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AAA & TAA
Cardiology
| Question | Answer |
|---|---|
| Pseudoaneurysm | well defined collection of blood & conn tissue outside vessel wall |
| Most common site of AAA formation: | infrarenal abdominal aorta |
| Atherosclerotic dz of aorta may produce: | stenotic obstruction or aneurysmal dilatation |
| Aneurysm types | Saccular; fusiform |
| Most common aneurysm type | Fusiform: symmetrical dilation (involves full circumference of aortic wall) |
| Aneurysm defn: | 1.5x or > the normal diameter of the vessel. |
| Aneurysm type: comparative prevalence | Abdominal (85%) > thoracic aneurysm (15%) |
| Half of newly detected AAAs are: | <5cm (& 2/3 eventually require repair) |
| AAAs usually involve: | aortic bifurcation (& often involve common iliac arteries) |
| AAA & Rupture | 80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse) |
| Healthy, young normal aorta: size | about 2 cm |
| Considered Aneurysm at size: | > 3 cm |
| AAAs arise in areas of: | dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture |
| 90% of AAAs originate where: | below renal arteries (infrarenal); 10% suprarenal |
| Infrarenal aneurysm may exhibit: | stenosis (narrowing) of aorta |
| AAA: Surgery recommended when: | >5 cm; women: appropriate at 4.5 - 5.0 cm |
| Decline of aortic elasticity & distensibility is accelerated in pts with: | HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries. |
| AAA: Risk Factors | Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH |
| FH in AAA: | 1/4 of AAA pts have first degree relative with hx of AAA |
| AAA Risk Factors for Rupture | Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD |
| AAA: what may prompt earlier endovasc repair? | Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range) |
| AAA Prognosis | 80% mortality with rupture |
| Cystic medial necrosis occurs most frequently in: | ascending aorta; aortic wall weakening => fusiform aneurysm |
| Cystic medial necrosis assoc with: | conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement |
| Asc TA: Etiologies | CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis |
| Desc TA: predominant cause = | atherosclerosis |
| Desc TA: called thoracoabdominal if they: | extend below level of diaphram into abd aorta |
| TAA: Tx: >5 cm | surgery (if Sx or rapid expansion: then sooner) |
| TAA: Clinical Findings | > 50% pts ASx at dx; Sx due to vascular consequence or mass effect |
| TAA: if surgery required, need: | coronary angiography |
| TAA: Inc rupture risk at smaller diameters with: | Marfan; bicuspid valve |
| TAA: Asc Aorta: surgery indicated at: | ≥ 5.5 cm (=/> 5.5) |
| TAA Marfan/ Bicuspid Valve: surgery indicated at: | ≥ 5.0 cm (=/> 5.0) |
| TAA Aortic valve replacement: surgery indicated at: | ≥ 4.0 cm (=/> 4.0) |
| TAA Desc Aorta: surgery indicated at: | ≥ 6.0 cm (=/> 6.0) |
| TAA: Prognosis | M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD) |
| Aortic dissection: usual direction of extension | antegrade (driven by the forward force of aortic blood flow); sometimes retrograde from site of intimal tear |
| Aortic dissection: intimal tear in aorta creates a false lumen between: | media & adventitia |
| Aortic dissection: >95% occur in the: | Ascend aorta just distal to aortic valve or just distal to left subclavian at ligamentum arteriosum |
| Aortic Dissection: Increased risk in: | pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation |
| Aortic Dissection: Debakey I = | Ascending A extending to distal |
| Aortic Dissection: Debakey II = | Ascending aorta only |
| Aortic Dissection: Debakey III = | Descending aorta only |
| Aortic Dissection: Stanford A = | Any involvement of ascending aorta |
| Aortic Dissection: Stanford B = | Not involving ascending aorta |
| Aortic Dissection: Proximal = | DeBakey Types I & II or Stanford Type A |
| Aortic Dissection: Distal = | DeBakey Type III & Stanford type B |
| Aortic Dissection: Clinical Findings | Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml |
| Aortic Dissection: PE | Increased or decreased BP; pt may be in shock; wide pulse pressure; diminished / asymmetric peripheral pulses; aortic insufficiency murmur if ascending aorta; syncope |
