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Vascular > Aneurysm > Flashcards

Aneurysm Flashcards

1
Q

Aneurysm

A

localised dilation >1.5 x normal size of artery segment

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2
Q

True aneurysm

A

Involves all 3 layers of arterial wall

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3
Q

False aneurysm

A

Not involving all arterial layers, actually compared thrombus/layer of fibrous tissue

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4
Q

Cause of aneurysm

A
  • Artherosclerosis 90%
  • Familial
  • Infective
  • Connective Tissue disorder
  • Traumatic/Iatrogenic
  • Inflammation
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5
Q

Definition of AAA

A

External diameter >3cm

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6
Q

Etiology of AAA

A
  • Artherosclerosis 90%
  • Infection
  • Connective Tissue Disease
  • Inflammation
  • Traumatic / Iatrogenic
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7
Q

Epidemiology of AAA: Percentage of AAA

1) infrarenal
2) associated wtih atherosclerosis
3) associated with other peripheral aneurysm

A

1) 95%
2) 95%
3) 20%

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8
Q

Triad of rupture AAA

A

Pulsatile mass

Abdominal pain radiating ot back

Shock

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9
Q

Risk factors for AAA

A

Male

Age

Smoking

Family Hx

(DM and female reduced risk)

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10
Q

Sequelae of ruptured AAA.

Percentage

1) do not reach hospital
2) not fit for surgery
3) anterior rupture, die before arrival
4) operative mortality

A

1) 50%
2) 30%
3) 20%
4) 50%

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11
Q

Management of ruptured AAA

A

Resuscitation according to ATLS, aim for permissive hypotension

Reassessment of responsiveness to resuscitation

Decision for CT or OT

Preparation for OT

OT procedure

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12
Q

1) Name a few predictive scores for AAA
2) Common parameters

A

1.

Glasglow Aneurysm Score

Hardman Index

RAAA-POSSUM

Edinburgh Ruptured Aneurysm Score

  1. Age, creatinine, Hb, GCS, SBP
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13
Q

Laplace’s law

A

Wall tension = pressure x radius

*Thus larger radius, easier for rupture

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14
Q

Early complications of AAA

A

Anastomotic bleeding

Thromboembolism to LL (trash foot)

Renal damage

Ischemic bowel

Spinal cord ischemia

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15
Q

Late complications of AAA repair

A

Infected graft

Sexual dysfunction

Aorto-enteric fistula

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16
Q

Anatomical requirements for Endovascular Grafting

A

Proximal landing zone ≥15mm

Angulation of neck < 60 degrees

Neck diameter ≤ 3.2cm

Distal landing zone ≥10mm

Distal fixation diameter 7-20mm

<25% of circumference with thrombosis and calcification

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17
Q

Endoleak

1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5

A

1) inadequate proximal and distal sealing
2) patent branch vessel
3) defect in fabric of graft
4) Leaking through porosity of graft
5) endotension

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18
Q

Evidence for EVAR vs open repair

A

DREAM

EVAR I

OVER

EVAR II

19
Q

Evidence for EVAR vs surveillance in smaller AA

A

CAESAR (2011)

PIVOTAL trial (J Vas Sur 2010)

Surgery for small asymptomatic abdominal aortic aneurysm (Cochrane 2012)

20
Q

Surveillance after EVAR

1) Aim
2) If no endoleak
3) If endoleak

A

1) identify endoleak, sac expansion, graft migration
2) Yearly duplex USG + plain XR
3) CTA

21
Q

Evidence for screening for AAA

A

UK MASS trial (2002 Lancet)

22
Q

Indication of treatment for thoracic aortic aneurysm

A
  • Size > 6cm
  • Symptomatic
  • Enlarging
  • Aortic valve incompetence in ascending aortic aneurysm
23
Q

