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Gen Surgery > Arterial Aneurysms > Flashcards

Arterial Aneurysms Flashcards

1
Q

What is an aneurysm?

A

A focal permanent dilatation of an artery that is > 1,5 times the normal diameter of the artery

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2
Q

What is ectasia?

A

Focal dilatation of an artery that is <1,5 the normal diameter but >1 x the diameter

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3
Q

What is arteriomegaly?

A

Diffuse dilatation of the entire arterial segment

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4
Q

What is aneurysmosis?

A

Multiple arterial aneurysms with intervening normal arterial segments

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5
Q

5 complications of arterial aneurysms

A 
Rupture 
Acute or chronic thrombotic occlusion 
Acute or recurrent thromboembolism 
Pressure related complications 
Spontaneous fistulisation
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6
Q

what is a true aneurysm

A

The wall of the aneurysm (sac) incorporates all the conventional layers of an artery, i.e. the intima, media and adventitia.

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7
Q

what is a false aneurysm?

A

The wall of the aneurysm comprises adventitia and compressed surrounding tissue only.

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8
Q

what is the aetiology of arterial aneurysms

A
  • degenerative aneurysms
  • infective aneurysms
  • connective tissue disorders
  • trauma
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9
Q

how are arterial aneurysms classified?

A 
Anatomical location
· Aneurysm type: True or false
(pseudoaneurysms)
· Morphology
· Size
· Aetiology
· Clinical presentation
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10
Q

explain the classification of arterial aneurysms based on anatomical location

A

aortic - abdominal aortic aneurysm, thoraco abdominal aortic aneurysm
non aortic - peripheral, renal,carotid, subclavian

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11
Q

explain the classification of arterial aneurysms based on morphology

A

fusiform - spindle shaped

saccular - saccular outpouching in an arterial segment ( complicated at a smaller diameter compared to fusiform )

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12
Q

explain the classification of arterial aneurysms based on size and the consequence for treatment

A

small: asymptomatic, low risk of complications - observe over time
large: even if asymptomatic have a high risk of complication therefore treat early

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13
Q

explain the classification of arterial aneurysms based on aetiology

A

degenerative: atherosclerotic, fibromuscular dysplasia, intimo medial mucoid degeneration
infective: tb, syphyllis
inflammatory/vascultis: takayasus, giant cell arteritis
connective tissue: marfans, ehler danlos
post dissection: cystic media necrosis, trauma
post stenotic: thoracic outlet syndrome, coarctation of the aorta
trauma:
congenital: turners, menkes syndrome, tuberous sclerosis

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14
Q

what is the most common aneurysm

A

abdominal aortic aneurysm AAA

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15
Q

how are AAAs classified anatomically?

A
  • Infra-renal: ~ 90% of AAAs are infra-renal
    · Juxta-renal: the proximal neck (distance between the renal arteries and the aneurysm sac) is less than 8mm in length.
    · Para-renal: one of the renal arteries comes off the aneurysm itself
    · Supra-renal: both the renal arteries and or the mesenteric vessels come off the aneurysm
    · Thoraco-abdominal aortic aneurysm (TAAA): This may involve any part of the aorta between the left subclavian artery and the aortic bifurcation. Some of these TAAAS have a AAA component as well.
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16
Q

why do AAAs develop? list 5 theories?

A 
Uncontrolled hypertension
· Hypercholesterolaemia
· Smoking
· Imbalances between proteases
and anti-proteases[ --> destruction of collagen and elastin in the media. These enzymes include elastase and metallo-proteinase (MMP) 2 and 9]
· Infection: chlamydia pneumonia
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17
Q

classify AAAs accordign to size

A

small: 4-5.5cm and low risk of rupture 1-2%
large: >5.5cm in diameter with high risk of rupture

