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Vascular Surgery by Emi > aortic disease > Flashcards

aortic disease Flashcards

1
Q

Rupture risk of aneurysm 3-3.9

A

0.3% / year

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2
Q

rupture risk of aneurysm 4-4.9

A

0.5 - 1.5%/year

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3
Q

rupture risk of aneurysm 5-5.9

A

1-11%

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4
Q

rupture risk of aneurysm 6-6.9

A

11-22%

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5
Q

rupture risk of aneurysm >7

A

> 30%

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6
Q

UK aneurysm trial highlights

A

prospective randomized trial
early surgery vs surveillance
4-5.5, 1090 pt, 17% female
surveillance!

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7
Q

VA (ADAM) trial highlights

A

prospective randomized
early surgery vs surveillance
4-5.4, 1163 patients, 1% female
surveillance!

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8
Q

Types of aortic arches

A
  1. all vessels originate on top fo the arch
  2. vessels originate between the planes of the inner and outer curve of the arch
  3. vessels originate along the upslope of the arch, proximal to the inner plane of the arch
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9
Q

most common arch anatomy variation

A
  1. bovine arch - common trunk of innominate and left CCA (16-24%)
  2. origin of the left vertebral artery from the arch between left CCA and left subclavian (7%)
  3. aberrant right subclavian in left sided arch (0.5 - 1%)
  4. right sided aortic arch (0.1%)
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10
Q

aortic landing zone 0

A

proximal to innominate artery

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11
Q

landing zone 1

A

proximal to left CCA

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12
Q

landing zone 2

A

proximal to left subclavian

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13
Q

landing zone 3

A

proximal descending thoracic aorta, <2cm from left subclavian

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14
Q

landing zone 4

A

2cm distal to left subclavian extending to proximal half of descending thoracic aorta (T6 vertebral body)

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15
Q

landing zone 5

A

distal half of descending aorta to celiac artery

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16
Q

landing zone 6

A

celiac to top of SMA

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17
Q

landing zone 7

A

SMA to suprarenal aorta

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18
Q

landing zone 8

A

perirenal aorta

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19
Q

landing zone 9

A

infrarenal aorta

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20
Q

landing zone 10

A

common iliac artery

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21
Q

landing zone 11

A

extends to external iliac artery

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22
Q

crawford I aneurysm

A

distal to left subclavian to above renal arteries

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23
Q

Crawford II aneurysm

A

distal to left subclavian to below the renal arteries

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24
Q

Crawford III aneurysm

A

from 6th intercostal space to below the renal arteries

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25
Q

Crawford IV aneurysm

A

from the diaphragm to aortic bifurcation

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26
Q

Crawford / Safi V aneurysm

A

below the 6th intercostal space to just above renal arteries

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27
Q

borders of brachiocephalic artery division

A

right sternoclavicular junction

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28
Q

IMH qualifying for OR

A

aorta >40mm

IMH >10 mm

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29
Q

Innominate artery aneurysm types

A

A: confined to IA, distal to origin
B: most common, involves IA and its origin
C: both IA and ascending aorta

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30
Q

aortic valve insufficiency doppler flow

A

to and fro blood flow pattern because of blood refluzing in insufficient valve

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31
Q

Aortic case planning fundamentals for GORE:

A
  1. measure inner wall to inner wall
  2. 2cm seal zone required proximally and distally (on the outer curve)
  3. same diameter size device: 5 cm overlap; different size device: 3cm overlap
  4. put larger device into a smaller device
  5. the two devices you’re joining cannot be more than 2 sizes apart
  6. if you can (depending on the etiology) deploy distal first, then proximal. (but rule 4 takes precedence).
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32
Q

minimal distal aortic diameter for Gore:

A

18mm

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33
Q

how far into the iliac does Gore excluder have to go

A

3cm

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34
Q

What causes aortic intramural hematoma

A

Ruptured vasa vasorum

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35
Q

Only known modifiable risk factor for aaa developement

A

Smoking

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36
Q

How many people with AAA have CAD

A

25% symptomatic

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37
Q

How many people with aaa have htn

A

40%

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38
Q

How many people with aaa have PAD

A

20-30%

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39
Q

How many aaa have an associated iliac aneurysm

A

25%

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40
Q

Operative mortality for elective aaa repair

A

2-10%

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41
Q

Operative mortality of ruptured aaa repair

A

37-50%

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42
Q

Graft size for innominate debranching

A

8-10mm

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43
Q

Graft size for subclavian and carotid revascuksriation

A

6-8 mm

44
Q

How do you know where your debranching of ascending aorta is

A

Put marker clips

45
Q

Embriologically what creates aortic arch and branches

A

Third and fourth dorsal arch
Seventh intersegmental arch arteries
Left dorsal aorta

