Aneurysms and carotid artery disease Flashcards
what is aneurysm disease of the aorta
dilatation of ALL layers of the aorta, leading to an increase in diameter of >50%
due to weakening of the vessel wall
artery wall is made up of what 3 layers of tunica
tunica externa
tunica media
tunica intima
causes of aneurysm disease? (3)
Degenerative disease
Connective tissue disease (e.g. Marfan’s disease)
Infection (mycotic aneurysm)
risk factors for abdominal aortic aneurysm disease?
male sex age smoking hypertension syphilis salmonella family history (30% prevalence in 1st degree male relatives)
prevalence of AAA disease in the UK?
3%
who is abdominal aortic aneurysm screening available for on the NHS
ultrasound for men during the year they turn 65
if a patient has a large AAA of >5.5cm on screening what happens?
urgent referral to vascular surgeon
what qualities must a screening test have?
high sensitivity (ability to designate an individual with disease as positive) and specificity (to see if it’s false)
criteria for screening for AAA?
Definable disease Prevalence Severity of disease Natural history – normal aorta which gets larger and larger and then bursts Reliable detection Early detection confers advantage Treatment options available Cost Feasibility Acceptability
symptoms that may present on impending rupture
increasing back pain
tender AAA
symptoms that may present on rupture
abdominal/ back/ flank
(between ribs and hip on side of body) pain
painful pulsatile mass
haemodynamic instability
hypoperfusion - cold feet, confused/unconscious
may cause sudden death
rare presentations of AAA
distal embolisation - trash foot
Aortocaval fistula - aneurysm erodes into inferior vena cava
blocking of one of the ureter tubes or small bowel
What is the management of AAA if patient is asymptomatic?
is the aneurysm a size to consider repair?
is the patient a candidate for repair?
is the aneurysm suitable for endovascular or open repair
How to assess patient fitness
Full history and examination bloods ECG ECHO PFTs - Pulmonary function tests End of bed test CPEX - Cardiopulmonary Exercise Test
What imaging can be done to assess AAA
ultrasound - inadequate for surgical planning
CT abdomen or MRA- magnetic resonance angiogram - blood vessels
what is the best imaging technique to choose
CT however radiation could cause problems with younger patients that may get lots of scans over the course of their life
treatment for AAA
conservative - patient or aneurysm may not be fit for repair. Consider event of rupture
endovascular repair
open repair
what is endoleak
persistent blood flow outside the lumen of an endoluminal graft but within the aneurysm sac
caused by incomplete sealing or exclusion of the aneurysm sac.
which type of aortic dissection is most common
type A- on the ascending aorta
open repair vs endovascular aortic repair
EVAR good in short term - less invasive
open is durable
however if you are not fit for it you don’t do anything
Management of symptomatic AAA
ABCDE - airways etc
history, check records
CTA maybe - computed tomography angiography
how do patients get diagnosed with AAA
usually incidental finding through screening or symptomatic
process of management/ treatment once anuerysm reaches 5.5cm or if it is expanding at >1cm a year or if symptomatic?
then assess patient’s fitness and assess aneurysm to see whether to do EVAR or open repair
who is involved in management of carotid disease to prevent further events
vascular surgeons
Transient Ischaemic Attack (TIA)
Focal CNS disturbance caused by vascular events such as microemboli and occlusion, leading to cerebral ischaemia.
Symptoms last less than 24 hours and there are no permanent neurological conditions as a consequence of this.
What is a stroke
rapidly developing
clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hours or leading to death, with no apparent cause other than that of vascular origin.
what is carotid disease
disease of the carotid arteries - narrowing or blockage of them perhaps by atherosclerosis
what are the 2 different types of stroke
haemorrhage
ischaemic
Causes of stroke (/TIA)
AF
Carotid atherosclerotic plaque rupture/thrombus (15%)
Endocarditis
MI
Carotid artery trauma/dissection
Drug abuse
Haematological disorder e.g. sickle cell disease
risk factors for carotid artery atherosclerosis
Smoking Diabetes Family history Male sex Hypertension Hyperlipidaemia/hypercholesterolaemia Obesity Age
How would you diagnose carotid disease?
History
Examination - neurological - checking both sides of body for symptoms.
