Cardiovascular System >
Aortic Aneurysm

“Abnormal dilation of an artery due to weakened vessel wall ( >3 cm)”

  • Differentiated by location of aneurysm:
    • Thoracic Aortic Aneurysm (TAA)
    • Abdominal Aortic Aneurysm (AAA)
    • Cerebral Aortic Aneurysm (AAA)
Risk Factors
  • Advanced age
  • Gender(male)
  • AAA more common than TAA
Aetiology
  • Aortitis ( aortic wall inflammation) due to autoimmune disease ( vasculitis, RA) or infection
  • Abdominal Aortic Aneurysm:
    • Smoking
    • Atherosclerosis
    • Hypercholesterolemia and arterial Hypertension (HTN)
  • Thoracic Aortic Aneurysm:
    • Arterial HTN
    • Connective disease ( Ehlers Danlos syndrome/ Marfan syndrome)
    • Bicuspid aortic valve
    • Trauma
    • Smoking
Pathophysiology
  • Inflammation & degeneration of CT protein (collagen and elastin and smooth muscle cells)
  • Loss of structural integrity of the aortic wall, weakened wall tissue → widening of the vessel
  • High BP acts on the wall causing dilation of the vessel
  • An aneurysm can cause disruption of laminar blood flow & turbulence
  • Formation of thrombi in aneurysm causing peripheral thromboembolism
  • Ascending TAA:
    • Due to Cystic medial necrosis
  • Descending TAA:
    • Atherosclerosis
Clinical Presentation
  • Abdominal Aortic Aneurysm:
    • Asymptomatic
    • Lower back pain
    • pulsatile abdominal mass
    • bruit on auscultation
  • Thoracic Aortic Aneurysm:
    • Thoracic back pain
    • A feeling of chest pressure
    • Mediastinal compression /obstruction
    • Dysphagia or cough
    • Upper venous congestion
Investigations
  • Abdominal Aortic Aneurysm:
    • Ultrasound  ( >3cm : confirmed diagnosis; >5.5. cm emergency )
    • CT scan ( angiography abdomen & pelvis with IV contrast)
    • Further imaging:
      • X-ray – calcification on plain X-ray
      • MR angiography
  • Thoracic Aortic Aneurysm:
    • Chest X-ray
    • CT angiography chest
    • Further imaging
      • MR angiography
      • Transthoracic echocardiography
Management
  • Unstable Patient (Risk of Repair):
    • Emergency repair within 90  min à either endovascular or open surgical repair
  • Symptomatic Patient (risk of rupture or leaking of AA):
    • Urgent repair within hours
    • Management of co-morbidities if present( Heart failure, AKI)
  • Asymptomatic Patients:
    • Elective Repair:
      •  Preoperative assessment for elective repair to calculate mortality risk
    • Surveillance:
      • Regular monitoring with  ultrasound to identify expansion and risk of rupture
  • ALL patients – reduce CV RF:
    • BP management
      • 140/90 mmHg in pat without diabetes
      • 130/80 mm Hg in pat with diabetes or CKD
    • SMOKING CESSATION
    • Lifestyle modification ( no competitive sport, no heavy lifting)
    • Appropriate management of atherosclerotic RF ( Diabetes, hyperlipidaemia)
Complications
  • Abdominal Aortic Aneurysm:
    • Rupture of AAA
    • Embolism → from thrombotic material from an aneurysm
    • Aortic dissection
    • Post OP complications
      • Ischaemia of bowel, kidneys and spinal cord
      • Anterior spinal artery occlusion
      • Prosthetic graft infection
  • Thoracic Aortic Aneurysm:
    • Embolism
    • Aortic valve regurgitation
    • Aortic dissection
    • TAA rupture

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