Aneurysm

types, management

1. ANEURYSM ANVIN THOMAS MSC NURSING

2. DEFINITION According to American heart association an aneurysm occurs when part of an artery wall weakness, allowing it to widen abnormally or balloon out. IN OTHER WORDS An aneurysm is a localized sac or dilation formed at a weak point in the wall of the aorta Because of the high pressure in the arterial system, aneurysms can enlarge, producing complications by compressing surrounding structures Aneurysm is the second most frequent disease of the aorta after atherosclerosis

3. CLASSIFICATION CAN BE BASED ON The layers of vessel wall involved True aneurysm False aneurysm Based Up On Morphology Saccular aneurysm Fusiform aneurysm Berry aneurysm Based on Location Based on Pathological Mechanism Secondary to atherosclerotic, Syphilis .

4. THE LAYERS OF VESSEL WALL INVOLVED TRUE ANEURYSM A True Aneurysm Is One That Involve All Three Layers Of The Wall Of An Artery( initima,media And Adventitia) PSEUDO ANEURYSM It Is A Collection Of Blood Leaking Completely Out Of An Artery Or Vein But Confined Next To The Vessels By The Surrounding Tissue A False Aneurysm Occurs When A Blood Vessel Wall Is Injured Like Coronary Angiography, Injury From Knife Or Bullets, Arterial Grafting Etc.

5. MORPHOLOGICAL FEATURES ( SHAPE AND SIZE OF ANEURYSM) The shape of aneurysm is not specific for a specific disease. TYPES SACCULAR ANEURYSM They are spherical in shape and involve only a portion of the vessel wall, they very in size and are often filled either partially or fully by a thrombus. FUSIFORM ANEURYSM A localized dilation of an artery in which the entire circumference  of the vessel is distended. The result is an elongated, tubular,  or spindle like swelling.

6. BERRY ANEURYSM A berry aneurysm, which looks like a berry on a narrow stem, is the most common type of brain aneurysm. They make up 90 percent  of all brain aneurysms, according to Stanford Health Care. Berry aneurysms tend to appear at the base of the brain where the major blood vessels meet, also known as the Circle of Willis . When a berry aneurysm ruptures, blood from the artery moves into the brain causing subarachnoid haemorrhage.

7. Aneurysm can be classified by there location and symptoms will differ by the site of the aneurysm Renal Aneurysm Abdominal Aortic Aneurysm Intra Cranial Aneurysm Thoracic Aortic Aneurysm LOCATION

8. RENAL ANEURYSM A renal artery aneurysm is a dilated segment of renal artery that exceeds twice the diameter of normal renal artery Incidence Renal artery aneurysm is very rare consist of only.1 to .o9% while rupture is even more rare. Signs and symptoms Flank pain and tenderness Hypertension Haematuria Signs of hypovolemic shock

9. INTRACRANIAL ANEURYSM / BRAIN ANEURYSM It’s a weakness in the wall of cerebral artery or vein causes a localized dilation or ballooning of the ballooning of the blood vessel. Classification of cerebral aneurysm Small aneurysm have a diameter less than 15mm. Large 15 to 25mm Giant 25 to 50mm Super giant over 50mm Signs and symptoms before large aneurysms ruptures Severe head ache Nausea , vomiting Vision and speech impairement

10. COMPLICATION OF BRAIN ANEURYSM The aneurysm ruptures it can lead to haemorrhage stroke. A raptured aneurysm quickly become life threatening and requires prompt medical treatment. According to the meta analysis done by Boogaarts ‘etal’ in the year 2015 they found that aneurysmal rupture prior to treatment is a major cause of death and morbidity in aneurysmal subarachnoid haemorrhage. They also found that aneurysm size is an important risk factor for aneurysmal bleeding.

11. ATHEROSCLEROTIC ANEURYSM Atherosclerotic Aneurysms are aneurysms caused by atherosclerosis and typically occur in the abdominal aorta. Inflammation associated with atherosclerosis leads to destruction, thinning and thus weakening of vascular wall, specifically the tunica media, which leads to aneurysmal dilation of the vessel.

