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Surgery Block > Vascular Surgery > Flashcards

Vascular Surgery Flashcards

1
Q

Define Acute mesenteric ischaemia

A

Sudden decrease in blood supply to the bowel resulting in bowel ischaemia and rapid gangrene

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2
Q

List the common causes of acute mesenteric ischaemia

A 
AAA
Embolism
Atherosclerosis (thrombus-in-situ)
Shock
Coagulopathy
Malignancy
Inflammatory disorders
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3
Q

Describe clinical features of mesenteric ischaemia

A
  • Generalised abdominal pain, out of proportion to other clinical findings
  • Nausea and vomiting
  • History indicating potential embolic sources
  • Presentation similar to bowel perforation (late stage)
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4
Q

What initial lab investigations would you order when considering mesenteric ischaemia?

A
  • ABG - assess degree of acidosis and serum lactate
  • Routine bloods: FBCs, U+Es, Clotting screen, LFTs, G+S
  • Amylase (will be raised)
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5
Q

What is the diagnostic test for acute mesenteric ischaemia?

A

CT angiography with IV contrast - Triple phase scan (thin slices taken in arterial phase)

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6
Q

What will a CT scan of arterial bowel ischaemia show?

A

Oedematous bowel
Loss of bowel wall enhancement
Pneumatosis intestinalis

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7
Q

What initial management is needed in acute mesenteric ischaemia?

A

Urgent resuscitation - IV fluids, catheter insertion, fluid balance chart
Broad spectrum antibiotics prescribed
Early ITU admission if significant acidosis

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8
Q

What is the definitive management for ischaemic bowel?

A
  • Excision of necrotic or non viable bowel

- Revascularisation of bowel - removal of thrombus or embolism via angioplasty

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9
Q

What are the main complications of acute mesenteric ischaemia?

A

Bowel necrosis

Bowel perforation

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10
Q

What is the mortality rate for acute mesenteric ischaemia?

A

50-80% (even with treatment)

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11
Q

Define chronic mesenteric ischaemia

A

Lack of blood supply to the bowel which gradually deteriorates over time as a result of atherosclerosis in the CT, SMA or IMA

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12
Q

Why do symptoms of chronic mesenteric ischaemia tend to occur after eating?

A

Increased demand of blood supply causes a transient ischaemia of the bowel

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13
Q

What is the pathophysiology of chronic mesenteric ischaemia?

A

Gradual build up of atherosclerotic plaques within the lumen of at least two of the CT, SMA or IMA causing reduced blood flow and so ischaemia

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14
Q

What are the main risk factors for chronic mesenteric ischaemia?

A

Smoking
Hypertension
Diabetes mellitus
Hypercholesterolaemia

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15
Q

Describe the classical clinical features of chronic mesenteric ischaemia

A 
Post prandial pain (10mins-4hrs post eating)
Weight loss
Concurrent vascular co morbidities 
Change in bowel habit
N+V
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16
Q

What is the gold standard diagnostic test for chronic mesenteric ischaemia?

A

CT angiography

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17
Q

What are possible differentials for chronic non specific abdominal pain?

A

Chronic pancreatitis
Gallstone pathology
Peptic ulcer disease
Upper GI malignancy

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18
Q

What medical management is indicated for chronic mesenteric ischaemia?

A

Antiplatelet agent
Statin
Lifestyle advice: weight loss, increasing exercise, smoking cessation

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19
Q

What surgical intervention may be indicated in chronic mesenteric ischaemia?

A

Endovascular - mesenteric angioplasty with stenting

Open - endarterectomy or bypass

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20
Q

When would surgical intervention be considered in chronic mesenteric ischaemia?

A

Severe disease
Progressive disease
Presence of debilitating symptoms (eg weight loss or malabsorption)

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21
Q

What are the main complications of chronic mesenteric ischaemia?

A

Bowel infarction
Malabsorption
Concurrent CVS disease

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22
Q

What is an aneurysm?

