B P5 C42 Diseases of the Aorta

Question 1

Begins at the aortic valve and extends to the sinotubular junction. This supports the bases of the aortic valve leaflets.

Answer 1

Aortic root

Question 2

The right and left coronary arteries arise from the __________________

Answer 2

Sinuses of Valsalva

Question 3

Begins at the sinotubular junction and rises to join the aortic arch. The proximal portion of the ascending aorta lies within the pericardial cavity, anterior to the pulmonary artery bifurcation

Answer 3

Upper portion of the ascending aorta

Question 4

Gives rise to the innominate artery, the left common carotid artery, and the left subclavian artery.

Answer 4

Aortic arch

Question 5

Begins distal to the left subclavian artery.

Answer 5

Descending thoracic aorta

Question 6

Marks the point at which the aortic arch joins the descending aorta

Answer 6

Ligamentum arteriosum

Question 7

Marks the site of transition between the relatively mobile ascending aorta and the fixed descending aorta making it vulnerable to deceleration trauma.

Answer 7

Aortic isthmus

Question 8

Gives rise to the celiac artery and the superior mesenteric artery anteriorly, followed by the posterolateral origins of the left and anterolateral right renal arteries.

Answer 8

Abdominal aorta

This segment of the aorta is called the suprarenal or visceral segment. The infrarenal aorta lies anterior to the lumbar spine, where paired lumbar artery branches arise posteriorly.

Question 9

The aorta ends by bifurcation into _________________

Answer 9

Common iliac arteries

Question 10

In the proximal aortic segments, the vasa vasorum supply additional nutrients to the outer third of the thoracic aortic media. The ____________ aorta normally lacks an independent microvascular supply.

Answer 10

Infrarenal

Question 11

The aortic wall pressure-diameter relationship is nonlinear; a more distensible component is demonstrated at lower pressures and a stiffer component at higher pressures, with the transition from distensible to stiff behavior occurring at pressures higher than _________________

Answer 11

80 mm Hg

Question 12

Aortic diameter is generally less than __________________ at the root and becomes smaller distally.

Answer 12

< 40 mm

Question 13

The bifurcation typically occurs at the level of the umbilicus and the _______________

Answer 13

L4 vertebral body.

Question 14

refers to a pathologic segment of aortic d tation that expands and can eventually rupture or dissect. One criterion for abnormal aortic dilatation is a diameter of at least 50% greater than expected for the same aortic segment or l dilation 50% greater than the adjacent normal aorta

Answer 14

Aortic aneurysm

Question 15

The more common type, are symmetrically dilated with involvement of the entire aortic circumference

Answer 15

Fusiform

Question 16

Exhubits focal outpouching. These both are “true” aneurysms with an intact aortic wall involving all layers.

Answer 16

Saccular

Question 17

Bleeding has occurred through the aortic wall r ing in a contained periaortic hematoma in continuity with the aortic lumen; may result from trauma, infection or contained rupture of an aortic aneurysm, dissection, or penetrating ulcer.

Answer 17

Pseudoaneuyrsm

Question 18

Defined by an abdominal aorta greater than 3.0 cm in diameter

Answer 18

AAA

Question 19

The most common form of aortic aneurysms, being present in 2.3% of those 75 to 79 years old.

Answer 19

AAA

Question 20

Most AAA (>80%) arise in the ______________

Answer 20

Infrarenal aorta

Question 21

AAAs are approximately five times more prevalent in _____ than in women, and are associated strongly with age, with most occurring in those ______________ and even higher risk in those older than 75 years.

Answer 21

Men
>60 years

Question 22

AAAs strongly are associated with ______________

Answer 22

Cigarette smoking

Current smokers are seven times more likely to have an AAA than nonsmokers with duration and quantity of smoking increasing risk. Smoking also increases AAA growth rate. Other risk factors include emphysema, hypertension, and hyperlipidemia.

A family history is a potent risk factor for AAA being present in about 20%

Question 23

Matrix-degrading enzymes released by inflammatory cells lead to ___________________ and play a role in dilation and rupture.

Answer 23

Medial degeneration

AAA formation associates with chronic aortic wall inflammation, increased local expression of proteinases, and degradation of structural connective tissue proteins

Question 24

Enzymes including ____________________ and elastolytic cathepsins degrade arterial matrix constituents contributing to aneurysm expansion and rupture.

Answer 24

Matrix metalloproteinases (MMPs)

Question 25

In the absence of vasa vasorum, the nutrient supply to the media of the distal aorta depends on __________________, which may be jeopardized by intimal thickening and atherosclerotic plaque.

Answer 25

Diffusion from the lumen

Question 26

Only ___________ of AAAs are noted on physical examination, although aneurysms larger than 5 cm can be detected in approximately 75% of patients, depending on body habitus

Answer 26

30% to 40%

Question 27

Patients with AAA may have coexisting ________ (25%) and have an increased prevalence of iliac and popliteal aneurysms

Answer 27

TAA disease

Question 28

_________________ can detect AAAs with high accuracy and is preferred over CT in screening for AAAs

Answer 28

Abdominal ultrasound

Question 29

________________ is more accurate than ultrasound; especially useful in demonstrating the relationship of the AAA to the renal, visceral, and iliac arteries and patterns of mural thrombus, calcification, or coexisting occlusive atherosclerosis; useful for follow up in larger AAA

Answer 29

CT angiography (CTA)

Question 30

The U.S. Preventive Services Task Force recommends a one-time ultrasound screening for AAAs in ____________________ and selective screening for those who never smoked

Answer 30

Men 65 to 75 years of age with a history of smoking

Question 31

The Society for Vascular Surgery (SVS) recommends a one-time screening for AAAs in _________________ of AAAs.

Answer 31

All men ≥65 years and for women ≥65 years with a history of tobacco use or a family history

Question 32

The Centers for Medicare and Medicaid Services will currently reimburse screening for ________________ of AAA.

Answer 32

Men 65 to 75 who ever smoked and men and women 65 to 75 with a family history

Question 33

AAAs expand gradually and variably with an average growth rate of ___________________ per year and larger aortas grow more rapidly

Answer 33

2.2 mm (range 1 to 5 mm) per year

Question 34

AAA ___________ is most important in predicting rupture

Answer 34

Diameter

Question 35

The ________________ may predict risk better in women.

Answer 35

Aortic size indexed to body size

Question 36

Factors associated with risk of AAA rupture include

Answer 36

Current smoking
Female gender
Emphysema
Hypertension
Immunotherapy after organ transplantation

Question 37

Repair should be considered for asymptomatic aneurysms greater than

Answer 37

5.0 to 5.5 cm in diameter

Question 38

Symptomatic aneurysms and those with rapid growth (_________) require more urgent consideration.