12. SYPHILITIC ANEURYSM Syphilitic Aneurysms arise during tertiary syphilis due to chronic inflammation in the tunica adventitia of large elastic arteries, particularly the aorta. Ischemia of the tunica media, combined with further syphilitic invasion into the tunica media itself, results in medial destruction and weakening, ultimately causing dilation and aneurysm-formation.

13. AORTIC ANEURYSM Aneurysm are out pouching or dilation of the arterial wall and are common problems involving aorta TYPES OF AORTIC ANEURYSM Thoracic Aortic Aneurysm Abdominal Aortic Aneurysm

14. THORACIC AORTIC ANEURYSM It is primarily in the thorax. It is the ballooning of the upper aspect of aorta, above the diaphragm. The principal causes of death due to thoracic aneurysmal disease are dissection and rupture. Once rupture occurs the mortality rate is 50 to 80%.

15. COMPLICATION OF THORACIC ANEURYSM Untreated or unrecognised aneurysm can be fatal due to dissection or popping of the aneurysm leading to nearly instant death.

16. SIGNS AND SYMPTOMS OF TAA Compression of Superior venacava may produce congestion of head, neck and upper extremities. Pulse and BP differences Chest pain Abnormal pulsation apparent on chest Shortness of breath Cough Hoarseness Dysphagia

17. ABDOMINAL AORTIC ANEURYSM It is an enlargement in the area in the lower part of the aorta , the major blood vessel that supplies blood to the body. It is defined by increase in size > 3 cm Most common form of aortic aneurysm Signs and symptoms A pulsating feeling near the navel Back pain Deep constant pain in your abdomen. V ast majority of aneurysm are asymptomatic unless raptured. R upture may result in pain in the abdomen or back, low blood pressure and often result in death.

18. COMMON CAUSES FOR ANEURYSM ETIOLOGY/ RISK FACTORS Atherosclerosis may contribute to weakening of blood vessel Infection which affect the arterial wall Syphilis Marfan syndrome Penetrating or blunt trauma High blood pressure it may enlarge or weaken the blood vessel Older age(greater than 60) Male sex Smoking Family history of aneurysmal disease

19. GENERAL PATHOPHYSIOLOGY Due To Etiological Reasons Like Atherosclerosis , Trauma Or Infection May Contribute To ↓ Weakening And Degeneration Of A Blood Vessel Wall ↓ Hypertensive Injury May Compound There Denegation And Accelerate The Expansion Of Aneurysm ↓ As The Aneurysm Expands The Wall Tension Increases ↓ Further Weakening Of Vessel Walls ↓ If Not Treated: Rupture

20. DIAGNOSIS History collection Physical examination X- Ray ECG ultrasonography CT angiography MRI Echocardiogram

21. PHYSICAL EXAMINATION In abdominal aortic aneurysm with palpation, pulsating mass in the middle of a patients abdomen Bruits may be auscultated with a stethoscope placed over the aneurysm Blue toe syndrome Patients may be hypotensive, even calm and quite extremities can be felt( specially in rupture)

22. Shows any abnormal widening of the thoracic aorta , widening of mediastinum A plan X- Ray of the abdomen may shows calcification within the wall of AAA. X- RAY

23. ULTRASONOGRAPHY Useful in screening of aneurysm and to serially monitor aneurysm size.

24. Ct angiography Most accurate test(gold standard) to determine the anterior to posterior length the cross sectional diameters and the presence of thrombus in aneurysm

25. Magnetic resonance imaging [MRI] MRI used assess the location and severity of aneurysm.

26. MANAGEMENT OF ANEURYSM The Goal Of Management Is To Prevent The Aneurysm From Rupturing. For Individuals With Small Aneurysm Less Than 4cm Conservative Therapy Is Typically Initiated. CONSERVATIVE THERAPY INCLUDE Risk factors modification Decreasing blood pressure Monitoring aneurysm size every 6 months using USG, MRI and CT scan.

