Centers of Excellence in Interventional Cardiology and Radiology

Interventional radiology

Aortic abdominal aneurysm

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Generalities

What is an aortic aneurysm?

Aorta is the body’s main supplier of blood; it runs from your heart through the center of your chest (thoracic aorta, with three segments: the aortic root and the ascending aorta, aortic arch, thoracic descending aorta) and abdomen ( abdominal descending aorta).

An aortic aneurysm is an enlarged area, wich can affect any part of the aorta. Because the aorta is the body’s main supplier of blood, a ruptured aortic aneurysm can cause life-threatening bleeding.

Depending on the size and rate at which your aortic aneurysm is growing, treatment may vary from watchful waiting to emergency surgery. Once an abdominal aortic aneurysm is found, doctors will closely monitor it so that surgery can be planned if it’s necessary. Emergency surgery for a ruptured abdominal aortic aneurysm can be risky.

Symptoms

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Abdominal aortic aneurysms often grow slowly and usually without symptoms, making them difficult to detect. Evolution varies: many start small and stay small, although many expand over time. Others expand quickly and can rupture ( aneurysm’s rupture isn’t mandatory). Predicting how fast an abdominal aortic aneurysm may enlarge is difficult.

As an abdominal aortic aneurysm enlarges, some people may notice:

• a pulsating feeling near the navel

• deep, constant pain in your abdomen or back pain

When to see a doctor?

1. Anyone age 60 and older who has risk factors for developing an abdominal aortic aneurysm (such as smoking or a family history of abdominal aortic aneurysm, mens) should consider regular screening for the condition. Because being male and smoking significantly increase the risk of abdominal aortic aneurysm, men ages 65 to 75 who have ever smoked cigarettes should have a one-time screening for abdominal aortic aneurysm using abdominal ultrasound.

2. If you have a family history of abdominal aortic aneurysm, your doctor may recommend an ultrasound exam to screen for the condition.

3. There are no specific screening recommendations for women. Ask your doctor if you need to have an ultrasound screening based on your risk factors.

Causes

Most aortic aneurysms occur in the part of your aorta that’s in your abdomen. Although the exact cause of abdominal aortic aneurysms is unknown, a number of factors may play a role, including:

• tobacco use – in addition to the damaging effects that smoking causes directly to the arteries, smoking contributes to the buildup of fatty plaques in your arteries (atherosclerosis) and high blood pressure. Smoking can also cause your aneurysm to grow faster by further damaging your aorta. The longer you’ve smoked or chewed tobacco, the greater your risk

• atherosclerosis – occurs when fat build up on the lining of a blood vessel, increasing your risk of an aneurysm.

• vasculitis – in rare cases, abdominal aortic aneurysm may be caused by an infection or inflammation that weakens a section of the aortic wall

• age – abdominal aortic aneurysms occur most often in people age 65 and older

• being male

• family history – people who have a family history of abdominal aortic aneurysm are at increased risk of having the condition; they tend to develop aneurysms at a younger age and are at higher risk of rupture.

Complications

1. The main complication af abdominal aortic aneurysm is aortic dissection (tears in the wall of the aorta causing blood to flow between the layers of the wall of the aorta, creating a false lumen)

2. A ruptured aortic aneurysm can lead to life-threatening internal bleeding. In general, the larger the aneurysm, the greater the risk of rupture.

Signs and symptoms that your aortic aneurysm has burst include:

• sudden, intense and persistent abdominal or back pain

• pain that radiates to your back or legs

• sweatiness

• dizziness

• nausea

• vomiting

• low blood pressure

• fast pulse

• loss of consciousness

• shortness of breath

3. Another complication of aortic aneurysms is the risk of blood clots – small blood clots can develop in the area of the aortic aneurysm. If a blood clot breaks loose from the inside wall of an aneurysm and blocks a blood vessel elsewhere in your body ( blocking the flow to the legs or abdominal organs) and it can cause severe ischemic damage.

Tests and diagnosis:

Abdominal aortic aneurysms are often found during an examination for another reason (during routine medical tests, such as a chest X-ray or ultrasound of the heart or abdomen).

During a routine exam, your doctor may feel a pulsating bulge in your abdomen, rising the suspicion of aortic aneurysm. If your doctor suspects that you have an aortic aneurysm, specialized tests can confirm it. These tests might include:

• abdominal ultrasound

• plain radiography

• computerized tomography scan

• magnetic resonance imaging

• angiography – is helpful in determining aortic anatomy and has been advocated for preoperative use if suspicion of suprarenal or thoracic aortic aneurysm, femoral or popliteal aneurysm, renal artery stenosis, unexplained impairment of renal function, occlusive iliofemoral disease, or visceral ischemia exists.

Angiography is limited by its invasiveness, cost, lack of operator availability, time involved, and risk of complications (eg, bleeding, perforation, embolization). Routine use of angiography in evaluation of abdominal aortic aneurysm is not recommended.

As i pointed above, regular screening for peoples at risk it’s important.

Indications

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In patients with small abdominal aortic aneurysm, attempt to reduce the expansion rate and rupture risk:

smoking cessation

Aggressively control hypertension – Institute beta-blocker therapyto – these agents can be administered safely unless the patient has contraindications to their use, such as asthma, allergy to the drug, bradycardia, or severe chronic heart failure.

Patients with an incidentally discovered aneurysm that is less than 3 cm require no further follow-up. If the aneurysm is 3-4 cm, annual ultrasound imaging should be used to monitor for further dilatation. At 4-4.5 cm should be evaluated by ultrasound every 6 months, and patients with aneurysm greater than 4.5 cm in diameter should be referred to a vascular surgeon.