A

A persistent, abnormal dilation of an artery (>1.5x its normal diameter)

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23
Q

Define an aneurysm

A

Persistent, abnormal dilation of an artery above 1.5x its normal diameter

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24
Q

What possible causes are there of aneurysms?

A

Trauma
Infection
CT disease
Inflammatory disease (eg. Takayasu’s aortitis)

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25
Q

What is the gold standard imaging for peripheral and visceral aneurysms?

A

CT angiography

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26
Q

What is an alternative investigation for aneurysms to reduce kidney damage?

A

MR angiography

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27
Q

What imaging modality can be used for detection and follow up of aneurysms?

A

US duplex scan

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28
Q

What are the two most common peripheral artery aneurysms?

A

Popliteal artery

Femoral artery

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29
Q

How may a popliteal artery aneurysm present?

A

Acute limb ischaemia
Intermittent claudication
Incidental finding

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30
Q

What are the main DDx for swelling in the popliteal fossa?

A

Politeal aneurysm
Bakers cyst
Lymphadenopathy

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31
Q

When should an asymptomatic popliteal aneurysm be treated?

A

If it is greater than 2cm

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32
Q

Why should all symptomatic popliteal aneurysms be treated?

A

High risk of embolisation

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33
Q

What surgical options are there for popliteal aneurysms?

A
  • Endovascular repair (stent insertion)

- Open repair (ligation of aneurysm or resection with a bypass graft)

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34
Q

What are the two major causes for development of a femoral artery aneurysm?

A
  • Percutaneous vascular interventions

- IVDU using the groin

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35
Q

What will a patient with femoral aneurysms normally present with?

A

Varying degrees of claudication or acute limb ischaemia

* Often may have no symptoms beside swelling in the groin

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36
Q

What causes the signs and symptoms of femoral aneurysms?

A

Thrombosis, rupture or embolisation

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37
Q

What additional features may be seen in an IVDU patient with a femoral aneurysm?

A

Concurrent infection

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38
Q

What is the main treatment for a femoral artery aneurysm?

A

Open surgical repair

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39
Q

Which visceral arteries are most commonly affected by aneurysm formation?

A
  • Splenic artery
  • Hepatic artery
  • Renal artery
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40
Q

How may a splenic artery aneurysm present?

A

Vague epigastric or LUQ pain

Rupture –> severe abdo pain and haemodynamic compromise

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41
Q

What is first line management for a splenic artery aneurysm?

A

Endovascular repair

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42
Q

What are the common causes of a hepatic artery aneurysm?

A

Percutaneous instrumentation
Trauma
Degenerative disease
Post liver transplant

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43
Q

What may a symptomatic case of hepatic artery aneurysms present like?

A

Vague RUQ or epigastric pain

Jaundice (if biliary obstruction)

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44
Q

What is first line management for hepatic artery aneurysms?

A

Endovascular repair –> best with embolisation or stent gradts

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45
Q

How may a patient with a symptomatic renal artery aneurysm present?

A

Haematuria
Resistent hypertension
Loin pain

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46
Q

What is the mainstay of treatment for a patient with a renal artery aneurysm?

A

Endovascular repair:

  • Hilar –> with coils and self expanding stents
  • Main artery –> stent
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47
Q

What are some of the risk factors for splenic artery aneurysms?

A
  • Female
  • Portal hypertension
  • Pancreatitis
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48
Q

What is chronic limb ischaemia typically caused by?

A

Atherosclerosis (typically in the lower limbs)

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49
Q

What are the risk factors for chronic limb ischaemia?

A 
Smoking
Diabetes mellitus
Hypertension
Hyperlipidaemia
Increasing age
Family history
Obesity + physical inactivity
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50
Q

Describe the fontaine classification of chronic leg ischamia

A

1 - Asymptomatic
2 - Intermittent claudication
3 - Ischaemic rest apin
4 - Ulceration or gangrene (or both)

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51
Q

Describe Buerger’s test briefly

A

Lie the patient supine and raise their legs until they go pale - note the angle at which this happens (= Buerger’s angle)
Then lower the legs until the colour returns/goes hyperaemic

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52
Q

What angle in Buerger’s test will indicate severe chronic limb ischaemia?

