aortic

ANCC/AACN CONTACT HOURS

How to protect a patient with

2.0

Learn how to recognize and respond to the danger signs and act immediately to help save his life.
BY GAIL HOOD IRWIN, RN, CEN, BSN

TROUBLE IS LOOMING when the largest artery in the body develops a bulge. According to the Society for Vascular Surgery, each year approximately 200,000 people in the United States are diagnosed with aortic aneurysma bulge or ballooning in the artery that leads from the heart. About 15,000 of these aneurysms are severe enough to rupture, creating an urgent situation with a high risk of death. Read on to learn how to protect a patient with a suspected or known aortic aneurysm.
Large vessel, big problem

An aneurysm is defined as an abnormal localized arterial dilation or ballooning thats greater than one and a half times the arterys normal circumference.1 To be considered a true aneurysm, the defect must involve all three layers, or tunicae, of the vessel wall (see Profiling the artery wall). The gravity of aortic aneurysm becomes clear when you consider the aortas size and function. At its origin at the upper part of the left ventricle, it measures about 3 cm in diameter and narrows to 2 cm or less in the abdomen. Arching over the heart and descending behind it through the thoracic and abdominal cavities, it

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aneurysm

supplies all the bodys arteries with oxygenated blood for delivery throughout the body. An aneurysm can form anywhere along the aorta, which has three anatomic sections: the ascending aorta exiting the left ventricle and aortic valve the transverse aorta or aortic arch crossing over the heart the descending aorta, which travels down the trunk and bifurcates into the right and left common iliac arteries. Aortic aneurysms are described as thoracic or abdominal. Thoracic aortic aneurysms, located above the diaphragm, are less common but more prone to life-threatening rupture or dissection for reasons Ill discuss shortly. Abdominal aortic aneurysms (AAAs), located below the diaphragmatic border, account for about 75% of aortic aneurysms and develop where the aorta isnt supported by skeletal muscle or where it branches into smaller arteries.2 Aneurysms are also classified by appearance. A fusiform aneurysm, the more common type, is a diffuse dilation involving the entire circumference of the artery wall. A saccular aneurysm is a bulge on only a portion of the artery wall.
How trouble begins

Profiling the artery wall

The aorta, like all arteries, consists of three layers called tunicae: the tunica externa or adventitia, the outermost covering, composed of fibrous and connective tissues that support the vessel the middle tunica media, composed largely of smooth muscle that constricts to regulate vessel diameter the inner tunica intima, which has an elastic layer and a thin layer of endothelial cells adjacent to the blood. A true aneurysm involves all three tunicae. If only the intimal and medial tunicae are disrupted, the bulge is called a pseudoaneurysm.
Elastic layer Connective tissue Endothelial cells

Tunica adventitia

Tunica media

Tunica intima

Typically occurring in people between ages 65 and 74, an aortic aneurysm develops over time as weakening of the arterial wall causes a permanent focal dilation.1 Men are four to five times more likely to be affected than women.2 Although the primary cause isnt clear, the following may be associated with aneurysm development: Smoking, hypertension, and dyslipidemia contribute to a degenerative process. Smokers have two to three times more risk of aneurysm than nonsmokers. Cellular changes within the tunica media (such as those seen with 38
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Marfan syndrome or Ehlers-Danlos syndrome) are considered an important cause of aneurysm formation. (See Tunica media under attack for details.) Inflammatory cellular changes in the aorta wall also can develop secondary to tertiary syphilis, tuberculosis, or bacterial or fungal infection. Chronic inflammation (aortitis) and blunt trauma, usually from motor vehicle crashes, are known causes of aneurysms in the descending thoracic aorta. Family history plays an important role. The incidence of AAA is 2% to 3% in the general population, but the incidence among primary relatives of someone with AAA is 15% to 33%.3 Atherosclerosis is commonly found in conjunction with aortic aneurysm, but someone with clean arteries also can develop an aneurysm.
Signs and symptoms reflect severity and location

