Aortic aneurysm

Question 1

What is an aneurysm

Answer 1

Local abnormal dilatation of a blood vessel >1.5 x normal diameter

Question 2

Common sites AA

Answer 2

Carotid artery, aortic arch, ascending aorta
Thoracic aorta
Renal artery
AAA
Femoral, politeal

Question 3

Risk for rupture of AAA

Answer 3

Smoking (development and rupture)
HPTN
Vascular disease
COPD
Hyperlipidaemia
Diabetes
Male
Obesity
Age
FH - connective tissue disorders eg marfans, EDS

Question 4

Presentation of AAA rupture

Answer 4

Collapse
Shock
Sudden onset abdo pain radiating to back
Loin to groin pain esp in elderly
Distal ischaemia
Palpable, tender, pulsatile and expansile AAA
V high mortality

Question 5

Immediate management of AAA rupture

Answer 5

A-E resus
Lower BP target - stop further blood loss
Early decision -> theatre
Palleative i cant operate

Question 6

When do you get screening for abdominal aneurysm

Answer 6

65 years old male

Question 7

What is the normal size for the abdominal aorta

Answer 7

<3cm diameter

Question 8

What management when AA 3-4.4cm

Answer 8

Annual re scans

Question 9

What management when AA 4.5-5.4cm

Answer 9

3 monthly rescans

Question 10

What management when AA >5.5cm

Answer 10

Refer to vascular surgery

Question 11

When does risk of rupture per year start increasing

Answer 11

> 5cm - 1-10%
7cm =30-50%

Question 12

Indications for surgical repair of AA

Answer 12

aneurysm >5.5cm
Rapid expansion >0.5cm <6 months
Evidence of AAA tenderness
Rupture

Question 13

Types of surgery for AA

Answer 13

CT angiography (evaluate pre-op)
Endovascular AA repair - EVAR
Open repair

Question 14

Surgical EVAR vs ooen benefits

Answer 14

EVAR - minimally invasive, faster recovery, reduced mortality
Open repair - better long term outcomes, 5% mortality
Emergency repair - 50% mortality

Question 15

Complications of AAA

Answer 15

Rupture
Occlusion
Distal embolism

Question 16

Men vs women AAA

Answer 16

75% AAA patients are male and screening only for me
Risk of rupture for women much higher with much maller aneurysms

Question 17

What is the greatest risk for AAA

Answer 17

Smoking

Question 18

Screening test for AAA

Answer 18

US abdomen

Question 19

Gold standard imaging for AAA

Answer 19

CT angiogram

Question 20

Blood tests for ruptured AAA

Answer 20

FBC - ascertian if low platelet count and need transfusion for surgery
U+Es - endovascular - pre renal failure
Coagulationscreen - no underlying bleeding risk heparin
Valid blood grouping - essential for surgeyr

Question 21

Ruptured AAA

Answer 21

Acute pancreatitis
Back pain
Renal colic
Lower limb ishcaemia

Question 22

Management of AAA

Answer 22

Anatomy of the aneurysm
Baseline health of the patient
Clinical state of the patient on admission

Question 23

Ruptured AAA repair

Answer 23

Open surgical repair
Endovascular aneurysm repair (EVAR)
Palliative care

Question 24

What artery is sacrificed or occluded in endovascular repiar

Answer 24

Inferior mesenterica artery
Can lead to bowel ischaemia if marginal supply to L colon inadequate

Question 25

Complications of ruptured AAA

Answer 25

Bowel ischaemia from IM artery occlusion in surgery - Can be detected and fixed if open surgery Acute limb ischaemia clot from RAAA Abdominal compartment syndrome Graft infection Bood transusion complications eg coagulopathy, electrolyte disturbance, lung injury

Question 26

WHat is abdominal comparmtent syndrome

Answer 26

Following AAA repair INta abdominal pressure -> fall in renal perfusion, compression of IV reduceing cardiac preload and systemic perfsion -> splinting of diaphragm, resp compromise and T2 resp failure

Question 27

Complications ass w open srugery for R AAA

Answer 27

Abdo wound dehisecence immediately post op Large laporotomy -> incisional hernias

Question 28

Complications from endovascular reapir for RAAA

Answer 28

Haematomas or pseudoanurysms in groin at access site to germoral arteries-> on going bleeding Leakage of blood around stent graft into aneurysm sac-> enlargement of aneurysm around graft = endoleak -> CT angiograms for monitoring for rest of life

Question 29

Survival rates AAA

Answer 29

50% patients who reach hospital and receive intervention survive 33% OF PATIETNS DIE BEFORE reaching hospital Screening reducing number of deaths

Question 30

WHen rescan every 12 months AAA

Answer 30

3-4.4cm - small aneurysm

Question 31

Low AAA rupture risk

Answer 31

asymptomatic, aortic diameter < 5.5cm (i.e. small and medium aneurysms) abdominal US surveillance (on time-scales outlines above) and optimise cardiovascular risk factors (e.g. stop smoking)

Question 32

High AAA rupture risk

Answer 32

symptomatic, aortic diameter >=5.5cm or rapidly enlarging (>1cm/year) treat with elective endovascular repair (EVAR) or open repair if unsuitable. In EVAR a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm. A complication of EVAR is an endo-leak,