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Cardiovascular system > Aortic dissection and aneurysm > Flashcards

Aortic dissection and aneurysm Flashcards

1
Q

What is meant by an aneurysm?

A

A permanent, localised dilatation of an artery of more than 50% of its normal diameter

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2
Q

What is the normal aortic diameter and at what size is an aortic aneurysm classified?

A

Normal diameter = 1.2 - 2cm
Aneurysm = >3cm

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3
Q

What are the 2 types of aneurysm?

A

True aneurysm
false aneurysm

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4
Q

What is meant by a true aneurysm?

A

An aneurysm in which all 3 wall layers are involved, so the artery ‘balloons’ at one distinct point

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5
Q

What is meant by a false aneurysm?

A

An aneurysm in which there is a defect in the artery wall and only 1 layer balloons out of the side of the artery

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6
Q

What can usually be found in the extra space of an aneurysm?

A

A platelet-rich thrombus caused by collagen exposure

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7
Q

What is the suspected pathogenesis of Abdominal Aortic Aneurysm?

A

Though it is not fully known, it is thought that it is due to abnormal regulation of elastin and collagen proteins in the aortic wall by enzymatic agents (Metallo-proteins)

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8
Q

What are some of the risk factors for Abdominal Aortic Aneurysm (AAA)?

A

Age - Risk increases with age
Sex - M:F = 6:1
Genetic - Male family members
Smoking
Hypertension
Atherosclerosis

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9
Q

What percentage of AAAs are asymptomatic?

A

75%

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10
Q

What are some of the common methods of screening for Abdominal Aortic Aneurysms (AAA)?

A

Ultrasound
CT scan

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11
Q

What are some common screening methods for AAA?

A

Ultrasound
CT scanning

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12
Q

What are the uses of ultrasound in AAA scanning?

A

It allows for screening and surveillance
It can give the AP diameter (Anterior - Posterior)
It can show involvement of the iliac arteries

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13
Q

What are the uses of CT scans in AAA?

A

It can give the aneurysm morphology, such as shape, size and iliac involvement
It allows for management planning

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14
Q

What occurs in an AAA rupture?

A

The blood is first, briefly contained in the retroperitoneum, before erupting into the rest of the abdominal cavity

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15
Q

At what point should intervention be started in AAA?

A

Evidence recommends repair of asymptomatic AAA when it reaches an AP diameter of 5.5cm, or when it becomes symptomatic

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16
Q

What are some common symptoms of AAA?

A

Rupture
Trashing
Pain

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17
Q

What is meant by trashing?

A

Micro-emboli moving down towards the feet due to breaking apart of the blood clot found in the aneurysm

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18
Q

What are the 2 classes of repair of AAA?

A

Elective aneurysm repair - prophylactic
Emergency aneurysm repair - Due to risk to life

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19
Q

What are the 2 types of treatment for AAA?

A

Open repair
EVAR = EndoVascular Aneurysm Repair

20
Q

What are the advantages and disadvantages of EVAR

A

It is not possible in 25% of people
It has a lower mortality risk (1-2%) than open repair
It has a much faster recovery time (7-10 days) than open repair
It requires on-going follow ups and investigations

21
Q

What are the advantages and disadvantages of open repair?

A

It is possible in most people
It has a greater mortality risk (3-4%) than EVAR
It has a much longer recovery time (8-9 months) than EVAR

22
Q

What is involved in the EndoVascular Aneurysm Repair (EVAR) procedure?

A

Local anaesthetic is applied
Percutaneous access in the groin allows passing of a stent up through the femoral artery
This is X-ray guided
The stent is then opened via balloon
The stent is modular so comes in many parts
This provides a stronger, narrower tube for blood to pass through

23
Q

What is involved in the open repair procedure?

A

General anaesthetic is required
A laparotomy is given (Incision to access abdominal cavity)
Aorta and iliac arteries are clamped to prevent exsanguination
Dacron grafting used where the old wall of the aneurysm is removed and a new wall is grafted around the aorta

24
Q

What are some of the complications of EVAR?

A

Stent misplacement may lead to the stent covering the renal arteries or internal iliac arteries
Endoleak - blood flow out of the stent and into the aneurysm sac
Stent migration and dislocation - Pieces of the stent can move apart from each other

25
Q

What are some complications of of open repair?

