periphral vascular disease 2
DESCRIPTION
Periphral Vascular Disease 2TRANSCRIPT
-
5/28/2018 Periphral Vascular Disease 2
1/44
Prof. Sami Asfar 1
Arterial Aneurysms
Sami AsfarM.B.,Ch.,B., M.D.(UK), FRCSEd, FACS
Professor and Chairman,
Departments of Surgery, Faculty of Medicine, Kuwait University
and Mubarak Al-Kabeer HospitalLiver Vascular SurgeryThis tafree3 includes every thing
-
5/28/2018 Periphral Vascular Disease 2
2/44
Prof. Sami Asfar 2
Objectives: To Learn:
Types of aneurysms
Clinical presentation of aneurysms Principles of management
Arterial Aneurysms
Outcome:
To be able: Recognize patients suffering from aneurysms
Timely referral of such patients to the vascular surgeon
-
5/28/2018 Periphral Vascular Disease 2
3/44
Prof. Sami Asfar 3
Internal Carotid
Subclavian
Thoracic
Innominate
Renal/Splenic
Iliac
Abdominal
Popliteal
Femoral
Shape
-
5/28/2018 Periphral Vascular Disease 2
4/44
Prof. Sami Asfar 4
Arterial Aneurysms
Site of vascular suturePuncture or trauma
Definition: Abnormal widening of a blood vessel
1.5 X diameter of the vessel proximal to the
dilatation
Types:True:here the ful l thickness of the wallis involved including (in tima, media, and adventi tia
)
False:
here it i s a puncture that cause
bleeding acuamil ated in one side the by time fibrosis
occur and i t become pulsating) and so it is called :
Pseudo-aneurysm
or
Pulsating Haemotoma
-
5/28/2018 Periphral Vascular Disease 2
5/44
Prof. Sami Asfar 5
AAA (Abdominal Aorti c Aneuri sm)
Incidence: General population . 1-5%
> 65 years age . 3-5%
> 70 years age .10%
M : F ...4 : 1 (most common female)
Risk Factors: Atherosclerosis 95% ( most impo.)
Hypertension ... 40%
Smoking
Age Males
Family history (1st degree relative)
-
5/28/2018 Periphral Vascular Disease 2
6/44
Prof. Sami Asfar 6
Pathogenesis of AAA
Atheromatous degeneration of intima
Neutrophils release
Elastase & Metalloproteinase cause
Loss of ELASTINin the media of Aortic wall
Compensatory expansion of adventitial layer
(Newman et al J Vasc Surg 1994)
-
5/28/2018 Periphral Vascular Disease 2
7/44
Prof. Sami Asfar 7
Intramural Haematomaall aneur isms have in tramur al thrombus
the thrombus break down the atheroma and then blood wi ll collect inside and give in tramural atheroma or so call ed
haematoma
Breakdown of atheromatous plaque
Splitting of the media with formation of Intramural haematoma
-
5/28/2018 Periphral Vascular Disease 2
8/44
Prof. Sami Asfar8
Associated Biochemical Conditions
Alpha-1-antitrypsin deficiency
Type III collagen synthesis disorders Fibrillin synthesis disorders
Elastin disorders
-
5/28/2018 Periphral Vascular Disease 2
9/44
Prof. Sami Asfar9
AAA
Life expectancy: of age-matched controls
Most deaths are due to:
Coronary artery disease
Ruptured AAA
Concomitant Abdominal Pathology (other pathologies can happenwith the AAA)
Asymptomatic G.B. calculi:5-20%
Colon cancer: 4-5%
Avoid concomitant aortic surgery
-
5/28/2018 Periphral Vascular Disease 2
10/44
Prof. Sami Asfar10
Natural History of AAA
Expansion: 0.2-0.8 cm/year Rupture:
Risk of rupture Size of the aneurysm The size of aneurysm is measur ed by its anterior -poster ior diameter
Laplace Law: T=Pxr
T: Tension on the wallP: Intraluminal pressure
r: Radius of the sac (diameter)
Aneurysm Size Risk of Rupture
5 cm 5% in 5 yrs (we do not operate itbecause there is a small chance to rupture)
5.5 cm 5% per yr cumulativewe operate it because it wil l rupture soon (25% in 5 yrs)
-
5/28/2018 Periphral Vascular Disease 2
11/44
Prof. Sami Asfar11
Abdominal Aortic Aneurysm
AAA
Presentation:
Asymptomatic:
Symptomatic:Distal embolisation:
Limb ischaemia, Blue toes
Back, abdominal pain:
Leaking aneurysm patient wi ll have tachycardia
Ruptured aneurysm patient wi ll be in shock
Incidental:
Clinical examination, U/S, CT-Scan
-
5/28/2018 Periphral Vascular Disease 2
12/44
Prof. Sami Asfar12
Diagnosis of AAA
Clinical: 95% accurate (expansile pulsation means pulsation in all directions) U/S: (best then CT SCAN) 95% accurate (reliable size measurement)
Plain X-Ray: Calcified aortic wall
-
5/28/2018 Periphral Vascular Disease 2
13/44
Prof. Sami Asfar13
Diagnosis of AAA
Spiral CT, MRA:Most accurate
Angiography:
Misleading because it outl ines the lumen only So we do not do it for aneurysms
-
5/28/2018 Periphral Vascular Disease 2
14/44
Prof. Sami Asfar14
Indications for Repair of AAA
Asymptomatic > 5.5 cm diameter ( i f the patiant isasymptomatic but the size is big, bigger than 5.5 cm)
SymptomaticRapidly expanding in 6-12 months by U/S
Ruptured or Leak
-
5/28/2018 Periphral Vascular Disease 2
15/44
Prof. Sami Asfar
15
Urgent SurgeryResuscitation in Operating Room
Why? Cause thi patient is bleedingso you are wasting the blood
AAA + Abdominal/Back pain
What do think about??
