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All right. I think we're live. Hi, everyone. Good evening. Hope everyone's doing well and having a great week so far. So, yeah, we're very delighted uh here trip to welcome Lauren and Emily back again to deliver part two of their webinar this week on vascular surgery. We're very looking forward to learning about the various conditions, etcetera. And uh yeah, we'll take it away any questions, please leave them in the chat and then afterwards, uh there will be an automatic feedback form generated with uh certificates provided as well once you fill that in. Uh But what without further a do? Well, welcome Lauren and Emily to the stage. That's great. Thank you. Uh Just checking. Can everyone see that? Yeah. Okay. Um So today we're just going to cover um I've done the aortic aneurysms and aortic dissection. Um So just kind of a session outline. So festival, we'll go through the anatomy. Um and then we'll go through the clinical aspects and if there are any questions, we can kind of come to them at the end. Uh Yeah. So first off the anatomy, so the learning outcomes are to describe the four sections of the aorta describe the major branches of the aortic arch, describe the layers of the aorta, uh the course of the abdominal aorta and then describe the branches of the abdominal aorta. Okay. So just starting off going over the sections of the aorta. So the aorta can be split up into four sections. Um So the ascending aorta is kind of the first part um which you can see kind of an orange there. Um and that arises from the aortic orifice from the left ventricle and it contains the aortic valve and that travels with the pulmonary trunk in the pericardial sheath. Um and that is sense to become the aortic arch. So the aortic arch starts um and the aortic root ends at the second sternocostal joint. Um and the aortic arch ends at level T four like vertebrae. So, the thoracic aorta, which on here is kind of labeled as the descending aorta um runs from T four. So back here to T 12 there and it leaves the thorax via the aortic hiatus in the diaphragm. And after that, it will become the abdominal aorta. So you can see that in purple here. So abdominal aorta ends at L4 uh just here where it bifurcates to form the right and left common iliac arteries. So just there on the diagram. Okay. And then, so now just a little bit more detail about the branches coming off the aortic arch. So, I mean, it's quite clearly labeled here. Um So you can see the break, acephalic artery comes off of the arch of the aorta on the right, and that forms the right subclavian artery and the right common carotid artery. Um And on the left, it differs slightly. So you've got the left common carotid artery coming directly off the arch aorta and the left subclavian also coming directly off of it. Um So the subclavian is responsible for applying spying the upper limb and then the common clotted are responsible for spying the head and neck. Okay. And then now just looking in a bit more detail about the layers making up the aorta. So you've got the innermost layer which is the tunica intima labeled in kind of a lighter color hair. Um You've got the middle layer, the tunica media and then the Ulta most layer, the tunica adventitia okay. And then this is just a lot more detail here, but looking at the same layers. So you've got the tunica intima here and you can see that you've got a basement membrane just relative marrows pointing. Um And then you've got endothelium lining that um and this layer is very delicate, so it's very vulnerable to damage. And then you've got the trick media which is the smooth muscle layer and that's arranged in like concentric layers. Um It's the thickest part um of the wall when looking at the like aorta and it contains elastic fibers of it which I think are these like little squiggly lines on the diagram. And then the tunica adventitia is don't which that almost bit here um is dominated by collagen fibers. And these provide tensile strength and also contains small blood vessels called visa vice or um and they supply blood to the wall of the vessel. Okay. So now just looking at the course of the abdominal aorta. So as kind of previously mentioned, um the aorta runs from T 12 to L4 where it divides where like bifurcates here. Um And when it enters the abdomen via the aortic opening, the diaphragm, it's accompanied by the esophagus vein and the thoracic duct. Um And the abdominal aorta is located in the retroperitoneal space and it descends to the left of the inferior vena cava, which you can just see here and it's over the anterior surface of the bodies of the lumbar vertebrae. Okay. So there's quite a lot on this slide. Um But I'll just kind of break it down. Um So this is just giving you the vegetable levels. Um And this is just giving detail about what each arteries kind of supplying. So, as you can see in this diagram here, you've got the inferior phrenic arteries um at T 12 and they go to supply the diaphragm. Um And essentially here, the inferior portion of the esophagus. Um You also have the celiac trunk here. Um and that forms the left gastric artery which can see supplies the stomach, um, and a portion of the esophagus. Um, you've also got the splenic artery, which kind of has the names, address, supplies the spleen as well as the stomach and the pancreas. And then finally, you've got the common hepatic artery which supplies the liver, stomach gallbladder, jodi, numb and pancreas. And then at L1, you have the superior mesenteric artery, um, and that supplies the disorder duodenum, the judge, no ileum, sending colon and part of the transverse