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Omar Al-Nouri, DO

General Surgery
LUMC
Overview
 Background
 Classification
 Pathogenesis
 Aneurysm Types
Background
 The term aneurysm is derived from the Greek word
aneurysma which means “widening” and is defined as a
permanent and irreversible localized dilatation of a blood
vessel, having at least 50% increase in diameter compared
with the expected normal diameter.
 Ectasia is defined as a dilatation less than 50% of the
normal diameter.
 In men, infrarenal aorta is normally between 14 and
24mm.
 In women, infrarenal aorta is normally between 12 and 21
mm.
 Therefore, abdominal aortic aneurysm (AAA) is diagnosed
if the diameter is 3cm or larger in a man or 2.6 cm or
larger in a women.
Background
 Aneurysms can develop
at any location in the
arterial tree, but are
most commonly located
in the aorta, followed by
iliac, popliteal and
femoral arteries.
Background
 The first elective operation for treatment of an
aneurysm was performed by Antyllus in the 2nd
century AD.
 He described ligation of the artery above and below
the aneurysm, then incising the aneurysm sac and
evacuating its contents.
 Endovascular aortic aneurysm repair EVAR dates back
to 1991 when Juan Parodi introduced this as a
treatment of AAA
Classification
 Aneurysms are classified
into two main groups: true
and false aneurysms.
 True aneurysms involve all
three layers of the vessel
wall
 False aneurysms do not
have all 3 layers of the wall
involved and typically
involve a defect in the
inner most two layers.
Classification
 Aneurysms are further
classified by
morphologic type
 The most common
aneurysms are spindle-
shaped fusiform
aneurysms
 Aneurysms that affect
only part of the arterial
circumference are
termed saccular
Pathogenesis
 The pathogenesis of aneurysmal disease is a multi-factorial,
complex process.
 More than 90% of aneurysms are associated with
atherosclerosis.
 Aneurysms are more accurately referred to as degenerative,
where an interaction of multiple factors rather than one single
process is responsible for the destruction of the media of the
vessel wall that leads to aneurysms formation.
 Congenital aneurysms associated with connective tissue
disorders (i.e. Marfans, Ehlos-Danlers) are rare.
 Infected (mycotic) aneurysms are somewhat more common
 Dissecting aneurysms are applied to dissections with
aneurysmal dilatation of the false lumen.
Pathogenesis
 Aneurysms are associated with alterations in the
connective tissue of the vessel wall.
 The normal vessel wall is made up of lamellar units that
consist of elastin, collagen (mainly types I and III) and
vascular smooth muscle cells.
 Elastin fibers are most abundant in the media and are the
main load-bearing component under most physiologic
conditions.
 Collagen provides the tensile strength and is considered
the “safety net”, acquiring load-bearing functions at higher
pressures when elastin fails.
 In the normal aorta, there is a gradual but marked
reduction in the number of medial elastin layers from the
proximal thoracic aorta to the infrarenal aorta.
Pathogenesis
 Histologically, the aneurysms wall is thinned, with a
marked decrease in the amount of medial elastin.
 Biochemical studies show there is an increase in the
collagen:elastin ratio in the aneurysms wall.
 Elastin fragmentation is the initial structural event
and elastin depletion is completed early in aneurysm
formation.
 Elastin degradation is a key step in the development
of aneurysms, but collagen degradation is ultimately
required for aneurysmal rupture.
Pathogenesis
 Proteolytic enzymes have also been shown to play a
major role in aneurysms formation.
 There is increased expression and activity of matrix
metalloproteinases (MMPs) in the wall of aneurysms.
 In AAAs, MMP activation favors elastin and collagen
degradation.
 Interstitial collagen degradation accompanies
increased expression of collagenases MMP-1 and
MMP-13 in AAAs.
 Elastases MMP-2, MMP-9 and MMP-12 also have
increased expression in aneurysmal aortic tissue.
Pathogenesis
 Increased serum levels of MMPs return to normal after
aneurysmal repair.
 Another prominent histologic feature of aneurysms is the
presence of an inflammatory infiltrate with a preponderance of
plasma cells in the media and T cells in the adventia.
 These cells subsequently release a cascade of cytokines that
result in the activation of many different proteases.
 Extensive lymphocytic and monocytic infiltrate in the media
and adventia and deposition of IgG in the vessel wall further
support the concept that aneurysm formation is autoimmune.
 An infectious cause of aneurysm formation has been suggested
with as many as 55% of aortic aneurysms demonstrate
Chlamydia pneumoniae.
Pathogenesis
 There is considerable evidence that genetics plays a
role in aneurysm formation.
 Familial clustering is seen in 15% to 25% of patients
undergoing AAA repair.
 Specific genetic abnormalities include decreased type
III collagen in the aortic media of familial aneurysms,
polymorphisms on the pro-α chain of type III collagen
and deficiencies in α1-antitrypsin.
Pathogenesis
 Once an aneurysms forms its
enlargement is governed by
Laplace's law. Laplace Law:
T=PR
 For a given transmural pressure,
the wall tension is
proportionate to the radius.
