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Cardiovascular: arterial disease > Aneurysmal Disease > Flashcards

Aneurysmal Disease Flashcards

1
Q

An artery with a dilatation > ___% of its original diameter has an aneurysm.

A

An artery with a dilatation > 50% of its original diameter has an aneurysm.

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2
Q

what is a true aneurysm?

A

abnormal dilatations that involve all layers of the arterial wall

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3
Q

what is a false aneurysm?

A

involve a collection of blood in the outer layer only (adventitia) which communicates with the lumen (eg after trauma). These can be very worrying if they rupture.

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4
Q

what is a fusiform aneurysm?

A

spindle shaped - most AAAa are fusiform

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5
Q

what are the three categories of aneurysm shape?

A
  • fusiform
  • sacular (eg berry aneurysms)
  • myototic- rare
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6
Q

how do myctotic aneurysms arise?

A

they arise secondary to an infectious process, involving all three layers of the artery. The artery expands rapidly because of the infection damage e.g in endocarditis or tertiary syphilis

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7
Q

where do most aneurysms occur? 4

A

aorta (infra-renal mot common)

iliac

femoral

popliteal

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8
Q

AAA:

  • They occur _ times more frequently in men and in one in _ male children of an affected individual.
  • Aneurysms may occur secondary to_____, _____
A
  • They occur 5 times more frequently in men and in one in 4 male children of an affected individual.
  • Aneurysms may occur secondary to atherosclerosis (bit iffy now though) , infection
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9
Q

what are the causes of AAA?

A

medial degeneration

  • there is an imbalance in the proteins of the vessel wall.
  • aneurysmal dilatation
  • increase in aortic wall stress
  • marfans syndrome
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10
Q

imbalance of proteins in the vessels wall - AAA
The problem is most likely due to impairment in the regulation of ____/_____ in the aortic wall and other enzymes
- _________ imbalance
Treatment of aneurysm could involve something that switches off this __________

A

The problem is most likely due to impairment in the regulation of elastin/collagen in the aortic wall and other enzymes

  • metalloproteinase 9 imbalance
  • Treatment of aneurysm could involve something that switches off this metalloproteinase
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11
Q

what are he risk factors for AAA?

A

age, smoking, male, hypertension

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12
Q

what are some complications of AAA

A

Rupture, thrombosis, embolism, fistulae, pressure on other structures

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13
Q

Elective aneurysm repair is a ______ operation to reduce the risk of____ balanced against the risk of the ______

A

Elective aneurysm repair is a prophylactic operation to reduce the risk of rupture balanced against the risk of the procedure

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14
Q

what are the two options for surgery of AAA?

A

1- EVAR - endovascular aneurysm repair)

2. open repair

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15
Q

what is EVAR?

A
  • exclude AAA from ‘inside the vessel
  • inserted via the peripheral arteries
  • It is X-ray guided
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16
Q

how is open repair done for AAA?

A
  • laparotomy

- clamp aorta and iliacs and insert dacron graft. Can use a tube or bifurcated graft

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17
Q

EVAR is not possible in __% of patients

A

25%

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18
Q

what are the benefits of EVAR vs open repair?

A

EVAR : Less mortality risk (2-4%)
(Far safer in complex aneurysms)
Much faster recovery (7-10 /7)

open repair:

  • Once recovered can forget
  • Rare further interventions
  • Known to be effective for life
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19
Q

what are the symptoms of unruptured AAA?

A

Most are asymptomatic: they are identified on imaging for other pathologies

Roughly a quarter are symptomatic
may cause abdominal/back pain,

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20
Q

what are the signs of unruptured AAA?

A

An aneurysm is suspected if a pulsatile, expansile abdominal mass is felt

Patients may present with ‘trash feet’ which is dusky discolouration of the digits secondary to emboli from the aortic thrombus

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21
Q

how is an AAA first investigated?

A

by ultrasound

22
Q

what does ultrasound for AAA allow you to assess?

A

this allows you to assess diameter and involvement of the iliac arteries

23
Q

which imaging technique used for AAA is more accurate and relates the anatomical relationship to the renal and visceral vessels ?

A

CT

with contrast. Allows you to assess aneurysm morphology eg shape, size and iliac involvement

24
Q

what is the only method of imaging to identify ruptured AAA?

A

CT

25
Q

what size must an AAA be before it is operated on?

A

size: over 5.5 AP diameter

if it is not fixed at this point the aneurysm tends to expand quicker past this diameter

26
Q

what expansion must an AAA present with before it is operated on?

A

over 0.5 in 6 months or over 1cm in 1 year

27
Q

what is the other thing that means AAA should be operated on?

A

symptomatic

28
Q

what things are needed for fitness of intervention

A
  1. cardiac assessment - Echo/Ejection fraction
  2. Respiratory assessment - PFT
  3. Cardiopulmonary eercise test - CPX testing
  4. Renal assessmet - U and E
  5. Vascular assessment - peripheral pulses / ABPI
  6. Anaesthetic assessment
  7. EBT- ‘End of bed or eyeball test’
29
Q

what is important to modify at time of diagnosis of AAA?

A

risk factors - to prevent rupture

30
Q

what are the symptoms of ruptured AAA?

