Definitions

Congenital or acquired localised area of

abnormal dilations of blood vessels or the
heart
Whats the importance?
Aneurysm & dissections are important causes of
stasis & subsequent thrombosis, tendency to rupture.

Types of
Aneurysm
True aneurysm

False Aneurysm

- Involves all 3 layers of

- wall defect that leads to

the artery

extravascular hematoma that

(intima, media, adventitia)

communicate with the

- attenuated wall of the heart

intravascular space

- Eg: atherosclerotic, congenital

(pulsating hematoma)

aneurysms, syphilitic aneurysm,

- Eg: ventricular rupture after MI

ventricular aneurysm from

contained by pericardial adhesions

transmural MI

& leaks at the junction of a

vascular graft with a natural artery

Spherical
outpouching
5cm 20cm
Often contain
thrombus
Cylindrical dilation
<20cm
Mostly involve
aortic arch,
abdominal aorta,
iliac arteries

Causes of Aneurysms
1) Loss of smooth muscles cells or change in the smooth muscle cell
synthetic phenotype (ischemia, Marfan syndrome)
Most commonly:
Atherosclerosis (Abdominal aortic aneurysm) and hypertension
(Ascending aortic aneurysm)
2) Excessive connective tissue degradation
(eg. Local inflammatory response Macrophages in atherosclerotic
plaque, MMP, TIMP cystic medial degeneration)
3) Weakened vessel walls (trauma, vasculitis, congenital defects berry
aneurysm, infections mycotic aneurysms, 3syphilis- obliterative
endarteritis esp ascending thoracic aorta)
4) Inadequate or abnormal connective tissue synthesis (eg. Marfan
syndrome-defective synthesis of fibrillin, Ehlers-Danlos syndrome-deficient
synthesis of type III collagen for bv, bowel wall)

Example of Aneurysms
Berry aneurysm
- replacement of muscular wall by fibrous tissue,
involve Circle of Willis at the point of branching, young to middle
age (suspect when young pt have chronic headache)
Predisposing factor : Hypertension
Complication : Subarachnoid hemorrhage
Capillary microaneurysm (Charcoat-Bouchard)
- rupture of branches of arteris in brain (eg: middle cerebral artery)
- adult, HPT due to hyaline arteriolosclerosis, cn cause stroke
Syphilitic aneurysm
- 3syphilis, ascending thoracic & arch of aorta
Mycotic aneurysm
- Bacterial or fungal infection via blood streeam
- Involve cerebral vessels

Abdominal Aortic Aneurysm

Anteropostero diameter of 3cm is generally
accepted as aneurysm
Degeneration of the elastin and collagen
(Local inflammatory infiltrates in atherosclerotic arteries
Excessive ECM degradation, destructive proteolytic
enzymes.Compromise diffusion of nutrients & wastes btw
vascular lumen & arterial wall, compress underlying media)
Degeneration & necrosis, thinning of arterial wall,
expansion accelerates, risk of rupture increases

Risk factors:

Men older than 60 y/o

Smoking
Familial predisposition (atherosclerosis/HPT)
Hereditary defects in structural component of
aorta ( Marfan syndromes)

Abdominal Aortic Aneurysm

Typically occur btw aortic bifurcation & renal arteries

Can be saccular or fusiform
Up to 15cm diameter, 25cm in length
Variants:
i) Inflammatory AAAs
characterized by dense periaortic dense fibrosis containing
many macrophages, giant cells
ii) Mycotic AAAs
occur when circulating microorganisms (as in
bacteremia from a Salmonella gastroenteritis),
suppuration accelerate medial destruction, rapid dilation,
rupture

Complications (ROCE) :
1) Rupture into peritoneal cavity/ retroperitoneal
tissues massive, fatal hemorrhage!!
2) Obstruction of a vessel branching off the aorta
( i.e. vertebralspinal cord, mesenteric arteries-GI
tract, renal-kidney, iliac-legs, reproductive organs)
3) Compression on adjacent structures ( ureter,
vertebrae)
4) Embolism from atheroma/mural thrombus

Symptoms of Abdominal Aortic Aneurysm

Asymptomatic
- pulsatile mass in abdomen
(incidentally discovered on abdominal examination,
calcification on plain abdominal X-ray, CT, ultrasound scan)
Symptomatic
- Abdominal pain/ back pain (need urgent surgery)
- due to rapid expanding aneurysm that causes pressure on
adjacent structures
- Fainting, hypotension (cardiovascular collapse), pain
that mimic renal colic pain due to leaking/ruptured aneurysm

Investigations for arterial disease

Angiography
CT scan
X ray (chest, abdominal)
Exercise ,resting ECG
echocardiography
Ultrasounds (carotid, abdominal, Dopplers
ultrasound)
Duplex ultrasonography
Urine test for sugar, blood glucose
Blood test for EST, CRP, serum cholesterol
Ankle brachial pressure index (to look for PVD)

Prevention of arterial disease

1) Patients
Quit smoking
Control blood sugar level
Lower cholesterol & blood pressure level
Eat food that are low in saturated fat (healthy diet)
Exercise regularly, maintain BMI
Sleep regularly (circadian rhythm)
Regular body checkup
Avoid contraceptive pills (choose alternatives), alcohol
(anti-ADH effects)
Drink lots of water, exercise foot & Wear elastic compression
stockings for long flight travel
Take prophylaxis (anticoagulants)

Prevention of arterial disease

2) Healthcare personnel
Monitor blood pressure, glucose, cholesterol level,
body weight of the patient
Ultrasound scan of abdominal aorta for all men
reaching 65 y/o
Give local anesthesia than general anesthesia
during surgery
Give prophylaxis (anticoagulant) perioperatively

Principles of Management of Arterial Disease

1) Non-surgical
Acute:
control ABCs (stop bleeding, resuscitation, treatment of thrombi or
emboli)
obtain intravenous access, and administer oxygen, baseline laboratory
studies, special investigations like ECG, chest radiograph, treatment of
thrombi or emboli (heparin infusion to increase APTT to 1.5 times normal
levels)
Contraindication in the presence of active internal bleeding, intracranial
bleeding, or bleeding at non-compressible sites.

Chronic:
Treat & monitor underlying diseases (eg.HPT, diabetes mellitus)
Regular risk factors assessment, screening, preventive measures

Principles of Management of Arterial Disease

2) Surgical
- Operative exploration (small vessels ligated, partial tear sutured or closed
with a vein patch, replace injured area with a segment of saphenous vein)
- Fasciotomy (split the deep fascia widely to relieve compartment pressure)
- Reconstructive surgery
- Insert stent-graft (endovascular repair)
- Angioplasty
- CABG
- Lumbar sympathectomy (increase blood supply to allow ulcer healing)
- Amputation