1. Aortic Aneurysms Dilshan Udayasiri

2. Some Anatomy ascending aorta arch of the aorta descending aorta abdominal aorta

3. Layers of the aorta

4. Types of aneurysms Shape SaccularFusiform Ruptured Causes Degenerative Dissecting Location Thoracic (25%) Ascending (60%) Aortic Arch - includes brachiocephalic arteries (10% Descending (40%) Thoracoabdominal (10%) Abdominal (75%) Percentage60%10-15 %25-30 % TypeDeBakey IDeBakey IIDeBakey III Stanford AStanford B ProximalDistal Classification of aortic dissection Percentage60%10-15 %25-30 % TypeDeBakey IDeBakey IIDeBakey III Stanford AStanford B ProximalDistal Classification of aortic dissection Percentage60%10-15 %25-30 % TypeDeBakey IDeBakey IIDeBakey III Stanford AStanford B ProximalDistal

5. Risk Factors Hypertension Hypercholesterolaemia Smoking Age (rare before 60) Genetic (Marfans, Ehlers-Danlos syndrome) Bicuspid Aortic Valve Inflammatory/infectious - eg Giant Cell Arteritis

6. Symptoms Incidental Pain - tearing, radiating to back Heart failure - due to AR Thromboembolic (stroke, painful/parathesia of limbs) Hoarseness of voice (compression of recurrent laryngeal nerve ) Can mimic other acute disorders (AMI, renal colic, pancreatitis)

7. Signs obs lack of peripheral pulses Pulsatile mass and tender abdomen Murmur Decreased BS and dullness to percussion Signs of heart failure Neurologic signs (Horner’s Syndrome - compression of cervical sympathetic ganglion)

8. Investigations

9. Treatment Watchful Waiting + medical Percutaneous or open intervention

10. Watchful Waiting Tight blood pressure control (MAP between 60 - 75) beta blocker favourable unless contraindicated persistent hypertension, check kidneys cease smoking treat hypercholesterolaemia Screening 6 months after initial scan then every 12 months unless symptomatic or increased rate of expansion or if size is 4.5cm - 5.5cm.

11. Indications for surgery HD unstable symptomatic diameter ≥ 5.5cm rate of growth ≥ 1.0cm/year

12. Endovascular repair Indications High perioperative risk pt’s Other Benefits shorter ICU stay Shorter Hospital Stay Quicker return to normal function Increased surviability in the short term Complications Endoleak (Type 1-4) Device Migration Infection Haematoma Stroke AMI Death

13. Surgery Incision depends on location Median sternotomy - arch left thoracomtomy - descending left thoracotomy extending across costal margin for retroperitoneal approach - thoracoabdominal Abdominal incision - AAA Considerations Distal perfusion cerebral protection Renal Dysfunction Staged procedure