Aneurysms

Question 2

What is a pseudoaneurysm and how do they form?

Answer 2

Breach to arterial wall so accumulation of blood between tunica media and tunica adventitia

Usually after damage to vessel wall (e.g following cardiac catheterisation, IVDU, inflammation or vasculitis)

Most common in femoral artery, but can occur in radial, carotid, abdominal/thoracic aorta

Question 3

What is a vascular complication of acute pancreatitis?

Answer 3

Splenic pseudoaneurysm

Question 4

What are the clinical features of a pseudoaneurysm?

Answer 4

- Pulsatile lump that is tender and painful

• Could be limb ischaemia due to distal arterial occlusion by compression so check pulses
• If infected will be erythematous, tender and purulent material may be discharging

Question 5

If a patient reports they have had a bleed from a pseudoaneurysm but it has stopped now, what should you do?

Answer 5

Close monitoring as could represent a Herald Bleed so could rebleed at any time

Question 6

How are pseudoaneuryms diagnosed an assessed?

Answer 6

- Gold standard: Duplex US which will show turbulent back and forward flow (yin-yang sign).

• Can do CT if cannot access with US

- Routine bloods (FBC, CRP, U+Es, clotting, crossmatch due to risk of rupture)

- Blood cultures and Pus MC+S if discharging

Question 7

How are small and large non-infected pseudoaneurysms managed?

Answer 7

Small: often left alone as can thrombose and close off, however some continue to grow until perforate

Large:

Ultrasound guided compression (can be painful and needs 30 mins direct compression)

OR ultrasound guided thrombin injection (follow up imaging to check resolution)

OR endovascular stenting

OR surgical repair/ligation

Question 8

Why is endovascular stenting and surgical repair of pseudoaneurysms more complication?

Answer 8

Endovascular stenting: sometimes insufficient space to put stent without covering a major branch, can leak so pseudoaneurysm still perfused, can migrate

Surgical repair/Ligation: need healthy proximal and distal artery, ligation can sometimes cause distal ischaemia so will need bypass graft

Question 9

How are infected psuedoaneurysms managed? (usually from IVDU)

Answer 9

- More likely to become septic or rupture so need urgent treatment

• If any discharge pressure dressing and urgent imaging

- Surgical ligation, sometimes requiring bypass graft due to acute limb ischaemia but be careful as graft can become infection

• Small risk of amputation even with collateral blood supply

Question 10

What are some risk factors for peripheral and visceral aneurysms?

Answer 10

• Smoking
• Hyperlipiadaemia
• HTN
• FHx
• Marfan’s
• Takayasu’s aortitis

Aneurysms are persisitent abnormal dilatations of an artery above 1.5X the normal diameter

Question 11

What vessels are classed as visceral aneurysms?

Answer 11

• Splenic (most common)
• Hepatic (second most common)
• Renal
• Intestinal arteries
• Mesenteric arteries

Question 12

How are peripheral and visceral aneurysms investigated and managed in general terms?

Answer 12

Ix:

• CT angiography or MRA if renal issues
• US duplex scans for detection or follow up

Mx

• Watchful waiting whilst optimising CVS factors so antiplatelet and statin therapy
• Surgical intervention (endovascular or open)

Question 13

What are the most common peripheral artery aneurysms?

Answer 13

- Popliteal (high risk of embolisation and/or occlusion)

• Femoral

Question 14

Popliteal aneurysms are the most common peripheral aneurysm. How do they present?

Answer 14

- Acute limb ischaemia (aneurysm thrombosis or emboli) OR

- Intermitten claudication

Can also be found incidentally during AAA work up or during TKR or from compression symptoms on popliteal vein or peritoneal nerve

Question 15

How are suspected popliteal aneurysms investigation?

Answer 15

• Initially US duplex to rule out other popliteal swellings e.g Baker’s cyst, lymphadenopathy

- CT angiogram or MRA

Question 16

How are popliteal aneurysms managed?

Answer 16

If symptomatic or asymptomatic and over 2.5cm should be given treatment

- If thrombosis in tibial vessel then embolectomy or thrombolysis

- Endovascular: stent insertion

- Open: ligation of aneurysm or resection with bypass graft

Question 17

What are the causes of femoral pseudoaneurysms?

Answer 17

• Patient self-injecting e.g IVDU
• Percutaenous vascular interventions

Question 18

How do femoral pseudoaneurysms present, and how are they investigated and managed?

Answer 18

Presentation

• Symptoms due to thrombosis, rupture, embolisation or infecton
• Varying degrees of claudication or acute limb ischaemia

Ix

• US duplex then CT angiogram or mra

Mx

• Open surgical repair

Question 19

What are some risk factors for splenic pseudoaneurysms and how do they present?

Answer 19

Risk factors: female, multiple pregnancies, portal hypertension, acute pancreatitis, pancreatic pseudocysts

Presentation: vague epigastric or LUQ pain, if ruptured then severe abdominal pain

Question 20

How are splenic and hepatic psuedoaneurysms investigated and managed?

Answer 20

Ix: CT angiography or MRA

Mx: 1st Line is endovascular repair wirh embolisation or stent graft once patient haemodynamically stable

Question 21

What is the cause of hepatic pseudoaneurysms and how do they present?

Answer 21

Causes: percutaneous instrumentation, trauma, degenerative disease, post liver transplant around vessel anastomoses

Presentation: usually asymptomatic but can have vague RUQ/Epigastric pain and jaundice if biliary obstruction

Question 22

How do renal artery pseudoaneurysms present, and how are they investigated and managed?

Answer 22

Presentation: often incidental finding/asymptomatic but can have haematuria, resistant hypertension or loin pain if renal infarction

Ix: CT angiogram or MRA

Mx: Endovascular repair with stent if affecting renal artery, or coils if affecting hilum. Can also do renal transplant rarely