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Aortic Aneurysms
Mark A. Farber, MD
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Aortic AneurysmsIncidence
• 30-60/1000
• Increasing incidence over past 3 decades
Incidence of AAAAutopsy 1.5-3.0%
U/S Screening 3.2%
Pts with CAD 5.0%
Pts with PVD 10.0%
Pts with femoral and pop.aneurysms 50.0%
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Aortic AneurysmsDefinition
• Pseudoaneurysm
• True Aneurysm
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Definitions
• Aneurysm - Increase in diameter of 50% (1.5x) its normal diameter – Focal region
• Ectasia - Diffuse dilatation of an artery with increase in diameter >50%
• Arteriomegaly - Diffuse enlargement of an artery, but not lg. Enough to meet criteria for an aneurysm
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Aortic AneurysmsAssociated Aneurysms
• Iliac - 41%
• Femoro-popliteal - 15%
• Pts with unilateral popliteal aneurysms-->8% AAA
• Pts with bilateral popliteal aneurysms--> 30%-50% AAA
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Aortic AneurysmsAssociated Medical Conditions
• Carotid Artery Stenosis - 10% have AAA
• Smoker:Nonsmoker - 8:1
• Male:Female - 4:1
• HTN - 40% of pts with AAA have HTN
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Aortic AneurysmsEtiology
• Atherosclerosis
• Cystic Medial Necrosis
• Dissection
• Ehlers-Danlos Syndrome
• Syphilis
• Familial Associated– Lysyl Oxidase deficiency
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Aortic AneurysmsEtiology
• Decrease in elastin and collagen in arterial wall
• Elastin becomes fragmented-->arterial elongation and dilatation
• Increase in the collagenase and elastase activity
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Aortic AneurysmsEtiology
Multifactorial
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Aortic AneurysmsPhysics
• Laplace’s Law
T = P x R
T - Tension
P - Pressure
R - Radius
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Aortic AneurysmsClinical Presentation
• Asymptomatic - 70-75%• Symptoms:
– Early satiety, N,V– Abd., Flank, or Back pain– 1/3 of pts experience abd. And flank pain
• Abrupt onset of pain -->Rupture or expansion of aneurysm
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Aortic AneurysmsRuptured Aneurysms
• Small tear-> pain, followed by frank rupture
• Usually occurs postero-laterally
• Can rupture in Vena Cava creating Aorto-Caval Fistula
• Occasionally can rupture anterior - usually fatal
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Ruptured AneurysmThumbnail Sketch
• 60-70 y/o who presents with c/o abd pain, hypotension and a pulsatile abdominal mass
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Aortic AneurysmsDiagnosis
• Physical Exam:– If <5cm in diameter, then cannot be detected by
routine physical exam
• Radiographs:– Calcified wall. Can determine size in 2/3– Cannot rule out and AAA
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Aortic AneurysmsDiagnosis
• Arteriography:– Cannot determine aneurysm size because of mural
thrombus– Indications for obtaining arteriography
• Suspicion of visceral ischemia• Occlusive disease of iliac and femoral arteries• Severe HTN, or impair renal function• ? Horseshoe Kidney• Suprarenal of TAAA component• Femoro-Popliteal Aneurysms
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Aortic AneurysmsDiagnosis
• Ultrasound– Establishes diagnosis easily– Accurately measures infrarenal diameter– Difficult to visualize thoracic or suprarenal
aneurysms– Difficult to establish relationship to renal arteries– Technician dependent– Widely available, quick, no risk, cheap
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Aortic AneurysmsCT Scan
• Very reliable and reproducible
• Can image entire aorta
• Can visualize relation ship to visceral vessels
• Longer to obtain and is more costly than U/S
• Most useful
• Requires contrast agent - renal toxicity
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Aortic AneurysmsMRA
• Now widely available
• More expensive than CT
• No contrast agent required
• Spacial resolution less than CT
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Aortic AneurysmsRisks
• Complications of AAA– Thrombosis– Distal embolization– Rupture Size Yearly
Rupture Rate5 YearRisk
5-6 cm 5-10% 25-50%
6-7 cm 7-15%% 30-75%
>7 cm 20-30% >90%
23.4% of aneurysms 4-5 cm will rupture
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Aortic AneurysmsRupture Risks
• Patients with COPD and HTN have increased risk of rupture
• Rate of enlargement:– 0.5 cm/ year
• Survival– 50% die prior to reaching hospital, and an
additional 24% prior to repair.
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Aortic AneurysmsTreatment Risks
• Mortality– 0.9 - 5% with current surgical techniques
• Morbidity– 5-10% usually associated with cardiac events
• Endovascular Techniques are significantly reducing morbidity and mortality associated with repair
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Aortic AneurysmsIndications for Treatment
• Presence of an infrarenal aneurysm > 5cm without associated co-morbid medical conditions
• Repair smaller aneurysms if rate of enlargement is greater than expected
• Repair all symptomatic aneurysms• If co-morbid conditions exist wait until risk of repair
and rupture are equal (approx. 6 cm)
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Aortic AneurysmsTreatment-Surgical
• Standard Surgical Repair– Replace diseased aorta with artificial artery– Requires 7 day hospital stay– Recovery time 3-6 months– Proven method with good long term results
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Aortic AneurysmsTreatment - Endovascular
• Repair through an incision in the groin with expandable prosthesis under fluoroscopic guidance
• Requires both surgical and radiological assistance
• Significantly reduced m+m• Long tern result unknown• Hospital stay 2 days, Recovery time 1-2 weeks