27. INDICATION OF SURGERY FOR AORTIC ANEURYSM Persistent pain Aortic valve involvement Coronary artery involvement Diameter grater than 5.5 cm or rapidly expanding ( greater than .5cm per year) for patients with no comorbidities. Symptomatic patients should undergo aneurysm resection, regardless of aneurysm size. Emergency operation is indicated in the setting of acute rupture.

28. ENDO VASCULAR GRAFT PROCEDURE It is an alternative to conventional surgical repair of AAA. This techniques involves the placement of a suture less aortic graft into the abdominal aorta inside the aneurysm via femoral artery cut down After the graft is delivered to the predetermined point , the graft is pressed or implanted against the vessel wall by balloon inflation The blood then flows through the vascular graft, thus preventing the expansion of the aneurysm due to pressure, and the aneurysmal wall begin to shrink over time because the blood is now being diverted through the endograft.

29. OPEN VS. EVAR OPEN SURGICAL REPAIR – Longer Recovery Time Longer Hospital Stay   – 90% Long Term Success   – Younger patients typically. EVAR – Shorter length of stay – Reduction in blood loss – ICU utilization reduced – Reduce morbidity/mortality rate – Older patients typically – Needs long-term follow-up – May need secondary procedures for end leaks.

30. BENEFIT V/S COMPLICATIONS OF ENDOVASCULAR REPAIR BENEFITS Decreased anaesthesia and operative time Smaller operative blood loss, small incision Decreased morbidity and mortality Shortened the length of hospital stay Quicker recovery Reduction in over all costs. COMPLICATIONS Aneurysm rupture Perigraft leaks Aortic dissection Graft dislocation and embolization Renal artery occlusion due to graft migration

31. SURGICAL MANAGEMENT Clipping the aneurysm Wrapping the aneurysm Coiling the aneurysm Endovascular graft procedure.

32. CLIPPING THE ANEURYSM Most common surgical treatment used for brain aneurysm(berry aneurysm) The goal of clipping is to place a small metallic clip or clips along the neck of the aneurysm This prevents blood from entering into the aneurysmal sac so that there is no longer pose a risk for bleeding Once an aneurysm is clipped ,the clip remains in place for life . The aneurysm will shrink and scar down permanently after clipping.

33. WRAPPING THE ANEURYSM Fusiform aneurysm are challenging to treat with direct clipping So it may be wrapped with biologic or synthetic wrap and prevent rupture .

34. COILING OF ANEURYSM A coil is used to occlude the aneurysm, coils are made of soft , springlike platinum. The softness of the platinum allows the coil to assume the shape of irregularly shaped aneurysm A catheter is introduced in to the femoral artery and threaded up to the cerebral blood vessel Platinum coils attached to a thin wire are inserted into the catheter and then placed in the aneurysm until the aneurysm is filled with the coil. So it packing prevents the blood from circulating through the aneurysm and reduce the risk of rupture.

35. NURSING DIAGNOSIS AND INTERVENTION Decreased cardiac out put related to changes in intra vascular volume, haemorrhage. Monitor vital signs, Obtain information regarding back or abdominal pain 2. Anxiety related to fear of death, sudden onset of illness as evidenced by increased alertness and restlessness Explain all procedures in simple words Reduce unnecessary external stimuli 3. Deficient knowledge (preoperatively and post operatively) related to newly identified need for aortic surgery. Instruct the patient not to lift any heavy objects(beyond 2.5 kg) for about 6 to 12 weeks after surgery . Teach the client about the importance of wound care.

36. CONCLUSION

37. BIBLIOGRAPHY 1.Lewis’s medical surgical nursing. Elsevier;2011.page 896-901. 2. Cagnazzo ‘ etal ’.Aneurysm rebleeding after placement of extericular drainage. A systematic review and meta analysis .actanerochirugica.2017 april 1;159(4):695-704. 3 .Richard Hatchett. Cardiac nursing.Elsevier;2007.page 397-405. 4.Joseph loscalzo . Harrison’s cardiovascular medicine. 2ed. Mc graw hill education;page 467-475. 5.Javeed Ansari, Davinder kaur . Medical surgical nursing.peeve;2015.page 8219-835.