Cardiac and auscultate carotids
CT
Carotid Ultrasound scan
what would happen to someones eyesight with TIA
rapid deterioration
What does carotid artery imaging/ doppler test help to evaluate
blood flow — images of arteries and info about blood flow re both its speed and direction
what happens to velocity as radius of a vessel decreases due to stenosis in carotid disease?
the velocity increases
there is a larger pressure drop than usual and blood is pushed faster through as heart pumping faster to make sure blood reaches tissues
Best treatment options to prevent carotid disease? (5)
smoking cessation control of hypertension antiplatelet medication statins - lower cholesterol diabetic control
what is the circle of willis
circulatory connection between cerebral arteries that keeps the brain and surrounding structures perfused
what is a carotid doppler test?
imaging test that uses ultrasound study to evaluate blood flow through a blood vessel
Carotid endarterectomy
surgical procedure to remove plaque from carotid artery if artery has 50-60% stenosis.
what can a carotid endarterectomy maybe prevent if carotid artery is severely narrowed?
a stroke
general and nerve complications with Carotid endarterectomy
General:-
Wound infection, bleeding, scar, anaesthetic risks
Nerve damage:-
vagus
hypoglossal
how can you tell if someone has hypoglossal nerve damage?
Usually, one side of the tongue is affected, and when the person sticks out his or her tongue, it deviates or points toward the side that is damaged.
Causes for perioperative stroke complication in endarterectomy
plaque rupture
hypoperfusion
virchow’s triad - raw intimal surface and thrombosis
TRUE or FALSE
there is no carotid stenting in Scotland
true
what do current guidelines suggest for treatment of asymptomatic patients with stenosis of 60-99% stenosis if under 75 years old?
Carotid endarterectomy (CEA) doesn’t normally fix it - more prophylactic
when is the most risky period for further event?
2 weeks after TIA or stroke
what do you offer for all symptomatic patients with >70% stenosis (except occluded)
carotid surgery
why is surgery not offered if carotid artery is 100% occluded?
because the risk of stroke and significant brain damage from the procedure is too great
where would you find a popliteal aneurysm
behind knee
where would you find a femoral aneurysm
near groin at front
aortic dissection-
RFs, signs, symptoms, diagnosis/investigation, management
RFs:
Hypertension, atherosclerosis, trauma, Marfan’s, Cystic medial necrosis
Signs: Back pain Reduced/absent peripheral pulses Acute - hypotension chronic - hypertension AR murmur pulmonary oedema
Symptoms:
Acute - sharp chest pain - radiating to the back
collapse (tamponade, acute A, external rupture)
Chronic - asymptomatic
Diagnosis/investigation:
CXR - widened mediastinum
CT/MRI
TOE - transoesophageal echocardiogram - ultrasound of your heart using a special probe that scans the heart from inside oesophagus
Management - Type A - surgery - arch replacement
Type B (not the ascending aorta) - meticulous antihypertensive treatment, Na nitroprusside + beta blocker
stenting
Long term follow up - CT/MRI
which is more commonly ruptured? aortic dissection or abdominal aorta aneurysm?
aortic dissection
symptoms/ signs of thoracic aortic aneurysm
signs:
hypotension
tachycardia
pulsatile mass
symptoms: Most asymptomatic rapid expansion/rupture: Severe pain, sudden death Stridor SOB hoarseness haemoptysis
what is coarctation of the aorta?
narrowing of the aorta at the distal to the insertion of the ductus arteriosus
coarctation of the aorta:
RFs, signs, symptoms, diagnosis/investigation, management
RFs:
Male
Turner syndrome
Bicuspid aortic valve
Signs: Upper limb hypertension weak, delayed pulses in legs Poor peripheral pulses in severe cases Mid-late systolic murmur - aortic stenosis Vascular bruits may be heard
Symptoms: Asymptomatic headaches nosebleeds claudication
diagnosis/investigations:
CXR - dilated aorta - indent at coarctation
ECG - LV hypertrophy
Echo - coarctation
CT/CMR - accurately demonstrate coarcation and quantify flow
Management:
neonates - surgical repair
older children/adults - balloon dilatation and stenting - angioplasty is an option but surgery still used often
if it is a second time having coarctation - angiplasty better option