An aortic aneurysm may be completely asymptomatic. In many cases, the aneurysm is found dur-

ing routine physical examination or diagnostic testing for other conditions. If a patient has symptoms, he may report vague but persistent chest, back, or abdominal pain caused by the aneurysm pressing on adjacent organs and structures. Signs and symptoms worsen as the aneurysm enlarges. Sudden, severe pain may signal a life-threatening aortic dissection or rupture. Aortic dissection is a tearing or separation of the intima that forms a blood-filled chamber within the vessel wall. An aneurysm may dissect or the aorta itself may dissect without prior aneurysm formation. A ruptured aortic aneurysm is a tearing of all three tunicae that causes bleeding into the thoracic or abdominal cavity. Whether nonspecific or clearly indicating a life-threatening emergency, the signs and symptoms of aortic aneurysm reflect its location and the organs affected. Thoracic aortic aneurysm should be suspected in anyone with chest pain or signs and symptoms of left ventricular failure. An
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aneurysm of the ascending aorta may cause an aortic valve murmur even if the patient is asymptomatic. If the aneurysm is developing rapidly, it may cause aortic regurgitation and life-threatening heart failure. An aneurysm in the proximal ascending aorta may impinge on the aortic valve or coronary arteries to precipitate myocardial ischemia or myocardial infarction (MI). An aneurysm of the aortic arch can cause neurologic signs and symptoms similar to those of a transient ischemic attack or stroke. The bulging aorta exerts pressure on the subclavian artery, decreasing blood flow through the common carotid arteries to the brain and causing neurologic effects. Reflecting compression of nerves and other structures, early manifestations of an aneurysm in the descending thoracic aorta include hoarseness (vagus or recurrent laryngeal nerve compression), a sensation of having a lump in the throat (esophageal compression), or wheezing, dyspnea, or cough (tracheal compression). Immediately assess and report complaints of numbness, tingling, or paralysis of the extremities because these may indicate pressure against arteries that supply the spinal cord. Abdominal aortic aneurysms are commonly asymptomatic. When signs and symptoms do occur, they typically include abdominal pain and gastrointestinal problems such as indigestion, distension, nausea and vomiting, and constipation. An AAA near the aortas renal branch can cause signs and symptoms like those of renal colic. Suspect AAA if a patient in late middle age or older (particularly a man) reports acute flank or back pain that radiates to the groin or testicle. A patient with an AAA also may develop hypertension and renal failure if the aneurysm compresses
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the renal arteries. You may be able to palpate an aneurysm near the umbilicus, but dont rule out the possibility of AAA if you cant detect pulsation. Signs and symptoms of arterial insufficiencythe five Ps (pallor, pain, paralysis, pulselessness, paresthesia)may signal an aneurysm in the distal abdominal aorta. A history of hypertension and an elevated diastolic pressure raise the risks for a patient with aortic aneurysm. Uncontrolled hypertension can further weaken the vessel wall with each high-pressure heartbeat, increasing the risk that the aneurysm will enlarge, dissect, or rupture. The amount of tension on the artery wall is directly proportional to the radius of the artery. So growth of the aneurysm increases tension in the vessel wall, along with the risk of rupture.
Diagnostic testing

Tunica media under attack

Within the tunica media of arteries, including the aorta, elastin allows for stretch and response to pressure changes and collagen limits distensibility. Destruction of the collagen-elastin matrix by the proteolytic enzymes collagenase and elastinase weaken the medial wall. Cystic medial necrosis is seen in connective tissue disorders such as Ehlers-Danlos syndrome type IV, where parallel configuration of the elastin fibers is destroyed, and in Marfan syndrome, an autosomal-dominant connective tissue disorder that destroys the cross-linkage of the collagen fibers in the tunica media. Cystic medial necrosis characteristically results in circumferential weakness and dilation of the proximal aorta, which can lead to development of a fusiform aneurysm in the ascending aorta. People with Marfan syndrome and Ehlers-Danlos syndrome should be monitored closely for aneurysm development; they have an increased risk of thoracic aneurysm rupture.