A

Angle of less than 20 degrees

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53
Q

What is Leriche syndrome?

A

Form of peripheral arterial disease affecting the aortic bifurcation – presents with buttock or thigh pain +/- erectile dysfunction

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54
Q

What three definitions are there for critical limb ischaemia?

A
  • Ischaemic rest pain for >2 weeks, requiring opioids
  • Presence of ischaemic lesions (or gangrene attributable to PVD)
  • ABPI >0.5
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55
Q

What clinical features are seen on examination of a limb with critical ischaemia?

A

Pale, cold and pulseless limb

Hair loss, skin changes (eg. atrophic, ulceration, gangrene), thickened nails

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56
Q

What are the two major differentials for limb ischaemia?

A 
Spinal stenosis ("neurogenic claudication")
Acute limb ischaemia
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57
Q

How may spinal stenosis be differentiated from chronic limb ischaemia?

A

Pain in the back radiating down lateral aspect of leg

Symptoms worse on initial movement and relieved by sitting

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58
Q

How is the ABPI used to quantify the severity of chronic limb ischaemia?

A 
Normal = >0.9
Mild = 0.8-0.9
Moderate = 0.5-0.8
Severe = <0.5
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59
Q

What may cause a falsely elevated ABPI?

A

Calcification and hardening of arteries

>1.2

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60
Q

What initial investigation should be used for critical limb ischaemia?

A

Doppler ultrasound

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61
Q

What additional assessment should be done to assess for risk factors in chronic limb ischaemia?

A

Cardiovascular risk assessment

  • BP
  • Blood glucose
  • Lipid profile
  • ECG
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62
Q

What should be checked in a patient <50yrs with chronic limb ischaemia?

A 
Thrombophillia screen
Homocysteine levels (higher is associated with CVS events)
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63
Q

What is the management for CVS risk factors in chronic limb ischaemia?

A
  • Lifestyle advice
  • Statin therapy
  • Antiplatelet therapy
  • Optimise diabetic control
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64
Q

What is first line management for intermittent claudication?

A

Enrolment into a local supervised exercise programme

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65
Q

When should surgical intervention be offered to patients with chronic limb ischaemia?

A
  • If risk factor modification has been discussed

- Supervised exercise has failed to improve symptoms

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66
Q

What are the two main surgical interventions used for chronic limb ischaemia?

A
  • Angioplasty +/- stenting
  • Bypass grafting (often for diffuse disease or younger)
  • Combination (eg. surgery to clean lesion to allow access for angioplasty to another region)
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67
Q

When should amputation be considered in chronic limb ischaemia?

A

Unsuitable for revascularisation with ischaemia causing incurable symptoms or gangrene leading to sepsis

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68
Q

What complications are there of chronic limb ischaemia?

A
  • Sepsis (secondary to infected gangrene)
  • Acute on chronic ischaemia
  • Amputation
  • Reduced mobility
  • Reduced QoL
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69
Q

What is the 5 year mortality rate of those diagnosed with chronic limb ischaemia?

A

~50%

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70
Q

Define acute limb ischaemia

A

Sudden decrease in limb perfusion that threatens the viability of the limb

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71
Q

What are the three main classifications of cause for acute limb ischaemia?

A
  • Thrombosis in situ
  • Embolisation
  • Trauma
72
Q

What are the 6 P’s of acute limb ischaemia?

A 
Pain
Pallor
Pulselessness
Parasthesia
Perishingly cold
Paralysis
73
Q

How can you identify an embolic occlusion as the cause of acute limb ischaemia?

A

Normal and pulsatile contralateral limb

74
Q

After what time period is presentation with acute limb ischaemia likely to result in paralysis?

A

> 6hrs post symptoms onset

75
Q

If both arterial and venous doppler are audible in acute limb ischaemia, what category is it?

A

I - Viable

76
Q

What are the main DDx for acute limb ischaemia?

A
  • Critical chronic limb ischaemia
  • Acute DVT
  • Spinal cord or peripheral nerve compression
77
Q

Why is a serum lactate indicated in acute limb ischaemia?

