Definition
Permanent localized dilatation of the affected artery over the normal diameter
~ 50% ~ 100% Arteriomegaly Aneurysms
As the age increases, arteries become stiffer, wider (aneurysm) and longer (tortousity)
Aetiology
Most aneurysms are caused by degenerative disease affecting the vessel (atherosclerosis) Structural weakness & Haemodynamic forces
Damage to, and loss of intima Reduction in the elastin and collagen content of the media Collagen; tensile strength, adventitia Elastin; recoil capacity, media
Risk factors
smoking, hypertension, hypercholesterolaemia
Aetiology
Laplaces 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
Post-stenotic
Coarctation of the aorta, Cervical rib, Popliteal artery entrapment syndrome
Traumatic
Gunshot, stab wounds, arterial punctures
Inflammatory
Takayasos disease, Behcets disease
Pregnancy associated
Splenic, cerebral, aortic, renal, iliac & coronary
Classification
False
Due to traumatic breach in the wall The sac made up from the compressed surrounding tissue
Fusiform
Spindle-shaped involving whole circumference
Saccular
Small segment of wall ballooning due to localized weakness
True
Dilatation involving all layers of the wall
Incidence- atherosclerotic
>90% affecting abdominal aorta Infra-renal segment in ~95% Male : Female ratio 4:1 More common in western countries 5% over 50s, 15% over 80s Associated with iliac aneurysms in 30% Associated with popliteal aneurysms in 10%
Pain
Central abdominal radiating to the back Chronic due to stretching the vessel wall or compression/erosion of surrounding structures Acute pain due to rupture
Complications of AAA
Fistulation, rare
Gut, IVC, left renal vein
Thrombosis, rare
Acute lower limb ischaemia
Distal embolism
Acute ischaemia to small distal areas (trash foot)
Distal obliteration
Claudication, rest pain, gangrene
Investigation
CXR, PFT ECG, Echo ESR U&Es USS Spiral CT with contrast Arteriography
Management of AAA
Elective repair for AAA >6cm
Mortality 5%
Anatomical suitability
Neck diameter & length Iliac arteries diameter & tortousity
Morbidity
Endoleak, migration, kink, thrombosis
Inflammatory AAA
Marked fibrosis of the aneurysm wall extending to the surrounding structures It involve the anterior and lateral aspects only It associated with inflammatory cell infiltrate of T- , Blymphocytes & plasma cells The fibrosis may compress the ureters leading to renal failure Rupture is less common and usually posterior Pt. presents with abdo. pain, weight loss, raised ESR Difficult surgery, therefore conservative/endovascular
popliteal aneurysms
Second most common site of atherosclerotic aneurysms Occasionally, present with pulsatile swelling Commonly, aneurysm thrombosis or distal emboli leading to peripheral ischaemia USS/CT/Arteriography to confirm diagnosis Surgical repair, resection/ligation and vein bypass 40% of pts with PA aneurysms have an AAA
Femoral aneurysms
Can occur in isolation but usually part of generalized arteriomegaly Often symptomless and rarely rupture Distal emboli & thrombosis may occur Surgical repair by using vein or synthetic graft
Splenic aneurysms
Male : female 1 : 4 It present in child bearing period Usually symptomless unless ruptured Rupture rate 25% in the third trimester Surgical treatment is indicated if the aneurysm diameter >3cm or patient is pregnant
1- AAA
A- is 4 time more common in males B- incidence is falling in western countries C- may safely observed if asymptomatic and >5.5cm in diameter D- is rarely amenable to endoluminal stenting E- is less common than popliteal aneurysms
2- AAA
A- may cause embolisation to lower limbs B- is more common in males C- can almost always be treated by endovascular stenting D- can be detected by screening E- should be operated upon when it is 5.5 cm long
3- AAA
A- typically rupture at 4cm diameter B- extends above the renal artery in 20% of cases C- is invariably visible on abdominal X-ray D- is associated with coronary artery disease E- has an association with smoking
answers
1- A 2- ABD 3- DE