Peripheral and Visceral Artery Aneurysms

Question 1

Risk factors

Answer 1

Smoking

HTN

Hyperlipidaemia

FH

Question 2

Possible causes

Answer 2

Trauma

Infection

Marfan’s/EDS

Takayasu’s

Question 3

Broadly speaking how will they present?

Answer 3

Asymptomatic and found incidentally

Symptomatic but not rupture

Symptomatic secondary to a rupture

Question 4

Investigation

Answer 4

Best is CT angiography

MR angiography is a good alternative due to less risk of kidney damage from radiation

US duplex scans can be useful for detection and follow up.

Question 5

General management

Answer 5

Watchful waiting with antiplatelets and statin therapy and smoking cessation

Surgical intervention that is endovascular or open depending on location and size

Question 6

What are the most common peripheral artery aneurysms?

Answer 6

Popliteal artery (70-80%) and femoral artery aneurysms.

Question 7

Why are popliteal aneurysms dangerous?

Answer 7

High risk of embolisation and/or occlusion

Question 8

Clinical features of PopAA

Answer 8

Usually present symptomatically with either ALI or less commonly with intermittent claudication

Thrombosis of a popliteal aneurysm has a 50% amputation rate due to trash to the tibial vessels.

They can however also be found incidentally, from e.g. compression symptoms on the poplitea vein or peroneal nerve.

Question 9

Investigations of PopAA

Answer 9

Ultrasound duplex scan to dx from popliteal fossa swelling like Baker’s cyst or lymphadenopathy.

Further imaging will often be via CT angiogram or MR angiogram.

Question 10

When should symptomatic popliteal aneurysms be treated?

Answer 10

Always regardless of size due to risk of embolic events.

Question 11

When should asymptomatic popAA be treated?

Answer 11

>2.5cm should be considered for treatment

If there is a large thrombus load a lower threshold should be considered

Question 12

Surgical approaches of popAA

Answer 12

Endovascular repair

Surgical repair

Question 13

Explain endovascular repair

Answer 13

Stent insertion across the aneurysm

This requires the artery above and below aneurysm to be well.

Question 14

Risks of endovascular repair

Answer 14

Incur risks of continued aneurysm sac filling through collateral vessels and in-stent thrombosis can occur.

This is however the preferred choice in unfit patients

Question 15

Explain surgical repair of popAA

Answer 15

Ligation of the aneurysm or resection of it with a bypass graft

The graft can be from a vein of the patient or a synthetic graft.

Question 16

Femoral artery aneurysms are typically pseudoaneurysms.

Two major causes of FeAA

Answer 16

Percutaneous vascular interventions

Patient self-injecting into femoral artery.

Question 17

Clinical features of FeAA

Answer 17

The symptoms and signs are from either thrombosis, rupture or embolisation of the anuerysm

In IVDU infection might also be concurrent

There will be varying degrees of claudication or ALI

But often no symptoms more than swelling in the groin

Question 18

Investigations of FeAA

Answer 18

US duplex scan first

Then CT angiography or MR angiography for anatomical mapping and operative planning

Question 19

Mainstay treatment for FeAA

Answer 19

Open surgical repair

Endovascular repair is very rarely performed

Question 20

Visceral arteries most commonly affected in aneurysm formation

Answer 20

Splenic artery

Hepatic artery

Renal artery

Question 21

Main risk factors of splenic artery aneurysm

Answer 21

Female

Multiple pregnancies

Portal HTN

Pancreatitis

Pancreatic pseudocyst formation

Question 22

Clinical features of SpAA

Answer 22

Vague epigastric or LUQ pain

Those that rupture will present with severe abdo pain and haemodynamic compromise

Question 23

Investigations of SpAA

Answer 23

CT angiography or MR angiography

Question 24

First line management of SpAA

Answer 24

Endovascular repair with embolisation or covered stent grafts.

Open repair might be advised if the patient is unstable

Question 25

Second most common visceral aneurysm

Answer 25

Hepatic artery

Question 26

Causes of HeAA

Answer 26

Percutaneous instrumentation (50%)

Trauma

Degenerative disease

Post-liver transplant

Question 27

Clinical features of HeAA

Answer 27

Usually asymptomatic

Vague RUQ or epigastric pain

Jaundice can occur

Question 28

Investigation of HeAA

Answer 28

CT angiography or MR angiography

Question 29

Firstline management of HeAA

Answer 29

Endovascular repair

Best done with embolisation or covered stent grafts, once the patient is haemodynamically stable, in those with suitable anatomy

Question 30

Clinical features of renal artery aneurysm.

Answer 30

Usually found incidentally and asymptomatic

Haematuria, resistant HTN or loin pain

Question 31

Investigation of ReAA

Answer 31

CT angiography or MR angiography

Question 32

First line treatment of ReAA

Answer 32

Endovascular repair

Stent can be inserted easily if it is the main renal artery that is affected.

Coils and covered stent graft might have to be used if it affects the hilum.