CHAPTER 60 ANEURYSMAL DISEASE

Question 1

An aneurysm is dilation of the arterial wall to _________ its normal diameter.

Answer 1

1.5 times

Question 2

Pathophysiology of aneurysm

Answer 2

A progressive decrease in elastin, collagen, and fibrolamellar units results in thinning of the media of the vascular wall and a decrease in its tensile strength.

Question 3

Laplace law:

Answer 3

wall tension = pressure × radius

Question 4

MC peripheral aneurysm

Answer 4

Popliteal artery aneurysms
-localized dilation of the popliteal artery of >2 cm or >150% of the normal arterial caliber.
-Sx: discomfort behind the knee, leg swelling with or without deep venous thrombosis, or claudication
-Rupture is rare

Most serious Cx: Sudden acute limb ischemia caused by thrombosis or embolization from the aneurysm

Question 5

Uncommon aneurysm

Answer 5

Aneurysms of the femoral artery

Question 6

Most common visceral artery aneurysm

Answer 6

renal
splenic
hepatic

All but splenic artery aneurysms are more common in elderly men.

Question 7

Diameter in abdominal aortic aneurysm

Answer 7

≥3.0 cm

Question 8

Repair is considered for aneurysm with diameter of?

Answer 8

≥5.0 cm

Question 9

Risk factors of AAA

Answer 9

first-degree relative with an aortic aneurysm
>60 years old,
males

Question 10

Most important environmental risk factor in AAA;
Major risk factor for accelerated aneurysmal growth and rupture.

Answer 10

Smoking
- prevalence of abdominal aortic aneurysm being more than four times that in lifelong nonsmokers.

Question 11

Most common presenting symptom with aortic aneurysm or rupture

Answer 11

Back or abdominal pain
-severe and abrupt in onset
-ripping or tearing pain

Question 12

Classic TRIAD of a ruptured abdominal aortic aneurysm

Answer 12

abdominal pain
pulsatile abdominal mass
hypotension

Question 13

The sensitivity of abdominal palpation increases with aortic aneurysm diameter

Answer 13

29% for a diameter of 3.0 to 3.9 cm
50% for a diameter of 4.0 to 4.9 cm
76% for a diameter of ≥5.0 cm

Question 14

Sign of aneurysmal expansion or rupture

Answer 14

Tenderness to palpation

Question 15

External signs of acute rupture: periumbilical ecchymosis

Answer 15

Cullen sign

Question 16

External signs of acute rupture:
flank ecchymosis

Answer 16

Grey Turner sign

Question 17

unexplained or highvolume upper or lower GI bleeding, especially in patients without liver disease.

Answer 17

aortoenteric fistulas

Fistulas most frequently involve the duodenum, with hematemesis, melenemesis, melena, or hematochezia

Question 18

Imaging modality of choice for unstable patients.

Answer 18

Bedside US
-Unstable patients should not be sent out of the ED for imaging

Question 19

Plain abdominal films (more obvious on a lateral view)

Answer 19

calcified and bulging aortic contour

Question 20

TRUE OR FALSE:
An aortic diameter <3.0 cm does not excludes acute aneurysmal disease.

Answer 20

FALSE

Question 21

Best detects the anatomic details of the aneurysm and associated hemorrhage

Answer 21

CT scanning with IV contrast

Question 22

ED Interventions for Symptomatic Abdominal Aortic Aneurysms

Answer 22

1. IV access - two large-bore IVs in place for rapid administration of crystalloids, blood, or medication
2. Consultation
3. Blood and fluids - permissive hypotension, a systolic blood pressure of 80–90 mm Hg, is recommended
4. Pain control - Avoid severe hypotension and respiratory depression

Question 23

In the event of suspected expanding aneurysm and severe hypertension, __________________ is recommended for its ability to be titrated to a target systolic blood pressure of 120 mm Hg.

Answer 23

Esmolol (half-life, 9 minutes)
-can be quickly stopped if the patient’s blood pressure drops suddenly

Question 24

TRUE OR FALSE: Symptomatic aneurysms of any size are considered emergent.

Answer 24

TRUE

Question 25

TRUE OR FALSE:
All asymptomatic aortic aneurysms should be referred for follow-up. Abdominal aortic aneurysms ≥5 cm in diameter are at an increased risk of rupture (size is measured from outer wall to outer wall) and require prompt (days) follow-up.

Answer 25

TRUE
-The patient should be instructed to return immediately for worsening symptoms or syncope.
-Abdominal aortic aneurysms in women have a greater likelihood of rupture than in men, often at smaller sizes.

Question 26

Notoriously difficult to suspect clinically because the iliac artery cannot be examined directly, and symptoms suggest urologic, bowel, or groin disorders

Answer 26

Iliac artery aneurysms

Question 27

TRIAD of jaundice, biliary colic, and upper GI bleeding
Seen when hemobilia from a leaking hepatic artery aneurysm occurs

Answer 27

Quincke’s triad

Question 28

Present with left upper quadrant pain, undifferentiated shock, or intra-abdominal hemorrhage
Poor prognosis because of its intraperitoneal location and nondescript presentation

Answer 28

Splenic artery aneurysms