| Aortic Dissection: poss Sx devt | Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop) |
| Aortic Dissection: mgmt: Type A = | Surgical repair, may require AVR |
| Aortic Dissection: mgmt: Type B = | Medical therapy (IV propranolol or nitroprusside) |
| Aortic Dissection: mgmt: All pts = | aggressive BP control; yearly imaging or if increased Sx |
| Aortic Dissection: Prognosis | Op mortality of type B 2x that of type A (bc comorbid illness); 30% have prog enlarging aneurysm that eventually req repair |
| Sudden onset ripping, tearing chest pain, diminished pulses = | Aortic dissection |
| Flank pain, hypotension, pulsatile abdominal mass = | AAA |
| RF/etiology of ascending aortic aneurysm: | CMT (cystic medial necrosis) |
| RF for TAA/AAA: | In order: tobacco, age, HTN, HLD, other atherosclerosis |
| 2 components of Aorta | thoracic (ascending, arch, descending); Abdominal |
| 3 layers of aorta: | Intima; Media; Adventitia |
| Intima: | thin, inner layer (delicate, easily traumatized) |
| Media: | thick middle layer (*strength of the aorta comes from media) |
| Adventitia: | somewhat thin outer layer (contains mainly collagen) |
| Strength of the aorta lies in: | media (= laminated, intertwining elastic tissue/ multiple layers, in a spiral manner, max tensile strength w/ distensible & elastic |
| Pseudoaneursym | well defined collection of blood & conn tissue outside vessel wall |
| Atherosclerotic vs inflammatory | inflame = extreme of atherosclerotic aneurysm |
| pathogenesis of AAAs: | multifactorial: genetic, environ, hemodynamic & immunological; Chlamydia pneumoniae? |
| Aorta most affected by atherosclerotic process: | infrarenal abdominal aorta |
| most common site of AAA formation: | infrarenal abdominal aorta |
| Atherosclerotic dz of aorta may produce: | stenotic obstrusion or aneurysmal dilatation |
| Aneurysm types | Saccular; fusiform |
| Most common aneurysm type | Fusiform |
| Has a fairly symmetrical dilation (involves full circumference of aortic wall) | Fusiform |
| More localized dilation (outpouching of a portion of aortic wall) | Saccular aneurysms |
| Flow disturbance thru the aneurysmal aortic segment: | blood may stagnate along walls, cause mural thrombus (may embolize) |
| Aneurysm defn: | 1.5x or > the normal diameter of the vessel. |
| Aneurysm type cf prevalence | Abdominal more common than thoracic aneurysm |
| Half of newly detected AAAs are: | <5cm (& 2/3 eventually require repair) |
| AAA & COPD: | COPD pts: rupture of smaller AAAs more likely |
| AAAs usually involve: | aortic bifurcation (& often involve common iliac arteries) |
| AAA & Rupture | 80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse) |
| Healthy, young normal aorta: size | about 2 cm |
| Considered Aneurysm at size: | > 3 cm |
| AAA Incidence in Men vs Women | 10:1 |
| AAA: men over 55 | 2% |
| AAAs arise in areas of: | dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture |
| 90% of AAAs originate where: | below renal arteries (infrarenal); 10% suprarenal |
| Infrarenal aneurysm may exhibit: | stenosis (narrowing) of aorta |
| AAA: Surgery recommended when: | >5 cm or if growing >0.5cm in 6 months or >1cm per year |
| Decline of aortic elasticity & distensibility is accelerated in pts with: | HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries. |
| Loss of aortic elasticity | loss of elastin & increase in collagen (=> lack of distensibility) |
| AAA: Risk Factors | Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH |
| FH in AAA: | 1/4 of AAA pts have first degree relative with hx of AAA |
| Initial dx test to screen for & follow known AAA = | Abdominal US: |
| Abdominal US: advantages | 100% sensitivity, no contrast, low cost |
| AAA: CT scan | pre-op or if US indeterminate; better defines shape & location/ extent of AAA |
| AAA: Catheter aortography may: | underestimate diameter |
| AAA Risk Factors for Rupture | Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD |
| AAA Surveillance | Trend: bigger AAA, more frequent surveil |
| AAA: for average risk pts, a threshold of ?? cm in diameter is appropriate for elective repair | 5.5 cm |
| AAA: what may prompt earlier endovasc repair? | Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range) |
