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AIP: Abdominal pain > Ruptured AAA > Flashcards

Ruptured AAA Flashcards

1
Q

What is the definition of an aneurysm?

A

abnormal dilatation of a blood vessel by more than 50% of its normal diameter

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2
Q

What is the definition of an abdominal aortic aneurysm?

A

dilatation of the abdominal aorta greater than 3cm

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3
Q

What proportion of men over 65 have an AAA?

A

1 in 70

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4
Q

Why is it important to identify and manage abdominal aortic aneurysm early?

A

for every 8mm increase in diameter, the relative risk of cardiovascular death increases by 1.34

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5
Q

What are 5 things thought to possibly cause AAA?

A
  1. Atherosclerosis
  2. Trauma
  3. Infection
  4. Connective tissue disease (e.g. Marfan’s disease, Ehler’s Danlos, Loey Dietz)
  5. Inflammatory disease (e.g. Takayasu’s aortitis)
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6
Q

What are 6 risk factors for triple A?

A
  1. Smoking
  2. Hypertension
  3. Hyperlipidaemia
  4. Family history
  5. Male gender
  6. Increasing age
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7
Q

What is a negative risk factor for AAA?

A

diabetes mellitus (it is unclear why)

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8
Q

How are many AAAs detected?

A

many are asymptomatic - incidental finding/screening

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9
Q

If a patient with AAA is symptomatic, what are 4 clinical features they may present with?

A
  1. Abdominal pain
  2. Back or loin pain
  3. Distal embolisation producing limb ischaemia
  4. Aortoenteric fistula
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10
Q

What are 3 things that may be present on examination in a patient with AAA?

A
  1. Pulsatile mass in abdomen - above umbilical level
  2. Rarely signs of retroperitoneal haemorrhage (Grey-Turner’s?)
  3. If ruptured - pain (abdo/back/loin), shock/syncope
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11
Q

What is the screening programme for AAA in the UK?

A
  • abdominal USS for all men in 65th year - National Abdominal Aortic Aneurysm Screening Programme (NAAASP)
  • 1.1% of those screened a diagnosed with AAA
  • 0.32% have AAA large enough to require direct referral for consideration of surgery (>55mm)
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12
Q

If the screening programme detects a man with AAA <55mm, what will be done next?

A

most will spend 3-5 years in surveillance prior to reaching threshold for elective AAA repair

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13
Q

What do the investigations for AAA detected in the outpatient setting involve?

A
  1. should be initially investigated with ultrasound scan
  2. once USS has confirmed diagnosis, follow-up CT scan with contrast warranted if >55mm
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14
Q

What is the advantage of performing a CT scan with contrast once AAA is detected on USS?

A

provides more anatomical details to determine suitability for endovascular procedures

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15
Q

Why is AXR not indicated in the workup for AAA?

A

will only rarely show AAA, if significant calcification of the arterial wall

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16
Q

When is medical management usually offered for AAA?

A

if <5.5cm

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17
Q

What are 5 aspects of management of AAA <5.5cm?

A
  1. Monitoring with duplex USS
  2. reduction of cardiovascular risk factors - smoking cessation,
  3. improved BP control
  4. statin + aspirin therapy
  5. weight loss and increased exercise
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18
Q

Why are AAAs <5.5cm monitored rather than surgically repaired?

A

prior to this, surgery provides no survival benefit for either open or endovascular repair

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19
Q

How frequent is monitoring of AAAs with duplex USS <5.5cm, depending on the size?

A
  • 3.0-4.4cm: yearly
  • 4.5-5.4cm: 3-monthly
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20
Q

What specific intervention must be made when AAAs are >6.5cm?

A

must notify DVLA, disqualified from driving until repaired surgically

21
Q

What are 3 situations when surgery for AAA is indicated?

A
  1. If AAA is >5.5cm in diameter
  2. AAA expanding at >1cm/year
  3. Symptomatic AAA in a patient who is otherwise fit
22
Q

When might an AAA beleft until 6cm until surgical repair is performed and why?

A

in unfit patients due to signficant risk of mortality from an elective repair compared to risk of mortality if not repaired

23
Q

What are the 2 main treatment options for AAA?

A
  1. Open repair: midline laparotomy or long transverse incision, exposing the aorta, clamping aorta proximally and iliac arteries distally, before segment removed and replaced with prosthetic graft
  2. Endovascular repair: introducing graft via femoral arteries, fixing stent across aneurysm
24
Q

What does open repair of AAA >5.5cm involve?

A
  • midline laparotomy or long transverse incision
  • exposure aorta and clamp proximally, clamp iliac arteries distally
  • segment removed and replaced with prosthetic graft
25
Q

What does endovascular repair of an AAA >5.5cm involve?

