Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 467 - файл
.pdf
178
https://t.me/medicina_free
19. A patient presents with a history of fatigue and dyspnea.
He is found to have hepatomegaly, ascites, and an elevated jugular venous pulse. Heart sounds are normal, no
murmurs are present, and the heart is of normal size. The
pulse pressure is decreased by palpation. Electrocardiography is normal except for low voltage. The most likely
diagnosis is:
A. Right atrial myxoma.
CHAPTER 21
B. Tricuspid valve disease.
C. Constrictive pericarditis.
D. Primary pulmonary artery hypertension.
Acquired Heart Disease
Answer: C
Classic physical exam findings include jugular venous distention with Kussmaul’s sign, diminished cardiac apical
impulses, peripheral edema, ascites, pulsatile liver, a pericardial knock, and, in advanced disease, signs of liver dysfunction, such as jaundice or cachexia. The “pericardial knock” is
an early diastolic sound that reflects a sudden impediment
to ventricular filling, similar to an S3 but of higher pitch.
Several findings are characteristic on noninvasive and invasive testing. Central venous pressure (CVP) is often elevated
15 to 20 mm Hg or higher. Electrocardiogram (ECG) commonly demonstrates nonspecific low voltage QRS complexes
and isolated repolarization abnormalities. Chest X-ray may
demonstrate calcification of the pericardium, which is highly
suggestive of constrictive pericarditis in patients with heart
failure, but this is present in only 25% of cases. Cardiac CT
or MRI (cMRI) typically demonstrate increased pericardial
thickness (>4 mm) and calcification, dilation of the inferior vena cava, deformed ventricular contours, and flattening or leftward shift of the ventricular septum. Pericardial
adhesions may also be seen on tagged cine MRI studies. As
discussed, it is most important to distinguish pericardial constriction from restrictive cardiomyopathy, which is best done
with either echocardiography or right heart catheterization.
Findings favoring constriction on echocardiography include
respiratory variation of ventricular septal motion and mitral
inflow velocity, preserved or increased mitral annulus early
diastolic filling velocity, and increased hepatic vein flow
reversal with expiration. Cardiac catheterization will show
increased atrial pressures, equalization of end-diastolic pressure, and early ventricular diastolic filling with a subsequent
plateau, called the “square-root sign.” Additional findings
upon catheterization that would favor constriction include
respiratory variation in ventricular filling and increased ventricular interdependence, manifest as a discordant change in
the total area of the left ventricular (LV) and right ventricular
(RV) systolic pressure curve with respiration. (See Schwartz
11th ed., p. 840.)
20. Pericarditis is usually treated with:
A. A short course of nonsteroidal anti-inflammatory
agents.
B. Use of steroids or IV antibiotics.
C. Surgical exploration and drainage.
D. Observation.
Answer: A
The preferred treatment depends on the underlying cause of
the pericarditis. The disease usually follows a self-limited and
benign course and can be successfully treated with a short
course of nonsteroidal anti-inflammatory agents (NSAIDs).
Some patients may require judicious use of steroids or intravenous (IV) antibiotics. In cases of purulent pyogenic pericarditis, surgical exploration and drainage are occasionally
necessary. Rarely, accumulation of fluid in the pericardium
may lead to tamponade, requiring prompt evacuation of the
pericardial space. While pericardiocentesis will typically suffice, surgical drainage may be required for thick, viscous,
or clotted fluid or in patients with significant scarring from
previous surgeries. More commonly, surgical intervention is
required to manage recurrent disease. (See Schwartz 11th ed.,
p. 840.)
179
https://t.me/medicina_free
21. Each of the following effects is anticipated after insertion
of an intra-aortic balloonpump (IABP) EXCEPT:
A. Preload decrease.
B. Increased total myocardial oxygen consumption.
C. Improvement in cardiac index.
D. Coronary blood flow increase.
22. Destination left ventricular assist device (LVAD) and
total artificial heart is indicated. Only in patients with
contraindications to heart transplantation they include:
A. Irreversible renal failure.
B. New York Heart Association Class III or Class IV.
C. Ejection fraction < 25%.
D. High oxygen requirements.
Answer: B
IABP is the most commonly used device for mechanical circulatory support, and it may be easily deployed in the catheterization laboratory, in the operating room or at the bedside.