An aortic aneurysm is best identified with various imaging tests. Depending on the urgency of the patients condition, he may undergo one or more of the following: On chest X-ray, the presence of a widened mediastinum suggests a thoracic aortic aneurysm. However, absence of this sign doesnt rule it out. Contrast aortography best delineates the length of the aneurysm and involvement of branch vessels, but the test is invasive and timeconsuming. It also requires administering intravenous (I.V.) contrast medium. A computed tomography scan with contrast is the most commonly performed imaging study for aortic aneurysm. Fast and readily available, it requires less injected contrast medium than aortography. Magnetic resonance imaging provides great clarity but takes longer and may not be readily available. Ultrasound performed at the bed-

side is an alternative for a patient whos too unstable to be moved. Transesophageal echocardiography, which can help pinpoint an ascending or descending thoracic aneurysm, can be performed in an emergency. The patient needs moderate sedation and analgesia to undergo this test.
Medical management

When a patient has an aneurysm with a diameter less than 5 cm or an uncomplicated, stable distal dissection, or if surgery is considered too risky, hes treated with medication and monitoring. The goal is to reduce injury to the weakened vessel wall from continuous high pulsatile pressure. An oral beta-blocker reduces blood pressure (BP), heart rate, and myocardial contractility. The diameter of an aortic aneurysm is monitored to determine rupture risk. At smaller diameters, the risk of intervention
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is greater than the risk of rupture. The patient should have annual ultrasounds if his aneurysm measures from 3 to 4 cm or an ultrasound every 6 months if its between 4 and 4.5 cm. Once the diameter reaches about 5 cm, the risk of rupture or dissection increases and elective repair may be indicated. The optionssurgical repair and endovascular grafting both use a prosthetic graft to reestablish the aortas integrity and isolate the aneurysm from arterial blood flow.
When aortic dissection or rupture threatens

dial contractility and systemic vascular resistance. The risk of rupture increases dramatically when the diameter of an aortic aneurysm reaches 6 cm. Paininstantly severeis the hallmark of a ruptured aneurysm, and many people die before reaching the hospital. The patients hemodynamic stability is quickly compromised, triggering signs and symptoms of hypovolemic shock: hypotension; tachycardia; cool, mottled skin; changes in mental status; and decreased urine output. He needs rapid fluid resuscitation and surgery to survive.
Preparing for emergency surgery

Open surgical repair

Aortic dissection and ruptured aneurysm can be fatal. A dissection diverts aortic blood flow to acutely compromise organ and tissue perfusion. Tearing of the intima and extension of the dissection also compromise various organs along the aortic pathway. Dissections are classified using the DeBakey or the Stanford system to guide treatment of the affected organs. (See Classifying aortic dissection by site.) According to the International Registry of Acute Aortic Dissection, sudden onset of severe, sharp, and unrelenting pain is the most common symptom.4 The pain intensity doesnt change over time, but its location follows the path of the dissection. For example, a thoracic dissection may cause chest pain that radiates to the back as the dissection progresses. A dissection below the diaphragm may cause abdominal and back pain that radiates to the groin and legs. Aortic dissection typically causes . extremely high BP Your patient may be treated with I.V. betablockers such as esmolol (Brevibloc) or labetalol (Normodyne) to decrease the effect of the arterial pressure wave and decrease force against the weakened vessel. Nitroprusside (Nipride) may be ordered concomitantly to decrease myocar40
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A ruptured aortic aneurysm and certain types of dissection must be repaired immediately with open surgery or an endovascular procedure to save the patients life. Nursing care focuses on restoring and maintaining hemodynamic stability. Administer supplemental oxygen, monitor the patients cardiovascular status, insert two largebore I.V. devices, and fluid resuscitate with 0.9% sodium chloride or lactated Ringers solution if hes hypotensive. To identify or rule out acute MI, perform a stat electrocardiogram and draw specimens for serum cardiac biomarkers within 10 minutes of his arrival and get a portable chest X-ray. If the patient is hypertensive, administer beta-blockers and nitroprusside as ordered. Manage pain with morphine sulfate or hydromorphone to keep him comfortable and to combat , pain-induced increases in BP heart rate, and oxygen demand. Preoperative blood work should include a complete blood cell count, serum electrolytes, blood urea nitrogen and creatinine levels, prothrombin and activated partial thromboplastin times, and blood type and crossmatch.

