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2D week 4/7 - aneurysms and dissections > aneurysms and aortic dissection > Flashcards

aneurysms and aortic dissection Flashcards

1
Q

why does atherosclerosis increase the risk of aneurysms?

A

Atherosclerosis induced pressure or ischaemic atrophy of the underlying media, with loss of elastic tissue causing weakness resulting in aneursmal dilation

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2
Q

risk factors for AAA (6)

A

age >50yrs; male; smoking; hypertension; family history; connective tissue disorders

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3
Q

presentation of an AAA

A

usually asymptomatic; can cause pain or tenderness

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4
Q

what is a mycotic aneurysm

A

an infection in the blood vessels arising due to haematogenous spread of an infection

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5
Q

presentation of a ruptured AAA

A

abdominal pain radiating to the back; collapse; pulsatile abdominal mass; tachycardia; drop in BP (if ruptures to the front)

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6
Q

ruptures AAA triad

A

hypotension; abdominal/back pain/ pulsatile abdominal mass

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7
Q

presentation of AAA embolisation and what causes it

A

caused by part of the thrombus inside the aneurysm breaking off and emobolising; acute limb ischaemia (6 Ps) and blue toe syndrome

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8
Q

what is blue toe syndrome

A

when there is a microembolism from atherosclerotic plaques/aneurysms that results in ischaemic toes with palpable foot pulse

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9
Q

size of normal aorta

A

around 2.5cm

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10
Q

at what size is an AAA referred to vascular

A

> 5.5cm; urgent referral, to be seen within 2 weeks

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11
Q

what should be done with an AAA 4.5-5.5cm AAA (screening)

A

screen every 3-6 months

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12
Q

rules for driving with an AAA

A

can continue to drive if <6cm; must notify DVLA if 6-6.4cm; must stop driving if >6.5; if a lorry/bus driver then must notify is <5.5 and stop if >5.5

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13
Q

management for a small AAA (<5.5) (4)

A

give antiplatelet and statins (decrease CVD risk); smoking cessation; treat hypertension; increase surveillance (12mo for 3-4.5cm and 3/6mo for 4.5-5.5)

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14
Q

indications for AAA surgery (3)

A

diameter >= 5.5cm; increase in size by >1cm per year; symptomatic (indicative of rupture/emboli)

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15
Q

what should be checked in the AAA pre-op assessment (8)

A

age; comorbidities; family/patient wishes; frailty; CT aortogram; bloods; CXR/ECG/lung function test etc.; optimal cardio/resp/renal function has been obtained

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16
Q

why should you clamp an AAA above and below during an open repair surgery

A

to stop blood flow to it - there is a collateral supply to the legs which can result in back bleeding

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17
Q

when is an open repair done over EVAR

A

younger patients (lasts for longer, less risky); aneurysm not suitable for EVAR; patient unstable

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18
Q

complications of open repair (8)

A

death; bleeding; ischaemia (colon and limbs); cardiac/resp/renal failure; wound infection/dehiscene; adhesive small bowel obstruction; graft infection; aorto-enteric fistula

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19
Q

what is trash foot

A

Acute lower limb ischaemia following aortic surgery

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20
Q

what is an aorto-enteric fistula

A

when a fistula between the small bowel and the aorta occurs allowing bleeding from the aorta into the bowel - life threatening

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21
Q

what must be considered anatomically for an EVAR (6)

A

infra renal neck - length (1.5cm min), diameter (30mm max), shape, angulation; iliac access - patency, tortuosity, diameter

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22
Q

pros of an EVAR

A

keyhole - less time in hospital, safer

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23
Q

complications of an EVAR (5)

A

contrast/radiation toxicity; wound haemotoma/infection; damage to access vessel; high reintervention rate (due to slipping, knotting, thrombosis, endoleak etc.); life long surveillance required

24
Q

what are endoleaks

A

blood flowing outside the stent graft but inside the aneurysm sack - may spontaneous seal or may rupture

25
Q

what is the worst type of endoleak?

A

endoleak 1

26
Q

what is a type 1 endoleak?

A

when there is a poor seal between the graft neck and the iliacs; it is rare but high risk (bc high pressure) and prone to rupture so usually treated

27
Q

what is a type 2 endoleak?

