Aneurysm Presentation, Investigation and Therapy Flashcards
What is an aneurysm?
When an artery exceeds 3cm or is over 50% of the normal size
What are the kinds of aneurysm?
Fusiform
Saccular
When is there an increased prevalence of aneurysm?
Men aged > 65 Male sex Smoking Chronic obstructive airway disease Hypertension Peripheral vascular disease Ischaemic heart disease Family history
What is the typical presentation of an aneurysm?
May be asymptomatic and found incidentally on examination or ultrasound
Emergency presentation with impeding or actual rupture - severe sudden onset back pain
What are some unusual presentations of aneurysm?
Aortic occlusion Distal embolisation Ureteric occlusion Aortocaval fistula Duodenal obstruction
What is the risk of rupture of an aneurysm < 5.5cm, and > 6cm
1% risk of rupture per year when < 5.5cm
10% risk of rupture per year when > 6cm
When is surgery considered in aortic aneurysms?
4.5-5cm and larger
At what point is surgery to correct an aortic aneurysm advantageous?
When > 5cm
What is the 30 day operative mortality of an aneurysm of 4.5-5cm?
5.8%
What investigations are necessary when considering surgical repair of an aortic aneurysm?
PMH Cardiac and respiratory fitness Routine bloods ECG Echo Cardiac perfusion scan CXR PFTs CT abdomen
What is the main hazard in abdominal aortic aneurysm operations?
Sudden changes in circulatory haemodynamics due to aortic cross-clamping or blood loss
What are the potential post-operative complications of an abdominal aortic aneurysm operation?
Haemorrhage Cardiac complications (6.6-12% Colonic ischaemia in 33% of ruptured AAA Infected grafts Aorto-duodenal fistula
What percentage of patients will get a post-operative graft infection? What is the mortality of this infection?
Infected grafts in 1% with over 50% mortality
How is an infected graft treated?
Graft removal and antibiotics
What should be assumed in all patients > 60 years with new onset renal colic?
Patient has a symptomatic AAA
What kind of shock do patients with a ruptured AAA normally have?
Hypovolaemic shock
What is the rupture mortality of an AAA?
60% community
50% operative
80-90% overall
What should be done in the immediate management of a ruptured AAA?
Diagnosis with clinical history and examination CXR to exclude thoracic component US or CT if unclear Restrict fluids Urgent cross-match Coagulation screen FBC U&Es Straight to theatre Prep patient prior to anaesthetic
What are the general issues with screening for AAA?
Definable disease Prevalence Severity of disease Natural history Reliable and early detection Appropriate treatment Cost Feasibility Acceptability
What screening is offered for AAA in Scotland? When was this started?
All men aged 65 are offered an ultrasound scan
Started in Scotland in 2012
What are the advantages of endovascular repair of AAA?
Less invasive, shorter hospital stay
Reduced systemic complications
Feasible and reasonably safe
Clinically effective on short-term follow up
Continuing improvement in technique and devices
More patients likely to become suitable
What are the disadvantages of endovascular repair of AAA?
Endoleak Possible fragmentation of device Migration of endovascular stent Only 50% of patients are suitable Durability of stents unknown Long-term follow-up required
What patients should EVAR not be offered to?
Young fit patients or very old unfit patients
How many patients in the UK have > 70% symptomatic stenosis of the internal carotid artery which is amenable to surgery?
160 per million
What investigations can be done for suspected stenosis of the internal carotid artery?
Duplex
MRA
CTA
Angiogram
What needs to be explained to the patient when gaining consent for a carotid endarterectomy?
Emphasise that it is a prophylactic operation
Discuss likelihood of a further neurological event with best medical therapy
Explain fully the risks
Risk-benefit analysis
What number of patients receiving carotid endarterectomies is needed to prevent one stroke?
9-12 patients
What are the potential complications of carotid endarterectomy?
Major stroke/death 3% Overall neurological events 6% Neck haematoma 5.5% Cranial nerve injuries - 7% permanent MI 1%
When should you consider a carotid endarterectomy?
Over 70% stenosis of internal carotid artery
Symptomatic carotid artery disease
Retained cognitive function
