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MBBS - Year 2 > Vascular System - Aortic Aneurysm and Dissection > Flashcards

Vascular System - Aortic Aneurysm and Dissection Flashcards

1
Q

Aneurysm definition

A

A localised dilatation of an artery with at least a 50% increase in diameter compared to expected normal diameter

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2
Q

Features of true aneurysms

A

Involve all 3 layers of arterial wall

Fusiform or saccular in shape

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3
Q

Features of false aneurysms

A

Hole in arterial wall

Pulsatile haematoma contained by adventitia & surrounding tissues

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4
Q

Location of true aneurysms

A 
Abdominal aorta and iliac 
Popliteal 
Femoral 
Thoracic aorta 
Thoracoabdominal aorta
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5
Q

Location of false aneurysms

A

Radial
Femoral
Anastomotic

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6
Q

Symptoms of aneurysms

A

Expansion thus compression/ eroding adjacent structures
Rupture
Distal embolism
Thrombosis

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7
Q

How can AAA cause death

A

Rupture (need out) or back pain by erosion of lumbar vertebrae but most are asymptomatic

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8
Q

Epidemiology of AAA

A

6,000 deaths per yr in UK

2% of death in men aged 65+ yrs

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9
Q

Risk factors of AAA

A 
Male 
65+ yrs 
Smoking 
HTN 
1st degree relative with AAA
(CTD) - rare cause of thoracic and abdominal aortic aneurysm
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10
Q

Px of AAA

A

Most are asymptomatic

Pain and/or tenderness

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11
Q

Px of AAA rupture

A

Abdominal pain radiating to back
Collapse
Pulsatile abdominal mass

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12
Q

Px of AAA embolisation

A

ALI (6 P’s)

Blue toe syndrome

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13
Q

Blue toe syndrome

A

Ischaemic toes with palpable foot pulses

Suggest micro-embolisation from atherosclerotic plaque or aneurysm

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14
Q

National AAA Screening Programme

A

Started in 2010
All men invited for screening US in 65th yr
Older men can self-refer

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15
Q

Risk of rupture of AAA

A

Normal aorta measure up to 2.5 cm in diameter
Risk of rupture of AAA increases w/ size
Size of 5.5 - 6cm has a risk of 5-15%

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16
Q

AAA and driving

A

Car drivers can continue if <6cm, must notify DVLA between 6-6.4cm and must stop when 6.5cm
Bus/lorry drivers must notify if <5.5cm and must stop if more

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17
Q

Mx of small AAA

A

Antiplatelet, statin, smoking cessation and treatment of HTN

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18
Q

Mx of small AAA - <3cm

A

No follow-up required if aged 65+

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19
Q

Mx of small AAA - 3-4.5cm

A

12 monthly surveillance US

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20
Q

Mx of small AAA - 4.5-5.5cm

A

3-6 monthly surveillance US

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21
Q

Mx of small AAA - >5.5 cm

A

Consider surgery

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22
Q

Indications of AAA surgery - Asymptomatic

A

Diameter > 5.5 cm

Increase in size > 1cm in a yr

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23
Q

Indications for AAA surgery - symptomatic

A

Rupture
Pain and/or tenderness (impending rupture)
Distal embolisation (ALI or blue toe syndrome)

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24
Q

Pre-operative assessment for aneurysm surgery

A

Bloods/ CXR/ ECG/ LFTs/ cardiopulmonary exercise test
Anaesthetic pre-assessment
Optimise cardiac, resp and renal functional
Ensure antiplatelet and statin
Consider age, frailty, co-mordities, pt wishes

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25
Q

Why should you ensure antiplatelet and statin before aneurysm surgery

A

Reduces risk of peri-operative MI

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26
Q

Open repair

A

Laparotamy incision in the midline from xiphisternum to pubic symphysis under GA
Aorta is identified in retroperitoneum
Heparin given as prophylaxis
Tubular graft is sewn to aorta inside sac

