Vascular

Aortic aneurysms
andrew l Tambyraja roderick T a chalmers

Epidemiology
There has been an increase in the incidence of aortic aneurysms over the past 20 years that is unrelated to improved methods of detection and diagnosis. Rupture of an abdominal aortic aneur ysm accounts for 10,000 deaths a year in the UK and is the thir teenth commonest cause of death in the developed world. Aortic aneurysm usually affects elderly men, with a prevalence of about 5% in Caucasian men aged >65 years. It is rare for aortic aneur ysm to be diagnosed in those aged <55 years (except in those with hereditary connective tissue disorders). Men are more likely to have abdominal aortic aneurysms than women (ratio is 4:1).

Abstract
This contribution discusses the basic features of aortic aneurysms.

Pathogenesis
The healthy aortic wall comprises smooth muscle, elastin and collagen arranged in concentric layers. Elastin is responsible for the main loadbearing properties of the vessel wall. An aortic aneurysm is characterized by a reduction in medial and adventi tial elastin and collagen, with thinning of the media and infiltra tion of lymphocytes and macrophages. This obliteration of the normal architecture of the vessel results in progressive dilation. Aneurysm formation involves proteolytic degradation of the con nective tissue of the aortic wall, inflammation and biomechanical wall stress. As an aneurysm dilates, the tangential stress upon the aortic wall is proportional to the radius and the internal pressure (sys temic blood pressure) within the vessel (Laplaces law). As an aneurysm enlarges, the stress placed upon the aneurysm wall increases (accounting for the increased risk of rupture in large aneurysms). Hypertension is a risk factor for growth and rupture of aneurysms. Normal laminar flow within the aortic lumen becomes turbu lent due to the distortion of the normal cylindrical morphology of the aorta. This alteration of flow dynamics predisposes to the for mation of thrombus, which becomes laminated against the aortic wall. This mural thrombus may become dislodged and embolize to the distal arterial tree.

Keywords aneurysm; embolism; heparin; abdominal; thoracoabdominal;

laplaces law

An aortic aneurysm is a permanent localized dilation of the aorta. If the maximum diameter of the normal aorta is 2.1 cm, aneurys mal dilation is said to occur when the diameter exceeds 3.0 cm. The abdominal aorta is the most commonly affected artery and accounts for 90% of aneurysms; the aortic arch, thoracic aorta and thoracoabdominal aorta are involved in about 10% of aneurysms. This contribution focuses on abdominal aortic aneurysm and should be read with Endovascular stent grafting of aortic aneurysms, page 342.

Aetiology
The cause of aneurysms is unclear, but 90% are thought to be due to degenerative process. Abdominal aortic aneurysms show familial clustering in 1525% of cases. It is inferred that suscep tibility to the development of abdominal aortic aneurysms is a multifactorial process with multiple genetic and environmental risk factors. Other causes of aortic aneurysm are: infection (mycotic aneurysms) cystic medial necrosis arteritis trauma disorders of connective tissue pseudoaneurysm caused by disruption at the anastomosis of an existing aortic graft.

Clinical features
About 75% of aortic aneurysms are asymptomatic and are dis covered incidentally. A small proportion present with symptoms related to pressure on adjacent structures (dysphagia, ureteric obstruction, caval obstruction). A small subset of abdominal aortic aneurysm cases may present with lower back pain, weight loss and raised erythrocyte sedimen tation rate. This triad is characteristic of inflammatory abdominal aortic aneurysms, which represent the most extreme end of the spectrum of chronic inflammatory change seen in degenerative aneurysms, and account for 10% of abdominal aortic aneurysms. Most of the clinical symptoms due to aortic aneurysms are related to aneurysm rupture or embolism of a mural thrombus. Aneurysm rupture is associated with an estimated overall mor tality of 90% and a significant proportion of patients will not reach hospital. Of those that present, most have a contained retroperitoneal haematoma acting as a tamponade and resulting in temporary
342

This article was first published in Surgery 2004; 22(11): 2946. Andrew L Tambyraja MRCS(Ed) is a Clinical Lecturer in Surgery at Edinburgh Royal Infirmary, Edinburgh, UK. Conflicts of interest: none declared. Roderick T A Chalmers FRCS(Ed) FRCS(Gen Surg) is a Consultant Vascular Surgeon at Edinburgh Royal Infirmary, Edinburgh, UK. Conflicts of interest: none declared.

