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Vascular Surgery > 2: Vascular Disease In Other Sites > Flashcards

2: Vascular Disease In Other Sites Flashcards

1
Q

What is renal-artery stenosis

A

Narrowing of one or both renal arteries

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2
Q

What are the two possible causes of renal artery stenosis

A
  • Atherosclerosis

- Fibromuscular dysplasia

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3
Q

What % of RAS is due to atherosclerosis

A

90

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4
Q

What % of RAS is due to fibromuscular dysplasia

A

10

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5
Q

In which population is atherosclerotic RAS more common

A

Males over 50

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6
Q

In which population is fibromuscular dysplasia RAS more common

A

Females under 50

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7
Q

how may renal artery stenosis present clinically

A
  • Renal bruit
  • Treatment-resistant HTN
  • Features of renal failure
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8
Q

Explain the pathophysiology of renal artery stenosis

A

Narrowing of the renal arteries causes ischaemic. This results in activation of RAAS system. Aldosterone increases sodium + hence fluid retention. Increases peripheral vascular resistance leading to secondary HTN. Ischaemia also causes ischaemic renal injury and progressive atrophy

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9
Q

What three investigations are important in work-up of RAS

A
  1. U+E
  2. Duplex USS
  3. CT/MR angiography
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10
Q

How will U+Es present in RAS

A

Raised creatinine

Hypokalaemia

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11
Q

What is treatment-resistant hypertension and hypokalaemia a good indicator of

A

Renal artery stenosis

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12
Q

Why is there hypokalaemia in renal artery stenosis

A

Renal ischaemia causes activation of RAAS and hyper-aldosteronism. This causes exchange of sodium for potassium causing hypokalaemia

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13
Q

What are the indications for duplex USS

A
  • HTN onset before 30
  • Resistant to three anti-HTN medications
  • Renal dysfunction with ACEi
  • Unexplained renal atrophy - difference of more than 1.5cm
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14
Q

On CT angiography if there is stenosis of proximal renal artery segment what does it suggest

A

Atherosclerotic pathophysiology

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15
Q

On CT angiography if there is stenosis of distal renal artery segment what does it suggest

A

Fibromuscular dysplasia

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16
Q

What lifestyle factors are used in management of renal artery stenosis

A

Smoking cessation
Weight loss
Control diabetes and HTN

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17
Q

Why should ACEi not be given to manage blood pressure in renal insufficiency

A

Due to toxic if renal damage

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18
Q

What is ultimate management of renal artery stenosis

A

Percutaneous trans-luminal angioplasty

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19
Q

What percentage of the renal artery must be stenosed to require percutaneous trans-luminal angioplasty

A

60%

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20
Q

Explain why ACEi are contraindicated in patients with renal artery stenosis

A

Normal system:
PGE2 causes vasodilation of renal artery to control blood flow through glomerulus and Angiotensin II controls efferent arteriole

In RAS:
There is narrowing of the afferent impairing flow. Therefore more reliant on efferent to control flow through glomerulus. If ACEi are used this is lost.

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21
Q

Define acute mesenteric ischaemia

A

occlusion of blood supply to the small bowel resulting in necrosis and possible perforation

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22
Q

In which age-group is mesenteric ischaemia more common

A

> 60

23
Q

What are 4 causes of mesenteric ischaemia

A
  1. Thrombosis
  2. Embolism
  3. Mesenteric venous thrombosis
  4. Non-occlusive disease
24
Q

When is mesenteric vein thrombosis more common

A

Younger patients w/ hyper-coagulable states

25
Q

Explain non-occlusive disease as a cause of mesenteric thrombosis

A

Drop in cardiac output

26
Q

What are three risk factors for acute mesenteric ischaemia

A
  • Hypercoagulable states
  • AF
  • Vasculitis
27
Q

What is the triad of symptoms for acute mesenteric ischaemia

A
  1. Severe abdominal pain
  2. No abdominal signs
  3. Rapid shock
28
Q

what is the stereotypical presenting complaint of acute mesenteric ischaemia

A

Abdominal pain disproportionate to clinical findings

29
Q

where is the abdominal pain in acute mesenteric ischaemia

A

Central

30
Q

if due to embolism describe onset of pain in acute mesenteric ischaemia

A

Abrupt onset and extremely painful

31
Q

if due to thrombosis explain symptoms of acute mesenteric ischaemia

A

Less severe - as there is collateral supply

32
Q

what artery is occluded in 90% of acute mesenteric ischaemia

A

Superior mesenteric artery

33
Q

what does the superior mesenteric artery supply

A

Midgut

34
Q

What investigations may be ordered in mesenteric ischaemia

A

FBC (Raised WBC)
Abdominal X-Ray
CT/MRI
CT angiography

35
Q

What investigations may be ordered in mesenteric ischaemia

A

FBC (Raised WBC)
Abdominal X-Ray
CT/MRI
CT angiography (confirmatory)

36
Q

How should acute mesenteric ischaemia be managed

A

Emergency laparotomy - remove necrotic segments

37
Q

What are main complications of acute mesenteric ischaemia

A

Peritonitis

Sepsis

38
Q

How common is chronic mesenteric ischaemia

A

Rare!

39
Q

In which individuals does chronic mesenteric ischaemia occur

A

> 60

40
Q

What is the most common presentation of chronic mesenteric ischaemia and when does this occur

A

Asymptomatic - when there is occlusion of single artery. More than this causes symptoms

41
Q

If symptomatic, how does chronic mesenteric ischaemia present

A

Intestinal angina - dull epigastric pain following meals

42
Q

What is the problem with chronic mesenteric ischaemia

A

Pain may cause avoidance of eating which can lea to weight loss

43
Q

What will be auscultated in chronic mesenteric ischaemia

A

abdominal bruit

44
Q

Explain chronic mesenteric ischaemia

A

stenosis of two or more main gastric arteries causes a post-prandial mismatch between blood supply and metabolic demand

45
Q

Why is one artery occluded asymptomatic

A

due to collateral supply from other vessels

46
Q

What is first line investigation for chronic mesenteric ischaemia

A

CT abdomen

47
Q

How is chronic mesenteric ischaemia managed

A

Nutritional support- regular small meals

Long-term anticoagulant

Revascularisation

48
Q

What medication is used to control risk factors contributing to carotid stenosis

A

Clopidogrel
Atorvostatin
ACEi

49
Q

What is first-line management for carotid stenosis

A

Carotid endarterectomy

50
Q

What are the indications for carotid endarterectomy in carotid stenosis

A
  1. Symptomatic, Cartoid.a stenosis >70% and life-expectancy >5y
  2. Asymptomatic and stenosis >80%
51
Q

if individuals are unfit for carotid endarterectomy what is second-line

A

Endovascular carotid.a stenting

52
Q

what is the main risk of carotid artery stenosis

A

stroke

53
Q

What are the indications for carotid endarterectomy in carotid stenosis

A
  1. Symptomatic, Cartoid.a stenosis >70% and life-expectancy >5y
  2. Asymptomatic and stenosis >80%
  3. Symptomatic and stenosis 50-69%
54
Q

Explain clinical presentation of carotid artery stenosis

A

asymptomatic. May cause gradual decline condition. Presents suddenly with stroke/TIA

Vascular Surgery (6 decks)

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