Aortic Aneurysm

SGD B2

outline
Introduction

Sign & Symptom

Prognosis

Definition

Diagnose

Complication

Epidemiology

Differential
Diagnose

Case

Etiology

Management

Risk Factor

Prevention

Pathophysiology

Prevention

INTRODUCTION
Aneurysm is an abnormal bulge in the wall

of an artery
Aneurysm 15.000 deaths yearly, 10th
leading causes
Atherosklerosis plaque formation and
rupture can increase the risk of aneurysm
In this presentation we would like to
elaborate more about the cause, sign &
symptoms, diagnosis, treatment, and
prevention

Definition

AAA
A maximum dilatation or widening of the abdominal

(infrarenal) aortic diameter of 3.0 cm or more or 1.5

times from expected normal diameter to compensate
for individual variation of the adjacent aorta

AAA: abdominal and thoracoabdominal

In the abdomen --> association with renal arteries

- infrarenal (85%)
- pararenal with involvement of 1 or both
renal arteries
- suprarenal
Common iliac arteries are often involved

Infrarenal AAA

TAA

Epidemiology
AAA
But AAA is
decreased

TAA

Older patients (65-80 years) --> 2.2%

Prevalence : men 4-8% and women 12%
Prevalence Aortic aneurysm is
increased,
From 15,000 to 13,000 deaths yearly
In 2000 --> 10th leading cause of
death in USA

- 6 cases per 100,000 personyears

Etiology

RISK FACTORS

PATOPHYSIOLOGY
Abdominal Aortic Aneurysm
Elastin
DECREASE OF
ELASTIN

MEDIAL THINNING
AND INTIMAL
THICKENING

Proteolysis, metalloproteinases, and

inlammation
INCREASE OF
CONCENTRATION OF
PROTEOLYTIC
ENZYMES

INCREASE OF
CONCENTRATION OF
THE INHIBITOR

PATOPHYSIOLOGY
INCREASED
METALLOPROTEINASE
S

DEGRADATION OF
ELASTIN AND
COLLAGEN

DECREASED
INHIBITIOR ACTIVITY

IMMUNOREACTIVE
PROTEIN MORE IN
ABDOMINAL AORTA

INCREASE OF
FREQUENCY OF
ANEURYSM

PATOPHYSIOLOGY

PATOPHYSIOLOGY

Thoracic Aortic Aneurysm

INCREASE OF
SPECIFIC ENZYMES

WEAKENING OF THE
AORTIC WALL, LOSS
OF ELASTICITY, AND
CONSEQUENT
DILATATION

DEGRADATION OF
STRUCTURAL PROTEIN

ELASTIC FIBER
FRAGMENTATION
DEGENERATION OF
MEDIA

PATOPHYSIOLOGY
Law of Laplace

The wall tension is proportional to the pressure

times the radius of the arterial conduit.

T=PXR

PATOPHYSIOLOGY
TENSION
INCREASED

PRESSURE
INCREASE

INCREASING
RADIUS

INCREASE THE RISK OF RUPTURE

Sign and Symptom

How to diagnose ?

Thoracic Aortic Aneurysm

Chest X-Ray
Abnormal aortic

sillhouette
Mediastinal mass
diffuse widening
mediastinum
Enlargement aortic
knob
Tracheal deviation
Change in aortic
contour

Aortography
Preoperative evaluation

define location an
extent of aneurysm
Replaced by CT and
MRI

CT Scan
Contrast-enhanced
observe the

morphology, pattern,
distribution of thrombus
and calcification, and
visualization of
dissection and intimal
flap.

CT Scan

Descending
thoracic aortic

Ascending
thoracic aortic

MRI
Best assessment of

true size, lumen

and vessel well,
observing excellent
vessel anatomy
and surrounding
structure.
Least renal toxicity,
but time
consuming and not
for unstable
patient.

