ANEURYSMS

Department of CardioVascular surgery

Medical University Plovdiv
University General Hospital Saint George-Plovdiv
 ANATOMICAL LAYERS
THORACIC AORTA
• 1. INTIMA:
• - endothelial cells;

• - connective tissue;

• - elastic membrane.

• 2. MEDIA:
• - elastin;

• - collagen;

• - smooth muscle cells;

• - ground matrix.

• 3. ADVENTITIA:
• - connective tissue;

• - collagen;

• - elastic fibres
 GENERAL
• Aneurysm - permanent localised dilatation of a segment of an
artery

• 2 main types according to layers of arterial wall involved:

• - True aneurysms - containing the 3 layers of the arterial

wall (intima, media, adventitia) in the aneurysm sac;

• - False aneurysms ( Pseudoaneurysm ) - consists of

thrombus contained by adventitia and surrounding tissues
( usually a result of defect in vessel intima from trauma,
dissection, previous surgery)
 GENERAL
• Aneurysms can also be grouped according to their shape:

• 1. Fusiform;
• - whole circumference affected

• 2. Saccular;
• - only part of the circumference is involved

• 3. Dissecting.
• - defect and flap in the intima of artery, resulting in blood tracking into
arterial tissues, splitting the medial layer and creating a false lumen
 GENERAL
• Aneurysms can also be grouped according to their etiology:

• 1. Atheromatous;
• 2. Traumatic;
• 3. Syphilitic;
• 4. Connective tissue disorders ( Marfan syndrome);
• 5. Mycotic
( hardly ever due to fungus, but in general due to bacteria )
 GENERAL
• Aneurysms occur all over the body:

• - in major vessels ( aorta, femoral, popliteal, subclavian,

carotid arteries );

• - in smaller vessels ( cerebral, mesenteric, splenic, renal

arteries and their branches )

• The majority are true fusiform atherosclerotic

aneurysms
 ANEURYSMS
WALL SHAPE ETIOLOGY
1. TRUE 1. FUSIFORM 1. ATHEROMATOUS

3 layers
-
(intima,media,adventitia)

2. FALSE 2. SACCULAR 2. TRAUMATIC

- Single layer
(fibrous tissue)

3. DISSECTING 3. SYPHILITIC

4. COLLAGEN
DISEASE

5. MYCOTIC
 SYPMTOMS
• All aneurysms can cause symptoms due to:

• 1. Expansion;
• 2. Thrombosis;
( thrombotic occlusion of popliteal aneurysm - well-recognised
cause of foot gangrene )

• 3. Rupture;
• 4. Release of emboli.
( emboli from aortic aneurysm can occasionally cause
ischaemia of the toes )
 SYPMTOMS

• Symtoms relate to:

• 1. Affected vessel;

• 2. Site of blood supply;

• 3. Compressed by aneurysm tissues.

 CLINICAL FEATURES

• Clinical features may be divided into:

• 1. INTRINSIC;

• 2. EXTRINSIC
 CLINICAL FEATURES
• INTRINSIC clinical features:
• - swelling exhibiting expansile pulsation in the course of the artery;

• - pulsation diminishes if proximal pressure is applied;

• - sac itself is usually compressible and fills again in 2-3 heart beats if
proximal pressure is released;

• - large aneurysms are frequently full of mural thrombus and may not
be compressible;

• - thrill may be palpable, auscultation sometimes reveals a bruit

 CLINICAL FEATURES
• EXTRINSIC clinical features:
• - Neighbouring or distal structures are affected;

• - Pressure on veins causes distal oedema;

• - Pressure on nerves - altered sensation;

• - Bones, joints, tubes ( trachea, oesophagus ) are sometimes

affected

• - Resilient structures ( intervertebral discs ) withstand

prolonged pressure
 DIFFERENTIAL DIAGNOSIS
• 1. Pulsating tumors:
• - Bone sarcoma;

• - Osteoclastoma;

• - Hypernephroma metastasis.

• 2. Abscesses
• - Swelling, of the chest wall, in the groin, axilla, popliteal fossa,
believed to be an abscess, make sure it does not pulsate, before
incision!!!
 THORACIC AORTIC
ANEURYSMS
• AORTA:
• - Continually exposed to high pulsatile pressure and shear forces;

• - Therefore, prone to mechanical injury, particularly in areas of vessel wall pathology.

