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Peripheral Vascular Disease - PowerPoint

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									Arterial Aneurysms
Sami Asfar
M.B.,Ch.,B., M.D.(UK), FRCSEd, FACS
Professor and Chairman, Departments of Surgery, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Hospital

Liver & Vascular Surgery

This tafree’3 includes every thing

Prof. Sami Asfar

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Arterial Aneurysms
• Objectives:
– To Learn: • Types of aneurysms • Clinical presentation of aneurysms • Principles of management

• Outcome:
– To be able: • Recognize patients suffering from aneurysms • Timely referral of such patients to the vascular surgeon
Prof. Sami Asfar

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Internal Carotid Innominate Subclavian Thoracic

Shape

Renal/Splenic Abdominal Iliac Femoral

Popliteal

Prof. Sami Asfar

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Arterial Aneurysms
Definition:
 Abnormal widening of a blood vessel
1.5 X diameter of the vessel proximal to the dilatation

Types:
 True: here the full thickness of the wall
is involved including (intima, media, and adventitia )

 False: here it is a puncture that cause
bleeding acuamilated in one side the by time fibrosis occur and it become pulsating) and so it is called :

“Pseudo-aneurysm” or Pulsating Haemotoma
Prof. Sami Asfar

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Puncture or trauma

Site of vascular suture

AAA (Abdominal Aortic Aneurism)
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)

Prof. Sami Asfar

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Pathogenesis of AAA
Atheromatous degeneration of intima Neutrophils release Elastase & Metalloproteinase cause Loss of ELASTIN in the media of Aortic wall Compensatory expansion of adventitial layer
(Newman et al J Vasc Surg 1994)

Prof. Sami Asfar

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Intramural Haematoma
all aneurisms have intramural thrombus the thrombus break down the atheroma and then blood will collect inside and give intramural atheroma or so called haematoma

Breakdown of atheromatous plaque

Splitting of the media with formation of Intramural haematoma

Prof. Sami Asfar

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Associated Biochemical Conditions

   

Alpha-1-antitrypsin deficiency Type III collagen synthesis disorders Fibrillin synthesis disorders Elastin disorders

Prof. Sami Asfar

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AAA
 Life expectancy: ½ of age-matched controls  Most deaths are due to:
 Coronary artery disease  Ruptured AAA

 Concomitant Abdominal Pathology (other pathologies can happen
with the AAA)

 Asymptomatic G.B. calculi:5-20%  Colon cancer: 4-5%

 Avoid concomitant aortic surgery
Prof. Sami Asfar

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Natural History of AAA
 Expansion:  Rupture:
0.2-0.8 cm/year

 Risk of rupture α Size of the aneurysm
 The size of aneurysm is measured by its anterior-posterior diameter

Laplace Law:

T=Pxr
T: Tension on the wall P: Intraluminal pressure r: Radius of the sac (diameter)

Aneurysm Size
≤ 5 cm
because there is a small chance to rupture)

Risk of Rupture
5% in 5 yrs (we do not operate it 5% per yr cumulative
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≥ 5.5 cm
we operate it because it will rupture soon Prof. Sami Asfar

(25% in 5 yrs)

Abdominal Aortic Aneurysm “AAA”
Presentation:
 Asymptomatic:
 Incidental:
Clinical examination, U/S, CT-Scan

 Symptomatic:
 Distal embolisation: Limb ischaemia, Blue toes  Back, abdominal pain: Leaking aneurysm patient will have tachycardia Ruptured aneurysm patient will be in shock

Prof. Sami Asfar

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Diagnosis of AAA
 Clinical: 95% accurate (expansile pulsation )  U/S: (best then CT SCAN) 95% accurate (reliable size measurement)
means pulsation in all directions

 Plain X-Ray: Calcified aortic wall

Prof. Sami Asfar

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Diagnosis of AAA

 Spiral CT, MRA:
Most accurate

 Angiography:
Misleading
because it outlines the lumen only So we do not do it for aneurysms

Prof. Sami Asfar

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Indications for Repair of AAA

 Asymptomatic > 5.5 cm diameter ( if the patiant is
asymptomatic but the size is big, bigger than 5.5 cm)

 Symptomatic  Rapidly expanding in 6-12 months by U/S  Ruptured or Leak

Prof. Sami Asfar

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AAA + Abdominal/Back pain What do think about?? ? Rupture ? Leak

If the patient isUnstable
(Low BP/Shock)

If the patient is Stable

U/S, CT-Scan
Urgent Surgery
“Resuscitation in Operating Room” Why? Cause thi patient is bleeding so you are wasting the blood

Leaking Aneurysm
Resuscitation in ICU & Prepare for Surgery

Prof. Sami Asfar

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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

Prof. Sami Asfar

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Elective Surgery for AAA
(Preoperative Assessment)

• Ejection Fraction < 50%
surgery

Increased Risk of death in the

(Cambria et al J Vasc Surg 1992)

• Preoperative management of cardiac abnormalities improves 5-year survival by 10-20% • 10% AAA patients require cardiac revascularisation
because there is a chance to develop infarction during or after the surgery (Johnstone KW J Vasc Surg 1994)

Prof. Sami Asfar

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Surgery for AAA
“Postoperative Mortality”

Type of Surgery
Elective Ruptured

Mortality
< 5% > 50%

Cardiac events are responsible for:
69% Early Death after aortic aneurysm is done 44% Late Death after aortic aneurysm is done

Prof. Sami Asfar

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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 during surgery Spinal Cord Ischaemia: seen in thoraco-abdominal sugery
“Artery of Adamkiewicz” T8, L1-L4 (if this artery is thrombosed or damaged you get spinal
cord ischaemia)

 1:400 AAA repair  1:5000 Aorto-iliac disease
Prof. Sami Asfar

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Infected Aortic Graft
Presentation:
Fever, malaise Abdomen & back pain Septic emboli to legs Groin abscess Aorto-enteric Fistula (most of the time it is between the duodenum)CAUSES: Recurrent upper GI bleed

Treatment:
 Graft Excision  Extra-anatomical By-pass (Axillo-Bifemoral)
• REMMBER: NO OTHER SURGERIES ARE DONE AT THE SAME TIME WHEN WE DO AORTIC SURGERY TO AVOID INFECTION OF THE GRAFT

.

