2: Arterial Aneurysms Flashcards
Define aneurysm
Dilation of a blood vessel to more than 50% of it’s original diameter
Define an abdominal aortic aneurysm
Dilation of abdominal aorta to more than 3cm
What age is the peak incidence for AAA
60-70
Which gender is AAA more common in
Males
What ethnicity is AAA more common in
Caucascians
What factors are thought to cause AAA
Atherosclerosis
Connective tissue diseases (Marfan, Ehlers)
Infection (Syhphillis)
What is the most important risk factor for AAA
Smoking
What are 5 risk factors for AAA
HTN Hyperlipidaemia FH Male Smoking Age
What is a protective factor for AAA
Diabetes
How do the majority of AAA present
Incidentally on screening
If AAAs present clinically, what symptoms may they present with
Back Pain
Limb ischaemia - due to embolisation
Pulsatile abdominal mass
Abdominal pain
Explain the NHS screening program for abdominal aortic aneurysms
Men are invited for a one-off abdominal US scan at 65 years
If a males screening test returns as below 3cm what is done
This is the normal diameter of the abdominal aorta so they are not invited for screening again
If AAA is >5.5cm on screening, how soon should individuals have a vascular review
Within 2W
If AAA is >3-5.4 cm on screening, how soon should individuals have a vascular review
Within 12W
What additional imaging option should be done for individuals with AAA >5.5cm
CT w/contrast
How often should an individual with an AAA of 3-4.4 be followed by AUS
Annually
How often should an individual with AAA of 4.5-5.4 be followed by AUS
3 monthly
What is the risk of AAA 3 - 5.4 cm rupturing
3%
How should AAA of 3-5.4cm be managed
Optimise risk factors including:
- anti-HTN
- Smoking cessation
- Statin
- Diabetic medication
- Aspirin
What are the three indications for operating on an AAA
- > 5.5cm
- Expanding at a rate of >1cm/year
- Symptomatic
What rate does an AAA have to be expanding per year to be operated
> 1 cm per year
What are the two treatment options for repairing a non-ruptured AAA
- Endovascular repair
2. Open repair
Explain an Endovascular repair
Graft is inserted through the femoral artery into AAA and stent put across
What is the advantage of Endovascular repair in the short-term
- Shorter hospital stay
- 30d mortality rate
What is the problem with Endovascular repair in long-run
Higher rates of re-innervation
What is the 2-year mortality rate for endovascular repair compared to open
Same
what does open repair involve
Midline laparotomy
what are four complications of AAA
- Rupture
- Distal embolisation
- Retroperitoneal leak
- Aorta-duodenal fistula
What is a true aneurysm
dilation of all three layers of the vascular wall
What is a false aneurysm
rupture in intima - meaning haematoma collects between vascular layers
What is the most common site of AAA
infra-renal
Is AAA or thoracic aortic aneurysm more common
AAA
What is the most common site of a thoracic aorta
ascending aorta
Who should receive a statin
- Individuals with cardiovascular disease including TIA, Cerebrovascular disease, IHD, PAD
- QRISK2 score >10%
- T1DM diagnosed over 10-year ago or aged >40Y with known nephropathy
What time of day should statins be taken and why
Night time - as this is when majority of cholesterol synthesis occurs
What are the criteria for primary prevention dose of statins
- QRISK2 >10%
- CKD eGFR <60
- T1DM
What dose of statins is given as primary prevention
20mg
What is the criteria for secondary prevention statins
established cardiovascular disease
What dose is given as secondary prevention
80mg
How will an individual with a ruptured AAA present
- abdominal pain that radiates to the back
- haemodynamically compromised
How will individual with ruptured thoracic aortic aneurysm present
tearing chest pain radiating to the back
As the thoracic dissection expands, what arteries are affected if a person presents with following symptoms
a. hemiplegia
b. paraplegia
c. anuria
a. carotid arteries
b. anterior spinal arteries
c. renal arteries
What is a complication of endovascular aneurysm repair
endoleak
what is an Endoleak
there is a leak in the prosthetic graft used to stent the aneurysm
what is the problem with Endoleaks
leaks are asymptomatic until severe and individual haemodynamically compromised - therefore requires regular post-op US
what is the most common type of Endoleaks following thoracic AA repairs
type 1
what is a type 1 endoleak
leak at the end of the graft due to an inadequate seal
what is the most common type of Endoleaks in AAA repairs
type 2
what is a type 2 endoleak
leak at branching vessels
what is a type 3 endoleak
leak occurs due to defect in fabric graft
what is a type 4 endoleak
leak due to porosity in the graft
what is a type 5 endoleaks
continued aneurysm expansion with no demonstrable leak
what are four risk factors for rupture of AAA
- Size of aneurysm
- Female
- Smoking
- HTN
what is the classical triad of symptoms for ruptured AAA
- Back pain
- Hypotension
- Pulsatile abdominal mass
what other symptoms may a ruptured AAA present with
Syncope
Vomiting
explain emergency work-up and management of patient with ruptured AAA
- ECG
- Bloods (Cross-Match, Amylase, U+Es)
- IV access - Rh O-ve blood if compromised maintain systolic BP <100 to contain leak
- Transfer to vascular unit
if patient with ruptured AAA is unstable what is done
Immediate transfer to surgery for open repair
if patient with ruptured AAA is stable what is done
CT angiogram and EVAR
how can a thoracic aortic aneurysm be divided
Anatomically into:
- Ascending aorta (60%)
- Aortic arch (10%)
- Descending aorta (40%)
- Thoracoabdominal aorta (10%)
what has a higher mortality TAA or AAA
TAA
what are 6 causes of thoracic AA
- Connective tissue disease
- Bicuspid aortic valve
- Aortic dissection
- Tertiary syphillis
- Takayasu’s arteritis (Inflammation)
- Trauma
what connective tissue diseases may cause thoracic AA
Ehlers Danlos
Marfans
which condition has a higher risk of bicuspid aortic valve and hence thoracic AA
Turner’s syndrome
Give 5 risk factors for thoracic aortic aneurysms
Smoking HTN Atherosclerosis Age FH Obese Male
How are thoracic aortic aneurysms most commonly identified
incidental finding on imaging
In symptomatic individuals, how does TAA present
pain depending on site of aneurysm
If pain is in the ascending aorta, where is the TAA
anterior chest pain
If pain is in the neck, where is the TAA
aortic arch
If the aneurysm is in the descending thoracic aorta where is the thoracic aortic aneurysm
pain between the shoulder blades
Why may an individual have the following in thoracic aortic aneurysm
a. back pain
b. hoarse voice
c. distended neck veins
d. heart failure
e. dyspnoea
a. due to aneurysm compressing spinal cord
b. recurrent laryngeal nerve compression
c. SVC compression
d. aortic valve involvement
e. tracheal obstruction
What is first-line investigation for thoracic abdominal aneurysm
CXR
what will be seen on CXR in thoracic abdominal aneurysm
widened mediastinum with possible tracheal deviation
what other imaging must be offered to those with thoracic AA to make a diagnosis
CT with contrast
what medical management is offered to those with thoracic aortic aneurysms
RF control: Smoking cessation Statin Anti-HTN Diabetic control Aspirin
when should ascending aortic aneurysms be operated on
> 5.5cm
if the aortic valve is involved in an ascending aortic aneurysm what procedure is performed
Bentall procedure
what does the bentall procedure involve
Graft contains a prosthetic aortic valve
what is criteria for operating on aortic arch aneurysm
> 5.5cm
what is criteria for operating on descending aortic aneurysm
> 6cm
what type of thoracic aortic aneurysm has the highest mortality
aortic arch aneurysm
