[3] Peripheral and Visceral Artery Aneurysms Flashcards
What is an aneurysm?
A persistent, abnormal dilation of an artery above 1.5x the normal diameter
What vessel is most commonly affected by aneurysms?
Abdominal aorta
What is the aetiology of peripheral and visceral aneurysm?
Largely unknown
What are the possible causes of peripheral and visceral aneurysms?
Trauma
Infection
Connective tissue disease
Inflammatory disease
Give an example of a connective tissue disease that can cause peripheral and visceral aneurysms
Marfans disease
Give an example of an inflammatory disease that can cause peripheral or visceral aneurysms
Takyasus aortitis
What are the risk factors for peripheral and visceral aneurysms?
Smoking
Hypertension
Hyperlipidaemia
Family history
What are the categories of presentations of peripheral and visceral aneurysms?
Asymptomatic (found incidentally)
Symptomatic, but not ruptured
Symptomatic secondary to rupture
How can peripheral or visceral aneurysms that are symptomatic secondary to a rupture be further classified?
Stable or unstable
How are peripheral and visceral aneurysms usually best investigated?
With CT angiography
Can MR angiography be used to investigate peripheral or visceral aneurysms?
Yes, it is a good alternative to CT
When in particular is MR angiography a good alternative to CT angiography in investigating peripheral or visceral aneurysms?
It has a reduced risk of kidney damage, so good in renal failure etc
When are US duplex scans useful in investigating peripheral and visceral aneurysms?
In detection and follow up
What is the limitation of US duplex scanning in peripheral and visceral aneurysms?
It is not helpful for planning treatment
What will management of peripheral and visceral aneurysms involve?
Either watchful waiting or surgical intervention
What are the options for surgical intervention in peripheral and visceral aneurysms?
Endovascular or open
What does the decision to wether to manage conservatively or surgically depend on?
The location and size, as well as associated symptoms
Where do peripheral artery aneurysms most commonly occur?
Popliteal artery
Femoral artery
What % of peripheral aneurysms are popliteal aneurysms?
70-80%
Why is active management advised for popliteal aneurysms?
Because they have a high risk of embolisation
How do popliteal aneurysms present?
Usually present symptomatically as either acute limb ischaemia or less commonly as intermittent claudication
Why can popliteal aneurysms cause acute limb ischaemia?
Due to aneurysm formation or distal emboli
When might popliteal aneurysm be found incidentally?
In patients being worked up for AAA or awaiting knee replacement
Is the rupture of popliteal artery aneurysms common?
No, it is rare
What will be found on clinical examination with popliteal artery aneurysms?
Pulsatile mass felt in the popliteal fossa
What are popliteal artery aneurysms often associated with?
Popliteal artery aneurysms in the other knee
Abdominal aortic aneurysms
What is the initial investigation for a popliteal artery aneurysm?
An ultrasound duplex scan
Why is a ultrasound duplex scan the first line investigation for a popliteal artery aneurysm?
As it will allow differentiation between other causes of popliteal fossa swelling
Looks for signs of aneurysm thrombosis
What other causes of popliteal swelling can be differentiated from popliteal aneurysms on Doppler ultrasound?
Bakers cyst
Lymphadenopathy
What further imaging may be done in popliteal artery aneurysms?
CT angiogram or MR angiogram
What is the use of CT angiogram or MR angiogram in popliteal artery aneurysms?
They allow good anatomical assessment of the aneurysm, which is useful for operative planning
Useful in the assessment of distal arteries to assess their patency
When should symptomatic popliteal aneurysms be treated?
Always, regardless of their size
Why should symptomatic popliteal arteries always be treated?
Due to the risk of embolic events
How will the detection of a thrombus on imaging in the investigation of popliteal artery aneurysms change the management?
It should warrant treatment at an early stage
When should asymptomatic popliteal artery aneurysms be treated?
If they are greater than 2cm
How should asymptomatic popliteal artery aneurysms be managed if they are under 2cm in size?
Routinely monitored with US scans
What are the surgical options for popliteal artery aneurysms?
Open and endovascular repair options
What does endovascular repair in popliteal artery aneurysms involve?
Stent insertion across the aneurysm
What does endovascular repair of popliteal artery aneurysm require?