CT Angiography
Good for imaging tortuous thoracic aorta
Reconstruct axial images to 3D
Accurate diameter

MR Angiography
Multiple planes 3D

with Gadollinium
Contrast
Accurate diameter,
shows blood flow, not
visualize adventitia
well

Transthoracic
Echocardiogram
Demonstration of aortic

enlargement
May find severe
atherosclerosis, mildly
enlarged aorta,
eccentric thickening of
one wall, and
echogenicity consistent
with thrombus
Good for unstable px,
operator-dependent

How to diagnose ?

Abdominal Aortic Aneurysm

Abdominal Aortic Aneurysm

Abdominal Examination
USG (most common used)
Contrast enhanced CT or MRI
CT Angiography
MR Angiography

Differential Diagnose
Abdominal Aortic Aneurysm

Differential diagnose
Thoracic Aortic Aneurysm

management

Abdominal Aortic Aneurysm

Rupture ?
Non-rupture ?

Unruptured

Rupture

The risk :

Risk check

Emergency

management

Abdominal Aortic Aneurysm

Endovasc
ular
Surgery

Open
Surgery

management

Thoracic Aortic Aneurysm


Ascending
Aortic
Aneurysms

Recommendations
Surgery is indicated in patients who have
aortic root aneurysm, with maximal aortic
diameter 50 mm for patients with Marfan
syndrome.
Surgery should be considered in patients
who have aortic root aneurysm, with
maximal ascending aortic diameters:
45 mm for patients
syndrome with risk factors.

with

Marfan

50 mm for patients with bicuspid valve

Figure 12. Composite aortic graft repair of

Figure 13. Valve-sparing procedure to
aneurysm involving
the risk
aorticfactors
root and
repair an aneurysm involving the aortic
with
ascending thoracic aorta. The coronary arteries
root and ascending thoracic aorta. The
are excised as buttons,
aneurysm
sinuses are excised,
the valve
mm
foris other aortic
patients
with butno
55and the
resected to the level of the aortic annulus, with
leaflets are not. The leaflets are then placed
elastopathy
sacrifice of the native
aortic valve. A prosthetic
within the lumen of a Dacron graft that is
valve is attached directly to a Dacron graft and
then sewn directly to the aortic annulus.
Lower
thresholds
for
intervention
may
be
this composite graft is sewn directly to the
The valve leaflets are
then reimplanted
annulus. The native
coronary buttons according
are then
the base
of the graftto
considered
towithin
body
surface
area restore
reimplanted into the graft.
competency.

in patients of small stature or in the case of

Recommendations

Aortic
Arch
Aneurys
m

Surgery should be considered in

patients who have isolated aortic
arch aneurysm with maximal
diameter 55 mm

Aortic
arch
repair
may
be
considered in patients with aortic
arch aneurysm who already have
an indication for surgery of an
adjacent aneurysm located in the
Figure 14. Repair of an aneurysm
ascending or descending aorta.
involving ascending thoracic aorta and
arch by using a multilimbed prosthetic
graft.

Recommendations

Descendin TEVAR should be considered, rather

g
aortic than surgery, when anatomy is
aneurysm suitable.

TEVAR should be considered in

patients who have descending aortic
aneurysm with maximal diameter
55 mm

When TEVAR is not technically

possible,
surgery
should
be
considered in patients who have
Figure 16. Minimally invasive repair of a
descending aortic
with using a
descending aneurysm
thoracic aortic aneurysm
transluminally
maximal diameter
60 placed
mmendovascular stent-graft. The
unexpanded stent is advanced and positioned across

When intervention
is Theindicated,
the aneurysm.
proximal portion is in
expandedand
Figure
15.
Repair
of
anchored. The covered stent then serves as a conduit
cases of Marfan
syndrome
or the
other
for
blood
flow
while
excluding
aneurysmal aorta
descending thoracic aortic
elastopathies, from
surgery
should
be sac then
the circulation.
The aneurysm
aneurysm.
indicated ratherthrombosis.
than TEVAR

