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General Surgery > Abdominal aneurysms and Aortic tears > Flashcards

Abdominal aneurysms and Aortic tears Flashcards

1
Q

Define aneurysm

A
  • Permanent localised dilatation
  • Affecting all layers of an artery
  • >50% of its normal diameter
    • <50% diameter = Ectasia
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2
Q

Differentiate true and false aneurysms

A
  • True aneurysm
    • Pathological degeneration of all/part of the vessel wall.
  • False aneurysm
    • Leakage of blood out of an artery, into a cavity surrounded by connective tissue, which is expansile and pulsatile.
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3
Q

Name the common sites of true aneurysms

A

Abdominal aorta Iliac artery Popliteal artery Femoral artery

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4
Q

Name 4 causes of aneurysms

A

Atherosclerosis Vasculitis Syphilis Infection (mycotic aneurysm) Trauma Congenital (berry aneurysm) Cocaine use

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5
Q

List three risk factors for aneurysms

A
  • Atherosclerosis
  • Male (4:1)
  • Increasing age
  • Caucasian
  • Smoking
  • FHx of familial aneurysm
  • Aortic dissection
  • Connective tissue disease: Marfan, Ehlers-Danlos
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6
Q

Why is it important to differentiate between aortic aneurysm and aortic dissection?

A

Aneurysm is managed surgically

Dissection is initially managed medically

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7
Q

What is the commonest site of an arterial aneurysm?

A

Infra-renal abdominal aortic aneurysm. Occurs in 5% of elderly males.

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8
Q

What factors increase the risk of AAA rupture?

A

Larger AAA Women Smoking HTN Strong FHx

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9
Q

Describe the presentation of AAAs

A
  • Majority are asymptomatic
  • Occasionally distal embolisation ➔ limb ischaemia
  • Inflammatory aneurysm
    • Abdominal pain
    • General malaise
    • Weight loss
  • Rupture
    • Abdominal/back pain
    • Pulsatile mass
    • Hypotension (less 1/3rd have this triad)
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10
Q

What laboratory investigations should be done for non-urgent AAA?

A
  • Abdominal USS
  • CT angiogram
  • Pre-op
    • FBC
    • Clotting
    • U+E
    • LFT
    • G+S
    • ESR and/or CRP if inflammatory aneurysm suspected
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11
Q

What are the indications for AAA repair?

A
  • Asymptomatic aneurysm >5.5cm
  • Balance risk of surgery vs risk of rupture
  • Ruptured, rapid expansion (>1cm/yr)
  • Sinister presentation e.g. abdominal pain
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12
Q

Outline the medical management of AAA

A
  • Regular USS monitoring
  • Treat underlying cause
  • Risk factor modification
    • Diet and exercise
    • Smoking cessation
    • BP control
    • Statins
    • Antiplatet therapy: primary prevention
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13
Q

What types of surgical management are available for AAA repair?

A
  • Surgical (open) repair
  • Endovascular repair (stent graft)
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14
Q

Name 3 complications of surgical (open) of AAA

A
  • Rupture
  • Haemorrhage​
    • Aortovenous fistula
    • GI bleed due to aortoenteric fistula
  • Embolisation of distal vessels ➔ limb ischaemia
  • Colonic ischaemia: due to ligation of IMA
  • Infected aneurysm
  • Death (5-10%)
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15
Q

Name two advantages and disadvantages of AAA endovascular repair

A

Advantages

  • Avoids open abdominal surgery
  • Avoids aortic cross clamping
  • Reduced morality in first 4 years of follow-up

Disadvantages

  • Requires follow-up USS/CT
  • Endograft failure
  • No long-term survival benefit compared with open repair
  • Significantly higher risks of reintervention and rupture
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16
Q

What is the association between aortic aneurysms and cardiovascular events?

A

People with aortic aneurysms are at increased risk of cardiovascular events, mostly unrelated to the aneurysm.

17
Q

Outline AAA screening

A

USS abdomen in men aged 65-74

Outcome:

  • Normal (<3cm) ➔ No further USS
  • Small (3-4.4cm) ➔ Annual USS
  • Medium (4.5-5.4cm) ➔ 3-monthly USS
  • Large (>5.5cm) ➔ indication for surgery
    • High-risk of rupture
    • Other indications: >1cm yearly expansion; symptomatic
18
Q

What are the sinister signs and symptoms of AAA?

A
  • Abdominal pain and vomiting
  • Abdominal and back pain with collapse
  • Renal colic in males >55yr
19
Q

Name two differential diagnoses for ruptured AAA

A
  • MI with cardiogenic shock
  • Massive PE
  • Acute pancreatitis
20
Q

Describe the initial management of a ruptured AAA

A
  • A-E assessment
  • Oxygen 15L/min
  • IV access IV fluids
    • Maintain systolic BP <100mmHg
  • Catheterise
  • Contact vascular surgeon ASAP
    • If haemodynamically unstable ➔ immediate transfer to vascular
    • If haemodynamically stable ➔ CT angiogram
      • To determine if suitable for EVAR
21
Q

What are endoleaks?

A

A complication characterised by persistent blood flow within the aneurysm sac after endovascular aneurysm repair (EVAR - Teflon material)

22
Q

Why is heparin given after AAA repair?

A

To reduce the risk of embolisation to distal arteries

23
Q

Define aortic dissection

A

Disruption of the intima of the aorta provoked by intramural bleeding ➔ separation of the aortic wall laters and formation of a true and false lumen

24
Q

Which age group is most commonly affected by aortic dissection?

A

50-70

25
Q

Name 3 risk factors for aortic dissection

A

HTN Smoking Direct blunt chest trauma Hypercholesterolaemia Pre-existing aortic disease Pre-existing aortic valve disease FHx of aortic disease Hx of cardiac surgery Connective tissue disease Familial thoracic aortic aneurysm

26
Q

Outline the Stanford classification of aortic dissection?

A

Type A (60%): involves the ascending aorta and arch Type B (40%): commences distal to left subclavian artery

27
Q

What is the importance of the Stanford classification of aortic dissection

A

It separates aortic dissections into those that need surgical repair (type A) and those that usually only require medical management (type B)

28
Q

What sign may be elicited with a type A aortic dissection?

A

Aortic regurgitation (50%): occurs when the dissection involves the aortic valve

29
Q

Describe the management of Type A dissections

A

Immediate surgical correction: Aortic graft

30
Q

Describe the initial management of Type B dissections

A

HTN management - typically IV B-block

31
Q

What are the indications for surgical management of Type B dissections?

A

Persistent pain Aneurysm >5cm End-organ or limb ischaemia Retrograde dissection to ascending aorta

32
Q

What surgical management is available for Type B dissections?

A

Thoracic endovascular aortic repair (TEVAR) Open repair

33
Q

How does a ruptured AAA present?

A

Rupture: abdominal/back pain, pulsatile mass, hypotension (less 1/3rd have this triad) Cold Sweaty NaV Tachycardia Postural hypotension Syncope

34
Q

What is the association between popliteal aneurysms and abdominal aortic aneurysms?

A

50% of patients with popliteal aneurysms also have AAAs

General Surgery (23 decks)

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