Vascular Surgery > AAA > Flashcards

AAA Flashcards

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1
Q

AAA screening recommendations

A

The new recommendations of surveillance intervals for patients with AAA were published in 2018 from the Society of Vascular Surgery:

1) imaging at 3-year intervals for AAA diameter between 3.0 and 3.9 cm;
2) imaging at 1-year intervals for AAA diameter between 4.0 and 4.9 cm; and
3) imaging at 6-month intervals for AAA diameter between 5.0 and 5.4 cm.

This was based on the meta-regression analysis by Thompson et al. They studied the AAA growth rate based on aneurysm diameter and the time to 10% probability of reaching a diameter of 5.5 cm. For an aortic diameter greater than 2.5 cm but less than 3 cm, it is now recommended to rescreen at 10 years.

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2
Q

What is definition of aneurysm?

A

50% increase in d compared to expected size (SVS)
>3cm
50% increase relative to adjacent normal size

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3
Q

what is ectasia?

A

intermediate stage of enlargement <50%

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4
Q

what is arteriomegaly?

A

diffuse continuous enlargement of multiple arterial segments dilated to >50% of normal

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5
Q

what is most significant RF for development of AAA? what are other RF?

A

smoking

age, maleness
famhx, white, DM
HTN increase rupture risk

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6
Q

What % of men >65 have AAA? women?

A

5%
1.7%

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7
Q

What % of TA have AAA?
What % of AAA have TA?
What % have iliac involvement?
what % of 1st degree family members have AAA?

A

50%
12%
40%
as high as 20%

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8
Q

What is the benefit from screening?

A

reduction of death (1 year and long-term)
not see for women

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9
Q

What is the benefit of intervention on small aneurysms <4.0?
What about with EVAR?

A

no benefit surveillance vs sx
no survival benefit at 20 months

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10
Q

What is LAPLACE’s law?

A

T=PR

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11
Q

What are some risk models used for estimating mortality with intervention on AAA? advantages/disadvantages?

A

glasgow aneurysm score
(open repair, good for elective or ruptured, poor external validity, performs poorly on high risk)

medicare model 
(open or EVAR)

Vascular governance
north west model

all the scoring systems for EVAR have ROC <70

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12
Q

What are advantages/disadvantages of EVAR over open in regards to outcomes?

A

more likely to DC home
lower mortality peri-op

Evar constant rupture risk after repair
more likely to have subsequent interventions

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13
Q

When should beta-blockers be started before AAA surgery?

A

one month. no benefit if not started before

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14
Q

What % of EVAR convert to open ?What is the mortality associated to open conversion after EVAR?

A

1.5% mort 12%
2% mort 10%

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15
Q

What are advantages/disad of transperitoneal approach?

A

more rapid, greatest flexibility
widest access
evaluation of intra-abdominal pathology

longer ileus
greater fluid loss
difficult exposure junta or pararenal

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16
Q

What are advantages/disad of retroperitoneal approach?

A

avoids hostile abdo
good for junta/para
less physiologic stress/less ileum
good for obese
inflam AAA/horseshoe kidney
(lower LOS, cost and plum comps)

poor access to R renal and iliac
cannot eval intra-abdo pathology
more flank bulges/chronic wound pain

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17
Q

When do you consider preserving IMA?

A

signif SMA/celiac disease
bilat hypo occlusion
large IMA
prior colonic resection
sluggish back bleeding

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18
Q

What are renal or IV abnormalities encountered in AAA?

A

retro-aortic LRV
circ LRV
left-sided IVC
accersory renal verin
pre-aortic confluence of the iliac vein

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19
Q

What physiologic changes occur with aortic cross clamping?

A

10% increase in BP

if supracelia

preload increase if clamp prox to celiac as sphlanic cannot act as venous reservoir

increase after load and preload increase cardiac contractility and myocardial O2 demand

increase filling pressure

decrease EF

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20
Q

What are the consequences of unclamping?

A

reduction in PVR
reperfusion hyperemia
toxic metabolites, lactate, K, reactive O2 species, prostaglandins

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21
Q

What are the mechanism of renal injury in AAA repair

A

ischemia
emboli
renal vasoc even with infrarenal clamp

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22
Q

What are the rate of
reintervention for bleeding?
MI?
resp comps?
R insuff? dialysis?
colonic ischemia?

A

1.2%
10%
20%
10% 0.5% (increase if pararenal)
1-5% (on histo 30%)

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23
Q

What are RF for colonic ischemia?

A

ligation of IMA,
failure to revasc hypo,
extensive iliofem dz,
SMA stenosis,
embolism,
retractor injury,
previous colonic resection

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24
Q

How does colonic ischemia present?

