Aneurysm + Dissection Flashcards
(48 cards)
What is an aneurysm and where common
Permanent dilatation of all layers of artery >50%
Caused by weakening of vessel wall
Normal =2cm
Aneurysm >3cm
Common - aorta (infra-renal), iliac, femoral, popliteal
What is a true aneurysm (fusiform vs saccular)
All 3 layers affected - intima (endothelium), media (smooth muscle) affected most, adventitia (connective tissue)
Fusiform = both sides bulge
Saccular = one side (also known as berry)
What is a false aneurysm
After trauma / dissection haematoma forms contained in layers which pushes extrernal wall of artery out
What causes AAA
Degenerative = most causes
Connective tissue - Marfan’s / Ehlers Danlos)
Infection (syphillis) - mycotic
Inflammation / vasculitis - Takayasu arhtritis
Trauma
Congenital - biscupid
What are the RF for AAA
Same as PAD Male Age Smoking Hypertension Atherosclerosis Collagen abnormality FH
What are the symptoms of AAA
Asymptomatic Expansile pulsatile mass Bruit may be heard Symptoms suggest impending rupture Increased back pain as enlarges Strands of fat on CT
What are the symptoms of rupture AAA
30% mortality pre-hospital Abdominal pain Flank pain Painful pulsatile mass Distended abdomen Hypo-tension Tachycardia SOB Dysphagia Confusion Cold Decreased urine Haemodynamic instability
What are unusual complications of AAA
Distal embolisation Aortacaval fistula Aortaenteric fistula Pressure on other structures Ureteric occlusion Duodenal obstruction
How do you screen for AAA and how else would you Dx
USS men >65 single abdo USS
90% will be infra-renal
AXR may show calcifcaiton
CT/ MRI = gold standard
What are the outcomes of screening
<3 = no further Small (3-4.4) = annual USS Medium (4.5-5.5) = 3 monthly Large >5.5 or expanding >1cm / year or symptomatic e.g. back pain = clinic as 15% rupture risk If >8cm = 30-50% rupture risk
How do you Dx rupture and Rx
Rapid ABCDE CT but don't waste time if unstable X-ray = widened mediastinum Inform anaethetist and vascular surgeon Prophylactic Ax Open or EVAR
How do you treat aneurysm
Modify cardiac RF
- Stop smoking / statin / BP etc
Offer surgery >5.5cm or if >1cm per year
- EVAR or open
What are general risks of surgery
Infection Bleeding Pain Scar Embolization MI, stroke, DVT Mortality
What are specific risks of EVAR and open
EVAR Endo-leak - enlargeing aneurysm Emboli Contrast Colonic ischaemia as IMA lose blood
Open
Colonic ischaemic
Renal failure if artery damaged
What are surgical options
EVAR
Open surgery - better for younger fitter patient
What is EVAR
Access from femoral artery and put in stent
Use LA
Need surveillance to check for leaks
What does open surgery involve
Open aneurysm sac - midline laparotomy Clamp aorta and common iliac Put graft in at top and bottom Blood transfusion High mortality
What are the symptoms of thoracic anueysrm
SOB HF Dysphagia Sharp chest pain Query dissection Pulsatile mass Hypotension Hoarse voice - if L recurrent nerve damaged as goes round back of arch of aorta
What is aortic dissection
Tear of the inner wall of aorta (intima) causing propagation as high pressure forces walls apart and blood tracks creating a false lumen
What is type A
Ascending aorta involved
What is type B
Descending aorta
Distal to subclavian
When does aorta cross diaphragm
T12
What are the symptoms of aortic dissection
Severe tearing chest pain radiating to back Abrupt onset Collapse due to hypo if tamponade Reduced pulses BP mismatch Absent subclavian Hypertension due to adrenaline Pulmonary oedema NEW diastolic murmur - AR Can present like HF May have paraplegia if affects spinal
What are RF for dissection
Hypertension
Atherosclerosis
Trauma
Same as PAD +
Rarer Bicuspid valve Marfan / Turner / Noonan Syphillis 3rd trimester