46
Q

What crates aortic arch emriologically

A

Left fourth arch

47
Q

What creates the innominate artery embriologically

A

Right fourth arch

48
Q

What creates descending thoracic aorta embriologically

A

Left dorsal aorta

49
Q

What creates carotid artery embriologically

A

Third aortic arches

50
Q

What creates subclavian and vertebral arteries embriologically

A

Seventh intersegmental arteries

51
Q

Right aortic arch

A

Most common anomaly of the arch
Results from inappropriate regression of arch (left instead of right dorsal arch)
Simplest and most benign form is meer image
May occu with aberrant left subclavian
Can form a complete or incomplete ring depending on origin of ligamentum arteriosum

52
Q

Definition of Kommerells diverticulum

A

Occur in number of anomalies of the aortic arch system. It usually refers to the bulbous configuration of the origin of an aberrant right subclavian artery but was originally described as diverticulum outpouching at origin of a left subclavian artery in the setting of right sided aortic arch
Instead of the right 4 arch regressing, the left 4th regressed
Can compress esophagus and trachea

53
Q

Aberrant right subclavian artery

A

Results from regression of the right fourth aortic arch between the carotid and subclavian arteries rather than distal to the subclavian artery

54
Q

What is an aortic ring

A

Non regressed fourth aortic arch creates duplicated arch around trachea and esophagus
May lead to compression

55
Q

What’s is a complete aortic ring

A

Both trachea and esophagus are fully wncircled by a vascular anomaly

56
Q

What is an incomplete aortic arch

A

Without full encirclement of trachea and esophagus (usually asymptomstic)

57
Q

What is mid aortic syndrome

A

Uncommon squired or congenital condition characterized by segmental narrowing of the abdominal or distal descending thoracic aorta
Frequently also Ostial stenosis of viscera beaches

58
Q

What causes acquired mid aortic syndrome

A 
Neurofibromatosia
Fibromuscular displasia
Retroperitoneal fibrosis
Williams syndrome
Mucopolysaccharisosis 
Giant cell arteritis
Acquired insult in uteri
59
Q

Etiology of congenita mid aortic syndrome

A

Developmental anomaly in the fusion and maturation of the paired embryonic dorsal aorta

60
Q

Symptoms of mid aortic syndrome

A

Arterial hypertension
Headache
Early fatigue on exertion
Lower limb claudicatoon

61
Q

Mid aortic syndrome on imaging

A

Robust collaterals on angiogram due to narrowing of the abdominal aorta

62
Q

Minimum proximal body distal overlap in ZFEN

A

24mm diameter and overlap no less than 2 stents

63
Q

Inclusion criteria for ZFEN

A
  1. Nonaneurysmal infearenal aortic neck proximal to the aneurysm of more or equal to 4 mm and less than 15mm
  2. Unsuitable for nonfenwatrated vascular graft
  3. Proximal neck diameter 19-31
  4. Proximal neck angulation <45 degrees relative to the long axis of the aneurysm
  5. Angle <45 degrees relative to the axis of the suprarenal aorta
  6. ipailatera iliac artery distal fixation site >30mm in lent h and 9-21mm in diameter measured outer wall to outer wall
  7. Contralateral iliac artery distal fixation site >30mm in length and 7-21mm in diameter
  8. Access vessel to accommodate up to 20fr sheath (8mm)
  9. Max three fenestrations, 2 of the same kimś
64
Q

Minimum distance between small fens at the same agent level for ZFEN

A

2h minimum

65
Q

Minimum distance between small fen and a scallop

A

1.5h

66
Q

Minimum distance between the edge of the fabric and middle of large top fen

A

10mm

67
Q

Only EVAR decide that does not come on an integrated delivery system

A

GORE excluder

68
Q

Endurant stent graft device characteristics

A

Indication: 10mm proximal neck, up to 60* angulation
Tip capture
Single piece laser cut nitinol aren’t with anchor pins
M-shaped proximal seal stent
High density multifilament polyester graft material

69
Q

What is the endurant agent graft size and vessel target

A

23-36mm
Target 19-32mm
(OD profile 18-20 fr)

70
Q

Aorta-uniiliac Endurant II device IFU

A

Indicated in the presence of adverse iliac anatomy precluding adequate deployment of a bifurcated graft’s two iliac limbs
Proximal neck of more than or equal to 10mm
Infrarenal nexk angulation Of less than or equal to 60*
Aortic neck diameters with a range of 19-32mm
Distal fixation length of more than or equal to 15mm
Iliac diameters with a range of 8-25mm
Morphology suitable for aneurysm repair

71
Q

Ovation anatomical criteria

A

Proximal aortic neck length more or equal to 7
Inner diameter between 16-30mm (aortic body device diameter 20-34mm)
Juxtarenal aortic neck angulation less than or equal to 60* for proximal neck of 10, or less than or equal to 45* if proximal neck less than 10mm
Distal seal One of more than or equal to 10mm and diameter between 8-25mm (limb device diameter 10-28mm)

