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Q1: Rupture (2 min)
"A 72-year-old smoker collapses with back pain and hypotension. Pulsatile mass palpable. What do you do?"
- Diagnosis: ruptured AAA (triad: pain + hypotension + pulsatile mass)
- Straight to theatre — no CT if unstable
- Massive transfusion protocol, crossmatch 6-10 units
- Permissive hypotension (SBP 70-80) until cross-clamp
- Emergency open repair or rEVAR
Q2: Surveillance thresholds (2 min)
"At what size do you repair an AAA? How do you follow up a 4.5 cm AAA?"
- Repair threshold: over 5.5 cm (UK Small Aneurysm Trial)
- Under 5.5 cm: ultrasound surveillance
- 4-5 cm: every 12 months
- 5-5.5 cm: every 6 months
- Rapid expansion (over 0.5 cm in 6 months): repair regardless of size
Q3: Open vs EVAR (3 min)
"Compare open repair and EVAR."
- Open: laparotomy, cross-clamp, Dacron graft. Mortality 2-5%. Durable (no surveillance). Higher morbidity.
- EVAR: femoral access, stent-graft, fluoroscopy. Mortality 1-2%. Requires suitable anatomy (neck). Lifelong surveillance for endoleak.
- EVAR-1 trial: EVAR lower 30-day mortality but similar long-term survival
- Endoleak: Type I (graft end, urgent), II (branch, observe), III (component, urgent)
Q4: Screening (2 min)
"Who do you screen for AAA?"
- Men aged 65-75 who ever smoked (one-time ultrasound) — MASS trial, 42% reduction in AAA mortality
- First-degree relatives of AAA patients from age 60
- Women: not routinely screened (lower prevalence), consider if risk factors
- Incidental detection on CT/ultrasound for other reasons