Aneurysm Presentation, Investigation and Therapy

Question 1

What is an aneurysm?

Answer 1

When an artery exceeds 3cm or is over 50% of the normal size

Question 2

What are the kinds of aneurysm?

Answer 2

Fusiform

Saccular

Question 3

When is there an increased prevalence of aneurysm?

Answer 3

Men aged > 65 
Male sex
Smoking 
Chronic obstructive airway disease 
Hypertension
Peripheral vascular disease
Ischaemic heart disease
Family history

Question 4

What is the typical presentation of an aneurysm?

Answer 4

May be asymptomatic and found incidentally on examination or ultrasound

Emergency presentation with impeding or actual rupture - severe sudden onset back pain

Question 5

What are some unusual presentations of aneurysm?

Answer 5

Aortic occlusion
Distal embolisation
Ureteric occlusion
Aortocaval fistula
Duodenal obstruction

Question 6

What is the risk of rupture of an aneurysm < 5.5cm, and > 6cm

Answer 6

1% risk of rupture per year when < 5.5cm

10% risk of rupture per year when > 6cm

Question 7

When is surgery considered in aortic aneurysms?

Answer 7

4.5-5cm and larger

Question 8

At what point is surgery to correct an aortic aneurysm advantageous?

Answer 8

When > 5cm

Question 9

What is the 30 day operative mortality of an aneurysm of 4.5-5cm?

Answer 9

5.8%

Question 10

What investigations are necessary when considering surgical repair of an aortic aneurysm?

Answer 10

PMH
Cardiac and respiratory fitness
Routine bloods
ECG 
Echo 
Cardiac perfusion scan 
CXR 
PFTs
CT abdomen

Question 11

What is the main hazard in abdominal aortic aneurysm operations?

Answer 11

Sudden changes in circulatory haemodynamics due to aortic cross-clamping or blood loss

Question 12

What are the potential post-operative complications of an abdominal aortic aneurysm operation?

Answer 12

Haemorrhage
Cardiac complications (6.6-12%
Colonic ischaemia in 33% of ruptured AAA
Infected grafts
Aorto-duodenal fistula

Question 13

What percentage of patients will get a post-operative graft infection? What is the mortality of this infection?

Answer 13

Infected grafts in 1% with over 50% mortality

Question 14

How is an infected graft treated?

Answer 14

Graft removal and antibiotics

Question 15

What should be assumed in all patients > 60 years with new onset renal colic?

Answer 15

Patient has a symptomatic AAA

Question 16

What kind of shock do patients with a ruptured AAA normally have?

Answer 16

Hypovolaemic shock

Question 17

What is the rupture mortality of an AAA?

Answer 17

60% community
50% operative
80-90% overall

Question 18

What should be done in the immediate management of a ruptured AAA?

Answer 18

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

Question 19

What are the general issues with screening for AAA?

Answer 19

Definable disease
Prevalence
Severity of disease
Natural history 
Reliable and early detection 
Appropriate treatment 
Cost
Feasibility 
Acceptability

Question 20

What screening is offered for AAA in Scotland? When was this started?

Answer 20

All men aged 65 are offered an ultrasound scan

Started in Scotland in 2012

Question 21

What are the advantages of endovascular repair of AAA?

Answer 21

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

Question 22

What are the disadvantages of endovascular repair of AAA?

Answer 22

Endoleak
Possible fragmentation of device
Migration of endovascular stent
Only 50% of patients are suitable 
Durability of stents unknown 
Long-term follow-up required

Question 23

What patients should EVAR not be offered to?

Answer 23

Young fit patients or very old unfit patients

Question 24

How many patients in the UK have > 70% symptomatic stenosis of the internal carotid artery which is amenable to surgery?

Answer 24

160 per million

Question 25

What investigations can be done for suspected stenosis of the internal carotid artery?

Answer 25

Duplex
MRA
CTA
Angiogram

Question 26

What needs to be explained to the patient when gaining consent for a carotid endarterectomy?

Answer 26

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

Question 27

What number of patients receiving carotid endarterectomies is needed to prevent one stroke?

Answer 27

9-12 patients

Question 28

What are the potential complications of carotid endarterectomy?

Answer 28

Major stroke/death 3% 
Overall neurological events 6% 
Neck haematoma 5.5%
Cranial nerve injuries - 7% permanent 
MI 1%

Question 29

When should you consider a carotid endarterectomy?

Answer 29

Over 70% stenosis of internal carotid artery
Symptomatic carotid artery disease
Retained cognitive function