x aortic aneurysm x = if time

Question 1

what are the risk factors for thoracic aortic aneurysms ?

Answer 1

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

Question 2

what are the risk factors for abdominal aortic aneurysms ?

Answer 2

advanced age

smoking - most important

atherosclerosis

arterial hypertension

hypercholesterolemia

Question 3

what is the classification of aortic aneurysms ?

Answer 3

ascending aorta - most common

descending aorta - thorax-abdominal

aortic arch

Question 4

what are the clinical features of thoracic aortic aneurysms ?

Answer 4

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)

Question 5

what is the classification o abdominal aortic aneurysms ?

Answer 5

infrarenal - below the renal arteries - most common
- 1/3 extend into the iliac artery

suprarenal

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shape
saccular
fusiform

Question 6

clinical features of abdominal aortic aneurysms ?

Answer 6

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

Question 7

diagnosis of thoracic aortic aneurysms?

Answer 7

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

Question 8

x

Answer 8

x

Question 9

x

Answer 9

x

Question 10

x

Answer 10

x

Question 11

diagnosis of abdominal aortic aneurysms?

Answer 11

Abdominal ultrasound

CT angiography abdomen and pelvis

MR angiography abdomen and pelvis with and without IV contrast

Arteriography (aortography abdomen)

Question 12

what is the management of thoracic aortic aneurysm?

Answer 12

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

===============

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

Question 13

what are the management of abdominal aortic aneurysms ?

Answer 13

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

=============

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

==========

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

=========

Surveillance after repair
Postoperative surveillance following EVAR is important because it can help to detect possible endoleaks, sac growth, device migration, and device failur

=========
All patients: reduction of cardiovascular risk factors
Appropriate medical management of other atherosclerotic risk factors (e.g., hypertension, diabetes, hyperlipidemia)
Smoking cessation

Question 14

conservative treatment for AAA is when ?

Answer 14

Small (< 5.5 cm), asymptomatic AAA can typically be observed with interval surveillance ultrasound

Question 15

conservative treatment for TAA is when ?

Answer 15

Ascending aorta < 4.5cm

aortic arch <3.9

descending <4.9cm

Question 16

what is the complication of thoracic aortic aneurysm?

Answer 16

embolism
aortic valve regurgitation
aortic dissection

thoracic aortic aneurysm rupture - when large aneurysm diameter and rapid aneurysm expansion

Question 17

what is acute aortic syndrome ?

Answer 17

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

Question 18

what are the clinical features of thoracic aortic aneurysm rupture ?

Answer 18

contained
severe chest pain - indistinguishable from MI
HEMODYNAMICALY STABLE

free rupture 
loss of consciousness 
severe chest pain 
hypotension 
hemoptysis 
gastrointestinal bleeding 
cardiogenic shock

Question 19

what is the diagnosis of thoracic aortic aneurysm rupture ?

Answer 19

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

Question 20

what is the management for aortic aneurysm rupture ?

Answer 20

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

Question 21

what is the complication of aortic aneurysm rupture ?

Answer 21

bleeding into mediastinum - causes a cardiac tampornase

left hemothroax

Question 22

clinical features of a ruptured abdominal aortic aneurysms ?

Answer 22

abdominal , flank or back pain
shock
syncope