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Multiple Aneurysms. In 1982 Cohen et al reviewed 1500 patients with AAA In 1982 Cohen et al reviewed 1500 patients with AAA 13% had multiple aneurysms.

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Presentation on theme: "Multiple Aneurysms. In 1982 Cohen et al reviewed 1500 patients with AAA In 1982 Cohen et al reviewed 1500 patients with AAA 13% had multiple aneurysms."— Presentation transcript:

1 Multiple Aneurysms

2 In 1982 Cohen et al reviewed 1500 patients with AAA In 1982 Cohen et al reviewed 1500 patients with AAA 13% had multiple aneurysms 13% had multiple aneurysms 72% synchronously/28% metachronously 72% synchronously/28% metachronously Cause: 62% - nonspecific, 23% dissection Cause: 62% - nonspecific, 23% dissection Location: Abdominal – 63% Location: Abdominal – 63% Thoracoabdominal - 14% Thoracoabdominal - 14% Descending aorta – 13% Descending aorta – 13% Aortic arch – 5% Aortic arch – 5% Ascending aorta - 5% Ascending aorta - 5% Rutherford

3 Multiple Aneurysms In 1990 Gloviczki et al reviewed 102 patients with multiple aneurysm – over two decades In 1990 Gloviczki et al reviewed 102 patients with multiple aneurysm – over two decades Age: range 20 – 81 yrs Age: range 20 – 81 yrs Total 201 aortic reconstructions – 3.4% of all aortic aneurysm performed during that time Total 201 aortic reconstructions – 3.4% of all aortic aneurysm performed during that time Location: Location: Infrarenal – 30.9% Infrarenal – 30.9% Descending aorta – 26.7% Descending aorta – 26.7% Thoracoabdominal – 23.0% Thoracoabdominal – 23.0% Aortic arch – 19.3% Aortic arch – 19.3% JVS, 1990

4 Gloviczki et al, cont’d 53.9% had Multiple aneurysm at first repair 53.9% had Multiple aneurysm at first repair 21 pts underwent simultaneous repair of at least 2 aortic aneuysm 21 pts underwent simultaneous repair of at least 2 aortic aneuysm 7 of the 21 pts (33.3%) died 7 of the 21 pts (33.3%) died 27 emergency procedures 27 emergency procedures 15 - rupture 15 - rupture 11 - pain 11 - pain 1 – distal embolization with leg ischemia 1 – distal embolization with leg ischemia 3 ruptured descending thoracic aneurysn 3 ruptured descending thoracic aneurysn ( 4cm, 4 cm, 3.8 cm ) ( 4cm, 4 cm, 3.8 cm ) One ruptured 2 days after AAA repair One ruptured 2 days after AAA repair

5 Two stage operation for multiple aneurysms of the thoracic aorta,abdominal aorta and left common iliac artery in octagenarian Kudaka et al Japanese Annal of Thoracic and Cardiovascular Surgery AAA and iliac aneurysm resected first due to risk of thromboembolism 52 days later – Repair of descending aorta AAA and iliac aneurysm resected first due to risk of thromboembolism 52 days later – Repair of descending aorta Discharged home POD#25 Discharged home POD#25

6 Genetics and aneurysm Familial clustering in 10-20% first degree relatives Familial clustering in 10-20% first degree relatives Marfan’s (fibrillin ) Marfan’s (fibrillin ) Ehler’s Danlos – type 4 ( procollagen III) Ehler’s Danlos – type 4 ( procollagen III) Aneurysms at an early age in these patients Aneurysms at an early age in these patients Less type III collagen in aortic media Less type III collagen in aortic media Abnormality on long arm of chromosome 16 Abnormality on long arm of chromosome 16

7 Aneurysm Classification by Etiology TypeExample CongenitalIdiopathicTurner’s Connective tissue disorder Marfan’s Ehlers Danlos Cystic medial necrosis Berry DegenerativeAtherosclerotic Fibromuscular dysplasia InfectiousBacterialFungalSyphilis Rutherford

8 InflammatoryTakayasu’sBehcet’sKawasaki Giant cell arteritis SLE Post Dissection IdiopathicTrauma Post stenotic Thoracic Outlet Syndrome Coarctation PseudoaneurysmTrauma Anastamotic disruption Miscellaneous Pregnancy associated Aneurysm Classification by Etiology cont’d

9 Thoracoabdominal Aneurysms Principle goal – prevent rupture and death Principle goal – prevent rupture and death Most Surgeons choose to intervene when > 6cm Most Surgeons choose to intervene when > 6cm Smaller aneurysm followed by CT scan every 6 months Smaller aneurysm followed by CT scan every 6 months If expands > 5mm in 6 months – intervene If expands > 5mm in 6 months – intervene Patient with family history of AA Patient with family history of AA Women of small stature with 5cm aneurysm Women of small stature with 5cm aneurysm Cameron

10 Spinal cord perfusion, minimize visceral organ ischemia and renal dysfunction

11 Visceral Aneurysms Relatively uncommon Relatively uncommon 25% present as emergency 25% present as emergency 8.5% result in death 8.5% result in death Frequency Frequency Splenic – 60% F:M 4:1, rupture during pregnancy Splenic – 60% F:M 4:1, rupture during pregnancy Hepatic – 20% M:F 2:1, trauma, IVD, inflammation Hepatic – 20% M:F 2:1, trauma, IVD, inflammation SMA – 5.5% SMA – 5.5% Aggressive approach in management because of high mortality associated with rupture

12 Popliteal Aneurysm Most frequent peripheral aneurysm – 70% Most frequent peripheral aneurysm – 70% M:F 30:1 M:F 30:1 >50% bilateral >50% bilateral 33% has AAA 33% has AAA Most common manifestation Most common manifestation - thrombosis ( 40% ) - thrombosis ( 40% ) - embolization ( 25% ) - embolization ( 25% ) 25% with distal thromboembolism come to amputation 25% with distal thromboembolism come to amputation Rupture – rare - < 5% Rupture – rare - < 5% Sabiston Indication for treatment Acute lower limb ischemia from acute occlusion Transverse diameter > 2cm

13 Diameter of normal arteries ( cm ) FemaleMale Aorta-Descending-Supraceliac-Suprarenal-Infrarenal 2.4 – – – – – – – 2.4 Iliac-Common-Internal 0.9 – – Popliteal0.90.9


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