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CVS > Aneurysm + Dissection > Flashcards

Aneurysm + Dissection Flashcards

1
Q

What is an aneurysm and where common

A

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

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2
Q

What is a true aneurysm (fusiform vs saccular)

A

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)

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3
Q

What is a false aneurysm

A

After trauma / dissection haematoma forms contained in layers which pushes extrernal wall of artery out

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4
Q

What causes AAA

A

Degenerative = most causes
Connective tissue - Marfan’s / Ehlers Danlos)
Infection (syphillis) - mycotic
Inflammation / vasculitis - Takayasu arhtritis
Trauma
Congenital - biscupid

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5
Q

What are the RF for AAA

A 
Same as PAD 
Male
Age
Smoking
Hypertension
Atherosclerosis
Collagen abnormality
FH
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6
Q

What are the symptoms of AAA

A 
Asymptomatic 
Expansile pulsatile mass 
Bruit may be heard 
Symptoms suggest impending rupture 
Increased back pain as enlarges
Strands of fat on CT
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7
Q

What are the symptoms of rupture AAA

A 
30% mortality pre-hospital
Abdominal pain
Flank pain
Painful pulsatile mass
Distended abdomen
Hypo-tension
Tachycardia 
SOB
Dysphagia 
Confusion
Cold 
Decreased urine 
Haemodynamic instability
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8
Q

What are unusual complications of AAA

A 
Distal embolisation 
Aortacaval fistula 
Aortaenteric fistula
Pressure on other structures 
Ureteric occlusion
Duodenal obstruction
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9
Q

How do you screen for AAA and how else would you Dx

A

USS men >65 single abdo USS
90% will be infra-renal

AXR may show calcifcaiton
CT/ MRI = gold standard

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10
Q

What are the outcomes of screening

A 
<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
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11
Q

How do you Dx rupture and Rx

A 
Rapid ABCDE 
CT but don't waste time if unstable
X-ray = widened mediastinum
Inform anaethetist and vascular surgeon
Prophylactic Ax
Open or EVAR
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12
Q

How do you treat aneurysm

A

Modify cardiac RF
- Stop smoking / statin / BP etc
Offer surgery >5.5cm or if >1cm per year
- EVAR or open

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13
Q

What are general risks of surgery

A 
Infection 
Bleeding
Pain
Scar
Embolization
MI, stroke, DVT
Mortality
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14
Q

What are specific risks of EVAR and open

A 
EVAR
Endo-leak - enlargeing aneurysm 
Emboli 
Contrast 
Colonic ischaemia as IMA lose blood

Open
Colonic ischaemic
Renal failure if artery damaged

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15
Q

What are surgical options

A

EVAR

Open surgery - better for younger fitter patient

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16
Q

What is EVAR

A

Access from femoral artery and put in stent
Use LA
Need surveillance to check for leaks

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17
Q

What does open surgery involve

A 
Open aneurysm sac - midline laparotomy
Clamp aorta and common iliac 
Put graft in at top and bottom
Blood transfusion
High mortality
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18
Q

What are the symptoms of thoracic anueysrm

A 
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
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19
Q

What is aortic dissection

A

Tear of the inner wall of aorta (intima) causing propagation as high pressure forces walls apart and blood tracks creating a false lumen

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20
Q

What is type A

A

Ascending aorta involved

21
Q

What is type B

A

Descending aorta

Distal to subclavian

22
Q

When does aorta cross diaphragm

A

T12

23
Q

What are the symptoms of aortic dissection

A 
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
24
Q

What are RF for dissection

A

Hypertension
Atherosclerosis
Trauma
Same as PAD +

Rarer 
Bicuspid valve
Marfan / Turner / Noonan
Syphillis 
3rd trimester
25
Q

How do you Dx

A

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

26
Q

How do you treat type A

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

27
Q

How do you treat type B

A

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
28
Q

What are the complications of dissection

A 
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
29
Q

How does a false aneurysm present

A 
Thrill
Bruit
Pulsatile mass
Ischaemia
Risk of rupture
30
Q

Anatomy

A 
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
31
Q

What is rupture till proven otherwise

A

Shock and back pain

32
Q

What is found on examination of AAA

A

Expansile mass above umbilicus

33
Q

When should you always consider ruptured aneurysm

A

Renal colic

34
Q

How does aorta ulcer present

A

Similar to dissection

Treat as this

35
Q

What does ECG show in dissection

A

ST elevation in II, III, avF if thoracic and RCA involved

Diff from ACS as back pain + normal vital signs

36
Q

If>5.5cm what should you do

A

Refer to vascular specialist 2 weeks

37
Q

What do you do if 3.5-5.5cm

A

Refer to be seen in 12 weeks

3 month USS

38
Q

What investigation if present with back pain

A

USS for AAA even if haem-dynamic unstable

39
Q

What do you do after

A

CT if think rupture

40
Q

What do you do if ruptured AAA

A 
ECG 
Blood - Hb, X-match
Cathterise 
IV access 
Resus
Theatre to clamp 
Prophylaxic Ax
41
Q

What does cardiac syphillis cause

A

AAA
Dissection
AR

42
Q

How does Takaysau arthritis present

A 
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
43
Q

How do you treat

A

Steroid

Treat complications

44
Q

What does congenital bicuspid valve cause

A

Cortication
Aneurysm
Dissection
Stensosi / regurg

45
Q

How do you monitor

A

ECHO / MRI

Low threshold for surgery

46
Q

How does co-arctation present in infancy

A

Heart failure

47
Q

How does it present in adult

A

Hypertension
Radio-femoral delay if after subclavian branches
Mid-systolic murmur
Notching of ribs

48
Q

What is associated

A

Turner
Bicuspid
Berry aneurysm
NF

CVS (30 decks)

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