Aneurysm 9

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ANEURYSM

Presented By:

Angelica Aguilera

Jeuel John Aldaba

Jean Claude David

Aprel Fajardo

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Aorta

The main artery of the body

An elastic artery composed chiefly of plates of

systolic blood pressure and provide elastic

recoil, although elasticity diminishes with age

The walls of aorta contain pressor receptorswhich, when stimulated by a rise in blood

pressure, lead reflexly to a fall in BP and HR

3 Divisions of Aorta

1. Ascending aorta2. Aortic Arch

3. Descending aorta

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Definition From the Greek word: aneurusma "dilation,

from aneurunein "to dilate"

a localized, blood-filled dilation (balloon-like bulge) of a blood vessel caused by disease orweakening of the vessel wall.

A permanent localized dilatation, stretching orballooning of an artery to around 50% increasein the size.

A point of weakness, dilation, or outpouching ofarteries to at least 1.5 times their normal sizewith a tendencies for enlargement and possiblerupture.

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Description

Aneurysms commonly affect the aorta and

peripheral arteries because of the high pressure in

these vessels.

Once initiated, the aneurysms grows larger as the

tension in the vessel wall increases.

As an aneurysm increases in diameter, the tension

in the wall of the vessel increases in direct

proportion to its increased size.

If untreated, the aneurysm may rupture because of

the increased tension which can result in severe

hemorrhage, other complications or even death.

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Description (contd)

Even an unruptured aneurysm can cause damage

by exerting pressure on adjacent structures.

Arterial aneurysm are most common in men over

age 50, most of whom are asymptomatic at the

time of diagnosis.

Hypertension is a major contributing factor in the

development of some types of aortic aneurysms.

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Classification

I. Location

Aneurysms are designated as either venous orarterial

They are also described according to the specificvessel in which they develop (e.g., aorta, splenicartery, femoral vein)

More precisely, according to the exact area of thevessel that they affect e.g., descending thoracicaorta, lower abdominal aorta.

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Classification (contd)

II. Etiology

In broadest terms, any vascular disease ( under

certain conditions) can give rise to an aneurysm.

The most common cause of aneurysm is

atherosclerosis, followed by syphilis and cystic

medionecrosis.

Other causes of aneurysms include congenital

defects of the arterial wall, trauma, and infections

that result in weakness of vessel walls.

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III. Gross Appearance

This classification lists aneurysms according to

their shape, anatomic features, and the size of the

aneurysmal dilatation.

Accordingly, the ff. types of aneurysms arerecognized:

1. True aneurysms

It caused by slow weakening of the arterial walldue to the long term eroding effects of

atherosclerosis and hypertension

Affect all 3 layers of the vessel wall and most are

fusiform

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a. Fusiform

- A uniform, spindle-shaped dilatation of a segment of anartery

b. Saccular

- An outpouching from an artery caused by localized thinningand stretching of the medial coat.

c. Dissecting

- A cavity formed by blood that has been forced between thelayers of the arterial wall.

2. False aneurysms

- One resulting from a complete rupture or wounding of allcoats of the artery, the blood then being retained by thesurrounding tissues.

- The vessel wall has ruptured and the blood clot is beingretained in an outpouching of tissue from the vessel wall.

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Risk Factors Atherosclerosis, a buildup of fatty deposits in the arteries.

Smoking. People who smoke are eight times more likely to

develop an aneurysm.

Overweight or obesity.

A family history of aortic aneurysm, heart disease, or other

diseases of the arteries.

Certain diseases that can weaken the wall of the aorta, such

as:

Marfan syndrome (an inherited disease in which tissues

don't develop normally)

Untreated syphilis (a very rare cause today) Tuberculosis (also a very rare cause today)

Trauma such as a blow to the chest in a car accident.

Severe and persistent high blood pressure between the ages

of35 and 60. This increases the risk for a cerebral aneurysm.

Use of stimulant drugs such as cocaine.

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Manifestations and Complications

Type or Location Manifestations Complications

Thoracic Aortic May be asymptomatic

Back, neck, substernal

pain

Dyspnea, stridor, or

brassy cough if pressingon trachea

Hoarseness and

dysphagia if pressing on

esophagus or laryngeal

nerve

Edema of the face and

neck

Distended neck veins

Rupture andhemorrhage

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Manifestations and Complications (contd)


Abdominal Aortic Pulsating abdominal

mass

Aortic calcification

noted on X-ray

Mild to severe

midabdominal or

lumbar back pain

Cool, cyanotic

extremities if iliacarteries are involved

Claudication

(ischemic pain with

exercise, relieved by

rest)

Peripheral emboli to

lower extremities

Rupture and

hemorrhage

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Manifestations and Complications (contd)


Aortic dissection Abrupt, severe,

ripping or tearing pain

in area of aneurysm

Mild or markedhypertension early

Weak or absent

pulses and blood

pressure in upper

extremities

Syncope

Hemorrhage

Renal failure

MI, heart failure,

cardiac tamponade

Sepsis

Weakness or paralysis

of lower extremities

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Signs & Symptoms

I. Aortic Aneurysms:

1) Thoracic Aortic Aneurysm: Symptoms of thoracic

aortic aneurysm are as follows: Pain in jaw, neck, upper back or chest.