• AORTIC ANEURYSMS:
• - Develop anywhere along its length;

• - 75% intra-abdominally;

• - 25% thoracic aortic + thoraco-abdominal aneurysms;

• Typically occurs in men and presents in 5th-7th decade;

• In younger pts. with connective tissue disorders ( Marfan syndrome )

 THORACIC & ABDOMINAL
AORTA: NORMAL DIMENSIONS
Aortic annulus 2-3 cm

Sinuses of Valsalva 2.5-3.5 cm

Sinotubular junction ( STJ ) 2-3 cm

Ascending aorta 2.5-3.5 cm

Aortic arch 2.5-3 cm

Descending aorta 2-3 cm

Diaphragmatic aorta 2-2.5 cm

Infrarenal aorta 1.5-2 cm

 CRAWFORD
CLASSIFICATION
I Beyond LSA to supra-renal abdominal aorta

II Beyond LSA to aorto-iliac bifurcation

III Lower descending aorta ( below 6-th rib ) to aorto-iliac bifurcation

IV Below diaphragm, a.k.a abdominal aneurysm

V Mid-descending thoracic aorta to above diaphragm

 CRAWFORD
CLASSIFICATION
 ETIOLOGY
• AORTIC ROOT & ASCENDING AORTIC
ANEURYSMS:
TRUE ANEURYSM
• - Tertiary syphilis - rare nowadays;

• - Connective tissue disorders ( Marfan syndrome,

Ehlers-Danlos syndrome, Osteogenesis imperfecta, Loeys-Dietz
syndrome ). TRUE ANEURYSM

• DESCENDING THORACIC AORTIC ANEURYSM:

TRUE ANEURYSM
• - Atherosclerosis;

• - Blunt chest injury. FALSE ANEURYSM

 NATURAL HISTORY
• Surgically untreated TAA carry the risk of:

• - 1. Rupture;
• - 2. Dissection;
• - 3. Death.
• Expansion of TAA occurs at faster rate in larger aneurysms
( 0.2 cm. per year in TAA <5 cm. compared to 0.8 cm. per year in TAA
>5cm. )
• The risk of rupture increases as the size of aneurysm
increases
( 0.3% per year for TAA 4-5 cm. compared to 3.6% for TAA >6 cm.)
 Contd…
• Median size for rupture is:

• - 6 cm. for ascending TAA;

• - 7 cm. for descending TAA.

• Mean time from onset of symptoms to rupture is 2 years;

• 5-year survival of surgically untreated
( symptomatic & asymptomatic ):
• - TAA: 39%;
• - Thoraco-abdominal aneurysms: 23%
 PATHOPHYSIOLOGY
• The media of the aorta normally contains:

• - 1. Elastin;

• - 2. Collagen;

• - 3. Smooth muscle cells;

• - 4. Ground matrix
 Contd…
• Aneurysms form after loss of:
• - 1. Smooth muscle cells;
• - 2. Fragmentation of elastin fibres

• The process is called “cystic medial degeneration”

• The result is loss of elasticity and tensile strength of the

media
• Normal aorta expands and recoils with systole and
diastole but dilates when elastic recoil is lost
 PREDISPOSING FACTORS
• 1. AGE;

• 2. BICUSPID AORTIC VALVE ( BAV );

• 3. CONNECTIVE TISSUE DISORDERS;

• 4. DISSECTION;

• 5. TRAUMA;

• 6. SYPHILITIC AORTITIS
 INDEPENDENT RISK FACTORS FOR
RUPTURE OF AORTIC ANEURYSM
• 1. AORTIC DIAMETER;

• 2. PAIN OR OTHER SYMPTOMS OF

EXPANSION;

• 3. AGE;

• 4. CHRONIC OBSTRUCTIVE PULMONARY

DISEASE ( COPD );

• 5. SMOKING
 CLINICAL FEATURES
• Asymptomatic - incidentally discovered on routine CX-R
• Symptomatic:
• - space-occupying lesion in thorax and develop late in the course of aneurysmal
dilatation;

