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Gwen - Vascular > Aortic disease > Flashcards

Aortic disease Flashcards

1
Q

What is an aneurysm?

A

https://www.youtube.com/watch?v=FgcHtmry3iA

A localized, blood-filled balloon-like bulge in the wall of a blood vessel. The arteries most frequently involved are the abdominal aorta, iliac, popliteal, femoral artery and thoracic aorta (in decreasing frequency)

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2
Q

What are the different types of aneurysms?

A
  • True aneurysm
  • False aneurysm
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3
Q

What is a true aneurysm?

A

One that involves all three layers of the wall of an artery (intima, media and adventitia).

True aneurysms include atherosclerotic, syphilitic, and congenital aneurysms, as well as ventricular aneurysms that follow transmural myocardial infarctions (aneurysms that involve all layers of the attenuated wall of the heart are also considered true aneurysms).

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4
Q

What are the subtypes of true aneurysms?

A
  • Fusiform
  • Saccular
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5
Q

What is the difference between a fusiform and saccular true aneurysm?

A

The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the blood vessel. A saccular-shaped aneurysm bulges or balloons out only on one side.

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6
Q

What disease processes are true aneurysms associated with?

A
  • Hypertension
  • Atherosclerosis
  • Smoking
  • Collagen abnormalities - e.g. Marfan’s, Ehler-Danlos
  • Trauma
  • Infection - syphilis, E. coli, Salmonella
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7
Q

What is a pseudo-aneurysm?

A

A collection of blood leaking completely out of an artery or vein, but confined next to the vessel by the surrounding tissue. Therefore, the surrounding tissues form the wall of the aneurysm, not the walls of the vessel. This blood-filled cavity will eventually either thrombose (clot) enough to seal the leak, or rupture out of the surrounding tissue.

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8
Q

What is the most common location for a AAA to occur?

A

Infrarenal - 95%

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9
Q

Which sex do AAA’s occur in more commonly?

A

Males

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10
Q

When does aortic dilation become classified as an aneurysm?

A

Exceeds 3.0 cm

or

Increases by 50% of normal circumference

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11
Q

What are the common sites for AAA’s to occur?

A
  • Aorta
  • Iliac artery
  • Femoral Artery
  • Popliteal artery
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12
Q

What are complications of AAA’s?

A
  • Rupture
  • Thrombosis/Embolism
  • Fistulae
  • Pressure on other structures
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13
Q

How would someone with an unruptured AAA present?

A

Typicall <5.5cm

Asymptomatically - often discovered incidentally

If symptomatic:

  • Central abdominal pain/back pain
  • Distal embolic events - due to aneurysmal emboli formation
  • Evidence of aortic occlusion - due to thrombus formation
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14
Q

How would someone with a ruptured AAA present?

A
  • Intermittent/continuous abdominal pain - radiates to the back, iliac fossa or groins
  • Collapse/Shock - hypovolaemic
  • Expansile abdominal mass

Shoch + backpain = treat as AAA

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15
Q

What might you see on an abdominal examination in someone with an AAA?

A

Expansile abdominal mass

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16
Q

If you suspected a ruptured AAA, what investigations would you do?

A
  • Ultrasound
  • CT
  • MRI
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17
Q

What age does screening for AAAs take place?

A

65 years

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18
Q

What threshold diameter of an aneurysm is used to determine whether endovascular repair would be beneficial?

A

5.5cm

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19
Q

What is the incremental risk of rupture for an aneurysm if it is less than 5.5cm?

A

1% per year

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20
Q

What is the incremental risk of rupture if an aneurysm is above 6.0cm?

A

10% per year

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21
Q

What factors increase the risk of an aneurysm rupturing?

A
  • HTN
  • Smoking
  • Female
  • Strong FH
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22
Q

Why is operating on an aneurysm <5.5 cm not advisable?

A

You risk doing more harm than good to the patient.

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23
Q

When assessing an individuals fitness for surgery for a AAA, what Pre-operative investigations would you perform?

A

Anaesthetic Work up

  • Routine bloods
  • ECG, Echo, cardiac perfusion scan
  • CXR, PFTs
  • CT abdomen - assess anatomy
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24
Q

What is the risk of operative mortality for open surgery on a AAA?

A

Approximately 5%

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25
Q

What are complications of open surgery on a AAA?