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18
Q

Relate aneurysm size and risk of rupture

A 
<4cm     0% per year
4-5cm    0.5 to 5% per year
5-6cm   3 to 15% per year
7-8cm    10 to 20% per year
7-8cm     20 to 40% per year 
>8cm    30 to 50% per year
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19
Q

clinical approach to aneurysms

A

asymptomatic
symptomatic
complicated

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20
Q

typical symptoms in patients with AAA

A 
Vague abdominal pain
· Recent onset backache
· Vomiting (duodenal
compression)
· Constipation (colonic
compression)
· Flank pain (ureteric
compression)
· Chronic venous disease
(venous compression)
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21
Q

complications of AAA

A

acute lower limb ischaemia (macro embolism)
blue toe syndrome ( microembolism)
rupture: free intraperitoneal or contained retroperitoneal or chronic contained leak
aorto enteric fistula
aorta caval fistula

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22
Q

which imaging modalities are used to confrim the diagnosis fo AAA

A

abdominal duplex ultrasound (DUS)
computed tomography angiography CTA
magnetic resonance angiography
conventional digital subtraction angiography

23
Q

why should we screen for AAA?

A

70% are asymptomatic (undetected) prior to rupture.
overall mortality for ruptured AAA = 90%
~75% die before reaching a hospital.

< 5% mortality with elective AAA repairs.

Ultrasound is effective and inexpensive.

MASS trial: ~53% reduction in aneurysm related mortality

24
Q

who do we screen for AAA?

A

Elderly Caucasian males > 65 years
· Elderly patients with documented peripheral aneurysms
· Patients with documented thoracic aortic aneurysms
· Family history of AAAs

25
Q

how do we conservatively treat AAA?

A 
Smoking cessation strategies
· Weight loss
· Anti-platelet therapy
· Lipid-lowering strategies
· B-Blockers
· Optimum blood pressure
control
26
Q

indications for surgical intervention

A 
-All symptomatic AAAs
· All complicated AAAs
· Asymptomatic AAA > 5.5 cm in males
· Asymptomatic AAAs > 5 cm in females
· Small AAAs on surveillence with rapid enlargement ( > 1
cm after 1 year on repeat scan) 
· Asymptomatic AAA with a large iliac aneurysm > 3cm
· Asymptomatic saccular AAA >3 cm
27
Q

surgical options

A

open repair
EVAR
laparoscopic assisted AAA repair +robotic assisted AAA repairs

28
Q

risk factors for operative mortality

A

Age > 70 years
Gender – females
Renal dysfunction / chronic renal failure
Severe pulmonary dysfunction
Cardiac co-morbidity: recent myocardial infarction,
intractable CCF,unstable angina, significant arrhythmia or valvular disease.

29
Q

what is the classic triad that pts present with after a ruptured AAA

A

-Sudden onset severe backache
· Shock
· Pulsatile abdominal mass

30
Q

what is cullens sign?

A

bluish discolouration involving the scrotum, around the umbilicus

31
Q

what is grey turners sign?

A

blue ish discolouration involving the flanks

32
Q

on admission pts should be evaluated with these investigations

A 
A full blood count
· Creatinine levels
· Electrocardiogram (ECG)
· Serial blood pressure recordings
· The patients age
· The patients co-morbidities
· History of previous abdominal /vascular surgery
33
Q

what are the 5 variables in the hardman risk index and what is it for?

A

It is a predictive scoring system that aids decision making for intervention
1. Age > 79 (octogenerians or older)
·2 Blood pressure persistently < 90 mmHg systolic
· 3Creatinine > 179 uMol/L
· 4 Haemoglobin level < 9 g/dL
· 5 Ischaemic ECG

34
Q

how does one interpret the hardman risk index score?