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haemodynamic stability. The characteristic triad of abdominal or back pain, hypovolaemic shock and a pulsatile abdominal mass is present in only a few patients. Other symptoms may include groin pain, syncope, paralysis or flank mass. A ruptured aneurysm should be considered in an elderly patient with unex plained hypotension and abdominal symptoms. The diagnosis may be confused with nephrolithiasis, diverticulitis, pancreatitis or disease affecting the lumbar spine. A small proportion of abdominal aortic aneurysms rupture into an adjacent structure, causing a primary aortic fistula; rup ture into the vena cava produces a large arteriovenous fistula. In this case, symptoms include tachycardia, congestive heart fail ure, leg swelling, abdominal thrill, abdominal bruit, renal failure and peripheral ischaemia. Abdominal aortic aneurysms may rup ture into the fourth portion of the duodenum and presentation may be with a herald upper gastrointestinal bleed followed by a massive haemorrhage. Embolism: patients with embolization of thrombus from an aor tic aneurysm may present with acute ischaemia of the lower limb due to occlusion of the femoral or popliteal artery. Small aortic aneurysms may also undergo acute occlusion due to thrombosis as the aortic lumen becomes progressively narrowed by the accu mulation of mural thrombus; these patients may present with acute ischaemia of the lower limbs.

Surgical management
The principles of elective management of aortic aneurysms are based on an assessment of the risk of aneurysm rupture balanced against the morbidity and mortality associated with surgical repair (Figure 2). Surgical repair of abdominal aortic aneurysms is a durable, costeffective procedure with longterm survival rates similar to the agematched healthy population. Indications: aneurysm rupture is an absolute indication for sur gery because death is almost certain without repair. Surgery in some patients may be futile due to comorbidity or poor preopera tive clinical condition (unconsciousness, cardiac arrest). Symptomatic, intact abdominal aortic aneurysms are a rela tive indication for surgical repair. It is thought that symptoms of pain attributable to an aneurysm are due to acute expansion or imminent rupture and urgent repair is recommended. Risk assessment: measurement of the maximum diameter of the aneurysm determines the risk of rupture. The results of the UK Small Aneurysm Trial showed that abdominal aortic aneur ysms of diameter <55 mm were associated with a mean risk of rupture of 1% per year. The surgical mortality associated with elective open repair of infrarenal abdominal aortic aneurysms is 510%. Elective repair is recommended in asymptomatic abdominal aortic aneurysms of diameter >5.5 cm. The rupture risk associated with abdominal aortic aneurysms >5.5 cm is less certain and this value represents only a relative indication for aneurysm repair. Patients with asymptomatic abdominal aortic aneurysms of diameter <5.5 cm should be kept under regular surveillance using ultrasound to monitor aneurysm growth.

Diagnosis
Aortic aneurysms cannot be accurately detected by clinical examination. Radiographs calcification of the aneurysm wall may be apparent on plain radiograph of the chest or abdomen, but this method lacks sensitivity and is unsatisfactory for routine use. B-mode ultrasound is the firstline investigation for the detec tion of abdominal aortic aneurysms, providing accurate assessment of the aneurysm diameter and some information regarding site. CT is the firstline investigation during preoperative assess ment to delineate abdominal aortic aneurysm morphology and the relationship to the visceral and renal arteries (Figure 1). CT or MRI will detect thoracic aortic aneurysms.

Management of infrarenal abdominal aortic aneurysms using aneurysm diameter size

Management of infrarenal AAA

34.5 cm

>4.55.5 cm

5.5 cm

Annual ultrasound

6-monthly ultrasound

Fit

High risk

Unfit

Open repair

Observe ?

Open repair if patient accepts risk or observe until risk of rupture is greater than risk of surgery
AAA: Abdominal aortic aneurysm

Figure 1 contrast-enhanced cT showing a abdominal aortic aneurysm, b mural thrombus and c lumen.