A
  • Spinal/visceral ischaemia
  • Haemorrhage
  • Aorto-duodenal fistula
  • Infected graft
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26
Q

What non-operative measures would you take for someone with an unruptured AAA?

A
  • Control of hypertension
  • Stop smoking
  • Lipid-lowering medication - statins
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27
Q

Why is ultrasound used as part of AAA screening programmes?

A

CT Abdomen is not suitable for AAA screening programs because of radiation exposure and cost.

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28
Q

If an individual had a AAA <5.5cm, how would you manage them?

A

Modify risk factors - HTN, Smoking, lipid lowering

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29
Q

What are the typical causes of Arterial aneurysms?

A

Atheroma

Trauma

Infection

Connective tissue disorders

Inflammatory - takayasu’s aortitis

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30
Q

If someone had a AAA >5.5 cm, how would you manage them?

A

Manage risk factors

Assess for either:

  • Endovascular repair
  • Open repair
31
Q

What is an EVAR?

A

Endovascular Aortic repair

Involves placing a stent graft inside the aneurysm via a femoral arteriotomy.

http://www.vascularinfo.co.uk/aortic-aneurysm-surgery/endovascular-aneurysm-stent-repair-evar/

32
Q

What is involved in open repair of an abdominal aortic aneurysm?

A

Making a cut in the belly in order to get to the aneurysm and sewing in an artificial artery (graft) into the normal artery just above where the aneurysm starts and into the normal artery just below where it finishes.

33
Q

What type of graft(s) is/are used in an open surgical repair of a AAA?

A
  • Dacron
  • Gore-Tex
34
Q

What are disadvantages of EVAR?

A
  • “Endoleak”
  • Fragmention of device
  • Migration of endovascular stent
  • Long term follow-up required
  • Increased complication rate
  • Increased post-op intervention rate
35
Q

What is the difference in terms of follow up between an open repair and a EVAR insertion?

A

Open repair only needs a few clinics and then can be sent on their merry way, whereas EVAR requires long term follow up

36
Q

What is endoleak?

A

Sac not excluded from circulation (still have blood going into the aneurysm sac). This means there is a continuing risk of rupture if endoleak develops.

37
Q

How would you manage a ruptured AAA?

A
  • ABCDE
  • Call vascular surgeon - warn them
  • ECG
  • Bloods - amylase, Hb, crossmatch
  • IV access
38
Q

What are causes of thoracic aortic aneurysm?

A
  • Atherosclerosis
  • Infection
  • Inflammation
  • Congenital
39
Q

What type of infection can cause thoracic aortic aneurysm?

A

Syphilis

40
Q

What type of inflammatory process can cause thoracic aortic aneurysm?

A

Takayasu’s arteritis

41
Q

What is takayasus arteritis?

A

https://www.youtube.com/watch?v=fKXHxcV6eLU

Granulomatous giant cell vasculitis which causes stenosis and aneurysms in the branches of the aortic arch, particularly around the branch points.

42
Q

What are congenital causes of Thoracic aortic aneurysm?

A
  • Bicuspid aortic valve
  • Marfan’s Syndrome
  • Coarctation of the Aorta
43
Q

What are is bicuspid Aortic Valve?

A

Normal Aortic Valve has 3 leaflets, bicuspid has 2

44
Q

What are signs/symptoms of thoracic aortic aneurysm?

A

Asymptomatic

If symptomatic:

  • SOB
  • Heart failure
  • Dysphagia and hoarseness
  • Sharp chest pain radiating to back
  • Pulsatile mass
  • Hypotension
45
Q

What is Aortic dissection?

A

https://www.youtube.com/watch?v=vrbsxsadiwI

Tear in the inner wall of the aorta. Blood penetrates the diseased medial layer and then cleaves the intimal laminal plain leading to dissection

46
Q

What is the area called in a dissection between the intima and media which forms?

A

False lumen

47
Q

What are causes of aortic dissection?

A
  • Chronic hypertension (stress, increased BV, coarcation)
  • Connective tissue disorders - Marfan’s, Ehler Danlos
  • Aneurysms
48
Q

What are signs/symptoms of aortic dissection?