• - pressure on adjacent structures may cause:

• - 1. Pain ( vertebra );

• - 2. Hoarseness ( left recurrent laryngeal nerve );

• - 3. Dysphagia ( oesophagus );

• - 4. Respiratory symptoms ( left main bronchus )

 Contd…

• Aortic root aneurysms lead to:

• - 1. Dilatation of the aortic root annulus;

• - 2. Aortic regurgitation.
 Contd…
• If rupture occurs, it can involve:

• - 1. Pericardium ( Cardiac tamponade );

• - 2. Left pleural space ( dyspnoea );

• - 3. Tracheobronchial airway ( haemoptysis );

• - 4. Oesophagus ( haematemesis )
 MARFAN SYNDROME

• 1. Autosomal dominant;
(fibrillin gene mutation on chromosome 15)

• 2. Many different genetic mutations result in

many different phenotypes;

• 3. Diagnosis is based on 2 or more of the

following clinical features:
 MARFAN SYNDROME
clinical features
• 1. Tall, thin patient - arm span greater than height;
• 2. Arachnodactyly - long tapered fingers;
• 3. High arched palate;
• 4. Scoliosis, pectus excavatum, protraio acetabulae;
• 5. Hypermobility of joints and skin laxity;
• 6. Spontaneous pneumothorax and apical bullae;
• 7. Eye signs ( ectopia lentis, myopia, retinal detachment );

• 8. Floppy mitral valve with mitral regurgitation and chordal rupture;

• 9. Aortopathy with weakened aortic wall which dilates even in
normotensive patients. This is caused by “cystic medial degeneration”
and may result in TAA or dissection.
 EHLERS-DANLOS
SYNDROME

• 1. Autosomal dominant condition;

• 2. Type IV results in structural defect of Type III

collagen and subsequent aortopathy;

• 3. Less common than Marfan syndrome;

 LOEYS-DIETZ SYNDROME
• 1. Autosomal dominant;
• 2. Four types of syndromes caused by 4 different gene
mutations: ( TGFBR1, TGFBR2, SMAD3, TGFB2);
• 3. Features similar to Marfan syndrome and Ehlers-Danlos
syndrome;
• 4. Considerable variability: from mild features to severe
systemic abnormalities;
• 5. Increased risk of ascending aortic aneurysm and dissection;
• 6. Arterial tortuosity - primary manifestation;
 LOEYS-DIETZ SYNDROME
clinical features
• 1. Arterial tortuosity ( winding course of blood
vessels );

• 2. Aortic root & ascending aortic aneurysms;

• 3. Bicuspid aortic valve ( BAV );

• 4. Persistent ductus arteriosus ( PDA );

• 5. Atrial septal defect ( ASD )

 LOEYS-DIETZ SYNDROME
clinical features
• 6. Skeletal / Spinal malformations;
• 7. Sternal abnormalities;
• 8. Contractures of fingers and toes;
• 9. Long fingers and lax joints;
• 10. Club feet;
• 11. Craniosynostosis;
“12,13,14.” distinguish Loeys-Dietz from Marfan
• 12. Hypertelorism; syndrome

• 13. Bifid / Split uvula;

• 14. Skin findings: translucency of skin, velvety texture, easy bruising,
abnormal scars
LOEYS-DIETZ SYNDROME
clinical features
 INVESTIGATIONS
• Echocardiography ( TTE, TEE );
• Contrast MSCT ( possible image reconstructions );
• Cardiac catheterisation / Aortography
( required to demonstrate the relation of arch vessels to
aneurysm and eventual coronary angiography for CAD
confirmation/exclusion );

• MRI
( only in stable pts., contraindicated in ATAAD pts., time-
consuming method )
 INDICATIONS FOR
INTERVENTION ON TAA
• Without surgical treatment, aneurysm is likely to expand and
ultimately rupture

• Important factors taken into consideration when planning

treatment are:

• - 1. Age;

• - 2. General condition;

