Aneurysm

By Dr. : ANAS B. AHMED

Definition
• Dilatations of localised segments of the arterial system are called
aneurysms when there is a >50% increase in the diameter of the
vessel; below 50% they are termed ectactic.
• They can either be:
• True aneurysms, containing the three layers of the arterial wall
(intima, media, adventitia) in the aneurysm sac,
• False aneurysms, having a single layer of fibrous tissue as the wall
of the sac, e.g. aneurysm following trauma.
Types
Types
Types of aneurysms
An aneurysm is a bulge or defect in the vessel
wall of an artery.
Different layers of the vessel wall can be
affected.
There are different types of aneurysms,
depending on the defect:
true aneurysm (involves all three layers),
false aneurysm (perforation of the vessel wall
with formation of an extravascular hematoma),
and dissecting aneurysm (tear in the intimal
layer and separation of the arterial wall layers
with formation of a second lumen).
Types
• Aneurysms can also be grouped according to their:
• Shape (fusiform, saccular) or
• Aetiology (atheromatous, traumatic, mycotic, etc.).
• The term mycotic is a misnomer because, although it indicates infection as
the cause of the aneurysm, it is due to bacteria, not fungi.
• Aneurysms may occur in the aorta, iliac, femoral, popliteal,
subclavian, axillary, carotid, cerebral, mesenteric, splenic and renal
arteries and their branches.
• The majority are true fusiform atherosclerotic aneurysms.
Types

Saccular and fusiform

abdominal aortic aneurysms
Saccular aneurysm:
asymmetrical dilatation of the
aortic wall (less common but
with a higher risk of rupture
compared to fusiform
aneurysms)
Fusiform aneurysm:
symmetrical dilatation of the
aortic wall (most common
shape)
Types
Classification
Pathophysiology
• Inflammation and proteolytic degeneration of connective tissue
proteins (e.g., collagen and elastin and/or smooth muscle cells) in
high-risk patients → loss of structural integrity of the aortic wall →
widening of the vessel → mechanical stress (e.g., high blood pressure)
acts on weakened wall tissue → dilation and rupture may occur.
• Possible formation of thrombi in the aneurysm → peripheral
thromboembolism
Clinical features
• The majority of arterial aneurysms are asymptomatic at the time of
identification and are often identified during routine health checks or
investigations for other pathologies.
• All aneurysms can cause symptoms, but aneurysms measuring twice
the size of the corresponding normal vessel are at increased risk of
complications.
• The symptoms relate to the vessel affected and the tissues it supplies
and occur as a result of compression of surrounding structures,
thrombosis, rupture or the release of emboli.
Clinical features
• Many aneurysms of clinical significance can be palpated and,
typically, an expansile pulsation is felt.
• Transmitted pulsation through a mass lesion, cyst or abscess lying
adjacent to a large artery may be mistaken for aneurysmal pulsation.
• Before incising a swelling believed to be an abscess, it is essential to
make sure that it does not pulsate.
• Finally, a tortuous (and often ectatic) artery, usually the innominate or
carotid, may seem like an aneurysm to the inexperienced clinician.
Clinical features
Clinical features
Abdominal aortic aneurysm
Abdominal aortic aneurysm
• Abdominal aortic aneurysm (AAA) is by far the most common type of large
vessel aneurysm and is found in 2% of the population at autopsy; 95% have
associated atheromatous degeneration and 95% occur below the renal
arteries.
• Most remain asymptomatic until rupture occurs; the risk of rupture
increases with increasing size (diameter) of the aneurysm.
• Asymptomatic aneurysms are found incidentally on physical examination,
radiography or ultrasound investigation.
• Symptomatic aneurysms may cause minor symptoms, such as back and
abdominal discomfort, before sudden, severe back and/or abdominal pain
develops from expansion and rupture.
• Rarely, symptoms may occur as a result of erosion or compression of
surrounding structures, e.g. aortoenteric fistula, ureteric obstruction.
Abdominal aortic aneurysm
Abdominal aortic aneurysm

