Aortic aneurysm (AAA and TAA) 09-x (1)

Question 1

AAA. 7 risk factors?

Answer 1

Age >60 years
Cigarette smoking
Male sex

History of atherosclerosis or connective tissue disease
HTN
Family history of AAA
white race

Question 2

AAA. whats about initial symptoms?

Answer 2

Patients are typically asymptomatic until the aorta rapidly expands or ruptures:

Question 3

AAA. Aorta rapidly expands. Symptoms? 2

Answer 3

Rapid expansion:

Dull abdominal/back pain
Distal embolization

Question 4

AAA. Aorta ruptures. when delayed HD instability?

Answer 4

If the bleeding is in retroperitoneum

Question 5

AAA. Aorta ruptures. when rapid onset HD instability?

Answer 5

Rapid onset hemodynamic instability and shock if bleeding is in peritoneum:

Question 6

AAA. Aorta ruptures. Rapid onset. 5 symptoms?

Answer 6

• Severe abdominal/back pain (left costovertebral angle tenderness may be present)
• Pulsatile abdominal mass at the umbilicus
• Umbilical or flank hematoma
• Shock
• Peripheral pulses are decreased

Question 7

AAA. Management? 4

Answer 7

Smoking cessation
Elective repair for size > 5,5 cm (asymptomatic)
Urgent repair for symptomatic and HD stable patients
Emergency repair for symptomatic and HD unstable patients

Question 8

AAA. management for HD stable?

Answer 8

Urgent repair for symptomatic and HD stable patients

Question 9

AAA. management for HD unstable?

Answer 9

Emergency repair for symptomatic and HD unstable patients

Question 10

AAA. management for asymptomatic?

Answer 10

Elective repair for size > 5,5 cm (asymptomatic)

Question 11

AAA. what increases risk of rupture?

Answer 11

a. Large aneurysm diameter (>5.5 cm)
b. Aortic expansion rate >0.5 cm in 6 months or >1 cm in 1 year
c. Current ongoing smoking. It increases risk probably because of degeneration of connective tissue in the aortic wall
d. Female gender
e. Hypertension. It has a weak association with AAA (in contrast to thoracic aortic aneurysm where hypertension has the greatest overall risk for dissection)

Question 12

AAA. what increases risk of rupture. size?

Answer 12

Large aneurysm diameter (>5.5 cm)

Question 13

AAA. what increases risk of rupture. expansion rate?

Answer 13

Aortic expansion rate >0.5 cm in 6 months or >1 cm in 1 year

Question 14

AAA. what increases risk of rupture. smoking, why?

Answer 14

Current ongoing smoking. It increases risk probably because of degeneration of connective tissue in the aortic wall

Question 15

AAA. whats about DM?

Answer 15

AAA progression and development in patients with diabetes is lower than in those without diabetes.

Question 16

AAA. complication?

Answer 16

Aortocaval fistula

Question 17

AAA. complication Aortocaval fistula. heart?

Answer 17

Leads to venous congestion and high-output cardiac failure

Question 18

AAA. complication Aortocaval fistula. kidney?

Answer 18

Can also lead to venous congestion of bladder, leading to hematuria that is misdiagnosed as nephrolithiasis

Question 19

AAA. CT findings? 2

Answer 19

Pulsatile abdominal mass, prevertebral aortic calcifications

Question 20

AAA. HD stable diagnosis?

Answer 20

CT scan

Question 21

AAA. Treatment - surgical. indications for operative or endovascular repair?

Answer 21

1. Aneurysm size >5.5 cm
2. Rapid rate of aneurysm expansion i.e. more that 0,5 cm in 6months or >1 cm in year
3. Presence of symptoms (abdominal, back, or flank pain; limb ischemia) regardless of aneurysm

Question 22

AAA. HD unstable diagnosis? 2

Answer 22

Known history of aneurysm –> surgery
No prior history of aneurysm –> focused abdominal ultrasound

Question 23

AAA. Treatment - surgical. what aneurysm size?

Answer 23

Aneurysm size >5.5 cm

Question 24

AAA. Treatment - surgical. what aneurysm expansion?

Answer 24

Rapid rate of aneurysm expansion i.e. more that 0,5 cm in 6months or >1 cm in year

Question 25

AAA. Treatment - surgical. what symptoms says we need surgery?

