Aneurysms 1- aneurysm disease

Question 1

Define aneurysms

Answer 1

weakened blood vessel wall, which is pushed outwards due to blood pressure causing excessive localised swelling in the wall of an artery
Dilatation of all layers of the aorta, leading to an increase in diameter of >50%

Question 2

What is the four sections of the aorta, where are they located and what do they supply

Answer 2

• The ascending aorta - rises up from the heart and is about 2 inches long. The coronary arteries branch off the ascending aorta to supply the heart with blood.
• The aortic arch - curves over the heart, giving rise to branches that bring blood to the head, neck, and arms.
• The descending thoracic aorta - travels down through the chest. Its small branches supply blood to the ribs and some chest structures.
• The abdominal aorta - begins at the diaphragm, splitting to become the paired iliac arteries in the lower abdomen. Most of the major organs receive blood from branches of the abdominal aorta.

Question 3

What is the three layers of the aorta and their functions

Answer 3

• The intima, the innermost layer, provides a smooth surface for blood to flow across.
• The media, the middle layer with muscle and elastic fibers, allows the aorta to expand and contract with each heartbeat.
• The adventitia, the outer layer, provides additional support and structure to the aorta.

Question 4

What layer of the aorta is at most risk of damage and why

Answer 4

The intima - thinest layer

Question 5

Where do aneurysms usually occur in aneurysm disease

Answer 5

abdominal aorta

Question 6

What does the aorta bifurcate to

Answer 6

Iliac vessels

Question 7

What is the aetiologies of aneurysm disease

Answer 7

Degenerative disease
Connective tissue disease (e.g. Marfan’s disease)
Infection (mycotic aneurysm)

Question 8

What is the risk factors for abdominal aortic aneurysm

Answer 8

Male sex
Age
Smoking
Hypertension
Family history

Question 9

What can be found of clinical examination of an abdominal aortic aneurysm

Answer 9

aneurysm can be palpated at abdomen above umbilicus.

Question 10

What is the purpose of aortic abdominal aneurism screening and what patients is it critical for

Answer 10

To detect a dangerous swelling of the aorta

Men over aged 65 with a heart problem

Question 11

What is the 4 outcomes of a screening that can be found (size dependant)

Answer 11

A) Normal aorta, discharged
B) Small AAA (3.0-4.4cm) will be invited for annual USS scans
C) Medium AAA (4.5-5.5cm) will be invited for 3 monthly USS scans
D) Large AAA (>5.5cm)

Question 12

What is the typical presentation of a AAA

Answer 12

asymptomatic

Question 13

When AAA becomes symptomatic what does this indicate

Answer 13

Means there is an impending rupture or has been a rupture

Question 14

What is the symptoms of an AAA impending a rupture

Answer 14

Increasing back pain
Tender AAA
Inflammation

Question 15

What is the symptoms of a ruptured AAA

Answer 15

abdominal, back, side pain; 
painful pulsatile mass;
 haemodynamic instability (unstable blood flow/pressure); hypoperfusion (shock)

Question 16

What is the unusual presentations of AAA

Answer 16

Distal embolisation
Aortocaval fistula
Aortoenteric fistula
(connection between the aorta and the intestines, stomach, or esophageus)
Ureteric occlusion 
(blockage in the ureters)
Duodenal obstruction
(failure of food to pass out of the stomach)

Question 17

How does AAA lead to distal embolisation

Answer 17

Aneurysm sack has flow channel and around it there’s a lot of thrombus and disease. Pieces of thrombus can flick off, travel and get lodged elsewhere leading to distal embolisation

Question 18

What three factors need to be investigated in the management of an asymptomatic AAA

Answer 18

Is the aneurysm a size to consider repair?
Is the patient a candidate for repair?
Is the aneurysm suitable for endovascular or open repair?

Question 19

Risk of rupture increases with size so what size in an aneurysm is surgical treatment offered

Answer 19

> 5.5cm

surgery does not serve any benefit is less that 5.5cm

Question 20

How do you asses that patients fitness of AAA surgery

Answer 20

Full history and examination to find out co morbidities, fitness, lung function, ECG, bloods, end of bed test etc

Question 21

How do you assess is an AAA is suitable for repair

Answer 21

Imaging: ultrasound, CTA, MRA

Question 22

What is the advantages and disadvantages of Ultrasound in AAA

Answer 22

ADV:
No radiation
No contrast
Cheap

DIS:
Operator dependent
Inadequate for surgical planning

Question 23

What is the advantages and disadvantages of CT/MRA in AAA

Answer 23

ADV:
Quick
Not operator dependent
Necessary for surgical planning – detailed anatomy due to contrast

DIS:
Contrast - retail failure
Radiation

Question 24

What is the two surgical treatments available for aortic aneurysm repair

Answer 24

〈 Endovascular repair (key hole approach)

〈 Open repair (more traditional operation).

Question 25

What does the procedure if an open repair of aortic aneurysm involve

Answer 25

A surgical incision into the abdominal cavity (Laparotomy) from the xiphisternum to pubic symphysis
Then occlude aorta proximally

Question 26

What is the general complication of an open repair of an AAA

Answer 26

Wound infection / dehiscence
Bleeding
Pain
Scar

Question 27

What is the technical complications of an open repair AAA

Answer 27

Damage to bowel, ureters, veins, nerves
Incisional hernia
Graft infection
Distal emboli
Renal failure
Colonic ischaemia

Question 28

What patients factors of complications in open and endovascular repair of AAA

Answer 28

DVT/PE
MI
Stroke
Death

Question 29

What happens in the procedure of endovascular repair

Answer 29

Key hole approach with a puncture at groin.

Operation takes 1 to 2 hours done under anaesthetic

Question 30

What is the technical complications of endovascular repair

Answer 30

5 different types of Endoleak
Femoral artery dissection / pseudoaneurysm
Rupture
Distal emboli / ischaemia / colonic ischaemia
Damage to femoral vein / nerve

Question 31

What is the general complications of endovascular repair

Answer 31

Wound infection
Bleeding / haematoma
Pain
Scar
Contrast – reaction / kidney injury
Radiation

Question 32

What is the less complicated method in rupture repair of an AAA

Answer 32

Endovascualr - damage to groin area but far less complications

Question 33

What is the management of the complication of endoleaks

Answer 33

Ongoing surveillance with scans needed to check for leaks.

Question 34

What is the treatment option if patient is unstable with an AAA rupture

Answer 34

Straight to theatre pre or post CT for an Emergency open repair

Question 35

What kind of operation is an emergency open repair

Answer 35

a massive transfusion protocol

Question 36

Why must abdomen be prepped rapidly before anaesthetising

Answer 36

As abdominal muscles as are more stable when you are awake, as work as a tamponade preventing further bleeding in the abdomen - therefore is wise to anaesthetise last minute, so maintain this tamponade for as long as possible before surgery

Question 37

What is the risk of emergency open repair rupture AAA

Answer 37

30-50% mortality,
significant morbidity
Risk of abdominal compartment syndrome.

Question 38

What is the management of an AAA before it reaches 5.5cm

Answer 38

Surveillance