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27
Q

Complications of open repair

A

Death
Bleeding
Ischaemia - limb (ALI or trash foot) or colon (iscahemic colitis)
Cardiac, resp and renal failure
Wound infection, dehiscence and incisional hernia
Adhesive small bowel obstruction

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28
Q

Worst complications of open repair of aneurysms

A

Graft infection

Aorta-enteric fistula

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29
Q

Anatomical suitability for EVAR - aneurysm

A

Diameter < 30mm
Length >15 mm
Shape - cylindrical not canal
Angulation

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30
Q

Anatomical suitability for EVAR - iliac access and fixation

A

Patency
Diameter
Length
Tortuosity

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31
Q

Complications of EVAR

A 
Death 
Contrast and radiation toxicity 
Wound haemotoma, serum, infection
Damage to access vessels 
Lifelong surveillance required
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32
Q

What are re-interventions of EVARs usually due to

A 
Slipping 
Kinking 
Thrombosis 
Endoleak 
Rupture
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33
Q

Endoleaks

A

Blood flowing out of the stent graft but inside the aneurysm sac
Can be low pressure or high pressure
May spontaneously seal with time

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34
Q

What can endoleaks cause

A

Expansion

Rupture

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35
Q

Type 1 endoleaks

A 
Caused by poor seal between graft and aneurysm neck or iliacs
Uncommon 
High pressure 
V concerning
High risk of rupture
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36
Q

Type 2 endoleak

A 
Caused by back bleeding lumbar arteries or IMA 
Common 
Usually low pressure 
Only concerning if sac is expanding 
Low risk of rupture
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37
Q

Mortality of open repair vs EVAR

A

Higher vs lower

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38
Q

Hosp stay in open repair vs EVAR

A

Longer in HDU bed vs shorter in ward bed

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39
Q

Late mortality of open repair vs EVAR

A

Lower vs higher

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40
Q

Who is open repair ideal for

A

Younger, more fit pts

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41
Q

What is EVAR better for

A

Older, less fit pts

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42
Q

Ruptured AAA - surgical emergency

A

Clinical dx
Emergency surgery
Try assess co-morbidities, pt and family wishes
Take bloods for FBC, U&E, glucose, clotting and crossmatch
Fluid resus to maintain BP
Invoke massive transfusion protocol

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43
Q

Clinical dx of rAAA

A

Age > 50yrs
Abdominal/back pain
Shock

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44
Q

What can popliteal aneurysm cause

A

Can cause a/c or c/c limb ischaemia by thrombosis or distal embolisation or DVT by compression of popliteal vein

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45
Q

Epidemiology of PAA

A

Commonest true peripheral aneurysm
50% bilateral
40% also have AAA

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46
Q

Indication for popliteal aneurysm surgery - asymptomatic

A

Diameter > 2-3cm

Significant lining thrombus

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47
Q

Indications for surgery - symptomatic PAA

A

Thrombosis (causing ALI)
Distal embolisation (causing c/c limb ischaemia or blue toe syndrome)
DVT (from compression of popliteal veins)

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48
Q

Typical popliteal artery bypass graft

A

Saphenous vein graft connecting superficial femoral artery and below-knee popliteal artery
Example of exclusion bypass

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49
Q

Endovascular treatment of PAA

A

Stent grafting

Thrombolysis

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50
Q

Stent grafting for PAA

A

Less morbidity and mortality

Inferior latency due to kinking and thrombosis

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51
Q

Thrombolysis for PAA

A

May clear run-off vessels in thrombosed popliteal aneurysm to allow bypass or stunting

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52
Q

How can other types of aneurysms cause death

A

Juxta-renal, suprarenal, thoraco-abdominal and thoracic aneurysms can cause death by rupture

