surgery - vascular arterial disease Flashcards by Rachel Hall

what is aneurysm

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

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what is AAA?

dilatation of the abdominal aorta greater than 3cm

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RF for AAA?

atherosclerosis, trauma, infection, connective tissue disease (e.g. Marfan’s disease, Ehler’s Danlos), or inflammatory disease (e.g. Takayasu’s aortitis).

smoking, hypertension, hyperlipidaemia, family history, male gender, and increasing age

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features of AAA

many asymptomatic
abdominal pain, back or loin pain, distal embolisation
pulsatile mass

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how may ruptured AAA present?

pain (abdominal, back, or loin) and a degree of shock or syncope

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AAA screening?

abdominal USS men 65yrs

men with a detected AAA will spend 3 to 5 years in surveillance

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ix for AAA?

USS
CT scan with contrast

threshold diameter of 5.5cm

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threshold of AAA?

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medical mx of AAA

Smoking cessation
blood pressure control
statin and aspirin therapy
Weight loss and increased exercise

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surgical mx of AAA

open repair or endovascular repair,

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what is open repair of AAA

better long term outcomes

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what is endovascular repair?

better short term outcomes

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complication of EVAR?

endovascular leak

an incomplete seal forms around the aneurysm resulting in blood leaking around the graft

If left untreated, the aneurysm can expand and subsequently rupture.

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classification of endoleaks

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how does ruptured AAA present

TRIAD= flank or back pain, hypotension, and a pulsatile abdominal mass

abdominal pain, back pain, syncope, or vomiting

haemodynamically compromised, with a pulsatile abdominal mass and abdominal tenderness

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management of ruptured AAA

high flow O2, intravenous access
bloods
FBC, U&Es, clotting) with crossmatch for 6 units
BP≤100mmHg

CT angio if stable or open surgical repair if unstable

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layers of artery wall?

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what is acute aortic syndrome?
examples

disruption of these layers of the arterial wall, and is split into 3 subgroups: aortic dissection, penetrating aortic ulcer; and intramural haematoma.

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what is aortic dissection?

a tear in the intimal layer of the aortic wall causing blood to flow between and splitting apart the tunica intima and media

acute (when diagnosed ≤14 days) or chronic (when diagnosed >14 days)

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what are anterograde and retrograde dissections?

Anterograde dissections propagate towards the iliac arteries and retrograde dissections propagate towards the aortic valve (at the root of the aorta)*.

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RF for aortic dissection?

men
connective tissue disorder
50-70yrs
HTN, atherosclerotic disease
bicuspid aortic valve

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what is penetrating aortic ulcer ?

ulcer that penetrates the intima and progresses into the media of the artery. This can progress to intramural haematoma, aortic dissection, perforation, or aneurysm formation.

what is intramural haematoma?

a contained aortic wall haematoma with bleeding in the media. This can progress to aortic dissection, perforation or aneurysm formation.

how are aortic dissections classified?

by two systems, DeBakey and Stanford.

explain Stanford classification

explain debakey classficiation

features of aortic dissection?

tearing chest pain tachycardia hypotension new aortic regurgitation reduced urine output, paraplegia, lower limb ischaemia, abdominal pain secondary to ischaemia, or deteriorating conscious level

ix for aortic dissection?

bloods (FBC, U&Es, LFTs, troponin, coagulation) with at least 4 units of packed red blood cells

imaging for aortic dissection?

CT angiogram transoesophageal ECHO

mx of aortic dissection

high flow oxygen and gain IV access fluid resus TYPE A = surgical TYPE B = medical

type A management

removal of the ascending aorta (with or without the arch) and replacement with synthetic graft.

type B management

management of hypertension with intravenous beta blockers (labetalol) (or calcium channel blockers as second line therapy). if aneurysm forms, endovascular repair

complications of aortic dissection?

Aortic rupture Aortic regurgitation Myocardial ischaemia Cardiac tamponade Stroke or paraplegia

what is carotid artery disease?

build-up of atherosclerotic plaque in one or both common and internal carotid arteries, resulting in stenosis or occlusion.

pathophysiology of carotid artery disease?

starting with a fatty streak, accumulating a lipid core and formation of a fibrous cap. The turbulent flow at the bifurcation of the carotid artery predisposes to this process specifically at this region.

classification of carotid artery disease

RF for carotid artery disease?

age (≥65 years) smoking hypertension hypercholesterolaemi obesity diabetes mellitus history of cardiovascular disease family history of cardiovascular disease.

features of carotid artery disease?

asymptomatic may present as a focal neurological deficit TIA stroke carotid bruit

ix for carotid artery disease

urgent non-contrast CT head Bloods - FBC, U&Es, clotting, lipid profile, and glucose ECG CT angiography FU with duplex USS and CT angio

acute mx of carotid artery disease

igh flow oxygen and blood glucose optimised (target 4-11mmol) swallowing screen assessment Initial management depends on the nature of the stroke:

long term mx of carotid artery disease?

Anti-platelet therapy long term, typically aspirin 300mg OD for two weeks, then clopidogrel 75mg OD high dose atorvastatin management of hypertension and/or diabetes mellitus Smoking cessation Regular cardiovascular exercise and active lifestyle with weight loss

complications of carotid artery disease?

dysphagia spasticity incontinence depression, anxiety, cognitive decline

what can thoracic aortic aneurysm involve?

the ascending aorta or aortic root (60%), aortic arch (10%), descending aorta (40%), or thoracoabdominal aorta (10%) segments

aetiology of thoracic aortic aneurysm?

due to degradation of the tunica media, artery loses structural integrity and dilates as the diameter increases, the wall tension rises and further increases the diameter i

causes of thoracic aneurysm?

Connective tissue diseases (e.g. Marfan’s syndrome or Ehlers-Danlos syndrome) Bicuspid aortic valve Other causes include trauma, aortic dissection, aortic arteritis (e.g. Takayasu Arteritis), and tertiary syphilis

how much do thoracic aneurysms grow?

mean rate of 1-2mm/year higher in those with Marfan’s syndrome, descending aneurysms, and a dissected aneurysm

RF of thoracic aneurysm?

FH hypertension, atherosclerosis smoking high BMI male advanced age.

features of thoracic aneurysm?

Ascending aorta – anterior chest pain Aortic arch – neck pain Descending aorta – posterior thoracic pain hoarse voice features of HF

ix for thoracic aneurysm

FBC, U&Es, clotting ECG CXR

what imaging for thoracic aneurysm?

CT angiogram TOE

mx for thoracic aneurysm

statin and anti-platelet therapy

mx of ascending aorta thoracic aneurysm?

mx of aortic arch thoracic aneurysm?

mx of descending aorta thoracic aneurysm?