| AAA Endovascular repair: No justification for: | endovascular repair at smaller diameters |
| AAA: for women, elective endovasc repair is appropriate at: | 4.5 or 5.0 cm |
| AAA Prognosis | 80% mortality with rupture |
| AAA mgmt: | Risk factor mod (stop SMK, aggressive HTN & Lipid Rx), med mgmt to slow progression |
| AAA operative mortality: | Elective = 2-5%, Expanding = 5-15%, Ruptured: >50% |
| Criteria for Endovascular Repair: Proximal neck: | length: min 15 mm; diameter: max 28 mm; angulation: <60 degrees |
| Criteria for Endovascular Repair: Iliac arteries | Common iliac a.: variable diameters; ext iliac a. <7 mm |
| USPSTF Screening Guidelines for AAA: repair what in who? | large AAA (> 5.5 cm) in men btw 65-75 w/ Hx of SMK; No gdln for men 65-75 no hx SMK; gdln against screen in women |
| USPSTF AAA Screen Consensus stmt | All M 60-85; All F 60-85 w/ 1 or more CVD risk factor; M&F > 50 w/ FH AAA |
| Thoracic aneurysm: prevalence | Far less common than AAAs |
| Thoracic aneurysm: classified by: | pt of aorta involved ( ascending, arch or descending TA) |
| Thoracoabdominal AA = | desc TA extends distally to involve AA |
| TAA: prevalence | Less common than AAA w/ diff pathogenesis; 60% = aortic root & ascend A; 40% desc A; 10% arch |
| Sm mx cell drop out & elastic fiber degen w/ media of cystic spaces filled w/ mucoid matl = | Cystic medial necrosis |
| Cystic medial necrosis occurs most frequently in: | ascending aorta |
| Cystic medial necrosis leads to: | aortic wall weakening => fusiform aneurysm |
| Aneurysm from cystic medial necrosis often involve: | aortic root & may consequently result in AI |
| CMN is accelerated by: | HTN (occurs somewhat w/ aging) |
| CMN assoc with: | conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement |
| Ascending TA: Etiologies | CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis |
| Ascending aneurysms usually caused by: | CMN |
| If Asc aneurysm due to atherosclerosis, assoc with: | diffuse aortic atherosclerosis |
| Aortic Arch aneurysms often contiguous with: | aneurysms of asc OR desc A & can be caused by any of the etiologies above. |
| Desc TA: predominant cause = | atherosclerosis |
| Desc TA: tend to originate: | just distal to origin of L subclavian; may be fusiform or accular |
| Aortic Arch Aneurysm: Etiologies | Ext of Asc or Desc aneurysms; Hx trauma or deceleration injury |
| Desc TA: called thoracoabdominal if they: | extend below level of diaphram into abd aorta |
| TAA: Spontaneous rupture prevalence | less common than AAA (bc inc of Sx due to compression of surrounding structures) |
| TAA: Tx: >5 cm | surgery (if Sx or rapid expansion: then sooner) |
| Sx pts or w/ AI: | Inc incidence of rupture |
| TAA: Clinical Findings | > 50% pts ASx at dx; Sx due to vascular consequence or mass effect |
| TAA: Vascular Sx | AI with CHF, or thromboembolism causing stroke, lower extremity or mesenteric ischemia, renal infarct |
| TAA: Mass Effect | SVC syndrome, tracheal deviation, cough, hemoptysis, dysphagia, hoarseness |
| Ascending or arch An can cause compression of: | SVC or innominate v. => obstruction of venous return |
| Desc/ arch An: may cause compression of: | trachea or main stem bronchus => tracheal deviation, wheezing, cough & positional dyspnea, hemoptysis or recurrent pneumonitis |
| Desc/ arch An: Compression of esophagus can cause: | dysphagia & compression of recurrent laryngeal n. can cause hoarseness |
| TAA: Clinical Findings | Pain ( 25% pts) from direct compression of intrathoracic structures or chest wall; substernal or in back/ neck; steady, deep & severe? |
| TAA Rupture: | excruciating pain; may be assoc w/ aortic dissection |
| Rupture occurs most commonly into: | L intrapleural space or mediastinum; results in severe hypotension |
| Desc An rupture into: | adjacent esophagus => life threatening hematemesis |
| TAA Evaluation | CXR (only rule in, cannot R/O); Echo (TTE vs TEE); CT/ MRI |
| TAA: Pos CXR: | Must differentiate from anterior mediastinal mass (ie thymoma, lung CA) |
| TAA: if surgery required, need: | coronary angiography |
| Echo: TTE vx TEE | TTE only good to visualize aortic root (good for Marfan); TEE to visualize entire aorta, but is semi invasive (CT/ MRI better) |