Abdominal aortic aneurvsm locations

Infrarenal aortic aneurysm: located distal to the
renal arteries, with a segment of normal,
nondilated aorta between the aneurysm and the
renal arteries
Suprarenal aortic aneurysm: extends proximal to
the renal arteries (without extension into the
chest)
Risk factors
• Smoking (most important risk factor)
• Nicotine and other components of smoke cause cell damage, inflammation and impaired cell
repair in vascular smooth muscle cells.
• This weakens the vessel wall resulting in an increased risk of developing an aneurysm and
aneurysmal rupture.
• Patients should therefore be encouraged to stop smoking.
• Advanced age
• Atherosclerosis (ASCVD)
• Wall degradation, inflammation and cell-death-mediated loss of elastic smooth muscle cells (SMC)
• Hypercholesterolemia and arterial hypertension
• Positive family history
• Male sex
• Trauma
Asymptomatic abdominal aortic aneurysm
• An asymptomatic abdominal aortic aneurysm in an otherwise fit patient
should be considered for repair if >55 mm in diameter (measured by
ultrasonography).
• The annual incidence of rupture rises from 1% or less in aneurysms that
are <55 mm in diameter to a significant level, perhaps as high as 25%, in
those that are 70 mm in diameter.
• Assuming open elective surgery (transabdominal) carries a 5% mortality
rate, the balance is in favour of elective operation once the maximum
diameter is >55 mm, provided there is no major comorbidity.
• Regular ultrasonographic assessment is indicated for asymptomatic
aneurysms <55 mm in diameter.
Investigations
• Full blood count, electrolytes, liver function tests, coagulation tests
and blood lipid estimation should be performed.
• Blood should be cross-matched a few days prior to surgery.
• Many patients now have an anaesthetic assessment and the need for
cardiac and respiratory function tests are decided at this time.
• ECG and chest radiographs are essential; further assessment may
include echocardiography or isotope ventriculography,
cardiopulmonary exercise testing and spirometry.
Investigations
• The morphology of the aneurysm is best assessed by CT scan.
• 75% of aneurysms are suitable for endovascular (minimally invasive)
repair, usually via the femoral arteries in the groin.
• If lower limb pulses are absent, there may be associated arterial
occlusive disease that should be assessed by duplex scanning initially.
Further assessment with CT, MR or DSA may be required and
angioplasty may be appropriate.
• The aneurysm is often filled with circumferential clot that produces a
falsely narrowed appearance on DSA; this method should not
therefore be used to assess aneurysm size.
Investigations

