Vascular System - Aortic Aneurysm and Dissection Flashcards
(197 cards)
1
Q
Aneurysm definition
A
A localised dilatation of an artery with at least a 50% increase in diameter compared to expected normal diameter
2
Q
Features of true aneurysms
A
Involve all 3 layers of arterial wall
Fusiform or saccular in shape
3
Q
Features of false aneurysms
A
Hole in arterial wall
Pulsatile haematoma contained by adventitia & surrounding tissues
4
Q
Location of true aneurysms
A
Abdominal aorta and iliac Popliteal Femoral Thoracic aorta Thoracoabdominal aorta
5
Q
Location of false aneurysms
A
Radial
Femoral
Anastomotic
6
Q
Symptoms of aneurysms
A
Expansion thus compression/ eroding adjacent structures
Rupture
Distal embolism
Thrombosis
7
Q
How can AAA cause death
A
Rupture (need out) or back pain by erosion of lumbar vertebrae but most are asymptomatic
8
Q
Epidemiology of AAA
A
6,000 deaths per yr in UK
2% of death in men aged 65+ yrs
9
Q
Risk factors of AAA
A
Male 65+ yrs Smoking HTN 1st degree relative with AAA (CTD) - rare cause of thoracic and abdominal aortic aneurysm
10
Q
Px of AAA
A
Most are asymptomatic
Pain and/or tenderness
11
Q
Px of AAA rupture
A
Abdominal pain radiating to back
Collapse
Pulsatile abdominal mass
12
Q
Px of AAA embolisation
A
ALI (6 P’s)
Blue toe syndrome
13
Q
Blue toe syndrome
A
Ischaemic toes with palpable foot pulses
Suggest micro-embolisation from atherosclerotic plaque or aneurysm
14
Q
National AAA Screening Programme
A
Started in 2010
All men invited for screening US in 65th yr
Older men can self-refer
15
Q
Risk of rupture of AAA
A
Normal aorta measure up to 2.5 cm in diameter
Risk of rupture of AAA increases w/ size
Size of 5.5 - 6cm has a risk of 5-15%
16
Q
AAA and driving
A
Car drivers can continue if <6cm, must notify DVLA between 6-6.4cm and must stop when 6.5cm
Bus/lorry drivers must notify if <5.5cm and must stop if more
17
Q
Mx of small AAA
A
Antiplatelet, statin, smoking cessation and treatment of HTN
18
Q
Mx of small AAA - <3cm
A
No follow-up required if aged 65+
19
Q
Mx of small AAA - 3-4.5cm
A
12 monthly surveillance US
20
Q
Mx of small AAA - 4.5-5.5cm
A
3-6 monthly surveillance US
21
Q
Mx of small AAA - >5.5 cm
A
Consider surgery
22
Q
Indications of AAA surgery - Asymptomatic
A
Diameter > 5.5 cm
Increase in size > 1cm in a yr
23
Q
Indications for AAA surgery - symptomatic
A
Rupture
Pain and/or tenderness (impending rupture)
Distal embolisation (ALI or blue toe syndrome)
24
Q
Pre-operative assessment for aneurysm surgery
A
Bloods/ CXR/ ECG/ LFTs/ cardiopulmonary exercise test
Anaesthetic pre-assessment
Optimise cardiac, resp and renal functional
Ensure antiplatelet and statin
Consider age, frailty, co-mordities, pt wishes
25
Why should you ensure antiplatelet and statin before aneurysm surgery
Reduces risk of peri-operative MI
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Open repair
Laparotamy incision in the midline from xiphisternum to pubic symphysis under GA
Aorta is identified in retroperitoneum
Heparin given as prophylaxis
Tubular graft is sewn to aorta inside sac
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Complications of open repair
Death
Bleeding
Ischaemia - limb (ALI or trash foot) or colon (iscahemic colitis)
Cardiac, resp and renal failure
Wound infection, dehiscence and incisional hernia
Adhesive small bowel obstruction
28
Worst complications of open repair of aneurysms
Graft infection
| Aorta-enteric fistula
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Anatomical suitability for EVAR - aneurysm
Diameter < 30mm
Length >15 mm
Shape - cylindrical not canal
Angulation
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Anatomical suitability for EVAR - iliac access and fixation
Patency
Diameter
Length
Tortuosity
31
Complications of EVAR
```
Death
Contrast and radiation toxicity
Wound haemotoma, serum, infection
Damage to access vessels
Lifelong surveillance required
```
32
What are re-interventions of EVARs usually due to
```
Slipping
Kinking
Thrombosis
Endoleak
Rupture
```
33
Endoleaks
Blood flowing out of the stent graft but inside the aneurysm sac
Can be low pressure or high pressure
May spontaneously seal with time
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What can endoleaks cause
Expansion
| Rupture
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Type 1 endoleaks
```
Caused by poor seal between graft and aneurysm neck or iliacs
Uncommon
High pressure
V concerning
High risk of rupture
```
36
Type 2 endoleak
```
Caused by back bleeding lumbar arteries or IMA
Common
Usually low pressure
Only concerning if sac is expanding
Low risk of rupture
```
37
Mortality of open repair vs EVAR
Higher vs lower
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Hosp stay in open repair vs EVAR
Longer in HDU bed vs shorter in ward bed
