Aneurysm + Dissection Flashcards
What is an aneurysm and where common
Permanent dilatation of all layers of artery >50%
Caused by weakening of vessel wall
Normal =2cm
Aneurysm >3cm
Common - aorta (infra-renal), iliac, femoral, popliteal
What is a true aneurysm (fusiform vs saccular)
All 3 layers affected - intima (endothelium), media (smooth muscle) affected most, adventitia (connective tissue)
Fusiform = both sides bulge
Saccular = one side (also known as berry)
What is a false aneurysm
After trauma / dissection haematoma forms contained in layers which pushes extrernal wall of artery out
What causes AAA
Degenerative = most causes
Connective tissue - Marfan’s / Ehlers Danlos)
Infection (syphillis) - mycotic
Inflammation / vasculitis - Takayasu arhtritis
Trauma
Congenital - biscupid
What are the RF for AAA
Same as PAD Male Age Smoking Hypertension Atherosclerosis Collagen abnormality FH
What are the symptoms of AAA
Asymptomatic Expansile pulsatile mass Bruit may be heard Symptoms suggest impending rupture Increased back pain as enlarges Strands of fat on CT
What are the symptoms of rupture AAA
30% mortality pre-hospital Abdominal pain Flank pain Painful pulsatile mass Distended abdomen Hypo-tension Tachycardia SOB Dysphagia Confusion Cold Decreased urine Haemodynamic instability
What are unusual complications of AAA
Distal embolisation Aortacaval fistula Aortaenteric fistula Pressure on other structures Ureteric occlusion Duodenal obstruction
How do you screen for AAA and how else would you Dx
USS men >65 single abdo USS
90% will be infra-renal
AXR may show calcifcaiton
CT/ MRI = gold standard
What are the outcomes of screening
<3 = no further Small (3-4.4) = annual USS Medium (4.5-5.5) = 3 monthly Large >5.5 or expanding >1cm / year or symptomatic e.g. back pain = clinic as 15% rupture risk If >8cm = 30-50% rupture risk
How do you Dx rupture and Rx
Rapid ABCDE CT but don't waste time if unstable X-ray = widened mediastinum Inform anaethetist and vascular surgeon Prophylactic Ax Open or EVAR
How do you treat aneurysm
Modify cardiac RF
- Stop smoking / statin / BP etc
Offer surgery >5.5cm or if >1cm per year
- EVAR or open
What are general risks of surgery
Infection Bleeding Pain Scar Embolization MI, stroke, DVT Mortality
What are specific risks of EVAR and open
EVAR Endo-leak - enlargeing aneurysm Emboli Contrast Colonic ischaemia as IMA lose blood
Open
Colonic ischaemic
Renal failure if artery damaged
What are surgical options
EVAR
Open surgery - better for younger fitter patient
What is EVAR
Access from femoral artery and put in stent
Use LA
Need surveillance to check for leaks
What does open surgery involve
Open aneurysm sac - midline laparotomy Clamp aorta and common iliac Put graft in at top and bottom Blood transfusion High mortality
What are the symptoms of thoracic anueysrm
SOB HF Dysphagia Sharp chest pain Query dissection Pulsatile mass Hypotension Hoarse voice - if L recurrent nerve damaged as goes round back of arch of aorta
What is aortic dissection
Tear of the inner wall of aorta (intima) causing propagation as high pressure forces walls apart and blood tracks creating a false lumen
What is type A
Ascending aorta involved
What is type B
Descending aorta
Distal to subclavian
When does aorta cross diaphragm
T12
What are the symptoms of aortic dissection
Severe tearing chest pain radiating to back Abrupt onset Collapse due to hypo if tamponade Reduced pulses BP mismatch Absent subclavian Hypertension due to adrenaline Pulmonary oedema NEW diastolic murmur - AR Can present like HF May have paraplegia if affects spinal
What are RF for dissection
Hypertension
Atherosclerosis
Trauma
Same as PAD +
Rarer Bicuspid valve Marfan / Turner / Noonan Syphillis 3rd trimester
How do you Dx
Bloods - troponin, baseline, X-match, G+S, clotting
CXR = widened mediastinum
ECG - unlikely to show change may see inferior ST II, III, aVF
CT = diagnostic but not suitable if unstable
TOE if unstable
CT angiography
>20mm pulse pressure diff
How do you treat type A
If unstable = ABCDE
HDU
Consider surgery in all - aortic root repair (endovascular or open)
BP control with BB and analgesia in all cases
BB
Na nitroprusside
How do you treat type B
HDU
Consider surgery if end organ ischaemia or failure of medical
Best rest
BP control
BB - IV labetalol to prevent progression = 1st line + analgesia = 1st line
Analgesia
If BP / HR not controlled Vasodilators Na nitroprusside GTN Stent or graft if renal
What are the complications of dissection
Cardiac tamponade if rupture externally Neuro symptoms if carotid MI / angina if extend proximal Paraplegia if spinal Limb ischaemia if distal Renal failure if renal artery affected Aortic regurgitation
How does a false aneurysm present
Thrill Bruit Pulsatile mass Ischaemia Risk of rupture
Anatomy
Aorta cross diaphragm at T12 Inferior phrenic – T12 Suprarenal Lumbar arteries at L1, L2 etc SMA = L1 R renal (behind IVC) L renal Gonadal IMA = L3 Aorta branch at L4/L5 into R+L common iliac External and internal iliac Median sacral
What is rupture till proven otherwise
Shock and back pain
What is found on examination of AAA
Expansile mass above umbilicus
When should you always consider ruptured aneurysm
Renal colic
How does aorta ulcer present
Similar to dissection
Treat as this
What does ECG show in dissection
ST elevation in II, III, avF if thoracic and RCA involved
Diff from ACS as back pain + normal vital signs
If>5.5cm what should you do
Refer to vascular specialist 2 weeks
What do you do if 3.5-5.5cm
Refer to be seen in 12 weeks
3 month USS
What investigation if present with back pain
USS for AAA even if haem-dynamic unstable
What do you do after
CT if think rupture
What do you do if ruptured AAA
ECG Blood - Hb, X-match Cathterise IV access Resus Theatre to clamp Prophylaxic Ax
What does cardiac syphillis cause
AAA
Dissection
AR
How does Takaysau arthritis present
Large vessel vasculitis Sx - fever / malaise Stenosis - renal artery Thrombosis Aneurysms Aortic regard Hypertension Heart faiure Stroke Vascular insufficiency - Absent pulses - Intermittent claudication - Unequal BP in UL - Carotid bruit
How do you treat
Steroid
Treat complications
What does congenital bicuspid valve cause
Cortication
Aneurysm
Dissection
Stensosi / regurg
How do you monitor
ECHO / MRI
Low threshold for surgery
How does co-arctation present in infancy
Heart failure
How does it present in adult
Hypertension
Radio-femoral delay if after subclavian branches
Mid-systolic murmur
Notching of ribs
What is associated
Turner
Bicuspid
Berry aneurysm
NF