A

introducing graft via femoral arteries and fixing stent across the aneurysm

26
Q

How do the outcomes of open vs endovacsular repair of AAA >5.5cm compare?

A
  • similar long term outcomes -mortality same at 2 years
  • endovascular has better short term outcome in terms of decreasing hospital stay and 30 day mortality
  • however endovascular has higher rate of reintervention and aneurysm rupture
27
Q

What type of unruptured AAA repair may be more appropriate in younger patients?

A

open repair as higher risk of reintervention and aneurysm rupture with endovascular repair

28
Q

What is an important complication of endovascular repair of AAA?

A

endovascular leak - incomplete seal around aneurysm, resulting in blood leaking around the graft

if untreated, aneurysm can expand and subsequently rupture

29
Q

What is required following an endovascular repair of an AAA >5.5cm and why?

A

regular surveillance - usually USS unless complication is noted

also need investigation for any aneurysm expansion for an endoleak

due to risk of endoleaks which are often asymptomatic

30
Q

What are the 5 classifications of endoleaks following endovascular AAA repair?

A
  1. Type 1: leak at graft ends due to inadequate seal
    1. 1a = proximal, 1b = distal, 1c = iliac occlude
  2. Type 2: sac filling from a branch vessel, aka retroleak. most resolve spontaneously
    1. 2a = single vessel, 2b = two or more vessels
  3. Type 3: leak through a defect in the graft fabric
    1. 3a = separation of sections of the graft, 3b = hole in the graft
  4. Type 4: leak through graft fabric due to graft porosity, often intraoperative, resolves with cessation of anticoagulants
  5. Type 5: continued expansion of aneurysm sac without any demonstrable leak on imaging (also termed endotension)
31
Q

What type of aneurysm repair is a type 1 endovascular leak most common following?

A

thoracic aneurysm repairs

32
Q

Which type of aneurysm repair is a type 2 endoleak most commonly seen after?

A

AAA repairs

33
Q

What is the most common outcome of a type 2 endoleak?

A

most resolve spontaneously

34
Q

When does a type 4 endoleak often occur and what causes it to resolve usually?

A

intraoperatively

resolves with cessation of anticoagulants

35
Q

What are 4 complications of AAA?

A
  1. Rupture
  2. Retroperitoneal leak
  3. Embolisation
  4. Aortoduodenal fistula
36
Q

What are 4 factors which increase the risk of ruptured AAA?

A
  1. Increases expontentially with the diameter of the aneurysm
  2. Smoking
  3. Hypertension
  4. Female gender
37
Q

What are 4 symptoms that AAA can present with?

A
  1. Abdominal pain
  2. Back pain
  3. Syncope
  4. Vomiting
38
Q

What are 3 signs on examination of a ruptured AAA?

A
  1. Haemodynamic compromise
  2. Pulsatile abdominal mass
  3. Tenderness
39
Q

What is said to be the ‘classic triad’ of ruptured AAAs, present in 50% of patients?

A
  1. Flank or back pain
  2. Hypotension
  3. Pulsatile abdominal mass
40
Q

In which direction do most AAAs rupture?

A
  • 20% rupture anteriorly into peritoneal cavity - very poor prognosis
  • 80% rupture posteriorly into the retroperitoneal space
41
Q

What is shown on the image of the CT scan?

A

ruptured AAA, rupturing into the retroperitoneal space

42
Q

During A-E assessment of suspected AAA rupture, what are 4 important aspects of management?

A
  1. High flow oxygen
  2. IV access - 2x large bore cannulae
  3. Urgent bloods taken: FBC, U+Es, clotting, crossmatch for minimum 6 units
  4. treat shock carefully: raising BP will dislodge any clot and may precipitate further bleeding so aim for BP <100mmHg
43
Q

What amount of blood should you request from crossmatching?

A

minimum of 6U units

44
Q

Why must shock in AAA rupture be treated very carefully?

A

raising BP will dislodge any clot and may precipitate further bleeding so aim to keep BP <100

= permissive hypotension, preventing excessive blood loss

as long as patient cerebrating, BP is generally adequate

45
Q

What is the aim for BP when managing ruptured AAA?

A

aim for <100mHg - permissive hypotension

as long as patient cerebrating, BP generally adequate

46
Q

Where should a patient with ruptured AAA be transferred and who should be informed?

A

local vascular unit

vascular registrar, consultant, anaesthetist, theatre and blood transfusion lab should be informed

47
Q

What will be required following A-E assessment for a patient who is unstable with AAA rupture?

A

will require immediate transfer to theatre for open surgical repair

48
Q

What will be required following A-E assessment for a patient who is stable with AAA rupture?

A

CT angiogram to determine whether aneurysm is suitable for endovascular repair

AIP: Abdominal pain (20 decks)

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