Aortic Aneurysm, Aortic Dissection, Miscll. Aneurysm and AV Fistula😍

Differentiation:

• Dissection: Involves intimal tear only

• Pseudoaneurysm: Involve Intimal and medial layer

• True aneurysm: Involves all 3 layers

True aneurysm

• Involves all 3 layers of vessel wall

Most Common Vessel Involved

Criteria for Surgical Repair of Aneurysms

Pseudoaneurysm

• Most common artery involved: Femoral artery

• Involves only intimal + medial layers
• Mnemonic: IM Psuedo

• Most commonly iatrogenic
• Repeated arterial puncture (blood sampling, catheterization)
• Invasive procedures
• such as angiography, cardiac catheterization, or arterial line placement

AORTIC INJURY

• MC site: Isthmus

• IOC: CT angiography

• Initial Mx: BP reduction → β blockers
• HR <80,
• MAP:70mm Hg

• Definitive Mx:
• Endovascular Aortic repair (EVAR) with graft

Abdominal Aortic Aneurysm (AAA)

Clinical Features

• Asymptomatic

• Blue Toe Syndrome
• Due to Emboli from Aneurysm

• Rupture into Left Retroperitoneum
• High Mortality > 50%

• Abdominal Pain

• Pulsatile Mass

IOC:

• Surveillance - ultrasound.

• Initial screening → USG doppler

• Pre-op - IOC → CT Angiography

• Most Common Site: Infrarenal Abdominal Aorta

• Most Important Risk Factor: Atherosclerosis

• Screening: Ultrasound (USG) (From 65 yrs)

Critical Diameter for males (Increased Risk of Rupture Beyond This Size)

Aneurysm Type	Male Threshold
Abdominal Aortic Aneurysm	5.5 cm
Ascending Thoracic Aortic Aneurysm	5.5 cm
Descending Thoracic Aortic Aneurysm	6 cm
Marfan’s + Thoracic Aortic Aneurysm	4.5–5 cm

• Less by 0.5 cm in females

• ↑ in size >0.5 cm per year→ indication for surgical intervention

• Mnemonic: AA = 55 = 5.5
• Ascending Aneurysm
• Abdominal Aneurysm

Treatment

Open Repair

• Indication: Longer Life Expectancy

EVAR (Endovascular Aneurysm Repair)

• Indications:
• High Risk Patients
• Hostile Abdomen

• Disadvantage: Life Long Follow-up

• Complications: Endoleaks

Types of Endoleaks

Exposure of Great Vessels

Complications of EVAR

• CVS:
• M/c/c of Mortality

• Renal Failure

• Aortoduodenal Fistula
• Hematemesis

• Left Sided Colonic Ischemia
• Due to Splenic Flexure / Griffith Point (Watershed Area)
• C/F: Bloody Diarrhea

• Paraparesis:
• Due to Artery of Adamkiewicz
• Mnemonic: Paralysis (Paraparesis) when Adam kiss ()

• Mortality:
• 2-3% (> 50% if Rupture +)

Aortic Dissection

Features

Features	Notes
False Lumen is Formed	Between Intima & Media
Most Common Site	Lateral Wall of Ascending Thoracic Aorta
Most Important Risk Factor	Hypertension (HTN)
Most Common Symptom	Chest Pain Radiating to interscapular area

• Males > Females

• Seen in 5th Decade

• Causes Coronary Insufficiency

• Different Blood Pressure (BP)
• Bilateral Upper Limbs

Investigations

• IOC:
• If patient is stable - CT Angiography.
• If patient is unstable - USG - Transesophageal Echocardiography

• Chest X-ray
• Widening of Mediastinum
• Depression of the Left Main Bronchus
• Left main bronchus lies just below the arch of aorta.
• Posteriorly related to descending thoracic aorta.
• left main bronchus is directly compressed
  → seen as depression/indentation on bronchoscopy or imaging.

Classification

DeBakey Classification

Stanford Classification

• A: DeBakey I & II

• B: DeBakey III

Mnemonic:

• DBK → 3 letter → 1, 2, 3

• SF → 2 letter → A, B

 

Type	Location
I (Most Common)	Ascending + Descending Aorta
II	Only Ascending Aorta
III	Only Descending Aorta

Management

1st Step:

• IV Esmolol for Permissive Hypotension

F/b:

• DeBakey Type 1 & 2 (Stanford A):
• Graft Repair (Open/EVAR)
• If Deterioration: Surgery

• DeBakey Type 3 (Stanford B):
• Monitor
• Deterioration → Surgery

Popliteal Aneurysm

• Most Common Peripheral Vessel Involved

Features

• Loss of Contour of Popliteal Fossa

• Pulsatile Swelling Behind Knee

Management

• Indications for surgery
• All Symptomatic Patients
• Asymptomatic + >2 cm Size

• Treatment: Graft Repair

Crisoid Aneurysm

• AV Malformation of Superficial Temporal Vessels
• (Biopsied vessel for temporal arteritis)

• Pulsatile Swelling on the Head

AV Malformations

Causes

• Traumatic

• Iatrogenic (Most Common):

• Cimmino/Radiocephalic Fistula
• For Dialysis
• Test for Radioulnar Patency: Allen’s Test

• Congenital

Clinical Features

• For congenital AV malformation
• Pulsatile Swelling
• Hypertrophy of Limb
• High Output Cardiac Failure

• Nicoladoni/Branham Sign:
• Pressing Feeding Vessel
• Size ↓
• Pulse ↓
• Systolic BP ↑
• Brui ↓↓
• Mnemonic: Nicole (Nicoladoni) Touched a Brahman (Branham) → His BP increased (SBP ↑↑)

Management

• IOC: MR Angiography/DSA

• Rx: Embolization

Pseudoaneurysm of Radial Artery

• Cause:
• Repeated arterial blood gas (ABG) or catheterization procedures
• → arterial wall injury.

• Pathology:
• Disruption of intimal and medial layers
• Dilated segment is lined only by adventitia (± perivascular clot)
• Not a true aneurysm (which involves all 3 layers)

• Clinical Features:
• Pulsatile swelling
• Systolic bruit on auscultation

• Diagnosis:
• Doppler ultrasound:
• Bidirectional “to-and-fro” flow
• aka yin-yang sign
• Need to learn KungFu (Yin Yang) to take ABG

• Treatment options:
• Endovascular stent insertion
• Ultrasound-guided thrombin injection
• Surgical repair