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VASCULAR > 2: AAA, TAA, Aortic Dissection > Flashcards

2: AAA, TAA, Aortic Dissection Flashcards

1
Q

define an aneurysm

A

an abnormal dilatation of a blood vessel by more than 50% of its normal diameter

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2
Q

define an abdominal aortic aneurysm

A

a dilatation of the abdominal aorta greater than 3cm

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3
Q

what are possible causes of AAA

A
  • atherosclerosis
  • trauma
  • infection
  • CT disorders e.g. Marfan’s, Ehler’s Danlos
  • inflamm disease e.g. Takayasu’s aortitis
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4
Q

what are risk factors for AAA

A
  • smoking
  • HTN
  • hyperlipidaemia
  • FHx
  • male
  • increasing age
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5
Q

how might a AAA patient present

A
  • mostly asymptomatic and only detected as an incidental finding/screening
  • if symptomatic: abdo pain, back/loin pain, distal embolisation - limb ischaemia
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6
Q

what can be felt on examination of an AAA

A

pulsatile mass in abdomen above the umbilical level
- rare: signs of retroperitoneal haemorrhage

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7
Q

describe the aneurysm screening programm

A
  • offer an abdominal USS for all men aged 65 years
  • men who have been screened have an approx 50% reduction in aneurysm-related mortality
  • most men w detected AAA will spend 3-5 years in surveillance prior to reaching threshold for elective repair
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8
Q

what are the main ddx for patients presenting with symptomatic AAA

A
  • renal colic
  • diverticulitis
  • bowel ischaemia
  • degenerative disc disease
  • ovarian torsion
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9
Q

what are important investigations in suspected AAA

A

USS
- once confirmed, follow up CT scan with contrast when threshold diameter of 5.5cm
- provides more anatomical details to determine suitability for endovascular procedures

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10
Q

how are patients with an AAA of less than 5.5cm managed (5)

A
  • monitored via duplex USS
    - 3.0-4.4cm: yearly ultrasound
    - 4.5-5.4cm: 3 monthly ultrasound
  • smoking cessation to reduce rate of expansion and risk of rupture
  • improve BP control
  • commence statin and aspirin therapy
  • weight loss and increased exercise
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11
Q

when is surgery indicated in pt w AAA

A
  • AAA >5.5cm
  • AAA expanding at >1cm/year
  • symptomatic AAA patient who is otherwise fit
  • in the UK, AAA>6.5cm must be notified to DVLA and disqualified from driving
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12
Q

what are the main surgical options for AAA

A

open
endovascular

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13
Q

what does open repair of AAA involve

A
  • midline laparotomy or long transverse incision
  • expose the aorta
  • clamp aorta proximally and iliac arteries distally
  • remove segement
  • replace with prosthetic graft
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14
Q

what does endovascular repair of AAA involve

A
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15
Q

compare and contrast open vs endovascular repair

A
  • endovascular repair has better short term outcomes e.g. decreased hospital stay and 30 day mortality
  • but higher rate of reintervention and aneurysm rupture
  • after 2 years the mortality for both procedures is the same so in young fit patients, open repair may be more appropriate
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16
Q

what is an important complication for EVAR

A

endovascular leak
- incomplete seals forms around the aneurysm resulting in blood leaking around the graft

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17
Q

how are endoleaks classified

A
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18
Q

what are the main complications of AAA (3)

A

aneurysmal rupture
- retroperitoneal leak
- embolisation
- aortoduodenal fistula

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19
Q

how might a ruptured AAA present

A
  • abdo/back pain
  • syncope
  • vomiting
  • O/E: haemodynamically compromised + pulsatile abdo mass
  • 50% classic triad: flank/back pain, hypotension, pulsatile abdo mass
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20
Q

what are the 2 ways in which a AAA can rupture

A
  1. anteriorly: into peritoneal cavity and have poor prognosis
  2. posteriorly: into retroperitoneal space where blood can tamponade itself and promote haematoma formation so better prognosis
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21
Q

how is a ruptured AAA managed

A
  • high flow O2
  • IV access x2 large bore cannulae
  • urgent bloods + crossmatch for min 6 units
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22
Q

why should patients in shock from ruptured AAA be treated w caution

A

raising the blood pressure too much will potentially dislodge any clot and may precipitate further bleeding
- aim to keep the BP≤100mmHg (termed ‘permissive hypotension’, preventing excessive blood loss)

23
Q

what is an aortic dissection

A

tear in the intimal layer of aortic wall causing blood to pool and split apart the tunica intima and media

24
Q

what are the different ways in which an aortic dissection can progress

A
  • anterograde: towards iliac arteries
  • retrograde: towards aortic valve
  • or in both directions from point of origin
25
Q

what can retrograde aortic dissection result in

A
  • prolapse of aortic valve
  • bleeding into the pericardium
  • cardiac tamponade
26
Q

what is a penetrating aortic ulcer

A

ulcer that penetrates the intima and progresses into the media of the artery

27
Q

what can a penetrating aortic ulcer progress to

A
  • intramural haematoma
  • aortic dissection
  • perforation
  • aneurysm formation
28
Q

what are the 2 systems used to classify aortic dissection

A

Stanford
DeBakey

29
Q

how does the Stanford classification divide aortic dissection

A
  • type A: involves the ascending aorta and can propagate to the aortic arch and descending aorta (i.e. DeBakey Types I and II) ; tear can originate anywhere along this path
  • type B: does not involve the ascending aorta, occurring in any other part of the aortic arch and descending aorta (i.e. DeBakey Type III)
30
Q

how does the DeBakey classification group aortic dissections (anatomically)