72
Q

AortofixTM anatomical IFU

A

Adequate iliac or femora access that is conpatible with vascular access techniques, implants and accessories
Aortic neck landing zone diameters with range of 19-29mm
Non aneurysmal proximal neck center line length of more than or equal to 15mm
Infrarenal aortic neck angulation including those up to and including 90*
Common iliac landing zone diameters with a range of 9-19mm
Distal fixation length more than or equal to 15mm

73
Q

Devices with suprarenal fixation

A

Cook zenith, Medtronic endurant II, teivascular ovation prime, endologic AFX

74
Q

What devices are approved for trauma indication in thoracic aorta

A

Gore c tag
Medtronic valiant
Cook TX2

75
Q

What devices are not approved for trauma indication in thoracic aorta

A

Cook TX2

Bolton

76
Q

What’s the aortic and device size for thoracic C TAG from gore

A

Vessel- 16-42

Device: 21-45

77
Q

How does a gore CTAG deploy

A

From the middle to the ends (avoids wind socking)

78
Q

How does a VALIANT Medtronic deploy

A

From the beginning to the end. Needs to be deployed very fast

79
Q

Only thoracic device with active fixation on BOTH ends

A

Cook zenith TX2

80
Q

Zenith cook TX2 deployment modification

A

Trigger wire tethers the distal end of the sealing stent to improve apposition to the inner curve of the arch

81
Q

Complications of CTAG study for dissection

A 
8% mortality,
14% reintervention
4% disabling stroke
4% retrograde dissection
6% paraplegia
4% aortic rupture
82
Q

Complications of VALIANT Medtronic for dissection

A 
8% mortality
9.5% reintervention
6% stroke
4.4% retrograde dissection
6% paralysis
8% aortic rupture
83
Q

What’s the minimum size for 20fr device

A

7 mm

84
Q

TEVAR surveillance

A

CT with and without contrast and 4view chest X-ray

Yearly for life

85
Q

When is left subclsvian revascularizwion required

A

LIMA to LAD bypass
Dominant left vertebral artery
Left vertebral artery ends in PICA but not basilar

86
Q

Where does artery of Adamkiewicz come of

A

T8-l1

87
Q

Preventive mesures for spinal ischemia in aortic surgery

A

MAP >80
Csf drainage to ICP in one digit number
Hb >10
?steroids

88
Q

Microbiology of aortic graft infection

A

Staph aureus 25-50%
Stain epidermidis responsible for late appearing indolent infections
Pseudocomans, E. coli, proteus, enterobacter
Aspergillus, candida

89
Q

Technique for supraceliac balloon control in ruptured aaa

A

Insert long sheath through contra femoral and inflate the ballon. Place and deploy the main body and ipsi leg through the other femoral.
Insert another balloon through ipsi side.
Remove first balloon with sheath support

90
Q

Predictors of aortic bifemoral graft occlusion

A

Age, HTN, graft size

91
Q

Axillary artery exposure in ax-fem bypass

A

Transverse infraclavicular incision
Dissect superior to axillary vein
Selective pectoralis minor tendon division
Dissect artery to the chest wall

92
Q

How do you tunnel ax gem graft

A 
External support conduit
No counterincision
Anterior to anterior superior iliac spine
Mid axillary line
Between pectoralis muscle
93
Q

Types of malperfusion in aortic dissection

A

Static obstruction - blind or propagating end of dissection enters and constricts branch Ostia
Dynamic obstruction - intermittent obstruction of branch flow due to compliance difference between true and false liken. Patency is branch on angio does not correlate with clinical behavior

94
Q

INSTEAD trial

A

No benefit of TEVAR in acute type B dissection in the first 2 years

95
Q

INSTEAD XL trial

A

In long term, TEVAR had improved mortality, improved aortic mortality and better aortic remodeling . Over 90% had complete false lumen thrombosis in BMT + TEVAR comparing to 22% with only BMT

96
Q

Who should get an elective TEVAR after type B aortic dissection

A 
6-8 weeks timing
Suitable anatomy
>2 years life expectancy
Poor BP control
>10 mm tear and / or >2cm proximal false lumen
Early aortic expansion
Intermittent pain and / or symptoms of malperfusion
Patient preference
97
Q

Risk of rupture increased with IMH

A

Aortic diameter >4 cm

IMH thickness >1 cm

98
Q

Grading of traumatic aortic injury

A

I - intimate tear
II - intramural hematoma
III - pseudoaneurysm
IV - rupture

99
Q

DeBakey I

A

Ascending and descending aortic dissection

100
Q

DeBakey II

A

Only ascending dissection

101
Q

DeBakey III a

A

Descending aortic dissection to the level of the diaphragm

102
Q

DeBakey IIIb

A

Descending aortic dissection to the level of below the renals

103
Q

Stamford A

A

DeBakey I abd II

DIssextion involving the ascending aorta

104
Q

Stamford B

A

DeBakey IIIa and b

Dissection not involving the ascending aorta

105
Q

Aortic tumors

A

Majority are “Intimal” tumors with polyploid or growing along the endothelial surface
Evenly distributed in the aorta

Vascular Surgery by Emi (15 decks)

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