Prevention of Aortic
Aneurysm
Preventive of Aortic Aneurysm is to modified its

risk factors.
If your parents and close - related family are
considered had Aortic Aneurysm before, it wise to
avoid:1,2
Smoking
Hyperlipidemia
Hypertension
control
Sedentary
lifestyle
References
1. Sakalihasan N, Limet R, Dewafe OD. Abdominal Aortic Aneurysm. Journal of Lancet. Vol 365; 2005. Accessed from
www.thelancet.com (17 April 2015)

PROGNOSIS
satisfied, with prompt diagnosis and proper surgical
treatment
In patients undergoing surgery for descending thoracic aortic
aneurysms, the operative mortality rate for all cases
(emergency or elective) averaged 11%. Elective surgical
repair of descending thoracic aortic aneurysms is also
associated with a mortality rate ranging from 5% to 14%.
Risk factors for early mortality and morbidity included
emergency operation, congestive heart failure, advanced
For
who suffer rupture
of an AAA before hospital
age,patients
and atherosclerotic
etiology.
arrival, the prognosis is guarded. The survival rate for
patients who can reach the emergency department at the
time is about 1% per minute, but it will higher (about more
than 50%) for those who dont

Complication

Next slide

Complication After
Abdominal Aortic
Aneurysm Repair

CONCLUSION
Aneurysms are permanent focal dilatation of

artery to 1.5 times from its normal diameter

AAA will be showed as pain in the abdomen,
radiating to back, nausea and vomiting. TAA
are mostly asymptomatic
Abdominal USG is primary method for
screening AAA
The treatment will be based on the part of
aortic that affected with aneurysm
It wise to avoid: smoking, hyperlipidemia,
hypertention, and sedentary life

Case 1

Case 1: Thoracic Aortic

Aneurysm
Reference: Duru S, Erdem M, Agca E, Kaplan T, Ardic S. Thoracic Aortic
Aneurysm: A Rare Case Report. Turkish Thoracic Society. 2013; 14: 78-80

CASE DESCRIPTION
Male, 72 years old admitted to Dept. of Chest Disease with:
ANAMNESIS
Chief complaint: back pain for the past two years which is
intermittent interscapular pain independent of position, breathing
and exercise. The last pain had been present for 2 months
Past history: hypertension for 20 years with an irregular
antihypertensive treatment, he did not have any known genetic
disease, no systemic connective tissue disease, infection, genetic
defects, inflammation, or history of trauma
Family history: his parents had suffered from hypertension and
diabetes
Social history: no history of smoking, coughing, weight loss,
dyspnoea, dysphagia and haemoptysis.

PHYSICAL EXAMINATION
1. Vital Sign : BP: 140/80 mm Hg, PR: 90 beats/minute, RR: 16
breaths/minute, T.ax : 36C
2. Cardiac and other system examinations were normal, but
there was a decrease of breathe sounds in the left
infrascapular area in the auscultation
SUPPORTING EXAMINATION
1. CBC, biochemical and serological analyses were normal
2. Normal erythrocyte sedimentation rate of 10 mm/h and a
white blood cell count of 9109/L
3. High sensitivity C-reactive protein and serum D-dimer
levels were found to be normal
4. Posteroanterior chest X- ray (Figure 1) examination
revealed a large left hilar mass. In addition to a lack of
aeration of the lower lobe of the left lung, there was
minimal costophrenic sinus bluntness

SUPPORTING EXAMINATION:
1. In echocardiographic examination, systolic function was normal
(fractional shortening: 30%, ejection fraction: 65%), there was
grade I diastolic dysfunction, mitral lid E-A velocity: 0.7 m/s, no
mitral failure, no valvular regurgitation and hypertrophy
(interventricular septum diastolic diameter: 10 mm).
2. Thorax CT scan showed that the mass was located in the
proximal part of the descending aorta, with a diameter of 8 cm,
suggesting a saccular aortic aneurysm
3. Defined thrombus material was pressurising the posterior of
the oesophagus and the left atrium. Also, due to compression,
atelectasis was seen on the posterobasal segment of the left
lung
4. Thoracic aortography examination showed an aneurysm
located in the proximal part of the descending aorta with a
diameter of 8 cm
5. A large thrombus (6 cm) and atherosclerotic atheroma plaques
were shown within the TAA

TREATMENT FOR THIS PATIENT

In surgical treatment, under general anaesthesia

penetrating to the femoral artery and using arcus
aortagraphy
and
toracal
aortagraphy,
an
aneurysm with a diameter of approximately 8 cm
was discovered. The 30x120 mm aortic stent graft
was applied to the aneurysm. In the postoperative
phase, the patient had no back pain. No
complication was seen; after follow-up and
improvement of their general condition, the
patient was discharged from the hospital on
postoperative day 15.

