Lecture Cardio Physiotherapy 3

7/30/2019 Lecture Cardio Physiotherapy 3

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AORTIC ANEURYSM


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DEFINITION

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 surroundingstructures


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CLASSIFICATION


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A fusiform aneurysm is a diffuse dilation that

involves the entire circumference of the arterial

segment. A saccular aneurysm is a distinct, localized out

pouching of the artery wall.

A dissecting aneurysm is created when bloodseparates the layers of an artery wall, forming a

cavity between them.

A false aneurysm (pseudoaneurysm) occurswhen the clot and connective tissue are outside

the arterial.


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ABDOMINAL AORTIC ANEURYSMS


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INCIDENCE 1. Approximately 36.5 abdominal aortic

aneurysms are diagnosed per 100,000 individuals.

Abdominal aneurysms are most common in

individuals older than 50 years of age.

They are more common in men than women, withratios of 2:1.

Three fourth of true aortic aneurysm occur in

abdomen and one fourth in the thoracic aorta

The average mortality rate for persons undergoing

elective abdominal aneurysm repair is 4 to 5

percent.


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Rupture of abdominal aortic aneurysm isthe 15th most common cause of death for

men in the United States.

Fifty percent of all persons whoseaneurysms rupture before they can be

transported into the operating

room will die.

For persons who undergo emergency

surgical repair mortality rate is also high,

around 54 percent.


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ETIOLOGY Atherosclerosis

Uncontrolled hypertension

inherited or congenital syndromes, such as Marfan

syndrome or Ehlers-Danlos syndrome.

Infection Tobacco use

Anastomotic (postarteriotomy) and graft

aneurysms

Blunt or sharp trauma, including operative trauma,

can damage the aortic wall.


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PATHOPHYSIOLOGY Most commonly, atherosclerotic plaque collects

on the intimal surface of the aorta.

This plaque formation will cause degenerative

changes in the media

The destruction of the medial layer of a segment

of the aorta leads to loss of elasticity, weakening

Dilation of the aorta


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CLINICAL MANIFESTATION

THORACIC AORTIC ANEURYSMS

Pulse and BP difference in upper extremities

Pain and pressure symptoms

Constant pain because of pressure

Intermittent and neuralgic pain

Dyspnea, Abnormal pulsation apparent on chest


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CONTINUED.. Hoarseness, voice weakness, or complete

aphonia, Dysphagia

Dilated superficial veins on chest

Cyanosis

Distended neck veins and edema of the head

and leg


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ABDOMINAL ANEURYSM

Asymptomatic

Abdominal pain is most common, either

persistent or intermittent often localized

in middle or lower abdomen to the left ofmidline

Lower back pain

Feeling of an abdominal pulsating mass

Thrill, auscultated as a bruit


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CONTINUED Hypertension

Distal variability of BP, pressure in arm greater

than thigh

Thrombi may form and and thenembolize,traveling to other arteries and

causing ischemia to affected limb

If rupture, will present with hypotension

and/or hypovolemic shock


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DIAGNOSTIC EVALUATION

Health history

Physical examination

Abdominal ultrasound

Arteriography

X-ray

Computed tomography


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COMPLICATIONS

Fatal hemorrhage

Myocardial ischemia

Stroke

Paraplegia due to interruption ofanterior spinal artery

Abdominal ischemia


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Continued.

Graft occlusion

Graft infections

Acute renal failure

Lower extremity ischemia

Death


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PROGNOSIS

With early diagnosis and treatment the

prognosis is good

When the aneurysm ruptures survival rate

drops dramatically to below 50 percent


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COLLABORATIVE CARE

Early treatment and detection is

imperative

If aneurysm is larger than 5-6cm or

increasing aneurysm by 0.5 cm over a six

month period surgical repair is the

treatment

For individuals with small aneurysm lessthan 4cm conservative therapy is initiated

Coronary and carotid artery should be

assessed for atherosclerotic disease


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Incising the diseased segment of the aorta


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1. insertion of synthetic graft


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3.suturing native aortic wall over synthetic

graft


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ENDOVASCULAR GRAFTING

Endovascular grafting involves the

transluminal placement and attachment of a

sutureless aortic graft prosthesis across an

aneurysm


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COMPLICATIONS OF ENDOVASCULAR

GRAFTING

bleeding,

hematoma,

wound infection at the femoral insertion site; distal

ischemia or embolization; dissection or

perforation of the aorta;


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CONTINUED.

