Understanding Aneurysms

• Aneurysms can happen in any vessel

Aneurysms

• Localized dilatation and weakening of the wall of a blood vessel.
• A sign of aneurysm is a pulsating swelling that produces blowing murmur on auscultation.
• Rupture can cause hemorrhage.
• Thrombus may form in "dilated pouch" and give rise to emboli that may obstruct smaller vessels
• Causes of aneurysms are weakening of the blood vessel wall or atherosclerosis.
• Aneurysms can be "ballooning" or dissecting/non-dissecting

Types of Aneurysms

• True Aneurysms involve the intima/media/adventitia (all 3 layers).
• False or Pseudo-aneurysms: Collection of blood leaking completely out of an artery or vein but confined next to the vessel by surrounding tissue forming a clot. The blood is leaking or freely flowing through the tissues.
• Aneurysms can be classified by shape and size: Saccular and Fusiform
• A Saccular aneurysm is usually spherical in shape and involves only a portion of the vessel wall.
• A Fusiform ("spindle-shaped") aneurysm often involves large portions of the ascending and transverse aortic arch, abdominal aorta, or less frequently the iliac arteries.
• Mycotic aneurysms are caused by the growth of fungi or bacteria within the vascular wall, usually following impaction of a septic embolus.
• Dissecting aneurysms result from hemorrhage that causes longitudinal splitting of the arterial wall, producing a tear in the intima and establishing communication with the lumen.

Aortic Aneurysms

• Infrarenal: Located below the renal arteries, often at the bifurcation of the aorta.
• Infrarenal aneurysms may be symptomatic or asymptomatic.
• If symptomatic, a chronic mid-abdominal &/or low back pain may be present
• A symptom of an infrarenal aortic aneurysm may be a pulsating abdominal mass.
• Rupture of an infrarenal aortic aneurysm is usually indicated by severe back or abdominal pain.
• Infrarenal aneurysms account for approximately 90% of aortic aneurysms.
• Thoracic: Usually due to artherosclerosis.
• Thoracic aneurysms may also be due to Marfan's syndrome, cystic medial necrosis, & vasculitis.
• Thoracic aneurysms due to trauma are usually a result of rapid deceleration accidents.
• Thoracic aneurysms are usually asymptomatic.
• If symptomatic, a substernal, back, or neck pain may be present.
• Pressure on the trachea, esophagus, or SVC (superior vena cava) can result in dyspnea, stridor, dysphagia, hoarseness, edema in cervical & UEs, and JVD (jugular venous distension).
• Thoracic aneurysms account for less than 10% of aortic aneurysms.

Aortic Dissection

• Aortic dissection originates at the site of an intimal tear and continues distally.
• Types of aortic dissection: Proximal dissections and Distal dissections
• Aortic dissection is LETHAL if undiagnosed.
• Aortic dissection is usually caused by a rupture of the aorta into the pericardial sac or pleural space, or due to acute aortic regurgitation with left ventricular failure.
• Symptoms are often confused with MI (myocardial infarction) and other causes of chest pain.
• If present, aggressive measures are taken to lower HTN with fast-acting medications.
• Ascending aorta lesions by the aortic valve require emergent surgical repair.
• Tears distal to the left subclavian artery are often managed with aggressive drug therapy.
• Some exceptions require surgical repair: severe pain, an aortic rupture, ischemia, or progression of dissection.
• Types of aortic dissection: Type A vs Type B (A involves any part of the ascending aorta).
• Aortic aneurysms are named for their locations (ex: AAA, TAA).

Peripheral Artery Aneurysms

• Most occur in men.
• Approximately 50% are symptomatic at the time of diagnosis.
• Popliteal artery aneurysms account for about 85% of all peripheral artery aneurysms.
• Use ultrasound to diagnose and measure diameter of popliteal artery aneurysms.
• Use arteriography to define the anatomy of outflow vessels in prep for surgery.
• Femoral artery aneurysm presents as a pulsatile mass on one or both sides of the thigh.
• Complications occur less frequently than w/popliteal aneurysms.
• Asymptomatic aneurysms are often NOT repaired.
• Pseudo-aneurysms may develop at distal anastomotic sites from previous aortic surgery, and these may require repair.

Treatment of Aneurysms

• Treatment for aneurysms is Surgical excision and grafting
• Endovascular repair (EVAR) vs Open repair.
• Complications include: MI, Bleeding, Respiratory insufficiency, Limb ischemia, Ischemic colitis, Renal insufficiency, Stroke.

Endocarditis

• Inflammation of endocardium (usually due to microbial infection).
• Causes: typically bacteria entering the blood.
• Can cause valve damage, and can be fatal.
• Endocarditis Characterized by: Fever, Murmur, Vegetation.
• Symptoms: Low-grade fever, Fatigue, Weight loss, Night sweats.
• Treatment is antibiotics.

Pericarditis

• Inflammation of pericardial sac (pericardium).
• Commonly caused by viral infection.
• Also caused by: Heart surgery, MI, Trauma, Tumors, Cancer, Radiation, Autoimmune diseases (such as RA, lupus or scleroderma), Immunosuppressive meds.
• Symptoms: Chest pain, dyspnea, high RHR, Fever, Pericardial rub on auscultation.
• May progress to Pericardial effusion (excess fluid around the heart).
• Leading to Cardiac Tamponade EMERGENCY.

Pericarditis Treatment

• Pain may be relieved with positioning (not so with MI).
• Worse in supine and with inspiration.
• Aspirin and NSAIDs to reduce inflammation and swelling.
• Antibiotics if the bacterial infection is the cause.
• If progresses to pericardial effusion and/or tamponade, perform surgery.
• Possible surgical interventions include Pericardiocentesis or Pericardial window

Cardiac Tumors

• Cardiac tumors are generally very rare and many are curable with surgery.
• Benign tumors are more common than malignant ones
• The most common tumor is myxoma
• Symptoms of myxoma include: DOE, PND, fever, weight loss, dizziness, syncope, hemoptysis, Raynaud's, arrhythmias, and sudden death.
• Malignant tumors are usually classified as sarcomas:
• Hemangiosarcomas (most common) and Rhabdomyosarcoma.
• Occasionally see small benign vascular tumors, such as Hemangiomas.
• Cardiac metastases are more frequent than primary neoplasms.
• Some tumors have a high propensity for cardiac or pericardial metastases.
• May see with leukemias, melanoma, thyroid cancer, lung cancer, sarcomas, esophageal cancer, renal cell cancer, lymphomas, and breast cancer.
• Treatment is for underlying disease and include surgery.