AAA for resident

1. Teaching Topic
AAA
For resident
F2 :Parach Sirisriro

2. • Greek word aneurysma, meaning “a widening”
• True aneurysms (dilatation of all layers of the
arterial wall)
• False aneurysms or pseudoaneurysms ( dilatation
not all layers of the arterial wall)

3. Shape
• Fusiform aneurysm
• Saccular aneurysm ( relate infected )

4. Size
• Aneurysms :as a focal dilatation at least >50% the expected
normal arterial diameter
• A practical working definition of an AAA is a transverse diameter
3 cm
Ruttherford Vascular Surgery, 9th ed
AAA can be defined as an abdominal aortic diameter of 3.0 cm or more
in either anterior-posterior or transverse planes. Level 2c, Grade B
the minimum anteroposterior diameter of the aorta reaches 3.0 cm
ACC/AHA Practice Guidelines

5. Conclusion AP Diameter≥ 3 cm

6. PATHOGENESIS
• atherosclerotic referred to as degenerative or
nonspecific in etiology
increased expression and activity of matrix
metalloproteinases (MMPs) in the wall of
aortic
 decrease elastin

8. • Chlamydia pneumoniae could be a possible
stimulus

9. EPIDEMIOLOGY
Dashed lines = incidence of all AAAs; solid lines = incidence of ruptured AAAs

10. Rutherford 6th

11. ***DM not risk factor

12. Screening
• Population screening of older women for AAA
does not reduce the incidence of aneurysm
rupture. Level 1b, Recommendation B.
• Men should be screened with a single scan at
65 years old. Level 1a, Recommendation A.

13. • Men≥ 60 years :have a sibling or parent with
an AAA should have a physical examination
and ultrasound screening.

14. • Screening seems reasonable for men > 60 who
would be candidates for at least an endovascular
repair.
• Screening may be beneficial for women if they
have other risk factors for AAA, such as a smoking
history or a family history of AAA
• Because familial AAAs tend to occur at younger
ages, screening for patients with a family history
should be performed earlier, such as age 50 – 55
Rutherford

16. • Physical examination and abdominal U/Sเพื่อ
ค้นหาAAA ในผู้ชายที่อายุ 60 ปีขึ้นไปและมีพี่น้องร่วมมารดาหรือ
บุตรของผู้ป่วยที่มี AAA
ACC/AHA guildline & ศัลยทั่วไปเล่ม 6

17. CLINICAL PRESENTATION AND
DIAGNOSIS
• Most AAAs are asymptomatic
• patients may describe a “pulse in their
abdomen or may palpate a pulsatile mass
• classic presentation of ruptured AAA:
abdominal or back pain, hypotension, and a
pulsatile abdominal mass
• 20% rupture antetior
• 80% rupture posterior ( Lt posterolateral )

18. • Fever  infected aneurysm , inflamatory
aneurysm
• GI bleeding  Aortoenteric fistular
• CHF  Aortocaval fistular

19. Crawford's classification
Aneurysms involving the immecdiate infrarenal segment are known as juxtarenal
AAAs, whereas those involving the origin of the renal arteries are called pararenal
AAAs.
infrarenal (I) juxtarenal (II) pararenal (III) suprarenal (IV)

20. Physical examination
• R/O AAA or mass above AAA
( in AAA Pulsatile Expansion all direction )
• R/O suprarenal and infrarenal AAA
The DeBakey sign(i.e., the upper part of an
aortic aneurysm can be palpated by fingers
placed under the costal wall) confirmed that
the aneurysm was infrarenal

21. • Fever R/O infected aneurysm
• Pulse all extremities preoperational (detect
post operative emboli )
• Grey turner’s sign

22. • continuous abdominal bruit in
a patient with usually a large
AAA.
• Manifestations of venous
hypertension are present and
include lower extremity
edema, priapism, rectal
bleeding, and hematuria.
“Steal” by the fistula may
result in decreased distal
pulses or frank ischemia to the
lower extremities.