A normal calibre artery above and below the aneurysm
Why does endovascular repair of a popliteal artery aneurysm require normal calibre artery above and below the aneurysm?
So the stent can seal in
What are the risks of endovascular repair of a popliteal artery aneurysm?
Continued aneurysm sac filling through collateral vessels
In stent thrombosis
What anaesthetic is required for the endovascular repair of popliteal artery aneurysms?
Local anaesthetic
Where is endovascular repair of popliteal artery aneurysms the preferred choice?
In unfit patients
What does surgical repair of popliteal artery aneurysms involve?
Ligation of the aneurysm or resection of the aneurysm with a bypass graft
What is used for a bypass graft in the repair of a popliteal artery aneurysm?
Either a vein from the patient (preferred) or a prosthetic graft
What approach can be taken in a bypass graft in popliteal aneurysm repair?
Above knee popliteal bypass
Posterior approach to knee, opening aneurysm sac, then inserting a tube graft from top to bottom
What are the major causes of the development of a femoral artery aneurysm?
Percutaneous vascular interventions
Intravenous drug users who inject into the groin
What causes symptoms and signs of a femoral artery aneurysm?
Thrombosis, rupture, or embolisation of the aneurysm
What may be present in cases of femoral artery aneurysms caused by IVDU?
Infection
How do femoral artery aneurysms present?
With varying degrees of claudication or acute limb ischaemia
Often no symptoms other than swelling in the groin
How should femoral artery aneurysms be investigated initially?
US duplex scan
What further imaging is done in femoral artery aneurysms?
CT angiography and MR angiography
What is the purpose of CT angiography and MR angiography in femoral artery aneurysms?
Further anatomical imaging and operative planning
What is the mainstay of treatment for femoral artery aneurysms?
Open surgical repair
What visceral arteries are most commonly affected by aneurysm formation?
Splenic artery
Hepatic artery
Renal artery
What % of total visceral artery aneurysms are splenic artery aneurysms?
Around 60%
What are the main risk factors for the development of splenic artery aneurysms?
Female sex
Multiple pregnancies
Portal hypertension
Pancreatitis or pancreatic pseudocyst formation
How do splenic artery aneurysms present?
Those who are symptomatic present with vague epigastric or LUQ pain
How do ruptured splenic arteries present?
Severe abdominal pain and haemodynamic compromise
What is the mainstay of investigation of splenic arterery aneurysms?
CT angiography or MR angiography
What is the first line management of splenic artery aneurysms?
Endovascular repair
How is endovascular repair of splenic artery aneurysms best performed?
Using embolisation or stent grafts once the patient is haemodynamically stable
What management may be recommended in splenic artery aneurysm when the patient is haemodynamically unstable?
Open repair
What % of total visceral artery aneurysms are hepatic artery aneurysms?
20%
What are the causes of hepatic artery aneurysms?
Percutaneous instrumentation
Trauma
Degenerative disease
Post-liver transplantation
What % of hepatic artery aneurysms are associated with percutaneous instrumentation?
50%
How can hepatic artery aneurysms form post liver transplants?
False aneurysms can form around the vessel anastomoses
How do hepatic artery aneurysms present?
Most cases are asymptomatic, yet stable symptomatic cases can often present with vague RUQ or epigastric pain
When may jaundice present in hepatic artery aneurysms?
If there is biliary obstruction
What is the mainstay of investigation for hepatic artery aneurysms?
CT angiography or MR angiography
What is the first line management of hepatic artery aneurysms?
Endovascular repair
How is endovascular repair best done in hepatic artery aneurysms?
Embolisation or stent grafts
When might open repair be advised in hepatic artery aneurysms?
Haemodynamically unstable patients
Those with unsuitable anatomy
How is a renal artery aneurysm usually discovered?
Incidentally (is asymptomatic)
What symptoms may be caused by renal artery aneurysms?
Haematuria
Resistant hypertension
Loin pain
How should renal artery aneurysms be investigated?
CT angiography or MR angiography
What is the mainstay of treatment in renal artery aneurysms?
Endovascular repair
When can a stent be inserted easily in the endovascular repair of renal artery aneurysms?
If the aneurysm is affecting the main renal artery
How can endovascular repair be performed in a renal artery aneurysm affecting the hilum?
With coils and self-expanding stents