The device is inserted percutaneously through the femoral
artery into the thoracic aorta. It is synchronized so that the
balloon is inflated during diastole and deflated during systole,
resulting in augmentation of diastolic perfusion of the coronary arteries and decreased afterload. Typically, this improves
cardiac index and decreases both preload and myocardial
oxygen consumption. (See Schwartz 11th ed., p. 835.)
Answer: A
Patients in need of ventricular assist devices (VADs) may
have preexisting chronic heart failure, refractory ventricular
arrhythmias, or acute heart failure following an MI, cardiopulmonary arrest, viral illness, pregnancy, or cardiotomy.
Device therapy is intended to preserve end-organ perfusion
and function and may be categorized as short- or long-term
support for the left heart, the right heart, or both. In general,
VADs may be used rarely for support while the heart recovers
(bridge to recovery, BTR), while the patient waits for a heart
transplant (bridge to transplant, BTT) or increasingly more
commonly to treat a chronic heart failure patient who is not a
transplant candidate (destination therapy, DT).
Current eligibility criteria for mechanical support as destination therapy include (a) New York Heart Association
Classification (NYHA) class III or IV heart failure despite
guideline-directed medical therapy including cardiac resynchronization therapy if indicated; (b) peak oxygen consumption <12 mL/kg per min or failure to wean from continuous
IV inotropes; (c) left ventricular ejection fraction < 25%; and
(d) presence of a contraindication for heart transplantation
(ie, age > 65 years, irreversible pulmonary hypertension,
chronic renal failure, insulin-dependent diabetes with endorgan damage, or other clinically significant comorbidities).
Once a patient has an LVAD inserted as DT, close and intensive
follow-up by a multidisciplinary heart failure team is required
in order to optimize medical therapy, reduce device-related
morbidity, and improve survival. (See Schwartz 11th ed.,
p. 837.)
CHAPTER 21
Acquired Heart Disease
23. The most common cardiac tumor is:
A. Papillary fibroelastoma.
B. Lymphangioma.
C. Myxoma.
D. Metastatic tumor.
Answer: C
Cardiac myxomas are the most common cardiac tumor and
are characterized by several distinguishing features. About
75% of the time, they arise from the interatrial septum near
the fossa ovalis in the left atrium. Most others will develop
in the right atrium, but, less commonly, they can arise from
valvular surfaces and the walls of other cardiac chambers.
Macroscopically, these tumors are pedunculated with a gelatinous consistency, and the surface may be smooth (65%),
villous, or friable. Size varies greatly with these tumors and
ranges from 1 to 15 cm in diameter.
Internally, myxomas are heterogeneous and often contain
hemorrhage, cysts, necrosis, or calcification. Histologically,
these tumors contain cells that arise from a multipotent mesenchyme and are contained within a mucopolysaccharide
stroma. (See Schwartz 11th ed., p. 842.)
180
https://t.me/medicina_free
24. Which of the following is NOT true of rhabdomyomas?
A. They often require resection.
B. They are often multicentric in the ventricles.
C. They are the most common primary cardiac tumor in
children.
D. They often disappear spontaneously.
CHAPTER 21
Acquired Heart Disease
Answer: A
In children, rhabdomyomas are the most common primary
cardiac tumor, whereas fibromas are the most commonly
resected cardiac tumor. Rhabdomyomas are myocardial hamartomas that are often multicentric in the ventricles. About
50% of cases are associated with tuberous sclerosis, and while
resection is occasionally necessary, most disappear spontaneously. Fibromas are congenital lesions that one-third of the
time are found in children younger than 1-year old. These
tumors, conversely, are ordinarily solitary lesions found in
the inner interventricular septum, and they may present with
heart failure, cyanosis, arrhythmias, syncopal episodes, chest
pain, or sudden cardiac death. (See Schwartz 11th ed., p. 843.)
CHAPTER 22
https://t.me/medicina_free
Thoracic Aneurysms and Aortic Dissection
1. Which of the following describes aortic aneurysms that
are true aneurysms?
A. Fusiform
B. Saccular
C. Pseudoaneurysm
D. Mega-aorta
2. Which of the following is the most common cause of
thoracic aortic aneurysms?
