VASKULARNA MEDICINA

ANEURIZMATSKA BOLEST

Blizu a daleko od ateroskleroze

Doc. Dr P. Popov

Dedinje Cardiovascular Institute, Belgrade

1Genes load the gun.Lifestyle pulls the triggerDr. Elliot Joslin

2Lifestyle FactorsIn the first half of the last century people were too busy trying to survive to worry about health as much we do today, much less about how we might practice healthier habits in order to prevent disease. Progress that did occur was brought about through the organization of unions in the workplace, legislatures, and public health ordinances. Toward the end of the century, in 1990, the Healthy People 2000 report made a call to work toward a culture that actively promotes responsible behavior and the "adoption of life-styles that are maximally conducive to good health (USDHHS, 1990). Since that time, there is more and more concrete evidence indicating that practicing healthy habits can significantly decrease our chances of developing chronic disease. Therefore, of all the health determinants that we have discussed, lifestyle factors are among the most controllable and influential factors influencing our health.

Author: Diane Wilson, USAFrom Lifestyle Factors and the Prevention Movement www.pitt.edu/~super1/lecture/lec4231/006.htm

Additionally, prevention of injuries with safer products, use of seat belts and child seats, awareness of safety in the home, smoke detectors, etc. have saved many lives and much injury over the course of the 20th century.

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Mukarci 2009dr petar popovnajea oboljenja aorte

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1900 vascular procedures per year5Definition Permanent localized dilatation of the affected artery over the normal diameter~ 50%Arteriomegaly~ 100%Aneurysms

As the age increases, arteries become stiffer, wider (aneurysm) and longer (tortousity)

To je proirenje arterije uzrokovano slabljenjem zida i obino zahvata vee arterije u telu a najee aortu.

Aorta je glavni autoput arterijskog sistema i raznosi krv u sve delove tela. Najee lokacija nastanka aneurizme je infrarenalni deo abdominalne aorte.

Aneurizma postepeno raste u promeru, obino je kliniki nema a u momentu rupture dolazi do unutranjeg krvarenja koje se zavrava smru. Cilj leenja je prevencija mogue rupture i leenje.

ANEURIZME

AAA, je lokalizovana dilatacija abdominalne aorte, koja prevazilazi normalni djiametar infrarenalne aorte za vie od 50% (prosean dijametar je 2 cm). Najeei uzroci su degenerativni procesi u aortnom zidu ali tana etiologija ostaje nepoznata.

ANEURIZMA ABDOMINALNE AORTE AAAdr petar popov

Aetiology Most aneurysms are caused by degenerative disease affecting the vessel (atherosclerosis) Structural weakness & Haemodynamic forcesDamage to, and loss of intimaReduction in the elastin and collagen content of the media Collagen; tensile strength, adventitiaElastin; recoil capacity, mediaRisk factorssmoking, hypertension, hypercholesterolaemia

AetiologyLaplaces low(Tension varies directly with radius when pressure is constant)

For every increase in the radius there is a large increase in tension, leading to further enlargement of the aneurysm

ANEURIZMATSKA ARTERIJSKA BOLEST

Incidence has tripled over last three decades

Age > 60, smoker, HTN, other atherosclerotic disease, Family history 20%,

Surgery for Ruptured AAA: 50% mortality

Elective repairs: 5 % morbidity and mortality

13What is PAD?PAD is a common disease, with prevalence in Europe and North America estimated at over 30 million people.1 PAD is a critical public health issue which remains largely under-diagnosed and under-treated.2PAD can be silent or generate symptoms ranging from exertional pain to critical limb ischemia. PAD significantly increases the risk for MI and stroke.A family history of cardiovascular disease also increases a patients risk of PAD.

References:Datamonitor. Cardiovascular Epidemiology estimates for 2002. Datamonitor Reference Code: BFHC0555. December 2002; 47.Belch JJ et al. Critical issues in peripheral arterial disease detection and management. Arch Intern Med 2003; 163: 884892.

Aneurizma abdominalne aorte najee se otkriva u starosnoj dobi od 50-70 godina. Otkriva se u 5-7% ljudi starijih od 60. Slabljenje zida aorte degenerativnim procesima najea je pojava kod starijih a trauma ili infekcija kod mlaih ljudi u procesu nastajanja AAA.

ANEURIZME ABDOMINALNE AORTE

Rare causes of aneurysmsCongenitalMarfans syndrome, Berry aneurysmsPost-stenoticCoarctation of the aorta, Cervical rib, Popliteal artery entrapment syndromeTraumaticGunshot, stab wounds, arterial punctures InflammatoryTakayasos disease, Behcets disease Rare causes of aneurysmsMycoticBacterial endocarditis, syphilisPregnancy associatedSplenic, cerebral, aortic, renal, iliac & coronary

Incidence- atherosclerotic >90% affecting abdominal aorta Infra-renal segment in ~95%Male : Female ratioMore common in western countries5% over 50s, 15% over 80sAssociated with iliac aneurysms in 30%

Associated with popliteal aneurysms in 10%

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ANEURIZMA ABDOMINALNE AORTE

Najee je locirana ispod odvajanja bubrenih arterija (90%), druge mogue lokacije su ili iznad ili juxtarenalno (suprarenalno i pararenalno). Aneurizma se esto iri i na iliane arterije jednu ili obe.

