Aneurysms Flashcards

1
Q

Definition of an aneurysm

A

Dilatation of all layers of the aorta leading to an increase in diameter of over 50% (in AA the diameter will be >3.5cm)

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2
Q

Causes of aneurysm

A

Degenerative disease
Connective tissue disease eg Marfan’s
Infection (mycotic aneurysm)

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3
Q

Risk factors

A
Male
Age 
Smoking
Hypertension
Family history (30% in 1st degree male relatives)

Prevalence of 3% in the uk

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4
Q

Presentation of AAA

A

Asymptomatic, screening is used

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5
Q

Criteria for a screening test

A
Definable 
Prevalence 
Severity 
Natural history
Reliable detection
Early detection confers advantage
Treatment available
Cost
Feasibility
Acceptability
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6
Q

4 outcomes of AAA screening

A
Normal 
Small AAA (3-4.4cm) annual scans
Medium AAA (4.5-5.5cm) 3 monthly scans
Large AAA (over 5.5cm)
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7
Q

Impending rupture of AAA symptoms

A

Increasing back pain and is tender

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8
Q

Symptoms of AAA rupture

A

Abdo/back/flank pain
Painful pulsatile mass
Haemodynamic instability
Hypoperfusion

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9
Q

Unusual presentation of ruptured AAA

A
Distal embolism
Aorticaval fissure
Aortoenteric fistula
Ureteric occlusion 
Duodenal obstruction
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10
Q

UK small aneurysm trial Lancet

A

Surgical repair of 4-5.5cm aneurysms doesn’t confer any benefit

With surgery 30day mortality is 5.8%
Risk of rupture is 1% per year

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11
Q

Patient fitness for surgery criteria

A
Full history and examination
Bloods
ECG 
ECGI
PFTs
MPS
CPEX
End of bed test
Patient preference
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12
Q

Different advantages of USS Vs CTA/MRA

A

USS- no radiation or contrast and is cheap but operator dependant and can’t plan surgery

CTA/MRA- quick, not operator dependant, needed for surgery planning (detail) but uses contrast and radiation

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13
Q

Treatment

A

Conservative (not fit) and consider event of rupture

Endovascular repair

Open repair

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14
Q

Complications of open repair

A

There are many
Eg wound infect etc
Damage to bowels and ureters veins and nerves hernias embolus

DVT/PE
MI
Stroke
Death

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15
Q

Complications of endovascular repair

A

Same as open but endoleak, femoral dissection, ischaemia etc

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16
Q

Types of endoleak

A

type I: leak at graft ends (inadequate seal) - most common after repair of thoracic aortic aneurysms 4

type II: sac filling via branch vessel (e.g. lumbar or inferior mesenteric artery)
most common after repair of abdominal aortic aneurysms 4 (80%)
sometimes referred to as a “retroleak”
most spontaneously resolve and require no treatment

type III: leak through a defect in graft fabric (mechanical failure of graft)

type IV: a generally porous graft (intentional design of graft)

type V: endotension

17
Q

EVAR study 1 and 2

A

1 sees 3fold reduction in operative mortality for EVAR and improved qol but no difference in overall mortality for open surgery

2 was against no intervention if unfit for open surgery
No difference in mortality, 9% opmort and 9% rupture rate per year

18
Q

Emergency open repair

A
Straight to theatre
Massive transfusion protocol
Rapid anaesthetic
Laparotomy xiphisternum to public symphysis
Occlude aorta proximally
30-50% mortality
19
Q

Emergency EVAR

A

Only if anatomical suitability
Local anaesthetic
For rupture no difference in mortality from open surgery

20
Q

Carotid disease

A

Atherosclerosis is associated with ischaemic stroke and Tia

Vascular surgeons involved to manage for prevention

21
Q

Virchow’s triad

A

Flow
Vessel wall
Coaguability

22
Q

Diagnosis of carotid artery atherosclerosis stroke or tia

A

Normal stroke exam

Plus auscultation and USS of carotids

23
Q

Poiseuilles law

A

As radius of a vessel decreases, velocity increases
<125cm/s <50% stenosis
>125 50-69% stenosis
>270 70-79% stenosis
End diastolic velocity >140 80-99% stenosis

24
Q

Management of carotid Artery disease

A
Smoking cessation
Control of hypertension
Antiplatelets
Statins 
diabetic control
25
Carotid endarterectomy
Incision plaque removed Artery closed May prevent stroke
26
Complications of carotid endarterectomy
Wound infection, scar etc Nerve damage (vagus and hypoglossal) Perioperative stroke from plaque rupture, hypoperfusion
27
When is stenting or endarterectomy used instead of best medical treatment
Over 50-70% (nascet-ECST) stenosis
28
Management of asymptomatic patients
CEA more benefits in males or bilateral disease | Asymptomatic should only be operated on by operators with good risks and for stenosis of 60-89% in under 75s