A

severe pain - epigastric pain radiating to the back, iliac fossae or groins - this should not be dismissed as renal colic

31
Q

what are the signs of ruptured AAA?

A
  • an expansile abdominal mass

- may cause Hypotension, tachycardia, tachypnoea, profound anaemia and sudden death

32
Q

Treatment for ruptured AAA

  1. Summon a vascular surgeon and an experienced anaesthetist
  2. Do an __, and take blood for amylase, Hb, crossmatch. Catheterise the bladder
  3. Gain IV access. Treat shock with ORh- ve blood (if desperate) but keep systolic BP less that __ to avoid ___ a contained leak ( NB: __ BP is common early on)
  4. take the patient straight to theatre.
  5. Give prophylactic __
  6. Surgery involves clamping the __ above the leak and inserting a __ __ (eg tube graft) or, if significant iliac aneurysm also a trouser graft with each ‘leg’ attached to an iliac artery
A
  1. Summon a vascular surgeon and an experienced anaesthetist
  2. Do an ECG, and take blood for amylase, Hb, crossmatch. Catheterise the bladder
  3. Gain IV access. Treat shock with ORh- ve blood (if desperate) but keep systolic BP less that 100mmHg to avoid rupturing a contained leak ( NB: raised BP is common early on)
  4. take the patient straight to theatre. Don’t waste time on X-rays.
  5. Give prophylactic antibiotics
  6. Surgery involves clamping the aorta above the leak and inserting a dacron graft (eg tube graft or, if significant iliac aneurysm also a trouser graft with each ‘leg’ attached to an iliac artery
33
Q

The ascending, arch or descending aorta may become aneurysmal. Ascending TAAs occur most commonly in ______ or_____.

A

The ascending, arch or descending aorta may become aneurysmal. Ascending TAAs occur most commonly in marfan’s syndrome or hypertension.

34
Q

Descending or arch TAAs occur secondary to ____ and are now rarely due to ____.

A

Descending or arch TAAs occur secondary to atherosclerosis and are now rarely due to syphilis.

35
Q

what are the symptoms of TAA?

A
  • Most are assymptomatic and are found on routine CXR or cardiologic investigation.
  • rapid expansion may cause severe chest pain (chest pain radiating to the upper back)
36
Q

what are the signs of TAA?

A
  • rupture is often associated with hypotension, tachycardia and death
  • chest symptoms from expansion may include stridor (compressed bronchial tree), haemoptysis (aortobronchial fistula) and hoarseness (compression of the recurrent laryngeal nerve)
37
Q

what investigations should be done for TAA?

A

CT scan

aortography

transoesophageal echocardiography

38
Q

why would an aortography be useful for TAA?

A

may be used to assess the position of the key bracnches in relation to the aneurysm

39
Q

If TA aneurysm is >___ then operative ___ or _____ may be appropriate, but these can technically be difficult and carry high mortality risk

A

If aneurysm is >6cm then operative repair or stenting may be appropriate, but these can technically be difficult and carry high mortality risk

40
Q

____ is te 1st line procedure in isolated descending thoracic aneurysms

A

EVAR

41
Q

what is aortic dissection?

A

where the blood splits the aortic media

42
Q

what is a type A dissection?

A

involving the aortic arch and the ascending aorta irrespective of the site of tear

43
Q

what is a type B dissection?

A

if the ascending aorta is not involved

44
Q

what are the symptoms of dissection?

A
  • severe and central chest pain (± radiation to the back and down arms ) mimicking MI
  • may have neurological symptoms secondary to loss of blood supply to the spinal cord
  • they may develop renal failure, acute lower limb ischaemia
45
Q

what are the signs of dissection?

A

As the dissection extends, branches of the aorta occlude sequentially leading to hemiplegia (carotid artery), unequal arm pulses and BP or acute limb ischaemia, paraplegia (anterior spinal artery) and anuria (renal arteries)

peripheral pulses may be absent

46
Q

what investigations should be done?

A

CXR, DO CT or transoesophageal echocardiography

47
Q

All patients with type __ dissection should be considered for surgery

A

All patients with type A should be considered for surgery

48
Q

definitive treatment for type _ is less clear and may be managed medically, with surgery reserved for distal dissections that are _____, _____ or compromising ____ _____

A

definitive treatment for type B is less clear and may be managed medically, with surgery reserved for distal dissections that are leaking, ruptured or compromising vital organs

49
Q

management of dissection:

  1. crossmatch 10ublood
  2. ECG and CXR
  3. CT/MRI or transoesophageal echocardiography (TOE)
  4. take to ITU
  5. hypotensives: keep systolic at ___ - ___mmHg : labetalol
A

management of dissection:

  1. crossmatch 10ublood
  2. ECG and CXR
  3. CT/MRI or transoesophageal echocardiography (TOE)
  4. take to ITU
  5. hypotensives: keep systolic at 100- 110mmHg : labetalol
50
Q

what are the complications of dissection?

A
  • aortic valve incompetence
  • inferior MI
  • Cardiac arrest
  • these may develop if the dissection moves proximally

Cardiovascular: arterial disease (2 decks)

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