aortic aneurysms

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    • Abdominal aortic aneurysms
      • An AAA is an increase in aortic diameter by greater than 50% of normal (MCQ)
      • Usually regarded as aortic diameter of greater than 3 cm diameter (MCQ)
      • More prevalent in elderly men (MCQ)
      • Male : female ratio is 4:1 (MCQ)
      • Risk factors (MCQ)
        • Hypertension
        • Peripheral vascular disease
        • Family history
      • Natural history
        • AAA diameter expands exponentially at approximately 10% per year(MCQ)
        • Risk of rupture increases as aneurysm expands
        • 5 year risk of rupture:
          • 5.0 to 5.9 cm is 25%
          • 6.0 to 6.9 cm is 35%
          • More than 7 cm is 75%
        • Overall only 15% aneurysms ever rupture
        • 85% of patients with a AAA die from an unrelated cause
      • Screening
        • Who should be screened? 
          • males over 65 years – especially hypertensives
            • Single US at 65 years reduces death from ruptured AAA by 70% in screened population
          • Patients with small aneurysms should undergo regular surveillance
            • Repeated ultrasound every 6 months
      • Clinical features
        • 75% are asymptomatic
        • Possible symptoms include: (MCQ)
          • Epigastric pain
          • Back pain
          • Malaise and weight loss (with inflammatory aneurysms)
          • Rupture presents with
          • Sudden onset abdominal pain
          • Hypovolaemic shock
          • Pulsatile epigastric mass
        • Rare presentations include
          • Distal embolic features
          • Aorto-caval fistula
          • Primary aorto-intestinal fistula
      • Indication for operation
        • Rupture
        • Symptomatic aneurysm
        • Rapid expansion
        • Asymptomatic more than 6 cm – exact lower limit controversial (MCQ)
    • Popliteal artery aneurysms
      • Defined as a popliteal artery diameter greater than 2 cm (MCQ)
      • Account for 80% of all peripheral aneurysms (MCQ)
      • 50% are bilateral
      • 50% are associated with an abdominal aortic aneurysm
      • 50% are asymptomatic
      • Symptomatic aneurysms present with features of:
      • Compression of adjacent structures ( veins or nerves)
      • Rupture
      • Limb ischaemia due to emboli or acute thrombosis
      • Treatment is by proximal and distal ligation
      • Revascularisation of the leg with a femoropopliteal bypass
      • With a symptomatic popliteal aneurysm 20% patients will undergo an amputation
    • THORACIC AORTIC ANEURYSMS
      • Aneurysm: Ballooning defect in the vessel wall
      • Dissection: Tear of the arterial intima
      • Types
        • Degenerative: (MCQ)
          • Due to abnormal collagen metabolism
          • Seen with Marfan and Ehlers–Danlos syndromes
        • Atherosclerotic: (MCQ)
          • Due to remodeling and dilatation of the aortic wall
      • Anatomic classification (MCQ)
        • DeBakey Type I: Ascending and descending aorta
        • DeBakey Type II: Ascending aorta only
        • DeBakey Type III: Descending aorta only
        • Stanford A: Ascending aorta (same as DeBakey I/II)
        • Stanford B: Descending aorta (same as DeBakey III)
      • Ascending aorta and aortic arch aneurysms are worse than descending aortic aneurysms. (MCQ)
      • Expansion rate (MCQ)
        • 0.56 cm/yr for arch aneurysms
        • 0.42 cm/yr for descending aorta.
      • Epidemiology
        • Male-to-female ratio is 2:1. (MCQ)
        • Familial clustering.
        • Patients tend to be younger than those with abdominal aortic aneurysm (AAA).
      • Signs and symptoms of expansion or rupture (MCQ)
        • Tearing” or “ripping” chest pain radiating to the back.
        • Acute neurologic symptoms (syncope, coma, convulsions, hemiplegia).
        • Palpable thrust may be seen in right second or third intercostal space.
        • Pulsating sternoclavicular joint may be seen (secondary to swelling at the base of the aorta).
        • Hoarseness.
        • Stridor.
        • Dysphagia.
        • New aortic regurgitation murmur.
        • Hemoptysis or hematemesis.
        • Absent or diminished pulses.