23. Investigation

24. • Abdominal B-mode U/S: initial confirmation of
a suspected AAA or for follow-up of small
AAAs
• more accurate in AP > lateral
• U/S cannot accurately determine :rupture and
the upper extent of an AAA

25. • CT defines the proximal and distal extent of an
AAA, more accurately images the iliac arteries,
• Spiral CT with 3D reconstruction : accurate
measurement for endovascular graft sizing
• MRI ( IV contrast contraindicated)

26. • Arteriography is not an accurate technique to
confirm the diagnosis of AAA or to measure
diameter accurately because thrombus within an
AAA usually diminishes the size of the contrast-
filled lumen.

27. Indication for angiogram
• Renal impairment, hypertension or audible
renal bruit
• Juxtrarenal or suprarenal aneurysm
• Suspected abnormal anatomy (multiple renal
arteries, horse-shoe kidney)
• Distal occlusive disease or popliteal aneurysm
• Clinical suspicion of visceral ischemia

28. A left retroperitoneal approach is advocated because it allows easier
management of the multiple accessory renal arteries

30. • Usually these are patients with associated
renal or mesenteric disease or iliofemoral
occlusive disease or patients with anomalies
such as horseshoe or pelvic kidney.

31. CTA
• Type AAA (sacular or fusiform)
• ดูแยก infraกับsupra renal AAA โดยดู Lt renal vein
• Extension
• Size
• Rupture or not

32. (Sign of rupture : contrast อยู่ใน thrombus
/Retroperitonium hematoma , discontinue aortic wall )

33. • recommend a CT size measurement for AAAs,
followed by ultrasound if they approach the
threshold for elective repair.

34. DECISION MAKING FOR ELECTIVE
ABDOMINAL AORTIC ANEURYSM REPAIR
(1) the rupture risk under observation
(2) the operative risk of repair
(3) the patient’s life expectancy
(4) the personal preferences of the patient

35. • 6 months F/U AAAs 4-4.9 cm
• 3 months F/U AAAs 5-5.5 cm

36. MEDICAL MANAGEMENT
• Smoking cessation is crucial, and hypertension
should be aggressively controlled
• beta blockers have not been shown to slow
the rate of growth of AAA
• b-blockers are recommended in patients with
ischaemic heart disease or who have
myocardial ischemia on stress testing and can
be started 1 month before intervention.

37. • Statins should be started one month before
intervention to reduce cardiovascular morbidity.
• Doxycycline seems more promising

38. • symptomatic must be repaired AAAs
• diameter ≥5.5 cm in men
• expand at a rate > 1 cm/year
• However, subsets of younger, low-risk patients,
with long projected life expectancy, may prefer
earlier repair. If the surgeon's operative mortality
rate is low, repair may be indicated at smaller
sizes (4.5-5.4 cm) if that is the patient's
preference.
In 2003, the Joint Council of the Vascular
Societies published guidelines for the treatment
of AAA

39. • For women and patients with a greater than average
rupture risk, an AAA diameter of 4.5 -5.0 cm is an
appropriate threshold for elective repair
• Atypical aneurysms (dissecting, pseudoaneurysms,
mycotic, saccular, and penetrating ulcers) may be an
indication for surgical treatment regardless of size.
• For high-risk patients, delay in repair until larger
diameter is warranted, especially if EVAR is not
possible.

40. Surgical management
Elective AAA
• EVAR
• Open surgery -Transabdominal
-Retroperitoneum
• Laparoscopic
Rupture AAA
•open -Transabdominal
Infected AAA -Extranatomical bypass

42. Performance suitable for
Surgery or EVAR
suitable
EVAR not
suitable
Open
Trans
abdominal
Retroperitoneum
Laparoscopic
High
risk
Non
operative
management
EVAR
suitable
EVAR
Not suitable
Non operative
management
EVAR suitable =high
risk anatomy suitable
for EVAR

43. Preoperative management

44. *

45. Elective AAA

46. • IV ATB (usually cephalosporin)
• intravenous access
• intra-arterial pressure recording
• Foley catheter monitoring of urine output

47. Lt>Rt retroperitoneal approach due to
spleen is easier to mobilize and retract
than the liver.
the advantage of giving ample exposure of the
distal right common iliac artery and its
bifurcation vessels when they are
involved by aneurysms or incidental occlusive
disease.

