortic root
Aortic aneurysm, with maximal aortic diameter ≥50 mm for
Aneurysms patients with Marfan syndrome.
  Surgery should be considered in patients who have
aortic root aneurysm, with maximal ascending aortic
diameters:
≥45 mm for patients with Marfan syndrome with risk
factors.
≥50 mm for patients with bicuspid valve with risk
Figure 12. factors
Composite aortic graft repair of Figure 13. Valve-sparing procedure to
aneurysm involving the aortic root and repair an aneurysm involving the aortic
ascending thoracic aorta. The coronary arteries root and ascending thoracic aorta. The
≥55 mm for other
are excised as buttons, and the aneurysm is patients with nosinuses
aortic elastopathy
are excised, but the valve
  Lower
resected to the level thresholds
of the aortic for intervention
annulus, with may
leaflets are be leaflets
not. The considered
are then placed
sacrifice of the native aortic valve. A prosthetic within the lumen of a Dacron graft that is
according
valve is attached directly to body
to a Dacron graft andsurface area in patients
then sewn directly to of smallannulus.
the aortic
this composite graft is sewn directly to the The valve leaflets are then reimplanted
stature or in the case
annulus. The native coronary buttons are then of rapid progression,
within the base of aortic valve restore
the graftto
reimplanted into theregurgitation,
graft. planned pregnancy,
competency. and patient’s
  Recommendations

Aortic Arch Surgery should be considered in patients

Aneurysm who have isolated aortic arch aneurysm
with maximal diameter ≥55 mm

  Aortic arch repair may be considered in

patients with aortic arch aneurysm who
already have an indication for surgery of an
adjacent aneurysm located in the ascending
or descending
Figure aorta.
14. Repair of an aneurysm
involving ascending thoracic aorta and
arch by using a multilimbed prosthetic
graft.
   Recommendations
Descending TEVAR should be considered, rather than
aortic surgery, when anatomy is suitable.
aneurysm

  TEVAR should be considered in patients who

have descending aortic aneurysm with maximal
diameter ≥55 mm

  When TEVAR is not technically possible,

surgery should be considered in patients who
have descending aortic
Figureaneurysm
16. Minimally withinvasive
maximal repair of a
descending thoracic aortic aneurysm using a
diameter ≥60 mm transluminally placed endovascular stent-graft. The
  When interventionunexpanded
is stent is advanced and positioned across
indicated, in cases of
the aneurysm. The proximal portion is expandedand
Figure 15. Marfan
Repair syndrome
of or The
anchored. other
coveredelastopathies,
stent then serves as a conduit
descending thoracic aortic for blood flow while excluding the aneurysmal aorta
surgery should be indicated rather than
from the circulation. The TEVAR
aneurysm sac then
aneurysm. thrombosis.
 Prevention of Aortic Aneurysm
• Preventive of Aortic Aneurysm is to modified its risk
factors.
If your parents and close - related family are considered had
Aortic Aneurysm before, it wise to avoid:1,2
Smoking

Hyperlipidemia

Hypertension control

Sedentary lifestyle

References
1. Sakalihasan N, Limet R, Dewafe OD. Abdominal Aortic Aneurysm. Journal of Lancet. Vol 365; 2005. Accessed from www.thelancet.com (17
April 2015)
2. Fauci AS, et al. Harrison’s Principles of Internal Medicine. 17th ed. McGraw-Hills Companies; United States of America, 2008.
 PROGNOSIS

satisfied, with prompt diagnosis and proper surgical treatment

In patients undergoing surgery for descending thoracic aortic aneurysms, the

operative mortality rate for all cases (emergency or elective) averaged 11%.
Elective surgical repair of descending thoracic aortic aneurysms is also
associated with a mortality rate ranging from 5% to 14%. Risk factors for
early mortality and morbidity included emergency operation, congestive
heart failure, advanced age, and atherosclerotic etiology.

For patients who suffer rupture of an AAA before hospital arrival, the
prognosis is guarded. The survival rate for patients who can reach the
emergency department at the time is about 1% per minute, but it will higher
(about more than 50%) for those who don’t
Complication

Next slide
Complication After Abdominal
Aortic Aneurysm Repair
CONCLUSION
Aneurysms are permanent focal dilatation of artery to
1.5 times from its normal diameter
AAA will be showed as pain in the abdomen, radiating
to back, nausea and vomiting. TAA are mostly
asymptomatic
Abdominal USG is primary method for screening AAA
The treatment will be based on the part of aortic that
affected with aneurysm
It wise to avoid: smoking, hyperlipidemia,
hypertention, and sedentary life
Case 1
Case 1: Thoracic Aortic Aneurysm
Reference: Duru S, Erdem M, Agca E, Kaplan T, Ardic S. Thoracic Aortic Aneurysm:
A Rare Case Report. Turkish Thoracic Society. 2013; 14: 78-80

CASE DESCRIPTION
Male, 72 years old admitted to Dept. of Chest Disease with:
ANAMNESIS
Chief complaint: back pain for the past two years which is intermittent
interscapular pain independent of position, breathing and exercise. The last
pain had been present for 2 months
Past history: hypertension for 20 years with an irregular antihypertensive
treatment, he did not have any known genetic disease, no systemic connective
tissue disease, infection, genetic defects, inflammation, or history of trauma
Family history: his parents had suffered from hypertension and diabetes
Social history: no history of smoking, coughing, weight loss, dyspnoea,
dysphagia and haemoptysis.
PHYSICAL EXAMINATION
1. Vital Sign : BP: 140/80 mm Hg, PR: 90 beats/minute, RR: 16
breaths/minute, T.ax : 36°C
2. Cardiac and other system examinations were normal, but there was a
decrease of breathe sounds in the left infrascapular area in the
auscultation