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Late mortality of open repair vs EVAR
Lower vs higher
40
Who is open repair ideal for
Younger, more fit pts
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What is EVAR better for
Older, less fit pts
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Ruptured AAA - surgical emergency
Clinical dx
Emergency surgery
Try assess co-morbidities, pt and family wishes
Take bloods for FBC, U&E, glucose, clotting and crossmatch
Fluid resus to maintain BP
Invoke massive transfusion protocol
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Clinical dx of rAAA
Age > 50yrs
Abdominal/back pain
Shock
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What can popliteal aneurysm cause
Can cause a/c or c/c limb ischaemia by thrombosis or distal embolisation or DVT by compression of popliteal vein
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Epidemiology of PAA
Commonest true peripheral aneurysm
50% bilateral
40% also have AAA
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Indication for popliteal aneurysm surgery - asymptomatic
Diameter > 2-3cm
| Significant lining thrombus
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Indications for surgery - symptomatic PAA
Thrombosis (causing ALI)
Distal embolisation (causing c/c limb ischaemia or blue toe syndrome)
DVT (from compression of popliteal veins)
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Typical popliteal artery bypass graft
Saphenous vein graft connecting superficial femoral artery and below-knee popliteal artery
Example of exclusion bypass
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Endovascular treatment of PAA
Stent grafting
| Thrombolysis
50
Stent grafting for PAA
Less morbidity and mortality
| Inferior latency due to kinking and thrombosis
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Thrombolysis for PAA
May clear run-off vessels in thrombosed popliteal aneurysm to allow bypass or stunting
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How can other types of aneurysms cause death
Juxta-renal, suprarenal, thoraco-abdominal and thoracic aneurysms can cause death by rupture
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What must be preserved during aneurysm repair
Blood supply
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What are false radial or femoral aneurysm usually caused by
Iatrogenic arterial puncture
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Treatment of false radial or femoral aneurysm
Spontaneous thrombosis
US guided compression
Thrombin injection
Surgery
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Classification of aortic dissection
Type A
| Type B
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Type A aortic dissection
Start proximal to the left subclavian artery and involve the ascending aorta
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Type B aortic dissection
Start distal to the left subclavian artery and involve the descending aorta
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Epidemiology of aortic dissection
3-4 people per 100,000/yr in UK
M 3x more than F
Peak ages 50-65 yrs
60
Risk factors for aortic dissection
```
HTN
Atherosclerosis
Aortic aneurysm
Bicuspid aortic valve
Coarctation of aorta
Fhx
CTD
Pregnancy
Cocaine use
High-intensity weightlifting
```
61
Px of aortic dissection
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Tearing chest pain radiating to back
Collapse
Pulse deficits
Radio-radial or radio-femoral delay
Difference in BP between arms > 20 mmHG
New aortic regurgitation murmur
Neurological signs of strokes or paraplegia
```
62
Ix of aortic dissection
CXR
ECG
CT/ CTAngio
ABG
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CXR for aortic dissection
Widened mediastinum
| Pleural effusion/ haemothorax
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ECG for aortic dissection
Ischaemic changes of coronary arteries malperfused
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CT angiogram for aortic dissection
Intimal flap
True and false lumen
Branch vessel perfusion
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Complications of aortic dissection
Malperfusion
Rupture
Aneurysmal dilatation
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Complications of aortic dissection - malperfusion
```
Coronary --> MI
Carotid --> stroke
Spinal --> paraplegia
Renal --> renal failure
Mesenteric --> a/c mesenteric ischaemia
Limb --> ALI
```
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Mx of Type A aortic dissection
Open surgery to replace ascending aorta +/- arch +/- aortic valve
May require re-implantation of coronary arteries or great vessels
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Mx of Type B aortic dissection - uncomplicated