48. • horseshoe kidneys
• “hostile” abdomens (previous operations) or
an abdominal wall stoma
• an inflammatory aneurysm, or anticipated
need for suprarenal endarterectomy or
anastomosis
indications for retroperitoneal exposure

49. A left retroperitoneal approach is advocated because it allows easier
management of the multiple accessory renal arteries

51. Rupture AAA
• classic presentation of ruptured AAA: abdominal
or back pain, hypotension, and a pulsatile
abdominal mass
• Patho : Two hit mechanism of injury
1 hemorrhagic shock
2 ischemic reperfusion injury post
revascularization
Multiorgan
failure
ศัลยศาสตร์ทั่วไปเล่ม 6

52. • Initial management
- IV fluid control SBP 70 mmHg
- Retain NG ( easy for supraceliac control )
- Retain foley cath
- 2 Large bore IV line (central line not
necessary)
- PRC 6 U FFP 6 U PLt 10 U

53. Operative management
• Scrub Prep before Anesthesia
(nipple line to knee )
• Midline incision xyphoid to symphysis

55. • If the patient's hemodynamic status deteriorates rapidly when the
tamponade effect of the abdominal wall is lost with can compress the
aorta against the spine above the celiac artery (Fig. 2) while the
anesthesia team catches up with resuscitation.

57. In cases of severe hypotension or
uncontrolled bleeding from intraperitoneal
rupture, or whenever the surgeon feels
that the extent of the hematoma or shape
or size of the aneurysm makes
conventional exposure too difficult or
impossible, control of the supraceliac
aorta can be obtained (Fig. 4).

58. •Divide Lt crus of aortic hiatus เนื่องจาก
มี celiac plexus มากตรง supraceliac
arota การตัด crus (Lt) ตัดที่ 2 O clock
The periaortic tissue is cleared with a finger and
the aortic clamp placed with tips against the
vertebral bodies.

59. Figure 65-20 A to D, Supraceliac control of the aorta can be accomplished by
dividing the gastrohepatic ligament and left crus of the diaphragm. Blunt finger
dissection through the left diaphragmatic crus and laterally around the aorta
allows proper clamp placement.

60. Foley cath เบอร์ 24

62. ควรเลาะ dorsal peritoneum
ให้ห่างจาก duodenum 1-2 cm
เพราะเวลาเย็บปิดจะได้ไม่เย็บ
โดน duodenum
ในกรณี hematoma ต้องหา friendly
triangle

63. Mobilising the renal vein
การตัด Rt renal vein ควรตัด
ให้ proximal ต่อ gonodal vein
and adrenal vein

64. Once the aorta has been exposed for clamping, a
dose of 3,000 to 5,000 units of heparin is given
intravenously. If massive hemorrhage has occurred,
heparin is not given due to the likelihood of severe
coagulopathy.

66. Bleeding lumbar arteries
and IMA are oversewn
from within the sack with
figure-of-eight 2-0 silk
sutures.

67. Ligate IMA ต้อง
ทาจาก ด้านใน
เพราะ กลัวโดน
collateral

68. Reimplant IMA
( ในทางปฏิบัติ try bulldog at IMA - no discolor of colon –ligation ได้ )

69. • reimplantation of IMA into the side of the graft
either as a Carrel patch or with a saphenous
vein graft should be carried out if possible.

71. 3-0 polypropylene

72. 4-0 polypropylene suture

76. Adventage
• Minimal invasive operation  ฟื้นตัวไว
• Cost < endovascular
• เหมาะในรายที่ทา endovascular ไม่ได้
Disadventage
• Require more learning curve
Laparoscopic Abdominal
Aortic Surgery

80. EVAR

81. The guidelines recommended EVAR
• preferred for older, high-risk patients
• those with “hostile” abdomens
• patients with other clinical circumstance
likely to increase the risk of open repair, if
their anatomy is appropriate.
• It was emphasized that patient preference is
of great importance

83. • Infrarenal aortic neck length > 1.5 cm
• Aortic neck-body angle < 60 degree
• Iliac seal zone > 1.5 cm
• Iliac angle < 90 degree

88. • Check pulse postoperative R/O

89. Infected aneurysm

92. • Fungal arterial infections are rare but
characteristically occur in patients with
chronic immune suppression or diabetes
mellitus

