AAA

Question 1

What are the differentials for acute, severe abdominal pain?

Answer 1

• Perforated gastric/duodenal ulcer
• Acute pancreatitis
• Biliary colic or acute cholangitis
• Acute mesenteric occlusion
• Ruptured or leaking abdominal aortic aneurysm
• Basal pneumonia
• Inferior MI

Question 2

At what level does the coeliac trunk come off the abdominal aorta?

Answer 2

T12

Question 3

What does the coeliac trunk supply?

Answer 3

• Supplies the organs before the major duodenal papilla (foregut)

Question 4

At what level does the SMA come off the abdominal aorta?

Answer 4

L1

Question 5

What does the SMA supply?

Answer 5

• Supplies the organs between the major duodenal papilla and proximal 2/3 of transverse colon (midgut)

Question 6

At what level does the IMA come off the abdominal aorta?

Answer 6

L3

Question 7

What does the IMA supply?

Answer 7

• Supplies the distal 1/3 of the transverse colon, splenic flexure, descending colon, sigmoid colon and rectum

Question 8

What are the consequences of supra-coeliac clamping of the aorta?

Answer 8

Highest stress on the heart

Ischaemia to all organs below the coeliac artery with subsequent reperfusion injury

Question 9

What are the consequences of supra-renal clamping of the aorta?

Answer 9

High stress on the heart

Ischaemia to all organs below to superior mesenteric artery with subsequent reperfusion injury

Question 10

What are the consequences of infra-renal clamping of the aorta?

Answer 10

Relatively less stress on the heart

Ischaemia to all organs below the kidneys with subsequent reperfusion injury

Question 11

What is an aneurysm?

Answer 11

Abnormal dilation of an artery which is >50% of its transverse diameter

Question 12

What increases the risk of rupture of an AAA?

Answer 12

If the diameter is >5.5cm

Question 13

How can an AAA present?

Answer 13

• Asymptomatic
• Symptoms of peripheral vascular disease
• Non-specific abdominal pain
• Palpable expansile pulsation in abdomen when palpated with both hands
• Found incidentally on abdominal x-ray

Question 14

What are the risk factors for AAA?

Answer 14

• Male sex
• > 60yrs
• HTN
• Smokers
• Family Hx of AAA

Question 15

What are the common misdiagnoses of AAA?

Answer 15

• Renal colic
• Diverticulitis
• GI bleed
• MI
• Muscular and mechanical back pain

Question 16

How do you diagnose AAA?

Answer 16

• Palpation
• US
• CT to confirm diagnosis and see whether endovascular repair will be feasible

Question 17

What do you do if the AAA is <5.5cm?

Answer 17

Surveillance US

Question 18

What do you do if the AAA is >5.5cm or symptomatic ?

Answer 18

Intervene
• Open surgery: replace affected segment with plastic graft, tube or bifurcate
• EVAR

Question 19

How does open surgery cause major CV and renal stress?

Answer 19

Cross aortic clamp

Question 20

What is a ruptured AAA?

Answer 20

Aneurysm ‘pop’s and starts bleeding into the abdominal cavity

Question 21

How can a ruptured AAA present?

Answer 21

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

Question 22

What would you do for a suspected ruptured AAA in a patient that is haemodynamically unstable?

Answer 22

Immediately transfer into theatre

- Should not be delayed by CT imaging