Anatomy of the abdominal aortaBegins at T12, Ends at L4Anterior relationsSplenic vein, pancreas, duodenumRightCisterna chyli, IVC, azygos veinLeftSympathetic trunk Surface anatomyJust above transpyloric plane in the mid line to a point left to the midline on the supracristal plane

Paired visceral branchesSuprarenal, renal, gonadalUnpaired visceral branchesCoeliac, SMA, IMAPaired abdominal wall branchesSubcostal, inferior phrenic,lumber branches of the abdominal aorta

Clinical features of AAAAsymptomatic in 75%Incidentally discovered during clinical exam.or radiographic investigation PainCentral abdominal radiating to the back Chronic due to stretching the vessel wall or compression/erosion of surrounding structuresAcute pain due to ruptureClinical features of AAARuptureRisk of rupture correlate with aneurysm sizeRetroperitoneal, back pain, stableIntraperitoneal, abdo/back/falnk pain, shock5-year rupture rate 0% in AAA 5cmRisk of rupture can be predicted by High diastolic BP, COADComplications of AAAFistulation, rareGut, IVC, left renal veinThrombosis, rareAcute lower limb ischaemiaDistal embolismAcute ischaemia to small distal areas (trash foot)Distal obliterationClaudication, rest pain, gangrene

INCIDENCA MOGUE RUPTURE AAA

Classification FalseDue to traumatic breach in the wallThe sac made up from the compressed surrounding tissueTrueDilatation involving all layers of the wall

FusiformSpindle-shaped involving whole circumference SaccularSmall segment of wall ballooning due to localized weakness

ANEURIZME-TIPOVISAKULARNEFUZIFORMNERUPTURIRANE

dr petar popovTerminologijaDisekantna aortna aneurizmaAneuronizma

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Aneurizma aortae30DetectionRupture: severe back, abdominal painUsually an incidental findingEasily missed on abdominal examAbdominal ultrasoundScreening programs

31ANEURIZME ABDOMINALNE AORTE

Degeneracija zida krvnog suda (atherosclerosis) Puenje

Hipertenzija

Hronina bolest plua

Pozitivna porodina anamneza

Starosna dob

Pol

Diabetes

Rasna pripadnost- crnci

Trauma

Infekcija

Bol u stomaku ili leima-jak, iznenadan i esto stalan. Bol moe da iridira u lea i prepone, gluteuse ili noge Oseaj pulsiranja u trbuhu Pojaana tenzija abdominalne mu. Anksioznost Muka i povraanje Vlana koa Ubrzan rad srca Kolaps Otok stomaka

SIMPTOMATOLOGIJA AAA PRISTUP BOLESNIKU

dr petar popovFizikalni pregled i anamneza od strane vaskularnog hirurga.

Sledee dijagnostike procedure su mogue:

Abdominal ultrazvuk

CT Scan Abdomena (MSCT)

Angiografija aorte NMR

AAA DIJAGNOSTIKA

Angioloki pregled

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Doppler index ASPISegmentni pritisciTestovi optereenja37AAA Screening and noninvasive diagnosticsDuplex ultrasonography is fast, safe, comfortable for patients, economical and very precise

CT scan - AAA

38Duplex-scan AAAin the patient with critical ishaemia and gangenous feet, with pneumonia

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AAA - HRONINA RUPTURAdr petar popovnajea oboljenja aorte

TORAKOABDOMINALNA ANEURIZMAdr petar popovnajea oboljenja aorte

TORAKOABDOMINALNA ANEURIZMAdr petar popovnajea oboljenja aorte

AAA- POPRENI PRESEKdr petar popovCT angiography showing anterior and lateral views of an abdominal aortic aneurysm

Aortography for redo surgery or when the upper limit of the aneurysm and occurrence of renal artery stenosis could not be definied by non-invasive methods (iuxtarenal AAA), peripheral vascular disease44OPCIJE LEENJA AAA

Male ( 4 cm), asimptomatske AAA treba periodino pratiti, obino na 6 meseci, ultrazvukom a po potrebi i skenerom.Simptomatske aneurizme moraju se tretirati hirukim ili endovaskularnim pristupom.

Bolesnici sa aneurizmom veom od 5.5 cm u diameteru i aneurizme koje ubrzano rastu zahtevaju hiruko leenje.Time preveniramo moguu rupturu i izvestan smrtni ishod.Rutinski skrining ljudi starijih od 65 godina sve je potrebniji obzirom na viestruki porast broja onih koji imaju asimptomatsku

OPCIJE LEENJA AAA

When to OperatePrevent rupture!