colon. Um And then here you can see bilaterally have the renal arteries. Um which again, as the name suggests, they supply the kidneys, they're gonna add large Aries that was repaired arteries, um which can just see here. Um And they supply the testes or the ovaries. Uh The infusion inferior mesenteric artery is just there. Um And that is a large unpaid artery that arises at L3 and it supplies the large intestine from the splenic flexure um to the upper part of the rectum. And down here, you've got the median sacred artery which is an impaired parietal artery that arises the L4 and supplies the coccyx lumbar vertebrae and sacrum. And I mean, if you look at the diagram all along, you can see 1st, 2nd, 3rd and 4th lumbar arteries. Um So those four pairs of labour arteries are rising between L1 to 4 and they supply the abdominal wall and the spinal cord. So that's kind of all the anatomy done. Um So now I'm just going to move on to kind of looking at abdominal aortic aneurysms. So the learning outcomes for this like clinical section are kind of covering what an abdominal aortic aneurysm is. What the possible risk factors are the clinical features. I'm going to go over a bit about the screening program in the UK. I'm gonna look at what other differentials you should consider these patient's um um like the relevant investigations and the relevant management. Um and gonna of course, because this is like surgery cover the surgical options um as well as main complications and what um the identification and management of a ruptured abdominal aortic aneurysm is ok. So just to start a definition of like an aneurysm in general is an abnormal dilatations of a blood vessel. So you can just see that here like um and for an abdominal aortic aneurysm, um it's a dilatation of the abdominal aorta by more than 1.5 times the expected. So that's normally about three centimeters, uh like more than three centimeters in diameter. Um And most of them are found below the renal arteries. So this is an example of that. Okay. So possible risk factors. So the etiology is largely unknown. Um So possible causes include atherosclerosis, trauma, infection, inflammatory disease or connective tissue disease. Um So the risk factors that kind of, as I mentioned, connective tissue disorders. Um and then also increasing age uh men are more likely um than women to get an abdominal aortic aneurysm. You've also got family history, smoking, high BP and you've got high lipid levels. Okay. So a little bit about the clinical features. So often these patient's um are asymptomatic and the aneurysm is detected as an incidental finding or as part of the screening program, which I'm going to cover in a bit. Um but they can present with abdominal pain or back or loin pain. Um and all clinical examination which you can kind of see in this photo here. Um upon palpations of the autor, you may find like a palpable pulse, it'll abdominal mass. Um You may also see like distal embolization which can produce them ischemia. Um and you'll get symptoms with a rupture, but I'll kind of cover that a bit more later. Okay. So the screening program in the UK um is four abdominal ultrasound scan for all men when they turn 65. And that's because as mentioned with the risk factors, men are more at risk than women um at about 1.1% of those screens are diagnosed. Um So I think this is just quite good image of what the ultrasound may show. So you've got the vertical body there and variant being a caver and then the abdominal aortic aneurysm there. Okay. And so possible differentials that you should consider. So you've got renal colic um which is would present with kind of back pain, um, diverticulitis. So they would have possibly that constipation and abdominal pain, um, like more commonly like left lower quadrant pain and you wouldn't expect to find a pulse, it'll mass um, of these patient's like you would often do ct to kind of pull that out. Um, so you've also got irritable bowel syndrome. So you may expect more intermittent symptoms with that as well as kind of gi symptoms, um, bloating, uh like changes to store frequency. Um And also women are more at risk for that than men, uh which is different from kind of what's expected for abdominal aortic aneurysms. Um You've also should consider inflammatory bowel disease. So that comedy presents a kind of crampy, left sided pain and then again, like g eye symptoms, so often diarrhea, um urgency defecation. Uh and then with regard to like appendicitis, that's another possible differential. So that's periumbilical kind of localized the white quadrant kind of pain. Um And then you may get like nausea as well. A variant or shin in women. Um that's continuous nonspecific pain in the lower abdomen. Um Sure to consider a G I hemorrhage. Um So hemorrhagic shock may mimic a rupture. So again, I'll come onto rupture in a bit more later. So investigations these patient's um so an abdominal aortic aneurysm is initially investigated by ultrasound scan. And then once the ultrasound scan has confirmed that they may have a follow up with the CT with contrast. Um and then you can kind of monitor the diameter. Um and that's also to determine if they're suitable for endovascular procedures. Okay. So now I'm just gonna cover a little bit about management. Um So looking at monitoring and then the surgical management. Okay. So monitoring um in the UK is um if they've got less than 5.5 centimeter, you monitor via duplex ultrasound scan. Um because it's been determined that surgery prior to this provides know survival benefits. Um If they've got diameter of 3 to 4.4 centimeters, um then they have a yearly ultrasound scan to