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CASE PRESENTATION 54 Y/OLD MAN /IHD(-) CC: asymptomatic RF: HTN /HLP/ SMOKER P/E: captopril 25 bd

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CASE PRESENTATION 54 Y/OLD MAN /IHD(-) CC: asymptomatic RF: HTN /HLP/ SMOKER P/E: captopril 25 bd

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  1. Aortic AneurysmsPresented by:Dr.Marzieh BalaghiResident of cardiology,Modarres Hospital,Shahid Beheshti University of Medical Sciences, Tehran, IranRevision and supervision:Dr.Habibollah Saadat Dr.Isa KhaheshiCardiovascular Research Center, Modarres Hospital,Shahid Beheshti University of Medical Sciences, Tehran, Iran

  2. CASE PRESENTATION 54 Y/OLD MAN /IHD(-) CC: asymptomatic RF: HTN /HLP/ SMOKER P/E: captopril 25 bd ECHO: EF=55%/MILD LVH ECG: NSR/NAX/ NO ST- T CHANGES LAB TEST:CR=1,HB=13,LDL:100, FBS=105 ;

  3. SONOGRAPHY: AAA (SIZE=4.5 cm in infrarenal) Dx: AAA

  4. WHAT IS YOUR MANAGMENT

  5. Aortic AneurysmsIncidence • 30-60/1000 • Increasing incidence over past 3 decades

  6. Definitions • Aneurysm : Increase in diameter of 50% (1.5x) its normal diameter – Focal region

  7. AAA is more common • Increase diameter to >3 cm • 3-9% men >50 y/old • Is more common in inferarenal(>80%) • Pararenal and suprarenal( 10%) • M/F=5/1 • Age depended • Usually is common in age>60 • Smoker/no smoker=5/1 • RF:male ,age ,smoking,HTN/HLP/emphysema • POSITIVE FH:20%

  8. TAA is less common • Incidence:10/100000 • Ascending Aorta:60% • Descending aorta:35% • Aortic arch<10%

  9. Aortic AneurysmsAssociated Aneurysms • Iliac - 41% • Femoro-popliteal - 15% • Pts with unilateral popliteal aneurysms-->8% AAA • Pts with bilateral popliteal aneurysms--> 30%-50% AAA

  10. Aortic AneurysmsAssociated Medical Conditions • Carotid Artery Stenosis - 10% have AAA • Smoker:Nonsmoker - 8:1 • Male:Female - 4:1 • HTN - 40% of pts with AAA have HTN

  11. Aortic AneurysmsEtiology • Atherosclerosis • Cystic Medial Necrosis • Dissection • Ehlers-Danlos Syndrome • Syphilis • Familial Associated • Lysyl Oxidase deficiency

  12. Aortic AneurysmsClinical Presentation • Asymptomatic - 70-75% • Symptoms: • Early satiety, N,V • Abd., Flank, or Back pain (1/3 of pts experience abd. And flank pain) -Abrupt onset of pain -->Rupture or expansion of aneurysm

  13. Ruptured Aneurysm • 60-70 y/o who presents with abd pain, hypotension and a pulsatile abdominal mass

  14. Aortic AneurysmsRuptured Aneurysms • rupturUsually occurs postero-laterally • Can rupture in Vena Cava creating Aorto-Caval Fistula • Occasionally can rupture anterior - usually fatal

  15. Aortic AneurysmsDiagnosis • Physical Exam: • If <5cm in diameter, then cannot be detected by routine physical exam • Radiographs: • Calcified wall. Can determine size in 2/3

  16. Aortic AneurysmsDiagnosis • Arteriography: • Cannot determine aneurysm size because of mural thrombus

  17. echocardiography • Proximal AoD- • TEE sensitivity 88-98%,specificity 90-95% • TTE 77-80% and 93-96% • Distal AoD-TEE better

  18. Aortic AneurysmsDiagnosis • Ultrasound • Establishes diagnosis easily • Accurately measures infrarenal diameter • Difficult to visualize thoracic or suprarenal aneurysms • Difficult to establish relationship to renal arteries • Technician dependent • Widely available, quick, no risk, cheap

  19. Aortic AneurysmsCT Scan • Very reliable and reproducible • Can image entire aorta • Can visualize relation ship to visceral vessels • Longer to obtain and is more costly than U/S • Most useful • Requires contrast agent - renal toxicity

  20. Aortic AneurysmsMRA • Now widely available • More expensive than CT • No contrast agent required • Spacial resolution less than CT

  21. Aortic Aneurysmscomplication • Complications of AAA • Thrombosis • Distal embolization • Rupture 23.4% of aneurysms 4-5 cm will rupture

  22. Aortic AneurysmsRupture Risks • Patients with COPD and HTN have increased risk of rupture -Survival • 50% die prior to reaching hospital, and an additional 24% prior to repair.

  23. TREATMENT • MEDICAL • SURGICAL

  24. MEDICAL TREATMENT • STOP SMOKING( more important) • RF MODIFICATION • STATINS( in all of paitent) ACEI( pt with ateroschelerosis)

  25. Aortic AneurysmsIndications for repair • Presence of an infrarenal aneurysm > 5cm without associated co-morbid medical conditions • Repair smaller aneurysms if rate of enlargement is greater than expected(>1 cm per year) • Repair all symptomatic aneurysms • If co-morbid conditions exist wait until risk of repair and rupture are equal (approx. 6 cm)

  26. Aortic AneurysmsTreatment-Surgical • Standard Surgical Repair • Replace diseased aorta with artificial artery • Requires 7 day hospital stay • Recovery time 3-6 months

  27. Aortic AneurysmsTreatment - Endovascular • Repair through an incision in the groin with expandable prosthesis under fluoroscopic guidance • Requires both surgical and radiological assistance • Significantly reduced diametr • Long tern result unknown • Hospital stay 2 days, Recovery time 1-2 weeks

  28. What is your management? • Stop smoking • Risk factor modification -Statin -ACEI -SONOGRAPHY(EVERY 6 MONTH)-

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