A. Atherosclerosis
B. Marfan syndrome
C. Takayasu’s arteritis
D. Nonspecific medial degeneration
3. Marfan syndrome is an autosomal dominant genetic disorder characterized by connective tissue defect that leads
to aneurysm formation. Which of the following statements is FALSE?
A. Marfan syndrome is also associated with joint hyper-
mobility and eye lens disorders.
B. The disease causes fragmentation of elastic fibers,
causing the aorta wall to be less elastic.
C. Abnormal fibrillin and degeneration of aortic wall
matric causes abnormal elasticity.
D. Most Marfan syndrome patients have dilation of
ascending aorta and dilation of the aortic annulus.
Answer: C
Aortic aneurysms can be either “true” or “false.” True aneurysms can take two forms: fusiform and saccular. Fusiform
aneurysms are more common and can be described as symmetrical dilatations of the aorta. Saccular aneurysms are
localized outpouchings of the aorta. False aneurysms, also
called pseudoaneurysms, are leaks in the aortic wall that are
contained by the outer layer of the aorta and/or the periaortic tissue; they are caused by disruption of the aortic
wall and lead blood to collect in pouches of fibrotic tissue.
(See Schwartz 11th ed., p. 853.)
Answer: D
Nonspecific medial degeneration is the most common cause
of thoracic aortic disease. Histologic findings of mild medial
degeneration, including fragmentation of elastic fibers and
loss of smooth muscle cells, are expected in the aging aorta.
However, an advanced, accelerated form of medial degeneration leads to progressive weakening of the aortic wall, aneurysm formation, and eventual dissection, rupture, or both.
The underlying causes of medial degenerative disease remain
unknown. (See Schwarz 11th ed., p. 855.)
Answer :B
Marfan syndrome is an autosomal dominant genetic disorder characterized by a specific connective tissue defect that
leads to aneurysm formation. The phenotype of patients
with Marfan syndrome typically includes a tall stature, high
palate, joint hypermobility, eye lens disorders, mitral valve
prolapse, and aortic aneurysms. Abnormal fibrillin causes
degeneration of the aortic wall matrix by increasing the activity of transforming growth factor beta (TGF-β). Between 75%
and 85% of patients with Marfan syndrome have dilatation
of the ascending aorta and annuloaortic ectasia (dilatation of
the aortic sinuses and annulus). Marfan syndrome also is frequently associated with aortic dissection, and aortic complications are the most common cause of death among patients
with Marfan syndrome. (See Schwartz 11th ed., p. 855.)
181
182
https://t.me/medicina_free
4. Vascular-type Ehlers-Danlos syndrome is characterized
by a defect in:
A. Elastin.
B. Metalloproteinase.
C. Type III collagen synthesis.
D. Fibrillin.
CHAPTER 22
Thoracic Aneurysms and Aortic Dissection
5. The most common cause of death in patients with type
IV Ehlers-Danlos syndrome is:
A. Myocardial infarction.
B. Aortic dissection.
C. Ruptured visceral artery.
D. Pulmonary emboli.
Answer: C
Ehlers-Danlos syndrome includes a spectrum of inherited
disorders of collagen synthesis. The subtypes represent differing defective steps of collagen production. Vascular-type
Ehlers-Danlos syndrome is characterized by an autosomal
dominant defect in type III collagen synthesis, which can have
life-threatening cardiovascular manifestations. Spontaneous
arterial rupture, usually involving the mesenteric vessels, is
the most common cause of death in these patients. Thoracic
aortic aneurysms and dissections are less commonly associated with Ehlers-Danlos syndrome, but when they do occur,
they pose a particularly challenging surgical problem because
of the reduced integrity of the aortic tissue. (See Schwartz
11th ed., p. 855.)
Answer: C
Ehlers-Danlos syndrome includes a spectrum of inherited
connective tissue disorders of collagen synthesis. The subtypes represent differing defective steps of collagen production. Vascular-type Ehlers-Danlos syndrome is characterized
by an autosomal dominant defect in type III collagen synthesis, which can have life-threatening cardiovascular manifestations. Spontaneous arterial rupture, usually involving
the mesenteric vessels, is the most common cause of death
in these patients. Thoracic aortic aneurysms and dissections
are less commonly associated with Ehlers-Danlos syndrome,
but when they do occur, they pose a particularly challenging
surgical problem because of the reduced integrity of the aortic
tissue. An Ehlers-Danlos variant of periventricular heterotopia associated with joint and skin hyperextensibility and aortic dilation has been described as being caused by mutations
in the gene encoding filamin A (FLNA), an actin-binding
protein that links the smooth muscle cell contractile unit to
the cell surface. (See Schwartz 11th ed., p. 855.)
