Comprehensive Overview of Aneurysms: Types, Risk Factors, and Surgical Interventions

1. Aneurysms; The Bubble Burst Mr JV Smyth Vascular Surgery

5. ‘Atherosclerotic’ Mycotic Inflammatory Connective tissue disorder False Simple Ureteric compression AV fistula Aortoenteric fistula Rupture Thrombosis/Embolism Aortic/iliac Popliteal Visceral Intracerebral Asymptomatic Back pain Tenderness Limb ischaemia Threshold for surgery Fusiform Saccular

7. The Paradigm Abdominal aortic aneurysm Asymptomatic Atherosclerosis Fusiform Infrarenal Principal risk is rupture

8. Aneurysms • Males 4:1 • 60’s and upward • Hypertensive smokers • Family history of AAA • 1 in 25 random 65yr males • 1 in 6 65 yr HT male smokers with FH • Usually incidental finding during Ix for something else

9. SCREENING • Common condition • Significant outcome if not diagnosed • Effective intervention • At-risk population subgroup • Widely available test • Safe, sensitive and specific • Economic (QALY) • National AAA screening programme recently announced

10. Mortality

11. Open repair • Replace aneurysmal segment • GA, laparotomy, aortic XC • Mortality 5-7% • 90% cardiac • Occasional respiratory/renal failure/PE • Patient selection • Echo, stress test • PFTs

12. Maximum transverse diameter Normal aorta < 2.5cm Ectasia < 3.5cm Small AAA < 4.5cm Large AAA >5.5cm Rupture is exponentially associated with MTD ~1% Annual risk at 4cm ~ 7% Annual risk at 6cm ~30% annual risk at 8cm

15. Endovascular repair • Reline aorta rather than replace • Dependent on radial force of stents for fixation rather than sutures • Modular system • Bilateral groin incisions (or punctures) • Avoids laparotomy, XC • Mortality 1.9% (EVAR 1 trial)

18. Why not everyone ? EARLY ENDOLEAKS

19. Endoleak Types • I around aortic or iliac landing zones • II from lumbars or IMA • III between graft components • IV loss of graft integrity

20. Anatomical suitability • Infrarenal neck, common iliac arteries • Length • Shape • Angulation • Thrombus • Iliac access • Tortuosity • Calibre

21. Oversizing • Suprarenal uncovered stent • Barbs • More flexible devices • Repositioning capability • Low profile delivery system • Custom made prosthesis

23. Complex EVAR • Iliac conduit • Carotid access • Iliac bifurcation device • Aorto-uniiliac and cross over • IIA embolisation • Fenestrated • Branched • Chimney

27. Why not everyone ? LATE ENDOLEAKS

28. Long term FU • Device integrity • Conformational change • Reinterventions proportional to time

29. Ruptured AAA • Lower back pain, hypotension, abdo mass • Most never get to hospital • Overall mortality 95% • Postoperative mortality ~50% • Get large IV lines in • Call vascular surgeons • Permissive hypotension, analgesia • Send blood for XM, FBC, clotting, U&E