Aneurysms Surgery - Presentation, Investigation & Therapy Flashcards
What does aneurysm of the aorta involve?
Dilatation of all layers of aorta
Increase in diameter of >50% (abdominal aorta >3cm)
What are the following branches of the aorta?
What are the causes of aneurysm disease?
- Degenerative disease
- Connective tissue disease (e.g. Marfan’s disease)
- Infection (mycotic aneurysm)
What are the risk factors for degenerative AAA disease?
Male sex
Age
Smoking
Hypertension
Family History
What level does the abdominal aorta bifurcate?
L4
What do you use to feel the AAA?
Two hands - pulsating
At what age in England are men invited for AAA screening?
65
What is presentation of AAA?
Asymptomatic
What is the criteria for screening (part 1)
Definable disease
Prevalence (must be considerable )
Severity of disease
Natural history
Reliable detection
What is the criteria for screening (part 2)
Early detection confers advantage
Treatment options available (needs to have a possible plan to treat once found)
Cost
Feasibility
Acceptability
What are the outcomes for screening?
- Normal aorta, discharged
- Small AAA (3.0-4.4cm) annual USS scans
- Medium AAA (4.5-5.5cm) 3 monthly USS scans
- Large AAA (>5.5cm)
What are the symptoms of an impending rupture?
Increasing back pain
Aorta tender to examine
Inflammation seen on CT
What are the symptoms of rupture?
Abdo/back/flank pain
Painful pulsatile mass
Haemodynamic instability (single episode or progressive)
Hypoperfusion
What are unusual presentations of abdominal aortic aneuryism?
Distal embolisation
Aortocaval fistula
Aortoenteric fistula
Ureteric occlusion
Duodenal obstruction
What is the cause of distal embolism
Blood flow through aortic sac has a lot of thrombus
If ruptured can embolise other parts of body
What is an aortocaval fistula
Aneurysm erodes into vena cava wall
Aortic blood circulates to venous system without perfusing limbs – perfuses into vena cava
What is aortoenteric fistula
Erodes into bowel - bleeds into duodenum
What is management of asymptomatic patients?
Appropriate Size to consider repair?
Is patient candidate for repair?
Is aneurysm suitable for endovascular repair?
At what level of aneurysm size does surgery stop confering benefit?
For aneurysms less than 5.5 cm
How do you assess patient fitness?
Full history and examination
Bloods
ECG
ECHO
PFTs (pulmonary function tests)
MPS (myocardial perfusion scans)
CPEX (cardiopulmonary exercise testing)
End of bed test
Patient preference
What are the two methods of aneurysm repair?
Endovascular - keyhole or open repair
What are the benefits and disadvantages of ultrasound scanning
Benefits:
- No radiation
- No contrast
- Cheap
Disadvantages:
- Operator dependent
- Inadequate for surgical planning
What are the benefits and disadvantages of CT/MRA
Advantages
Quick
Not operator dependent
Necessary for surgical planning – detailed anatomy
Disadvantages:
Contrast
Radiation
Which type of operating procedure has a higher risk of rupture?
Open repair - less than 6%
Endovascular repair - less than 1%
What are the general complications of open repair
- Wound infection / dehiscence
- Bleeding
- Pain
- Scar
What are the technical complications of open repair
- Damage to bowel, ureters, veins, nerves
- Incisional hernia
- Graft infection
- Distal emboli
- Renal failure
- Colonic ischaemia
What are the general complications of endovascular repair
- Wound infection
- Bleeding / haematoma
- Pain
- Scar
- Contrast – reaction / kidney injury
- Radiation
What are the technical complications of endovascular repair
- Endoleak
- Femoral artery dissection / pseudoaneurysm
- Rupture
- Distal emboli / ischaemia / colonic ischaemia
- Damage to femoral vein / nerve
What are the patient factors related to open repair and endovascular repair
- DVT/PE
- MI
- Stroke
- Death
What is an endoleak?
Blood travels into aneurysm sack instead of inserted tube
What is management of symptomatic AAA?
ABCDE
History, check records
Examination - pulsatile mass in abdomen
CTA - if considering treatment
What are the key features of an emergency open repair of AAA?
Transfusion protocol
Prep abdomen, rapid anaesthetic
Laparotomy xiphisternum to pubic symphysis
Occlude aorta proximally
30-50% mortality, significant morbidity
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Why don’t we always use endovascular repair?
Relying on the radial force holding the grafts in place in the diseased aorta AAA is a degenerative disease, over time the aneuryism progresses and causes endoleaks. Needs ongoing surveillance and scans and maybe intervention in the future. Increased costs. Longer term mortality is similar between both methods. For those who were not fit for operation, there is no advantage giving them an endovascular repair.
What is a risk of emergency EVAR?
Abdominal compartment syndrome – no removal of blood from abdomen
Too much pressure in abdomen – kidney failure
Is there any benefit for EVAR or open repair in the case of ruptured AAA?
No difference in mortality - severity of damage results in health complications
