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Cardio > Aneurysm surgery > Flashcards

Aneurysm surgery Flashcards

1
Q

What is aneurysm disease?

A

Dilation of all layers of the aorta, leading to an increase in diameter of at least 50%

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2
Q

How big does the aorta need to be before it is considered an aneurysm?

A

> 3.5cm

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3
Q

Where on the aorta can an abdominal aortic aneurysm take place?

A

95% are infrarenal

Between the branching of the left & right renal arteries and the bifurcation into the common Iliac arteries

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4
Q

What arteries branch off the aorta in the section in which AAA’s can be located?

A

Superior mesenteric artery (leaves at roughly the same level as the renal arteries)

Inferior mesenteric artery (about half way in between the renal branches & the Iliac bifurcation)

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5
Q

What are the 3 layers of an artery?

A

Tunica intima
Tunica media
Tunica externa

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6
Q

Where are the internal and external elastic membranes found?

A

Internal - Between the intima & media

External - Between the media & externa

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7
Q

What are the non modifiable risk factors for abdominal aortic aneurysm?

A

Male gender
Being old
Strong family history
CT diseases - Marfan’s, Ehlers-Danlos syndrome)

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8
Q

What are non-modifiable risk factors or secondary causes of AAAs?

A

Hypertension
Hypercholesterolaemia
Smoking

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9
Q

What diseases n shite can cause AAA’s?

A

Atherosclerosis

Infection (mycotic) - Syphilis, Ecoli, Salmonella

Trauma

Marfan’s, Ehlers-Danlos syndrome

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10
Q

Give an example of a connective tissue disease that would cause aneurysms

A

Marfan’s syndrome

what Michael Phelps has - fun fact

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11
Q

Give an example of an aneurysm that is associated with infection

What group of people is most likely to get this sort of infection?

A

Mycotic aneurysm

Caused by injection with non sterile needles - infection

Injected drug users often get mycotic aneurysms

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12
Q

What are the risk factors for degenerative AAA disease?

A 
Male 
Elderly 
Smoker 
Hypertension 
Family history
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13
Q

Why is family history an important risk factor for degenerative AAA?

A

Prevalence of 30% in 1st degree male relatives

basically, if a man has a DAAA then his son has a 30% of also having a DAAA in his lifetime

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14
Q

How common is AAA in the UK?

A

3% prevalence

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15
Q

Aneurysms often present as asymptomatic

How are they identified?

A

Examination (for something else)

Identified as at risk on family tree and then found on investigation

Incidental finding on imaging (CT etc)

Screening programme for AAA

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16
Q

What are the 2 main criteria for the AAA screening programme?

A

1) Age 65 and above

2) Male

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17
Q

What imaging does the screening programme use?

A

An ultrasound scan

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18
Q

What are the 4 screening programmes in the uk?

A

Breast cancer
Cervical cancer
Bowel cancer

Aortic aneurysm

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19
Q

List the criteria to be considered for a screening programme to be introduced

A 
Definable disease 
Prevalence
Severity of the disease 
Natural history 
Reliable detection 
Early detection confers advantage 
Treatable 
Cost 
Feasibility 
Acceptability
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20
Q

For screening:

Why must the disease be definable?

A

Got to to know what we’re looking for

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21
Q

For screening:

Why is prevalence important?

A

The disease has got to be common enough for a screening programme to be worth doing

If some spicy disease only affects 1 in 200 million people, a multimillion pound screening programme is pointless

22
Q

For screening:

Why must the disease be severe?

A

Screening programmes aim to stop people dying

If it’s not severe enough to kill people, then there’s no point investing money into preventing it

23
Q

For screening:

Why is natural history important?

A

Screening programmes aim to detect the early stage of a disease, providing the disease ‘naturally’ progresses to become worse

24
Q

For screening:

Why must detecting the disease early be advantageous & why must treatment options be available?

A

What the point in having a screening programme for something which can’t be cured once theyve found it

If spicy disease X is only detectable when it’s probably going to kill the person then screening serves no benefit to society

25
Q

For screening:

What is meant by cost & feasibility?

A

Economically, the screening programme must save money

The costs of:
(screening programme + early treatment must be < cost of treating patients with late disease + loss to society)

So it must be cheap enough to actually save money overall, and feasible enough to introduce

26
Q

For screening:

What does acceptability mean?

A

How acceptable the screening is:

How invasive/uncomfortable it is & whether or not the public are willing to have it done

27
Q

Screening programmes must be specific & sensitive

What does this mean?