A

3 or more variables: 100% operative mortality
2 variables: 70% mortality - can be offered surgery
1 or less variables” benefit enormously from surgery
0 variables: operative mortality still 15%

35
Q

where are thoraco abdominal aortic aneurysms located

A

distal to the left subclavian artery and involves both the descending thoracic and abdominal aorta

36
Q

aetiology of TAAAs 6 examples

A 
- Non-specific degenerative
 · Takayasu’s disease
· Intimo-medial mucoid degeneration
· HIV-related aneurysms 
· Mycotic aneurysms
· Tuberculous aortitis with aneurysms
37
Q

clinical features of TAAA

A 
-High interscapular backache 
· Chest and/or abdominal pains 
· Dysphagia
· Dysnoea
· Stridor, hoarseness, superior vena cava syndrome (these are more common in aortic arch aneurysms)
38
Q

treatment options for TAAA

A
  1. open surgical repair
  2. hybrid procedures
  3. endovascular repair
39
Q

explain how a dissecting aortic aneurysm develops

A

complication of chronic aortic dissection –> arterial wall dissects via an intimal tear resulting in a true lumen and a false lumen –> the false lumen gradually enlarges to become aneurysmal

40
Q

what is the difference between stanford A and stanford B acute aortic aneurysms?

A

stanford A: arising from ascending aorta and treated surgically
stanford B: arising from distal to the left subclavian artery and mostly managed medically
B more common than A

41
Q

clinical features of dissecting aortic aneurysms

A

Features of compression (chest pain, dysnoea, dysphagia, etc)
· Rupture (overall mortality > 95%)
· Malperfusion. The dissection may extend into aortic branch vessels resulting in ischaemic complications viz. stroke, mesenteric ischaemia, renal dysfunction, lower extremity ischaemia, paraplegia.

42
Q

treatment options for dissecting aortic aneurysms

A
  1. Open surgical repair
  2. Endovascular thoracic aneurysm repair (TEVAR)
  3. Hybrid procedures
43
Q

clinical features of peripheral aneurysms ( lower extremity > upper extremity)

A
  1. Thrombo-embolic complications
    · Acute limb ischaemia
    · Claudication
    · Critical limb ischaemia
    · Blue toe syndrome / Blue digit syndrome
  2. Features of compression
    · Regional / discomfort
    · Limb swelling /distended veins(venous compression)
    · Nerve compression
  3. Rupture. This is exceptionally rare in peripheral aneurysms (< 5%)
44
Q

clinical presentation of popliteal aneurysms

A

Approximately 50% are bilateral
· Approximately 50% have an associated AAA
· Approximately 40% – 50% will have an associated femoral aneurysm
· Approximately 50% will present clinically with acute limb ischaemia

45
Q

2 most common peripheral aneurysms

A

popliteal and femoral account for 90% of peripheral aneurysms

46
Q

aetiology of popliteal aneurysms

A

non specific degenerative
trauma
HIV related
tuberculous aneurysm

47
Q

indications for treatment of popliteal aneurysm

A

· All symtomatic or complicated aneurysms

· All asymptomatic non-specific degenerative aneurysms > 2cm

48
Q

treatment of popliteal aneurysm

A
  1. Open surgical repair.
  2. Endovascular popliteal
    aneurysm repair (EVPAR) using peripheral covered stents.
49
Q

complications of popliteal aneurysms

A

thrombotic occlusion
thromboembolism
rupture

50
Q

aetiology of femoral aneurysms

A 
· Pseudoaneurysms. These are anastomotic aneurysms = =most common femoral aneurysms.
· Non-specific degenerative aneurysms
· HIV-related aneurysms
· Tuberculous aneurysms
· Mycotic aneurysms
· Trauma
51
Q

clinical presentation of femoral aneurysms

A

· Approximately 70% are bilateral

· Approximately 25% are associated with a AAA

52
Q

indications for treatment of femoral aneurysms

A

· All symptomatic or complicated femoral aneurysms

· All asymptomatic non-specific degenerative aneurysms > 2.5 cm

53
Q

treatment of femoral aneurysms

A

open surgical repair

Gen Surgery (31 decks)

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