Answer 38

> 1 cm/year

Question 39

AAA repair at smaller size (closer to ___________) should be considered for women due to increased risk of rupture.

Answer 39

5 cm

Question 40

In patients with AAAs larger than 4.5 cm, _________ is preferred over ultrasound for more accurate measurement.

Answer 40

CT

Question 41

The following surveillance imaging strategy for AAAs of various sizes has been proposed:

2.5 to 2.9 cm
3.0 to 3.9 cm
4.0 to 4.9 cm
5.0 to 5.4 cm

Answer 41

2.5 to 2.9 cm, every 7 years
3.0 to 3.9 cm, every 3 years
4.0 to 4.9 cm, every 1 year
5.0 to 5.4 cm, every 3 to 6 months

Question 42

True or False

Patients with small AAAs should exercise regularly because moderate physical activity does not adversely influence the risk for rupture and may limit AAA growth.

Answer 42

True

Question 43

AAA repair is recommended when the diameter exceeds _______ with earlier repair considered for those with rapid expansion, young age, and in women.

Answer 43

5.4 cm

Question 44

AAA is treated surgically by either open surgical repair (OSR) or EVAR, with _______ associated with a threefold less perioperative mortality

Answer 44

EVAR (1.5% with EVAR vs. 4.2% to 5.2% for OSR)

Perioperative medical management to reduce cardiac risk may include continuation of beta blockers, statins, and/or aspirin.

Selection of the approach depends on the AAA anatomy, age, and risks associated with anesthesia and surgery,

Question 45

Late complications develop in as many as _______ of patients after OSR for AAAs, including hernia and bowel obstruction, perianastomotic aneurysms (including pseudoaneurysms at suture lines and true aneurysms proximally), graft infection, graft-enteric fistula, and graft limb occlusions with lower extremity ischemia.

Answer 45

15% to 30%

OSR for AAAs should optimally be performed at centers with demonstrable operative mortality rates lower than 5%

After OSR patients should generally have annual clinical follow-up with CT at 5-year intervals, or more frequently if there are small aneurysms in adjacent vessels

Question 46

In patients with suitable anatomy, EVAR offers a less invasive alternative to OSR. EVAR requires adequate ________________ attachment sites.

Answer 46

Nonaneurysmal proximal and distal

Question 47

Long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention

Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair.

Answer 47

DREAM trial (Long-Term Outcome of Open or Endovascular Repair of Abdominal Aortic Aneurysm)

Question 48

Long-term, multicenter, randomized, controlled trial comparing open repair with endovascular repair in 351 patients with an abdominal aortic aneurysm of at least 5 cm in diameter who were considered suitable candidates for both techniques. The primary outcomes were rates of death from any cause and reintervention

Six years after randomization, endovascular and open repair of abdominal aortic aneurysm resulted in similar rates of survival. The rate of secondary interventions was significantly higher for endovascular repair.

Answer 48

DREAM trial (Long-Term Outcome of Open or Endovascular Repair of Abdominal Aortic Aneurysm)

Question 49

Randomly assigned 1252 patients with large abdominal aortic aneurysms (≥5.5 cm in diameter) to undergo either endovascular or open repair; 626 patients were assigned to each group. Patients were followed for rates of death, graft-related complications, reinterventions, and resource use until the end of 2009

Endovascular repair of abdominal aortic aneurysm was associated with a significantly lower operative mortality than open surgical repair. However, no differences were seen in total mortality or aneurysm-related mortality in the long term. Endovascular repair was associated with increased rates of graft-related complications and reinterventions and was more costly

Answer 49

EVAR-1 trial (Endovascular versus Open Repair of Abdominal Aortic Aneurysm)

Question 50

It is reasonable to consider an ________ first strategy for younger, low-risk patients with long life expectancy.

Answer 50

OSR

Question 51

Persistent blood flow in the aneurysm sac outside the endograft) develop in almost 25% of patients at follow-up with many requiring subsequent therapy

Answer 51

Endoleaks

Question 52

The most common endoleak, result from retrograde filling of the aneurysm sac by aortic branch vessels, usually by the lumbar or inferior mesenteric arteries

Answer 52

Type II

Question 53

Types of endoleaks and treatment

loss of complete sealing at the proximal or end of the stent graft, lead to increased pressure in the aneurysm sac and are associated with increased risk for rupture and therefore warrant repair

Answer 53

Type I

Question 54

Caused by separation of components or disruption of the endograft fabric and require treatment, usually by re-lining with a stent graft.

Answer 54

Type III

Question 55

Endoleaks are related to blood seeping through porous graft material and are self-limited.

Answer 55

Type IV

Question 56

An enlarging AAA after EVAR without a demonstrated endoleak and with a diameter increased to greater than 10 mm, usually requires repair

Answer 56

Type V

Question 57

Imaging with contrast-enhanced CTA is typically performed at ____________ after implantation of the device.

Answer 57

One month and annually

Question 58

Aortic diameters ____________ in adults generally considered to be enlarged.

Answer 58

Greater than 40 mm

Question 59

Prolonged _____________ exercise is associated with an increased prevalence of ascending aortic dilatation.

Answer 59

Endurance exercise

Question 60

Most common (approximately 60%) of TAA

Answer 60

Aortic root or ascending aortic aneurysms

Followed by aneurysms of the descending aorta (approximately 35%) and aortic arch (<10%)

Question 61

_______________ (approximately 10%) refers to descending thoracic aneurysms that extend distally to involve the abdominal aorta.

Answer 61

Thoracoabdominal aortic aneurysm

Question 62

Many of the heritable disorders preferentially involve the ___________________, but some may involve the arch and descending aorta.

Answer 62

Aortic root and ascending aorta

Causes of TAAs include heritable disorders, congenital disorders, degenerative (atherosclerotic), mechanical,inflammatory,and infectious diseases.

Question 63

Up to _______ of patients with AAA have either synchronous or metachronous TAA.

Answer 63

25%

Question 64

__________ describes degeneration and fragmentation of elastic fibers, loss of SMCs, increase in deposition of collagen, and interstitial “cysts” of mucoid-appearing basophilic-staining extracellular matrix

Answer 64

Cystic medial degeneration (CMD)

Question 65

Syndromic HTADs

Answer 65

MFS
LDS
vEDS

Nonsyndromic HTADs (also called familial TAA disorders) are due to mutations in multiple genes. 7 Up to 20% of individuals with a TAA will have a family history of TAA or will have an affected first-degree relative.