Analgesia - morphine
Strict control of BP with IV labetalol (systolic 100 -120)
Surveillance
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Mx of Type B aortic dissection - complicated
TEVAR to cover entry tear and promote thrombosis of false lumen
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Symptoms of complicated Type B aortic dissection
```
Ongoing pain
Uncontrolled BP
Malperfusion
Aneurysmal dilatation
Rupture
```
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Impact on family in chronic illness in childhood
Changes in roles, role expectations, responsibilities and patterns of interactions
Loss of 'perfect' child
Increased practical & emotional stress, depression
Strain on parental rships
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Why is coping important
Severe illness and the many challenges associated with it can be viewed as stressors
Place demands on pt, requiring adaptation
Adaption achieved via physiological, behavioural, cognitive, emotional response
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How can coping strategies be classified
In terms of function served, methods/ modes, type of action
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Most common coping classification distinguishes
Emotion-focused coping
| Problem-focused coping
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Emotion-focused coping
Aimed at modifying response by regulating the emotional distress caused by the stressor or potential stressor
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Problem-focused coping
These strategies attempt to alleviate or eliminate stressful situations through trying to take control i.e. doing something constructive about -ve events
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Spp coping strategies - problem focused
```
Problem solving
Support seeking
Escape avoidance
Distraction
Cognitive restructuring
```
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Spp coping strategies - emotional focused
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Rumination
Helplessness
Social withdrawing
Emotional regulation
Info seeking
Negotiation
Opposition
Delegation
```
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When should problem-focused coping strategies be used
In controllable situations
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When should emotion focused coping strategies be used
When there is no/little control
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Coping in the a/c phase vs c/c phase
Emotion-focused coping in a/c and problem-focused in c/c is best
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Influences on coping
Illness related factors
Background/ personal factors
Physical/ environmental factors
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Illness related factors influencing coping
Level of threat to life/ functioning
Obviousness
Treatment regimens
Side effects
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Background/ personal factors influencing coping
```
Personality
Socio-demographic
Timing in life
Knowledge
Beliefs
Motivation
Education
```
86
Phsyical/ environmental factors influencing coping
```
Hosp/ home environment
Social support
Finance
Resources availability
Educational opportunities
```
87
What factors can facilitate coping and adjustment in c/c childhood illness
A flexible, cohesive and supportive family with open and clear communication
Parental coping style is adaptive
General support system
Pre-illness personality and functioning of the child
Understanding of disease
88
The clinicians role in coping
Identify challenges
Steer emotion or problem-focused coping in +ve direction
misconception
Introduce pts to ideas of coping
Ensure pts equipped to adopt necessary coping
Assess and enhance social support
89
Branches of the arch of aorta
From L - R
Brachiocephalic trunk
Left common carotid artery
Left subclavian artery
90
What does the brachiocephalic trunk give rise to
Right subclavian artery
| Right common carotid artery
91
Posterior intercostal arteries
Branches of descending thoracic aorta found at each vertebral level
92
What do the posterior intercostal arteries anstamose with
Anterior intercostal arteries
93
What are the anterior intercostal arteries a branch of
Internal thoracic artery
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Where do the internal thoracic arteries lie
Parasternally
95
Venous drainage of the thoracic cavity
Azygous venous system
96
Azygous vein
Found on the right
| Drains into superior vena cava
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Where is the hemiazygous vein found
On the left, where intercostal veins drain into
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What does the hemiazygous vein drain into