| TAA Mgmt: major factors in rupture risk | Size & rate of growth |
| TAA Mgmt: Annual growth rate for <5cm aneurysm | 2% |
| TAA Mgmt: Annual growth rate for 5-5.9 cm | 3% |
| TAA Mgmt: Annual growth rate for >6 cm | 7% |
| TAA: Inc rupture risk at smaller diameters with: | Marfan; bicuspid valve |
| Asc Aorta: surgery indicated at: | ≥ 5.5 cm (=/> 5.5) |
| Marfan/ Bicuspid Valve: surgery indicated at: | ≥ 5.0 cm (=/> 5.0) |
| Aortic valve replacement: surgery indicated at: | ≥ 4.0 cm (=/> 4.0) |
| Desc Aorta: surgery indicated at: | ≥ 6.0 cm (=/> 6.0) |
| Aortic Root Replacement: Bentall: | Dacron graft w/ prosthetic valve sewn directly into aortic annulus; coronary arteries reimplanted into the graft (op mortality risk 5%) |
| Aortic Root Replacement: David = | valve sparing Bentall (re-implant native valve within dacron graft) |
| TAA: Prognosis | M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD) |
| TAA: 1 month op mortality = | 8-20% |
| TAA: operative complications | pulmo comps & damage to laryngeal or phrenic n., carotid or subclavian a. poss |
| Tear in aortic intima usu preceded by medial wall degen/ CMN = | aortic dissection |
| Aortic dissection: intimal tear in aorta creates a false lumen between: | media & adventitia |
| Aortic dissection: time course | May be acute or chronic |
| Aortic dissection: >95% occur in the: | Ascend aorta just distal to aortic valve or just distal to L subclavian at lig arteriosum |
| Intimal tears resulting in dissection: prevalence: | 65% Ascend A; 20% Desc A; 10% A Arch; 5% Abd A. |
| Aortic Dissection incidence | 3/100,00/year (7,000 cases/year in US); most common in 6th-8th decade; M>F 2:1 2:1 |
| Aortic Dissection: Increased risk in: | pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation |
| Aortic Dissection: 80% of pts are: | Hypertensive |
| Aortic Dissection: Clinical Findings | Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml |
| Aortic Dissection: poss Sx devt | Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop) |
| Aortic Dissection Eval: CXR = | wide mediastinum, poss L sided pleural effusion |
| Aortic Dissection Eval: Echo = | 98% sensitive, 99% specific, +/- pericardial effusion |
| Aortic Dissection Eval: CT helpful in: | acute presentation |
| Aortic Dissection Eval: MRA/MRI useful for: | serial follow up |
| Aortic Dissection Eval: EKG = | LVH, nonspecific or inferior abnormalities (dissections preferentially extend into Right coronary ostium) |
| Aortic dissection: CXR = | Wide aortic silhouette & mediastinum; Left pleural effusion; 10%-20% normal |
| Aortic Dissection: mgmt: Type A = | Surgical repair, may require AVR |
| Aortic Dissection: mgmt: Type B = | Medical therapy |
| Aortic Dissection: mgmt: Type B: Exceptions to med tx: | Rupture, Limb/ visceral ischemia, Saccular morphology, ongoing pain, uncontrolled HTN, Marfan, AI |
| Aortic Dissection: mgmt: Chronic & asymptomatic = | medical Rx |
| Aortic Dissection: mgmt: All pts = | aggressive BP control; yearly imaging or if increased Sx |
| Aortic Dissection: Prognosis | Op mortality of type B 2x that of type A (bc comorbid illness) |
| Aortic Dissection: 5 yr survival: repaired Type A = | 70-80% repaired type A |
| Aortic Dissection: 5 yr survival: repaired Type B = | 50-70% repaired type B |
| Aortic Dissection: Prognosis: chronic type B | 30% => progressively enlarging aneurysm that eventually requires repair |
| Aortic aneurysm etiologies = | atherosclerosis (most common); Marfan (esp TAA); aortitis (mycotic, salmonella, syphilis, other infxn), giant cell arteritis |
| Complications of aortic aneurysm | rupture (esp if >5.5cm); thromboembolism; distal ischemia |
| Aortic aneurysm dx studies | U/S; CT; aortography (used before surgery); CXR (to show calcifications) |
| Aortic dissection etiologies: | HTN; Marfan; cystic medial necrosis; iatrogenic comp of cath |
| Aortic dissection pathophysiology | intimal tear with formation of false channel in media by hematoma |
| Aortic dissection on CXR = | wide superior mediastinum; displaced trachea; L pleural effusion; enlarged aortic knob |
| Which medication (ACE, diuretic, CCB, sotalol) will decrease morbidity of patient with AAA? | Sotalol |
Created by:
Abarnard
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