Question 66

Give the corresponding gene affected

Marfan Syndrome
Loeys-Dietz Syndrome
Vascular EDS

Answer 66

Marfan Syndrome - FBN1
Loeys-Dietz Syndrome - TGFBR1, TGFBR2
Vascular EDS - COL3A1

Question 67

MFS, an autosomal dominant disorder of connective tissue, results from abnormal fibrillin-1 due to mutations in the FBN1 gene.

Aortic dilation in MFS affects most prominently the _________________

Answer 67

Sinuses of Valsalva

Question 68

____________ is the major component of the microfibril, a primary component of the extracellular matrix, and by interaction with lysyl oxidase (encoded by LOX), promotes vascular SMC adhesion and elastin support.

Answer 68

Fibrillin-1

Question 69

___________mutations in multiple genes in the TGF-β signaling pathway, leads to craniofacial abnormalities (hypertelorism, bifid/broad uvula, cleft palate, craniosynostosis), arterial tortuosity, and aneurysms and dissections of the aorta and branch vessels. Cutaneous features include easy bruisability, visible veins, widened scars, and facial milia.

Answer 69

Loeys-Dietz Syndrome

Question 70

___________ may have a more aggressive phenotype than TGFBR1 mutations and aortic surgery is recommended at aortic root dimensions of 4 to 4.5 cm.

Answer 70

TGFBR2 mutations

Question 71

___________ due to SMAD3 mutations, involves severe osteoarthritis and osteochondritis dissecans, in addition to the vascular, skeletal, and cutaneous features of LDS and may merit aortic surgery at relatively small aortic root diameters and mutations in TGFB2 share features of MFS and LDS.

Answer 71

Aneurysms-osteoarthritis syndrome (AOS or LDS3)

Question 72

____________ due to mutations in COL3A1 causing abnormal type III procollagen synthesis, associates with aortic and branch vessel aneurysm, rupture, and/or dissection and rupture of visceral organs at a young age leading to reduced lifespan

Answer 72

vEDS

Question 73

Aortic root disease is less common in vEDS, with more frequent involvement of the _________________

Answer 73

Descending and abdominal aorta and branch vessel

Individuals with vEDS have risk for spontaneous arterial dissection and rupture, often involving medium-sized arteries that did not exhibit significant dilation.

Question 74

_______________ are inherited as an autosomal dominant trait with decreased penetrance and variable expression (especially in women) and are more common than syndromic aortopathies.

Answer 74

Nonsyndromic HTADs (familial TAA)

Question 75

__________ affects 1% of the population, associates with ascending aortic aneurysm, coarctation of the aorta, and aortic dissection

Answer 75

BAV

Question 76

____________ due to helical flow patterns in the setting of BAVs may underlie the aortopathy of BAV disease

Answer 76

Abnormal aortic wall shear stress

The BAV exhibits abnormal leaflet folding, wrinkling, and increased leaflet doming, which can result in turbulence even in the absence of a stenotic or regurgitant lesion.

Question 77

The aortic dilatation in BAV disease occurs most often in the ___________

Answer 77

Proximal to mid-ascending aorta

Ascending TAAs a ated with BAVs may develop independent of valve function and may develop late after aortic valve replacement (AVR).

Question 78

________ underlies the aortic aneurysm and risk for dissection associated with BAVs.

Answer 78

CMD

Question 79

When BAV and TAA coexist, CMD is more pronounced in ____________ than stenotic BAV.

Answer 79

Regurgitant

Question 80

The lifetime risk of aortic dissection for the BAV patient is ____________ higher than the risk in the general population, but the absolute risk is very low unless aortic aneurysm is present.

Answer 80

4 to 8 times

Question 81

____________ results from complete or partial loss of a second sex chromosome (XO, Xp)

Answer 81

Turner Syndrome

Question 82

Patients with TS have an estimated ______________ for aortic dissection than do age-matched controls

Answer 82

100-fold greater risk

Question 83

Women with TS but without risk factors for aortic dissection should undergo reevaluation of the aorta every _____________ or when clinically indicated (such as when contemplating pregnancy).

Answer 83

5 to 10 years

Most women with TS who suffer aortic d tion have risk factors, including aortic dilatation, BAV, coarctation of the aorta, or hypertension

Question 84

TS patients have increased aortic diameter relative to body surface area and a higher risk for dissection at ________________.

Answer 84

smaller absolute aortic diameters

Question 85

Degenerative TAAs occur most commonly in the _____________, have a _______ predominance (1.7 to 1), present at an average age of ________, and are associated with aortic __________________.

Answer 85

Descending aorta
Male
65 years
Atherosclerosis

These aneurysms tend to originate just distal to the origin of the left subclavian artery, may be either fusiform or saccular, and may extend into the abdominal aorta or coexist with AAAs.

Question 86

Aneurysm formation develops during the chronic stage of dissection, being most common in the ________________

Answer 86

Proximal descending aorta

Question 87

____________ the embryologic remnant located at the origin of an aberrant subclavian artery that may lead to aneurysmal dilatation, rupture, or aortic dissection.

Answer 87

Kommerell diverticulum

Question 88

Surgical intervention is considered when the diverticulum diameter exceeds ________ and/or the diameter of the descending aorta adjacent to the diverticulum exceeds ___________

Answer 88

30 mm

50 to 55 mm.

Question 89

Cardiovascular syphilis occurs in the tertiary stage and typically involves the _________________

Answer 89

Ascending aorta and arch

Pathologic features include lymphocytic and plasma cell inflammation in the adventitia, with the classic appearance of a “tree bark” or wrinkled appearance of the aortic intima.

Tertiary syphilis may cause aortic valvulitis, aortic regurgitation (AR), and coronary ostial stenosis.

Question 90

Symptoms of TAAs usually relate to

Answer 90

Local mass effect
Progressive AR
Systemic embolization due to mural thrombus or atheroembolism
Eelated to acute dissection or rupture

Question 91

Obstruction of the superior vena cava or innominate vein may result from ascending aorta or arch aneurysms. TAAs may compress the trachea, bronchus, or esophagus or lead to hoarseness from __________________

Answer 91

Laryngeal nerve compression

Persistent chest or back pain may occur because of a direct mass effect from the TAA, with compression of intrathoracic structures or erosion into bones. The most serious complications

Question 92

The most serious complications of TAAs are _________________

Answer 92

Rupture and dissection

Question 93

Aortic rupture leads to sudden severe chest or back pain.

