1. Valvular Heart Disease/Myopathy/Aneurysm
By Nancy Jenkins

2. Definition
Abnormal dilation of a blood vessel at a site of weakness or a tear in the vessel wall.
Usually secondary to atherosclerosis.
Most commonly affect the aorta

3. Bing Video: Abdominal Aortic Aneurysm Surgery

4. Aortic Aneurysms Atherosclerotic plaques deposit beneath the intima
Plaque formation is thought to cause degenerative changes in the media
Leading to loss of elasticity, weakening, and aortic dilation
Dilated aortic wall can become lined with thrombi than can embolize
Leads to acute ischemic symptoms in distal branches
Important to assess peripheral pulses

5. Aorta
Largest artery
Responsible for supplying oxygenated blood to essentially all vital organs
**Aneurysm can occur in any artery but the aorta is most common
Growth rate unpredictable
**Larger the aneurysm greater risk of rupture

6. May also involve the aortic arch or the thoracic aorta,
Most (3/4) are found in abdominal aorta
below renal arteries
¼ are found in the thoracic area

7. Abdominal aortic aneurysms (AAA)
Studies suggest strong genetic predisposition
*Male gender and smoking stronger risk factors than hypertension and diabetes
Abdominal aortic aneurysms (AAA)
Occur in 4.1% to 14.2% of men
0.35% to 6.2% of women over 60
Cause of 16,000 deaths per year

8. Risk Factors- Atherosclerosis

9. Aortic Aneurysms Classification by type and location
2 basic classifications- True and False
True aneurysm
Wall of artery forms the aneurysm
At least one vessel layer still intact
Fusiform
Circumferential, relatively uniform in shape
Saccular
Pouchlike with narrow neck connecting bulge to one side of arterial wall

11. Fusiform
Most AAA are fusiform and 98% are below the renal artery

12. Aortic Aneurysms Classification
False aneurysm
Also called pseudoaneurysm
Not an aneurysm
Disruption of all layers of arterial wall
Results in bleeding contained by surrounding structures
Pseudoaneurysm: an outpouching of a blood vessel, involving a defect in the two innermost layers (the tunica intima and media) with continuity of the outermost layer, the adventitia. Alternatively, all three layers are damaged and bleeding outside of the vessel is contained by a clot or by surrounding tissue.

13. False Aneurysms May result from Trauma Infection
After peripheral artery bypass graft surgery at site of anastomosis
Arterial leakage after cannulae removal

14. Aortic Aneurysm Diagnostic Studies
X-rays- Most are diagnosed without symptoms on routine X-ray
Chest - Demonstrate mediastinal silhouette and any abnormal widening of thoracic aorta
Abdomen -May show calcification within wall of AAA
ECG -to rule out MI

15. Aortic Aneurysm Diagnostic Studies
Echocardiography
Assists in diagnosis of aortic valve insufficiency
Related to ascending aortic dilation
Ultrasonography
Useful in screening for aneurysms
Monitor aneurysm size

16. Aortic Aneurysm Diagnostic Studies
CT scan
Most accurate test to determine
Anterior to posterior length
Cross-sectional diameter
Presence of thrombus in aneurysm
MRI
Diagnose and assess the location and severity

17. Aortic Aneurysm Diagnostic Studies
Angiography
Anatomic mapping of aortic system using contrast
Not reliable method of determining diameter or length
Can provide accurate info about involvement of intestinal, renal or distal vessels

18. Clinical Manifestations By Location- Thoracic Aortic Aneurysm
Frequently asymptomatic
May have substernal, neck or back pain
Coughing, due to pressure placed on the windpipe (trachea)
Hoarseness
Difficulty swallowing
Swelling (edema) in the neck or arms
Myocardial infarction, or stroke due to dissection or rupture involving the branches of the aorta

20. Ascending Aortic Aneurysm Aortic Arch Clinical Manifestations
ASH
Angina
Hoarseness
If presses on superior vena cava
Decreased venous return can cause
Distended neck veins
Edema of head and arms

21. Abdominal Aortic Aneurysm Clinical Manifestations
Abdominal aortic aneurysms (AAA)
Often asymptomatic
Frequently detected
On physical exam
Pulsatile mass in periumbilical area (Grey’s Anatomy)
Bruit may be auscultated
When patient examined for unrelated problem (i.e., CT scan, abdominal x-ray)

22. Aortic Aneurysm Clinical Manifestations
AAA, con’t
May mimic pain associated with abdominal or back disorders
Pain correlates to the size- can be excrutiating
May spontaneously embolize plaque
Causing “blue toe syndrome” patchy mottling of feet/toes with presence of palpable pedal pulses
It can rupture, causing shock and death in 50% of rupture cases

23. Nursing Diagnoses Risk for Ineffective Tissue Perfusion
Risk for Injury
Anxiety
Pain
Knowledge Deficit

24. Medical Treatment of Aneurysms- if less than 5cm
Anti-hypertensives
Beta blockers,
Vasodilators
Calcium channel blockers
Nipride
Sedatives
Niacin, mevocor, statins
Post-op anti-coagulants

25. Complication Aortic Dissection
Blood invades or dissects the layers of the vessel wall- most often thoracic
Aortic dissection - Wikipedia, the free encyclopedia

26. Dissecting aneurysms are unique and life threatening
Dissecting aneurysms are unique and life threatening. A break or tear in the tunica intima and media allows blood to invade or dissect the layers of the vessel wall. The blood is usually contained by the adventitia, forming a saccular or longitudinal aneurysm.