A

Symptoms

  • Tearing/severe chest pain radiating to the back
  • Collapse

Signs

  • Reduced/abscent peripheral pulses
  • Hypotension/hypertension
  • Soft early diastolic murmur (AR)
  • Pulmonary oedema
49
Q

What complications of aortic dissection can cause a patient to present with sudden collapse?

A
  • Tamponade
  • Acute AR
  • External rupture
50
Q

Why might there be reduced/absent peripheral pulses in someone with aortic dissection?

A

As the dissection extends, branches of the aorta occlude sequentially leading to unequal arm pulses, acute limb ischaemia, and other signs of obstructive ischaemia

51
Q

If someone with aortic dissection had anuria, what might have happened?

A

Dissection has spread down to the renal arteries and has occluded them

52
Q

If someone with aortic dissection had hemiplegia, what may have happened?

A

Occlusion of the carotid artery

53
Q

What classification systems are used to classify aortic dissections?

A
  • Debakey - Type I, II, III
  • Stanford - Type A, B
54
Q

What is the difference between a type A and type B dissection (based on stanford classification)?

A
  • Type A - all dissecitons involving ascending aorta, regardless of site of origin
  • Type B - all dissections not involving ascending aorta
55
Q

What classifies as a type I debakey dissection?

A

Originates in the ascending aorta, and propagates at least to the aortic arch and often beyond it distally

56
Q

What classifies as a type II debakey dissection?

A

Originates in and is confined to the ascending aorta

57
Q

What classifies as a type III debakey dissection?

A

Originates in the descending aorta and extends distally downwards.

Can rarely move retrograde into the arch and ascending aorta

58
Q

How would you investigate someone with a suspected aortic dissection?

A
  • CXR - Mediastinum may be widened
  • Urgent CT Angiography scan
  • Transoesophageal Echocardiocraphy
59
Q

If someone presented with a Stanford Type A aortic dissection, what would you do to manage them?

A

Surgery - immediately call cardiothoracic surgeons

60
Q

How would you manage someone with a Stanford type B aortic dissection?

A

Meticulous BP control

  • Sodium Nitroprusside + β-blockers
61
Q

How does AR occur in aortic dissection?

A

Could cause dilation of the ascending aorta

62
Q

How would you generally manage someone with suspected aortic dissection?

A

Determine need for surgical intervention

  • Crossmatch
  • ECG
  • CXR
  • CT/MRI/TOE
  • Hypotensives
63
Q

What is the mortality rate for ruptured AAA which are treated?

A

41%

64
Q

What debakey classification is the following aneurysm?

A

Type I - involves ascending and descending aorta (= Stanford A)

65
Q

What debaey classification is the following dissection?

A

Type II - involves ascending aorta only (= Stanford A)

66
Q

What debakey classification is the following dissection?

A

Type III - involves descending aorta only, commencing after the origin of the left subclavian artery (= Stanford B)

67
Q

What debakey classification is the following dissection?

A

Type III - involves descending aorta only, commencing after the origin of the left subclavian artery (= Stanford B)

68
Q

What stanford classification is the following type of dissection?

A

Type A - A affects ascending aorta and arch

69
Q

What stanford classification is the following dissection?

A

Type B - ​B begins beyond brachiocephalic vessels

70
Q

What is the screening for AAA?

A
  • Open to men >65yrs (ultrasound used)
  • Annual imaging if 3-4.4cm
  • 3 monthly imaging 4.5-5.4cm
71
Q

What’s co-arctation of the aorta?

A

A narrowing of the descending aorta (usually occurs just distall to origin of left subclavian artery)

72
Q

What conditions are co-arctation of the aorta assocaited with?

A
  • Tuner syndrome
  • Bicuspid aortic valve
73
Q

Key presentation features of co-arctation of the aorta/?

A
  • Infancy: GHF
  • Adult: hypertension

Signs:

  • CVS general
    • Increased BP in upper limbs
    • Decreased BP in lower limbs (symtpoms of claudication in lower limbs due to decrease blood flow)
  • CVS pulses
    • ​Radio-femoral delay (femoral pulse later than radial pulse)
    • Weak femoral pulse
  • CVS auscultation
    • ​Scapular brui
    • Systolic murmur best heard over left scapulae
74
Q

Management of co-arctation of aorta

A

Ballon dilation +/- stenting

Gwen - Vascular (11 decks)

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