1. Aortic Aneurysms Presented by:Dr.Marzieh Balaghi Resident of cardiology,Modarres Hospital,Shahid Beheshti University of Medical Sciences, Tehran, Iran Revision and supervision: Dr.Habibollah Saadat Dr.Isa Khaheshi Cardiovascular Research Center, Modarres Hospital,Shahid Beheshti University of Medical Sciences, Tehran, Iran

2. CASE PRESENTATION 54 Y/OLD MAN /IHD(-) CC: asymptomatic RF: HTN /HLP/ SMOKER P/E: captopril 25 bd ECHO: EF=55%/MILD LVH ECG: NSR/NAX/ NO ST- T CHANGES LAB TEST:CR=1,HB=13,LDL:100, FBS=105 ;

3. SONOGRAPHY: AAA (SIZE=4.5 cm in infrarenal) Dx: AAA

4. WHAT IS YOUR MANAGMENT

5. Aortic Aneurysms Incidence 30-60/1000 Increasing incidence over past 3 decades

6. Definitions Aneurysm : Increase in diameter of 50% (1.5x) its normal diameter – Focal region

7. AAA is more common Increase diameter to >3 cm 3-9% men >50 y/old Is more common in inferarenal(>80%) Pararenal and suprarenal( 10%) M/F=5/1 Age depended Usually is common in age>60 Smoker/no smoker=5/1 RF:male,age,smoking,HTN/HLP/emphysema POSITIVE FH:20%

8. TAA is less common Incidence:10/100000 Ascending Aorta:60% Descending aorta:35% Aortic arch<10%

9. Aortic Aneurysms Associated Aneurysms Iliac - 41% Femoro-popliteal - 15% Pts with unilateral popliteal aneurysms-->8% AAA Pts with bilateral popliteal aneurysms-- > 30%-50% AAA

10. Aortic Aneurysms Associated Medical Conditions Carotid Artery Stenosis - 10% have AAA Smoker:Nonsmoker - 8:1 Male:Female - 4:1 HTN - 40% of pts with AAA have HTN

11. Aortic Aneurysms Etiology Atherosclerosis Cystic Medial Necrosis Dissection Ehlers-Danlos Syndrome Syphilis Familial Associated –Lysyl Oxidase deficiency

12. Aortic Aneurysms Clinical Presentation Asymptomatic - 70-75% Symptoms: –Early satiety, N,V –Abd., Flank, or Back pain (1/3 of pts experience abd. And flank pain) -Abrupt onset of pain -->Rupture or expansion of aneurysm

13. Ruptured Aneurysm 60-70 y/o who presents with abd pain, hypotension and a pulsatile abdominal mass

14. Aortic Aneurysms Ruptured Aneurysms rupturUsually occurs postero- laterally Can rupture in Vena Cava creating Aorto-Caval Fistula Occasionally can rupture anterior - usually fatal

15. Aortic Aneurysms Diagnosis Physical Exam: –If <5cm in diameter, then cannot be detected by routine physical exam Radiographs: –Calcified wall. Can determine size in 2/3

16. Aortic Aneurysms Diagnosis Arteriography: –Cannot determine aneurysm size because of mural thrombus

17. echocardiography Proximal AoD- TEE sensitivity 88- 98%,specificity 90-95% TTE 77-80% and 93-96% Distal AoD-TEE better

18. Aortic Aneurysms Diagnosis Ultrasound –Establishes diagnosis easily –Accurately measures infrarenal diameter –Difficult to visualize thoracic or suprarenal aneurysms –Difficult to establish relationship to renal arteries –Technician dependent –Widely available, quick, no risk, cheap

19. Aortic Aneurysms CT Scan Very reliable and reproducible Can image entire aorta Can visualize relation ship to visceral vessels Longer to obtain and is more costly than U/S Most useful Requires contrast agent - renal toxicity

20. Aortic Aneurysms MRA Now widely available More expensive than CT No contrast agent required Spacial resolution less than CT

21. Aortic Aneurysms complication Complications of AAA –Thrombosis –Distal embolization –Rupture 23.4% of aneurysms 4-5 cm will rupture

22. Aortic Aneurysms Rupture Risks Patients with COPD and HTN have increased risk of rupture -Survival –50% die prior to reaching hospital, and an additional 24% prior to repair.

23. TREATMENT MEDICAL SURGICAL

24. MEDICAL TREATMENT STOP SMOKING( more important) RF MODIFICATION STATINS( in all of paitent) ACEI( pt with ateroschelerosis)

25. Aortic Aneurysms Indications for repair Presence of an infrarenal aneurysm > 5cm without associated co-morbid medical conditions Repair smaller aneurysms if rate of enlargement is greater than expected(>1 cm per year) Repair all symptomatic aneurysms If co-morbid conditions exist wait until risk of repair and rupture are equal (approx. 6 cm)

26. Aortic Aneurysms Treatment-Surgical Standard Surgical Repair –Replace diseased aorta with artificial artery –Requires 7 day hospital stay –Recovery time 3-6 months

27. Aortic Aneurysms Treatment - Endovascular Repair through an incision in the groin with expandable prosthesis under fluoroscopic guidance Requires both surgical and radiological assistance Significantly reduced diametr Long tern result unknown Hospital stay 2 days, Recovery time 1-2 weeks

28. What is your management? Stop smoking Risk factor modification -Statin -ACEI -SONOGRAPHY(EVERY 6 MONTH)-