Surgical repair of an aortic aneurysm commonly involves a large midline incision. The surgeon cross-clamps the aorta and secures a synthetic graft proximally and distally to healthy tissue. The graft wont hold if the tissue is too fragile. Surgery is definitive but risky. Cross-clamping can trigger emboli, ischemia, or hemodynamic changes. Both cardiac workload and myocardial oxygen demands are increased, which can cause myocardial ischemia or MI. Releasing the clamp restores perfusion but also triggers release of toxins, particularly oxygen free radicals, into the systemic circulation. These highly reactive compounds decrease myocardial function and may result in reperfusion injury.
Endovascular repair

Endovascular aneurysm repair (EVAR) using stent deployment is an alternative for some patients who are too frail to undergo open repair. Requiring less time and eliminating the need for general anesthesia, EVAR is less invasive and less traumatizing. Because cross-clamping isnt used, perfusion issues are minimized. However, EVAR isnt appropriate for everyone. The aneurysm location and involvement of other structures may require open surgery for successful correction. The EVAR technique consists of fitting a compressed stent-graft onto a catheter and percutaneously inserting it into a femoral artery using a guidewire. When released from the catheter at the aneurysm site, the stent-graft expands to a predetermined size and shape and is anchored with proximal and distal hooks for stability and structure. In 70% to 80% of cases, the excluded aneurysm sac around the stent-graft thromboses within hours.
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Classifying aortic dissection by site

Stanford system A ascending aorta (proximal dissection) B descending aorta (distal dissection)

DeBakey system I ascending aorta but involving the descending aorta as well II only the ascending aorta III descending aorta

Source: Kasper DL, et al. (eds), Harrisons Principles of Internal Medicine, 16th edition, New York, N.Y., McGraw-Hill, 2005.

Complications of EVAR include emboli from use of the guidewire and catheter and development of an endoleak that can sequester blood between the graft and the artery wall to cause dissection or rupture. The leak may resolve over time, but open surgery may be necessary to repair a large leak.
Postprocedure nursing care

Whether your patient has undergone open surgery or EVAR, he needs vigilant nursing care to prevent and detect postoperative problems, including hemorrhage and infection. After surgery, the patient typically spends the first 24 hours in an intensive care unit with an arterial line to monitor his BP and possibly a pulmonary artery catheter to assess cardiac function. He may also need mechanical ventilation. A patient whos undergone EVAR typically recovers in a medical/surgical unit. In either case, your goals are to prevent and monitor for complications, promote comfort, and facilitate his return to normal daily activities after discharge. Watch for complications associated with any major surgery, such as respiratory complications, infecwww.nursing2007.com

tion, and paralytic ileus and others that are specific to aneurysm graft placement. Hemodynamic instability. The need for BP control continues after aneurysm repair. An elevated BP stresses the graft site and can cause graft failure. It also increases myocardial oxygen demand; an imbalance between oxygen supply and demand can precipitate myocardial ischemia and lead to MI. Immediately after surgery, administer I.V. beta-blockers and nitroprusside as ordered to lower BP and decrease the hearts workload and oxygen demand. Monitor for and immediately report any cardiovascular changes such as chest discomfort, ST-T wave changes, or dysrhythmias. Keeping the patients BP within the normal range is critical to maintain end organ perfusion, so prevent hypotension too. Overcorrection of BP before or during surgery, excess bleeding, reperfusion injury, or third-space fluid shifts can cause hypotension. Failure to treat it can lead to multiorgan dysfunction syndrome and drastically increase the patients risk of dying. Monitoring mean arterial pres-

