Surg - 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

CTUSMRI

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 performanceDetect aneurysm and free fluiSimple/CheapDisad:Imperfect sensisitvity

Question 7

Ad/Disad MRI

Answer 7

Ad:Specific and sensitive
No contrast needed
Tissue characterisation

Disad:Long time - not approrpirate for AAA
CostLower 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 MIParaplegiaHAP/VAPARDSACSIleus

Late:Resp weanSmall bowel obstHerniaDVTSexual 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 <90MI on ECG
LOC on arrival

(1 point each)

Question 13

Glascow Aneurysm Score Variables

Answer 13

Perioperative risk

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
Patients most at risk of ischaemic spinal cord injury:
-advanced age, those who present as an emergency
-patients with more extensive aortic disease including previous aortic intervention
-patients with certaincomorbidities, such as diabetes and chronic kidney disease.

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 readyX-match 6 units, activate major haemorrhage protoco
lSystolic of 90
Analgesia
Ix;FBC, U&E, Coag, GasECG
Imaging if time
SURGERY

Question 19

Non graft related comps

Answer 19

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

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Late:
Resp wean
Small bowel obst
Hernia
DVT
Sexual dysfunction```