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Rosalynn's ABSITE > Vascular aneurysms > Flashcards

Vascular aneurysms Flashcards

1
Q

At what diameter does an abdominal aneurysm occur?

A

> 1.5 times normal

>3 cm

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2
Q

where do most AAA occur?

A

infra renal

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3
Q

true or false

most AAA are true aneurysms

A

True

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4
Q

what layers are usually involved in pseudo aneurysms?

A

adventitia

connective tissue

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5
Q

what are the 4 main etiologies of AAAs?

A

Degenerative
Inflammatory
Traumatic
Infections

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6
Q

how do degenerative AAA form?

A

atherosclerotic AAA

associated w/matrix metalloproteinases

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7
Q

where are matrix metalloproteinases in the vessel of degenerative aneurysm?

A

the media

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8
Q

how to inflammatory AAA form?

A

exaggerated inflammation leading to fibrotic reaction around the aneurysm the can encase the surrounding structures

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9
Q

what are inflammatory AAAs associated with?

A

ureteral obstruction

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10
Q

how are infectious AAAs formed?

A

may be caused by primary infection of arterial wall or foreign bodies (prior vascular repair)

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11
Q

what bacteria are associated w/infectious AAAs

A 
Salmonella
Staph
Candida
Aspergillus
Mycobacterium tuberculosis
Treponema pallidum
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12
Q

what are the biggest RFs for AAA development?

A 
smoking
increased age (over 70)
male
family hx
concurrent aneurysms
HTN
HLD
CAD
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13
Q

what are 2 protective factors for AAA

A

diabetes

DVT

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14
Q

what are risk factors for rupture?

A 
female
decreased FEV1
large initial aortic diameter
current smoker
uncontrolled HTN
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15
Q

at what diameter does risk for rupture exponentially increase?

A

5.0 cm (1-11%)

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16
Q

what is the screening recommendation for AAA

A

U/S screening in men or women 65-75 years w/hx of tobacco use

or

U/S screening in first degree relative of Pts w/AAA, do at age 65-75 or 75 and older and in good health

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17
Q

is there a higher incidence of peripheral aneurysms in those with AAA?

A

yes

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18
Q

How can AAAs cause distal ischemic symptoms

A

atheroembolism

acute thrombosis of AAA can cause acute lower body ischemia (very rare)

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19
Q

what is the best imaging test for AAA?

A

U/S
almost 100% sensitivity and specificity
not good for detecting rupture

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20
Q

what SBP is the goal for a ruptured AAA?

A

70-90 mmHg

permissive hypotension

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21
Q

when do you repair a AAA besides rupture?

A

diameter > 5.5 cm
> 5 mm growth in 6 months or >1 cm growth in 1 year
symptomatic abdominal pain (emergent repair)
signs of embolism
mycotic aneurysm

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22
Q

what is a relative indication for repair?

A

saccular AAA

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23
Q

what are the disadvantages of endovascular repair?

A 
higher rate of reintervention
need long term follow up and imaging
no difference in mortality rate 2-3 years after intervention
high cose
not for everyone
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24
Q

what do you need to do an EVAR?

A

10-15 mm “landing zone in normal infra renal aorta and iliac artery
less than 25% circumferential thrombus in “landing zone”
no significant tortuosity in infrarenal landing zone
large enough iliac arteries for delivery sheaths

25
how big do the iliac arteries have to be to do an EVAR
6-7 mm w/o significant plaque burden
26
what are the warning signs of colon ischemia?
early post op diarrhea, melena, hematochezia, leukocytosis, metabolic acidosis/lactate, hypotension
27
treatment for colon ischemia includes
``` sigmoidoscopy aggressive IVF broad spec abx bowel rest ex-lap if full thickness bowel ischemia ```
28
how does a graft infection present?
"herald bleed" inflammation or bleeding into bowel on CT direct visualization of graft material on EGD
29
how to treat graft infection?
removal of entire graft wide debridement of affected tissues in situ recon or extra anatomical bypass (staged)
30
what are options for in-situ reconstruction of graft infection?
rifampin soaked or silver coated polyester grafts cryopreserved arterial allograft saphenofemoral vein allograft
31
how to treat a stable patient with graft infection?
staged axillary bifemoral bypass then 24-48 hrs laters RTOR to explant infected graft
32
if doing a bypass for graft infection what must you make sure to do?
oversew aortic stump in 2 layers and cover with mental patch to prevent stump break down and blow out
33
what is a type I endoleak?
failure to achieve satisfactory seal at proximal (type Ia) or distal zone (1B) aneurysmal sac is not excluded
34
what is a type II endoleak?
continued retrograde filling of aneurysmal sac by lumbar branches or IMA
35
what is a type III endoleak?
failure of individual component or of seal between components of graft system aneurysmal sac not excluded
36
what is a type IV endoleak?
leakage through the porous material of the graft (rare)
37
what is a type V endoleak?
persistent growth of aneurysmal sac without detectable leak (endotension)
38
which types of endoleaks do you have to repair?
Types I and III because the sac is not excluded
39
how do you repair a type II endoleak?
requires repair if there is continued aneurysm sac expansion | embolization of back bleeding branches or direct aneurysm sac puncture w/injection of thrombotic agents
40
what is the most common endoleak type?
type II
41
when do you follow up with someone with 2.5-2.9 cm AAA
10 years
42
when do you follow up with someone with 3.0-3.9 cm AAA
3 years
43
when do you follow up with someone with 4.0-4.9 cm AAA
1 year
44
when do you follow up with someone with 5.0-5.4 cm AAA
6 months
45
what is the follow up after an EVAR?
baseline imaging at 1 month post-op with contrast enhanced CT and duplex U/S
46
if no leak after 1 month of EVAR when is the next follow up?
repeat imaging at 12 months
47
if there is an endoleak 1 month after EVAR when is the next follow up?
repeat imaging at 6 months
48
should accessory renal arteries be preserved when possible?
yes
49
what approach is helpful with a horse shoe kidney?
retroperitoneal allows mobilization of the kidney anteriorly do not divide the isthmus of the horseshoe kidney
50
during an open AAA repair, if an asymptomatic colon mass or cholelithiasis is found should it be taken out?
no
51
if during an open AAA repair you injure the bowel how do you manage it?
repair the enterotomy | consider aborting case and closing abdomen, return at later date to repair aneurysm
52
management of bowel injury after graft implantation
repair enterotomy copious irrigation consider IV abx
53
how to manage a ureteral injury during open AAA
IV methylene blue can help ID injury | intra op urology repair
54
how to manage a venous injury during open AAA
can be from clamp injury or dissection manual compression proximal and distal division of ipsilateral iliac artery may be needed to visualize and repair injury
55
how to manage distal embolization after open AAA
can be from clamping disease vessels or failure to adequately flush prior to completion of an anastomosis
56
how to manage femoral artery injury during EVAR
get open exposure of artery primary repair if possible complete femoral endarterectomy w/patch angioplasty if needed
57
how to manage iliac artery injury during EVAR
covered stent placement for perforation if needed | consider balloon occlusion and open repair if needed
58
how to manage groin hematoma after EVAR
localized pressure reverse coagulopathy arterial duplex to assess for active flow or pseudoaneurysm
59
how to manage a femoral pseudoaneurysm
localized pressure reverse coagulopathy arterial duplex to assess neck, if narrow can do thrombin injection, if short/wide or clinically unstable or skin necrosis needs open repair

Rosalynn's ABSITE (33 decks)

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