Rupture risk increases with aneurysm size, HTN, COPD, female sex, current smoking5 year rupture rates: 7cm = 75%, 6cm = 35%, 5 cm = 25%

Surgical repair at 5cm or rapid growth (>0.5 cm in 6 months)48Elective surgical repair6-unit X-matched bloodMid line or transverse incisionAneurysm neck defined and controlledControl of normal vessels distal to AAASystemic heparinization, 5000IUAAA sac opened and thrombus removedBack bleeding from lumber arteries controlled by suturesInlay tube or trouser synthetic graftClosure of aneurysm sac over graft

OTVORENA REKONSTRUKCIJA AORTE

dr petar popovEmergency surgical repairUnstable patient, no investigationStable patient, USS/spiral CT10-unit of x-matched bloodUrinary catheter & 2 large-bore i.v. linesResustation to systolic BP ~100mmHgCrash anaesthetic inductionNo heparinizationRapid entrance to abdomen & neck controlIf difficult, supra-renal clamp for short period

Repair of AAA A ruptured AAA has a mortality rate approaching 90%.

When an AAA is repair electively, the mortality drops to less than 5%.

AAA affects 4% to 7% of adult over the age of 65 years, with a far greater prevalence in male than in female, this problem will encounter more frequently as population ages.

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Autotransfusion with sell saver53Complications of aortic surgeryHaemorrhage, DICCVAColonic ischaemia spinal cord ischaemiaAorto-enteric fistulaGraft thrombosisMyocardial ischaemiaRenal failure, ARDS, MODSFalse anastomotic aneurysmDistal embolism (trash foot)

Streptococcus 66%Enterobacteriaceae 23%Haemophilus parainfluenzae 8%Candida albicans 3%Mycotic aneurysms and distribution of microbs found by intraoperative culture 55

Mycotic aneurysmsin the patient with retroperitoneal abscessus56

Mikroembolizacija stopala iz velikog prizidnogAneurizmatskog tromba57

Mycotic aneurysms intraoperative signs of inflammation of aneurysmatic wall58Inflammatory AAAMarked fibrosis of the aneurysm wall extending to the surrounding structuresIt involve the anterior and lateral aspects onlyIt associated with inflammatory cell infiltrate of T- , B-lymphocytes & plasma cellsThe fibrosis may compress the ureters leading to renal failureRupture is less common and usually posteriorPt. presents with abdo. pain, weight loss, raised ESRDifficult surgery, therefore conservative/endovascular

Inflammatory (mycotic)aneurysm 60Open vs EndovascularOpen repairPros:long lasting gold standardeffectiveCons: major surgery5-10% M&Mlong recovery Endovascular repairPros:less invasiveshort recoveryCons: long term results not knownrequires long term F/Uexpensive61Resection of AAA and aortobiiliacal by pass

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Avoid laparotomy Reduce cardiac complications Reduce septic complications Less invasive Rapid recovery Combined treatment?Endovascular Treatment

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Elective Endograft1997-Inclusion Criteria Proximal neck length > 25 mm Proximal neck diameter < 26 mm Neck angulation < 40 Iliac arteries anatomy2008-Inclusion CriteriaProximal neck length > 15 mm Proximal neck diameter < 28 mm Neck angulation < 60 Iliac arteries anatomy Patient Age > 75 ys old Unsuitable for Surgery: Hostile Abdomen, High risk for comorbilities

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ENOVASKULARNA REKONSTRUKCIJA AAA

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Endovascular OutcomesGoal of endografting is to exclude the AAA from the circulation thereby preventing growth and ruptureEndoleak: early and lateShrinkage of AAA sacGraft migration, loss of structural integrity73Endovaskularna implantacija stent-grafta-a

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ENDOVASKULARNO REAVANJE AAAdr petar popov

Torakoabominalnea aneurizme-klasifikacija

Resekcija torakoabdominalne aneurizme sa interpozicijom grafta

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Stent graft torakalne aorte78Stent graft torakalne aorte - kontrola

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TEVAR

popliteal aneurysmsSecond most common site of atherosclerotic aneurysmsOccasionally, present with pulsatile swellingCommonly, aneurysm thrombosis or distal emboli leading to peripheral ischaemiaUSS/CT/Arteriography to confirm diagnosis Surgical repair, resection/ligation and vein bypass40% of pts with PA aneurysms have an AAA

FEMORAL ANEURYSMSCan occur in isolation but usually part of generalized arteriomegalyOften symptomless and rarely ruptureDistal emboli & thrombosis may occurSurgical repair by using vein or synthetic graft

Splenic aneurysmsMale : female 1 : 4It present in child bearing periodUsually symptomless unless rupturedRupture rate 25% in the third trimesterSurgical treatment is indicated if the aneurysm diameter >3cm or patient is pregnant

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ANEURIZMA TRUNKUSA CELIAKUSAdr petar popovnajea oboljenja aorte

LIJENALNA ARTERIJSKA ANEURIZMALijenalna aneurizmadr petar popov

Noninvasive postoperative follow up

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