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Vascular YR3 > Abdominal Aortic Aneurysm > Flashcards

Abdominal Aortic Aneurysm Flashcards

1
Q

What is an aneurysm?

A
  • Defined as a blood vessel more than 50% it’s usual diameter (1.5x)
  • AAA defined as dilatation abdominal aorta more than 3cm - normal diameter is 2cm
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2
Q

Cause of AAA

A

Largely unknown.
Possible causes inc:
* Atherosclerosis
* Trauma
* Infection
* Connective tissue disease (eg Ehlers danlos/Marfans)
* Inflammatory disease (eg Takayasu aortitis)

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3
Q

RF for AAA

A
  • Smoking
  • HTN
  • Increasing age
  • Male gender
  • Hyperlipidaemia
  • FH

Diabetes mellitus is actually a NEGATIVE RF - mechansim not understood

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4
Q

Clinical features

A
  • Asymptomatic
  • Usually detected during screening or incidentally
  • If symptomatic - inc abdo pain, back/loin pain, distal embolisation (limb ischaemia)
  • If ruptured - shock/syncope
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5
Q

Examination findings AAA

A
  • Pulsatile mass
  • Above umbilical level
  • Rarely - signs of retroperitoneal haemorrhage
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6
Q

Screening for AAA

A
  • Abdominal USS for all men aged 65
  • Screening results in 50% lower mortality rate
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7
Q

Management depending on AAA screening result

A
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8
Q

Differentials for AAA

A
  • Renal colic
  • Diverticulitis
  • Bowel ischaemia
  • Degenerative disc disease
  • Ovarian torsion
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9
Q

Investigations for AAA

A
  • Duplex USS
  • Once confirmed CT angiography scan with contrast if 5.5cm or more
  • Group and save and clotting screen - blood and loss
  • Crossmatch for surgery
  • U&Es - for contrast
  • FBC - low platelet?
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10
Q

Medical and lifestyle management of AAA

A

If less than 5.5cm:
* Monitoring as appropriate (mentioned above)
* Smoking cessation
* Weight loss
* Increased exercise - avoid strenous, contact sports and heavy lifting though
* Improve BP control
* Statin and aspirin therapy

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11
Q

When is surgery considered for AAA?

A
  • If AAA greater than 5.5cm in diameter OR
  • If increasing at more than 1cm per year OR
  • Symptomatic in otherwise well person
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12
Q

Surgical management of AAA

A
  • Open repair OR
  • Endovascular repair (EVAR)
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13
Q

Open repair AAA

A
  • Midline laparotomy (xiphisternum to pubic symphysis) or long transverse incision
  • Expose aorta
  • Clamp aorta proximally and iliac arteries distally
  • Segment then removed and replaced with synthetic graft
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14
Q

Endovascular repair for AAA

A
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15
Q

Open repair vs endovascular suitability

A

Open:
* Any shape (eg if involving renal and iliac arteries)
* Need good baseline function - general anaesthetic, laparotomy
* Cross clamping = huge afterload = cardiac stress could cause cardiac arrest

Endovascular:
* Good for very frail patients - only need incision in groin and local anaesthetic
* Suitable for those with significant cardiac disease - no cross clamping
* Not suitable if involves renal arteries and need to be able to access femoral artery for catheter

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16
Q

Complication of endovascular repair

A
  • Endovascular leak
  • Blood leak arounds graft due to incomplete seal
  • Often asymptomatic - need surveillance - USS usually
17
Q

Level aorta pierces diaphragm

A

T12

18
Q

Aorta anatomy

A
  • Split into thoracic and abdominal aorta (usuing diaphragm)
  • Thoracic = ascending, arch and descending
  • Abdominal - supra-renal, juxtarenal and infrarenal
19
Q

Where are 90% of AAA?

A

90% infrarenal

20
Q

Abdominal aorta branches

A
21
Q

Where does abdominal aorta divide into iliac vessels?

A

L4

22
Q

Whos AAA is more likely to rupture?

A
  • If female (but men more likely to have to begin with)
  • Larger AAA
  • Smoking
  • HTN

Not all rupture

23
Q

Classification of AAA options

A
  • Location - thoracic, abdominal (suprarenal vs juxta vs infrarenal)
  • Size - most common
  • Wall - true vs false (true consists of all 3 layers of vessel wall, false only involves intima)
  • Aetiology
  • Morphology - fusiform (both sides wall) vs saccular (one sides)
24
Q

Pathophysiology with AAA

A
  • Atheroma = inflammatory reaction
  • = release of metalloproteases enzyme release from inflammatory cells
  • = damage to internal and external elastic lamina of aortic wall
  • = loss of elasticity and ability to cope with pressure changes during
  • = dilatation
  • Then fibrosis occurs = loss of more elasticity, thinning and loss of strength
  • = weaker than systolic pressure
  • = rupture
25
Q

Referral size of AAA

A
  • If 5cm females for 5.5cm male = seen within 2 weeks
  • 3-5.4cm - seen within 3 months
26
Q

Main complication of AAA

A
  • Ruptured - anteriorly (20%) into peritoneal cavity or posterolaterally (80%) into retroperitoneal space
  • Posterolaterally can be temporarily tamponaded by anatomy sometimes
27
Q

Endoleaks classification

A
  • Type 1 - proximal (1a) or distal (1b) site attachment leaks
28
Q

Risks of AAA surgery

A
  • Endoleak in EVAR
  • Abdominal compartment syndrome - compressed IVC and reduced renal perfusion
  • Erectile dysfunction
  • Acute limb ischaemia - emboli from clot in AAA or injury to lower limb vessels
  • Graft infection
  • Blood transfusion complications
29
Q

When is surgery not suitable

A
  • Patient preference
  • Size
  • Progression
  • Co-morbidities
  • Baseline
  • Ceiling of care
  • Risk > benefit
  • Life expectancy

–> palliative care

30
Q

Manageemnt ruptured AAA

A
  • Patient unstable, they will require immediate transfer to theatre for open surgical repair
  • If the patient is stable, they will require a CT angiogram to determine whether the aneurysm is suitable for endovascular repair

Vascular YR3 (16 decks)

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