1. Mr Andrew Cowan FRCS Consultant Vascular Surgeon Royal Devon
& Exeter NHS Foundation Trust
2. Anatomy From the Greek to raise or lift General Micro Macro
Surface 3. General Elastic artery Systole Inflow > Outflow 4.
General Elastic artery Systole Winkessel Effect air chamber elastic
reservoir blood store potential energy 5. General Elastic artery
Diastole energy released Smoothing of pulse pressure wave Common
Carotid Subclavian Pulmonary 6. Clinical Note Atherosclerosis
Hardening of the wall Less distensible Raised systolic pulse
pressure Hypertension CVA MI AAA 7. Micro 3 Layer structure Tunica
intima Tunica media Tunica adventitia Vasa vasorum on outside to
nourish 8. Media Structurally most important layer Elastic lamellae
in concentric layers Smooth muscle Not esp active - stiffness
Elastic Matrix Dominant layer Elastin Collagen Proteoglycans Etc 9.
Macro/Surface How big 2-2.5cm at hiatus 15-20mm at renals Similar
at bifurcation Size of your thumb 10. Aorta enters abdomen
Diaphragmatic hiatus 2-2.5cmT12 11. Inferior phrenic Coeliac Trunk
Hepatic -GDA Splenic Left GastricL1 12. Inferior phrenic Coeliac
Trunk Hepatic -GDA Splenic Left Gastric Supra renals SMA MidgutL1
13. Inferior phrenic Coeliac Trunk Hepatic -GDA Splenic Left
Gastric Supra renals SMA Midgut Lumbars 4 paired Median sacralL1
14. Artery of Adamkiewicz (Great radicular artery of) Typically
LEFT posterior intercostal 75% T8 L1 Lower 2/3 cord Anterior spinal
artery BUT V occ from LUMBAR arteries 15. Clinical Note Occlusion
Anterior spinal syndrome Double incontinence Impaired motor
function Sensation often spared EVAR/FEVAR (1-5%) Open AAA
(thoraco) (1-10%) Aortic Dissection Coelic plexus block 16.
Gonadals Lumbars Renal Arteries Left renal veinL2 17. Clinical Note
Retro Aortic LEFT Renal Vein 2% of population At risk Open AAA
Spinal surgery Nutcracker syndrome Loin pain Haematuria 18. Lumbars
IMA Hindgut supply Sacrificed in AAA Sacrificed in AAA surgery ?
Reimplant Importance of Int Iliacs Maintain 2 of 3L3 19. Aortic
Bifurcation ASIS UmbilicusL4 20. Aortic Bifurcation Hypogastric
plexus Iliac surgery 10% Impotence Women ? 21. Iliacs Internal
Buttocks Pelvis Occlusion Buttock claudication Erectile impotence
Distal colonic ischaemia Emergency embolistaion Trauma Obstetric
bleeds 22. Iliacs External iliac artery 23. Iliacs External iliac
artery Rectus sheath haematoma Warfarin Cough 24. Abdominal Aortic
Aneurysm 25. Aims Epidemiology Pathology Aetiology Presentation
Conventional Repair Endovascular Repair (EVAR) Screening 26.
Epidemiology Rare 55 years~5.5% ~9% Women 1% 20% of patients with
carotid disease 3 x more common in patients with inguinal hernia
27. Why repair? 2% of all post mortem examinations 7,500 deaths per
annum in UK 5% of sudden deaths in men > 50 yrs Mortality from
rupture still > 80% Locally ~ 13% in hospital Vs 25% without
cell salvage Elective mortality 0.5 - 1.5% 28. Cell Salvage 29.
Pathology Extracellular matrix contains collagen and elastin Not
passive dilatation but remodeling Elastolysis Failure of elastin
Load on to collagen 30. Pathology Infiltration of inflammatory
cells into adventitia Release of matrix degrading enzymes Cigarette
smoking Premature ageing 31. Microscopic 32. Aetiology Age Gender
33. Risk of aneurysm death vs age 13FemaleMale9 7 641116065701 751
80 34. Aetiology Age Gender Genetic 30% prevalence in first degree
male relatives Difficult questions... 35. Aetiology Age Gender
Genetic 30% prevalence in first degree male relatives Difficult
questions... Tobacco smoking Largest avoidable risk factor 36.
Aetiology Age Gender Genetic Tobacco smoking Hypertension COPD
Occlusive arterial disease 37. Presentation Usually asymptomatic -
75% urological or colorectal investigation Screening programmes
Symptomatic Back or abdominal pain Rupture / leak / enlargement
Vertebral erosion (5%) Mimics renal colic 38. Presentation Local
pressure effects Rare Duodenal obstruction Embolisation 39.
Popliteal aneurysm 10% of AAA pts 50% are bilateral 40% chance of
AAA 40% chance of Fem aneurysm Thrombosis -50% limb loss 40. When
to Repair? Symptoms Abdominal and back pain Radiates loin to groin
Hypotension and collapse Restless 41. 56 year old male Sudden onset
RIF pain to small of back - groin Sweaty, clammy Smoker 50/day P88
BP 105/64 Tender RIF Obese - No obvious masses RENAL COLIC 42. Men
over 55 years with their FIRST ever episode of renal colic have
ruptured AAA until proven otherwise 43. Fluid Resuscitation If
talking BP is adequate as brain is perfused Only clamp required
Fluids increase BP Increase bleeding Dilute red cells Dilute
clotting factors Increase retroperitoneal swelling Difficult to
close abdomen 44. When to Repair? Change in size >5mm in 6
months (average < 3mm/year) Absolute size 5.5cm Small Aneurysm
Trial The Lancet, Volume 353, Issue 9150, Page 408, 30 January 1999
RAP Scott, Chichester, UK 45. % Yearly Risk of Rupture 30 25 20
1510 5 0 5.5cmOpen Repair after cardiovascular work up Open Repair
after cardiovascular work upCT AngiogramSuitable for EVAREVAR 48.
Increased myocardial afterload Limb ischaemia 49. Hypotension
Reperfusion (Lactate etc) Tachycardia 50. Risks for mortality
Severe angina Cardiac failure Diuretic therapy ECG ischaemia VEs
Inability to walk 500 yds Creatinine > 120 Age (per decade)
Vascular Anaesthesia Societyx3 x2 x2 x2 x3 x3 x3 x1.5 51.
Complications (%) Cardiac 15 Respiratory 10 Renal 5 - 12 DVT 8
Bleeding 25 Limb ischaemia 1 4 Wound Infection 4cm diameter 77. AAA
related mortality for Gloucestershire 50 45 40 35 30 2565-73
Other20 15 10 5 019941995199619971998 78. Majority of deaths in 15%
who declined screening 79. BJS July 2001 1988 223 men 65 yrs age
Aorta < 26mm USS at 5 and 12 years 8 lost to FU 86 died nil from
AAA No significant increase in remainder 80. Conclusion Single
normal ultrasound at age 65 effectively rules out the risk of
clinically significant aneurysmal disease 81. Comparison Screening
programme Cost/Life year saved Breast cancer (UK) 3,044Breast
cancer (NL) 2,440Cervical cancer (NL) 10,000Aneurysm screening 795
82. If you were 65 and fit... EVAROpen Repair 2 day stay ITU 0.5%
mortality 7 days Rapid recovery 2% mortality Life long follow up 2
month recovery No surveillance required