• - 3. Co-existence of CAD
 Contd…
• SIZE:
• - 1. Ascending aortic aneurysms >5.5 cm.;
• - 2. Ascending aortic aneurysms >4.5 cm. for pts. undergoing
AVR or CABG;
• - 3. Ascending aortic aneurysms 4.0-5.0 cm. for pts. with
Connective tissue disorder ( Marfan syndrome );
• - 4. Aortic arch aneurysms >5.5 cm.;
• - 5. Descending aortic aneurysms >5.5 cm.;
• - 6. Thoraco-abdominal aneurysms >6.0 cm.
 Contd…
• SYMPTOMS:
• - 1. Expansion: chest pain, back pain;
• - 2. Compression: dyspnoea, dysphagia,
hoarseness;
• - 3. Fistula formation: haematemesis, haemoptysis.
• RAPID RATE OF EXPANSION >1cm/year
• RECURRENT EMBOLI ( cerebral emboli from aortic
arch )
 PRINCIPLES OF
AORTIC ANEURYSM SURGERY
• - 1. Aim of surgery to prevent:

• - RUPTURE;

• - DISSECTION;

• - LOCAL COMPRESSION;

• - FISTULA FORMATION.

• - 2. When combined risk of operative mortality and

permanent neurological deficit is less than combined risk
of rupture and dissection
 INDICATIONS FOR
AORTIC ROOT REPLACEMENT
• - 1. Annulo-aortic ectasia - dilatation of the aortic root;

• - 2. Aneurysm of sinus of Valsalva

( non-coronary sinus - most frequently );

• - 3. Aortic root access

( IE of aorta-mitral curtain - Comando operation );

• - 4. DeBakey type I,II ( Stanford type A ) aortic dissection extending

into the aortic root;

• 5. Small aortic root;

• 6. Bicuspid aortic valve and ascending aortic aneurysm or dissection

BICUSPID AORTIC VALVES
 AORTIC ROOT REPLACENET
( BENTALL OPERATION )
• 1. Median sternotomy;
• 2. CPB established between RA & ( IA/SA/FA );
• 3. Mild or deep hypothermia;
• 4. Aorta: cross-clamped above aneurysm;
• 5. Cardioplegia infused into coronary ostia;
• 6. Aorta and aortic valve are resected, coronary ostia are preserved on buttons;
• 7. Composite valved-graft conduit is sutured to the aortic root;
• 8. Coronary ostia are re-implanted into the composite graft;
• 9. Distal anastomosis between the composite graft and native aorta;
• 10. Rewarming patient, excluding air from heart, cardiac activity returns
 VALVE-SPARING ROOT
REPLACEMENT
• If aortic root is dilated but aortic valve is
structurally normal VSRR should be considered:
• - 1. Tirone David operations
( remodelling or reimplantation );
• - 2. Yacoub remodelling procedure.
• In 1 & 2 the structurally normal aortic valve is
preserved, not removed compared to Bentall
operation.
 ASCENDING AORTIC ANEURYSM
SURGERY

• 1. Circulation and myocardium are managed in similar

way to aortic root replacement;

• 2. Procedure involves:

• - 2,1. Resection of the affected aorta;

• - 2,2. Prosthetic Dacron interposition tube graft

replacement
 AORTIC ARCH ANEURYSM SURGERY

• Surgery on this section of the aorta is formidable

undertaking because the cerebral and subclavian
vessels have to be anastomosed to the graft:

• - 1. Separately;

• - 2. En bloc ( peninsula or island technique )

 DESCENDING AORTIC ANEURYSM
SURGERY

• 1. Left thoracotomy;

• 2. Left heart bypass ( no oxygenator )

• 3. Excision of aneurysm and replacement with

prosthetic Dacron interposition tube graft
 THORACIC ENDOVASCULAR AORTIC
REPAIR ( TEVAR )

• 1. Hybrid OR / Cathlab;

• 2. Fluoroscopy;

• 3. Avoiding CPB and SURGERY

• 4. Rapid and full recovery after procedure;

• 5. Expensive in Bulgaria
 OPERATIVE MORTALITY
• 1. Aortic root & ascending aortic surgery: 2-5%

• 2. Aortic arch surgery: 5-10%

• 3. Thoraco-abdominal aortic surgery: 10-20%

• Risk of neurological injury:

• 1. Stroke: 5-10%;

• 2. Paraplegia: 5-10%
( descending aortic replacement )
 LATE RESULTS
5-YEAR SURVIVAL

• Ascending aortic aneurysm - 82%;

• Aortic arch aneurysm - 70%;

• Descending aortic aneurysm - 65%;

• Thoraco-abdominal aneurysm - 65%

 ACUTE AORTIC SYNDROME
• Group of life-threatening thoracic aortic
pathologies that includes:

• - 1. AORTIC DISSECTION;

• - 2. PENETRATING AORTIC ULCER;

• - 3. INTRAMURAL HAEMATOMA;

• - 4 LEAKING AORTIC ANEURYSM

 ACUTE AORTIC SYNDROME
• Management of pts. with acute aortic syndrome should
be similar to those with thoracic aortic aneurysm:
• - 1. Ascending aorta: SURGERY;
• - 2. Descending aorta: MEDICAL MANAGEMENT, but
TEVAR or SURGERY should be considered in pts. with:
• - Impending rupture;
• - Unremitting pain;
• - Organ malperfusion
 INTRAMURAL HAEMATOMA
• Blood within aortic media without presence of intimal tear
• Etiology:
• - 1. Rupture of vasa-vasorum of the media;
• - 2. Haemorrhage within atherosclerotic plaque;
• - 3. Progression from a PAU
• It can resolve spontaneously or progress and increase size
• Unlike dissections, intramural haematomas occur closer to
the adventitia and are at greater risk of RUPTURE than
dissections
 PENETRATING AORTIC ULCER
PAU
• Local intimal defects occurring at the site of
atherosclerotic plaques
• Progressive intimal erosion eventually results in
pulsatile blood entering the media and hence PAUs may
lead to intramural haematomas, dissection, rupture, as
well as pseudo aneurysm and aneurysm formation
• Surgery is indicated for pts. with:
• - 1. Descending aortic ulcers with > 20mm. diameter and
>10mm. depth
• - 2. Ascending aortic ulcers
 AORTIC DISSECTION
• Intimal tear resulting in a split in the aortic wall
between the internal and external elastic
laminae within the media

• TIMING:
• - 1. ACUTE ( <14 days );

• - 2. SUBACUTE ( 14 days - 2 months );

• - 3. CHRONIC ( >2 months )

AORTIC DISSECTION
CLASSIFICATIONS
 AORTIC DISSECTION
CLASSIFICATIONS

STANFORD classification
Type A Ascending aorta involved

Type B Ascending aorta not involved

DeBakey classification
Type I Whole aorta involved

Type II Only ascending aorta involved

Type IIIa Only descending thoracic aorta involved

Type IIIb Descending and abdominal aorta involved

 PATHOPHYSIOLOGY
• Entry tear - point where blood tracks through the
intimal into the media;
• Dissection - classified by the extent of media
stripping from entry tear to the distal re-entry point
• Dissection begins with entry tear and is
propagated by the ingress of blood into the media
spiralling through the length of the aorta
• Multiple re-entry tears - often present in the
descending aorta
ENTRY TEAR LOCATION

65% ASCENDING AORTA

20% DESCENDING AORTA

10% AORTIC ARCH

PREDISPOSING FACTORS
• 1. AGE
• 2. ATHEROSCLEROSIS
• 3. ANEURYSM
• 4. BICUSPID AORTIC VALVE
• 5. HYPERTENSION
• 6. CONNECTIVE TISSUE DISORDERS
• 7. TRAUMA
• 8. SURGERY
• 9. IATROGENIC
• 10. PREGNANCY
 CLINICAL FEATURES
STANFORD TYPE A DISSECTION
• 1. PAIN ( tearing retrosternal chest pain radiating into back or
neck );

• 2. SYMPTOMS OF ORGAN MALPERFUSION ( myocardial

ischaemia, stroke, abdominal pain );

• 3. DYSPNOEA ( secondary to AR, tamponade, haemothorax );

• 4. BLOOD PRESSURE DIFFERENCE between the left and
right arms;

• 5. AORTIC REGURGITATION MURMUR;

• 6. ABSENT PERIPHERAL PULSES