Ultrasonogram of an
aortic aneurysm
showing the large
clot-filled sac with a
small central lumen
(transverse and
longitudinal
scans).
Investigations
Symptomatic abdominal aortic aneurysm
• These patients most commonly present with abdominal and/ or back pain but the
aneurysm is not ruptured on CT scan.
• Pain may also occur in the thigh and groin because of nerve compression.
• Gastrointestinal, urinary and venous symptoms can also be caused by pressure from an
abdominal aneurysm.
• About 3% of all aneurysms cause pain as a result of inflammation of the aneurysm itself.
• Finally, a few cause symptoms from distal embolisation of fragments of their
intraluminal thrombus.
• An operation is usually indicated in patients who are otherwise reasonably fit.
• Pain may be a warning sign of stretching of the aneurysm sac and imminent rupture;
surgery should be performed as soon as possible (usually on the next available operating
list).
• The operative mortality of symptomatic aneurysms is usually higher than elective cases.
Ruptured abdominal aortic aneurysm
• Abdominal aortic aneurysms can rupture anteriorly into the peritoneal cavity
(20%) or posterolaterally into the retroperitoneal space (80%).
• Less than 50% of patients with rupture survive to reach hospital.
• Anterior rupture results in free bleeding into the peritoneal cavity; very few
patients reach hospital alive.
• Posterior rupture, on the other hand, produces a retroperitoneal haematoma.
• Often a brief period ensues when a combination of moderate hypotension and
the resistance of the retroperitoneal tissues arrests further haemorrhage and
may allow transport to hospital.
• The patient may remain conscious but in severe pain.
• If no operation is performed, death is virtually inevitable.
• Operative mortality is around 50% and the overall combined mortality
(community and hospital) is around 80–90%.
Ruptured abdominal aortic aneurysm
• Ruptured abdominal aortic aneurysm is a surgical emergency; it should be
suspected in a patient with the triad of:
• Severe abdominal and/or back pain, hypotension and a pulsatile abdominal
mass.
• If there is doubt about the presence of an aneurysm an ultrasound scan may
help, but this cannot diagnose rupture.
• CT scanning should be used to establish the diagnosis and to determine whether
an endovascular repair is possible.
• Good venous access is needed for infusion of saline or volume expanding fluids,
but the systolic blood pressure should not be raised any more than is necessary
to maintain consciousness and permit cardiac perfusion (<100 mmHg).
• Many surgeons now adopt a policy of permissive hypotension, where fluids are
withheld if the patient is conscious (and cerebral perfusion is therefore adequate)
in order to avoid provoking further uncontrolled haemorrhage.
Ruptured abdominal aortic aneurysm
• After CT scanning, the patient should be transferred immediately to
an operating theatre, where a urinary catheter and arterial line are
usually inserted.
• If the patient appears stable, surgery may be delayed until cross-
matched blood is available but surgery should commence
immediately if haemodynamic instability develops.
• The abdomen is usually prepared and draped with the patient awake.
• It is important to remember that the treatment of ruptured
aneurysm is operation, not monitoring and resuscitation.
Ruptured abdominal aortic aneurysm
Invasive treatment: AAA repair
• Indications
• Emergency repair: unstable patients
• Urgent repair: impending rupture or leaking AAA
• Elective repair
• Fusiform aneurysm with maximum diameter ≥ 5.5 cm and low or
acceptable surgical risk
• Small fusiform aneurysm expanding ≥ 1 cm per year
• Saccular aneurysm
• Aneurysm with maximum diameter 5.0–5.4 cm in women
• Small aneurysm (4.0–5.4 cm) in patients requiring chemotherapy,
radiotherapy, solid organ transplantation
Invasive treatment: AAA repair
• Procedures
• The long-term survival and complication rates of endovascular and open
surgical repair are similar, and these procedures each have their advantages
and disadvantages.
• Endovascular aneurysm repair (EVAR)
• Indications: minimally invasive procedure that is preferred over open surgical repair for
most aneurysms, especially in patients with a high operative risk
• Disadvantage: Reintervention rates are higher for EVAR than for OSR.
• Open surgical repair (OSR)
• Indications
• Mycotic aneurysm or infected graft
• Persistent endoleak and aneurysm sac growth following EVAR
• Anatomical contraindications for EVAR
• Procedure: A laparotomy is performed and the dilated segment of the aorta is
replaced with a tube graft or Y-prosthesis (bifurcated synthetic stent graft).
EVAR