There are two approaches to abdominal aortic aneurysm repair. The standard surgical procedure for aneurysm repair is called the open repair. A newer procedure is the endovascular aneurysm repair (EVAR).

Abdominal aortic aneurysm open repair – remains the standard procedure for an abdominal aortic aneurysm repair. Open repair of an abdominal aortic aneurysm involves an incision of the abdomen to directly visualize the aortic aneurysm. The procedure is performed in an operating room under general anesthesia. Once the abdomen is opened, the aneurysm will be repaired by the use of a long cylinder-like tube called a graft. Grafts are made of various materials, such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, a nontextile synthetic graft). The graft is sutured to the aorta connecting one end of the aorta at the site of the aneurysm to the other end of the aorta.

Endovascular aneurysm repair (EVAR) – EVAR is a minimally-invasive (without a large abdominal incision) procedure performed to repair an abdominal aortic aneurysm. EVAR may be performed in an operating room, radiology department, or a catheterization laboratory. The doctor may use general anesthesia or regional anesthesia. The doctor will make a small incision in each groin to visualize the femoral arteries in each leg. With the use of special endovascular instruments, along with X-ray images for guidance, a stent-graft will be inserted through the femoral artery and advanced up into the aorta to the site of the aneurysm. A stent-graft is a long cylinder-like tube made of a thin metal framework (stent), while the graft portion is made of various materials such as Dacron or polytetrafluoroethylene (PTFE) and may cover the stent. The stent helps to hold the graft in place. The stent-graft is inserted into the aorta in a collapsed position and placed at the aneurysm site. Once in place, the stent-graft will be expanded, attaching to the wall of the aorta to support the wall of the aorta.

The doctor will determine which surgical intervention is most appropriate, either open repair or EVAR.

Indications:

Reasons an abdominal aortic aneurysm repair may be performed include:

• to prevente risk of rupture

• to relieve symptoms

• to restore a good blood flow

• size of aneurysm greater than 5 centimeters in diameter (about two inches)

• growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over one year

• when risk of rupture outweighs the risk of surgery

• emergency life-threatening hemorrhage (uncontrolled bleeding)

There may be other reasons for your doctor to recommend an abdominal aortic aneurysm repair.

Procedure

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EVAR is a minimally-invasive (without a large abdominal incision) procedure performed to repair an abdominal aortic aneurysm. EVAR may be performed in an operating room, radiology department, or a catheterization laboratory. The doctor may use general anesthesia or regional anesthesia. Thedoctor will make a small incision in each groin to visualize the femoral arteries in each leg. With the use of special endovascular instruments, along with X-ray images for guidance, a stent-graft will be inserted through the femoral artery and advanced up into the aorta to the site of the aneurysm. An aortogram (injection of contrast dye to visualize the position of the aneurysm and adjacent blood vessels) will be performed. A stent-graft is a long cylinder-like tube made of a thin metal framework (stent), while the graft portion is made of various materials such as Dacron or polytetrafluoroethylene (PTFE) and may cover the stent. The stent helps to hold the graft in place. The stent-graft is inserted into the aorta in a collapsed position and placed at the aneurysm site. Once in place, the stent-graft will be expanded, attaching to the wall of the aorta to support the wall of the aorta, excending distally into the iliac arteries. The graft serves to contain aortic flow and decrease the pressure on the aortic wall, leading to a reduction in aneurysm size over time and a decrease in the risk of aortic rupture. An aortogram will be repeated to check for an endoleak (blood leaking out into the aneurysm sac) of the stent-graft. Once no leak has been determined, the instruments will be removed.

Is it painful?

The doctor may use general anesthesia or regional anesthesia, so the patient will not feel any pain, and after the procedure it will received pain drugs.

Risks

• damage to surrounding blood vessels, organs, or other structures by instruments

• kidney damage

• limb ischemia (loss of blood flow to leg/feet) from clots

• groin wound infection or groin hematoma

• bleeding

• endoleak (continual leaking of blood out of the graft and into the aneurysm sac with potential rupture)

• spinal cord injury

Before procedure

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

You will be asked to sign a consent form that gives permission to do the procedure.

In addition to a complete medical history, your doctor may perform a physical examination to ensure you are in good health before you undergo the procedure. You may also undergo blood tests and other diagnostic tests.

You will be asked to fast for eight hours before the procedure, generally after midnight.

If you are pregnant or suspect that you are pregnant, you should notify your health care provider.

Notify your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).

Notify your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.

Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.

If you smoke, you should stop smoking as soon as possible prior to the procedure, in order to improve your chances for a successful recovery from surgery and to improve your overall health status.

You may receive a sedative prior to the procedure to help you relax.

Based on your medical condition, your doctor may request other specific preparation.

After procedure

In the hospital:

You may or may not be taken to the intensive care unit (ICU). You will be connected to monitors that will constantly display your electrocardiogram (ECG or EKG) tracing, blood pressure, other pressure readings, breathing rate, and your oxygen level. You will be given pain medication for incisional pain or you may have had an epidural during surgery which will help with postoperative pain. Your activity will be gradually increased as you get out of bed and walk around for longer periods of time. Your diet will be advanced to solid foods as tolerated. Arrangements will be made for a follow-up visit with your doctor.

At home

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The surgical incision may be tender or sore for several days after an aneurysm repair procedure. Take a pain reliever for soreness as recommended by your doctor. You should not drive until your doctor tells you to. Other activity restrictions may apply.

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.

DOCTORS
that perform the procedure

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Sună Mesaj