Aortic Aneurysms

Mark A. Farber, MD
 Aortic Aneurysms
Incidence
30-60/1000
Increasing incidence over past 3 decades

Incidence of AAA
Autopsy 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%
 Aortic Aneurysms
Definition

Pseudoaneurysm

True Aneurysm
 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
 Aortic Aneurysms
Associated Aneurysms
Iliac - 41%
Femoro-popliteal - 15%

Pts with unilateral popliteal aneurysms--

>8% AAA
Pts with bilateral popliteal aneurysms-->
30%-50% AAA
 Aortic Aneurysms
Associated Medical Conditions

Carotid Artery Stenosis - 10% have AAA

Smoker:Nonsmoker - 8:1
Male:Female - 4:1
HTN - 40% of pts with AAA have HTN
 Aortic Aneurysms
Etiology

Atherosclerosis
Cystic Medial Necrosis
Dissection
Ehlers-Danlos Syndrome
Syphilis
Familial Associated
Lysyl Oxidase deficiency
 Aortic Aneurysms
Etiology
Decrease in elastin and collagen in arterial
wall
Elastin becomes fragmented-->arterial
elongation and dilatation
Increase in the collagenase and elastase
activity
Aortic Aneurysms
Etiology

Multifactorial
 Aortic Aneurysms
Physics
Laplaces Law

T=PxR
T - Tension
P - Pressure
R - Radius
 Aortic Aneurysms
Clinical 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
 Aortic Aneurysms
Ruptured 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
 Ruptured Aneurysm
Thumbnail Sketch

60-70 y/o who presents with c/o abd pain,

hypotension and a pulsatile abdominal mass
 Aortic Aneurysms
Diagnosis

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
 Aortic Aneurysms
Diagnosis
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
 Aortic Aneurysms
Diagnosis
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
 Aortic Aneurysms
CT 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
 Aortic Aneurysms
MRA
Now widely available
More expensive than CT
No contrast agent required
Spacial resolution less than CT
 Aortic Aneurysms
Risks
Complications of AAA
Thrombosis
Distal embolization
Rupture Size Yearly 5 Year
Rupture Rate Risk
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

 Aortic Aneurysms
Rupture 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.
 Aortic Aneurysms
Treatment 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
 Aortic Aneurysms
Indications 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)
 Aortic Aneurysms
Treatment-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
 Aortic Aneurysms
Treatment - 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