monitor. If it's 4.5 to 5.4, then you'll have a three monthly ultrasound scan. Um And then you'd also want to be managing cardiovascular risk factors for these patient's. So getting them to stop smoking, increased exercise, um, weight loss and then also manage their BP and then to subscribe statin and aspirin therapy. Um And it's also kind of worth noting that if they, they're aneurysm is more than 6.5 centimeters, um, then the D B L A needs to be informed. Um, and I'm disqualified from driving. Okay. So now I'm just going to have a look at the surgical management. So, um there's kind of two procedures for this. So I'll just go to the both of them and then the complications that can occur from both of them. So, surgery should be considered if the diameter is more than 5.5 centimeters. Or if it's expanding at more than one centimeter per year or if they're like symptomatic. Um As long as they're like otherwise fit, um if they're unfit, then you may leave it a bit longer. You may leave it till it's six centimeters or more. Um just due to the risk of mortality from undergoing the repair. So, patient have a choice of an endovascular repair. So IV are or open repair. So for an open repair, you'd make a midline laparotomy or long transverse incision need to expose the aorta. Um You clamp the aorta approximately and iliac arteries distantly before like segment was removed and then you can replace with a prosthetic graft. So you can just kind of see that in the image here, the graft in place. And then for Eva um you can use the catheter um to get to the site of the aneurysm and that's done kind of via the femoral arteries. Um And then you can open the stent um as you insurance show you this picture here um and that fixed, that's fixed in place across the aneurysm uh which you can see has the aneurysm there and then the stent covering it. So just think about complications uh for the endovascular repair, you've got the risk of an endovascular leak. So any complete seal could form around the aneurysm and that would cause blood to kind of leak around the graph So just into the spit here and you kind of need to monitor for this because it can go undetected otherwise. Um it's often a symptomatic and it can lead to a rupture. So that's something to consider. You also can get device migration, um get and and a graft infection or wound. You can also get embolization and then for the open repair that's associated with much higher risk of complications and like the longer hospital stay, you'd be concerned about kind of would infection or infection of graft um embolization and aorta enteric fistula. And now just talking about ruptured abdominal aortic aneurysms um and how they present. So the risk of rupture increases with diameter. Um and your risk factors are kind of smoking, high BP. And actually, if you're female, that increases your risk of rupture and some like symptoms that they may present with would be kind of abdominal pain, back pain, kind of syncope, vomiting, and they'd be like hemodynamically compromised with a pulse, it'll abdominal mass and tenderness. So this is just showing kind of the classic triad to 50% of patient's will present with this. Um And so they'll have flank or back pain, a postal abdominal mass and hypertension and the aneurysm can rupture anteriorly into the peritoneal cavity or posteriorly into the retroperitoneal space. Um And anterior is associated with a very poor, diagnosed, very poor prognosis. So, management, uh you give immediate high flow oxygen get IV access, you'd want urgent blood. So full blood count you any clotting and then group and save and you'd want to have a minimum of six units ready. Uh You don't want to keep BP below 100 because if you raise it too high, you can, may dislodge any clots and then you can get further bleeding because of that. Um If they're unstable, then they need an immediate transfer to theater for an open repair. But if they're stable, they can have a CT angiogram and you can see if they're suitable for an endovascular repair. So that's kind of the end of my section. So Emily now, so yes, I'm going to talk about aortic dissection. I'm gonna see if I can share my slides. It didn't like it last time. So I it might not let it. Can you not access the slides on? Now? Uh It's taking ages. Um Lauren, do you mind just clicking through? Uh um I'm going to talk about aortic dissection. So the learning outcomes it's not going to be as long as the first bit because it's not actually as much talk about, we've covered quite a lot of the anatomy. Um So we're just going to sort of understand what aortic dissection is, how you would classify it and then sort of thinking more clinically how you would manage and how a patient might present with it all obviously very important clinically. Um So a aortic dissection is a tear in the interme a layer of the aortic wall. So as we discussed earlier, about the layers of the, as we talked earlier, about the layers of the blood vessels, we we can see here, we've got the intima media and adventitia. So a dissection occurs when you get that sort of the tear in the intimate layer which causes blood to pull between the intimate and media layer. As you can see from this diagram. Um and as you can see, you then get this bulging. So this dissection can progress distantly approximately or both. Um So it can sort of sort of progress further apple down. And so anterograde can move towards the iliac arteries and then retrograde can move towards the route at the, at the aortic valve. Um So, dissections are classified in two ways. Um So obviously, it's it's good to have an appreciation of both because clinically