A

diarrhea, melena
left colon almost always affected

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25
What are finding of CI on flex sig?
early petechial hemmorhage interspersed with areas of pale oedematous mucosa late segmental erythema, +/- ulcerations and bleeding with severe mucosa cyanotic, dusky, grey or black
26
What is the rate of aorta-enteric fistula after AAA? sexual dysfunction? abdo wall hernias? RP bulge? SBO at 4 years?
1.6% 50% 30% 30-50% 25%
27
what are most common bacteria for infected AAA?
staph, salmonella, strep, E.Coli
28
What are signs of infected AAA on CT scan?
periaortic soft tissue mass, stranding of fluid, signs of destruction of the surrounding tissue 50% have contained rupture
29
What % of type II resolve with 6-12months?
80% eurostar says no association with rupture
30
What is the yearly rupture rate for EVAR?
1% per year
31
Name some EVAR RCT and describe their results
EVAR-1, Dream, OVER mortality higher for open then EVAR but no difference at 2 years. reintervention rate higher in EVAR
32
What are techniques to fix type I endoleak?
proximal extension palmaz snorkel aorto-uni with fem fem fenestrated
33
What factors affect migration?
increased angulation of neck, short neck, neck thrombus, large diameter, neck dilation, sac shrinkage
34
How often doe limb occlusion occur? what are risk factors?
5% 4 years AI dz, small distal aorta \<14mm, tortuous iliacs
35
What are consequences of IA embolization?
pelvic ischemia buttock claudication 50%, necrosis, colorectal ischemia 2%, erectile dysfunction 2% paraplegia if bilat 3%
36
What is the rate of Type I endoleak with snorkel?
5% (50% require tx) 30d mort 4%
37
What are bladder pressure measurements for abdominal compartment syndrome? When is a laparotomy indicated?
grade I 10-15mmHg grade II 16-25mmHg grade III 26-35mmHg grade IV \>35mmHg grade III-IV
38
What are common venous anomalies encountered during open surgery for AAA?
retro-aortic renal 1-3% circumaortic 0.5-1.5% Left sided vena cava \<1% duplicated IVC 1-3%
39
What is the evidence for AAA screening?
RCT \>65, 40% reduction in AAA mortality MA 44% in AAA mortality
40
What growth rate for AAA is concerning?
\>1cm/year
41
How does family history effect rupture rate of AAA?
higher rupture rate if have a family hx of AAA
42
What cutoff for cardiopulmonary exercise testing predicts high risk after AAA?
10-15 ml/kg/min
43
What level of wall tension is high risk for AAA rupture?
\>40N/cm \<30 is low risk
44
What non-IFU related scenarios favour open \>EVAR? EVAR\>opan
horsehoe kidney with multiple arteries require IMA latency redo abdo stoma wall defects poor pulmonary
45
What are renal abnormalities that can be encountered during AAA repair?
horseshoe pancake crossed-fused renal ectopia all of these usualy have multiple RA
46
What adjuncts can be used to protect kidneys during AAA?
cold hyperosmolar crystalloid HTK solution saline with mannitol cooling kidney by 30% reduces metabolic demands by half
47
List collateral pathways that supply colon.
marginal artery meandering artery GDA middle sacral hypo (lateral sacral, middle rectal, superior rectal, obturator)
48
What is repair threshold for iliac aneurysm?
3-3.5cm
49
Which graft does not have suprarenal fixation?
Gore, aorfix
50
What were results of EVAR-1?
RCT open vs EVAR 30d mort 1.7 vs 4.7 (E vs O) secondary more common in EVAR no diff at 6 years
51
What were the results of the DREAM trial?
RCT peri-op mort 1.2 vs 4.6 in EVAR vs OPEN combined MACE and mort favoured EVAR no diff at 6 years
52
What were the results of the OVER trial?
peri-op mort 0.5 vs 3% E vsO no diff at 2 years
53
From eurostar data which graft had highest migration/endoleak highest rate of limb occlusion
aneurs, talent zenith
54
What is the rate of ED in EVAR?
20% for unilateral embolization
55
What are mortality rates for rAAA?
2/3 before hospital 50% with open 30% with EVAR
56
What are some management considerations for rAAA?
permissive hypotension avoid hypothermia cell saver blood in room
57
What are outcomes for rAAA? bleeding colinic ischemia
10% 40% open, 20% EVAR
58
What features indicate high peri-op mortality for rAAA?
cardiac arrest liver failure MOF
59
What are SVS guidelines for pre-op workup for AAA?
EKG NIST if 3 or \> RF for CAD
60
Ideally how long to wait after PCI?
4-6 weeks for BMS 12months for DES
61
What are screening recommendations for AAA?
One-time screening for men \>65 yo 55 yo if fam hx of AAA women \>65 with fam hx of aaa or who have smoked Re-screening not recommended if \>65yo and aortic diameter \<2.6cm
62
When do increase surveillance to q6months?
\>4.5cm
63
What are signs and symptoms of aortocaval fistula?
machinery murmur high output failure limb edema hematuria
64
List local factors associated with development of anastomotic aneurysm.
Arterial wall degen Suture line disruption Prosthetic graft failure Infection/inflammation Technical factors Mechanical stress
65
List systemic factors associated with anastomotic aneurysm.
Smoking DLP HTN Anticoagulation Vasculitides Generalized arterial weakness
66
What are indications for treatment for anastomotic aneurysm?
\>2.5cm symptomatic
67
Is endovascular better then open repair for anastomotic aneurysms?
endo can offer lower mortality and morbidity rates with high success rates in certain patients