Main azygous vein
99
Thyro-cervical trunk as branch of subclavian artery
Thyro-cervical artery --> supra scapular artery --> circumflex scapular arteries
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Where does the internal thoracic artery branch from
Subclavian artery
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Where does the abdominal aorta pass through the diaphragm
T12
102
Unapired arteries of abdominal aorta
Coeliac axis
Superior mesenteric artery
Inferior mesenteric artery
103
Paired arteries of abdominal aorta
Inferior phrenic arteries
Middle suprarenal arteries
Renal arteries
Gonadal arteries
104
What level does the inferior phrenic arteries leave at
T12
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What level does the coeliac axis/ trunk leave at
T12
106
What does the coeliac axis supply blood to
The foregut - stomach, first 2 parts of duodenum, liver, spleen and pancreas
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Which level does the middle suprarenal arteries leave at
L1
108
What do the middle suprarenal arteries supply blood to
Suprarenal gland
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What level does the superior mesenteric artery leave at
L1
110
What does the superior mesenteric artery supply blood to
Midgut
111
What does the midgut consist of
```
3rd and 4th part of duodenum
Rest of small intestine (jejunum and illeum)
Caecum
Ascending colon
2/3rds of transverse colon
```
112
What levels do the renal arteries leave at
Between L1/2
113
What level do the renal arteries leave at
L2
114
What level does the inferior mesenteric artery leave at
L3
115
What does the inferior mesenteric artery supply blood to
Last third of transverse colon
Descending colon
Rectum
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Where does the abdominal aorta bifurcate
L4 - umbilicus
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What is the inferior vena cava formed by
The union of common iliac veins at L5
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Where are parietal vessels found
Coming off at each vertebral level
| All paired
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What do the parietal vessels supply
Body wall
| Diaphragm
120
Where are the lumbar arteries found
Leaving each vertebral level from L1 - L4
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What do paired visceral arteries supply
Bilateral organs
122
Why does venous drainage from the abdomen have to pass through the liver
Venous blood holds all the digestion products
123
What does the hepatic vein drain into
Inferior vena cava
124
What is the portal vein formed from
Splenic vein
Superior mesenteric vein
Inferior mesenteric vein
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What do the vertebral arteries join together to form
Basilar artery
126
What is the basilar artery a branch of
Subclavian artery
127
What do the basilar arteries give rise to
Pontine arteries
| Posterior cerebral artery --> posterior communicating artery
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Where does the left common carotid bifurcate at
L4
| Into internal carotid artery and external carotid artery
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Branches of internal carotid artery
Middle cerebral artery
Opthalmic artery
Anterior cerebral artery --> anterior communicating artery
130
Branches of external carotid artery
Facial artery
Maxillary artery
Occipital artery
Superficial temporal artery
131
Venous drainage of head and neck
No veins, instead there are sinuses
132
Sinuses
Venous channels running in between meningeal layers
133
What does confluence of sinuses in the head form
Internal jugular vein
134
What is the axillary artery a part of
Brachial plexus
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Where does the axillary artery start at
Lateral border of 1st rib
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Origin of axillary artery
Subclavian
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Where does the brachial artery start
Inferior border of teres major
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What does the brachial artery pass under
Bicipital aponeurosis
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What does the bicipital aponeurosis do
Anchors biceps brachii to medial side
| Separates arterial and venous vessels
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Which arteries start at the antecubital fossa
Radial artery
| Ulnar artery
141
Which is artery is deeper - radial or ulnar
Ulnar is deeper
| Radial is more superficial
142
What does the radial artery pass through
Anatomical snuffbox
| 1st webspace
143
Deep palmar arch
Comes from radial artery
144