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53
Q

What must be preserved during aneurysm repair

A

Blood supply

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54
Q

What are false radial or femoral aneurysm usually caused by

A

Iatrogenic arterial puncture

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55
Q

Treatment of false radial or femoral aneurysm

A

Spontaneous thrombosis
US guided compression
Thrombin injection
Surgery

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56
Q

Classification of aortic dissection

A

Type A

Type B

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57
Q

Type A aortic dissection

A

Start proximal to the left subclavian artery and involve the ascending aorta

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58
Q

Type B aortic dissection

A

Start distal to the left subclavian artery and involve the descending aorta

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59
Q

Epidemiology of aortic dissection

A

3-4 people per 100,000/yr in UK
M 3x more than F
Peak ages 50-65 yrs

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60
Q

Risk factors for aortic dissection

A 
HTN 
Atherosclerosis 
Aortic aneurysm
Bicuspid aortic valve 
Coarctation of aorta 
Fhx 
CTD
Pregnancy 
Cocaine use 
High-intensity weightlifting
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61
Q

Px of aortic dissection

A 
Tearing chest pain radiating to back 
Collapse 
Pulse deficits 
Radio-radial or radio-femoral delay 
Difference in BP between arms > 20 mmHG
New aortic regurgitation murmur 
Neurological signs of strokes or paraplegia
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62
Q

Ix of aortic dissection

A

CXR
ECG
CT/ CTAngio
ABG

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63
Q

CXR for aortic dissection

A

Widened mediastinum

Pleural effusion/ haemothorax

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64
Q

ECG for aortic dissection

A

Ischaemic changes of coronary arteries malperfused

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65
Q

CT angiogram for aortic dissection

A

Intimal flap
True and false lumen
Branch vessel perfusion

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66
Q

Complications of aortic dissection

A

Malperfusion
Rupture
Aneurysmal dilatation

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67
Q

Complications of aortic dissection - malperfusion

A 
Coronary --> MI 
Carotid --> stroke 
Spinal --> paraplegia 
Renal --> renal failure 
Mesenteric --> a/c mesenteric ischaemia 
Limb --> ALI
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68
Q

Mx of Type A aortic dissection

A

Open surgery to replace ascending aorta +/- arch +/- aortic valve
May require re-implantation of coronary arteries or great vessels

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69
Q

Mx of Type B aortic dissection - uncomplicated

A

Analgesia - morphine
Strict control of BP with IV labetalol (systolic 100 -120)
Surveillance

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70
Q

Mx of Type B aortic dissection - complicated

A

TEVAR to cover entry tear and promote thrombosis of false lumen

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71
Q

Symptoms of complicated Type B aortic dissection

A 
Ongoing pain
Uncontrolled BP
Malperfusion
Aneurysmal dilatation
Rupture
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72
Q

Impact on family in chronic illness in childhood

A

Changes in roles, role expectations, responsibilities and patterns of interactions
Loss of ‘perfect’ child
Increased practical & emotional stress, depression
Strain on parental rships

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73
Q

Why is coping important

A

Severe illness and the many challenges associated with it can be viewed as stressors
Place demands on pt, requiring adaptation
Adaption achieved via physiological, behavioural, cognitive, emotional response

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74
Q

How can coping strategies be classified

A

In terms of function served, methods/ modes, type of action

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75
Q

Most common coping classification distinguishes

A

Emotion-focused coping

Problem-focused coping

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76
Q

Emotion-focused coping

A

Aimed at modifying response by regulating the emotional distress caused by the stressor or potential stressor

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77
Q

Problem-focused coping

A

These strategies attempt to alleviate or eliminate stressful situations through trying to take control i.e. doing something constructive about -ve events

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78
Q

Spp coping strategies - problem focused

A 
Problem solving
Support seeking
Escape avoidance 
Distraction 
Cognitive restructuring
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79
Q

Spp coping strategies - emotional focused

A 
Rumination 
Helplessness 
Social withdrawing 
Emotional regulation 
Info seeking 
Negotiation 
Opposition 
Delegation
80
Q

