Aortic Disease

Question 1

What is an aortic aneurysm?

Answer 1

Dilation/localised enlargement of all layers of the aorta, leading to an increase in diameter of >50%, caused by weakening of the vessel wall

Question 2

How quickly to aortic aneurysms grow?

Answer 2

Aneurysms grow approx 2mm a year and as it gets bigger, the walls get thinner

Question 3

Name the 3 layers of the aorta

Answer 3

Tunica externa

Tunica media

Tunica intima

Question 4

What is a ‘true’ AAA?

Answer 4

Weakness and dilation of wall that involves all 3 layers

Question 5

What is a ‘false’ AAA?

Answer 5

Not all layers are dilated, rupture contained by adventitial layer

Question 6

What term is used to describe a AAA on one side?

Answer 6

Saccular

Question 7

What term is used to describe a AAA on both sides?

Answer 7

Fusiform

Question 8

What are the causes of AAA?

Answer 8

Degenerative disease/atherosclerosis

Connective tissue disease/hyper-elasticity conditions

• Ehlers Danlos
• Marfan’s syndrome

Syphilis

Question 9

Name some risk factors for AAA

Answer 9

M>F

>Age

Smoking

HTN

FH

Question 10

How does an AAA present?

Answer 10

Back/abdomen pain

Painful pulsatile abdominal mass

Sharp angina

• Radiating to the back between shoulder blades

Dyspnoea

Hoarseness

Haemodynamic instability/shock

• Tachycardia
• Hypotension

Question 11

Name some complications of an AAA

Answer 11

Distal embolisation

Hypoperfusion/inadequate perfusion to tissues

Aortocaval or Aortoenteric fistula

Ureteric occlusion

Question 12

What investigations are used in AAA diagnosis?

Answer 12

US

CT

• Ruptured AAA are diagnosed clinically as patients do not have time for a CT to confirm diagnosis

Question 13

Describe the AAA screening programme

Answer 13

Single abdominal US for males 65

If aorta is less than 3cm/normal, no further action is taken

Question 14

How many cm is a normal aorta?

Answer 14

<3cm

Question 15

How many cm is a small AAA?

Answer 15

3-4.4cm

Question 16

How many cm is a medium AAA?

Answer 16

4.5-5.5cm

Question 17

How many cm is a large AAA?

Answer 17

>5.5cm

Question 18

How often do patients with a small AAA go for US?

Answer 18

Rescan annually

Question 19

How often do patients with a medium AAA go for a US?

Answer 19

Rescan every 3 months

Question 20

What size does an AAA have to be to be considered for surgery?

Answer 20

>5.5cm

Question 21

What is a low rupture risk AAA?

Answer 21

Asymptomatic

Aortic diameter < 5.5cm (i.e. small and medium aneurysms)

Question 22

What is a high rupture risk AAA?

Answer 22

Symptomatic

Aortic diameter >=5.5cm or rapidly enlarging (>1cm/year)

Question 23

What is the management of a low rupture risk AAA?

Answer 23

Abdominal US surveillance

Optimise cardiovascular risk factors

Question 24

What is the management of a high rupture risk AAA?

Answer 24

Refer within 2 weeks to vascular surgery

Elective endovascular repair (EVAR), in which stent is placed into the abdominal aorta via the femoral artery

Open repair if unsuitable for EVAR

Question 25

Give a complication of EVAR

Answer 25

Endo-leak, where the stent fails to exclude blood from the aneurysm, presenting without symptoms on routine follow up

Question 26

What is the management of a ruptured AAA?

Answer 26

Immediate vascular review and emergency surgical repair

Question 27

What is an aortic dissection?

Answer 27

Tear in the inner wall of the aorta (tunica intima) resulting in the redirection of blood flow

Question 28

What are the causes of an aortic dissection?

Answer 28

HTN Trauma/Surgery Atherosclerosis Marfan's/connective tissue disorders Pregnancy Turners and Noonans Syphillis Aneurysms Bicuspid aortic valve

Question 29

How does an aortic dissection present?

Answer 29

Tearing chest pain * Anterior if ascending aorta * Back pain if descending * Very similar to MI Collapse **Radial-radial delay** **Abscent femoral pulse** Auscultation * Soft early diastolic murmur, aortic regurgitation Neurological symptoms

Question 30

What investigations are used in the diagnosis of an aortic dissection?

Answer 30

CXR * **Widened mediastinum** CT of chest, abdomen and pelvis * **Tennis ball sign** * Contrast shows true lumen as white while false lumen is grey due to fibrosis Transoesophageal echocardiography (TOE) * More suitable for unstable patients who are too risky to take to CT scanner

Question 31

What classification is used in aortic dissections?

Answer 31

Sandford

Question 32

What are the two classifications of aortic dissections?

Answer 32

A * Involves the ascending aorta B * Descending aorta, distal to left subclavian origin

Question 33

What is the management of an aortic dissection?

Answer 33

Type A * Aortic root replacement and IV labetolol Type B * HTN control/IV Labetalol

Question 34

Give complications of aortic dissections

Answer 34

Backward tear * Aortic regurgitation * MI Forward tear * Stroke * Renal failure