A

Assess level of ischaemia

78
Q

What initial investigation is used for acute limb ischaemia?

A

Doppler USS of both limbs

79
Q

When should a CT angiogram be done in acute limb ischaemia?

A

If the limb is considered salvageable - identifies anatomical location of occlusion

80
Q

What is the immediate management for a patient with acute limb ischaemia?

A

High flow o2 + adequate IV access

**Therapeutic dose of heparin or bolus dose then heparin infusion

81
Q

How are Rutherford stage 2a and 2b differentiated in acute limb ischaemia?

A 
2a = minimal sensory loss 
2b = sensory loss i more than toes + rest pain
82
Q

What is conservative management for acute limb ischaemia?

A

Prolonged course of heparin (only for Rutherford 1 and 2a)

83
Q

What surgical intervention is used for embolic acute limb ischaemia?

A
  • Embolectomy via a Fogarty catheter
  • Local intra-arterial thrombolysis
  • Bypass surgery
84
Q

What surgical intervention is used for thrombotic acute limb ischaemia?

A
  • Local intra-arterial thrombolysis
  • Angioplasty
  • Bypass surgery
85
Q

What will irreversible limb ischaemia look like?

A

Mottled, non blanching limb with hard, woody muscles

86
Q

What long term management is needed for acute limb ischaemia?

A
  • Reduction of CVS mortality risk
  • Antiplatelets
  • ?Anticoagulation
87
Q

What is the mortality rate of acute limb ischaemia?

A

~20%

88
Q

What are the complications of acute limb ischaemia?

A
  • Reperfusion injury
  • Compartment syndrome
  • Hyperkalaemia
  • Acidosis
  • AKI (from myoglobin release)
89
Q

What is the gold standard investigation for acute limb ischaemia?

A

CT angiography

90
Q

Define varicose veins

A

Tortuous dilated segments of veins associated with valvular incompetence, permitting blood flow from the deep venous system into the superficial

91
Q

What is the result of blood flow from the deep venous system into the superficial venous system?

A

Venous hypertension and dilation of superficial veins

92
Q

List the common secondary causes of varicose veins

A

DVT
Pelvic masses (eg. Pregnancy, uterine fibroids, ovarian masses)
AV malformations

93
Q

List the four major risk factors for the development of varicose veins

A
  • Prolonged standing
  • Obesity
  • Pregnancy
  • Family history
94
Q

What will patients with varicose veins usually present with?

A

Cosmetic issues (eg visible veins or discolouration)
Pain
Aching
Swelling (often worse on standing)

95
Q

What is seen on examination of a patient with varicose veins?

A

Varicosities along course of great and/or short saphenous veins
Features of venous insufficiency

96
Q

What are some features of venous insufficiency?

A 
Oedema
Varicose eczema
Thrombophlebitis 
Ulcers (often over medial maleolus)
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie blanche
97
Q

What is a saphena varix?

A

Dilation of the saphenous vein at the saphenofemoral junction
Displays a cough impulse —> often mistaken for a femoral hernia

98
Q

What system is used for classification of varicose veins?

A

CEAP

  • Clinical features
  • aEtiology
  • Anatomical
  • Pathophysiology
99
Q

What is the gold standard investigation for varicose veins?

A

Duplex ultrasound

100
Q

Name some non-invasive treatments for varicose veins

A

Patient education - avoid prolonged standing, weight loss + exercise
Compression stockings
Four layer bandaging (for venous ulceration)

101
Q

What are the criteria for surgical referral with varicose veins?

A
  • Symptomatic primary or recurrent varicose veins
  • Lower limb skin changes from venous insufficiency
  • Superficial vein thrombosis with suspected venous incompetence
  • Venous leg ulcer
102
Q

What are the main surgical treatment options for varicose veins?

A
  • Vein ligation, stripping and allusion
  • Foam scleropathy
  • Thermal ablation
103
Q

What are the main complications of varicose veins?