Cough, hoarseness or experiencing trouble in

breathing.

Pain in left shoulder or between shoulder blades.

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Signs & Symptoms

2) Abdominal Aortic Aneurysms (AAAs): Symptoms of AAAs

include:

Deep penetrating pain the back or side of abdomen.

Steady gnawing pain in the abdomen lasting for hoursor days

Coldness, numbness or tingling of feet

In case of rupture of AAA symptoms include sudden

severe pain in lower abdomen and back; nausea and

vomiting; sweaty skin, light headedness and rapid heartrate when standing up.

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Signs & Symptoms

II. Cerebral Aneurysm: Signs and symptoms of cerebral

aneurysm are:

Drooping of eyelids

Double vision or blurred vision

Pain above or behind the eye

A dilated pupil

Numbness or weakness on one side of the face

A cerebral aneurysm rupture leads to sudden severe

headache, nausea and vomiting, stiff neck and loss of

consciousness.

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Signs & Symptoms

III. Peripheral Aneurysm: Signs and symptoms of

peripheral aneurysm are as follows:

Pulsating lump felt in the neck, arm or leg

Pain in the leg or arm or cramping with exercise

Painful sores on toes or fingers

Gangrene (i.e., death of tissue) due to severe

blocking of blood in limbs

An aneurysm in the popliteal artery can compress the

nerves and cause pain, weakness and numbness in

knee and leg (1) & (4).

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Diagnostic Procedures

Computed tomography scan (Also called a CT or CAT scan) - adiagnostic imaging procedure that uses a combination of x-raysand computer technology to produce cross-sectional images (oftencalled slices), both horizontally and vertically, of the body. A CTscan shows detailed images of any part of the body, including thebones, muscles, fat, and organs. CT scans are more detailed thangeneral x-rays.

Magnetic Resonance Imaging (MRI) - a diagnostic procedure thatuses a combination of large magnets, radiofrequencies, and acomputer to produce detailed images of organs and structureswithin the body.

Ultrasound - uses high-frequency sound waves and a computer tocreate images of blood vessels, tissues, and organs. Ultrasounds

are used to view internal organs as they function, and to assessblood flow through various vessels.

Arteriogram (angiogram) - an x-ray image of the blood vesselsused to evaluate various conditions, such as aneurysm, stenosis(narrowing of the blood vessel), or blockages. A dye (contrast) willbe injected through a thin flexible tube placed in an artery. Thisdye makes the blood vessels visible on x-ray.

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Diagnostic Procedures

Chest X-ray to visualize thoracic aorticaneurysms

Abdominal ultrasonography diagnose

abdominal aortic aneurysms

Transesophageal echocardiography identifythe specific location and extent of a thoracicaneurysm and to visualize a dissecting

anuerysm

Angiography uses contrast injected to theaorta or involved vessel to visualize the precisesize and location of the aneurysm.

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Medical Management

Thoracic aortic aneurysms

- Long-term beta-blocker therapy

- Additional Antihypertensive drugs

Clients with aortic dissection

- Intravenous beta blockers such as: propanolol (Inderal), metropolol

(Lopressor), labetalol (Normodyne) or esmolol (Brevibloc) to reduceheart rate to about 60 bpm.

- Sodium nitroprusside (Nipride) reduce systolic pressure to120mmHg or less.

- Calcium channel blockers

- Direct vasodilators such as: diazoxide (Hyperstat) and hydralazine(Apresoline) are avoided as they may actually worsen the dissection.

Following surgical correction of an aneurysm

- Anticoagulant therapy

- Heparin therapy used initially with conversion to oralanticoagulation, prior to discharge.

- Lifelong low-dose aspirin therapy reduce the risk of clot formation

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Treatment

Throughout history, the treatment of arterial aneurysms has been surgicalintervention, or watchful waiting in combination with control of bloodpressure. In recent years, endovascular or minimally invasive techniques havebeen developed for many types of aneurysms.

Cranial aneurysms

At the current time, there are two treatment options for brain aneurysms:surgical clipping or endovascular coiling.