um the management will change depending on them. So the first system is the stand for the classification. So that's the type A type B as you can see on the bottom of the diagram. So quite simply put type A is any aortic dissection that involves the ascending aorta. So it doesn't matter where the dissection originated from. It's just if it involves the ascending aorta, that is a type A in the stand for the classification type B. However, is um where it just basically simply doesn't include the ascending aorta, but it can occur anywhere along this descending aorta. Then you've got the DeBakey classification. So this classifies them according to type one, type two, type three A and type three be. So as you can see here, this is all the different presentations. So type one is one, a dissection. You can see where it begins in the ascending aorta and involves at least the aortic arch. Um if not the whole way or to which is what this type one demonstrates. Type two is where it just happens in the ascending aorta. Type three A is where it occurs in the descending aorta, but it happens above the diaphragm. And then type three B is where it happens in the ascending aorta and it involves the aorta below the diaphragm. So this classification is really important because as vascular surgeons will be discussing the where the dissection is, they might not say. So you to have an appreciation of what these mean anatomically is really important for management and things like that. So a patient will present with a variety of different symptoms. So, an aortic dissection is a medical emergency. So it's really important to not miss it. Um Lauren, do you mind changing his life? Oh, so it's also really important to make sure you're looking out for what the risk factors of it could be. Um So, because you can then have an idea when the patient's are presenting to you what this could be um potentially So, like we said before, it's all similar risk factors to an aortic um abdominal aneurysm. So if they are male, they have a higher risk. If they have high BP, this can also be not necessarily like longstanding BP, but if they do an activity, which has sort of an event that's raised their BP. So for example, after weightlifting or after cocaine use, that could also um cause a dissection. Um connective tissue disorders involve things like Marfan's or stand loss. So it's always have an appreciation in the history to explore this as well as a bicuspid aortic valve and any atherosclerotic disease. Um So these patient's will come to you with a variety of the different symptoms. So the classic presentation is this tearing chest pain which radiates to the back. It's quite distinct. And obviously, as soon as you hear this, you're starting to think, could this be a medical emergency? Do we need to call the vascular surgeons urgently? However, this actually might be more subtle. So some patient's don't always present with this typical chest pain. So it's important to have an appreciation of what other things patient might present with. So other symptoms include and other signs you might be looking out for is things like tachycardia. So if they have a high BP, high part rate and a low BP, they have a low BP because peripherally there, if they've had a dissection, they could be not perfusing. Um They could also present with collapse or syncope. Um They can also have things like neurological symptoms such as um weakness or loss of sensation as a result of the loss of blood flow. Um They might also have week, they'll have weakened radial pulses. So you'll want to check the pulses and if they're weak or sort of getting concerned, um they might have a new onset murmur. So a new aortic regurg murmur as well as other signs of end organ hyperfusion. So, um they could be very pale, not well perfused, sort of things like that. So as always, whenever you've got a patient coming in, you want also want to have an appreciation of what else could be going on. So you don't want to be going in with a hyper folk hyper fixation on it's an aortic dissection and it ends up not being, it's also have an appreciation what else could be causing sort of similar symptoms. So, first, actually, you'd want to make sure it's not an M I it's not a myocardial infarction. So because patient's might have the similar sort of symptoms. So for an MRI, you'd want to be doing an E C G and a proponent. And then if the E C G has abnormal changes and there's a hide her opponent, you're more going down the route. This is an M I, you'd also want to, if the patient is experienced any dyspnea. So any shortness of breath or anything like that, difficulty breathing. You're thinking maybe this is a pa, so you might be considered to get a CT P A to rule this out. It could also be a pericarditis, which is typically associated with pleuritic chest pain, um which is often relieved on the patient sitting forward. So you'd want to make sure that it's not that and it could also be a musculoskeletal back pain. Um And you wouldn't expect to see any of the hypertension tachycardia. You wouldn't expect to see the systemics shock symptoms with that. So, you've, you've already taken the history, you've, you've suspecting it might be an aortic dissection and you're, you're thinking, how can I rule this out? We've touched upon some of these before, but just to go in, you'd want to start with the bedside. So you'd be thinking, I want to get E C G on this patient um to exclude that acute coronary syndrome that we discussed. Um And you'd want to get the observations, you'd want to see how stable they are as they could be quite acutely unwell. So you'd want to sort of assess where