sure and maintaining a reading of at least 70 mm Hg ensures adequate perfusion of major organs. Careful infusion of I.V. fluids such as lactated Ringers or 0.9% sodium chloride solution or blood products helps stabilize BP. A urine output of 50 mL/hour indicates an adequate glomerular filtration rate and renal perfusion. Meticulously document intake and output and promptly report any discrepancies. Respiratory compromise. Any patient whos had general anesthesia is at risk for respiratory complications, including atelectasis, pneumonia, and pulmonary embolism (PE). Extubation as soon as hes stable helps prevent these problems. Applying antiembolism devices at the end of surgery or when hes in the postanesthesia care unit helps prevent deep vein thrombosis, which can lead to life-threatening PE. When your patient is breathing independently, teach him to splint the surgical site with a pillow or blanket roll and to use incentive spirometry, coughing, and deep breathing to help keep his lungs clear. Help him sit in a chair and walk in the hallway to encourage lung expansion and mobilize secretions. Medicating him for pain will help him tolerate these activities. Because opioids used to manage postoperative pain can cause respiratory depression, closely monitor his respiratory rate and effort, lung sounds, cough, and oxygen saturation to assess for respiratory compromise. Infection. Nosocomial infection is a concern, especially when the patient has an incision involving the vascular system. To prevent wound infection, hell receive I.V . antibiotics. If hes receiving oral antibiotics at discharge, teach him the importance of finishing the course as directed.
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Problems related to aneurysm repair include graft rupture, hemorrhage, and graft occlusion. Hemorrhage, a risk with any surgery, occurs if the graft ruptures. Closely monitor your patients hemodynamic status: A drop in his BP or urine output, increased heart rate, and a change in mental status may indicate shock from blood loss. Carefully and frequently assess his abdomen, regardless of the aneurysm site, for pain, distension, and increasing girth and document your findings. Keep the head of his bed elevated to 45 degrees or less (unless contraindicated) to prevent tension or torsion of the graft. Encourage him to splint the surgical site during coughing, deep-breathing exercises, and position changes. Graft occlusion, usually due to thrombus formation or embolization, decreases end organ perfusion. The manifestations depend on the graft site. An occlusion after thoracic aneurysm repair can lead to coronary ischemia and MI, cerebral ischemia and stroke,

ischemic colitis, or spinal cord ischemia resulting in paralysis. Occlusion of an abdominal graft can compromise renal blood flow, causing acute tubular necrosis and renal failure, or compromise peripheral circulation, leading to limb loss. Frequently calculate your patients ankle/brachial index to evaluate lower extremity perfusion. (Review the technique in How to Measure Ankle/Brachial Index in the January issue of Nursing2005.) Quickly report any complaints of numbness or tingling, change in color or temperature, or decreased or absent distal pulses.
Zeroing in