6. Bovine aortic arch:
A. Is a normal variant where the innominate and left
common carotid arteries have a common origin.
B. Is associated with bicuspid aortic disease.
C. Is associated with increased risk of aortic dissection.
D. Does not appear to be associated with increased risk
of aneurysm.
7. Mycotic aneurysms:
A. Are associated exclusively with fungal infections of
the aorta.
B. Can occur via bacterial invasion with endocarditis,
endothelial trauma, or infected laminar clot.
C. Is an acute complication of syphilis.
D. Are generally fusiform type.
Answer: A
Bovine aortic arch—a common origin of the innominate and
left common carotid arteries—has been considered a normal
anatomic variant. Studies from Yale University have identified a higher prevalence of bovine aortic arch in patients with
thoracic aortic disease; an association was found between
this anomaly and a generalized increase in aortic aneurysmal disease (without any predisposition to a particular aortic region). However, bovine aortic arch was not associated
distinctly with bicuspid aortic valve or aortic dissection, but
with a higher mean aortic growth rate: 0.29 cm per year in
patients with bovine aortic arch, compared with 0.09 cm per
year in controls. Therefore, bovine aortic arch may be better characterized as a precursor of aortic aneurysm than as a
simple normal anatomic variant. Further studies are needed
to delineate the underlying mechanism for this association.
(See Schwartz 11th ed., p. 856.)
Answer: B
Primary infection of the aortic wall resulting in aneurysm
formation is rare. Although these lesions are termed mycotic
aneurysms, the responsible pathogens usually are bacteria
rather than fungi. Bacterial invasion of the aortic wall may
result from bacterial endocarditis, endothelial trauma caused
by an aortic jet lesion, or extension from an infected laminar
clot within a preexisting aneurysm. The most common caus-
https://t.me/medicina_free
ative organisms are Staphylococcus aureus, Staphylococcus
epidermidis, Salmonella, and Streptococcus. Unlike most other
causes of thoracic aortic aneurysms, which generally produce
fusiform aneurysms, infection often produces saccular aneurysms located in areas of aortic tissue destroyed by the infectious process.
Although syphilis was once the most common cause of
ascending aortic aneurysms, the advent of effective antibiotic
therapy has made syphilitic aneurysms a rarity in developed
nations. In other parts of the world, however, syphilitic aneurysms remain a major cause of morbidity and mortality. The
spirochete Treponema pallidum causes an obliterative end-
arteritis of the vasa vasorum that results in medial ischemia
and loss of the elastic and muscular elements of the aortic
wall. The ascending aorta and arch are the most commonly
involved areas. Because syphilitic aortitis often presents
10 to 30 years after the primary infection, the incidence of
associated aneurysms may increase in the near future. (See
Schwartz 11th ed., p. 856.)
183
CHAPTER 22
Thoracic Aneurysms and Aortic Dissection
8. Aortic diameters at increased risk for rupture, dissection,
and mortality include:
A. Critical hinge-point, the diameter where the risk of
rupture increases dramatically, diameters are 6 cm
for ascending aorta and 7 cm for descending aorta.
B. Fusiform aneurysm is more likely to rupture than
saccular aneurysm.
C. Disease etiology rather than diameter is more rel-
evant than diameter.
D. Average expansion rates are about 1 cm per year
for both ascending and descending thoracic aorta
aneurysms.