Rupture into the pleural cavity (usually ______) or into the mediastinum is associated with hypotension, rupture into the esophagus leads to hematemesis, and rupture into the bronchus or trachea leads to hemoptysis.

Answer 93

Left

Question 94

_____________ are associated with pain, fever, and fistulas.

Acute aortic expansion, contained rupture, and pseudoaneurysm can cause chest or back pain.

Answer 94

Infected TAAs

Question 95

Some TAAs are evident on chest x-rays with features including

Answer 95

Widened mediastinum
Prominent aortic knob
Displaced trachea

Question 96

_________________ provide outstanding detail of aortic and branch vessel anatomy in TAA disease

Answer 96

Contrast-enhanced CT and MRA

Multidetector CTA and MRA allow r tion of the axial data into three-dimensional images, permitting aortic measurement in a double oblique technique to obtain an accurate diameter

Question 97

TAAs are relatively indolent, with a growth rate of approximately ______________ and marked individual variability.

Answer 97

1 to 2 mm/year

Question 98

Rupture and acute dissection are the major complications of TAAs. Less than half of patients with rupture arrive at the hospital alive; mortality at 24 hours reaches ______

Answer 98

75%

Question 99

The risk of aortic dissection, rupture, and death increases with enlarging aortic diameters with “hinge points” at

aortic diameters greater than ______________ for ascending aortic aneurysms and ____________ for descending aortic aneurysms

Answer 99

> 5.25 to 5.75 cm - ascending

Above 6.0 cm - descending

Question 100

_______________ is the most important risk factor for aneurysm complications, but other factors influence this risk including sex, body surface area and height, and indexing of aortic size in certain populations may inform risk.

Answer 100

Aortic diameter

Question 101

Size Threshold for Prophylactic Aortic Root or Ascending Aortic Aneurysm Resection for Various Conditions

Degenerative aneurysm
BAV
BAV with risk factors or low surgical risk
BAV requiring AVR
MFS
MFS with risk factors
LDS
Familial thoracic aortic aneurysm
Turner syndrome

Answer 101

Degenerative aneurysm - >/= 5.5
BAV - >/= 5.5
BAV with risk factors or low surgical risk - >/= 5.0
BAV requiring AVR - >/= 4.5
MFS - >/= 5.0
MFS with risk factors - >/= 4.5
LDS - 4.0 - 4.5
Familial thoracic aortic aneurysm - 4.5 - 5.0
Turner syndrome - >2.5cm/m2

Question 102

Identify the ffg aortic landmarks

Answer 102

Question 103

Treatment of ascending TAAs involves opening the ascending aorta and placement of a prosthetic graft with or without concomitant AVR.

A composite graft consisting of a Dacron tube with a prosthetic aortic valve sewn into one end (the _______________________) is generally the method of choice in treating ascending TAAs involving the root and associated with significant aortic valve disease.

Answer 103

Modified Bentall procedure

The valve and graft are sewn directly into the aortic annulus, and the coronary arteries are reimplanted into the Dacron graft.

Question 104

Patients with structurally normal aortic valve leaflets and those whose AR is secondary to dilation of the sinotubular junction or aortic annulus may be able to undergo a valve-sparing root replacement—reimplanting the native valve within a Dacron graft ( _____________) or by remodeling the aortic root ( _____________ )

Answer 104

David procedure
Yacoub procedure

The reimplantation technique is preferable to the remodeling technique (especially in genetic aortopathy) because it stabilizes the annulus and limits aortic dilation and late AR

Question 105

A pulmonary autograft (the _______________) is an alternative to a composite aortic graft in appropriate candidates.

Answer 105

Ross procedure

This procedure involves replacing the native aortic valve and root with the patient’s own pulmonary root, inserted into the aortic position. The pulmonary root is replaced with a cryopreserved homograft root.

Question 106

The Ross procedure carries risks of late autograft ______________ and should not be used in patients with genetically triggered aortic root diseases.

Answer 106

Aneurysm formation

Question 107

Aortic arch aneurysms are more difficult to treat surgically because reconstruction of the aortic arch vessels requires interruption of blood flow to these vessels

One approach uses a ______________—the arch vessels remain intact, with the upper aortic arch as a roof, and the remaining arch is replaced.

_________________ requires either removing the entire arch and using branched grafts to replace the arch and great vessels, by using bypasses constructed to each great vessel, or less often reimplanting an island of arch tissue that includes the origins of the great vessels

Answer 107

Hemiarch resection
Extended arch resection

Question 108

A modification of this procedure uses a c ered endovascular stent graft attached to a vascular graft to allow fixation of the stent graft within the descending aorta and vascular graft reconstruction of the aortic arch

This _____________ procedure allows total replacement of the arch and descending aorta in a single stage for complex aneurysms and also the treatment of acute type A dissection

Answer 108

“frozen elephant trunk”

Because the aortic disease often extends distally, the polyester graft can be extended as an elephant trunk into the descending aorta, and necessitates a second procedure to complete the repair. In this procedure, the distal anastomosis is created to the midportion of a graft and the distal graft is within the lumen of the aorta and thus can be retrieved without manipulation of the arch. A

Question 109

______________ occurs in 5% to 9% of frozen elephant trunk procedures.

Arch aneurysm surgery has a morbidity and mortality rate of _______ risk for both death and stroke.

Answer 109

Spinal cord injury

2% to 7%

Question 110

Descending TA

The European Society for Vascular Surgery Guidelines recommend that repair should be considered when descending TAA reaches ________ and may be considered for aneurysms of 56 to 59 mm, with lower thresholds to be considered in _______________

Answer 110

60 mm
Women and in those with heritable aortic disease

Question 111

The Society for Vascular Surgery Guidelines recommend TEVAR for _______ individuals with descending TAA diameter greater than ________

Answer 111

Low-risk
55 mm

Question 112

TEVAR are associated with a perioperative mortality of 10% (5% to 22%) and a paraplegia rate of approximately ___________

Answer 112

2% to 6%

Question 113

Describes the extent of the aneurysm, and this predicts morbidity, mortality, and risk for paralysis with repair

Answer 113

Crawford Classification

Question 114

Because of the risk of the p dure, in general, surgical repair is considered for ___________ patients with TAAA greater than ______ (less for those with heritable aortic disease, rapid growth [>10 mm/year], or with symptoms)

Answer 114

Low- to moderate-risk

60 mm

Question 115

Involves the entire thoracic aorta and the upper a inal aorta extending from the proximal descending aorta above the T6 vertebra to the level of the renal arteries (approximately 25 of TAAAs

Answer 115

Type I

Question 116

The highest-risk group, with the aneurysm involving the entire thoracic and most or all of the abdominal aorta extending from the proximal descending aorta above T6 to below the renal arteries, often to the iliac bifurcation (30% of TAAAs)

Answer 116

Type II

Question 117

Involve the distal half of the descending thoracic aorta below T6 and extend into the abdominal aorta (<25% of TAAAs)

Answer 117

Type III

Question 118

Extends from the diaphragm and involves most of the abdominal aorta to the aortic bifurcation (<25% of TAAAs

Answer 118

Type IV

Question 119

Distal half of the descending aorta (below T6) and extend into the abdominal aorta, but are limited to the visceral segment.

