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Vascular > Aneurysms > Flashcards

Aneurysms Flashcards

1
Q

That percentage dilatation of original diameter defines an aneurysm?

A

> 50% of original diameter

Or a dilatation of to 1.5x the original size

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2
Q

What is the difference between a true aneurysm and a pseudoaneurysm?

A

A true aneurysm involve all the layers of the arterial wall dilating

A false aneurysm occurs when there is a collection of blood in the adventitia which communicates with the lumen of the artery- this can occur after trauma for example

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3
Q

How’re the different shapes of aneurysms described?

A

Fusiform- symmetrical dilatation

Berry/Sac Like- unilateral dilatation

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4
Q

Where do the majority of aneurysms occur?

A

In the aorta

60% are in the abdominal aorta
40% in the thoracic aorta

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5
Q

Where do the majority of abdominal aortic aneurysms occur?

A

Infrarenal- below the left and right renal arteries (95%)

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6
Q

How might the different shapes of aneurysms be described?

A

Fusiform- symmetrical dilation

Sac-like/Berry- Unilateral/ asymmetrical dilation

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7
Q

What are the layers of a muscular artery?

A

Tunica intima- Inner layer lined by endothelium
Tunica media- Muscle and elastic tissue
Tunica adventitia- Connective tissue that anchors the artery to nearby tissues

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8
Q

What is the vasa vasorum?

A

Small blood vessels that run in the tunica adventitia and supply the large arteries and the muscle within their tunica media with blood

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9
Q

What are some causes of aneurysm?

A

Anything that causes weakness in the blood vessel wall

  • Connective tissue disorders (Ehlers Danlos, Marfans)
  • HTN
  • Atherosclerotic disease (especially affecting the vasa vasorum, leading to atrophy of smooth muscle of tunica media)
  • Infection
  • Vasculitis
  • Trauma
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10
Q

What infection is associated with causing thoracic aortic aneurysms?

A

Tertiary syphilis

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11
Q

How does atherosclerotic disease increase the risk of developing aneurysms?

There’s two reasons

A

1) Atherosclerotic disease affecting the vessels of the vasa vasorum disrupts the blood supply to the tunica media and there is resulting smooth muscle atrophy and weakening of the vessel wall
2) Atherosclerotic disease in the vessel itself creates a diffusion barrier to the oxygen that would supply the smooth muscle- resulting atrophy and wall weakness

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12
Q

What are the risk factors for aneurysms?

A 
Increasing age
HTN
Atherosclerotic disease
History of MI/Stroke
Smoking 
Alcohol
Hyperlipidaemia
Male gender
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13
Q

How does tertiary syphilis increase the risk of developing aneurysm? What site is particularly associated with this? What is the condition called underpinning this?

A

It causes inflammation of the vessels of the vasa vasorum which then leads to reduced blood supply to the smooth muscle of the tunica media, this weakness the vessel wall

The condition is called Endarteritis Obliterans

The thoracic aorta is most associated with this

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14
Q

What is endarteritis obliterans?

A

Inflammation of intima of an artery that results in occlusion of the lumen, known to happen in tertiary syphilis

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15
Q

What is the name for aneurysms due to a bacterial or fungal infection?

A

Mycotic aneurysms

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16
Q

How can bacterial infections increase the risk of developing aneurysms?

A

Embolic bacteria can break off from a site of infection in the body. Travel to a distal site and invade the blood vessel wall to cause inflammation which weakens the wall- increasing the risk of aneurysm- can occur with endocarditis.

Common sites include- intracranial arteries, visceral arteries, limb arteries

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17
Q

What bacteria commonly cause mycotic aneurysms?

A

Bacteroides fragilis
Pseudomonas aeruginosa
Salmonella species

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18
Q

What fungal infections can cause mycotic aneurysms?

A

Aspergillus
Candida
Mucor

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19
Q

What genetic conditions increase and individuals risk of developing aneurysms?

A

Ehlers Danlos

Marfan’s

20
Q

What are some complications of aneurysms?

A

Direct compression of other structures- e.g. dysphagia if thoracic, SVC obstruction
Rupture, haemorrhage and downstream ischaemia
Thrombosis and Embolism- due to turbulent flow

21
Q

What is are some of the signs and symptoms of abdominal aortic aneurysms?

A

Vast majority are asymptomatic except on rupture
Severe left flank pain- abdomen, chest, lower back, groin
Expansile Palpable Pulsatile Mass
Hypotension
Bruit- heard due to turbulent flow

22
Q

What is the screening process in the UK for AAA? What’s the follow up?

A

Men aged 65 are invited for an abdominal USS to investigate for AAA

Follow up depends upon the findings:
No Aneurysm- no further screening
Small Aneurysm (3-4.4cm)- Annual monitoring
Medium Aneurysm (4.5-5.4cm)- Every three months
Large Aneurysm- (>5.5 cm)- Consideration of surgery

23
Q

What are the symptoms of a ruptured AAA?

A

Intermittent or continuous abdominal pain
Radiates to back, iliac fossa and groins
Collapse due to haemorrhagic state
Pallor
Palpitations
Shock
Grey-Turner’s sign- indication of retroperitoneal bleed

24
Q

What is the definition of an AAA? (cm size)?