? Rupture ? Leak
If the patient is StableIf the patient isUnstable
(Low BP/Shock)
U/S, CT-Scan
Leaking Aneurysm
Resuscitation in ICU & Prepare for Surgery
-
5/28/2018 Periphral Vascular Disease 2
16/44
Prof. Sami Asfar
16
Elective Surgery for AAA(Preoperative Assessment) you should prepare and do
- Anaesthesia Consultation
- Chest X-ray
- Cardiac Function Tests:
ECG
Echocardiogram (Ejection Fraction, Ventricular Function)
Stress Tests: Treadmill, Thallium Scan
? Cardiac Catheterisation
- Pulmonary Function Tests
- Bowel Preparation: 4 Liters Go-Lytely
-
5/28/2018 Periphral Vascular Disease 2
17/44
Prof. Sami Asfar
17
Elective Surgery for AAA(Preoperative Assessment)
Ejection Fraction < 50% I ncreased Risk of death in thesurgery
(Cambria et al J Vasc Surg 1992)
Preoperative management of cardiac abnormalities
improves 5-year survival by 10-20%
10% AAA patients require cardiac revascularisationbecause there is a chance to develop i nfarcti on dur ing or after the surgery
(Johnstone KW J Vasc Surg 1994)
-
5/28/2018 Periphral Vascular Disease 2
18/44
Prof. Sami Asfar
18
Surgery for AAAPostoperative Mortality
Type of Surgery Mortality
Elective < 5%
Ruptured > 50%
Cardiac events are responsible for:69% Early Death after aor tic aneurysm is done
44% Late Death after aort ic aneurysm is do ne
-
5/28/2018 Periphral Vascular Disease 2
19/44
Prof. Sami Asfar
19
Complications of AAA Surgery
Renal Failure: Elective 2% Rupture 21%
Ischaemic Colitis: 6%
Acute Limb Ischaemia
Trash foot
Graft infection: 1%
Neurogenic Impotence you could damage nerves dur ing sur gery
Spinal Cord Ischaemia: seen i n thoraco-abdominal sugery
Artery of Adamkiewicz T8, L1-L4 (if thi s artery i s thrombosed or damaged you get spinalcord ischaemia)
1:400 AAA repair
1:5000 Aorto-iliac disease
-
5/28/2018 Periphral Vascular Disease 2
20/44
Prof. Sami Asfar
20
Infected Aortic Graft
REMM BER: NO OTHER SURGERIES ARE DONE AT THE SAME TI ME WHEN WE DO AORTIC SURGERY TO
AVOID I NFECTION OF THE GRAFT.