CASE DISCUSSION
1.
2.

3.

4.

5.

Rupture of TAA and dissections are very rare, despite the very
high morbidity and mortality rates
Thoracic aortic aneurysms are usually asymptomatic (about
75%), but pain is known as the predominant referable
symptom in about 17% of patients.
Chest pain, back pain, hoarseness due to recurrent laryngeal
nerve compression, difficulty in swallowing due to
compression of the oesophagus and shortness of breath due
to the bronchial compression may be seen
In aneurysms, smoking history, chronic obstructive
pulmonary disease, advanced age, pain, hypertension, and a
diameter of more than 5 cm of the aorta increases the risk of
aortic rupture
Nowadays, because of low morbidity, mortality and hospital
stay, thoracic endovascular stent graft surgery, generally
under epidural anaesthesia, is the preferred surgical method
in especially old TAA patients

6.
7.

8.

Thoracic endovascular stent graft surgery was applied to

this patient
The lack of postoperative complications suggests that
endovascular stent graft surgery in TAA without rupture or
dissection will diminish mortality rates
Despite its rare incidence, TAA should not be forgotten in
the differential diagnosis of chronic back pain because
early diagnosis diminishes mortality rates and increases
the quality of life for patients.

Case 2

CASE 2: Abdominal Aortic

Aneurysm (AAA)

References : Yan L, Yang C, Gao B, Xu D, Wu C, Tang J. Management of Lethal

Complications Following a Ruptured Abdominal Aortic Aneurysm: A Case Report and
Literature Review. Journal of Vascular Medicine and Surgery. 2014; 2(2): 1-4

Figure 1: Computed tomography scan showed

abdominal aortic aneurysm (11.3*7.7 cm) with
hematoma and vessel thrombosis.

TREATMENT FOR THIS

PATIENT
Possibility of aortic aneurysm

ruptureemergency surgeryThree
endovascular stent grafts (ENDURANT)
were implanted into artery.

Figure 2: Computed tomography

angiography
at
2
years
post
endovascular aneurysm repair showed
the successful treatment of ruptured
abdominal aortic aneurysm.

POSTOPERATIVE:
Postoperatively, he presented with

hemorrhagic shock: PR: 60 beats/minutes and

BP: undetectable
Laboratory data showed a decreased HB: 41
g/L.
Fluid resuscitation and blood transfusion
were all used to restore the intravascular
volume.
To be worse, he developed ACS (abdominal
compartment syndrome): abdominal
expansion, abdominal wall tension, oliguria, and
high IAP (bladder pressure > 40 mmHg).

13 HOURS
POSTOPERATIVE:

Exploratory laparotomy, intestinal

adhesions lysis and abdominal

decompression were performed
600 mL of blood was aspirated and
another 1000 mL of blood from the
retroperitoneum was removed
The IAP (intra abdominal pressure) fell to
19.5 mmHg

FEW HOURS LATER:

Followed by diuresis
Bogota bag was used for temporary

abdominal closure (TAC).

However, his condition did not improve
after the surgeon, function of multiple
organs continued deteriorating

CASE DISCUSSION
ACS should be a deadly attack to

critically ill patients. It is happened because

of aggressive fluid resuscitation after EVAR
and a large retroperitoneal hematoma
expanding into the abdominal domain
In retrospect, if the doctor had performed
the limited fluid resuscitation, ACS may
have been avoided
Hypotensive resuscitation might have a
beneficial effect on the survival in case of
rAAA.