Aneurysm (abdominal, thoracic)

Question 1

What is an aneurysm?

Answer 1

There are 3 layers in the aorta: intima, media, adventitia

Aneurysms are when all 3 layers are intact, but dilated.

Question 2

What is a false aneurysm?

Answer 2

False aneurysms (or pseudoaneurysm) occur when the inner two layers (intima and media) rupture and there is dilation of the vessel, with the blood only being contained within the outer (adventitia) layer of the aorta. This typically occurs after trauma, such as a road traffic accident. It can also occur after surgery to the aorta or infection in the vessel.

Question 3

What are the risk factors for developing an aneurysm?

Answer 3

Male
Increased age
Smoking
Hypertension
Family history
Existing cardiovascular disease
Marfan syndrome and other connective tissue disorders

Question 4

Which is the most common area affected in thoracic aneurysm?

Answer 4

ascending aorta

Question 5

Sx of unruptured thoracic aneurysm

Answer 5

Until reupture, Sx occur do to the aneurysm taking up space in the mediastinum

Chest or back pain
Trachea or left bronchus compression may cause cough, shortness of breath and stridor
Phrenic nerve compression may cause hiccups
Oesophageal compression may cause dysphagia (difficulty swallowing food)
Recurrent laryngeal nerve compression may cause a hoarse voice

Question 6

Sx of a ruptured thoracic aneurysm

Answer 6

Severe chest pain or back pain
Haemodynamic instability (hypotension and tachycardia)
Collapse
Death (often patients do not reach hospital)

Question 7

Complications of ruptured thoracic aneurysm

Answer 7

Bleeding into
Oesophagus, causing haematemesis (vomiting blood)
Airways or lungs, causing haemoptysis (coughing up blood)
Pericardial cavity, causing cardiac tamponade (compression of the heart)

Question 8

Ix for suspected thoracic aneurysm

Answer 8

Often picked up accidentally.

Can be dx with echo, CT or MRI angiogram.

Question 9

Mx once thoracic aneurysm is identified

Answer 9

Surveillance with regular imaging to monitor the size

Thoracic endovascular aortic repair (TEVAR), with a catheter inserted via the femoral artery inserting a stent graft into the affected section of the aorta

Open surgery (midline sternotomy) to remove the section of the aorta with the defect in the wall and replace it with a synthetic graft

Question 10

What is the screening test for AAA

Answer 10

All men in England are offered a screening ultrasound scan at age 65

Question 11

What diameter does AA have to be for referral to vascular team?

Answer 11

Patients with an aorta diameter above 3cm are referred to a vascular team (urgently if more than 5.5cm).

Question 12

How does AAA present?

Answer 12

Non-specific abdominal pain
Pulsatile and expansile mass in the abdomen when palpated with both hands

Question 13

How is AAA Dx?

Answer 13

Ultrasound, CT angiogram

Question 14

Surveillance programme for AAA

Answer 14

Yearly for patients with aneurysms 3-4.4cm

3 monthly for patients with aneurysms 4.5-5.4cm

> 5.5: refer within 2 weeks for surgery

Question 15

Elective repair is offered for AAA patients who have:

Answer 15

Symptomatic aneurysm
Diameter growing more than 1cm per year
Diameter above 5.5cm

Question 16

DVLA for AAA patients

Answer 16

Inform the DVLA if they have an aneurysm above 6cm
Stop driving if it is above 6.5cm

Question 17

Ruptured AAA signs and Sx

Answer 17

Severe abdominal pain that may radiate to the back or groin
Haemodynamic instability (hypotension and tachycardia)
Pulsatile and expansile mass in the abdomen
Collapse
Loss of consciousness

Question 18

Ruptured AAA managed in stable/unstable Pts:

Answer 18

Unstable: IMMEDIATE surgical repair

Stable: CT angiogram to diagnose rupture AAA before surgical repair