Figure 2

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Preoperative assessment: patients with asymptomatic abdomi nal aortic aneurysms of diameter >5.5 cm who are candidates for surgical repair need careful risk assessment of their cardio respiratory and renal status. The main causes of perioperative complications relate to cardiac and respiratory dysfunction and chronic renal impairment. Preoperative assessment should include: full blood count serum urea and electrolytes liver function tests pulmonary function tests cardiac assessment with resting ECG and echocardiography. Further cardiovascular assessment (exercise ECG, dobuta minestress echocardiography, coronary angiography) may be indicated in patients with a history (or symptoms) of ischaemic heart disease. In patients with significant and irreversible comorbidity, it is appropriate to continue surveillance using ultrasound until aneur ysm diameter reaches a size where the risk of rupture outweighs the increased risk of surgical mortality. It may not be possible to justify elective surgical repair (regardless of size) in a minority of patients with overwhelming comorbidity. Repair of intact abdominal aortic aneurysms Under general anaesthesia and with perioperative broadspectrum antibiotic (e.g. cephalosporin (i.v.)) and thromboembolic pro phylaxis (heparin (i.v.)), a transverse supraumbilical or midline incision is made to permit a transperitoneal approach to the aorta. Epidural analgesia may be used to improve respiratory function. The transverse colon is reflected upwards and the small bowel reflected to the right. Division of the posterior peritoneum exposes the aneurysm. The left renal vein and the neck of an infrarenal aneurysm will be identified. The common iliac vessels are also identified and exposed. A bolus of heparin is given intravenously (to reduce the risk of thrombosis in situ and perioperative cardiac injury), after which aortic and iliac clamps are applied. If the aneurysm extends into the common iliac arteries, the vessels may be mobilized to the common iliac bifurcation and control obtained of the internal and external iliac arteries. The aneurysm sac is opened longitudinally and mural thrombus removed. Back bleeding from the lumbar, median sacral and inferior mesen teric arteries may ensue, and is controlled by oversewing these vessels. The aneurysm may be repaired using a tube or bifur cated prosthetic aortic graft made from sealed or coated knitted Dacron. The graft is secured proximally and distally using an inlay technique and endtoend anastomosis with a mono filament suture (Figure 3). The lower limbs are reperfused sequentially upon comple tion of the anastomoses. The anaesthetist must be warned before releasing the clamps of each limb because of the hypotension caused by limb reperfusion and the sudden release of anoxic metabolites from the lower limbs into the systemic circulation. The aneurysm sac is closed over the aortic graft to reduce the risk of late postoperative aortoenteric fistulation. The lower limbs and left colon should be inspected to ensure adequate per fusion. Postoperatively, patients are extubated and managed in an HDU.
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Inlay technique for repair of abdominal aortic aneurysm

Duodenum Left renal artery Left renal vein

Inferior vena cava Graft in place Aneurysm sac opened

Left common iliac artery Left common iliac vein

Figure 3

Early procedurespecific complications are mainly cardiac and respiratory, although renal dysfunction, colonic ischaemia and microembolism to the lower limbs may also occur. The patient should be encouraged to mobilize early and oral intake can be reestablished within 24 hours. The patient is in hospital for 714 days. Repair of ruptured abdominal aortic aneurysms The surgical mortality associated with ruptured abdominal aor tic aneurysms is >40%. Suitable patients should be transferred to theatre immediately if a ruptured abdominal aortic aneurysm is diagnosed. In general, patients should receive cautious fluid resuscitation. Hypotension, in the context of preserved cerebral function, does not warrant overzealous intravenous volume replacement. Sudden overloading of the intravascular compart ment (together with the associated increase in systemic blood pressure) may cause expansion and rupture of a contained retroperitoneal haematoma, resulting in further haemorrhage and potential exsanguination. In theatre, the patient is prepared and draped before the induction of anaesthesia; central venous access can be obtained after induction. Rapidsequence induction is done together with rapid entry into the abdomen (limiting the potential hypotensive effects of anaesthesia caused by the loss of tamponade from relax ation of the musculature of the anterior abdominal wall). The neck of the aneurysm must be identified for clamping despite the significant distortion of anatomy that may be caused by a large

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retroperitoneal haematoma; iatrogenic injury in this period may prove fatal. If access to the infrarenal aortic neck is not possible, the aorta may be clamped at the diaphragmatic hiatus or control achieved by passing a balloon occlusion catheter up the lumen of the aorta. These techniques are associated with significant morbidity owing to the resultant visceral and renal ischaemia. When haemorrhage has stopped, aortic repair may be done as for intact abdominal aortic aneurysms. Aggressive correction of haemostatic variables is recommended to limit the problems of coagulopathy caused by massive haemorrhage and transfusion.

Thoracoabdominal aortic aneurysms Aortic aneurysmal disease extends above the renal arteries to involve a variable length of the thoracic aorta in 510% of patients. Rupture of these aneurysms conveys an even higher mortality than that seen in abdominal aortic aneurysms. Elective surgery involves replacement with a Dacron aor tic prosthesis and reimplantation of the visceral and intercostal arteries. The results of surgery in specialist centres are good, but it is associated with complications (e.g. paraplegia, organ dysfunction) and significant mortality.

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