Answer 119

Type V

Question 120

TEVAR, a far less invasive alternative to OSR of descending TAAs, has lower morbidity and mortality rates than OSR and is preferable when feasible.

For TEVAR, the aorta must have adequate proximal and distal landing zones of at least ________P_ in length and diameters that accommodate the endograft and adequate vascular access.

Answer 120

20 to 25 mm

Question 121

TEVAR for descending TAA has a lower 30-day mortality rate than OSR (5.6% vs. 17%) and a lower risk of ______________

Stroke risk in TEVAR for TAA disease is 3% to 6%.

Answer 121

Stroke and paraplegia

Question 122

Transposition of the ______________ or a left carotid-to-subclavian bypass is recommended before TEVAR when covering the left subclavian is required to lessen ischemic risk

Answer 122

Left subclavian artery

Question 123

_______________ with the development of paraparesis or paraplegia is a major source of morbidity

Answer 123

Spinal cord dysfunction

Question 124

Drainage of cerebrospinal fluid has been used in combination with a mean arterial pressure of at least ___________ (>90 mm Hg in those at high risk) to lessen spinal cord complications

Answer 124

70 mm Hg

Question 125

Placement of a spinal drain is also associated with complications and routine use is typically not recommended unless there are risk factors such as

Answer 125

Coverage greater than 15 cm of descending thoracic aorta
Loss of the left subclavian, hypogastric, or lumbar arteries from prior or concomitant aortic surgery or occlusive disease

Question 126

_____________ are the most common complication of endovascular repairs and occur in 10% to 20% of patients

Answer 126

Endoleaks

Question 127

Recommended timing of surveillance imaging for

Degenerative TAA 4.0 - 4.5 cm
Degenerative TAA 4.5 - 5.4 cm

Small TAA

MFS and familial TAAD 3.5 - 4.4 cm
MFS and familial TAAD 4.5 - 5.0 cm

BAV with aortic dilatation

Answer 127

Degenerative TAA 4.0 - 4.5 cm - Annual
Degenerative TAA 4.5 - 5.4 cm - 612 months

Small TAA - 2.-3 years

MFS and familial TAAD 3.5 - 4.4 cm - Annual
MFS and familial TAAD 4.5 - 5.0 cm - Annual or Biannual

BAV with aortic dilatation - Annual

Question 128

Aortic events have been associated with _______________ use and avoidance of this antibiotic class is recommended for those with or at risk for aneurysm disease.

Answer 128

Fluoroquinolone

Question 129

Avoidance of strenuous physical activity, especially ___________

Answer 129

Isometric exercise and weightlifting

Question 130

Include aortic dissection, aortic intramural hematoma (IMH), and penetrating atherosclerotic aortic ulcer (PAU)

Answer 130

Acute aortic syndromes

Question 131

In 80% to 90% of acute aortic syndromes, ___________ is present, with intimal disruption leading to a dissection plane in the media that may propagate anterograde

Answer 131

Aortic dissection

In aortic dissection, an intimal flap exists between the two lumens (true and false lumens).

Question 132

Ten to 20% of acute aortic syndromes result from ________, where bleeding in the aortic wall occurs without imaging evidence of an intimal tear or dissection flap

Answer 132

IMH

Question 133

_________ also lead to acute aortic syndromes in approximately 5% of cases.

Answer 133

PAUs

Question 134

Two thirds of aortic dissections occur in _______

Acute aortic dissection has a very high early mortality, with up to a _______death rate

Answer 134

Men

1% per hour after type A dissection

Question 135

_____________ occurs most commonly in individuals between 50 and 60 years of age

_____________ at a peak of 60 to 70 years of age.

Women present at older ages than men

Answer 135

Type A aortic dissection

Type B dissection

Question 136

The main hypothesis for acute aortic dissection is a primary entry tear in the ____________ with blood penetrating into the diseased media and leading to propagation of the dissection and creation of the true and false lumens.

Answer 136

Aortic intima

Primary rupture of the vasa vasorum with r tant intimal disruption is a second hypothesis.

Question 137

Distention of the false lumen with blood causes the intimal flap to compress the true lumen and narrow its caliber and may lead to __________________

Answer 137

Malperfusion syndromes

Question 138

Give the classification of dissection

Originates in the ascending aorta and extends at least to the aortic arch and typically to the descending aorta (and beyond)

Answer 138

Stanford A Debakey I

Question 139

Identify

Answer 139

Stanford B Debakey III

Most type A dissections begin within a few centimeters of the aortic valve, and most type B dissections begin just distal to the left subclavian artery.

Approximately 65% of intimal tears occur in the ascending aorta, 30% in the descending aorta, less than 10% in the aortic arch, and approximately 1% in the abdominal aorta.

Question 140

Entry tear originates only in the ascending aorta (zone 0)

Answer 140

Type A

Question 141

Cut offs for the Classical definition of Duration of dissection from symptom onset

Answer 141

Acute: < 14 days
Chronic : > 14 days

Question 142

Several conditions predispose the aorta to dissection, most due to _________________ or _________________.

Some 75% of all patients with aortic dissection have __________

Answer 142

Disruption of the integrity of the aortic wall

Marked increases in aortic wall circumferential stress

Hypertension

In the IRAD, conditions associated with dissection included: hypertension (77%), atherosclerosis (27%), previous cardiac surgery (16%), known aortic aneurysm (16%), MFS (5%), iatrogenic (3%), and cocaine use

Question 143

Type B dissection may also complicate HTAD, may be the first presentation of the disease, and is more common after _______________

Answer 143

Prior root replacement

Question 144

________ is an important risk factor for ascending aortic aneurysm and dissection

Answer 144

BAV

Question 145

Cocaine-related aortic dissection is more commonly _________, often presenting with hypertension and small aortic diameters.

Answer 145

Type B

Question 146

Women with ________________ have increased risk for acute aortic dissection related to pregnancy.

