x aortic aneurysm x = if time Flashcards
what are the risk factors for thoracic aortic aneurysms ?
arterial hypertension
smoking
advanced age
trauma
tertiary syphilus - obliterative endarteritis of the vasa vasorum
connective tissue diseases - marfan syndrome , ehlers dans syndrome
bicuspid aortic valve
what are the risk factors for abdominal aortic aneurysms ?
advanced age
smoking - most important
atherosclerosis
arterial hypertension
hypercholesterolemia
what is the classification of aortic aneurysms ?
ascending aorta - most common
descending aorta - thorax-abdominal
aortic arch
what are the clinical features of thoracic aortic aneurysms ?
chest pressure
thoracic back pain
features of mediastinal
compression or obstruction -
1) difficulty swallowing - oesophagus
2) upper venous congestion - superior vena cava syndrome - fullness in the head,
dyspnea,
edema of the upper extremities,
distention of the superficial veins of the chest, face, and upper extremities
3) hoarseness - recurrent laryngeal nerve
4) cough wheeze stridor - trachea
5) sympathetic trunk - horner syndrome
miosis (an abnormally small pupil), partial ptosis (drooping of the upper eyelid), and facial anhidrosis (absence of sweating)
what is the classification o abdominal aortic aneurysms ?
infrarenal - below the renal arteries - most common
- 1/3 extend into the iliac artery
suprarenal
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shape
saccular
fusiform
clinical features of abdominal aortic aneurysms ?
stable aneurysm - usually asymptomatic
lower back pain
pulsatile abdominal mass
pain on palpitation means higher risk of rupture
bruit on auscultation
decrease in the ankle brachial index - the ratio of systolic ankle blood pressure (BP) to systolic brachial BP
diagnosis of thoracic aortic aneurysms?
chest x ray - abdominal aortic contour
widened mediastinum
tracheal deviation
CT golden standard Dilatation of the aorta [8] Possible mural thrombus (nonenhancing) Possible dissection, perforation, or rupture
MR angiography chest with and without IV contrast
Transthoracic echocardiography
Indications
Rapid assessment in hemodynamically unstable patients
Evaluation for concomitant heart disease
Transesophageal echocardiography: allows for more accurate assessment than TTE
Indication: intraoperative monitoring
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diagnosis of abdominal aortic aneurysms?
Abdominal ultrasound
CT angiography abdomen and pelvis
MR angiography abdomen and pelvis with and without IV contrast
Arteriography (aortography abdomen)
what is the management of thoracic aortic aneurysm?
Unstable patients (e.g., in the case of rupture): emergency TAA repair
Symptomatic patients: urgent TAA repair
or if over >5.5cm
Asymptomatic patients
Aneurysm surveillance
Elective TAA repair when size or growth thresholds are passed
All patients: conservative management
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immediate cardiothorac surgeon consult
A-E
Conservative management
Blood pressure management to reduce aortic wall stress:
= Less than 140/90 mm Hg in patients without diabetes
=Less than 130/80 mm Hg in patients with diabetes or CKD
Preferred agents:
Beta blockers (e.g., propranolol , metoprolol )
ACE inhibitor (e.g., lisinopril , enalapril )
Angiotensin receptor blocker (e.g., losartan , candesartan )
NPO
establish 2 IV access
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decision to perform elective TAA repair in asymptomatic patients depends on the size and expansion rate of the aneurysm.
Open surgical repair (OSR) is recommended for patients with TAA of the ascending aorta and involving the aortic arch.
patients with descending thoracic or thoracoabdominal aortic aneurysms - thoracic endovascular aneurysm repair (TEVAR) Under fluoroscopic guidance, an expandable stent graft is placed via the femoral or iliac arteries intraluminally at the site of the aneurysm.
or OSR can be performed
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Smoking cessation
Lipid profile optimization: in patients with atherosclerotic aortic aneurysms
Preferred agent: statin (e.g., atorvastatin )
Lifestyle modification
No participation in most competitive sports
No heavy weight lifting
what are the management of abdominal aortic aneurysms ?
call for help
Patients with any symptoms: immediate vascular surgery consult
Suspected or known rupture (regardless of patient stability) : emergency repair within 90 minutes
Asymptomatic patients: elective aneurysm repair or aneurysm surveillance
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A-E
Ensure blood product availability.