• 1% after Aortic Repair (months-years)
• > 50% Mortality • Organisms:
• Staph aureus • E. coli
Prof. Sami Asfar
(Lorentzen et al Surgery 1985)

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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)

Prof. Sami Asfar

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Small (< 5.5 cm) AAA
WE DO NOT OPERATE IT CUASE THE COMPLICATIONS 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)

Prof. Sami Asfar

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Medical Management of Small AAA
INSTEADE OF HAVING A SURGERY WE GIVE THE PATIENT WITH SMALL AAA THE FOLLOWING:

Propranolol:
 Increases tensile strength of aortic connective tissue  Reduction in expansion rate of aneurysm
(Gadowski et al J as Surg 1994)

Doxycycline:
 Potent metalloproteinase inhibitor  Very effective (DONE ON animal studies ONELY)
(Petrinee et al J Vasc Surg 1996)

Prof. Sami Asfar

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Inflammatory Aortic Aneurysm
• 5-10% of AAA • Pathology: we do not know the cause it is an inflammatory 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% High ESR (50-100 mm/1st hr)

Treatment:
Prof. Sami Asfar

Same as AAA

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Endovascular Repair of AAA
this comes recently without major surgery

• Transfemoral placement of intraluminal prosthetic graft “Stent graft” into the infrarenal aorta • Less morbidity and immediate postprocedure mortality • Require suitable length of normal calibre aorta below renal arteries for graft fixation • Initially it was thought that 40% of AAA are suitable

Prof. Sami Asfar

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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 excellent  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)

Prof. Sami Asfar

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Other Arterial Aneurysms
• • • • • • Iliac artery aneurysm Splenic artery aneurysm Renal artery aneurysm Femoral artery aneurysm Popliteal artery aneurysm Mycotic aneurysms

Prof. Sami Asfar

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Iliac Artery Aneurysm

• • • •

Rarely isolated Usually extension of AAA Pulsatile mass palpable by PR examination Rupture into sigmoid colon:
– Lower G.I. Bleed

Prof. Sami Asfar

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Splenic Artery Aneurysm • 1% of population • F:M 4:1 • Causes:
• • • • Fibromuscular dysplasia Portal hypertension: 10% Multiparity Pancreatitis: pseudo-aneurysm

Prof. Sami Asfar

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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
Prof. Sami Asfar

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Splenic Artery Aneurysm Rate of Rupture
 Asymptomatic nonpregnant: 2%  First discovered during pregnancy: 95%
• Maternal Mortality 75%
(Angelakis Obst Gyn 1993)

• Treatment:
– Endovascular embolisation
• For women in child-bearing age

Prof. Sami Asfar

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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

Prof. Sami Asfar

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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
After one year

Prof. Sami Asfar

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Popliteal Artery Aneurysm
most 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

Prof. Sami Asfar

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Popliteal Artery Aneurysm
Clinical Presentation
 50% Symptomatic:  Distal ischaemia:
Most common and serious presentation  Distal embolisation  Acute thrombosis of aneurysm

 Rupture: 4%
 Compression of popliteal nerve or vein

Prof. Sami Asfar

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Popliteal Artery Aneurysm
Diagnosis:
 U/S, MRA, CT-Scan  Angiography

Treatment:
 Proximal & distal ligation  Femoro-popliteal bypass

Prof. Sami Asfar

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Popliteal Artery Aneurysm
Prognosis:
Depends on the patient’s presentation

 Asymptomatic patients:
 5-yr graft patency  Limb salvage 80% 98%

 Ischaemic symptoms:
 65% 5-yr graft patency  20% amputation

Prof. Sami Asfar

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Mycotic Aneurysms
    Bacterial infection of the arterial wall Usually saccular In atypical locations Lack calcification of the wall

Organisms:
o Staph species o Salmonella species o Streptococcus species 30% 10% 10%

Prof. Sami Asfar

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Mycotic Aneurysms
Presentation:
 Fever, Leukocytosis  Rapidly enlarging, warm, tender pulsatile mass  Septic emboli  Deeply seated:
 PUO  Rupture: Shock

 Blood culture: +ve only 50%

Prof. Sami Asfar

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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

Prof. Sami Asfar

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Thoraco-Abdominal & Dissecting Aneurysms

Prof. Sami Asfar

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Aortic Dissection “DeBakey Classification”
Type I:
Ascending, Descending & Abdominal Aorta

Type II:
Ascending Aorta

Type IIIa:
Descending Aorta

Type IIIb:
Descending & Abdominal Aorta

Marfan’s Syndrome Ehler’s-Danlos Syndrome Takayasu’s aortitis
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Prof. Sami Asfar

Aortic Dissection
1. Intimal tear
Entrance False Lumen

Exit

True Lumen

4. Double channel Aorta 2. Blood under pressure dissects the media 3. Splitting of media (intimomedial flap)
Prof. Sami Asfar

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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

Prof. Sami Asfar

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