Answer 146

MFS, LDS, nonsyndromic HTAD, vEDS, TS, and BAV with aneurysm

Question 147

Individuals with TAA have risk for aortic dissection, with higher risk for dissection and rupture as aortic size increases.

True or False

However, many aortic dissections occur in patients with aortic dimensions that are not markedly dilated and are below thresholds for prophylactic aortic repair.

Question 148

_____________ is the most classic feature.

Answer 148

Abrupt onset of severe chest or back pain

Distinct from the discomfort of coronary ischemia, the pain is described as severe in approximately 90% of patients and usually of sudden onset, with maximum intensity occurring at its inception.

Some patients describe a “sense of doom.” The pain quality is most often described as “sharp,” “severe,” or “stabbing,” and descriptors such as “tearing” or “ripping” are less common.

Question 149

Acute CHF related to type A dissection may result from ___________

Question 150

__________ in patients with type A dissection usually associates with hemopericardium, rupture, arch vessel involvement, or stroke.

Answer 150

Syncope

Question 151

_______________ occurs in 6% of patients and associates with syncope, stroke, previous aortic aneurysm, and prior cardiac surgery.

Answer 151

“Painless” aortic dissection

Other clinical features at presentation include congestive heart failure (CHF) (<10%), syncope (9%), acute stroke (6%), acute MI, paraplegia, and cardiac arrest or sudden death.

Question 152

A ___________ is reported in 30% of type A dissections and 20% of type B dissections with frank limb ischemia less common.

Malperfusion, occurring in up to 30%, is the most common _________, but may be static or mixed.

Answer 152

Pulse deficit

Dynamic

Question 153

_________________ results from the pressurized false lumen pushing the septum toward the true lumen leading to collapse of the true lumen, obstructing branch vessels.

Answer 153

Dynamic malperfusion

Question 154

_____________ results from stenosis or occlusion of a branch artery due to the dissection flap, hematoma, embolism, or thrombosis

Answer 154

Static malperfusion

Question 155

__________ occurs in 41% to 76% of patients with type A dissection, with a diastolic murmur audible in 40%

Answer 155

Aortic regurgitation

Question 156

Mechanisms of AR relate to the functional aortic annulus and aortic valve and may be due to

Answer 156

Acute dilation of the aortic sinuses and/or sinotubular junction, commissural disruption
Restrictive cusp mobility
Aortic leaflet prolapse
Circumferential dehiscing intimal flap prolapsing into the left ventricular outflow tract during diastole interfering with valve coaptation
Preexisting AR due to a preexisting aortic root aneurysm or BAV

Question 157

______________ occur in 15% to 40% of patients with aortic dissection and are more common with type A dissections.

Answer 157

Neurologic manifestations

Neurologic syndromes include persistent or transient ischemic stroke, spinal cord ischemia, ischemic neuropathy, and hypoxic encephalopathy and are related to malperfusion of one or more branches supplying the brain, spinal cord, or peripheral nerves

Question 158

Coronary ischemia is present in 5% to 10% of patients with type A dissection and ST-segment elevation myocardial infarction (STEMI) occurs in approximately 2% (most commonly affecting the ___________)

Answer 158

Right coronary artery

Coronary malperfusion may be due to the false lumen involving the coronary ostium, dissection flap extending into the coronary, or avulsion of the coronary artery

Question 159

Renal artery involvement occurs in at least 5% to 10% of patients and may lead to ______________________

Answer 159

Renal ischemia, infarction, or renal insufficiency or refractory hypertension

Question 160

_________________ occurs in less than 5% of dissection and associates with a marked increase in mortality.

Answer 160

Mesenteric ischemia

Question 161

Aortic dissection may lead to a ______________ bland or inflammatory pleural effusion, but hemothorax may occur from aortic rupture.

Answer 161

Left-sided

Question 162

The most common abnormalities are _______________________, appearing in approximately 70% to 80% of cases
(83% of type A; 72% of type B).

Answer 162

Abnormal aortic contour or widening of the aortic silhouette

Question 163

Patients with acute aortic dissection have elevated _________ levels making this a very useful biomarker for classic acute dissection

Answer 163

D-dimer

In patients seen within the first 24 hours of onset, a D-dimer level lower than 500 ng/mL had a negative likelihood ratio of 0.07 and a negative predictive value of 95%. D-dimer is reported as having a sensitivity of 97% and a specificity of 47%. 1 , 41 Notably, normal D-dimer levels can occur with aortic dissection and a thrombosed false lumen, as well as with aortic IMH and PAU

Question 164

The modality most commonly used for evaluating aortic dissection and is best performed with an ECG-gated, multidetector scanner, which may eliminate aortic pulsation motion artifacts

Answer 164

Contrast-enhanced CTA

On CTA, aortic dissection is diagnosed by the presence of two distinct lumens with a visible intimal flap or by detection of two lumens by their differing rates of opacification with contrast material

Contrast-enhanced CT has a sensitivity and specificity of 98% to 100% in diagnosing aortic dissection, but false-negative results may occur with inadequate contrast bolus. CTA allows three-dimensional reconstruction for evaluation of the dissection and branch vessels and is critical for endovascular repair

Question 165

Characteristics of false lumen

Answer 165

If the false lumen is completely thrombosed, it demonstrates low attenuation.

The false lumen usually has slower flow and a larger diameter than the true lumen

Question 166

Echocardiogram (and ultrasound) diagnosis of aortic dissection is based on the presence of an _________________ with independent motion within the aortic lumen that separates the true and false lumens.

Answer 166

Undulating intimal flap

Question 167

Features of the true lumen on TEE include a __________________________

Answer 167

Smaller lumen, systolic expansion, systolic anterograde flow, communication from the true to the false lumen in systole, and early and fast contrast-enhanced echocardiographic flow

TEE may not adequately visualize the distal ascending aorta and proximal aortic arch, but it interrogates the remaining thoracic aortic segments

Question 168

True or False

Routine coronary angiography is not recommended before surgery for acute type A aortic dissection because of concern about delay in emergency surgery.

Answer 168

True

Coronary angiography may be technically difficult in the setting of dissection. Arterial access may fail to gain entry into the true lumen, and injury to the aorta from the catheter or guidewire may cause extension of the dissection or perforation of the aorta.