When should problem-focused coping strategies be used

A

In controllable situations

81
Q

When should emotion focused coping strategies be used

A

When there is no/little control

82
Q

Coping in the a/c phase vs c/c phase

A

Emotion-focused coping in a/c and problem-focused in c/c is best

83
Q

Influences on coping

A

Illness related factors
Background/ personal factors
Physical/ environmental factors

84
Q

Illness related factors influencing coping

A

Level of threat to life/ functioning
Obviousness
Treatment regimens
Side effects

85
Q

Background/ personal factors influencing coping

A 
Personality 
Socio-demographic 
Timing in life 
Knowledge
Beliefs
Motivation 
Education
86
Q

Phsyical/ environmental factors influencing coping

A 
Hosp/ home environment 
Social support
Finance 
Resources availability 
Educational opportunities
87
Q

What factors can facilitate coping and adjustment in c/c childhood illness

A

A flexible, cohesive and supportive family with open and clear communication
Parental coping style is adaptive
General support system
Pre-illness personality and functioning of the child
Understanding of disease

88
Q

The clinicians role in coping

A

Identify challenges
Steer emotion or problem-focused coping in +ve direction
misconception
Introduce pts to ideas of coping
Ensure pts equipped to adopt necessary coping
Assess and enhance social support

89
Q

Branches of the arch of aorta

A

From L - R
Brachiocephalic trunk
Left common carotid artery
Left subclavian artery

90
Q

What does the brachiocephalic trunk give rise to

A

Right subclavian artery

Right common carotid artery

91
Q

Posterior intercostal arteries

A

Branches of descending thoracic aorta found at each vertebral level

92
Q

What do the posterior intercostal arteries anstamose with

A

Anterior intercostal arteries

93
Q

What are the anterior intercostal arteries a branch of

A

Internal thoracic artery

94
Q

Where do the internal thoracic arteries lie

A

Parasternally

95
Q

Venous drainage of the thoracic cavity

A

Azygous venous system

96
Q

Azygous vein

A

Found on the right

Drains into superior vena cava

97
Q

Where is the hemiazygous vein found

A

On the left, where intercostal veins drain into

98
Q

What does the hemiazygous vein drain into

A

Main azygous vein

99
Q

Thyro-cervical trunk as branch of subclavian artery

A

Thyro-cervical artery –> supra scapular artery –> circumflex scapular arteries

100
Q

Where does the internal thoracic artery branch from

A

Subclavian artery

101
Q

Where does the abdominal aorta pass through the diaphragm

A

T12

102
Q

Unapired arteries of abdominal aorta

A

Coeliac axis
Superior mesenteric artery
Inferior mesenteric artery

103
Q

Paired arteries of abdominal aorta

A

Inferior phrenic arteries
Middle suprarenal arteries
Renal arteries
Gonadal arteries

104
Q

What level does the inferior phrenic arteries leave at

A

T12

105
Q

What level does the coeliac axis/ trunk leave at

A

T12

106
Q

What does the coeliac axis supply blood to

A

The foregut - stomach, first 2 parts of duodenum, liver, spleen and pancreas

107
Q

Which level does the middle suprarenal arteries leave at

A

L1

108
Q

What do the middle suprarenal arteries supply blood to

A

Suprarenal gland

109
Q

What level does the superior mesenteric artery leave at

A

L1

110
Q

What does the superior mesenteric artery supply blood to

A

Midgut

111
Q

What does the midgut consist of

A 
3rd and 4th part of duodenum
Rest of small intestine (jejunum and illeum)
Caecum
Ascending colon
2/3rds of transverse colon
112
Q

