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Medicine Y3 TCD 13-24 > 18. AAA and aortic dissection > Flashcards

18. AAA and aortic dissection Flashcards

1
Q

what is atherosclerosis caused by

A

chronic inflammation and activation of the immune system in the artery wall
causes deposition of lipids in the wall, followed by fibrotic plaques

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2
Q

What can atherosclerosis plaques cause

A

stenosis leading to reduced blood flow (ie in laudation)

rupture giving off a thrombus that blocks a distal vessel leading to ischaemia (eg in ACS)

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3
Q

What are the risk factors for atherosclerosis and AAA

A 
older age 
family history 
male 
smoking and alcohol consumption 
poor diet 
low exercise 
obesity 
diabetes
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4
Q

what are the end results of atherosclerosis

A 
angina 
ACS
TIA
strokes 
peripheral arterial disease 
chronic mesenteric ischaemia
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5
Q

What odes peripheral arterial disease result from

A

atherosclerosis and narrowing of the arteries supplying the limbs and periphery

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6
Q

what is critical limb ischameia

A

is the end-stage of peripheral arterial disease, where there is an inadequate supply of blood to a limb to allow it to function normally at rest

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7
Q

what is intermittent claudication

A

symptom of having ischaemia in a limb during exertion that is relieved by rest. It is typically a crampy, achy pain in the calf muscles associated with muscle fatigue when walking beyond a certain intensity.

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8
Q

What is leriche’s syndrome and what is the clinical triad

A 
associated with occlusion in the distal aorta or proximal common iliac artery 
clinical triad: 
- thigh/buttock claudication 
absent femoral pulses 
male impotence (ED)
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9
Q

What examination findings would you see in atherosclerosis

A 
•	Weak peripheral pulses
o	Radial
o	Brachial
o	Carotid
o	Aorta
o	Femoral
o	Popliteal
o	Dorsalis Pedis
o	Femoral
•	Pallor
•	Cold
•	Skin changes (ulceration, hair loss)
•	Buerger’s Test
•	You can use a handheld doppler to more accurately assess pulses
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10
Q

what investigations would you carry out if you suspected atherosclerosis

A
  • Ankle-Brachial Pressure Index (ABPI)
  • Arterial Doppler
  • Angiography (CT or MRI)
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11
Q

how do you measure the ankle-brachial pressure index (ABPI)

A

• The ratio of systolic blood pressure in the ankle (around the lower calf) vs the arm
• E.g. an ankle SBP of 80 and an arm SBP of 100 gives a ratio of 0.8
• Results
o >0.9 is normal
o 0.6 – 0.9 is mild disease
o 0.3 – 0.6 is moderate to severe disease
o <0.3 is severe disease to critical ischaemic

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12
Q

what are the signs of critical limb ischemia (the 6 Ps)

A 
pain 
pallor 
pulseless
paralysis
Paraesthesia
Perishing cold
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13
Q

what is the management of intermittent claudication

A
  • General lifestyle changes to reverse modifiable risk factors (diet, smoking, exercise etc)
  • Optimise medical treatment of comorbidities (hypertension, diabetes etc)
  • Medical treatments, Atorvastatin 80mg, Clopidogrel 75mg once daily (alternatively aspirin plus dipyridamole), Naftidrofuryl oxalate (peripheral vasodilator)
  • Surgical treatments: Angioplasty and stenting or bypass
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14
Q

What is the management of critical limb ischemia

A 
•	Urgent referral to vascular team
•	Analgesia
•	Urgent revascularization by
o	Angioplasty and stenting
o	Bypass surgery
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15
Q

What is an abdominal aortic aneurysm (AAA)

A

a dilated abdominal aorta (increased circumference)

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16
Q

what is a ruptured AAA

A

this is when the aneurysm “pops” and starts bleeding into the abdominal cavity

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17
Q

What is the presentation and examination findings for AAA

A
  • Often asymptomatic
  • Symptoms of peripheral vascular disease
  • Non-specific abdominal pain
  • Palpable expansile pulsation in abdomen when palpated with both hands
  • Found incidentally on abdominal Xray
  • Diagnosis by ultrasound or angiography (CT or MRI)
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18
Q

what is the management of AAA

A 
•	Treat reversible risk factors
•	Monitoring size
•	Treating peripheral arterial disease
•	Surgical (usually considered >5.5cm)
o	Endovascular stenting
o	Laparoscopic repair
o	Open surgical repair
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19
Q

The risk of rupture of an AAA increases with the diameter of the aneurysm
it is roughly ____% for 5cm aneurysm
it is roughly ____% for 8cm aneurysm

A

5%

40%

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20
Q

how do patients with a ruptures AAA present

A
  • Known AAA or pulsatile mass in abdomen
  • Severe abdominal pain (non- specific, possibly radiating to the back or loin)
  • Haemodynamic instability (hypotension, tachycardia)
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21
Q

Name some differentials of severe abdominal pain

A
  • Perforated viscus eg perforated gastric/duodenal ulcer
  • Acute pancreatitis
  • Biliary colic or acute cholangitis
  • Acute mesenteric occlusion (possibly due to an embolus)
  • Ruptured or leaking abdominal aortic aneurysm
  • Rarely some diseases that originate above the diaphgram such as basal pneumonia or an inferior MI
22
Q

ruptured AAA causes generalised shock state and bilateral leg ischemia
if the patient has shock and one leg ischaemic then what conditions should you be thinking of

A

aortic dissection or significant peripheral vascular disease (PVD)

23
Q

What should you always suspect in men older than 60 with a first presentation of renal colic

A

AAA

24
Q

in patients with GI bleeding and PMH of aortic surgery what should you suspect until proven otherwise