Question 169

A bedside risk assessment stratifies patients into low (score 0), intermediate (score 1), and high (score 2 to 3) risk group

Answer 169

Aortic Dissection Detection [ADD] Risk Score

Question 170

Give high risk conditions

Answer 170

• Marfan syndrome
• Family history of aortic disease
• Known aortic valve disease
• Recent aortic manipulation
• Known thoracic aortic aneurysm

Question 171

Give high risk pain features

Answer 171

Chest, back, or abdominal pain described as the following:

• Abrupt in onset
• Severe in intensity
• Ripping or tearing

Question 172

Give high risk exam features

Answer 172

• Evidence of perfusion deficit

• Pulse deficit
• Systolic BP differential
• Focal neurologic deficit (in conjunction with pain)

• Murmur of aortic insufficiency (new or not known to be old and in conjunction with pain)

• Hypotension or shock state

Question 173

Disposition for patients with ADD risk score of >/= 2

Answer 173

Immediate surgical consultation and arrange for expedited aortic imaging.

Question 174

Initial medical management includes stabilizing the patient, controlling pain, and lowering blood pressure with beta blockers to ___________________

Answer 174

Reduce the rate of rise in the force (dP/dt) of left ventricular contraction.

Question 175

Emergency surgery improves survival for acute type A dissections with an 18% in-hospital mortality for surgically treated and ______ mortality for medically treated patients

Answer 175

56%

Question 176

Reduction of systolic blood pressure to ______________________ and a heart rate of 60 to 80 beats/min is recommended.

Answer 176

100 to 120 mm Hg or the lowest level necessary for adequate perfusion

Question 177

When encountering refractory hypertension in acute dissection one must consider ______________

Answer 177

Renal artery malperfusion (especially with signs of renal ischemia)

Question 178

Effect of pericardiocentesis in patients with dissection and cardiac tampnade?

Answer 178

Pericardiocentesis for acute hemopericardium in patients with dissection can result in recurrent bleeding and acute hemodynamic collapse, especially if a larger volume of fluid is removed and increased blood pressure causes further brisk bleeding into the pericardial space.

Hypotension or shock from h cardium secondary to ascending dissection requires emergency aortic surgery.

In patients with persistent hypotension or shock from hemopericardium due to type A dissection who will not survive open surgery, careful aspiration of small volumes of pericardial fluid associates with improved blood pressure and may be lifesaving and should be considered in this setting.

Question 179

Definitive therapy for acute aortic dissection includes _____________ for type A dissection in patients considered surgical candidates

Answer 179

Emergency surgery

In large registries, the mortality rate of patients with type A aortic dissection undergoing surgery was 18%, as opposed to 56% in those treated medically (typically because of advanced age and comorbid conditions)

Factors associated with mortality include shock, heart failure, cardiac tamponade, MI, renal failure, age, extent of dissection, and malperfusion.1

Question 180

Acute retrograde type A dissection with a primary intimal tear in the descending aorta is usually treated _____________

Answer 180

Surgically

Question 181

Patients with acute TBAD have a lower acute mortality rate than do those with acute type A dissection, with overall in-hospital mortality rates of approximately ______

Answer 181

10%

Question 182

The in-hospital mortality rate is lower for uncomplicated type B dissection, reported as _________ in those requiring only medical therapy

Answer 182

1% to 6%

Question 183

Indications for TEVAR (or less commonly OSR when TEVAR is not feasible) in complicated TBAD include

Answer 183

Rupture/Impending rupture
Malperfusion
Hemothorax
Refractory pain
Refractory hypertension
dilatation (>55 mm)
Rapid increase in aortic diameter
Recurrent symptom

Question 184

___________ performed as expediently as possible, is the treatment of choice for acute type A aortic dissection to prevent life-threatening complications

Answer 184

Open surgical repair

Surgical goals are to excise the intimal tear; to restore flow in the true lumen and obliterate the false channel by oversewing the edges of the aorta; and to reconstitute the aorta with placement of an interposition graft.

Question 185

In type A dissection, AR is treated by _______________ or by prosthetic AVR.

Answer 185

Resuspension of the aortic valve leaflets

Question 186

_________________ is a potentially lethal complication that may occur during TEVAR for TBAD, emphasizing the requirement for an open repair team at institutions performing TEVAR for aortic dissection.

Answer 186

Retrograde ascending dissection

Question 187

first randomized controlled trial on acute aortic dissection and compares OMT with OMT plus TEVAR, performed with the aim to cover the primary entry tear in patients with uncomplicated ABAD

One-year results demonstrated that thrombosis of the FL and reduction of its diameter are induced by the stent-graft in uncomplicated ABAD patients, but long-term results are needed

Answer 187

ADSORB trial

Question 188

One hundred forty patients in stable clinical condition at least 2 weeks after index dissection were randomly subjected to elective stent-graft placement in addition to optimal medical therapy (n=72) or to optimal medical therapy alone (n=68) with surveillance

There was no difference in all-cause deaths, with a 2-year cumulative survival rate of 95.6+/-2.5% with optimal medical therapy versus 88.9+/-3.7% with TEVAR (P=0.15)

Answer 188

INSTEAD trial

In the first randomized study on elective stent-graft placement in survivors of uncomplicated type B aortic dissection, TEVAR failed to improve 2-year survival and adverse event rates despite favorable aortic remodeling.

Question 189

Typical indications for TEVAR (or OSR) in chronic type B AD include

Answer 189

Progressive aortic enlargement (>5 to 10 mm/year)
Aneurysmal enlargement (>55 to 60 mm)
Malperfusion syndromes
Recurrent pain

Question 190

Currently, OSR is reserved for patients with aortic diameters greater than ______________ who are good surgical candidates, including those with heritable/genetic aortic conditions, and at greater than 60 mm for reasonable candidates, whereas those at high surgical risk should be considered for ___________ at dedicated centers.

Answer 190

55 to 60 mm

TEVAR

Question 191

The __________________ are the areas at highest risk for aneurysm formation after aortic dissection.

Answer 191

Distal arch and the proximal descending aorta

Question 192

Typical imaging after acute dissection includes CT or MRA at ____________ thereafter

Answer 192

1 to 3, 6, and 12 months and annually

Question 193

Clinical and Imaging Characteristics Predicting Risk of Late Aortic Complications in Initially Uncomplicated Type B Aortic Dissection

Answer 193

Primary entry tear diameter >10 mm
Initial aortic diameter >40 mm
False lumen diameter >22 mm
Partially thrombosed false lumen
Saccular false lumen formation

Question 194

True or False

Many late deaths following surgery for aortic dissection result from rupture of the aorta at the site of previous dissection or from rupture of another aneurysm at a remote site.

Answer 194

True

Question 195

Rapid aortic growth (____________) or aortic diameter greater than _________ are risk factors for rupture.

