1. Multiple Aneurysms

2. Multiple Aneurysms In 1982 Cohen et al reviewed 1500 patients with AAA
13% had multiple aneurysms
72% synchronously/28% metachronously
Cause: 62% - nonspecific , 23% dissection
Location: Abdominal – 63%
Thoracoabdominal - 14%
Descending aorta – 13%
Aortic arch – 5%
Ascending aorta - 5%
Rutherford

3. Multiple Aneurysms
In 1990 Gloviczki et al reviewed 102 patients with multiple aneurysm – over two decades
Age: range 20 – 81 yrs
Total 201 aortic reconstructions – 3.4% of all aortic aneurysm performed during that time
Location:
Infrarenal – 30.9%
Descending aorta – 26.7%
Thoracoabdominal – 23.0%
Aortic arch – 19.3%
JVS , 1990

4. Gloviczki et al, cont’d 53.9% had Multiple aneurysm at first repair
21 pts underwent simultaneous repair of at least 2 aortic aneuysm
7 of the 21 pts (33.3%) died
27 emergency procedures
15 - rupture
11 - pain
1 – distal embolization with leg ischemia
3 ruptured descending thoracic aneurysn
( 4cm , 4 cm, 3.8 cm )
One ruptured 2 days after AAA repair

5. Two stage operation for multiple aneurysms of the thoracic aorta,abdominal aorta and left common iliac artery in octagenarian Kudaka et al Japanese Annal of Thoracic and Cardiovascular Surgery
AAA and iliac aneurysm resected first due to risk of thromboembolism 52 days later – Repair of descending aorta
Discharged home POD#25

6. Genetics and aneurysm
Familial clustering in 10-20% first degree relatives
Marfan’s (fibrillin )
Ehler’s Danlos – type 4 ( procollagen III)
Aneurysms at an early age in these patients
Less type III collagen in aortic media
Abnormality on long arm of chromosome 16

7. Aneurysm Classification by Etiology
Type
Example
Congenital
Idiopathic
Turner’s
Connective tissue disorder
Marfan’s
Ehlers Danlos
Cystic medial necrosis
Berry
Degenerative
Atherosclerotic
Fibromuscular dysplasia
Infectious
Bacterial
Fungal
Syphilis
Rutherford

8. Aneurysm Classification by Etiology cont’d
Inflammatory
Takayasu’s
Behcet’s
Kawasaki
Giant cell arteritis
SLE
Post Dissection
Idiopathic
Trauma
Post stenotic
Thoracic Outlet Syndrome
Coarctation
Pseudoaneurysm
Anastamotic disruption
Miscellaneous
Pregnancy associated

9. Thoracoabdominal Aneurysms
Principle goal – prevent rupture and death
Most Surgeons choose to intervene when > 6cm
Smaller aneurysm followed by CT scan every 6 months
If expands > 5mm in 6 months – intervene
Patient with family history of AA
Women of small stature with 5cm aneurysm
Cameron

10. Spinal cord perfusion , minimize visceral organ ischemia and renal dysfunction

11. Visceral Aneurysms Relatively uncommon 25% present as emergency
8.5% result in death
Frequency
Splenic – 60% F:M 4:1 , rupture during pregnancy
Hepatic – 20% M:F 2:1, trauma, IVD, inflammation
SMA – 5.5%
Aggressive approach in management because of high mortality associated with rupture

12. Popliteal Aneurysm Most frequent peripheral aneurysm – 70% M:F 30:1
>50% bilateral
33% has AAA
Most common manifestation
- thrombosis ( 40% )
- embolization ( 25% )
25% with distal thromboembolism come to amputation
Rupture – rare - < 5%
Indication for treatment
Acute lower limb ischemia from acute occlusion
Transverse diameter > 2cm
Sabiston

13. Diameter of normal arteries ( cm )
Female
Male
Aorta
-Descending
-Supraceliac
-Suprarenal
-Infrarenal
2.4 – 2.6
2.1 – 2.3
1.9
1.2 – 2.1
2.4 – 3.0
2.5 – 2.7
2.0 – 2.3
1.4 – 2.4
Iliac
-Common
-Internal
0.9 – 1.0
0.5
1.1 – 1.2
Popliteal
0.9