A
  • Type I – originates in the ascending aorta and propagates at least to the aortic arch
    - typically seen in patients under 65yrs and carry the highest mortality, quoted at 1% per hour in the acute setting
  • Type II – confined to the ascending aorta
    - classically in elderly patients with atherosclerotic disease and hypertension
  • Type III – originates distal to the subclavian artery in the descending aorta
    - further subdivided into IIIa which extends distally to the diaphragm and IIIb which extends beyond the diaphragm into the abdominal aorta
31
Q

what are the risk factors of aortic dissection

A
  • HTN
  • atherosclerotic disease
  • male
  • CT disorders
  • bicuspid aortic valve
32
Q

what is the characteristic presentation of acute aortic syndrome + clinical signs

A

tearing chest pain radiating through to the back
- tachycardia
- hypotension
- new aortic regurg murmur
- signs of end-organ hypoperfusion e.g. reduced urine output, paraplegia, lower limb ischaemia

33
Q

what are ddx for aortic dissection (4)

A
  • MI – classically crushing and central chest pain, with signs of cardiac ischaemia on ECG and / or raised serum troponin levels
  • PE – dyspnoea will be a prominent feature, with potential hypoxia present, can be confirmed with a CTPA (or V/Q scan)
  • pericarditis – classically pleuritic chest pain, with the ECG showing diffuse ST elevation, as well as potential pericardial rub on auscultation
  • musculoskeletal back pain – the patient will not present with systemic signs of shock and will be tender to palpation of the chest wall or paraspinal muscles
34
Q

what is the appropriate management for aortic dissection

A
  • baseline blood tests
  • crossmatch 4 units packed RBCs
  • ECG to exclude cardiac pathology
35
Q

what are the appropriate imaging options for aortic dissection (2)

A
  • CT angio
  • transoesophageal ECHO
36
Q

what is the urgent initial management of aortic dissection

A
  • high flow oxygen
  • x2 large bore IV cannulas
  • fluid resus
37
Q

what is the follow up management of aortic dissection

A
  • antihypertensive therapy
  • surveillance imaging (1,3,12 months post discharge)
38
Q

how are type A dissections treated

A

high mortality!
- surgery: removal of ascending aorta and replacement with synthetic graft

39
Q

how are type B dissections treated

A
  • uncomplicated managed medically
  • 1st line is managing HTN with B-Blockers e.g. labetalol
  • lowers SBP, PP and pulse rate to minimise stress on dissection
40
Q

in the acute setting, why is endovascular repair of type B dissection not recommended

A

risk of retrograde dissection

41
Q

what is the most common complications of type B dissections

A

can go on to become chronic –> formation of aneurysm

42
Q

what are possible complications of aortic dissection

A
  • Aortic rupture
  • Aortic regurgitation
  • Myocardial ischaemia - secondary to coronary artery dissection
  • Cardiac tamponade
  • Stroke or paraplegia - secondary to cerebral artery or spinal artery involvement
43
Q

why do thoracic aortic aneurysms develop

A

degradation of tunica media (provides tensile strength and elasticity) –> loss of structural integrity and dilates
- diameter increases - rise in tension - further diameter increase

44
Q
A
45
Q

where do thoracic aortic aneurysms commonly affect

A
  • ascending aorta or aortic root (60%)
  • aortic arch (10%)
  • descending aorta (40%)
  • thoracoabdominal aorta (10%) segments
46
Q

what are the 2 main causes of thoracic aortic dissection

A
  • CT disorders
  • bicuspid aortic valve
47
Q

what are the clinical features of thoracic aortic aneurysms

A

chest pain - depending on site of aneurysm
* Ascending aorta – anterior chest pain
* Aortic arch – neck pain
* Descending aorta – posterior thoracic pain

48
Q

what are secondary symptoms of thoracic aortic aneurysms (3)

A
  • back pain (spinal compression)
  • hoarse voice (damage to left RLN in arch aneurysm)
  • heart failure (involvement of aortic valve)
49
Q

what are appropriate investigations into thoracic aneurysms

A
  • routine bloods
  • ECG
  • CXR
50
Q

what might a CXR of thoracic aneurysm show

A
  • widened mediastinal silhouette
  • enlarged aortic knob
  • possible tracheal deviation
51
Q

what is the preferred imaging modality of thoracic aneurysms

A

CTA
- can visualise sac and lumen and detect potential complications e.g. rupture or mural thrombus

52
Q

what are patients with confirmed thoracic aneurysms started on

A

medical management
- statins
- anti-platelet therapy
- smoking cessation

53
Q

when is surgical intervention indicated for thoracic aneurysms

A
  1. Ascending Aorta – diameter >5.5cm, the affected region of the aorta is excised and replaced with a dacron graft; if the aortic root is involved, a Bentall procedure is often performed, using a graft that also contains a prosthetic aortic valve
  2. Aortic Arch – aneurysm is over 5.5cm; affected aorta is replaced with a multi-limbed graft, allowing for the branching of the great vessels (such procedures have a high risk of cerebral ischaemia from embolisation)
  3. Descending Aorta – diameter exceeds 6.0cm; open or with endovascular

VASCULAR (5 decks)

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