Indication for treatment of popliteal aneurysm

A
  • >2cm
  • Symptomatic
24
Q

Margins of the popliteal fossa

A

Superior: supracondylar line of femur

Inferior: soleal line of tibia

Superiolateral: bicep femoris

Superior-Medial: semitendinous

Inferior lateral: lateral head of gastrocnemius

Inferior medial: medial head of gastrocnemius

25
Q

Contents of the popliteal fossa

A

Popliteal artery

Popliteal vein

26
Q

Treatment options for popliteal aneurysm

A
  • Conservative
  • Surgical Bypass
    • Aneurysm exclusion and bypass
    • Inline reconstruction
  • Endovascular stent grafting
27
Q

Approaches for surgical repair of popliteal aneurysm

A

1) Medial approach (for aneurysm exclusion/ligation and bypass)
2) Posterior approach (inline reconstruction)

28
Q

Definition of femoral artery aneurysm

A

Aneursym >2cm

29
Q

Indication for surgical repair fo femoral artery aneurysm

A

1) symptomatic
2) >3cm

30
Q

Percentages for femoral artery aneurysm

1) isolated CFA
2) involving bifurcation
3) isolated SFA/ Profundus artery aneurysm
4) concomitant AAA/popliteal aneurysm

A

1) 40%
2) 50%
3) 5%
4) 50%

31
Q

Management of infected pseudoaneurysm

A
  • If non-IVDA: ligation + bypass
  • If IVDA: Triple ligation adn resection of aneurysm
32
Q

Indication for surgery in asymptomatic iliac artery aneurysms

A

> 3-4 cm

Via exclusion and bypass

33
Q

Triple ligation

A
  • Groin incision
  • Dissection down to extraperitoneal plane
  • Locate and control external iliac artery
  • Axial incision along fmoeral artery
  • Identify and clamp superficial and profunda femoris artery
  • Ligation of tripe (CFA, SFA, Profunda femoris artery), if fail, for ligation of EIA
  • Debridement of necrotic tissue
  • Layered closure of groin wound
  • Postop observation of leg viability
34
Q

EVAR 1

A

Elective EVAR vs open in AAA> 5.5

Lancet

Primary outcome: 30-day mortality, 4 years and 8 years FU

Result:

  • Significantly better 30 day mortality
  • At 4 years, lower aneurysmal related mortality in EVAR
  • At 8 years, no difference in aneurysmal related survival. High graft related complications and re-interventions in EVAR
35
Q

OVER trial

A

Elective EVAR vs open (US)

Patient: AAA> 5 or 4.5cm with rapid growth

Outcome: 30 day mortality, 2 year mortality

Result: EVAR better than open for 30 day mortality, but at 2 years, no difference

36
Q

EVAR II

A

EVAR vs no intervention in non-fit patients

Primary outcome: 30 day mortality

Result: EVAR does not decrease all cause mortality, higher graft related complications +mreintervention, more costly

Conclusion: non surgically fit patients should have no intervention

37
Q

DREAM

A

Elective EVAR vs open

NEJM 2005 RCT

Result: no difference in aneurysmal related mortality, survival advantage of EVAR no sustained beyond first postoperative year

38
Q

IMPROVE trial

A

Ruptured AAA: EVAR vs Open

Primary outcome: 1 year all cause mortality

Result: no difference in all cause mortality or reintervention. EVAR shorter hospital stay, higher QALY, lower cost

39
Q

UK Small Aneurysm Trial

A

Asymptomatic AAA from 4- 5.5 cm

Intervention: early elective open repair vs USG surveillance

Conclusion: Early repair has no survival benefit, 30day mortality of 5.8%

40
Q

ADAM trial

A

Open repair vs surveillance in 4.0-5.5cm AAA

Conclusion: no difference in survival up to 8 years

41
Q

Evidence for ruptured AAA

A

IMPROVE

AJAX

ECAR

42
Q

AJAX

Amsterdam Acute Aneurysm Trial

A

Multicenter RCT

EVAR v Open repair for rAAA

Outcome: application rate of EVAR

Conclusion: 45% applicable for EVAR, but applied in less

43
Q

ECAR trial

A

French multicenter RCT

EVAR vs Open repair for rAAA

Outcome: 30day and 1 year mortality

Conclusion: similar mortality, EVAR associated with less severe complications and less consumption of hospital resources

Vascular (6 decks)

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