W8: Aneurysms; Carotid Artery Surgery; Aortic Disease

Question 1

Describe the clinical presentation of arterial occlusive disease.

Answer 1

Hypotension, SOB, HF or ASYMPT.

AAA = pulsatile mass

DISSECTION = sharp back pain between shoulder blades

ASCENDING AO. = dysphagia, hoarseness

Question 2

Aortic Aneurysm: pathophys & categorisation

Answer 2

Localised enlargement of artery d/t weakening of vessel wall

1. TRUE: all 3 layers: saccular, fusiform
2. FALSE: ao wall rupture, haemotoma contained by surrounding tiss. or adventitia (inflamm, iatrogenic, thrill, bruit, puls. mass)

Question 3

Aortic Dissection: pathophys predisposing factors & typing/classification

Answer 3

HT, atheroscl., trauma, marfans | ACUTE EMERGENCY

• inner ao tear and blood forces walls apart
• CYSTIC MEDIAL NECROSIS: basophil infiltration forms cysts

DE BAILEY CLASSIFICATION
I - ascending -> arch
II - aschending source and confined
III - descending ao. -> retrograde to arch + ascending

A (involve ascending) = surgery
B (not ascending) = BP control + nitrates + BB

=> FALSE LUMEN: compl. where retrograde progression results in true lumen occlusion: mesenteric, renal, carotid, spinal
=> rupture = tamponade

Question 4

Infective & Inflammatory Cause of Ao. Aneurysms

Answer 4

1. SYPHILLIS: treponneum pallidum = syphillic aortitis
   => abx
2. TAKAYASU’S ARTERITIS: female. Ao and main bronchi.
   * granulomatous vasculitis => steroids and surgery

Question 5

AAA Screening

Answer 5

USS => 65y/o Males. cheap

• identifies the maximum AP diameter of aorta
• > 5.5cm ↑↑risk rupture (SMALL ANEURYSM STUDY) = intervention

Question 6

AAA Tx and implications and nuances

Answer 6

1. EVAR REPAIR => STENt inserted below renal arteries via FEMORAL ACCESS | compl. stent leak.

(EVAR 1 Trail) evar superior to open-repair d/t ↑post-mort for open repair. (MI, stroke, complications).

(EVAR 2) older population, no sig diff between open V EVAR and arising complications and higher mort.

EVAR higher durability

Pt selection: predicted survival, baseline, malignancies, renal. CT Angio used to assess suitability.

2. OPEN AAA REPAIR if poor landing zoned/t tortuous nature or calcification

Question 7

AAA Complication

Answer 7

RUPTURED AAA

(ERAS Trial):
* Hb <9; BP <90, GCS <15 = score out of 3 = mortality
anterior rupture ↑mortality and raipid haemorrage into peritoneal cavity
posterior rupture: haemotoma contained by retroperitoneal shunt: back pain and hypoT

IMPROVE TRIAL: no difference in EVAR v open w/ RUPTURE.

Question 8

SCREENING: sens and spec.

Answer 8

sensitivity: identify those with the disease (true positive rate),
specificity: identify those without the disease (true negative rate)

Question 9

Ao Dissection End-Organ Symptoms

Answer 9

neurological, syncope, seizure, limb paraesthesias, pain or weakness, flank pain, SOB + haemoptysis