Surgical clipping

introduced by Walter Dandy of the Johns Hopkins Hospital in 1937. It consistsof performing a craniotomy, exposing the aneurysm, and closing the base ofthe aneurysm with a clip. The surgical technique has been modified andimproved over the years. Surgical clipping remains the best method topermanently eliminate aneurysms.

Endovascular coilingintroduced by Guido Guglielmi at UCLA in 1991. It consists of passing acatheter into the femoral artery in the groin, through the aorta, into the brainarteries, and finally into the aneurysm itself. Once the catheter is in theaneurysm, platinum coils are pushed into the aneurysm and released. Thesecoils initiate a clotting or thrombotic reaction within the aneurysm that, ifsuccessful, will eliminate the aneurysm. In the case of broad-basedaneurysms, a stent is passed first into the parent artery to serve as a scaffoldfor the coils ("stent-assisted coiling").

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Treatment

Aortic and peripheral aneurysms

Aneurysms are treated by either endovascular techniques(angioplasty with stent) or open surgery techniques. Open techniquesinclude exclusion and excision. Exclusion of an aneurysm meanstightly tying suture thread around the artery both proximally anddistally to the aneurysm, to cut off blood flow through the aneurysm.If the aneurysm is infected or mycotic, it may then be excised (cut outand removed from the body). If uninfected, the aneurysm is often left

in place. After exclusion or excision, a bypass graft can be placed, toensure blood supply to the affected area. For some aneurysm repairsin the abdomen, where there is adequate collateral blood supply,bypass grafts are not needed.

For aneurysms in the aorta, arms, legs, or head, the weakened sectionof the vessel may be replaced by a bypass graft that is sutured at thevascular stumps. Instead of sewing, the graft tube ends, made rigid

and expandable by nitinol wireframe, can be inserted into thevascular stumps and permanently fixed there by externalligature. New devices were recently developed to substitute theexternal ligature by expandable ring allowing use in acute ascendingaorta dissection, providing airtight, easy and quick anastomosisextended to the arch concavity Less invasive endovascular techniquesallow covered metallic stent grafts to be inserted through the arteriesof the leg and deployed across the aneurysm.

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Nursing Diagnosis: Fear/AnxietyRelated to:

Unfamiliar environment and separation from significant others;

Lack of understanding of diagnostic tests, surgical procedure, and postoperativecare;

Anticipated loss of control associated with effects of anesthesia;

Risk of disease if blood transfusions are necessary;

Anticipated postoperative discomfort and potential change in sexual functioning;

Possibility of death.

Desired Outcome

- The client will experience a reduction in fear and anxiety

Nursing Actions and Selected Purposes/Rationales:

1. Implement additional measures to reduce fear and anxiety:

2. Orient client to critical care unit if appropriate

3. Describe and explain the rationale for equipment and tubes that may be present

postoperatively (e.g., cardiac monitor, ventilator, intravenous and intra-arteriallines, nasogastric tube, urinary catheter)

4. Explain that B/P may be taken in both arms and thighs in order to better evaluatecirculatory status

5. Reinforce physician's explanations and clarify misconceptions client has abouteffects of the surgery on sexual functioning (impotence can result fromdiminished blood flow in the mesenteric or internal iliac arteries during or after

surgery and/or from nerve damage during surgery).

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Nursing Diagnosis: Risk for Imbalanced

Fluid and Electrolytes

Third-spacing of fluid related to:

1. Increased capillary permeability in surgical area associated with the inflammation that occursfollowing extensive dissection of tissue during major abdominal surgery.

2. Increased vascular hydrostatic pressure associated with excess fluid volume if present.

3. Hypoalbuminemia associated with the escape of proteins from the vascular space into theperitoneum (a result of increased capillary permeability in the surgical area);

Excess fluid volume related to:Vigorous fluid replacement

Fluid retention associated with

1. Increased secretion of antidiuretic hormone (output of ADH is stimulated by trauma, pain,and anesthetic agents)

2. Renal insufficiency (can occur if there is inadequate blood flow to the kidneys during or aftersurgery)

3. Reabsorption of third-space fluid (occurs about the 3rd postoperative day);

4. Deficient fluid volume related to restricted oral fluid intake before, during, and after surgery;

blood loss; and loss of fluid associated with nasogastric tube drainage;5. Hypokalemia, hypochloremia, and metabolic alkalosis related to loss of electrolytes and

hydrochloric acid associated with nasogastric tube drainage.