1% after Aortic Repair (months-years) > 50% Mortality
Organisms: Staph aureus
E. coli (Lorentzen et al Surgery 1985)
Presentation:
Fever, malaiseAbdomen & back pain
Septic emboli to legs
Groin abscess
Aorto-enter ic Fi stula (most of the time it i s between the duodenum)CAUSES: Recurrent upper GI bleed
Treatment:
Graft ExcisionExtra-anatomical By-pass (Axillo-Bifemoral)
-
5/28/2018 Periphral Vascular Disease 2
21/44
Prof. Sami Asfar
21
Screening for AAA
U/S Screening of people > 60 years age
every 6-12 months
Decreased the incidence of Rupture by 85%(Scott et al Br J Surg 1995)
-
5/28/2018 Periphral Vascular Disease 2
22/44
Prof. Sami Asfar
22
Small (< 5.5 cm) AAAWE DO NOT OPERATE I T CUASE THE COMPLI CATIONS AFTER THE OPERATION ARE BAD AND EARLY surgery is
NOT associated with any long-term survival advantage
U.K. Small Aneurysm Trial:
U/S Surveillance is safe
Early surgery is NOT associated with any long-term
survival advantage (Lancet 1998;352:1619-55)
Predictors of increased risk of rupture:
Chronic obstructive pulmonary disease
Systolic hypertension
Increased pulse pressure (Crenenwett et al Surgery 1985)
-
5/28/2018 Periphral Vascular Disease 2
23/44
Prof. Sami Asfar
23
Medical Management of Small AAAINSTEADE OF HAVING A SURGERY WE GIVE THE PATIENT WITH SMALL AAA THE FOLLOWING:
Propranolol:
Doxycycline:
Increases tensile strength of aortic connective tissue
Reduction in expansion rate of aneurysm(Gadowski et al J as Surg 1994)
Potent metalloproteinase inhibitor
Very effective (DONE ON animal studies ONELY)
(Petrinee et al J Vasc Surg 1996)
-
5/28/2018 Periphral Vascular Disease 2
24/44
Prof. Sami Asfar
24
Inflammatory Aortic Aneurysm
5-10% of AAA Pathology: we do not know the cause it is an inf lammatory process
Marked thickening of the media & adventitia of the aneurysm wall
(AAA: the media is thin)
Dense retroperitoneal inflammatory fibrotic reaction incorporating:
Duodenum, IVC, Lt Renal vein, Ureters
Presentation:Pain with No rupture
Ureteric obstruction: 3-4%
Weight loss: 5%H igh ESR (50-100 mm/1st hr)
Treatment: Same as AAA
-
5/28/2018 Periphral Vascular Disease 2
25/44
Prof. Sami Asfar
25
Endovascular Repair of AAAthi s comes recentl y without major surgery
Transfemoral placement of intraluminal
prosthetic graft Stent graft into the
infrarenal aorta
Less morbidity and immediate post-
procedure mortality Require suitable length of normal
calibre aorta below renal arteries for
graft fixation
Initially it was thought that 40% ofAAA are suitable
-
5/28/2018 Periphral Vascular Disease 2
26/44
Prof. Sami Asfar
26
Endovascular Repair of AAA
EVAR-1 & EVAR-2
Most recent results of two randomized studies: Only reduced in-hospital mortality to 1.2% from 3.8%
which is excel lent
Overall survival after 4 yrs NOT significant
Re-intervention 5% a year because of endoleaks
1% a year incidence of rupture
33% more cost than normal major surgery(F/U with repeat CT-scans)
Did not improve health related quality of life
(Lancet 2005;365:2156-2158)
Suitable for high risk patients who have suitable anatomic
conditions (Aortic neck below renal arteries).
(Lancet 2005;365:2156-2158)
-
5/28/2018 Periphral Vascular Disease 2
27/44
Prof. Sami Asfar
27
Other Arterial Aneurysms
Iliac artery aneurysm
Splenic artery aneurysm
Renal artery aneurysm Femoral artery aneurysm
Popliteal artery aneurysm
Mycotic aneurysms
-
5/28/2018 Periphral Vascular Disease 2
28/44
Prof. Sami Asfar
28
Iliac Artery Aneurysm
Rarely isolated
Usually extension of AAA
Pulsatile mass palpable by PR examination
Rupture into sigmoid colon: Lower G.I . Bleed
-
5/28/2018 Periphral Vascular Disease 2
29/44
Prof. Sami Asfar 29
Splenic Artery Aneurysm
1% of population
F:M 4:1
Causes: Fibromuscular dysplasia
Portal hypertension: 10%
Multiparity
Pancreatitis: pseudo-aneurysm
-
5/28/2018 Periphral Vascular Disease 2
30/44
Prof. Sami Asfar 30
Splenic Artery Aneurysm
Presentation Incidental:
Plain X-ray: Signet ring calcification in 70%
U/S, CT-Scan
Rupture: Intra-peritoneal bleeding: shock
Stomach: Upper GI bleeding
Double rupture phenomenon
(lesser sac then peritoneum)
