Aneurysm

Question 1

Aneurysm

Answer 1

localised dilation >1.5 x normal size of artery segment

Question 2

True aneurysm

Answer 2

Involves all 3 layers of arterial wall

Question 3

False aneurysm

Answer 3

Not involving all arterial layers, actually compared thrombus/layer of fibrous tissue

Question 4

Cause of aneurysm

Answer 4

• Artherosclerosis 90%
• Familial
• Infective
• Connective Tissue disorder
• Traumatic/Iatrogenic
• Inflammation

Question 5

Definition of AAA

Answer 5

External diameter >3cm

Question 6

Etiology of AAA

Answer 6

• Artherosclerosis 90%
• Infection
• Connective Tissue Disease
• Inflammation
• Traumatic / Iatrogenic

Question 7

Epidemiology of AAA: Percentage of AAA

1) infrarenal
2) associated wtih atherosclerosis
3) associated with other peripheral aneurysm

Answer 7

1) 95%
2) 95%
3) 20%

Question 8

Triad of rupture AAA

Answer 8

Pulsatile mass

Abdominal pain radiating ot back

Shock

Question 9

Risk factors for AAA

Answer 9

Male

Age

Smoking

Family Hx

(DM and female reduced risk)

Question 10

Sequelae of ruptured AAA.

Percentage

1) do not reach hospital
2) not fit for surgery
3) anterior rupture, die before arrival
4) operative mortality

Answer 10

1) 50%
2) 30%
3) 20%
4) 50%

Question 11

Management of ruptured AAA

Answer 11

Resuscitation according to ATLS, aim for permissive hypotension

Reassessment of responsiveness to resuscitation

Decision for CT or OT

Preparation for OT

OT procedure

Question 12

1) Name a few predictive scores for AAA
2) Common parameters

Answer 12

1.

Glasglow Aneurysm Score

Hardman Index

RAAA-POSSUM

Edinburgh Ruptured Aneurysm Score

2. Age, creatinine, Hb, GCS, SBP

Question 13

Laplace’s law

Answer 13

Wall tension = pressure x radius

*Thus larger radius, easier for rupture

Question 14

Early complications of AAA

Answer 14

Anastomotic bleeding

Thromboembolism to LL (trash foot)

Renal damage

Ischemic bowel

Spinal cord ischemia

Question 15

Late complications of AAA repair

Answer 15

Infected graft

Sexual dysfunction

Aorto-enteric fistula

Question 16

Anatomical requirements for Endovascular Grafting

Answer 16

Proximal landing zone ≥15mm

Angulation of neck < 60 degrees

Neck diameter ≤ 3.2cm

Distal landing zone ≥10mm

Distal fixation diameter 7-20mm

<25% of circumference with thrombosis and calcification

Question 17

Endoleak

1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5

Answer 17

1) inadequate proximal and distal sealing
2) patent branch vessel
3) defect in fabric of graft
4) Leaking through porosity of graft
5) endotension

Question 18

Evidence for EVAR vs open repair

Answer 18

DREAM

EVAR I

OVER

EVAR II

Question 19

Evidence for EVAR vs surveillance in smaller AA

Answer 19

CAESAR (2011)

PIVOTAL trial (J Vas Sur 2010)

Surgery for small asymptomatic abdominal aortic aneurysm (Cochrane 2012)

Question 20

Surveillance after EVAR

1) Aim
2) If no endoleak
3) If endoleak

Answer 20

1) identify endoleak, sac expansion, graft migration
2) Yearly duplex USG + plain XR
3) CTA

Question 21

Evidence for screening for AAA

Answer 21

UK MASS trial (2002 Lancet)

Question 22

Indication of treatment for thoracic aortic aneurysm

Answer 22

• Size > 6cm
• Symptomatic
• Enlarging
• Aortic valve incompetence in ascending aortic aneurysm