A

aortic-enteric fistula

25
Q

When palpating a swelling like an abdominal swelling what are the 2 main types of pulsations and how do you distinguish between them

A

transmitted and expansile pulsations

  • fingers move outwards if expansile
  • fingers move upwards in transmitted pulsations
26
Q

In a transmitted pulsation how can you make the pulsation disappear

A

if you can move the swelling away from the aorta

- do this by asking patient to go into the knee-elbow position

27
Q

In what kind of patients is it difficult to pick up on an AAA

A

obese ones

28
Q

in what kind of patients can you get a false positive finding of AAA

A

thin individuals

29
Q

Name the 3 main arteries that are branches of the abdominal aorta that supply the GI tract

A

coeliac artery
superior mesenteric
inferior mesenteric

30
Q

name the main branches of the coeliac artery

A

left gastric
splenic
common hepatic

31
Q

what does the abdominal aorta continue as

A

Common iliac and then external/internal iliac

32
Q

where does the coeliac artery originate from

A

the aorta at the level of L1 (almost immediately after entering the abdominal cavity through the diahpgram at T12)

33
Q

what scan is used to confirm a AAA

A

CT scan

34
Q

Out of the following levels of clamping, rank them from causing the highest stress on the heart to causing the least stress on the heart
infrarenal
suprarenal
supra-coeliac

A

Supra-coeliac clamp
supra renal clamp
infrarenal clamp

35
Q

What is the difference between a true and false AAA

A

a true aneurysm- all 3 layers of the arterial wall are involved
a false aneurysm- only a single layer of fibrous tissue forms the aneurysm wall

36
Q

The UK is now introducing the aneurysm screening programme to perform an abdominal aortic ultrasound measurement in all men aged ______

A

65 years

37
Q

what are the indications for surgery for an AAA

A
  • Symptomatic aneurysms (80% annual mortality if untreated)
  • Increasing size above 5.5cm if asymptomatic
  • Rupture (100% mortality without surgery)
38
Q

In numerical form what is an aortic aneurysm and what is the background science behind it

A 
a swelling (dilation or aneurysm) of the aorta greater than 1.5X its normal size 
- represents an underlying weakness in the wall of the aorta and associated with extensive atherosclerosis in the adjoining regions of the aorta
39
Q

there is an increased risk of rupture of an AAA if it is greater than what diameter

A

5.5cm

40
Q

AAA should be viewed as a ‘local manifestation’ of what is essentially a generalised arterial disease
- what other arterial diseases do these patients have

A

ischaemic heart disease
cerebrovascular disease
poor ,mesenteric/renal circulation etc

all of these will influence the overall outcome if these patients undergo surgery

41
Q

what is an aortic dissection

A

there is pathology in the lumen of the aorta

a break in the lumen causes blood to flow between the layers of the wall of the aorta

42
Q

name the most common places that an aortic dissection can occur

A

around the ascending aorta and the aortic arch, but it can affect any part of the aorta

43
Q

What are the risk factors for aortic dissection

A 
older age 
family history 
male 
smoking and alcohol consumption 
poor diet 
low exercise 
obesity 
diabetes

also
• Ehlers-Danlos Syndrome
• Marfan’s Syndrome
(both connective tissue disorders)

44
Q

what is the presentation of an aortic dissection

A
  • Tearing chest pain of sudden onset
  • Radiating to the back
  • Hypertension
  • Hypotension (as the dissection becomes more severe)
45
Q

what is the management of an aortic dissection

A
  • Resuscitation
  • Confirmation by immediate imaging (Ultrasound, CT or MRI angiogram)
  • Urgent vascular input and surgical repair
  • Manage hypertension (beta blockers)
  • Urgent surgical stenting or repair (time critical – each passing hour increases mortality)
46
Q

In which layers do you tend to find a false lumen accumulating in aortic dissection

A

between the tunica intimate and tuna media (tuna adventitia is the other layer for completeness)

47
Q

what are the main causes of an aortic dissection

A 
hypertension (more than 67% of the time)
connective tissue disease such as marfans syndrome and Ehlers-danlos 
aneurysm 
trauma - car accident 
men are 3x more likely than women 
peak age is 50-65 years
48
Q

What is the difference in class-action between Stanford A aortic dissection ad Stanford B aortic dissection

A

if the dissection is before the left subclavian artery it is type A, if it is after then it is type B

49
Q

Explain an AAA as if you were doing it to a patient

A

• The aorta is the main blood vessel that supplies blood to your body, it runs from the heart down through your chest and abdomen
• In some people, as they get older, the wall of the aorta in the abdomen can become weak
• A weakening and expansion of the aorta which is the main blood vessel in the body
• Large aneurysms are rare but can be very serious
• Approximately 3000 men aged 65 and over in England and wales die every year from ruptured AAA
• Men are 6x more likely to have AAA than women and the chances increases with age
• Risk also increases if;
o You smoke
o Have high BP
o Your family members have had a AAA

50
Q

What is buergers test

A

Buerger’s test is used to assess the adequacy of the arterial supply to the leg. It is performed in two stages.

With the patient supine, elevate both legs to an angle of 45 degrees and hold for one to two minutes. Observe the color of the feet. Pallor indicates ischaemia

Then sit the patient up and ask them to hang their legs down over the side of the bed at an angle of 90 degrees. Gravity aids blood flow and colour returns in the ischaemic leg. The skin at first becomes blue, as blood is deoxygenated in its passage through the ischaemic tissue, and then red, due to reactive hyperaemia from post-hypoxic vasodilatation.

Medicine Y3 TCD 13-24 (32 decks)

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