Answer 25

Presence of symptoms (abdominal, back, or flank pain; limb ischemia) regardless of aneurysm size

Question 26

AAA. Screening? sex, age, risk factor?

Answer 26

MALES, age 65-75 If they have ANY prior history of smoking (ie, any lifetime exposure of >100 cigarettes)

Question 27

AAA. Screening method?

Answer 27

One-time abdominal duplex ultrasound (duplex = UG + doppler (colorful)).

Question 28

AAA. screening - in what other population also may be done?

Answer 28

Screening may also be done in patients with age 65-75 with no smoking history if they have other significant risk factors (eg, first-degree family history of AAA rupture)

Question 29

AAA unstable. Algorithm. Symptoms suggesting unstable AAA?

Answer 29

Abdominal/flank/groin pain Pulsatile mass flank ecchymosis limb ischemia -----> ITS HD INSTABILITY NOTE: abdominal bruit is RENAL ARTERY STENOSIS OR FIBROMUSCULAR DYSPLASIA.

Question 30

AAA unstable. Algorithm. HD stable --> whats next?

Answer 30

CT of abdomen

Question 31

AAA unstable. Algorithm. HD stable --> CT aneurisma detected --> whats next? if yes and no

Answer 31

Yes - medical optimization or repair No - explore other diagnoses

Question 32

AAA unstable. Algorithm. HD unstable --> whats next?

Answer 32

evaluate if patients has KNOWN AAA.

Question 33

AAA unstable. Algorithm. HD unstable --> has known AAA -->?

Answer 33

Emergency repair

Question 34

AAA unstable. Algorithm. HD unstable --> does not have known AAA -->?

Answer 34

Obtain focused abdominal UG

Question 35

AAA unstable. Algorithm. HD unstable --> does not have known AAA --> aneurysm detected on UG --> ? and what to do if not detected?

Answer 35

Emergency repair Not detected --> explore other diagnoses

Question 36

TAA. which part of aorta usually involves?

Answer 36

Most TAAs (60%) involve ascending aorta (between the aortic valve and the brachiocephalic artery) A minority of aneurysms involve the descending aorta (distal to the left subclavian artery)

Question 37

TAA. what is ascending aorta?

Answer 37

between the aortic valve and the brachiocephalic artery

Question 38

TAA. what is descending aorta?

Answer 38

distal to the left subclavian artery

Question 39

TAA. most common etiology? what risk factors? what mechanism?

Answer 39

Age-related degenerative changes (more common). Risk factors including dyslipidemia, hypertension, tobacco use, and family history. Leads to disruption of aortic wall medial layer with loss of elasticity  aortic dilation

Question 40

TAA. connective tissue?

Answer 40

Connective tissue disease (eg, Marfan or Ehlers-Danlos syndrome)

Question 41

TAA. infection?

Answer 41

Endarteritis of vasa vasorum due to tertiary syphilis

Question 42

TAA. initial symptoms?

Answer 42

Mostly asymptomatic until discovery is made incidentally

Question 43

TAA what pain?

Answer 43

Vague chest/back pain

Question 44

TAA. compression? 4

Answer 44

Hoarseness (left recurrent laryngeal nerve or vagus nerve) hemidiaphragmatic paralysis (phrenic nerve), dysphagia (esophagus), respiratory manifestations, including wheeze, cough, hemoptysis, and dyspnea (tracheobronchial obstruction).

Question 45

TAA. rupture symptoms?

Answer 45

Rupture: severe pain, hemodynamic instability

Question 46

TAA. diagnostic methods? 2

Answer 46

Chest X-ray: Widened mediastinum; Enlarged aortic knob; tracheal deviation CT scan with contrast (diagnostic)

Question 47

TAA differential?

Answer 47

Differentials: Hilar/mediastinal lymphadenopathy. Enlarged lymph nodes appear as opacities that are discrete from the heart borders Xray - hilar limphadenopathy on both sides + mediastinal widening.

Question 48

TAA: x ray - what seen?3

Answer 48

Widened mediastinum; Enlarged aortic knob; tracheal deviation

Question 49

TAA. instrumental diagnostic?

Answer 49

CT scan with contrast (diagnostic)