Aneurysms Surgery - Presentation, Investigation & Therapy

Question 1

What does aneurysm of the aorta involve?

Answer 1

Dilatation of all layers of the aorta, leading to an increase in diameter of >50% (abdominal aorta >3cm)

Question 2

What are the following branches of the aorta?

Answer 2

Question 3

What are the causes of aneurysm disease?

Answer 3

• Degenerative disease
• Connective tissue disease (e.g. Marfan’s disease)
• Infection (mycotic aneurysm)

Question 4

What are the risk factors for degenerative AAA disease?

Answer 4

Male sex

Age

Smoking

Hypertension

Family History

Question 5

What level does the abdominal aorta bifurcate?

Answer 5

L4

Question 6

What do you use to feel the AAA?

Answer 6

Two hands - pulsating

Question 7

At what age in England are men invited for AAA screening?

Answer 7

65

Question 8

What is presentation of AAA?

Answer 8

Asymptomatic

Question 9

What is the criteria for screening?

Answer 9

—Definable disease (can’t be vague)

—Prevalence (must have a considerable prevalence)

—Severity of disease (no point screening for the common cold)

—Natural history

—Reliable detection

—Early detection confers advantage

—Treatment options available (needs to have a possible plan to treat once found)

—Cost

—Feasibility

—Acceptability

Question 10

What are the outcomes for screening?

Answer 10

A) Normal aorta, discharged

B) Small AAA (3.0-4.4cm) will be invited for annual USS scans

C) Medium AAA (4.5-5.5cm) will be invited for 3 monthly USS scans

D) Large AAA (>5.5cm)

Question 11

What are the symptoms of an impending rupture?

Answer 11

Increasing back pain

Aorta tender to examine

Inflammation seen on CT

Tender AAA

Question 12

What are the symptoms of rupture?

Answer 12

Abdo/back/flank pain

Painful pulsatile mass

Haemodynamic instability (single episode or progressive)

Hypoperfusion

Question 13

What are unusual presentations of abdominal aortic aneuryism?

Answer 13

—Distal embolisation - blood flow through aortic sac has a lot of thrombus (Rupture thromboses and can embolise to other parts of the body)

—Aortocaval fistula – aneurysm erodes into the wall of the vena cava. aortic blood circulates to venous system without perfusing the limbs – perfuses into the vena cava

—Aortoenteric fistula - erodes into the bowel - bleeding into usually the duodenum

—Ureteric occlusion

—Duodenal obstruction

Question 14

What is management of asymptomatic patients?

Answer 14

Is the aneurysm a size to consider repair?

Is the patient a candidate for repair?

Is the aneurysm suitable for endovascular repair?

Question 15

At what level of aneurysm size does surgery stop confering benefit?

Answer 15

For aneurysms less than 5.5 cm

Question 16

How do you assess patient fitness?

Answer 16

—Full history and examination

—Bloods

—ECG

—ECHO

—PFTs (pulmonary function tests)

—MPS (myocardial perfusion scans)

—CPEX (cardiopulmonary exercise testing)

—End of the bed test?

—Patient preference

Question 17

What are the two methods of aneurysm repair?

Answer 17

Endovascular (keyhole or open repair)

Question 18

What are the benefits and disadvantages of ultrasound scanning

Answer 18

Benefits:

• No radiation
• No contrast
• Cheap

Disadvantages:

• Operator dependent
• Inadequate for surgical planning

Question 19

What are the benefits and disadvantages of CT/MRA

Answer 19

Advantages

Quick

Not operator dependent

Necessary for surgical planning – detailed anatomy

Disadvantages:

Contrast

Radiation

Question 20

Which type of operating procedure has a higher risk of rupture?

Answer 20

Open repair is less than 6%

Endovascular repair is less than 1%

Question 21

What are the complications of open repair?

Answer 21

General:

• Wound infection / dehiscence
• Bleeding
• Pain
• Scar

Technical:

• Damage to bowel, ureters, veins, nerves
• Incisional hernia
• Graft infection
• Distal emboli
• Renal failure
• Colonic ischaemia

Patient Factors:

• DVT/PE
• MI
• Stroke
• Death

Question 22

What are the endovascular repair complications?

Answer 22

• General:
• Wound infection
• Bleeding / haematoma
• Pain
• Scar
• Contrast – reaction / kidney injury
• Radiation

Technical

• Endoleak
• Femoral artery dissection / pseudoaneurysm
• Rupture
• Distal emboli / ischaemia / colonic ischaemia
• Damage to femoral vein / nerve

Patient factors:

• DVT/PE
• MI
• Stroke
• Death

Question 23

What is an endoleak?

Answer 23

When the blood travels into the aneurysm sack instead of the inserted tube

Question 24

What is management of symptomatic AAA?

Answer 24

—ABCDE

—History, check records

—Examination - of pulsatile mass in adomen

—

—CTA - if considering treatment

Question 25

What are the key features of an emergency open repair of AAA?

Answer 25

—Massive transfusion protocol – need blood because of leak

—Prep abdomen, rapid anaesthetic (Patient needs to be kept away to keep them using the abdominal muscles provides tamponade to bleeding)

—Laparotomy xiphisternum to pubic symphysis

—Occlude aorta proximally

—30-50% mortality, significant morbidity

—

Question 26

Why don’t we always use endovascular repair?

Answer 26

Relying on the radial force holding the grafts in place in the diseased aorta AAA is a degenerative disease, over time the aneuryism progresses and causes endoleaks. Needs ongoing surveillance and scans and maybe intervention in the future. Increased costs. Longer term mortality is similar between both methods. For those who were not fit for operation, there is no advantage giving them an endovascular repair.

Question 27

What is a risk of emergency EVAR?

Answer 27

—Abdominal compartment syndrome – no removal of blood from abdomen. Too musch pressure in the abdomen – kidney failure.

Question 28

Is there any benefit for EVAR or open repair in the case of ruptured AAA?

Answer 28

No difference in the end for all cause mortality - any form of repair will result in health complications becasue of severity of the damage.