What levels do the renal arteries leave at

A

Between L1/2

113
Q

What level do the renal arteries leave at

A

L2

114
Q

What level does the inferior mesenteric artery leave at

A

L3

115
Q

What does the inferior mesenteric artery supply blood to

A

Last third of transverse colon
Descending colon
Rectum

116
Q

Where does the abdominal aorta bifurcate

A

L4 - umbilicus

117
Q

What is the inferior vena cava formed by

A

The union of common iliac veins at L5

118
Q

Where are parietal vessels found

A

Coming off at each vertebral level

All paired

119
Q

What do the parietal vessels supply

A

Body wall

Diaphragm

120
Q

Where are the lumbar arteries found

A

Leaving each vertebral level from L1 - L4

121
Q

What do paired visceral arteries supply

A

Bilateral organs

122
Q

Why does venous drainage from the abdomen have to pass through the liver

A

Venous blood holds all the digestion products

123
Q

What does the hepatic vein drain into

A

Inferior vena cava

124
Q

What is the portal vein formed from

A

Splenic vein
Superior mesenteric vein
Inferior mesenteric vein

125
Q

What do the vertebral arteries join together to form

A

Basilar artery

126
Q

What is the basilar artery a branch of

A

Subclavian artery

127
Q

What do the basilar arteries give rise to

A

Pontine arteries

Posterior cerebral artery –> posterior communicating artery

128
Q

Where does the left common carotid bifurcate at

A

L4

Into internal carotid artery and external carotid artery

129
Q

Branches of internal carotid artery

A

Middle cerebral artery
Opthalmic artery
Anterior cerebral artery –> anterior communicating artery

130
Q

Branches of external carotid artery

A

Facial artery
Maxillary artery
Occipital artery
Superficial temporal artery

131
Q

Venous drainage of head and neck

A

No veins, instead there are sinuses

132
Q

Sinuses

A

Venous channels running in between meningeal layers

133
Q

What does confluence of sinuses in the head form

A

Internal jugular vein

134
Q

What is the axillary artery a part of

A

Brachial plexus

135
Q

Where does the axillary artery start at

A

Lateral border of 1st rib

136
Q

Origin of axillary artery

A

Subclavian

137
Q

Where does the brachial artery start

A

Inferior border of teres major

138
Q

What does the brachial artery pass under

A

Bicipital aponeurosis

139
Q

What does the bicipital aponeurosis do

A

Anchors biceps brachii to medial side

Separates arterial and venous vessels

140
Q

Which arteries start at the antecubital fossa

A

Radial artery

Ulnar artery

141
Q

Which is artery is deeper - radial or ulnar

A

Ulnar is deeper

Radial is more superficial

142
Q

What does the radial artery pass through

A

Anatomical snuffbox

1st webspace

143
Q

Deep palmar arch

A

Comes from radial artery

144
Q

What does the deep palmar arch anastomose with

A

Superficial palmar arch

145
Q

Testing the anastomosis between the palmar arches

A

Allen’s test

146
Q

Which artery supplies the scaphoid

A

Radial

147
Q

Path of ulnar artery

A

Passes under pronator teres and rests under flexor carpi ulnaris
Runs alongside ulnar nerve

148
Q

What does the ulnar artery run in

A

Guyon’s canal

149
Q

What does the ulnar artery pass over

A

Flexor retinaculum (no risk of compression)

