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CVS > Aneurysms Surgery - Presentation, Investigation & Therapy > Flashcards

Aneurysms Surgery - Presentation, Investigation & Therapy Flashcards

1
Q

What does aneurysm of the aorta involve?

A

Dilatation of all layers of aorta

Increase in diameter of >50% (abdominal aorta >3cm)

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2
Q

What are the following branches of the aorta?

A
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3
Q

What are the causes of aneurysm disease?

A
  • Degenerative disease
  • Connective tissue disease (e.g. Marfan’s disease)
  • Infection (mycotic aneurysm)
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4
Q

What are the risk factors for degenerative AAA disease?

A

Male sex

Age

Smoking

Hypertension

Family History

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5
Q

What level does the abdominal aorta bifurcate?

A

L4

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6
Q

What do you use to feel the AAA?

A

Two hands - pulsating

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7
Q

At what age in England are men invited for AAA screening?

A

65

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8
Q

What is presentation of AAA?

A

Asymptomatic

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9
Q

What is the criteria for screening (part 1)

A

Definable disease

Prevalence (must be considerable )

Severity of disease

Natural history

Reliable detection

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10
Q

What is the criteria for screening (part 2)

A

Early detection confers advantage

Treatment options available (needs to have a possible plan to treat once found)

Cost

Feasibility

Acceptability

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11
Q

What are the outcomes for screening?

A
  1. Normal aorta, discharged
  2. Small AAA (3.0-4.4cm) annual USS scans
  3. Medium AAA (4.5-5.5cm) 3 monthly USS scans
  4. Large AAA (>5.5cm)
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12
Q

What are the symptoms of an impending rupture?

A

Increasing back pain

Aorta tender to examine

Inflammation seen on CT

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13
Q

What are the symptoms of rupture?

A

Abdo/back/flank pain

Painful pulsatile mass

Haemodynamic instability (single episode or progressive)

Hypoperfusion

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14
Q

What are unusual presentations of abdominal aortic aneuryism?

A

Distal embolisation

Aortocaval fistula

Aortoenteric fistula

Ureteric occlusion

Duodenal obstruction

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15
Q

What is the cause of distal embolism

A

Blood flow through aortic sac has a lot of thrombus

If ruptured can embolise other parts of body

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16
Q

What is an aortocaval fistula

A

Aneurysm erodes into vena cava wall

Aortic blood circulates to venous system without perfusing limbs – perfuses into vena cava

17
Q

What is aortoenteric fistula

A

Erodes into bowel - bleeds into duodenum

18
Q

What is management of asymptomatic patients?

A

Appropriate Size to consider repair?

Is patient candidate for repair?

Is aneurysm suitable for endovascular repair?

19
Q

At what level of aneurysm size does surgery stop confering benefit?

A

For aneurysms less than 5.5 cm

20
Q

How do you assess patient fitness?

A

—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

21
Q

What are the two methods of aneurysm repair?

A

Endovascular - keyhole or open repair

22
Q

What are the benefits and disadvantages of ultrasound scanning

A

Benefits:

  • No radiation
  • No contrast
  • Cheap

Disadvantages:

  • Operator dependent
  • Inadequate for surgical planning
23
Q

What are the benefits and disadvantages of CT/MRA

A

Advantages

Quick

Not operator dependent

Necessary for surgical planning – detailed anatomy

Disadvantages:

Contrast

Radiation

24
Q

Which type of operating procedure has a higher risk of rupture?

A

Open repair - less than 6%

Endovascular repair - less than 1%

25
Q

What are the general complications of open repair

A
  • Wound infection / dehiscence
  • Bleeding
  • Pain
  • Scar
26
Q

What are the technical complications of open repair

A
  • Damage to bowel, ureters, veins, nerves
  • Incisional hernia
  • Graft infection
  • Distal emboli
  • Renal failure
  • Colonic ischaemia
27
Q

What are the general complications of endovascular repair

A
  • Wound infection
  • Bleeding / haematoma
  • Pain
  • Scar
  • Contrast – reaction / kidney injury
  • Radiation
28
Q

What are the technical complications of endovascular repair

A
  • Endoleak
  • Femoral artery dissection / pseudoaneurysm
  • Rupture
  • Distal emboli / ischaemia / colonic ischaemia
  • Damage to femoral vein / nerve
29
Q

What are the patient factors related to open repair and endovascular repair

A
  • DVT/PE
  • MI
  • Stroke
  • Death
30
Q

What is an endoleak?

A

Blood travels into aneurysm sack instead of inserted tube

31
Q

What is management of symptomatic AAA?

A

—ABCDE

—History, check records

—Examination - pulsatile mass in abdomen

—CTA - if considering treatment

32
Q

What are the key features of an emergency open repair of AAA?

A

Transfusion protocol

Prep abdomen, rapid anaesthetic

Laparotomy xiphisternum to pubic symphysis

Occlude aorta proximally

30-50% mortality, significant morbidity

—

33
Q

Skip

Why don’t we always use endovascular repair?

A

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.

34
Q

What is a risk of emergency EVAR?

A

Abdominal compartment syndrome – no removal of blood from abdomen

Too much pressure in abdomen – kidney failure

35
Q

Is there any benefit for EVAR or open repair in the case of ruptured AAA?

A

No difference in mortality - severity of damage results in health complications

CVS (26 decks)

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