1. Aortic Emergencies LISA BROUGHTON, PHD, RN, CCRN

2. Aorta Anatomy

3. Types of Aneurysms A aneurysm is a localized sac or dilation in a weakened part of the vessel wall. Types: Fusiform Saccular Dissecting

4. Causes Most common causes are atherosclerosis and uncontrolled hypertension. Also caused by: Congenital such as Marfan’s or Turner’s Syndromes Trauma (most likely causes aortic dissections)

5. Aortic Aneurysms As tension increases, further widening occurs, and the aneurysm grows larger. Symptoms occur from resulting pressure on surrounding structures or from rupture (hypovolemic shock!!!!). Two major types: thoracic and abdominal aortic aneurysms.

6. Thoracic Aortic Aneurysm Can occur from the aortic root to the diaphragm. Symptoms occur from the pressure on the surrounding structures: Pain in the chest, jaw, neck, or upper back Shortness of breath or coughing Hoarseness Difficulty swallowing

7. Video Review Please watch this video review of thoracic aortic aneurysms: https://www.youtube.com/watch?v=xHUsdE880so

8. Abdominal Aortic Aneurysms Occurs just below the diaphragm to above the bifurcation of the iliac arteries. Symptoms occur from the pressure on the surrounding structures: Intense back or abdominal pain Pulsating mass in the abdomen Many are asymptomatic

9. Video Review Please watch this video review of abdominal aortic aneurysms: https://www.youtube.com/watch?v=P1paaFPcdak Please watch this video review of aortic dissections: https://www.youtube.com/watch?v=PRl8TLUleZg

10. Management Usually diagnosed with CT, MRI, echo, or arteriogram. Medical versus surgical treatment depends on the size of the aneurysm: TAA is treated medically if < 5 cm AAA is treated medically if < 7 cm Medical management includes: Strict blood pressure control with anti-hypertensives Routine CT scans every 6 months to one year to assess for size and any enlargement Statins if related to atherosclerosis Reduction of risk factors such as smoking, obesity, high blood pressure, high cholesterol

11. Management The aneurysm is treated surgically if > 5 cm (thoracic) or > 7 cm (abdominal), if the aneurysm is enlarging > 1 cm/ year, or there is evidence of leaking or dissection. Dissections are almost exclusively treated surgically. Dissections are characterized by an intense ‘ripping’ or ‘tearing’ sensation. Can be surgically treated with either an open repair or an endovascular repair (newer, more commonly used method).

12. Surgical Management Thoracic aortic aneurysms: If located in the aortic root, ascending aorta, or aortic arch, and open repair must be done. If located in the descending aorta, an endovascular repair can be done. Abdominal aortic aneurysms are most often treated through an endovascular repair now.

13. Surgical Repair Care of the client with an open chest procedure to repair an aneurysm in the aortic root, ascending, or aortic arch is similar to the care of a client with a CABG or valve replacement surgery. TEVAR (thoracic endovascular aneurysm repair) involves placing a stent through the femoral artery and advancing under fluoro until reaching the aneurysm. The stent is then expanded to reinforce the walls of the aorta. The aneurysm will shrink over time.

14. TEVAR Complications specific to TEVAR include: Graft failure or leak, which would include symptoms of hypovolemic shock Spinal cord injury from the stent blocking the arteries that perfuse the spinal cord A spinal drain is inserted operatively to measure the pressure in the spinal column and for drainage of CSF to reduce swelling and maintain perfusion to the cord The head of bed must remain flat at all times Neuro checks are extremely important!!!!! Spinal pressure should remain 70

15. Video Review Please watch the following video review of a TEVAR: https://www.youtube.com/watch?v=_zpT8RJwF10

16. Surgical Repair If an abdominal aortic aneurysm is repaired using an open procedure, care is similar to any abdominal surgery. Endovascular repair is similar to a TEVAR

17. Video Review Please watch this video review of an open abdominal aortic aneurysm repair: https://www.youtube.com/watch?v=LrfEyO1dDZ4

18. Nursing Considerations Regardless of the type of surgical repair, it is important to assess: Signs of infection or bleeding Perfusion Organ failure from ischemic damage Vital signs and strict blood pressure control For TEVAR systolic blood pressure should be less than 150 but with a mean at least 80 mm Hg (to maintain perfusion of the cord). For open repairs, blood pressure should be lower; systolic 90-120, with a mean of at least 65-70.