Maintain BP strictly within normal parameters. between 70 and 100 mmHg
Consult anesthesia.
NPO
establish IV access two large bore peripheral IV lines
check CBC , blood type and screening , obtain patient consent for transfusion
blood type and screening
initiate pain mangement - IV opoid analgensis
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if aneurysm is or more than 5.5cm - risk of rupture overtakes risk of surgery for most
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prep op care
IV antibiotic prophylaxis
First-generation cephalosporin, e.g., cefazolin
Anticipate and treat acute blood loss anemia
Ensure blood product availability.
Central venous access and arterial line monitoring during the procedure
Multimodal pain management
E.g., morphine
Consider epidural analgesia after OSR
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invasive
Indications
Emergency repair: unstable patients
Urgent repair: impending rupture or
leaking AAA
EVAR
Endovascular aneurysm repair
minimally invasive procedure that is preferred over open surgical repair (OSR) for most aneurysms,
Under fluoroscopic guidance, an expandable stent graft is placed via the femoral or iliac arteries intraluminally at the site of the aneurysm.
Open surgical repair
A laparotomy is performed and the dilated segment of the aorta is replaced with a tube graft or Y-prosthesis
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Surveillance after repair
Postoperative surveillance following EVAR is important because it can help to detect possible endoleaks, sac growth, device migration, and device failur
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All patients: reduction of cardiovascular risk factors
Appropriate medical management of other atherosclerotic risk factors (e.g., hypertension, diabetes, hyperlipidemia)
Smoking cessation
conservative treatment for AAA is when ?
Small (< 5.5 cm), asymptomatic AAA can typically be observed with interval surveillance ultrasound
conservative treatment for TAA is when ?
Ascending aorta < 4.5cm
aortic arch <3.9
descending <4.9cm
what is the complication of thoracic aortic aneurysm?
embolism
aortic valve regurgitation
aortic dissection
thoracic aortic aneurysm rupture - when large aneurysm diameter and rapid aneurysm expansion
what is acute aortic syndrome ?
when group of conditions affecting the aorta that have a similar clinical presentation and that may be impossible to differentiate between until surgery.
Includes aortic dissection, intramural hematoma, penetrating aortic ulcer,
and thoracic aortic rupture
what are the clinical features of thoracic aortic aneurysm rupture ?
contained
severe chest pain - indistinguishable from MI
HEMODYNAMICALY STABLE
free rupture loss of consciousness severe chest pain hypotension hemoptysis gastrointestinal bleeding cardiogenic shock
what is the diagnosis of thoracic aortic aneurysm rupture ?
if hemodynamically unstable there is no time for detailed assessment - starts continuous vital signs analysis HR BP RR capillary refill time POINT OF CARE ULTRASOUND bedside trans thoracic echocardiography
what is the management for aortic aneurysm rupture ?
call for hep- immediate cardiothroacic surgeon
A-E
intubation can worsen hypotension
mange hypotension
starts fluid resuscitation
give blood as soon as available - red cells
patents are at risk for massive transfusion associated reaction - give blood products in a balanced ratio
1:1 FFP/RBC
starts vasopressors if refectory - Examplies include dobutamine, dopamine, epinephrine
initiate IV pain management - opioid analgesia may worsen hypotension
emergency - open surgical repair
Thoracic endovascular aortic repair - in descending aorta
what is the complication of aortic aneurysm rupture ?
bleeding into mediastinum - causes a cardiac tampornase
left hemothroax
clinical features of a ruptured abdominal aortic aneurysms ?
abdominal , flank or back pain
shock
syncope
