1. Aneurysm

2. Aneurysm
It is a blood sac that communicates with the lumen of an artery
They are classified according to
Etiology
congenital
Acquired
pathological ,
traumatic and

3. Aneurysm They are classified according to Structure Shape true or
false
Shape
fusiform
saccular
dissecting

4. Aneurysm

5. Aneurysm (Etiology) Congenital Acquired
–Cerebral , splenic , renal or celiac
Acquired
Degenerative Atherosclerosis (Commonest)
Traumatic
Blunt trauma that weakens an area of the wall
Penetrating trauma causing false aneurysm (pulsating hematoma)
Post stenotic
Cystic medial necrosis
Septic emboli of subacute endocarditis
Marfan’s syndrome
Ehler Danlos syndrome
Syphilis

6. Aneurysm (Clinical) A- Silent
B- The presence of a swelling (6 criteria )
On the line of an artery
Expansile pulsation
Decrease with proximal compression
Increase with distal compression
A murmur or bruit
Weak distal pulses

7. Aneurysm (Clinical) C-Secondary effects D- Complications
Adjacent structures compression
Vein ~thrombosis
Nerve~sensory or motor affection
Bone ~ erosion
Ischemic limb
Embolism & thrombosis
D- Complications
Rupture
Thrombosis ~ to acute ischemia
Distal emboli~ distal ischemia
Infection ~secondary hemorrhage due to rupture

8. Differential diagnosis
Very vascular tumors
Pulsating hematoma
Abscess
A swelling overlying an artery
A swelling under an artery
AV fistula
Turtous artery ( Circoid aneurysm)
Pulsating empyema
encephalocele

9. Investigations Doppler U/S Plain X ray ( calcification) Spiral CT scan
Arteriography

10. Treatment
Surgery is indicated if the size is more than 4 cm(range up to 7 cm )
Standard treatment is
excision with graft replacement
Insertion of the graft can be done inside the sac without its removal
Excision with arterial ligation in aneursyms of small arteries
Procedures not in use
Endo-aneurysmorraphy
Endoluminal thrombosis

11. Abdominal aortic aneurysms
An AAA is an increase in aortic diameter by greater than 50% of normal
Usually regarded as aortic diameter of greater than 3 cm diameter
More prevalent in elderly men
Male : female ratio is 4:1

12. Abdominal aortic aneurysms
AAA diameter expands exponentially at  approximately 10% / year ( 3mm Year)
Risk of rupture increases as aneurysm expands (Laplace law)
5 year risk of rupture:
o        5.0 – 5.9 cm = 25%
o        6.0 – 6.9 cm = 35%
o        More than 7 cm = 75%
Overall only 15% aneurysms ever rupture
85% of patients with a AAA die from an unrelated cause

13. Screening
AAA are suitable for screening as elective operation of asymptomatic aneurysms can reduce mortality associated with rupture
Mortality of emergency operation is > 50%
Mortality of elective surgery is < 5%

14. Screening Who should be screened ?
Probably males over 65 years - especially hypertensives
Single U/S at 65 years reduces death from ruptured AAA by 70% in screened population
Patients with small aneurysms should undergo regular surveillance
Repeated ultrasound every 6 months

15. Clinical features 75% are a-symptomatic Possible symptoms include
Epigastric pain
Back pain
Malaise and weight loss (with inflammatory aneurysms)
Multiple small infarction in the on the foot
DIC

16. Clinical features Rupture presents with Rare presentations include
o        Sudden onset abdominal pain
o        Hypovolaemic shock
o        Pulsatile epigastric mass
Rare presentations include
o        Distal embolic features
o        Aorto-caval fistula
o        Primary aorto-intestinal fistula

17. Pre-operative investigation
Need to determine
Extent of aneurysm
Fitness for operation
Methods
Ultrasound,
Conventional CT and
More recently spiral CT
Determines
Aneurysm size,
Relation to renal arteries,
Involvement of iliac vessels

18. Pre-operative investigation
Most significant post operative morbidity and mortality related to cardiac disease
so if there is pre-operative symptoms of cardiac disease patient will need
cardiological opinion
May need thallium scan or
cardiac catheterisation
Cardiac revascularisation required in up to 10% patients

19. Surgery

20. Surgery

21. Surgery

22. Surgery

23. Surgery

24. Endo-vascular repair Introduced by Parodi 1991
There is a few clinical trials over the past 10 years .
the complications of the technique is not yet finally determined.

25. Endo-vascular repair
It is done to avoid complications of open surgery which is mainly related to cross clamping of the aorta especially if it is above the renal arteries
spinal cord ischemia ,
renal ischemia

26. Endo-vascular repair