REFERENCES 1. Upchurch GR, Jr., Schaub TA. Abdominal aortic aneurysm. American Family Physician. 73(7):1198-1204, April 1, 2006. 2. Ignatavicius DD, Workman ML. Medical Surgical Nursing: Critical Thinking for Collaborative Care. Philadelphia, Pa., W.B. Saunders, 2002. 3. King J. Abdominal aortic aneurysm. In Melander S (ed), Case Studies in Critical Nursing: A Guide for Application and Review, 3rd edition. Philadelphia, Pa., W.B. Saunders, 2004. 4. Hagan PG, et al. The international registry of acute aortic dissection (IRAD): New insights into an old disease. Journal of the American Medical Association. 283(7):897-903, February 16, 2000. RESOURCES Beese-Bjurstrom S. Hidden danger: Aortic aneurysm and dissections. Nursing2004. 34(2):36-41, February 2004. Newberry L (ed). Sheehys Emergency Nursing Principles and Practice, 5th edition. St. Louis, Mo., Mosby, 2003. Trimarchi S, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection Experience. The Journal of Thoracic and Cardiovascular Surgery. 129(1):112-122, January 2005. Diseases of the aorta and its branches. The Merck Manual. http://www.merck.com/mrkshared/ mmanual/section16/chapter211/211a.jsp. Accessed June 6, 2006. The Society of Thoracic Surgeons. Aortic aneurysms. http://www.sts.org/sections/patient information/aneurysmsurgery/aorticaneurysms/ index.html. Accessed June 8, 2006.
Gail Hood Irwin is a clinical educator in emergency services at Albert Einstein Medical Center in Philadelphia, Pa. The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.

By knowing the risk factors for aortic aneurysm and zeroing in on the signs and symptoms, you can help a patient manage the problem before it becomes an emergency. And if an aortic aneurysm becomes an emergency, knowing the appropriate responses can help save your patients life.

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How to protect a patient with aortic aneurysm

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2.0 How to protect a patient with aortic aneurysm

ANCC/AACN CONTACT HOURS

GENERAL PURPOSE To provide nurses with an overview of aortic aneurysm. LEARNING OBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Indicate the risk factors for aortic aneurysm. 2. Identify signs and symptoms of aortic aneurysm. 3. Indicate the treatment options for aortic aneurysm.
1. Approximately how many people in the United States are diagnosed with aortic aneurysm each year? a. 100,000 c. 300,000 b. 200,000 d. 400,000 2. In which age-group does aortic aneurysm typically occur? a. under 65 years c. 75 to 84 years b. 65 to 74 years d. 85 years and older 3. Which characteristic is not associated with increased risk of aortic aneurysm? a. female sex b. family history of aneurysms c. hyperlipidemia d. Marfan syndrome 4. Which type of pain is typical of aortic dissection? a. absent c. moderate b. mild d. severe 5. Signs and symptoms of stroke would most likely indicate an aneurysm in which area of the aorta? a. ascending c. descending b. aortic arch d. abdominal 6. An aneurysm that causes hoarseness would most likely be located in the a. ascending aorta. b. aortic arch. c. descending thoracic aorta. d. abdominal aorta. 7. Which imaging test is used most commonly to detect aortic aneurysm? a. magnetic resonance imaging b. computed tomography scan with contrast c. contrast aortography d. transesophageal echocardiography 8. Treatment goals for aortic dissection include a. increasing the patients heart rate. b. increasing systemic vascular resistance. c. strengthening myocardial contraction. d. decreasing BP. 9. Which action is your highest priority when a patient with an aortic aneurysm has sudden, severe chest pain? a. Obtain an electrocardiogram. b. Draw serum cardiac biomarkers. c. Insert two large-bore I.V. catheters. d. Administer ordered pain medication. 10. Which of the following is the most significant complication of EVAR? a. reperfusion dysrhythmias b. dissection c. MI d. pneumonia 11. Your patients mean arterial pressure after aortic aneurysm repair should be at least a. 50 mm Hg. c. 70 mm Hg. b. 60 mm Hg. d. 80 mm Hg. 12. What urine output indicates adequate renal perfusion after aortic aneurysm repair? a. 20 mL/hour c. 40 mL/hour b. 30 mL/hour d. 50 mL/hour 13. When should you apply an antiembolism device if your patient has surgery to repair an aortic aneurysm? a. immediately following surgery b. upon admission to the intensive care unit c. when deep vein thrombosis is suspected d. at the first signs of limb hypoperfusion 14. To prevent graft tension or torsion, elevate the head of your patients bed no more than a. 45 degrees. c. 75 degrees. b. 60 degrees. d. 90 degrees.

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