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What is Aneurysm?

Permanent, localized outpouching or dilation of the vessel wall


Aneurysms occur in men more often than in women and in whites more often than African Americans. True or False.



Can aneurysms may occur in more than one location?



Peripheral artery aneurysms is common than aortic aneurysm. True or False.



Three fourths of aortic aneurysms occur in the ______ aorta and one fourth in the ______ aorta.

abdominal; thoracic


Most abdominal aortic aneurysms (AAAs) occur _____ (below or above) the renal arteries.



Smoking increases the risk for aortic aneurysm. True or False.



The incidence of AAA decreases with age. True or False.

False. It increases with age.


The larger the aneurysm, the lesser the risk of rupture. True or False

False. It is greater the risk of rupture.


What are the causes of aortic aneurysm?

- Degenerative (e.g., long term smoking, long term atherosclerosis)
- Congenital (e.g., Ehlers-Danlos syndrome, Marfan's syndrome)
- Mechanical (e.g, penetrating or blunt trauma, atherosclerosis)
- Inflammatory response (e.g., Takayasu's arteritis)
- Infection (e.g., HIV)


What are the risk factors of aortic aneurysm?

Tobacco users, HTN, CAD, High cholesterol, Obesity, Lower extremities PAD, Family history, Age, Male, previous stroke


What is true aneurysm?

Aneurysm with at least one layer of wall of the artery is still intact


What is false aneurysm or pseudoaneurysm?

It is not an aneurysm. It is a disruption of all arterial wall layers with bleeding that is contained by surrounding anatomic structures.


What is fusiform aneurysm?

The bulge is relatively uniform in shape in all sides of the arterial vessel (Remember: uniform rhyme with fusiform)


What is saccular aneurysm?

The bulge is pouchlike with a narrow neck on one side of the arterial wall.


What are the examples of true aneurysm?

fusiform aneurysm
saccular aneurysm


What are the examples of false aneurysm?

trauma, infection, surgery


What are the clinical manifestations of thoracic aortic aneurysm (TAA)?

Often asymptomatic. If present: deep diffuse chest pain, stroke like symptoms, and pressure of the laryngeal nerve (cough, SOB, hoarseness, dysphagia).


What are the clinical manifestations of abdominal aortic aneurysm (AAA)?

Often asymptomatic. Pulsatile mass (you can hear the pulse in periumbilical area slightly to the left of the midline), Bruit, Back pain, Patchy mottling (blue) feet and toes "blue toe syndrome", Stomach discomfort or bowel issues.


What are the complications of AAA?

* Retroperitoneal rupture (s/s: severe back pain, Turner's sign)
- bleeding may be controlled by surrounding structures
* Thoracic or Abdominal rupture (s/s: hypovolemic shock with tachycardia, hypotension, pale clammy skin, decreased urine output, altered LOC, abdominal tenderness)
- volume resuscitation and surgical repair must be done to control bleeding.


What is the highest risk factor for causing the weakening of arterial vessel wall leading to AAA?



What is the highest risk factor for AAA?



What is the most serious complication of AAA?



What are the diagnostic tests done to check for AAA?

Chest X-ray, Abdominal x-ray, Ultrasound, CT Scan, MRI,
Angiography, Echocardiography, 12 lead EKG, Lab tests: Troponin, CKMD, Myoglobulin, LDL


What is the primary goal in the care of patient with AAA?

prevention of rupture


What is the plan of care for asymptomatic AAA less than 4.0 cm in diameter?

Monitor by ultrasound every 2 to 3 years.


What is the plan of care for asymptomatic AAA 4.0 cm to 5.4 cm in diameter?

- Work on modifiable risk factors such as cease smoking, gradually increase physical activity, optimize lipid profile, decrease BP)
- Monitor by ultrasound or CT Scan every 6 to 12 months
- Lower growth rate with beta blockers, ACE inhibitors, ARB, statins, and antibiotics


What is the plan of care for asymptomatic AAA 5.5 cm in diameter or larger?

Surgical repair


When is surgical repair recommended for patients with AAA?

- 5.5 cm in diameter or larger
- becomes symptomatic
- patients with genetic disorders such as Marfans syndrome or Ehlers-Danlos syndrome
- rapidly expanding aneurysm
- high risk for rupture
- assess co-morbidities (esp. lungs, kidneys, or heart)


It is important to know the ____ of the AAA to provide correct treatment.



What does OAR stand for?

open aneurysm repair


How is OAR performed?

The surgeon cuts into the diseased aortic segment, removes /cleans up any obstruction such as plaque or thrombus in the aortic segment, places a synthetic graft suturing it to proximal and distal to aneurysm, and finally, sutures the wall of the aorta around the graft as a protective cover.


All OARs require aortic _________ proximal and distal to the aneurysm.



What MUST be monitored after OAR?

kidney perfusion


The risk for acute kidney injury is _____ (high/low) for patients who have OAR above the level of renal arteries.