93. DIAGNOSIS
• Laboratory Studies
-Gram stains Aneurysm wall
-Aneurysm wall and contents culture ( aerobic
and anaerobic bacteria and fungi )

94. • Radiologic Studies
arteriographic criteria for infection in an
aneurysm are as follows
▪ Saccular aneurysm in an otherwise normal-
appearing vessel
▪ Multilobulated aneurysm
▪ Eccentric aneurysm with a relatively narrow
neck

95. Diagnostic radiology studies of a patient with Staphylococcus aureus microbial aortitis
with aneurysm. A, Contrast-enhanced CT scan shows contained rupture of infected
aneurysm (curved arrow) and the adjacent aorta (straight arrow). B, Digital subtraction
aortogram shows saccular eccentric infected aneurysm of the infrarenal aorta (arrow).

96. • CT and MRI fails to give specific information
about the presence or absence of infection.

97. Preoperative Care
• Treatment of narcotic addicts should include
active and passive tetanus prophylaxis
• broad-spectrum antibiotic therapy should be
initiated
• Chloramphenicol, ampicillin, a quinolone, or a
third-generation cephalosporin should be
included to combat Salmonella species

98. Six general principles apply in the operative
management of infected aneurysms:
1. Control of hemorrhage
2. Confirmation of the diagnosis tissue smears for
Gram stains and C/S specimens for aerobic and
anaerobic bacteria and fungi
3. Operative control of sepsis :aneurysm resection
and ligation of healthy artery followed by wide
débridement of all surrounding infected tissue with
antibiotic irrigation and placement of drains

99. 4. postop wound care, including frequent
dressing changes and necessary débridement
5. Continuation of prolong ATB
6. Arterial reconstruction of vital arteries through
uninfected tissue planes with selected use of
interposition grafting through the bed of the
resected aneurysm and use of autologous
tissue for reconstruction

100. • The entire aneurysm is
resected, the infected tissues
are thoroughly débrided,
drainage is established
• Extra anatomical bypass

101. • Prolong ATB 6 wk

102. Postoperative complication
• Post-op care
• - ICU monitoring
• - ECG , Cardiac enzyme 3 days
• - คลำ distal pulse OD
• - ดูเรื่อง ischemic colitis – LLQ tenderness
• - Follow up Cr -- ARF
Death note of surgery

103. Cardiac complication
• MI
• Prevent
-Adequate preload
-Adequate oxygen
-Control pain
-HCT> 28

104. Renal failure
• Suprarenal > infrarenal cross clamp
Prevent
-Optimal IV fluid
-Mannitol
-Loop diuretic Or Low dose dopamine

105. Distal embolisation
Cause aneurysmal debris from mobilisation AAA
or Aortoilliac cross clamping
• Vary small emboliTrash foot(small red dot at skin )
• small emboli blue toe
• large emboi Acute arterial occlusion
Prevent –systemic heparin ,clamp atherosclerosis
area , adequate debridement, flush before last
stich suture
Treatment -embolisation

106. Colonic ischemia
The classic presentation of bloody diarrhea early after surgery occurs in only
one third of patients with documented ischemic colitis.
should always prompt flexible sigmoidoscopy
Transmural colitis shows deep ulcerations and pseudomembranes
on colonoscopy, mandates bowel resection

107. • Although colonoscopy can detect ischemic colitis
easily, it is more difficult to differentiate transmural
infarction, such that clinical correlation and
experience are required to determine optimal
management
• Grade I &II -ATB and bowel rest
strictures may develop after moderate
ischemia resolves
• Grade III -Bowel resection

108. Arotoenteric fistula
• Hx abdominal aneurysm or previous
prosthetic aneurysm repair
• Sentinel bleed  massive bleed  dead
• Aorta connect to 3 rd or 4 th part of
duodenum
• CT scan with contrast : air around the graft (
suggestive of an infection ), pseudoaneurysm
, rarely iv contrast leak to duodenum lumen

109. • Treatment
- ligated aorta proximal to the graft
- remove prosthesis
- extranatomical bypass
- primary duodenum repair

110. THE END