      • Diagnosis
        • CXR
          • Widened mediastinum (MCQ)
          • Abnormal aortic contour
          • “Calcium sign”: (MCQ)
            • Reflects separation of intimal calcification from the adventitial surface
        • Contrast CT
          • Two distinct lumens (true and false) separated by intimal flap (MCQ)
          • Sensitivity 85–100%
          • Specificity 100%
        • Magnetic Resonance Imaging (MRI)
          • Excellent sensitivity and specificity
          • Gives info about branch vessels that CT does not
          • No need for contrast
          • Limited to stable patients
        • Angiography
          • Requires contrast dye like CT
          • Invasive    
        • Transesophageal Echocardiography (TEE)
          • Presence of intimal flap separating the true from the false lumen
          • Features of the false lumen: (MCQ)
          • Larger in diameter, slower blood flow velocity
          • Can be used in relatively unstable patients as well
        • Transthoracic Echocardiography (TTE)
          • Available at bedside
          • Noninvasive
          • Suitable for unstable patients
          • Requires operator expertise
          • Moderate ability to detect ascending and arch dissections (MCQ)
          • poor for detecting descending arch dissection (MCQ)
      • Treatment and prognosis
        • Medical
          • Control hypertension with nitroprusside or labetalol.
          • Parenteral analgesia.
        • Surgical
          • For ruptured aneurysms, it is the only definitive therapy.
          • Carries very high risk of mortality.
          • Most patients die before reaching the operating room.
          • Of those that reach the OR, less than 50% survive.
          • Elective repair is considered for  (MCQ)
            • aneurysms > 7 cm
            • when aneurysm diameter is > 2.5× that of adjacent aorta.
          • Mortality rate is 10–15%.
          • For degenerative aneurysms, the entire aortic root must be replaced.
          • Atherosclerotic aneurysms can be repaired  (MCQ)
            • via open approach
              • median sternotomy approach for ascending arch
              • posterolateral thoracotomy for descending arch
            • via endovascular technique.
          • Ascending and descending arch aneurysms are repaired with patient under cardiopulmonary bypass, anticoagulation, and in mild-moderate hypothermia. (MCQ)
          • Aortic arch aneurysms are repaired with patient in circulatory arrest and profound hypothermia.
      • Complications
        • Hemorrhage
        • Paraplegia
        • Stroke
        • MI
        • Visceral ischemia
    • THORACOABDOMINAL ANEURYSMS
      • Crawford classification: (MCQ)
        • Type I:
          • Most of descending thoracic aorta and abdominal aorta proximal to renal arteries
        • Type II:
          • Most of descending thoracic aorta and abdominal aorta distal to renal arteries
        • Type III:
          • Distal one-half of descending thoracic aorta and abdominal aorta proximal to renal arteries
        • Type IV:
          • Distal one-half of descending thoracic aorta and abdominal aorta distal to renal arteries
      • Diagnosis
        • Made incidentally (routine physical exam or imaging for other reasons) or on postmortem exam (for ruptured ones).
      • Treatment
        • Elective repair undertaken after weighing risk vs. benefit.
        • Open surgical approach is used: (MCQ)
          • Type I: Thoracic incision
          • Types II and III: Incision from sixth intercostal space into abdomen
          • Type IV: Retroperitoneal incision from left flank to umbilicus


    Aortic Aneurysm – For Nursing Students & Nurses!!
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    This 3D animation on abdominal aortic aneurysm surgery depicts the anatomy of the aorta and both the open and endovascular procedure for repairing an abdominal aortic aneurysm. Abdominal aortic aneurysm (also known as AAA, pronounced “triple-a”) is a localized dilatation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50 percent. In the open procedure the abdomen and aorta are opened and a graft is sown into place. In an endovascular procedure catheters are used to place a stent graft in the aneurysm. ANH00012
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    Abdominal Aortic Aneurysm
    This 3D animation on abdominal aortic aneurysms depicts the anatomy of the aorta and both the open and endovascular procedure for repairing an abdominal aortic aneurysm. Abdominal aortic aneurysm (also known as AAA, pronounced “triple-a”) is a localized dilatation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50 percent. In the open procedure the abdomen and aorta are opened and a graft is sown into place. In an endovascular procedure catheters are used to place a stent graft in the aneurysm
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