A 
Haemorrhage
Thrombophlebitis 
DVT
Disease recurrence
Nerve damage
104
Q

What does the term chronic venous insufficiency encompass?

A

DVT
Valvular insufficiency
Varicose veins

105
Q

What is deep venous insufficiency characterised by?

A

Valvular reflux
Venous hypertension
Obstruction

106
Q

What is meant by primary causes of deep venous insufficiency?

A

Underlying defect in the vein wall or valvular component eg. Congenital defects + CT disorders

107
Q

What is meant by secondary causes of deep venous insufficiency?

A

Defects occur secondary to damage

Eg. Post-thrombotic disease, post-phlebitis disease, venous outflow obstruction + trauma

108
Q

List the main risk factors for deep venous insufficiency

A 
Increasing age
Female
Pregnancy
Previous DVT or phlebitis
Obesity
Smoking
109
Q

Describe a classical presentation of deep venous insufficiency

A

Chronically swollen lower limbs
Aching, pruritic and painful
Venous claudication - bursting pain and tightness on walking resolving on leg elevation

110
Q

What signs may be seen on a patient with deep venous insufficiency?

A 
Varicose eczema
Thrombophlebitis
Haemosiderin skin staining
Lipodermatosclerosis
Atrophie Blanche
\+ possible dependent oedema and venous ulcers
111
Q

What are the symptoms of post thrombotic syndrome?

A
  • Heaviness
  • Cramping
  • Pain
  • Pruritis
  • Paraesthesia
  • Pretibial oedema
  • Skin induration
  • Hyperpigmentation
  • Venous entasis
  • Ulceration
112
Q

What scale is used to monitor the degree of post thrombotic syndrome?

A

Villalta scale - assesses progression with treatment

113
Q

What is the primary investigation for deep venous insufficiency? What is it looking for?

A

Doppler USS

Extent of venous reflux, sites of stenosis and presence of DVT or varicose veins

114
Q

What investigation should be done before compression therapy is initiated?

A
  • Documentation of foot pulses

- ABPI

115
Q

What conservative management is there for deep venous insufficiency?

A
  • Compression stockings
  • Analgesic control
  • 4 layer bandage for venous ulcer
116
Q

When may venous stunting be used for deep venous insufficiency?

A

Severe post thrombotic syndrome with occluded iliac veins

117
Q

What are common complications of deep venous insufficiency?

A
  • Swelling
  • Recurrent cellulitis
  • Chronic pain
  • Ulceration
118
Q

What are the serious complications of deep venous insufficiency?

A
  • DVT
  • Secondary lymphoedema
  • Varicose veins
119
Q

What is subclavian steal syndrome?

A

Neurological deficits occurring when there is increased blood supply to the affected arm
—> secondary to a proximal stenosing lesion or occlusion in the subclavian artery

120
Q

How is the blood supply redirected in subclavian steal syndrome?

A

Blood is drawn from collateral circulation causing a reversed blood flow in the ipsilateral vertebral artery

121
Q

What are the common causes of subclavian steal syndrome?

A
  • Atherosclerosis **
  • Vasculitis
  • Thoracic outlet syndrome
  • Complications post aortic coarctation repair
122
Q

What are the main clinical features of subclavian steal syndrome?

A
  • Arm claudication

- Cerebral symptoms eg. Vertigo, diplopia, dysphagia, visual loss, syncope

123
Q

What initial investigation is usually used for subclavian steal syndrome? What will it show?

A

Duplex USS

Shows retrograde flow in the affected vertebral artery during exercise

124
Q

Why is a CXR done in subclavian steal syndrome?

A

Assess for any external compression on the subclavian artery

125
Q

What is the definitive investigation for subclavian steal syndrome?

A

CT angiography (or MR angiography)

126
Q

Describe the three grades of subclavian steal syndrome

A

Pre-subclavian steal: demonstrating purely a reduced anterograde vertebral flow

Intermittent alternating flow: antegrade flow in diastolic phase, retrograde flow in systolic

Advanced disease: permanent retrograde flow

127
Q

What is the management for subclavian steal syndrome?

