Lecture Cardio Physiotherapy 3
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Transcript of 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