If iliac arteries are also aneurysmal along with AAA, then the entire segment is replaced with a _______ graft.



What is the minimally invasive surgical repair of AAA?

endovascular aneurysm repair (EVAR)


What is the main difference between OAR and EVAR?

In OAR, the diseased aortic segment is cut and a graft is sutured proximal and distal to the aneurysm. In EVAR, a sutureless graft is place into the aneurysm via femoral arteries. Then the graft (stent) is expanded to preset size and set against vessel wall using balloon inflation.


What is the purpose of post procedure angiography after placement of stent-graft?

- check for leakage
- confirm patency


OAR is less invasive than EVAR. True or False.

False. EVAR is less invasive.


What are the advantages of EVAR?

- less invasive
- fewer complications
- shorter hospital stay
- lower mortality rate
- usage of safe vessel for insertion


What is the most common complication after AAA repair?



What is endoleak?

Seepage of blood back into the old aneurysm caused by inadequate seal, tear through graft fabric, or between graft segments.


How is endoleak repaired?

coil embolization


Follow up check are not necessary after endoleak repair. True or False.

False. Follow up checks are required after endoleak repair.


Endoleak are most common in EVAR or OAR?



What are the complications after AAA repair?

Endoleak, aneurysm growth above or below the graft, aneurysm rupture, aortic dissection, bleeding, renal artery occlusion, graft thrombosis formation, incisional site hematoma, and incisional infection.


Patients undergoing EVAR require periodic imaging for the rest of their lives to monitor for _______, document stability of aneurysm ______, and determine the need for ______ intervention.

endoleak; sac; surgical


What is the potentially lethal complication of emergency repair of ruptured AAA?

Intraabdominal hypertension (IAH) with associated abdominal compartment syndrome (ACS)


Persistent Intraabdominal hypertention (IAH) reduces blood flow to the viscera and causes ______ _____ ____.

multisystem organ failure


Intraabdominal hypertention (IAH) is confirmed by measuring it through a catheter and transducer system utilizing a special indwelling ______ ______.

urinary catheter


What are the treatment goals for controlling situations leading to Intraabdominal hypertention (IAH)?

Return to surgery and decompress and percutaneous drainage with or without tPA infusion.
Patient may need intubation, ventilation, positioning, gastric decompression, cautious fluid resuscitation, pain management, and temporary dialysis (hemofilteration) depending the severity.


What are the nursing assessments for patients with aneurysm?

- thorough history and physical assessment
- signs of coexisting issues (atherosclerosis, hx of smoking, obesity, previous MI)
- monitor for signs of rupture (diaphoresis, pallor, weakness, tachycardia, hypotension, severe back pain, abdominal pain, groin pain or periumbilical pain, changes in LOC or pulsating abdominal mass)
- establish baseline (mark peripheral pulses, renal and neurological status)


What is the preoperative care for patients with AAA?

- Emotional support and patient education
- Bowel preparation (e.g., laxatives, enemas)
- NPO (after midnight the day before surgery, provide oral care frequently, ice chips or lozenges for dry/irritated throat)
- Skin cleansing (e.g., Hibiclens)
- Beta blockers (esp. if pt has hx of CVD)
- Mark the pedal pulses with single use marker and document skin lesions on lower extremities
- Antibiotics preoperatively (IV give just before incision)


What is the post-operative goal for patients with AAA?

- Maintain normal tissue perfusion esp. renal and cardiac
- Adequate respiratory function
- Fluid and electrolyte balance
- Intact motor and sensory function
- Pain control
- Graft patency
- No complications from the surgical repair such as thrombosis, bleeding, infection or rupture.


What is the post-operative nursing care for patients with AAA?

- ICU for 24-48 hrs for close monitoring primarily for bleeding and renal function (urine output - creatinine may increase, blood in urine may be present)
- Devices used include endotracheal tube, arterial line, central venous pressure (CVP) or pulmonary artery (PA) catheter, peripheral IV lines, indwelling urinary catheter, NG tube. If thoracic surgery then chest tube will be present.
- continuous EKG and pulse oximetry
- Pain control via epidural or PCA
- Monitor for cardiac ischemia, dysrhythmias, infections, VTE, and neurological complications


Prolonged low BP may result in graft ___________



What is the post operative nursing care to maintain graft patency?

- Maintain adequate blood pressure
- Replace fluid/blood as needed
- Assess CVP, PA pressure
- Hourly urine output (helps assess hydration and renal perfusion status)
- Avoid severe hypertension
- IV diuretics, IV antihypertensives (beta blockers,
hydralazine, nitroprusside)


What is the post operative nursing care to maintain cardiovascular status?

