Aneurysms Surgery - Presentation, Investigation & Therapy

Question 1

What does aneurysm of the aorta involve?

Answer 1

Dilatation of all layers of aorta

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

Question 2

What are the following branches of the aorta?

Answer 2

Question 3

What are the causes of aneurysm disease?

Answer 3

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

Question 4

What are the risk factors for degenerative AAA disease?

Answer 4

Male sex

Age

Smoking

Hypertension

Family History

Question 5

What level does the abdominal aorta bifurcate?

Answer 5

L4

Question 6

What do you use to feel the AAA?

Answer 6

Two hands - pulsating

Question 7

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

Answer 7

65

Question 8

What is presentation of AAA?

Answer 8

Asymptomatic

Question 9

What is the criteria for screening (part 1)

Answer 9

Definable disease

Prevalence (must be considerable )

Severity of disease

Natural history

Reliable detection

Question 10

What is the criteria for screening (part 2)

Answer 10

Early detection confers advantage

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

Cost

Feasibility

Acceptability

Question 11

What are the outcomes for screening?

Answer 11

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)

Question 12

What are the symptoms of an impending rupture?

Answer 12

Increasing back pain

Aorta tender to examine

Inflammation seen on CT

Question 13

What are the symptoms of rupture?

Answer 13

Abdo/back/flank pain

Painful pulsatile mass

Haemodynamic instability (single episode or progressive)

Hypoperfusion

Question 14

What are unusual presentations of abdominal aortic aneuryism?

Answer 14

Distal embolisation

Aortocaval fistula

Aortoenteric fistula

Ureteric occlusion

Duodenal obstruction

Question 15

What is the cause of distal embolism

Answer 15

Blood flow through aortic sac has a lot of thrombus

If ruptured can embolise other parts of body

Question 16

What is an aortocaval fistula

Answer 16

Aneurysm erodes into vena cava wall

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

Question 17

What is aortoenteric fistula

Answer 17

Erodes into bowel - bleeds into duodenum

Question 18

What is management of asymptomatic patients?

Answer 18

Appropriate Size to consider repair?

Is patient candidate for repair?

Is aneurysm suitable for endovascular repair?

Question 19

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

Answer 19

For aneurysms less than 5.5 cm

Question 20

How do you assess patient fitness?

Answer 20

—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

Question 21

What are the two methods of aneurysm repair?

Answer 21

Endovascular - keyhole or open repair

Question 22

What are the benefits and disadvantages of ultrasound scanning

Answer 22

Benefits:

• No radiation
• No contrast
• Cheap

Disadvantages:

• Operator dependent
• Inadequate for surgical planning

Question 23

What are the benefits and disadvantages of CT/MRA

Answer 23

Advantages

Quick

Not operator dependent

Necessary for surgical planning – detailed anatomy

Disadvantages:

Contrast

Radiation

Question 24

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

Answer 24

Open repair - less than 6%

Endovascular repair - less than 1%

Question 25

What are the general complications of open repair

Answer 25

* Wound infection / dehiscence * Bleeding * Pain * Scar

Question 26

What are the technical complications of open repair

Answer 26

* Damage to bowel, ureters, veins, nerves * Incisional hernia * Graft infection * Distal emboli * Renal failure * Colonic ischaemia

Question 27

What are the general complications of endovascular repair

Answer 27

* Wound infection * Bleeding / haematoma * Pain * Scar * Contrast – reaction / kidney injury * Radiation

Question 28

What are the technical complications of endovascular repair

Answer 28

* Endoleak * Femoral artery dissection / pseudoaneurysm * Rupture * Distal emboli / ischaemia / colonic ischaemia * Damage to femoral vein / nerve

Question 29

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

Answer 29

* DVT/PE * MI * Stroke * Death

Question 30

What is an endoleak?

Answer 30

Blood travels into aneurysm sack instead of inserted tube

Question 31

What is management of symptomatic AAA?

Answer 31

—ABCDE —History, check records —Examination - pulsatile mass in abdomen —CTA - if considering treatment

Question 32

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

Answer 32

Transfusion protocol Prep abdomen, rapid anaesthetic Laparotomy xiphisternum to pubic symphysis Occlude aorta proximally 30-50% mortality, significant morbidity —

Question 33

# Skip Why don't we always use endovascular repair?

Answer 33

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.

Question 34

What is a risk of emergency EVAR?

Answer 34

Abdominal compartment syndrome – no removal of blood from abdomen Too much pressure in abdomen – kidney failure

Question 35

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

Answer 35

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