Question 23

Indication for treatment of popliteal aneurysm

Answer 23

• >2cm
• Symptomatic

Question 24

Margins of the popliteal fossa

Answer 24

Superior: supracondylar line of femur

Inferior: soleal line of tibia

Superiolateral: bicep femoris

Superior-Medial: semitendinous

Inferior lateral: lateral head of gastrocnemius

Inferior medial: medial head of gastrocnemius

Question 25

Contents of the popliteal fossa

Answer 25

Popliteal artery Popliteal vein

Question 26

Treatment options for popliteal aneurysm

Answer 26

* Conservative * Surgical Bypass * Aneurysm exclusion and bypass * Inline reconstruction * Endovascular stent grafting

Question 27

Approaches for surgical repair of popliteal aneurysm

Answer 27

1) Medial approach (for aneurysm exclusion/ligation and bypass) 2) Posterior approach (inline reconstruction)

Question 28

Definition of femoral artery aneurysm

Answer 28

Aneursym \>2cm

Question 29

Indication for surgical repair fo femoral artery aneurysm

Answer 29

1) symptomatic 2) \>3cm

Question 30

Percentages for femoral artery aneurysm ## Footnote 1) isolated CFA 2) involving bifurcation 3) isolated SFA/ Profundus artery aneurysm 4) concomitant AAA/popliteal aneurysm

Answer 30

1) 40% 2) 50% 3) 5% 4) 50%

Question 31

Management of infected pseudoaneurysm

Answer 31

* If non-IVDA: ligation + bypass * If IVDA: Triple ligation adn resection of aneurysm

Question 32

Indication for surgery in asymptomatic iliac artery aneurysms

Answer 32

\> 3-4 cm Via exclusion and bypass

Question 33

Triple ligation

Answer 33

* Groin incision * Dissection down to extraperitoneal plane * Locate and control external iliac artery * Axial incision along fmoeral artery * Identify and clamp superficial and profunda femoris artery * Ligation of tripe (CFA, SFA, Profunda femoris artery), if fail, for ligation of EIA * Debridement of necrotic tissue * Layered closure of groin wound * Postop observation of leg viability

Question 34

EVAR 1

Answer 34

Elective EVAR vs open in AAA\> 5.5 Lancet Primary outcome: 30-day mortality, 4 years and 8 years FU Result: * Significantly better 30 day mortality * At 4 years, lower aneurysmal related mortality in EVAR * At 8 years, no difference in aneurysmal related survival. High graft related complications and re-interventions in EVAR

Question 35

OVER trial

Answer 35

Elective EVAR vs open (US) Patient: AAA\> 5 or 4.5cm with rapid growth Outcome: 30 day mortality, 2 year mortality Result: EVAR better than open for 30 day mortality, but at 2 years, no difference

Question 36

EVAR II

Answer 36

EVAR vs no intervention in non-fit patients Primary outcome: 30 day mortality Result: EVAR does not decrease all cause mortality, higher graft related complications +mreintervention, more costly Conclusion: non surgically fit patients should have no intervention

Question 37

DREAM

Answer 37

Elective EVAR vs open NEJM 2005 RCT Result: no difference in aneurysmal related mortality, survival advantage of EVAR no sustained beyond first postoperative year

Question 38

IMPROVE trial

Answer 38

Ruptured AAA: EVAR vs Open Primary outcome: 1 year all cause mortality Result: no difference in all cause mortality or reintervention. EVAR shorter hospital stay, higher QALY, lower cost

Question 39

UK Small Aneurysm Trial

Answer 39

Asymptomatic AAA from 4- 5.5 cm Intervention: early elective open repair vs USG surveillance Conclusion: Early repair has no survival benefit, 30day mortality of 5.8%

Question 40

ADAM trial

Answer 40

Open repair vs surveillance in 4.0-5.5cm AAA Conclusion: no difference in survival up to 8 years

Question 41

Evidence for ruptured AAA

Answer 41

IMPROVE AJAX ECAR

Question 42

AJAX Amsterdam Acute Aneurysm Trial

Answer 42

Multicenter RCT EVAR v Open repair for rAAA Outcome: application rate of EVAR Conclusion: 45% applicable for EVAR, but applied in less

Question 43

ECAR trial

Answer 43

French multicenter RCT EVAR vs Open repair for rAAA Outcome: 30day and 1 year mortality Conclusion: similar mortality, EVAR associated with less severe complications and less consumption of hospital resources