Graft thrombosis; graft infection; breakof the attachment system;

Graft migration; proximal or distal graft

leaks; delayed rupture

Bowel ischemia.


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PATIENT EDUCATION AND HEALTH

MAINTENANCE

Instruct patient about medications to control

BP and the importance of taking them.

Discuss disease process and signs andsymptoms of expanding aneurysm or

impending rupture,

For postsurgical patients, discuss warningsigns of postoperative complications (fever,

inflammation of operative site, bleeding, and

swelling).


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CONTINUED..

Encourage adequate balanced intake for woundhealing.

Encourage patient to maintain an exercise schedule

postoperatively. Instruct patient that due to use of a prosthetic graft

to repair the aneurysm, he will require prophylactic

antibiotic use for invasive procedures, includingroutine dental examinations and dental cleaning


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EVALUATION: EXPECTED OUTCOMES

TISSUE COLOR, SENSATION, AND

TEMPERATURE NORMAL; NONTENDER,

NONSWOLLEN, AND INTACT

NO SIGNS OF INFECTION

REPORTS CONTROL OF PAIN WITH

MEDICATION


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AORTIC DISSECTION


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DEFINITION

Aortic dissection, occurring most

commonly in the thoracic aorta, is the

result of a tear in the intimal (innermostlining of the arterial wall) that allows

blood to enter between the intima and

media, thus creating a false lumen


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CLASSIFICATION


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CLASSIFICATION

Type A dissections

Include types I and II of DeBakey'sclassification

Involve the ascending aorta or the ascending

and descending aorta

Are the most common and lethal type

Require immediate surgicaL treatment

CONTINUED


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CONTINUED.

Type B dissections

Do not involve the ascending aorta

Begin distal to the subclavian artery and

extend downward into the descending and

abdominal aorta

Are also known as type III of DeBakey's

classification often initially treated with medical therapy


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INCIDENCE

They are three times more common in men than in

women

most commonly in the 50- to 70-year-old age group

Approximately 60,000 cases are diagnosed each

year in the United States.


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ETIOLOGY

Marfan syndrome

Congenital heart disease

A history of hypertension

Pregnancy

Trauma

Iatrogenic injuries

Atherosclerosis


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Continued

A rupture may occur through adventitia orinto the lumen through the intima,

Allows blood to reenter the main channel

Resulting in chronic dissection or occlusionof branches of the aorta.

As the heart contracts, each systolic

pulsation causes increased pressure on the

damaged area, which further increases the

dissection


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The dissection of the aorta may progress

backward in the direction of the heart,

obstructing the openings to the coronary

arteries or producing hemopericardium

(effusion of blood into the pericardial sac) or

aortic insufficiency,

it may progress forward , causing occlusion ofthe arteries supplying the gastrointestinal

tract, kidney, spinal cord, and legs


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Sudden onset of pain that is described as severe and

tearing. The pain is typically associated with diaphor-esis.

The typical patient with acute aortic dissection usuallyhas sudden, severe pain in the anterior part of the

chest or intra scapular pain radiating down the spineinto the abdomen or legs

Location of the pain depends on the site of the dissec-tion.

Typically, the pain is localized to either the front or theback of the chest.

The pain may migrate along the direction of the dis-

section.


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Cardiac tamponade

Hypertension or hypotension

Absence of peripheral pulses

Aortic regurgitation from damage to the aorticvalve

Pulmonary edema

Neurologic findings are due to dissection of majorarteries.

Carotid artery obstruction produces hemiplegia orhemi anesthesia.

Spinal cord ischemia can cause paraplegia.

Compression of adjacent structures


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DIAGNOSTIC EVALUATION

Health history and physical examination

ECG-Left hypertrophy

Chest x-ray

angio CT scan 64

Transesophageal echocardiogram (TEE)

Angiogram

Magnetic resonance imaging (MRI)


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COMPLICATION

Cardiac tamponade-Hypotension, narrowed

pulse pressure, distended neck veins, muffled

heart sounds and pulsus paradoxus

Haemmorhage

Ischemia

Death


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Type A dissections usually are repaired

surgically

Type B dissections often are managed

medically


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SURGICAL TREATMENT Surgical treatment is indicated in several

circumstances:

(1) location of dissection in ascending aorta,

(2) development of ischemic complication, (3) poor response to medical management

with continued pain,

(4) aneurysmal degeneration

(5) in selected Stanford type B patients


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Surgical management

Aortic replacement,

Fenestration of the intimal flap

Extra-anatomic bypass

Lecture Cardio Physiotherapy 3

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