9. The most common complication of extensive repair for
distal aortic aneurysms is:
A. Spinal cord ischemia.
B. Renal failure.
C. Pulmonary dysfunction.
D. Left recurrent laryngeal nerve injury.
Answer: A
An analysis by Elefteriades of data from 1600 patients with
thoracic aortic disease has helped quantify these wellrecognized risks. Average expansion rates were 0.07 cm per
year in ascending aortic aneurysms and 0.19 cm per year in
descending thoracic aortic aneurysms. As expected, aortic
diameter was a strong predictor of rupture, dissection, and
mortality. For thoracic aortic aneurysms > 6 cm in diameter, annual rates of catastrophic complications were 3.6% for
rupture, 3.7% for dissection, and 10.8% for death. Critical
“hinge-point” diameters, at which the incidence of expected
complications significantly increased, were 6 cm for aneurysms of the ascending aorta and 7 cm for aneurysms of the
descending thoracic aorta; the corresponding risks of rupture
after reaching these diameters were 31% and 43%, respectively. (See Schwartz 11th ed., p. 857.)
Answer: C
Although spinal cord ischemia and renal failure receive the
most attention, several other complications warrant consideration. The most common complication of extensive repairs
is pulmonary dysfunction. With aneurysms adjacent to the
left subclavian artery, the vagus and left recurrent laryngeal
nerves are often adherent to the aortic wall and thus are susceptible to injury. (See Schwartz 11th ed., p. 871.)
10. Which of the following is NOT TRUE regarding anastomotic pseudoaneurysms?
A. These can arise from deterioration of aortic tissue
due to infection.
B. These have increased in incidence with an influx of
cardiovascular surgery.
C. These commonly occur in patients with Marfan
syndrome.
D. These are associated with high incidence of morbid-
ity and rupture.
Answer: B
Anastomotic pseudoaneurysms can be caused by technical
problems or by deterioration of the native aortic tissue, graft
material, or suture. Commonly, they occur in patients with
Marfan syndrome. Tissue deterioration usually is related to
either progressive degenerative disease or infection. Improvements in sutures, graft materials, and surgical techniques
have decreased the incidence of thoracic aortic pseudoaneurysms. Should thoracic aortic pseudoaneurysms occur, they
typically require expeditious surgical or other intervention
because they are associated with a high incidence of morbidity and rupture. (See Schwartz 11th ed., p. 857.)
184
https://t.me/medicina_free
11. The most common presenting symptom in patients with
an ascending thoracic aneurysm is:
A. Anterior chest pain.
B. Posterior chest pain.
C. Aortic valve insufficiency.
D. Sudden death.
CHAPTER 22
12. The primary modes to study for thoracic aorta disease
Thoracic Aneurysms and Aortic Dissection
is/are:
A. Invasive aortography.
B. Cardiac catheterization.
C. Cross-sectional imaging (computed tomography
[CT] and magnetic resonance angiography [MRA]).
D. Abdominal ultrasound.
Answer: A
Initially, aneurysmal expansion and impingement on adjacent structures cause mild, chronic pain. The most common
symptom in patients with ascending aortic aneurysms is anterior chest discomfort; the pain is frequently precordial in location but may radiate to the neck and jaw, mimicking angina.
Aneurysms of the ascending aorta and transverse aortic arch
can cause symptoms related to compression of the superior
vena cava, the pulmonary artery, the airway, or the sternum.
Rarely, these aneurysms erode into the superior vena cava or
right atrium, causing acute high-output failure. (See Schwartz
11th ed., p. 857.)
Answer: C
Although catheter-based contrast aortography was previously
considered the gold standard for evaluating thoracic aortic
disease, cross-sectional imaging (ie, CT and MRA) has largely
replaced this modality. Technologic improvements have
enabled CT and MRA to provide excellent aortic imaging
while causing less morbidity than catheter-based studies do,
so CT and MRA are now the primary modes for evaluating
thoracic aortic disease. Today, the use of invasive aortography
in patients with thoracic aortic disease is generally limited to
those undergoing endovascular therapies or when other types
of studies are contraindicated or have not provided satisfactory results. (See Schwartz 11th ed., p. 859.)
13. Endovascular repair of thoracic artery aneurysms is generally not recommended for:
A. Descending thoracic aortic aneurysm and dissection.
B. Blunt aortic injury.
C. Penetrating aortic ulcers.
D. Repair of aneurysms of proximal aorta.
14. Initial assessment and management of aortic dissection:
A. Differs depending on the location and type of the
dissection.
B. Requires aggressive pharmacologic treatment.
C. Requires repair within 24 hours.
D. Is not altered by signs of organ dysfunction.
Answer: D
Experience with purely endovascular treatment of proximal aortic disease remains limited and only investigational.