150
Q

What does the ulnar nerve create

A

Superficial palmar arch - metacarpal branches, digital branches

151
Q

Arterial supply of upper limb

A

Subclavian –> axillary –> brachial

  • -> radial –> deep palmar arch
  • -> ulnar –> superficial palmar arch
152
Q

Superficial veins of arms

A

Dorsal venous arch - cephalic, basilic, median cubital vein

153
Q

Where is the cephalic vein found

A

Radial side of arm

154
Q

Where is the basilic vein

A

Ulnar side of arm

155
Q

Where is the median cubital vein found

A

In between cephalic vein and basilic vein

156
Q

Where do the veins in the dorsal venous arch drain into

A

Brachial vein as well as radial and ulnar vein

At same landmarks turn into axillary vein then subclavian

157
Q

Which veins in the arms also drain into subclavian vein

A

Cephalic

Basilic

158
Q

Deep veins in arms

A 
Radial 
Ulnar 
Brachial 
Axillary 
Subclavian
159
Q

What supplies blood to the pelvis

A

Primarily internal iliac artery

160
Q

What do the common iliac arteries divide into

A

External iliac artery

Internal iliac artery

161
Q

Branches of internal iliac artery

A

Umbilicus artery
Obturator artery
Superior and inferior gluteal arteries

162
Q

Venous drainage of pelvis

A

Matches arteries

163
Q

Start of femoral artery

A

Inguinal ligament

164
Q

Division of femoral artery

A

Profunda femoris

Superficial femoral artery

165
Q

What does profunda femoris supply

A

Anterior and posterior aspects of thigh
2 circumflex femoral arteries from perforating arteries join with cruciate anastomosis around hip joint - creates retinacular vessels

166
Q

What is the femoral triangle bound by laterally

A

Sartorius

167
Q

What is the femoral triangle bound by medially

A

Adductor longus

168
Q

What is the femoral triangle bound by superiorly

A

Inguinal ligament

169
Q

What is the floor of the femoral triangle

A

Pectinueus and Iliopsoas

170
Q

Roof of the femoral triangle

A

Skin

171
Q

Where does the femoral artery sit at

A

Mid-inguinal point

172
Q

Mid-inguinal point

A

Found between pubic symphysis and ASIS

173
Q

Midpoint of inguinal ligament

A

Between pubic tubercle and ASIS

174
Q

What is the popliteal fossa found by superiorly

A

Hamstring muscles

175
Q

What is the popliteal fossa bound by laterally

A

Rectus femoris

176
Q

What is the popliteal fossa bound by medially

A

Semimembranosus

Semitendinosus

177
Q

What is the popliteal fossa bound by inferiorly

A

Gastrocnemius

178
Q

Where does the popliteal artery start

A

Adductor hiatus

179
Q

What do the popliteal arteries give rise to

A

Genicular arteries

180
Q

How many genicular arteries do we have in each leg

A

4
Superior and inferior, both lateral and medially

These form an anastomosis around knee joint

181
Q

What do popliteal arteries divide into

A

Posterior and anterior tibial arteries at the inferior border of popliteus

182
Q

Terminal branch of anterior tibial artery

A

Dorsalis pedis at ankle joint

183
Q

Branch of posterior tibial artery

A

Lateral - peroneal artery

184
Q

Terminal branch of posterior tibial artery

A

Medial and lateral plantar arteries

185
Q

Deep venous drainage of legs

A 
Anterior tibial vein 
Posterior tibial vein 
Popliteal vein 
Femoral vein 
External iliac vein
186
Q

Superficial drainage of legs

A

Dorsal venous arch - short and long/great saphenous veins

187
Q

Where does the long saphenous vein run from

A

Runs from medial aspect of dorsal venous arch and drains into femoral vein

188
Q

Short saphenous vein

A

Runs posteriorly and laterally to drain into popliteal vein

189
Q

What is venous blood pushed around by

A

Arterial pressure

190
Q

Features helping venous drainage in legs

A

Soleal pump o pushes on veins and causes blood to travel up

Deep fascia compartmentalising muscles - when muscles contracts, pushes on veins

191
Q

Venae commintantes

A

Veins running alongside arteries

192
Q

Structures at particular risk of supracondylar humeral fracture

A

Brachial artery

Median nerve

193
Q

Arterial supply to the lower limb

A

External iliac –> femoral –> popliteal

  • -> anterior tibial –> dorsalis pedis
  • -> posterior tibial –> peroneal
194
Q

Where are aortic aneurysms usually located

A

Abdomen - infrarenal to bifurcation

195
Q

What does lifelong surveillance of EVAR entail

A

Yearly CT and/ or US

Monitoring position of stent grafts, size of aneurysm sac and any endoleaks

196
Q

Symptoms of ruptured aneurysm - haemorrhage

A

Hypotension
Pale, clammy
High HR

197
Q

Investigation for ruptured aneurysm

A

ECG
Amylase
CT

MBBS - Year 2 (20 decks)

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