A
  • Antiplatelet and statin therapy
  • Address modifiable CVS risk factors
  • Surgical: endovascular or bypass
128
Q

When is bypass surgery indicated for subclavian steal syndrome?

A

Longer or distal occlusions

129
Q

What does ‘carotid artery disease’ refer to?

A

Build up of atherosclerotic plaque in one or both of common and internal carotid arteries

130
Q

How is carotid artery disease classified?

A

Radiologically based on the degree of stenosis

131
Q

How will symptomatic carotid artery disease present?

A

Focal neurological deficit

  • TIA
  • Stroke
132
Q

What are the main vascular DDx of carotid artery disease?

A
  • Carotid dissection
  • Thrombotic occlusion of carotid artery
  • Fibromuscular dysplasia
  • Vasculitis
133
Q

What is fibromuscular dysplasia?

A

Hypertrophy of vessel wall causing stenosis of the artery

134
Q

What initial investigations are indicated for any stroke patient?

A
  • Urgent CT head
  • Bloods: FBC, U&Es, Coag, Lipid profile, Glucose
  • ECG
135
Q

What is the role of CT angiography in carotid artery disease?

A

Gives percentage stenosis and characterises diseased portion of vessel for surgical intervention

136
Q

What is indicated for ischaemic stroke prevention?

A

Carotid endarterectomy

137
Q

What are the risks associated with carotid endarterectomy?

A
  • Stroke
  • Nerve damage (CN 9, 10, 12)
  • MI
  • Bleeding
  • Infection
138
Q

Define an aneurysm

A

Abnormal dilation of a blood vessel by >50% of its normal diameter

139
Q

Define an abdominal aortic aneurysm

A

Dilation of the abdominal aorta >3cm

140
Q

What possible causes are there for development of an AAA?

A
  • Atherosclerosis
  • Trauma
  • Infection
  • CT disorders eg. Marfan’s, Ehler’s Danlos, Loey Dietz
  • Inflammatory disease eg. Takayasu’s aortitis
141
Q

What are the main risk factors for AAA?

A
  • Smoking
  • Hypertension
  • Hyperlipidaemia
  • FHx
  • Male
  • increasing age
142
Q

How may a AAA present?

A
  • Incidental finding/on screening
  • Abdominal pain
  • Back/Loin pain
  • Distal embolisation producing limb ischaemia
  • Aortoenteric fistula
143
Q

Briefly outline the National AAA screening programme

A

Offer an abdominal USS for all men aged 65

  • 3-4.4cm –> Yearly screening
  • 4.5-5.4cm –> Scan every 3 months
  • > 5.5cm dilation –> consider for surgery
144
Q

Give the main DDx for a symptomatic AAA

A
  • Renal colic *

- Abdominal pathology eg diverticulitis, IBD, GI haemorrhage, appendicitis, ovarian torsion/rupture, splenic infarct

145
Q

What investigation is done to follow up a diagnosis of a AAA on a USS?

A

CT scan with contrast

146
Q

What lifestyle advice can be given to patients with a small/medium AAA?

A
  • Smoking cessation
  • Improve BP control
  • Commence statin and aspirin therapy
  • Weight loss
  • Increase exercise
147
Q

What indications are there for surgical intervention of a AAA?

A
  • AAA >5.5cm
  • AAA expanding at >1cm per year
  • Symptomatic AAA in an otherwise fit patient
148
Q

What are the main surgical options for AAA?

A
  • Open repair

- Endovascular repair

149
Q

Compare the outcomes of open and endovascular repair for a AAA

A

Similar long term outcomes at 2 years
Endovascular repair has improved short term outcomes - reduced hospital stay and 30 day mortality but higher rate of intervention + aneurysm rupture

150
Q

What is involved in an open repair for a AAA?

A

Midline laparotomy or long transverse incision - clamp either end and remove the segment - then replace with a prosthetic graft

151
Q

What does endovascular repair involve for a AAA?

A

Introduction of a graft via the femoral arteries + fixing a stent across the aneurysm

152
Q

What is an endovascular leak?