A

Must be specific to the disease they are screening for & only pick that up (no false +ves etc)

Must be sensitive enough to pick up on the disease in an early enough stage that treatment is beneficial

28
Q

Describe the outcomes of screening for AAA

A

Depends on size of aneurysm:

A) Normal aorta:
- discharge

B) Small AAA (3.0 - 4.0 cm):
- Invited for annual USS scans

C) Medium AAA (4.5 - 5.5cm):
- Invited for 3 monthly USS scans

D) Large AAA ( > 5.5cm ):
- Urgent referral to vascular surgeon

29
Q

Someone with symptomatic AAA has either got an impending rupture or there aorta has already ruptured

How would a patient with an impending rupture present?

A

Increasing back pain

Tended AAA

CT scan shows ‘stranding’ on the aortic wall

30
Q

How would someone with a ruptured aneurysm present?

A

Severe abdominal/back/flank pain

Shock

Painful pulsatile mass

Haemodynamic instability (single episode or progressive)

Hypoperfusion

31
Q

AAA’s can present unusually

How can they present unusually?

A

Distal embolisation (black toes due to small emboli trapped in small vessels)

Aortocaval fistula

Aortoenteric fistula

Ureteric occlusion

Duodenal obstruction

32
Q

What must you consider for the management of asymptomatic aneurysms?

A

1) Is it big enough to need repaired?
2) Is the patient a candidate for repair?
3) Is the aneurysm suitable for endovascular or open repair?

33
Q

The UK small aneurysm trial (Lancet, 1998) gives evidence about when an aneurysm becomes big enough to need repaired

What was the outcome of this trial?

A

Surgery did not confer any benefit (eg survival) for aneurysms less than 5.5 cm

Basically - only operate on aneurysms that are > 5.5 cm

34
Q

How do you determine whether or not a patient is fit enough for surgery for an AAA?

A

Full history + examination

End of bed test

ECG
ECHO 
PFTs 
MPS
CPEX 
Patient preference
35
Q

When assessing an AAA to decide on what type of surgery

What are 2 imaging routes that can be taken?

A

Ultrasound

CTA / MRA

36
Q

What are the benefits and problems with CTA / MRA assessment of an AAA?

A

Quick
Not operator dependant
Necessary for surgical planning - gives detailed anatomy/image

However, uses contrast and radiation

Contrasts pose risks such as renal failure

37
Q

What is conservative treatment?

A

When the patient/aneurysm is not fit for repair

Surgery only done in the event of a rupture (emergency)

38
Q

What is the basic difference between open repair and endovascular repair?

A

Open repair = big incision to open up abdomen

Endovascular (EVAR) = minimally invasive operation doing up through the groin using mad special instruments

39
Q

What are general complications involved with open repair?

A

Infection /dehiscence
Bleeding
Pain
Scar

40
Q

What are technical complications involved with open repair?

A

Damage to bowel, ureters, veins, nerves

Incisional hernia

Graft infection

Distal emboli

Renal failure

Colonic ischaemia

41
Q

What are the patient factor complications associated with open repair surgery?

A

Deep vein thrombosis / pulmonary embolism

Myocardial infarction

Stroke

Death

42
Q

What general complications can happen in endovascular repair surgery (EVAR)?

Compare this to open repair

A

Infection
Bleeding / haematoma
Pain
Scar

Contrast - reaction/kidney injury
Radiation

EVAR done under guidance from CT/contrasts so has risks associated with those whereas open surgery does not use CT

43
Q

What technical complications can happen during endovascular repair surgery (EVAR)?

A

Endoleak

Femoral artery dissection/pseudoaneurysm

Rupture

Distal emboli or ischaemia / colonic ischaemia

Damage to femoral vein / nerve

44
Q

Compare the relative risk of EVAR and open surgery

A

EVAR has lower short term mortality than open surgery

Long term mortality is roughly the same

EVAR also has shorter hospital stays

45
Q

What type of endoleak is most common?

A

Type 2

46
Q

In basics, what is an endoleak?

A

Blood leaking out of the graft/stent thing

47
Q

Which is better

EVAR or Open repair?

A

Neither

Which one you use depends on ‘which set of compromises best fits your patient’

48
Q

Which type of AAA repair surgery is carried out in emergency situations?

A

Both EVAR and open repair

49
Q

Describe the process of an Emergency open repair

A

Prep abdomen & give rapid anaesthetic

Laparotomy xiphisternum to pubic symphysis (literally a giant cut down their abdomen)

Occlude the aorta proximally

Carry out repair

50
Q

What are the problems associated with an emergency open repair?

A

High mortality (30-50%)

Significant post op morbidity

Cardio (41 decks)

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