 Thus, the larger the vessel
radius, the larger the wall
tension required to withstand a
given internal fluid.
 HTN, increasing transmural
pressure, is a major risk factor
for rupture.
Pathogenesis
 The pathogenesis of degenerative aortic aneurysms is
mulitfactorial involving disordered remodeling of the
extracellular matrix, activation of proteolytic
enzymes, chronic inflammation, genetic
predisposition and biomechanical wall stress.
 Degenerative aneurysms account for more than 90%
of aneurysmal disease
Abdominal Aortic Aneurysms
 Aortic aneurysms are most
commonly located in the
infrarenal aorta, with the
segment immediately
below the renal arteries
usually being spared.
 The iliac arteries are
involved in 40% of pts
with AAA.
 In the U.S. between 3.5
and 6.6 per 1000 people
have AAAs
Abdominal Aortic Aneurysms-Risk
Factors
 Risk factors: Age, gender, race, tobacco use, and family history
 The frequency of aneurysms increases steadily in men older
than 55 yrs, reaching a peak of 6% at 8o to 85 yrs. In women
peak at 4.5% at older then 90 yrs.
 Male:female ratio is 4:1 to 5:1 in the 60 to 70 year age group, but
beyond age of 80 it approaches 1:1.
 AAA is primarily a disease of elderly white men, with white
males being two to three times more likely develop AAA than
black males.
 Smoking is associated with 78% of AAAs and there is an 8:1
preponderance in smokers vs nonsmokers.
 There is an inverse relationship between DM and development
of AAA. Pts with DM where two times less likely to develop
AAA than those without DM.
Abdominal Aortic Aneurysms-Risk
Factors
 The most frequent and lethal complication of AAAs is
rupture.
 Rupture AAAs are the 13th leading cause of death in
the United States.
 After rupture of an AAA, only half of patients arrive at
the hospital alive.
 One studied showed, 50% reach the hospital alive, 7%
died before surgery, 17% died during the operation
and 37% died within 30 days of the operation for an
overall mortality rate for open surgical repair of 45%
Abdominal Aortic Aneurysms-Risk
Factors
 For AAAs between 5.5 and 6cm, the annual rupture risk is
between 5 and 10%.
 AAAs between 6.o and 7.0cm the annual rupture risk is
between 10% to 20%.
 AAAs >8cm have a 100% 5-year risk of rupture.
 Low risk for rupture: <5cm, <0.3cm/yr, no COPD, no
Fmhx, normal BP, fusiform
 High risk for rupture: >6cm, >0.6cm/yr, severe COPD,
+Fmhx, poorly controlled HTN, very eccenteric
 Recommended that repair of AAAs occurs when size >5.5
cm or growth of > 0.5cm/yr.
Abdominal Aortic Aneurysms-
Diagnosis
 Most asymptomatic aneurysms are
discovered on routine physical
exam with the palpation of a
pulsatile abdominal mass or during
radiographic study.
 Chronic vague abdominal or back
pain is the most common symptom,
present in up to 30% of patients.
 Classic presentation of ruptured
AAA present with the triad of
sudden-onset midabdominal pain
or flank pain, shock and the
presence of a pulsatile mass.
 Most AAAs rupture on the left
posterolateral wall, 2-4cms below
renals
Abdominal Aortic Aneurysms-
Diagnosis
 Abdominal ultrasound is
the most widely used
noninvasive test for AAAs.
 Provides structural detail
of the vessel and can
accurately measure the
size of the aneurysm in the
longitudinal as well as
cross-sectional directions.
 The thoracic and
suprarenal aorta cannot be
well visualized with U/S
because of the overlying
lung tissue.
Abdominal Aortic Aneurysms-
Diagnosis
 CT scan is the most
precise test for imaging
AAAs
 It can identify proximal
and distal extent of the
aneurysm, identify
occlusive or aneurysmal dz
in the renal, visceral and
iliac arteries.
 Identify the size of the
aortic lumen, amount and
location of mural
thrombus and presence of
calcific dz.
Abdominal Aortic Aneurysms-
Diagnosis
 Spiral CT scanners w/
3D CT angiography have
largely replaced
conventional
angiography for
evaluation of AAAs
Abdominal Aortic Aneurysms-
Medical Management
 Pt with low-risk AAAs that are being followed with serial
CT exams, attempts are made to reduce expansion rate
and rupture risk.
 Risk factor modification: smoking cessation, BP control
and reduction of cholesterol, triglycerides and
lipoproteins.
 Β-blocker use has failed to show a beneficial effect of
slowing growth of aortic aneurysms.
 NSAIDs in experimental studies has shown to inhibit
elastase-induced AAAs in rats through inhibition of COX-
2 and reduction of prostaglandin E2, interleukin-6, and
MMP-9.
 MMP inhibitors have been proposed as another
therapeutic approach to slow aneurysm expansion.
Abdominal Aortic Aneurysms
 Inflammatory aneurysm represent 5% of all infrarenal
AAAs.
 Dense adhesions to the 3rd and 4th portion of the
duodenum.