A

Myocardial infarction
cerebrovascular accident
Pneumonia
Wound infection
UTI
Graft infection
Pulmonary Embolism
Renal failure
mesenteric ischaemia (No blood to intestines)
Lower limb ischaemia
Trash foot
Erectile dysfunction
Death

26
Q

What tests are performed to check fitness for intervention?

A

Cardiac assessment - Echo/Ejection function
Respiratory assessment - Pulmonary Function
Cardiopulmonary exercise test (CPX)
Renal assessment
Vascular assessment
Anaesthetic assessment
End of Bed test

27
Q

What is involved in surveillance for AAA?

A

When a patient has an aneurysm between 3 and 5.5cm, they are put under surveillance which allows them to receive regular ultrasound testing

28
Q

Who can be screened for AAA?

A

Only males over 65 can be screened via ultrasound, for AAA
Females are at a lower risk of getting AAA, but are at higher risk of death once it has developed

29
Q

What are the 3 types of Acute Aortic Syndromes?

A

Penetrating Aortic Ulcer (PAU)
Intra Mural Haematoma (IMH)
Aortic Dissection

30
Q

What is a Penetrating Aortic Ulcer?

A

A hole in the intimal layer f the aortic wall that allows blood to move into the wall as an ulcer

31
Q

What is an intra mural haematoma?

A

A Penetrating Aortic Ulcer in which the outer edge becomes disrupted, allowing blood to pass out of the aorta, through the ulcer

32
Q

What is an aortic dissection?

A

Necrosis of the medial layer allows medial degeneration. A tear in the intima layer allows blood to move into the media layer and propagate, forming a flap between the true lumen and false lumen

33
Q

What is meant by transmural bleeding?

A

Bleeding between the layers and eventually through the tunica adventitia

34
Q

Where can propagation of an aortic dissection move to?

A

The aortic arch
The aortic valve
The coronary arteries
The mesenteric and renal arteries
The iliac arteries and down the limb

35
Q

What allows a person to be predisposed to aortic dissection?

A
  • Family history due to gene mutations such as Fibrillin-1 and Transforming growth factor ß1
  • Connective tissue disorders such as Ehlers Danlos syndrome, Marfans syndrome and Loeys dietz syndrome
  • Trauma, including iatrogenic trauma
36
Q

How are aortic dissections usually classified?

A

Stanford classification (Type A and Type B)

37
Q

What is meant by a Type A aortic dissection?

A

A dissection that is proximal and affects the ascending aorta and arch of the aorta central to the left subclavian artery
This is a cardiothoracic emergency!

38
Q

What is meant by a Type B aortic dissection?

A

A dissection that is distal and affects anywhere distal to the left subclavian artery, including the thoracic and abdominal aorta
This requires vascular surgery

39
Q

What are the risks of propagation of the dissection flap?

A

Acute aortic valve regurgitation
Myocardial infarction
Cardiac tamponade
Stroke
Upper limb ischaemia
Lower limb ischaemia
Mesenteric ischaemia
Spinal ischaemia (Paraplegia)

40
Q

What are the main symptoms of Aortic dissection?

A
  • Acute excruciating pain (tearing pain between the scapulae
  • Chest pain
  • Back pain
  • Abdominal pain
  • Syncope
  • Pulse deficits
  • Hypotension/shock
  • Visceral ischaemia
  • Renal ischaemia
  • Limb ischaemia
  • Recurrent pain
  • Spinal cord ischaemia (Paraplegia)
41
Q

How is an aortic dissection diagnosed?

A

Via a CT scan from aortic arch to the femoral arteries, showing the full anatomy involved, the full extent of the dissection and perfusion to the limbs

42
Q

What is the purpose of treatment of aortic dissection?

A

To prevent progression and rupture

43
Q

What are the 2 main forms of treatment?

A

Blood pressure management
Surgery

44
Q

What is the aim for blood pressure lowering treatment?

A

To reduce the aortic wall stress and reduce the force of left ventricular ejection
The target systolic blood pressure is around 100-120mmHg with a heart rate below 60bpm

45
Q

What are the 2 forms of surgery available for aortic dissection?

A

Thoracic EndoVascular Repair - Stent graft
Open Repair

46
Q

What are the risks of surgical intervention for aortic dissection?

A

30-40% mortality risk
10% stroke risk
2% spinal cord ischaemia (Paraplegia)

47
Q

When are follow-up examinations performed after surgical intervention?

A

3, 6 and 12 months

Cardiovascular system (45 decks)

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