- Dysrhythmias may occur from electrolyte imbalances
- Hypoxemia
- Hypothermia
- Myocardial ischemia or infarction (due to low O2)
- Monitor and Replace electrolytes
- Monitor EKG/continuous pulse oximetry
- Frequent electrolyte and ABG
- Administer O2
- IV anti-dysrhythmic and antihypertensive
- Adequate pain control
- Restart on cardiac drugs


What is the post operative nursing care to prevent infection?

- Give broad spectrum antibiotics
- Good nutrition for healing
- Infected graft is rare but life threatening
- Assess for signs and symptoms of infection (fever, elevate WBC)
- Assess surgical site for signs of infection (redness, swelling, drainage and/or EVAR femoral sites)
- Watch your central lines and Foley


What is the post operative nursing care to maintain gastrointestinal status?

- High risk for postoperative ileus after OAR (swollen, bruised intestine, peristalsis may cease)
- NG tube placement (low intermittent suction to decompress stomach, prevent aspiration, and decrease pressure on suture lines)
- Record I and O
- Assess for bowel sounds every 4 hours
- Passing flatus
- Early ambulation
- Postoperative ileus should resolve before day 4


What is the gastrointestinal complication of AAA repair?

- temporary ischemia or infarction of intestinal tissue (absent bowel sounds, fever, abdominal distention and pain, diarrhea, bloody stools)
- immediate re-operation is a MUST to restore bowel function


What is the post operative nursing care to maintain neurological status?

- If surgery is done on the aortic arch, assess for change in LOC thorough pupil assessment, facial symmetry, tongue position, speech, upper extremity movement and hand grasps
- If surgery is done on descending aorta, neurovascular assessment of lower extremities


What is the post operative nursing care to maintain peripheral perfusion status?

- depends on the location of aneurysm
- frequent assessment of all peripheral pulses, if needed use Doppler. Compare findings with baseline.
- skin temperature, skin color, capillary refill, neurovascular assessment of lower extremities
- Bad news (must inform HCP) - Cool, pale and/or mottled, painful extremity may indicate embolization or graft occlusion


What is the post operative nursing care to maintain renal perfusion status?

- Foley placement
- Hourly assessments esp. urine output
- Assess renal function - BUN, Creatinine
- CVP, PA readings provide hydration status
- Record I and O
- Record daily weights until patient resumes regular diet
- High risk for acute kidney injury


What is the post operative nursing care for pain management?

- Splinting with coughing/deep breathing and moving
- Opioids
- Keep pain in control


What is the home care teaching for postoperative patients?

- Gradually increase activity
- May be more fatigued
- Poor Appetite
- Monitor bowel habits
- No heavy lifting for 6 weeks (anything you strain to pick up)
- Report to HCP s/s of infection at surgical site such as redness, swelling, increased pain, drainage from incisions, fever > 100F (37.8C)
- Teach to monitor pulses, changes in color or warmth of extremities
- Males may develop sexual dysfunction - refer to see a urologist


What is aortic dissection?

It is a false lumen between the intima and media layer of the arterial wall (separation of the two walls where blood flows in through a tear).


What are the classification of aortic dissection?

Type A - ascending aorta and arch
Type B - descending aorta


Nontraumatic aortic dissection is caused by degenerated ______ fibers in the arterial wall.



What are the predisposing factor for aortic dissection?

Men, 60-70 years of age, Other aortic complications, Atherosclerosis, Blunt trauma, Iatrogenic trauma (surgical, balloon pump), Tobacco use, Cocaine use, Congenital Heart Defects (Bicuspid or aortic valve)
Connective tissue disorders (Marfan's or Ehlers-Danlos), Family history, Heart surgery history, Pregnancy, Poorly controlled HTN


Increased pressure on damage areas causes _______ dissection.



What are the clinical manifestations of aortic dissection?

Sudden, sharp, stabbing, tearing, ripping chest pain - worst pain I have every felt
Elderly: more vague symptoms, less likely to complain of the sharp pain in chest or back, hypotension


What is the severe and life threatening complication of an acute ascending aortic dissection?

cardiac tamponade


What are the complications of aortic dissection?

rupture of aorta, hemorrhage in mediastinal, pleural, or abdominal cavities, ischemia of spine (decreased sensation and rarely paralysis), kidneys (renal failure), and mesenteric (abdominal pain, decreased bowel sound and function, bowel necrosis).


What is the treatment of aortic dissection?

- If in ICU, manage HR, BP, Morphine for pain - frequent vitals every 2-3 to every 15 minutes
- IV Beta blocker (esmolol) to keep HR around 60, BP 100-110
- IV Diltiazem if beta blockers are contraindicated
- Bed rest, semi fowler, quiet (helps keep HR & BP low)
- Surgery-EVAR-Type B only for both acute and chronic dissections
- Surgery-Type A- acute type A is a surgical emergency-only 50% survive after surgery, otherwise control BP, HR, and pain for conservative treatment
- Surgery is delayed if possible to allow edema to reduce and blood clot to form
- High Mortality