they are. You're then thinking what laboratory tests can we do. So you're thinking blood tests. So you'd want to get a full blood count to see if they're anemic. You want to get the user knees to check their renal function. You want to get their LFTs, so their liver function tests because they might be higher. If the hepatic perfusion has been compromised, you obviously want to get your troponin life. I said you want to get your coagulation screen and then your group in and saved than them. Because if they need to go for uh for surgery, you'll need to have blood on standby. So you need to be ready with the transfusion ready to go. You then got to think what imaging might be next. So you've got various different imaging you can do. So there's the trans thoracic echo. Um And that's, you can do that. If you suspect there is a deception, you can also do a CT angiogram which can help with surgical planning as well as an MRI angiogram, which will really help with surgeons identifying what they need to do for the next steps. Um And you can also do a transesophageal echo as well. So you've, you've done these investigations, but at the same time, you're also trying to manage this patient because they're acutely unwell. You're not, you're not going, I'll wait for the blood results come back. You're gonna help the patient in front of you. So you've got to think you're trying to resuscitate this patient and make them stable to go to surgery. So you thinking you wanting to be giving them high flow oxygen, um You're wanting to ensure you're getting IV access with large bore cannulas. So you're thinking if these patient's then peripherally shut down because of blood loss. You want have had this IV access in early. Um or else it's just going to make your job harder later. You're also thinking this patient might be in pain. They've come in with this, with this chest pain. You wanting to give them some analgesia and then you're thinking, who do I need to speak to, to fix this, fix this problem if it's an aortic dissection. So you're wanting to liaise with the vascular surgeon. Um and potentially like I T you to uh to prepare for if this patient needs um invasive surgery. So the management surgically is dependent upon the classification. So, like I said before, that's why the classification is really important. So type a classification you would require because Taipei involves the ascending aorta, you'd require urgent surgical management and this is often done by an open approach. Um And then in type B, there is two ways that it can, it can be managed. So typically, if it's complicated, type B, you would use the thoracic endovascular aorta repair um to repair the dissection or an open surgery. If, if that other option was not possible, alternatively, you can sometimes medically manage these patient's if the dissection isn't too bad. Um So things like putting the patient on antihypertensives, um long term to reduce their BP to prevent it getting worse. Um You'd want to potentially put them on beat, beat a blockers for this. Um And minimize the stress and also making those lifestyle changes, um, to reduce their risk factors, to prevent it from getting any worse. And you might be thinking about this in patient's that wouldn't potentially tolerate a surgery. Um, so these are some diagrams which we've got of what the repair can involve. So, in the open surgery, um, this is a major op. So if patients have a type a dissection, you're expecting there's a high mortality if they don't have surgery. So it's really essential that these patients are treated quickly. But the way it works is is you would remove the area of the dissection. So where the intimate, intimate, uh intimate has broken down and it's worn away, you'd remove that and you'd want to replace it with a graft as you can see here. So obviously, the aorta is the main blood vessel that supplies most of the body. So you can't just take, you know, cut it and because the patient will lose all their blood. So often you might need like bypass um to put in place so that they can still perfuse themselves and they don't end up with um, and lack of perfusion to their major organs. Um So yeah, so that's obviously a very high risk surgery, but you, you simply just remove where the dissection is above and below and you replace it with the graft. And so suits that back in and then take them off bypass and you know, bring them, bring the blood flow back and check it's not leaking. Alternatively, the trans thoracic, the thoracic endovascular aortic repair. This involves, like we said before, the stent, which you put in. So you use a catheter through the femoral artery or wherever to um put this graft in and basically it buy it, basically pass it up to the region of the, the dissection and covers it. So you basically don't get any more of uh of a leak sort of thing. Um So complications of the open surgery, like with most major ops, it's, you know, mortality, bleeding and infection and then the T V A R. So the uh thoracic and vascular are you also repair, has less complications because it's slightly less invasive, but you can still get endovascular leak, infection, bleeding and graph migration. So those are the two ways you would manage these patient's surgically. Obviously, like I say, you want to be liaising with all the relevant teams to ensure these patient's um have the best care. Does anyone have any questions? Well, in that case, thank you, everyone for coming along. I think there'll be a feedback form automatically generated in the chat. Um But yeah, thank you so much from long hope you learned something um and just refreshed a bit on vascular surgery.