 Ureteral entrapment occurs in 25% of cases
 Mycotic aneurysms are caused by #1 Salmonella
followed by #2 Staphylococcus.
 Abdominal pain, fevers and 50% will have positive
blood cultures.
Iliac Artery Aneurysms
 Iliac artery aneurysms occur in
conjunction with AAAs in 40% of
patients.
 Isolated iliac aneurysms are rare,
accounting for less than 2% of all
aortoilliac aneurysms.
 Much like AAAs, iliac aneurysms
are associated with atherosclerosis.
 Marfans, Ehlers-Danlos, Kawasaki,
Takayasu’s, cystic medial necrosis
and arterial dissection.
 Most isolated iliac artery aneurysms
involve the common iliac artery
(70%) and the hypogastric artery
(20%).
 Multiple iliac aneurysms occur in
most patients are bilateral in 33% of
pts.
Iliac Artery Aneurysms
 Clinical presentation is variable and because of their location in
the pelvis, they are not easily palpable.
 Many pts have symptoms in the absence of rupture, which can
caused by compression of adjacent pelvic structures (e.g.
Bladder, colon, ureter, lumbosacral n.), but most present with
lower abdominal and groin pain.
 Iliac aneurysms <3cm can be treated conservatively by serial
radiologic exam.
 Iliac aneurysms >3.5cm are repaired if possible. Common iliac
aneurysms associated w/ AAAs >2cm are repaired at the time of
AAA repair.
 Internal iliac artery aneurysms can be treated with catheter
based techniques by injecting embolization coils or use of
thrombogenic material.
Femoral Artery Aneurysms
 Femoral artery aneurysms are the 2nd most common peripheral artery
aneurysm after popliteal.
 They are bilateral in 50% of pts and 92% of pts have concomitant
aortoiliac aneurysm.
 True aneurysms are almost always degenerative atherosclerotic
aneurysms, whereas pseudoaneurysms are commonly found after
surgical revascularization or after percutaneous catherization.
 Diagnosis of FAAs are usually made by physical exam and confirmed
by U/S.
 All true FAAs >2 cm need to be considered for repair because of risk
for thromboembolic complications and increased risk of rupture.
 High risk of rupture is attributed to large FAAs and involvement of
profunda femoris artery.
Popliteal Artery Aneurysms
 Popliteal artery aneurysms (PAAs)
are the most common peripheral
aneurysms and account for 70% of
the peripheral artery aneurysms.
 Early recognition is important due
to the high risk of limb loss.
Amputation rates in pts with acute
thromboembolism due to PAAs
have ranged from 0% to 30%.
 Almost all pts are men (97%), have
contralateral aneurysms (50%) and
have aortoiliac aneurysms (50%).
 Most PAAs are diagnosed with
physical exam and confirmed with
duplex scanning.
 Indications for repair: symptomatic
dz, size >2 cm and aniographic
evidence of distal embolization.
Upper Extremity Aneurysms
 Aneurysms of the upper extremity
are rare, accounting for 1% all
peripheral aneurysms.
 Subclavian artery aneurysms are the
most common of upper extremity
aneurysms.
 Pts may feel neck, chest or shoulder
pain from aneurysm expansion or
rupture.
 Primary complication with
subclavian aneurysm is distal
emoblization to the upper
extremity.
 Diagnosis can be established with
duplex U/S or CT scan. Aortic arch
and upper extremity angiography is
necessary to define the extent of the
disease.
Splanchnic Artery Aneurysms
 Aneurysms of the visceral branches of the abdominal aorta are
three times more common then renal artery aneurysms and
their clinical significance is a high mortality for ruptured
aneurysms.
 The most common visceral artery aneurysm is splenic artery
aneurysms.
 Women are four times more like to have splenic artery
aneurysms than men.
 The incidence is also increased in multiparous women. As well
as pts with splenomegaly and following orthotopic liver
transplantation.
 Splenic artery aneurysms are usually diagnosed incidentally on
CT scan.
 Indication for repair: symptomatic, pt is pregnant or in women
of childbearing age.
Splanchnic Artery Aneurysms
 Hepatic artery aneurysms are divided into two types: extrahepatic
(true) aneurysms and intrahepatic (false) aneurysms.
 Degenerative atherosclerosis and fibroplasia are the most frequent
causes of extrahepatic aneurysms.
 Most hepatic aneurysms require intervention because rupture is
frequent and lethal.
 Superior mesenteric artery aneurysms are most commonly caused by
degenerative atherosclerosis, but as many as 1/3 are cause by septic
emboli.
 Herald bleeding and abdominal pain are the most typical
presentations.
 Acute mesenteric ischemia due to thromboembolism is associated
with rupture in 50% of pts.
Renal Artery Aneurysms
 Renal artery aneurysms are
uncommon and their rupture is
rare.
 True renal artery aneurysms are
most frequently caused by
medial fibroplasia followed by
degenerative atherosclerosis.
 Most frequent cause of false
renal artery aneurysms are
spontaneous or traumatic
dissections.
 Indication for surgery: size >2
cm in women of childbearing
age.