Desired Outcome

The client will experience resolution of third-spacing as evidenced by:

1. Absence of ascites

2. B/P and pulse within normal range for client and stable with position change.

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Nursing Diagnosis: ImbalancedFluid

and Electrolytes

Nursing Actions and Selected Purposes/Rationales:

Assess for and report signs and symptoms of third-spacing:

1. Ascites (e.g., increase in abdominal girth, dull percussion note overabdomen with finding of shifting dullness)

2. Evidence of vascular depletion (e.g., postural hypotension; weak,rapid pulse).

3. Monitor serum albumin levels. Report below-normal levels (lowserum albumin levels result in fluid shifting out of vascular spacebecause albumin normally maintains plasma colloid osmoticpressure).

Implement measures to prevent further third-spacing and/orpromote mobilization of fluid back into the vascular space:

Administer albumin infusions if ordered to increase colloid osmoticpressure.

Consult physician if signs and symptoms of third-spacing worsen orfail to resolve within expected length of time (reabsorption usuallybegins on 3rd postoperative day).

Desired Outcome

The client will not experience excess fluid volume

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Nursing Diagnosis: Deficient Knowledge, Ineffective Therapeutic

Regimen Management, or Ineffective Health Maintenance

*The nurse should select the diagnostic label that is most appropriate for the client's

discharge teaching needs.

Desired OutcomeThe client will identify ways to prevent or slow the progression of atherosclerosis.

Nursing Actions and Selected Purposes/Rationales

Inform the client that certain modifiable factors such as elevated serum lipids, a sedentary

lifestyle, smoking, and hypertension have been shown to increase the risk of atherosclerosis. Assist client to identify changes in lifestyle that could reduce the risk for atherosclerosis (e.g.,

dietary modifications, smoking cessation, physical exercise on a regular basis).

Provide instructions on ways the client can reduce intake of saturated fat and cholesterol:

1. Reduce intake of meat fat (e.g., trim visible fat off meat; replace fatty meats such as fatty cutsof steak, hamburger, and processed meats with leaner products)

2. Reduce intake of milk fat (avoid dairy products containing more than 1% fat)

3. Reduce intake of trans fats (e.g., avoid stick margarine and shortening and foods such ascommercial baked goods that are prepared with these products)

4. Use vegetable oil rather than coconut or palm oil in cooking and food preparation

5. Use cooking methods such as steaming, baking, broiling, poaching, microwaving, and grillingrather than frying

6. Restrict intake of eggs (recommendations about the number of whole eggs allowed per weekvary depending on the client's lipid levels).

Instruct client to take lipid-lowering agents (e.g., HMG-CoA reductase inhibitors ["statins"],ezetimibe, gemfibrozil, niacin) as prescribed.

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Prognosis

Cerebral Aneurysm

An unruptured aneurysm may not cause any symptomsover an entire lifetime. Surgical procedures areavailable for dealing with the aneurysm, but the risk

from surgery may be at least as great as that from theaneurysm itself. The prognosis for people whoexperience a ruptured aneurysm is not good. About 15to 25 percent of those who experience a rupture do notsurvive the event. An additional 25 to 50 percentsurvive the immediate episode, but die of complicationscaused by bleeding in the brain. Of those who do

survive, about 15 to 50 percent suffer permanent braindamage or physical disability.

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Prognosis

Abdominal Aortic Aneurysm

The outlook for an untreated abdominal aorticaneurysm depends on its size. An abdominal aorticaneurysm larger than 7 centimeters in diameter has a

75% chance of rupturing within 5 years. At 6centimeters, the risk of rupture is 35% over 5 years.Between 5.0 and 5.9 centimeters, the rupture risk isabout 25% over 5 years. The risk of rupture is muchlower for aneurysms smaller than 5 centimeters (2inches).

With successful surgical repair, the prognosis is goodand depends more on the severity of atherosclerosisaffecting other organs, especially the heart, brain andkidneys.

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Prognosis

Thoracic aortic aneurysm

The long-term prognosis for patients with

thoracic aortic aneurysm is determined byother medical problems such as heart disease

and diabetes, which may have caused or

contributed to the condition.

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Incidence

Abdominal aortic aneurysms occur most

commonly in individuals between 40 and 70

years and are more common among men and

smokers.

Aortic Dissection occur more often in men

between 50 and 70 years of age, most of

whom are hypertensive.

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Thoracic aneurysm United States

The incidence of aortic aneurysm is 5.9 cases per 100,000 person-years.

Mortality/Morbidity

The cumulative risk of rupturing a thoracic aortic aneurysm (TAA) isrelated to aneurysm diameter. In a recent series of 133 patients withTAA, risk of rupture at 5 years was 0% for diameter less than 4 cm, 16%for diameter 4-5.9 cm, and 31% for aneurysms greater than 6 cm indiameter.

Race

Thoracic aortic aneurysm is most common among whites.

Sex

Men are affected 2-4 times more frequently than women.

Age

The mean patient age at diagnosis is 60-65 years.

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