Red Book - AAA

Question 1

Mortality of AAA

Answer 1

50% of patients get to hospital alive

50% die before surgery

further 50% do not survive surgery

Question 2

Risk Factors for AAA

Answer 2

Male
Age>65
Smoking
Hypertension
MI/Cerebrovascular disease
Genetics/Familial - Marfans/Ehler's

Question 3

AAA presentation

Answer 3

Classical - Triad:
Pain (back)
Circulatory compromise - shock
Pulsatile mass

Atypicals:
Back pain, radiation to legs
Chronic back pain (contained rupture)
Transient Lower Limb paralysis

GI bleed - aorto-enteric fistula (usually an eroding graft)

Question 4

Imaging modalities (list them)

Answer 4

CT
US
MRI

Question 5

Adv/Disad of CT for AAA

Answer 5

Ad:

Best for diagnosis when uncertain
Analysis of extent of disease
Confirm and localise rupture site
Evaluate aortic wall

Disad:
Needs to be stable for transfer
Delays surgery
Contrast??

Question 6

Ad/Disad of US

Answer 6

Ad:
Rapid performance
Detect aneurysm and free flui
Simple/Cheap

Disad:
Imperfect sensisitvity

Question 7

Ad/Disad MRI

Answer 7

Ad:
Specific and sensitive
No contract needed
Tissue characterisation

Disad:
Long time - not approrpirate for AAA
Cost
Lower spatial resolution

Question 8

Classify complications of AAA repair

Answer 8

Early and Late

Graft and Non Graft related

Question 9

Graft related comps

Answer 9

Early - 
Massive transfusion
Distal emboli
Aortic branch involvement - pancreatitis/AKI
Endoleak

Late-
Infection
Graft occlusion
Aorto-enteric fisutla

Question 10

Non graft related comps

Answer 10

Early:
Renal failure 
MI
Paraplegia
HAP/VAP
ARDS
ACS
Ileus

Late:
Resp wean
Small bowel obst
Hernia
DVT
Sexual dysfunction

Question 10

Non graft related comps

Answer 10

Early:
Renal failure 
MI
Paraplegia
HAP/VAP
ARDS
ACS
Ileus

Late:
Resp wean
Small bowel obst
Hernia
DVT
Sexual dysfunction

Question 11

Prognositcation

Answer 11

Hardman Index (score 0-5, >2 = 80% mort)

Glascow Aneurysm Score (score of 84 = 65% pred mort)

Question 12

Hardman index variables

Answer 12

Age>76
Creatinine> 190 umol
Hb <90
MI on ECG
LOC on arrival

(1 point each)

Question 13

Glascow Aneurysm Score Variables

Answer 13

Age ( points in years)
Shock (17)
Myocardial disease (7)
Cerebrovascular disease (10)
Renal disease (14)

Question 14

When to do elective repair

Answer 14

AAA>5.5 in men, 5 in women

Growth > 1cm/year

Question 15

When to insert a spinal drain

Answer 15

Rescue therapy for delayed paraplegia post op

Reduce CSF pressure after an abdo EVAR with risk of cord ischaemia

Other:
Lower ICP
Monitor CSF chemistry
Drainage of shunts (specially if infected)

Question 16

Principles of spinal drainage

Answer 16

Cord perfusion pressure = MAP - CSF pressure

Drain CSF, reduce CSF pressure to reduce spinal cord ischaemia

Therefore increase cord perfusion pressure

Question 17

Contraindications to spinal drain

Answer 17

Absolute;
Anti coagulation
Bleeding diathesis

Not recommended:
Non-communicating hydrocephalus
Large intra-cranial mass (tumour, bleed)
Infection of surround tissues for insertion site

Question 18

Management of rupture

Answer 18

ABCDE, surgical team, senior anaesthetic, ODP and ITU.

Do not delay for investigations

Resus:
large bore iv access, rapid infusors ready
X-match 6 units, activate major haemorrhage protocol
Systolic of 90
Analgesia

Ix;
FBC, U&E, Coag, Gas
ECG
Imaging if time

SURGERY