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AAA for resident

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  1. 1. Teaching Topic AAA For resident F2 :Parach Sirisriro
  2. 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. 3. Shape • Fusiform aneurysm • Saccular aneurysm ( relate infected )
  4. 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. 5. Conclusion AP Diameter≥ 3 cm
  6. 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
  7. 7. • Chlamydia pneumoniae could be a possible stimulus
  8. 8. EPIDEMIOLOGY Dashed lines = incidence of all AAAs; solid lines = incidence of ruptured AAAs
  9. 9. Rutherford 6th
  10. 10. ***DM not risk factor
  11. 11. 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.
  12. 12. • Men≥ 60 years :have a sibling or parent with an AAA should have a physical examination and ultrasound screening.
  13. 13. • 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
  14. 14. • Physical examination and abdominal U/Sเพื่อ ค้นหาAAA ในผู้ชายที่อายุ 60 ปีขึ้นไปและมีพี่น้องร่วมมารดาหรือ บุตรของผู้ป่วยที่มี AAA ACC/AHA guildline & ศัลยทั่วไปเล่ม 6
  15. 15. 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 )
  16. 16. • Fever  infected aneurysm , inflamatory aneurysm • GI bleeding  Aortoenteric fistular • CHF  Aortocaval fistular
  17. 17. 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)
  18. 18. 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
  19. 19. • Fever R/O infected aneurysm • Pulse all extremities preoperational (detect post operative emboli ) • Grey turner’s sign
  20. 20. • 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.
  21. 21. Investigation
  22. 22. • 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
  23. 23. • 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)
  24. 24. • 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.
  25. 25. 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
  26. 26. A left retroperitoneal approach is advocated because it allows easier management of the multiple accessory renal arteries
  27. 27. • Usually these are patients with associated renal or mesenteric disease or iliofemoral occlusive disease or patients with anomalies such as horseshoe or pelvic kidney.
  28. 28. CTA • Type AAA (sacular or fusiform) • ดูแยก infraกับsupra renal AAA โดยดู Lt renal vein • Extension • Size • Rupture or not
  29. 29. (Sign of rupture : contrast อยู่ใน thrombus /Retroperitonium hematoma , discontinue aortic wall )
  30. 30. • recommend a CT size measurement for AAAs, followed by ultrasound if they approach the threshold for elective repair.
  31. 31. 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
  32. 32. • 6 months F/U AAAs 4-4.9 cm • 3 months F/U AAAs 5-5.5 cm
  33. 33. 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.
  34. 34. • Statins should be started one month before intervention to reduce cardiovascular morbidity. • Doxycycline seems more promising
  35. 35. • 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
  36. 36. • 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.
  37. 37. Surgical management Elective AAA • EVAR • Open surgery -Transabdominal -Retroperitoneum • Laparoscopic Rupture AAA •open -Transabdominal Infected AAA -Extranatomical bypass
  38. 38. 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
  39. 39. Preoperative management
  40. 40. *
  41. 41. Elective AAA
  42. 42. • IV ATB (usually cephalosporin) • intravenous access • intra-arterial pressure recording • Foley catheter monitoring of urine output
  43. 43. 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.
  44. 44. • 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
  45. 45. A left retroperitoneal approach is advocated because it allows easier management of the multiple accessory renal arteries
  46. 46. 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
  47. 47. • 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
  48. 48. Operative management • Scrub Prep before Anesthesia (nipple line to knee ) • Midline incision xyphoid to symphysis
  49. 49. • 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.
  50. 50. 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).
  51. 51. •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.
  52. 52. 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.
  53. 53. Foley cath เบอร์ 24
  54. 54. ควรเลาะ dorsal peritoneum ให้ห่างจาก duodenum 1-2 cm เพราะเวลาเย็บปิดจะได้ไม่เย็บ โดน duodenum ในกรณี hematoma ต้องหา friendly triangle
  55. 55. Mobilising the renal vein การตัด Rt renal vein ควรตัด ให้ proximal ต่อ gonodal vein and adrenal vein
  56. 56. 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.
  57. 57. Bleeding lumbar arteries and IMA are oversewn from within the sack with figure-of-eight 2-0 silk sutures.
  58. 58. Ligate IMA ต้อง ทาจาก ด้านใน เพราะ กลัวโดน collateral
  59. 59. Reimplant IMA ( ในทางปฏิบัติ try bulldog at IMA - no discolor of colon –ligation ได้ )
  60. 60. • 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.
  61. 61. 3-0 polypropylene
  62. 62. 4-0 polypropylene suture
  63. 63. Adventage • Minimal invasive operation  ฟื้นตัวไว • Cost < endovascular • เหมาะในรายที่ทา endovascular ไม่ได้ Disadventage • Require more learning curve Laparoscopic Abdominal Aortic Surgery
  64. 64. EVAR
  65. 65. 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
  66. 66. • Infrarenal aortic neck length > 1.5 cm • Aortic neck-body angle < 60 degree • Iliac seal zone > 1.5 cm • Iliac angle < 90 degree
  67. 67. • Check pulse postoperative R/O
  68. 68. Infected aneurysm
  69. 69. • Fungal arterial infections are rare but characteristically occur in patients with chronic immune suppression or diabetes mellitus
  70. 70. DIAGNOSIS • Laboratory Studies -Gram stains Aneurysm wall -Aneurysm wall and contents culture ( aerobic and anaerobic bacteria and fungi )
  71. 71. • 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
  72. 72. 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).
  73. 73. • CT and MRI fails to give specific information about the presence or absence of infection.
  74. 74. 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
  75. 75. 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
  76. 76. 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
  77. 77. • The entire aneurysm is resected, the infected tissues are thoroughly débrided, drainage is established • Extra anatomical bypass
  78. 78. • Prolong ATB 6 wk
  79. 79. 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
  80. 80. Cardiac complication • MI • Prevent -Adequate preload -Adequate oxygen -Control pain -HCT> 28
  81. 81. Renal failure • Suprarenal > infrarenal cross clamp Prevent -Optimal IV fluid -Mannitol -Loop diuretic Or Low dose dopamine
  82. 82. 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
  83. 83. 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
  84. 84. • 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
  85. 85. 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
  86. 86. • Treatment - ligated aorta proximal to the graft - remove prosthesis - extranatomical bypass - primary duodenum repair
  87. 87. THE END