27. Aortic Dissection Affects men more often than women
Occurs most frequently between fourth and seventh decades of life
Acute and life threatening
Mortality rate 90% if not medically or surgically treated

28. Aortic Dissection Etiology and Pathophysiology
As heart contracts, each systolic pulsation ↑ pressure on damaged area
Further ↑ dissection
May occlude major branches of aorta
Cutting off blood supply to brain, abdominal organs, kidneys, spinal cord, and extremities
People with Marfan’s at risk

30. Aortic Dissection Collaborative Care
Initial goal
↓ BP and myocardial contractility to diminish pulsatile forces within aorta
Drug therapy
IV β-adrenergic blocker
Esmolol (Brevibloc)
Other hypertensive agents
Calcium channel blockers
Sodium Nitroprusside
Angiotensin-converting enzyme

31. Aortic Dissection Surgical therapy When drug therapy is ineffective or
When complications of aortic dissection are present
Heart failure, leaking dissection, occlusion of an artery
Surgery may be delayed to allow edema to decrease and permit clotting of blood.
Even with prompt surgical intervention
30-day mortality of acute aortic dissections remains high (10%-28%)

32. AAA-Medical Treatment - Surgery or Stent
Usually repaired if >5cm
Open procedure- abd incision, cross clamp aorta,aneuysm opened and plaque removed, then graft sutured in place. Care much like after CABG (Not done as much anymore unless a rupture)
Pre-op assess all peripheral pulses
Post-op-check urine output and peripheral pulses hourly for 24 hours- (when to call Dr.)
Endovascular stents- placed through femoral artery

33. Stent Graft Repair

34. Aortic Aneurysm Endovascular graft procedure, con’t
Approach is percutaneous femoral access
Advantages
Shorter operative time
Shorter anesthesia time
Reduction in use of general anesthesia
Reduced groin complications within first 6 months

35. Open Repair of AAA Post-Op- Similar to CABG ICU monitoring
Arterial line
Central venous pressure (CVP) or pulmonary artery (PA) catheter
Mechanical ventilation
Urinary catheter
Nasogastric tube
ECG
Pulse oximetry
Pain medication

36. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Cardiovascular status
Continuous ECG monitoring
Electrolyte monitoring
Arterial blood gas monitoring
Oxygen administration
Antidysrhythmic/pain medications

37. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Infection
Antibiotic administration
Assessment of body temperature
Monitoring of WBC
Adequate nutrition
Observe surgical incision for signs of infection

38. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Gastrointestinal status
Nasogastric tube
Abdominal assessment
Passing of flatus is key sign of returning bowel function
Watch for manifestations of bowel ischemia

39. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Neurologic status
Level of consciousness
Pupil size and response to light
Facial symmetry
Speech
Ability to move upper extremities
Quality of hand grasps

40. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Peripheral perfusion status
Pulse assessment
Mark pulse locations with felt-tip pen
Extremity assessment
(5P’s) Temperature, color, capillary refill time, sensation and movement of extremities

41. Nursing Management Nursing Implementation
Acute Intervention
Postop, continued
Renal perfusion status
Urinary output
Fluid intake
Daily weight
CVP/PA pressure
Blood urea nitrogen/Creatinine

42. Nursing Management Ambulatory and Home Care
Encourage patient to express concerns
Patient instructed to gradually increase activities
No heavy lifting
Educate on signs and symptoms of complications
Infection
Neurovascular changes

43. Prevention
1.Ultrasound is extremely effective at detecting AAAs.The U.S. Preventive Services Task Force (USPSTF) recommends that anyone aged 65 to 75 who has ever smoked undergo a one-time ultrasound screening for AAA
2.Prevent atherosclerosis
3.Treat and control hypertension
4.Diet- low cholesterol, low sodium and no stimulants
5.Careful follow-up if less than 5cm. It can grow .5cm /year

44. Other Complications Rupture- signs of ecchymosis (triad) Thrombi
Back pain
Hypotension
Pulsating mass
Thrombi
Renal Failure

45. Rupture Triad
Back pain
Pulsating hematoma
Hypotension

46. Rupture Rupture- serious complication related to untreated aneurysm
Posterior rupture
Bleeding may be tamponaded by surrounding structures, thus preventing exsanguination and death
Severe pain
May/may not have back/flank ecchymosis
Anterior rupture
Massive hemorrhage
Most do not survive long enough to get to the hospital WHY??

47. Rupture
False Aortic Aneurysm with Rupture of the Aorta : Medical Animation

48. Student Case Study