SUPPORTING EXAMINATION
1. CBC, biochemical and serological analyses were normal
2. Normal erythrocyte sedimentation rate of 10 mm/h and a white blood cell
count of 9×109/L
3. High sensitivity C-reactive protein and serum D-dimer levels were found
to be normal
4. Posteroanterior chest X- ray (Figure 1) examination revealed a large left
hilar mass. In addition to a lack of aeration of the lower lobe of the left
lung, there was minimal costophrenic sinus bluntness
SUPPORTING EXAMINATION:
1. In echocardiographic examination, systolic function was normal (fractional
shortening: 30%, ejection fraction: 65%), there was grade I diastolic
dysfunction, mitral lid E-A velocity: 0.7 m/s, no mitral failure, no valvular
regurgitation and hypertrophy (interventricular septum diastolic diameter:
10 mm).
2. Thorax CT scan showed that the mass was located in the proximal part of
the descending aorta, with a diameter of 8 cm, suggesting a saccular aortic
aneurysm
3. Defined thrombus material was pressurising the posterior of the oesophagus
and the left atrium. Also, due to compression, atelectasis was seen on the
posterobasal segment of the left lung
4. Thoracic aortography examination showed an aneurysm located in the
proximal part of the descending aorta with a diameter of 8 cm
5. A large thrombus (6 cm) and atherosclerotic atheroma plaques were shown
within the TAA
TREATMENT FOR THIS PATIENT

In surgical treatment, under general anaesthesia penetrating to the

femoral artery and using arcus aortagraphy and toracal
aortagraphy, an aneurysm with a diameter of approximately 8
cm was discovered. The 30x120 mm aortic stent graft was
applied to the aneurysm. In the postoperative phase, the patient
had no back pain. No complication was seen; after follow-up
and improvement of their general condition, the patient was
discharged from the hospital on postoperative day 15.
CASE DISCUSSION
1. Rupture of TAA and dissections are very rare, despite the very high
morbidity and mortality rates
2. Thoracic aortic aneurysms are usually asymptomatic (about 75%), but
pain is known as the predominant referable symptom in about 17% of
patients.
3. Chest pain, back pain, hoarseness due to recurrent laryngeal nerve
compression, difficulty in swallowing due to compression of the
oesophagus and shortness of breath due to the bronchial compression may
be seen
4. In aneurysms, smoking history, chronic obstructive pulmonary disease,
advanced age, pain, hypertension, and a diameter of more than 5 cm of the
aorta increases the risk of aortic rupture
5. Nowadays, because of low morbidity, mortality and hospital stay, thoracic
endovascular stent graft surgery, generally under epidural anaesthesia, is
the preferred surgical method in especially old TAA patients
6. Thoracic endovascular stent graft surgery was applied to this patient
7. The lack of postoperative complications suggests that endovascular stent
graft surgery in TAA without rupture or dissection will diminish
mortality rates
8. Despite it’s rare incidence, TAA should not be forgotten in the
differential diagnosis of chronic back pain because early diagnosis
diminishes mortality rates and increases the quality of life for patients.
Case 2
(AAA)
References : Yan L, Yang C, Gao B, Xu D, Wu C, Tang J. Management of Lethal Complications
Following a Ruptured Abdominal Aortic Aneurysm: A Case Report and Literature Review. Journal of
Vascular Medicine and Surgery. 2014; 2(2): 1-4
Figure 1: Computed tomography scan showed abdominal
aortic aneurysm (11.3*7.7 cm) with hematoma and vessel
thrombosis.
TREATMENT FOR THIS
PATIENT

Possibility of aortic aneurysm ruptureemergency

surgeryThree endovascular stent grafts
(ENDURANT) were implanted into artery.

Figure 2: Computed tomography

angiography at 2 years post
endovascular aneurysm repair showed
the successful treatment of ruptured
abdominal aortic aneurysm.
POSTOPERATIVE:
Postoperatively, he presented with hemorrhagic
shock: PR: 60 beats/minutes and BP: undetectable
Laboratory data showed a decreased HB: 41 g/L.
Fluid resuscitation and blood transfusion were all
used to restore the intravascular volume.
To be worse, he developed ACS (abdominal
compartment syndrome): abdominal expansion,
abdominal wall tension, oliguria, and high IAP
(bladder pressure > 40 mmHg).
13 HOURS POSTOPERATIVE:
Exploratory laparotomy, intestinal adhesions lysis
and abdominal decompression were performed
600 mL of blood was aspirated and another 1000 mL
of blood from the retroperitoneum was removed
The IAP (intra abdominal pressure) fell to 19.5 mmHg
FEW HOURS LATER:
Followed by diuresis
Bogota bag was used for temporary abdominal closure
(TAC).
However, his condition did not improve after the
surgeon, function of multiple organs continued
deteriorating
CASE DISCUSSION
ACS should be a deadly attack to critically ill
patients. It is happened because of aggressive fluid
resuscitation after EVAR and a large retroperitoneal
hematoma expanding into the abdominal domain
In retrospect, if the doctor had performed the limited
fluid resuscitation, ACS may have been avoided
Hypotensive resuscitation might have a beneficial
effect on the survival in case of rAAA.