Mortality: 25%
Abdominal pain:
Epigastric & left upper quadrant
http://www.aso-group.co.jp/aih/kouhou/kakuka/housya/tf/case308/AXR.jpg -
5/28/2018 Periphral Vascular Disease 2
31/44
Prof. Sami Asfar 31
Splenic Artery Aneurysm
Rate of RuptureAsymptomatic nonpregnant: 2%
First discovered during pregnancy: 95%
Maternal Mortali ty 75%(Angelakis Obst Gyn 1993)
Treatment: Endovascular embolisation
For women in chil d-bearing age
-
5/28/2018 Periphral Vascular Disease 2
32/44
Prof. Sami Asfar 32
Renal Artery Aneurysm
Rare: 0.1% population
Saccular < 1.5 cm
Incidental
Rupture is uncommon except in pregnancy Associated with:
Medial fibroplasia
Polyarteritis nodosa:
Multiple microaneurysms
http://www.scvir.org/members/caseclub/0698/0698_02/0698_022.html -
5/28/2018 Periphral Vascular Disease 2
33/44
Prof. Sami Asfar 33
Management of Renal Artery Aneurysm
Indications Symptomatic + > 2 cm diameter
Child-bearing age
Surgery
Vein patch:
Saphenous vein graft
Internal iliac artery graft
Ex-vivo repair
Percutaneous Embolisation
Af ter one year
http://www.scvir.org/members/caseclub/0698/0698_02/0698_025.htmlhttp://www.scvir.org/members/caseclub/0698/0698_02/0698_024.html -
5/28/2018 Periphral Vascular Disease 2
34/44
Prof. Sami Asfar 34
Popliteal Artery Aneurysmmost common after AAA
Most common peripheral artery aneurysm
Popliteal artery > 2 cm diameter
Bilateral: 50% so when you diagnose it in one side most probably you have another one at the other side
Associated with AAA: 40%
Aetiology:
- Atherosclerosis
- Popliteal artery entrapment: Poststenotic dilatation
-
5/28/2018 Periphral Vascular Disease 2
35/44
Prof. Sami Asfar 35
Popliteal Artery Aneurysm
Clinical Presentation
50% Symptomatic:Distal ischaemia:
Most common and serious presentationDistal embolisation
Acute thrombosis of aneurysm
Rupture: 4%
Compression of popliteal nerve or vein
-
5/28/2018 Periphral Vascular Disease 2
36/44
Prof. Sami Asfar 36
Popliteal Artery Aneurysm
Diagnosis: U/S, MRA, CT-Scan
Angiography
Treatment: Proximal & distal ligation
Femoro-popliteal bypass
-
5/28/2018 Periphral Vascular Disease 2
37/44
Prof. Sami Asfar 37
Popliteal Artery Aneurysm
Prognosis:
Depends on the patients presentation
Asymptomatic patients:
5-yr graft patency 80% Limb salvage 98%
Ischaemic symptoms:
65% 5-yr graft patency
20% amputation
-
5/28/2018 Periphral Vascular Disease 2
38/44
Prof. Sami Asfar 38
Mycotic Aneurysms
Bacterial infection of the arterial wall
Usually saccular
In atypical locations
Lack calcification of the wall
Organisms:
o Staph species 30%
o Salmonella species 10%
o Streptococcus species 10%
-
5/28/2018 Periphral Vascular Disease 2
39/44
Prof. Sami Asfar 39
Mycotic Aneurysms
Presentation:
Fever, Leukocytosis
Rapidly enlarging, warm, tender pulsatile mass
Septic emboli
Deeply seated:
PUO
Rupture: Shock
Blood culture: +ve only 50%
-
5/28/2018 Periphral Vascular Disease 2
40/44
Prof. Sami Asfar 40
Mycotic Aneurysms
Affected Arteries: Aorta 40%
Peripheral arteries 35%
Visceral arteries 20% (Brown et al J Vasc Surg 1985)
Treatment: Antibiotics
Depending on the site:
Excision or bypass
-
5/28/2018 Periphral Vascular Disease 2
41/44
Prof. Sami Asfar 41
Thoraco-Abdominal & Dissecting Aneurysms
-
5/28/2018 Periphral Vascular Disease 2
42/44
Prof. Sami Asfar 42
Aortic Dissection
DeBakey Classification
Type I:Ascending, Descending & Abdominal Aorta
Type II:
Ascending Aorta
Type IIIa:Descending Aorta
Type IIIb:Descending & Abdominal Aorta Marfans Syndrome
Ehlers-Danlos Syndrome
Takayasus aortitis
-
5/28/2018 Periphral Vascular Disease 2
43/44
Prof. Sami Asfar 43
Aortic Dissection
1. Intimal tear
Entrance
Exit
2. Blood under pressure dissects the media
3. Splitting of media (intimomedial flap)
4. Double channel Aorta
True Lumen
False Lumen
-
5/28/2018 Periphral Vascular Disease 2
44/44
Prof. Sami Asfar 44
Thoraco-Abdominal Aneurysms (TAAA)
Crawford Classification
Type I:Descending & Abdominal Aorta
Not involving the Renal arteries
Type II:Thoracic & Abdominal Aorta
Type III:Distal Thoracic & Abdominal Aorta
Type IV:All or most of Abdominal Aorta