A

Complication of endovascular repair - incomplete seal forms around the aneurysm resulting in blood leaking around the graft

153
Q

What are the main complications of a AAA?

A
  • Rupture
  • Retroperitoneal leak
  • Embolisation
  • Aortoduodenal fistula
154
Q

How can a AAA rupture present?

A
  • Abdominal pain
  • Back pain
  • Syncope
  • Vomiting
155
Q

What is the classic triad for a ruptured AAA?

A
  • Flank or Back Pain
  • Hypotension
  • Pulsatile abdominal mass
156
Q

How is the BP controlled in a ruptured AAA?

A

Permissive hypotension - maintain at <100mmHg

— Raised BP can dislodge any clots and precipitate further bleeding

157
Q

What is the management for a ruptured AAA?

A

A-E

  • If unstable –> immediate transfer to theatre for open surgical repair
  • If stable –> CT angiogram to determine if endovascular repair is suitable
158
Q

Define an aortic dissection

A

Tear in the intimal layer of the aortic wall –> causes blood to flow between and so causing a split between the tunica intima and tunica media

159
Q

What is the difference between the timescale for an acute and chronic aortic dissection?

A 
Acute = diagnosed <14 days
Chronic = diagnosed >14 days
160
Q

How does an anterograde aortic dissection propagate?

A

Towards the iliac arteries

161
Q

How does a retrograde aortic dissection propagate? What can this cause?

A

Towards the aortic valve –> valvular prolapse, bleeding into the pericardium + cardiac tamponade

162
Q

What two classification systems can be used for an aortic dissection?

A
  • DeBakey

- Stanford

163
Q

Briefly describe the DeBakey classification for aortic dissections

A

Type 1 - originates in ascending aorta + propagates to at least the aortic arch
Type 2 - confined to ascending aorta
Type 3 - originates distal to subclavian artery in descending aorta
- 3a = extension distally to diaphragm
- 3b = extension beyond diaphragm to abdominal aorta

164
Q

Briefly describe the Stanford classification of aortic dissection

A

Group A - DeBakey 1+2

Group B - DeBakey 3

165
Q

What risk factors are there for aortic dissections?

A
  • Hypertension
  • Atherosclerotic disease
  • Male gender
  • CT disorder eg. Marfan’s or Ehler’s Danlos
  • Bicuspid aortic valve
166
Q

How does an aortic dissection classically present?

A

Tearing chest pain, radiating to the back

167
Q

What clinical signs are commonly seen for an aortic dissection?

A
  • Tachycardia
  • Hypotension
  • New aortic regurgitation murmur
  • Signs of end organ hypoperfusion
168
Q

What are the main DDx for an aortic dissection?

A
  • MI
  • PE
  • Pericarditis
  • MSK back pain
169
Q

What first line imaging is there for an aortic dissection? Why?

A

CT angiogram - allows classification, establish anatomy and assists surgical planning

170
Q

How is management of aortic dissection different by classification?

A

Stanford Type A - surgical

Stanford Type B - medical

171
Q

What long term management is there for aortic dissections?

A
  • Lifelong antihypertensive therapy

- Surveillance imagine (1, 3, + 12 months post discharge and then at 6-12 month intervals)

172
Q

What surgical management is indicated for aortic dissections?

A

Removal of ascending aorta + replacement with synthetic graft
+ ensure additional branches are re-implanted into the graft

173
Q

What medical management is given for aortic dissections?

A

Management of hypertension (rapidly lower systolic pressure, pulse pressure + pulse rate –> minimise stress of dissection + limit further propagation)

174
Q

When is surgical intervention indicated in a type b aortic dissection?

A

Complications eg

  • Rupture
  • Visceral or limb ischaemia
  • Refractory pain
  • Uncontrollable hypertension
175
Q

What are the main complications of an aortic dissection?

A
  • Aortic rupture
  • Aortic regurgitation
  • MI (secondary to coronary artery dissection)
  • Cardiac tamponade
  • Stroke/paraplegia (secondary to cerebral/spinal artery involvement)

Surgery Block (12 decks)

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