Aneurysms

Question 1

Define aneurysm

Answer 1

Abnormal dilatation of a blood vessel to >50% of its normal diameter

Question 2

Define true aneurysm

Answer 2

Dilatation of a blood vessel involving all layers of
the wall and is >50% of its normal diameter. Can be;
Fusiform - AAA
Saccular - Berry

Question 3

Define false aneurysm

Answer 3

Collection of blood around a vessel wall that

communicates with the vessel lumen. Usually iatrogenic eg cannulation

Question 4

What are some of the causes of an aneurysm?

Answer 4

Congenital - PCKD (Berry), Marfan’s, Ehlers Danos

Acquired - Atherosclerosis, HTN, Trauma, Inflammatory, Infection

Question 5

What complications can occur from an aneurysm?

Answer 5

Rupture
Thrombosis
Fistula eg IVC + intestines
Pressure on surrounding structures eg oesophagus

Question 6

What is the presentation of a popliteal aneurysm?

Answer 6

50% also have AAA
Very easy to palpate popliteal pulse
50% bilateral
Rarely rupture
Thrombosis/distal embolism are main concern.

Question 7

How can popliteal aneurysms be managed?

Answer 7

Acute - embolectmy, fem-distal bypass

Stable - elective grafting + tie off vessel

Question 8

What is the pathology of a AAA?

Answer 8

Dilatation of the abdominal aorta ≥3cm
90% infrarenal, 30% involve iliac arteries
M:F ratio of 3:1

Question 9

What is the presentation of AAA?

Answer 9

Usually asymptomatic + discovered incidentally or during screening (Men at 65 y/o)
May have back pain/umbilical pain which can radiate to groin
Acute limb ischaemia
Acute rupture

Question 10

What can be found on examination in a patient with AAA?

Answer 10

Pulsatile mass above umbilicus
Bruits may be heard
Tenderness + shock suggests rupture

Question 11

What investigations can be done in a patient with AAA?

Answer 11

AXR - May see calcification
Abdominal US
CT/MRI
Angiography can be used to assess relationship with renal arteries

Question 12

What is the conservative management of AAA?

Answer 12

Regular monitoring;

Question 13

What is the surgical management of AAA?

Answer 13

Mortality is lower with elective surgery
Need to operate when risk of rupture is higher than risk of surgery
Indications - Symptomatic, diameter >5.5cm, rapidly expanding (>1cm/yr), complications eg emboli
Open Vs Endovascular Aneurysm Repair (Doesn’t last as long as open surgery)

Question 14

What can increase the risk of AAA rupture?

Answer 14

↑BP
Smoker
Female
Strong FH

Question 15

How does a ruptured AAA present?

Answer 15

Sudden onset severe abdominal pain.
- Can be intermittent or continuous
- Can radiate to back or flanks 
Expansile abdominal mass
May be vomiting, pale/sweating, pulse weak/thready, may have acute abdomen due to bleeding into peritoneum
*May go into shock*

Question 16

What is the management of a ruptured AAA?

Answer 16

2 cannulas
Fluids - keep SBP >100, give blood if severe
Do bloods - FBC, U+Es, Clotting, Amylase, Cross match
Call vascular surgeon, Anaesthetist + theatre
Analgesia
Central venous pressure line
Urinary catheter
Prophylactic antibiotics
Insert graft in theatre

Question 17

Define Ectasia

Answer 17

Localised area of enlargement in the artery but less than 50%

Question 18

What are the complications of AAA repair - open surgery?

Answer 18

Haemorrhage
Bowel ischaemia
Renal failure
Limb ischaemia
Respiratory complications
Cardiac events
Death

Question 19

What are the complications of AAA repair - Endovascular aneurysm repair?

Answer 19

Graft migration
Fracture of supporting wires
Endoleak - Leaking of blood into where aneurysm was
Endotension - HTN where aneurysm was

Question 20

What are the two types of rupture?

Answer 20

Intraperitoneal - Immediately fatal
Retroperitoneal - Usually survive to get to hospital due to contained leak. If left, will eventually rupture intraperitoneally

Question 21

What is the classical triad of symptoms for aneurysm rupture?

Answer 21

Abdominal/Back pain
Pulsatile mass
Hypotension

Question 22

What are the differentials for AAA?

Answer 22

MI
Massive PE
Acute pancreatitis