A

back bleeding lumbar arteries/IMA; common but low risk as it is low pressured; kept under surveillance - concerning if sack expanding; may resolve spontaneously

28
Q

how many lumbar arteries are there and why might there be an endoleak

A

4 arteries; they may already be occluded and so blood may flow into the low pressure sac instead

29
Q

Open repair vs EVAR (5 each)

A

OR - higher early mortality, HDU bed, longer hospital stay/recovery, lasts longer, less expensive; EVAR - lower early mortality, ward bed, shorter hospital stay/recovery, higher mortality rate, more expensive

30
Q

what is permissive hypotension

A

maintaining a low blood pressure after trauma (one that the body has stabilised itself) in order to prevent bleeding out as a result of higher BP - don’t give fluids

31
Q

management of ruptured AAA (6)

A

bloods (FBC, U&Es, LFT, glucose, clotting and cross matching for transfusion etc.); ECG; Large bore IV + catheter; fluid resuscitation (permissive hypotension 70-90); assess age/comorbidities/functional status etc.; CT to diagnose anatomical EVAR suitability

32
Q

wilson and junger

A

criteria for screening disease

33
Q

national AAA screening program criteria

A

offered to men >= 65yrs; is <3cm then discharged, 3-5.5 then enrolled for further screening; >=5.5 referred to vascular (within 2 weeks)

34
Q

pathophysiology of aortic dissection

A

tear in intima -> flowing blood enters and dissects through the media -> intimal flap, false lumen and re-entry tear occurs

35
Q

types or aortic dissection

A

type A - proximal to the L subclavian and involved the ascending aorta, more severe; type B - distal to L subclavian and involves the descending aorta

36
Q

aortic dissection epidemiology

A

men x3 more likely; people aged 50-65 (if under 40 likely to have a CT disease);

37
Q

risk factors for aortic dissection (10)

A

hypertension; atherosclerosis; aortic aneurysm; bicuspid aortic valve; coarctation; FH; CT disorder; pregnancy; cocaine use; high intensity weight lifting

38
Q

presentation of aortic dissection (7)

A

tearing chest pain radiating to back; collapse; pulse deficits; radial-radial/ radial-femoral delay; difference >20mmHg between arms; new aortic regurgitation murmur; neurological signs of stroke/ paraplegia

39
Q

aortic dissection investigation (3 - 2,1,3)

A

CXR - widened mediastinum, pleural effusion/haemothorax; ECG - Mi mimic due to ischaemic changes if coronary arteries mal perfused; CT angiogram - intimal flap, true/false lumen, branch vessel perfusion

40
Q

what is the definitive investigation for an aortic dissection

A

CT angiogram

41
Q

complications of aortic dissection (3)

A

malperfusion; rupture; aneurysmal dilation

42
Q

malperfusion of different organs…

A

coronary - MI; carotid - stroke; spinal - paraplegia; renal - renal failure; mesenteric - acute mesenteric ischaemia; limb - acute limb ischaemia

43
Q

management of type A aortic dissection

A

open repair to replace aortic arch/valve; may require reimplantation of coronary/great arteries

44
Q

management of type B dissection

A

uncomplicated - management of BP using IV labetalol, analgesia, surveillance; complicated (malperfusion, fluctuating BP etc.) - TEVAR (Thoracic endovascular repair) to cover entry tear and promote thrombosis of false lumen

45
Q

what is an aneurysm

A

localised dilation of an artery with >50% increase in diameter (otherwise called ectasia)

46
Q

true vs false aneurysm

A

true - involves all 3 walls, fusiform or saccular in shape; false - hole in arterial wall, pulsatile haematoma contained by externa

47
Q

where are false aneurysms likely to occur

A

radial; femoral; anastomotic

48
Q

what is a type 3 endoleak

A

poor seal between graft compnents

49
Q

what is a type 4 endoleak

A

porosity of the graft

50
Q

what is a type 5 endoleak

A

‘endotension’; sac expansion with no demonstrable endoleak

51
Q

when is a popliteal aneurysm indicative for surgery?

A

diameter >2-3cm; significant lining thrombus; symptomatic (DVT, PE, ALI etc.)

52
Q

treatment for popliteal aneurysm

A

stent grafting; thrombolysis (may clear vessels to allow for stenting); exclusion bypass surgery

52
Q

treatment for popliteal aneurysm

A

stent grafting; thrombolysis (may clear vessels to allow for stenting)

53
Q

treatment of radial/femoral aneurysm

A

spontaneous thrombus; US guided compression; thrombin injection; surgery

54
Q

how to popliteal aneurysms present?

A

ALI due to thrombosis; chronic limb ischaemia; CVT due to compression of popliteal vein

2D week 4/7 - aneurysms and dissections (3 decks)

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