Arterial access for endovascular aneurysm

repair (EVAR) of abdominal aortic aneurysm
(AAA)
Main image: EVAR requires bilateral
iliofemoral arterial access, which can be
achieved either via femoral artery cutdown
(shown here) or percutaneously.
Inset: enlarged view of femoral artery
cutdown showing insertion of guidewire
EVAR
Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA)
Many configurations of EVAR stent grafts exist, but, in principle, they are
composed of a supportive metal frame (stent) and an impermeable graft
material. The procedure is performed under fluoroscopic guidance.
EVAR using example of a 2-component bifurcated stent graft and an infrarenal
aneurysm:
1) The guidewire is inserted via the ipsilateral femoral artery into the
abdominal aorta
2) Main body of the stent graft is advanced over the guidewire and positioned
with the upper end of the graft material positioned immediately below the
renal arteries.
3) The central part of the stent graft (with graft material) is deployed
(expanded).
4) The Second guidewire is passed through the contralateral femoral artery
and into the short limb of the main stent graft. The upper part of the stent (no
graft material) is deployed, anchoring it to the wall of the aorta.
5) The iliac extension component of the stent graft is advanced over the
contralateral guidewire until there is sufficient overlap between it and the
main body.
6) The iliac extension is deployed and both iliac limbs are anchored distally.
7) The guidewires are removed.
OSR
Postoperative complications
• The most common complications after open repair are cardiac (ischaemia
and infarction) and respiratory (atelectasis and lower lobe consolidation).
• A degree of colonic ischaemia because of lack of a collateral blood supply
occurs in about 10% of patients, but fortunately this usually resolves
spontaneously.
• Renal failure is an uncommon event after elective procedures but may
complicate procedures undertaken for rupture. Renal failure is more likely
if there is preoperative renal impairment or considerable intraoperative
blood loss.
• Neurological complications include sexual dysfunction and spinal cord
ischaemia.
Postoperative complications
• An aortoduodenal fistula is an uncommon but treatable complication
of abdominal aortic replacement Surgery. It should be suspected
whenever haematemesis or melaena occurs in the months or years
after operation.
• Prosthetic graft infection is also uncommon; it may require removal
of the original graft and replacement with an autologous deep vein
(superficial femoral vein) graft limb.
Postoperative complications
• Cardiac, respiratory, renal and neurological complications are less
common after endovascular repair.
• However, there are complications that are unique to EVAR such as
endoleak, graft migration, metal strut fracture and graft limb
occlusion.
• Life-long surveillance with duplex or CT (together wit plain abdominal
x-ray for strut fracture) is required to detect endoleak and migration.
• Overall, 10–20% of patients with EVAR will require secondary
interventions to treat complications at some future date, although
many of the interventions can be performed with a percutaneous
approach via the femoral artery in the angiography suite.
Peripheral aneurysm
Popliteal aneurysm
• Popliteal artery aneurysm accounts for 70% of all peripheral aneurysms classically diagnosed in
males in their seventh decade of life; 50% are bilateral.
• Examination of the abdominal aorta is indicated if a popliteal aneurysm is found because one-
third are accompanied by aortic dilatation.
• Popliteal aneurysms present as a swelling behind the knee or with symptoms caused by
complications, such as severe ischaemia following thrombosis or distal ischaemia as a result of
emboli.
• The diagnosis is usually confirmed with duplex scanning but assessment of the distal vessels (with
CT, MR or DSA) is important prior to repair if the foot pulses are diminished or absent.
• An asymptomatic aneurysm exceeding 20 mm in diameter should be considered for elective
repair, to prevent future complications. Some surgeons would also offer elective repair for smaller
diameters if the sac contains thrombus, because of a perceived increased risk of distal
embolisation.
• All symptomatic popliteal aneurysms, including those in which single crural vessel embolisation
has occurred, should be considered for repair.
Popliteal aneurysm
Femoral aneurysm
• True aneurysm of the femoral artery is uncommon.
• Complications occur in less than 3% so conservative treatment is
generally indicated, but it is important to look for aneurysms
elsewhere as over half are associated with abdominal or popliteal
aneurysms.
• Large aneurysms should be repaired.
• False aneurysm of the femoral artery occurs in 2% of patients after
arterial surgery at this site.
Iliac aneurysm
• This usually occurs in conjunction with aortic aneurysm and only
rarely on its own.
• When occurring in isolation it is difficult to diagnose clinically, so
about half present already ruptured.
• Open surgery usually involves an inlay graft but some iliac aneurysms
may be suitable for EVAR.
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