Answer 195

> 5 mm/year

> 60 mm

Question 196

In general, patients with descending aorta diameter after dissection that exceeds ___________ or if the rate of aortic expansion exceeds ___________ should have evaluation for repair.

Answer 196

5.5 to 6 cm

1 cm/year

Question 197

___________ defined as a hematoma in the medial layer of the aortic wall without identifiable communication between the lumen and hematoma and no evidence of an intimal flap or false lumen.

Answer 197

Aortic IMH, representing 10% to 20% of acute aortic syndromes (and higher incidence [30%] in Asia

Question 198

IMH involves the ascending aorta in 30%, the arch in 10%, and the ________________ in 60% to 70%.

Answer 198

Descending aorta

Question 199

IMH may result from rupture of the _____________ and subsequent mural hemorrhage.

Answer 199

Vasa vasorum

Supporting this theory is the location of IMH in the outer aortic media in distinction to the inner medial location of a classic dissection.

Question 200

IMH is classified as _______________ as for classic aortic dissection.

Answer 200

Type A or type B

Question 201

The proximity of the IMH to the adventitia may explain the frequent coexistence of _________________, ________________, _________________ and underlies the higher risk for aortic rupture.

Answer 201

Pleural effusion, pericardial effusion, and periaortic hematoma

Question 202

__________ is less common in IMH

Answer 202

Malperfusion

Question 203

__________________ is the hallmark of IMH in imaging

Answer 203

Crescentic or circumferential wall thickening without a visible intimal flap

Question 204

CT features of IMH

Answer 204

Non–contrast-enhanced CT - area of high attenuation (due to bleeding) in the aortic wall

Contrast-enhanced CT - the aortic wall demonstrates low attenuation (because no contrast material enters the wall)

Question 205

TEE features of IMH

Answer 205

Focal crescentic or circumferential aortic wall thickening ≥5 mm
An eccentric aortic lumen, displaced intimal calcification
Areas of echolucency within the aortic wall and no intimal flap or flow in the aortic wall

Question 206

Findings associated with higher complication risk

Answer 206

Focal intimal disruptions
Ulcer-like projections (ULP) (a localized blood-filled pouch protruding into the hematoma in the aortic wall which may be due to micro-intimal defects)
Focal contrast enhancement (intramural blood pools) within the hematoma
Thick hematoma
Large aortic diameter

Question 207

IMH has a ________________ distinct from an aneurysm with mural thrombus

Answer 207

Smooth lumen and curvilinear wall

Thickening beneath the intima suggests IMH, whereas thickening above the intima (on the luminal side) occurs with mural thrombus.

In contrast to aortic atherosclerosis, IMH is not typically associated with diffuse intimal irregularities unless related to a penetrating ulcer.

Question 208

Current guidelines recommend _________ for type A IMH especially in the setting of hemodynamic instability, hemopericardium, rupture, or proximal aortic complications, and ___________ for type B IMH.

Answer 208

Type A - surgery
Type B - medical therapy

Question 209

Type B IMH is treated ___________ in the vast majority with endovascular procedures performed for complications

Answer 209

Medical therapy

Question 210

representing approximately 5% of acute aortic syndromes, is an atherosclerotic plaque that penetrates through the internal elastic lamina into the media and often associates with a variable degree of IMH.

Answer 210

Penetrating Atherosclerotic Aortic Ulcer

Question 211

PAUs are more common in the ___________________

Answer 211

mid-to distal descending aorta than in the arch or ascending or abdominal aorta

Question 212

CT findings of PAU

Answer 212

Focal aortic ulceration, associated IMH, and a calcified, displaced intima

Typically, a crater-like outpouching with irregular edges occurs in the setting of heavy atherosclerosis.

Question 213

In general, patients with ascending PAUs undergo surgical resection. Stable patients with type B PAUs may be managed medically, with close follow-up and serial imaging.

Answer 213

Patients with refractory or r rent pain, overlying IMH or periaortic hemorrhage, or rapid increase in size are at increased risk of rupture and should undergo TEVAR

Question 214

Indications for TEVAR (or less often, surgery) may include hemorrhage, periaortic hematoma, expanding pseudoaneurysm, saccular aneurysm formation, continued pain, or rupture.

Answer 214

Predictors of disease progression include increasing aortic wall thickness, ulcer craters greater than 15 to 20 mm in diameter or greater than 10 mm in depth, increasing aortic hematoma, and increasing pleural effusion

Question 215

The classic triad of an infected aortic aneurysm includes

Answer 215

Fever (67%)
Pain (77%) in the abdomen, back, or chest
Pulsatile tender mass

Question 216

Infected aneurysms most commonly involve the ________________ (60%) and the descending aorta.

Answer 216

Infrarenal aorta

Question 217

Infected TAAs are less common, most commonly affect the __________________, and are often accompanied by rupture (in 44%) or pseudoaneurysm.

Answer 217

Descending aorta

Question 218

The most common microorganisms associated with infected aortic aneurysms include __________________, but infections with gram-negative bacilli and fungi can occur.

___________ may directly penetrate an intact intima of a normal aortic wall and lead to arteritis and aneurysm formation.

Answer 218

Staphylococcus aureus, streptococcal, and Salmonella species

Salmonella
Thus, suspicion for aortic seeding is prudent when Salmonella bacteremia occurs.

Question 219

Features on CT include

Answer 219

Disruption of calcification, irregular wall thickening, periaortic mass, rim enhancement, and periaortic stranding.

The presence of gas and vertebral body erosion is highly suggestive of infection.

Question 220

MRI features of infected aneurysms include

Answer 220

Soft tissue mass, stranding, and rim enhancement.

Question 221

Overall mortality from infected aortic aneurysms ranges from ___________ with medical therapy alone

Answer 221

50% to 100%

Question 222

_______ of infected AAAs involves excision and debridement or exclusion of the infected aortic tissue, revascularization (in situ or extra-anatomic bypass), and prolonged antibiotic therapy.

Answer 222

OSR

Question 223

Acute and chronic management pathway for type B intramural hematoma (IMH)

Medical treatment and close follow-up with imaging techniques

Answer 223

• Every 3 months (1st year)
• Every 6 months (2nd and 3rd year)
• Annually (3rd year)

Question 224

Tumors affecting the aorta most commonly arise secondarily from direct invasion by adjacent cancer or metastases, especially from the _______________

Answer 224

Lung and esophagus

The average age at diagnosis is 60 years, with a male preponderance.

These tumors most commonly localize in the descending thoracic (38%) and abdominal (43%) aorta

Symptoms include pain, embolism, claudication, visceral ischemia, or constitutional symptoms.