A

Dilation of the abdominal aorta to 3cm or more

25
Q

Describe the general approach to aneurysms once they are discovered?

A

Early intervention has failed to show any mortality benefits. Once discovered the management is guided by the size of the aneurysm- as the largest ones are most likely to rupture. It is also important to reduce the risk factors for aneurysm rupture medically.

3-4.4cm- Annual Monitoring
4.5-5.4cm- Monitoring every 3 months
>5.5cm - Consideration of surgery

26
Q

What are some of the risk factors for aneurysm rupture?

A 
HTN
Increasing aneurysm size
Smoking
Family history
Male
27
Q

What else is important to consider on top of the size of the aneurysm?

A

The rate at which it is expanding

28
Q

In terms of size and progression what are the indications for surgery?

A

Greater than 5.4cm
Growth rate greater than 1cm/year

A symptomatic aneurysm is also an indication for surgery as it is associated with an increased risk of rupture.

29
Q

What may flank bruising be a sign of?

A

Retroperitoneal bleeding
This is called Grey-Turner’s Sign

Cullen’s sign is bruising around the umbilicus

30
Q

What symptoms might a thoracic aortic aneurysm cause due to compression of a certain nerve?

A

Recurrent laryngeal nerve hooks under the thoracic aorta and so compression/stretch can occur with aneurysms here leading to hoarse voice

31
Q

What are the surgical options for aneurysm repair?

A

This depends upon the location of the aneurysm
Open Surgery with grafts
Endovascular Approaches

32
Q

Outline the management for a ruptured AAA?

A

Surgical emergency and requires urgent surgery
Call anaesthetist and vascular surgeon
IV Access via two large bore cannula
Bloods for Hb, U and Es, Cross Match, Amylase, Lactate
Fluid resuscitation
Urgent transfer to surgery

33
Q

What is the leading cause of a false femoral artery aneurysm?

A

Due to trauma which is most commonly due to interventional radiology procedures or any other endovascular procedure which utilises the femoral artery for access

34
Q

What are some of the symptoms of a popliteal artery aneurysm?

A

Popliteal artery aneurysms are very unlikely to rupture and the majority of symptoms are due to compression on surrounding structures within the popliteal fossa

Venous compression- Varicose veins, venous ulcers, skin changes
Nerve compression- Neuropathic pain, sensory and motor deficit

35
Q

If a popliteal artery aneurysm is found on examination what is important to do?

A

Check the other side for one- 25% have bilateral aneurysms

Also check for AAA

36
Q

What spinal level does the aorta enter the abdomen?

A

T12

37
Q

At what spinal level does the aorta bifurcate?

A

L4

38
Q

At what spinal level is the IVC formed?

A

L5

39
Q

What is the normal diameter of the abdominal aorta?

A

1.5cm-2cm

40
Q

How can the size of an AAA be estimated using a CT scan?

A

Vertebral bodies are approximately 5cm across and so compare it to this

41
Q

What percentage of AAA are infrarenal?

A

95%

42
Q

Is diabetes a risk factor for AAAs?

A

Unlike other cardiovascular diseases diabetes is a protective risk factor for AAA, no one knows why yet

43
Q

What are the indications for surgical in AAA?

A

Size above 5.5cm
Growth rate greater than 1cm/year
Distal ischaemia because the aneurysm is throwing off clots- e.g. critical limb ischaemia, trash foot
Symptomatic aneurysms- often due to compression on local structures, also abdominal pain

44
Q

Outline the approach to the management of AAA. Group the answers.

A

Conservative- Lifestyle changes, Stop Smoking, HTN Control with antihypertensives, Diet, Exercise, Monitoring according to size
Minimally Invasive- EVAR- Uses grafts delivered via an endovascular route to restore normal lumen diameter
Maximally Invasive- Open Repair- Laparotomy to access the AAA with grafts/bypass

Note- evidence suggests that EVAR has no mortality benefit over an open surgical approach. Furthermore EVAR requires annual follow up and is associated with greater complications and the need for surgical revision.

45
Q

What are the complications of surgical aneurysm repair? Group the answers

A

Immediate- Death, Haemorrhage, Ischaemia of GI tract or Leg due to clots coming from the aneurysm, Renal Failure if disruption of renal perfusion
Early- Death, Haemorrhage, Ischaemia, Graft leaks, Renal Failure, Infection, Standard post operative complications (e.g DVT, PE)
Late- Recurrence of aneurysm, occlusion of graft, infection, aortic-enteric fistula, rupture

46
Q

What are some differentials for sudden onset pain radiating to the back?

A 
Ruptured AAA
Aortic dissection
Inferior MI/Atypical MI
Pancreatitis
Renal colic
Disc herniation

Note- Ruptured AAA is commonly mistaken for renal colic. Less likely now due to CT KUB being the investigation of choice but is important to consider the risk of it being an AAA, check the abdomen and consider previous history of AAA (especially in those aged 60-70.

47
Q

What are the treatment options for a femoral pseudoaneurysm?

A

Direct compression- for a long duration of time
Thrombin injection
Endovascular repair
Surgery to repair the tear

Vascular (4 decks)

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