Endovascular therapy has become an accepted treatment
for descending thoracic aortic aneurysm. Its role in treating proximal aortic disease and thoracoabdominal aortic
aneurysm remains experimental; nonetheless, endoluminal
stenting is approved by the US Food and Drug Administration for the treatment of isolated descending thoracic aortic
aneurysm, and several different devices have been approved
for the treatment of blunt aortic injury and penetrating aortic
ulcer. (See Schwartz 11th ed., pp. 868, 872.)
Answer: B
Regardless of the location of the dissection, the initial treatment is the same for all patients with suspected or confirmed
acute aortic dissection (see Fig. 22-1). Furthermore, because
of the potential for rupture before the diagnosis is confirmed,
aggressive pharmacologic management is started once there
is clinical suspicion of dissection, and this treatment is continued during the diagnostic evaluation. The goals of pharmacologic treatment are to stabilize the dissection and prevent
rupture. (See Schwartz 11th ed., p. 878.)
FIG. 22-1. Illustration of the classification schemes for aortic dissection based on which portions of the aorta are involved. Dissection
https://t.me/medicina_free
can be confined to the ascending aorta (left) or the descending aorta (middle), or it can involve the entire aorta (right). (Reproduced with
permission from Baylor College of Medicine.)
185
CHAPTER 22
Thoracic Aneurysms and Aortic Dissection
15. Mortality rates for operative repair of an aortic arch
aneurysm have been significantly reduced intraoperatively by:
A. Deep hypothermia to allow circulatory arrest.
B. Innominate and left carotid artery cannulation to
permit oxygenation of the brain.
C. Right heart to left subclavian artery bypass to con-
tinue brain perfusion.
D. Use of an intra-aortic balloon pump to maintain dis-
tal circulation.
16. Endoleaks:
A. Type I and Type IV generally require early and
aggressive intervention.
B. Are uncommon.
C. Can during the initial procedure or over time.
D. Are categorized by leak site.
Answer: A
Like the operations themselves, perfusion strategies used
during proximal aortic surgery depend on the extent of the
repair. Aneurysms that are isolated to the ascending segment can be replaced by using standard cardiopulmonary
bypass and distal ascending aortic clamping. This provides
constant perfusion of the brain and other vital organs during
the repair. Aneurysms involving the transverse aortic arch,
however, cannot be clamped during the repair, which necessitates the temporary withdrawal of cardiopulmonary bypass
support; this is called circulatory arrest. To protect the brain
and other vital organs during the circulatory arrest period,
hypothermia must be initiated before pump flow is stopped.
However, hypothermia is not without risk, and coagulopathy
is associated with deep levels of hypothermia (<20°C), which
have been traditionally used in open arch repair. Recently,
more moderate levels of hypothermia (often between 22°C
and 24°C) have been introduced that appear to decrease risks
associated with deep hypothermia while still providing sufficient brain protection. (See Schwartz 11th ed., p. 865.)
Another significant complication of descending thoracic
aortic stent grafting is endoleak. An endoleak occurs when
there is a persistent flow of blood (visible on radiologic imaging) into the aneurysm sac, and it may occur during the
initial procedure or develop over time. Although endoleaks
are a relatively common complication, they are not benign,
because they lead to continual pressurization of the sac,
which can cause expansion or even rupture. These complications are categorized (Table 22-1) according to the site
of the leak. Although all endoleaks may progress such that
they can be considered life-threatening, type I and type III
186
https://t.me/medicina_free
CHAPTER 22
Thoracic Aneurysms and Aortic Dissection
endoleaks generally necessitate early and aggressive intervention. Recently published reporting guidelines aid standardized reporting. (See Schwartz 11th ed., p. 875.)