What does the deep palmar arch anastomose with
Superficial palmar arch
145
Testing the anastomosis between the palmar arches
Allen's test
146
Which artery supplies the scaphoid
Radial
147
Path of ulnar artery
Passes under pronator teres and rests under flexor carpi ulnaris
Runs alongside ulnar nerve
148
What does the ulnar artery run in
Guyon's canal
149
What does the ulnar artery pass over
Flexor retinaculum (no risk of compression)
150
What does the ulnar nerve create
Superficial palmar arch - metacarpal branches, digital branches
151
Arterial supply of upper limb
Subclavian --> axillary --> brachial
- -> radial --> deep palmar arch
- -> ulnar --> superficial palmar arch
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Superficial veins of arms
Dorsal venous arch - cephalic, basilic, median cubital vein
153
Where is the cephalic vein found
Radial side of arm
154
Where is the basilic vein
Ulnar side of arm
155
Where is the median cubital vein found
In between cephalic vein and basilic vein
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Where do the veins in the dorsal venous arch drain into
Brachial vein as well as radial and ulnar vein
| At same landmarks turn into axillary vein then subclavian
157
Which veins in the arms also drain into subclavian vein
Cephalic
| Basilic
158
Deep veins in arms
```
Radial
Ulnar
Brachial
Axillary
Subclavian
```
159
What supplies blood to the pelvis
Primarily internal iliac artery
160
What do the common iliac arteries divide into
External iliac artery
| Internal iliac artery
161
Branches of internal iliac artery
Umbilicus artery
Obturator artery
Superior and inferior gluteal arteries
162
Venous drainage of pelvis
Matches arteries
163
Start of femoral artery
Inguinal ligament
164
Division of femoral artery
Profunda femoris
| Superficial femoral artery
165
What does profunda femoris supply
Anterior and posterior aspects of thigh
2 circumflex femoral arteries from perforating arteries join with cruciate anastomosis around hip joint - creates retinacular vessels
166
What is the femoral triangle bound by laterally
Sartorius
167
What is the femoral triangle bound by medially
Adductor longus
168
What is the femoral triangle bound by superiorly
Inguinal ligament
169
What is the floor of the femoral triangle
Pectinueus and Iliopsoas
170
Roof of the femoral triangle
Skin
171
Where does the femoral artery sit at
Mid-inguinal point
172
Mid-inguinal point
Found between pubic symphysis and ASIS
173
Midpoint of inguinal ligament
Between pubic tubercle and ASIS
174
What is the popliteal fossa found by superiorly
Hamstring muscles
175
What is the popliteal fossa bound by laterally
Rectus femoris
176
What is the popliteal fossa bound by medially
Semimembranosus
| Semitendinosus
177
What is the popliteal fossa bound by inferiorly
Gastrocnemius
178
Where does the popliteal artery start
Adductor hiatus
179
What do the popliteal arteries give rise to
Genicular arteries
180
How many genicular arteries do we have in each leg
4
Superior and inferior, both lateral and medially
These form an anastomosis around knee joint
181
What do popliteal arteries divide into
Posterior and anterior tibial arteries at the inferior border of popliteus
182
Terminal branch of anterior tibial artery
Dorsalis pedis at ankle joint
183
Branch of posterior tibial artery
Lateral - peroneal artery
184
Terminal branch of posterior tibial artery
Medial and lateral plantar arteries
185
Deep venous drainage of legs
```
Anterior tibial vein
Posterior tibial vein
Popliteal vein
Femoral vein
External iliac vein
```
186
Superficial drainage of legs
Dorsal venous arch - short and long/great saphenous veins
187
Where does the long saphenous vein run from
Runs from medial aspect of dorsal venous arch and drains into femoral vein
188
Short saphenous vein
Runs posteriorly and laterally to drain into popliteal vein
189
What is venous blood pushed around by
Arterial pressure
190
Features helping venous drainage in legs
Soleal pump o pushes on veins and causes blood to travel up
| Deep fascia compartmentalising muscles - when muscles contracts, pushes on veins
191
Venae commintantes
Veins running alongside arteries
192
Structures at particular risk of supracondylar humeral fracture
Brachial artery
| Median nerve
193
Arterial supply to the lower limb
External iliac --> femoral --> popliteal
- -> anterior tibial --> dorsalis pedis
- -> posterior tibial --> peroneal
194
Where are aortic aneurysms usually located
Abdomen - infrarenal to bifurcation
195
What does lifelong surveillance of EVAR entail
Yearly CT and/ or US
| Monitoring position of stent grafts, size of aneurysm sac and any endoleaks
196
Symptoms of ruptured aneurysm - haemorrhage
Hypotension
Pale, clammy
High HR
197
Investigation for ruptured aneurysm
ECG
Amylase
CT