68
What are the causes of primary AEF?
aneurismal aorta (most common) foreign body tumor radiation infection GI dz
69
What portion of the duodenum is involved in AEF?
3rd or 4th
70
Where do secondary AEF and AEE occurs?
AEF suture line AEE on graft
71
What are the causes of secondary AEF?
``` infection pulsatile pressure (graft non compliant) technical error (injury to bowel) ```
72
what is the classic triad for secondary AEF?
GI bleeding abdo pain pulsatile mass 11%
73
What is the classic feature of a secondary AEF?
herald bleed
74
What are findings on CT scan that indicate AEF?
Effacement of fat planes around aorta Perigraft fluid and soft tissue thickening, ectopic gas, tethering of adjacent thickened bowel loops toward aortic graft, rarely extrav
75
What are signs of AEF on endoscopy?
need to see 3-4th portions visualization of graft ulcer erosion with adherent clot extrinsic pulsatile mass
76
What are the most common bacteria for primary AEF?
salmonella klebsiella
77
What are the most common bacteria for secondary AEF?
s.aureus
78
What are repair options?
graft excision without replacement if enough ollaterals insitu graft replacement neo-aortoiliac procedure extra-anatomic revasc endovascular (as bridge)
79
What grafts can be used for replacement?
allograft synthetic graft silver coated dacron antibiotic impregnated grafts
80
What are the result of operative repair for AEF?
mortality 30% amputation 10% 3 yr survival 50%
81
What are most common complications after PCI?
bleeding/hematoma PSA AVF dissection thrombosis
82
What are RF for complications after endo procedure?
larger sheath interventional procedures previous cath small BMI female uncontrolled HTN GIIbIIIa increased age
83
What are indications for intervention for femoral hematoma?
hemo instability persistent anemia skin necrosis nerve compression severe pain
84
What nerves can be affected in the retroperitoneal space (4)?
lateral cutaneous nerve of the thigh genitofemoral nerve femoral nerve nerve to cremaster muscle
85
What does the lateral cutaneous nerve of the thigh innervate?
innervates skin on lateral thigh
86
What does the genitofermoral nerve innervate?
sensation upper anterior thigh sensation anterior scrotum/mons
87
What does the femoral nerve innervate?
sensation ant/medial thigh/medial chin/arch of foot extends knee
88
What does the nerve of the cremaster muscle innervate?
cremasteric reflex
89
What are signs/symptoms of RPB?
non-specific groin/back pain oliguria numbness weakness LE ecchymosis flank (grey turner) ecchymosis umbilicus (cullens)
90
What is natural hx of AVF from endovascular procedure?
30-80% resolve spontaneously within 1 year (most within 1 month)
91
What are treatment strategies for PSA?
US compression US guided thrombin observation surgical Endovascular
92
what is success of thrombin injection for PSA? describe procedure.
95-100% Anesthetize skin Fill sac with 0.1-0.2ml of thrombine Direct needle away from inflow of the PSA If perist then another dose Check distal pulses and repeat US in 24-48 hours Recurrence 3%
93
What are indications for surgical intervention on PSA?
Infected Hemo instability Skin necrosis Distal limb ischemia Neurologic defecit Failure of US treatment Large aneurysm \>5cm with wide necks
94
What causes thrombosis after endovasclar procedure?
large sheath aggressive compression closure device failure
95
What are methods of nerve injury in brachial access?
hematoma direct damage schema from arterial thrombosis
96
What are different types of closure devices and give an e.g.?
``` collagen based (angioseal) suture based (per close) metal/disk based (star close) ```
97
What is the evidence for closure devices?
MA no difference in complication rate then with compression alone
98
What are active and passive closure devices?
active suture/clip extravascular prothrombotic matrix passive (faciliatate compression) external patches with prothrombotic coating assisted compression
99
What were the rates of life threatening hemorrhage in TOPAS and STILE trial?
13% 6%
100
At what fibrinogen levels do you alter thrombolysis management?
\<100 stop
101
List ways to assess graft latency intra-operatively.
inspection palpation arteriography doppler duplex angioscopy IVUS
102
What b/w to send off before initiating heparin in thromboses grafts?
Plt Functional activated protein C resistance Anticardiolipin antibodies ATIII Protein S HITT assay
103
What are RF for graft thrombosis?
Single vessel runoff high rate of graft failure Below knee target DM Preop tissue loss BMI \>35 Early revision African American smoking failure to go to surveillance
104
What are the critical elements for sustained flow in bypass graft?
Inflow Outflow Conduit Operative technique Coagulation profile
105
What are 30 day causes of graft thrombosis?
technical error graft thrombogenicity poor runoff obstructive venous disease
106
What are 18 month causes of graft failure?
neointimal hyperplasia vein graft structural abnormalities
107
What are 5 year causes of graft failure?
vein or prosthetic graft structural abnormalities progressive athero
108
What are indications for angioplasty for intimal hyperplasia?
Post CTD to bridge to OR High risk for OR Difficult to approach surgically
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