TABLE 22-1 Classification of and common treatment
strategies for endoleak
Type I
• Incomplete seal between stent graft and aorta at the proximal landing
site (Type Ia), the distal landing site (Type Ib), or branch module,
fenestration, or plug (Type Ic)
• Early reintervention to improve seal or conversion to open surgery
Type II
• Retrograde perfusion of sac from excluded collateral arteries
• Surveillance; as-needed occlusion with percutaneous or other
interventions
Type III
• Incomplete seal between overlapping stent graft or module (Type IIIa),
or tear in graft fabric (Type IIIb)
• Early reintervention to cover or conversion to open surgery
Type IV
• Perfusion of sac due to porosity of material
• Surveillance; as-needed reintervention to reline stent graft
Type V
• Expansion of sac with no identifiable source
• Surveillance; as-needed reintervention to reline stent graft
17. Treatment of descending aortic dissection by nonoperative, pharmacologic management:
A. Has lower morbidity and mortality rates than tradi-
tional surgical treatment.
B. Most common cause of death during nonopera-
tive treatment are aortic rupture and end-organ
malperfusion.
C. A CT scan obtained on day 2 or 3, compared with the
initial scan, is sufficient to rule out significant aortic
expansion.
D. Inadequate blood pressure control has been found to
be associated with late aneurysm formation.
Answer: C
Nonoperative, pharmacologic management of acute descending aortic dissection results in lower morbidity and mortality
rates than traditional surgical treatment does. The most common causes of death during nonoperative treatment are aortic rupture and end-organ malperfusion. Therefore, patients
are continually reassessed for new complications. At least two
serial CT scans—usually obtained on day 2 or 3 and on day 8
or 9 of treatment—are compared with the initial scan to rule
out significant aortic expansion. Once the patient’s condition
has been stabilized, pharmacologic management is gradually shifted from intravenous (IV) to oral medications. Oral
therapy, which usually includes a beta antagonist, is initiated when systolic pressure is consistently between 100 and
110 mm Hg and the neurologic, renal, and cardiovascular
systems are stable. Many patients can be discharged after
their blood pressure is well controlled with oral agents and
after serial CT scans confirm the absence of aortic expansion.
Long-term pharmacologic therapy is important for patients
with chronic aortic dissection. β-Blockers remain the drugs
of choice. In a 20-year follow-up study, DeBakey and colleagues found that inadequate blood pressure control was
associated with late aneurysm formation. Aneurysms developed in only 17% of patients with “good” blood pressure control, compared with 45% of patients with “poor” control. (See
Schwartz 11th ed., p. 884.)
187
https://t.me/medicina_free
18. Which of the following is the most typical presenting
symptom in a patient with an aortic dissection?
A. “Tearing” pain
B. Paraplegia
C. Abdominal pain
D. Cold left arm
19. Delay of emergency repair of ascending aortic dissection
should be considered in:
A. Patients who present with severe acute stroke or mes-
enteric ischemia.
B. Dissections that occur in the first 3 weeks after car-
diac surgery.
C. Patients who are in stable condition and may benefit
from transfer to specialized centers.
D. All of the above.
Answer: A
The onset of dissection often is associated with severe chest or
back pain, classically described as “tearing,” that migrates distally as the dissection progresses along the length of the aorta.
The location of the pain often indicates which aortic segments
are involved. Pain in the anterior chest suggests involvement
of the ascending aorta, whereas pain in the back and abdomen generally indicates involvement of the descending and
thoracoabdominal aorta. (See Schwartz 11th ed., p. 879.)
Answer: D
Because of the risk of aortic rupture, acute ascending aortic
dissection is usually considered an absolute indication for
emergency surgical repair. However, specific patient groups
may benefit from nonoperative management or delayed
operation. Delayed repair should be considered for patients
who (a) present with severe acute stroke or mesenteric ischemia, (b) are elderly and have substantial comorbidity, (c) are
in stable condition and may benefit from transfer to specialized centers, or (d) have undergone a cardiac operation in
the remote past. Regarding the last group, it is important that
the previous operation should not be too recent; dissections
that occur during the first 3 weeks after cardiac surgery pose
a high risk of rupture and tamponade, and such dissections
warrant early operation. (See Schwartz 11th ed., p. 882.)
CHAPTER 22
Thoracic Aneurysms and Aortic Dissection
20. A patient with a subclavian artery malperfusion as a
complication of aortic dissection would most likely
experience:
A. Paraplegia.
B. Cold, painful extremity.
C. Incontinence.
D. Shock.
Answer: B
See Schwartz 11th ed., Table 22-5, p. 879.
Соседние файлы в папке @xirurgi_2025