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Cardiovascular system 16/17 > Aneurysms and carotid artery surgery > Flashcards

Aneurysms and carotid artery surgery Flashcards

1
Q

When does a dilatation of the aorta become classified as an aneurysm?

A

When it dilates to an increase of > 50% (normal diameter of the aorta = 2cm)

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2
Q

Where are the majority of aneurysms found?

A

95% are infrarenal abdominal aneurysms - Located in the part of the abdominal aorta below the kidneys

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3
Q

Whats the difference between true and false aneurysms?

A

True - disease affects all 3 layers of the aorta wall

False - usually only affects outer layer, usually caused by trauma

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4
Q

What can cause aneurysms?

A

Degenerative disease
Connective tissue disease
Infection (mycotic aneurysm)
Trauma

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5
Q

What are the risk factors for aneurysms?

A 
Male
Age
Smoking
Hypertension
Family History
Genetics
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6
Q

How can asymptomatic aneurysms be found?

A

Clinical exam - pulsatile mass (false a etc)
After family member diagnosis
Screening - all males over 65yo get US
Incidentally in a scan for something else

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7
Q

What is the criteria for a successful screening regime?

A 
Definable disease
Prevalence
Severity of disease
Natural history is understood
Reliable detection 
Early detection confers advantage
Treatment options available 
Cost effective
Feasibility
Deemed acceptable - complaincy
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8
Q

What classifies as a small aneurysm?

A

3-4.4cm

Annual USS scans

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9
Q

What classifies as a medium aneurysm?

A

4.5-5.5cm

3 monthly USS scans

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10
Q

What classifies as a large aneurysm?

A

> 5.5cm

Immediately referred to vascular surgeon

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11
Q

What are some unusual presentations of aneurysms?

A 
Distal embolisation
Aortocaval fistula
Aortoenteric fistula (connection between aorta and intestines/stomach/oesophagus) 
Ureteric occlusion
Duodenal obstruction
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12
Q

How do we assess patient fitness for aneurysm surgery?

A 
Full history and exam - comorbidity, function
Full blood tests
ECG
ECHO
Pulmonary function tests
Myocardial perfusion scans
Cardio-pulmonary exercise testing
End of the bed test?
Patient preference
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13
Q

What are some pros of cranial ultrasound?

A

No radiation
No contrast - safe in renal failure
Cheap

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14
Q

What are some cons of cranial ultrasound

A

Operator dependent

Inadequate for surgical planning

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15
Q

What are some pros of CTA and MRA when planning surgery?

A

Quick

Not operator dependent

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16
Q

What are some cons of CTA or MRA for planning surgery?

A

Contrast used

Radiation

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17
Q

What is done to assess aneurysm before surgery?

A

Ultrasound
Computed tomography angiography
Magnetic resonance angiography

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18
Q

What procedure involves making a large incision in the abdomen to expose the aorta and aneurysm sac?

A

Laparotomy - from xiphisternum to pubic symphysis

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19
Q

What are some complications of open surgery on aneurysms?

A 
General anaesthetic use
Big operation - healing time, infection
Incisional hernia
Damage to nearby anatomy
Risk of preoperative MI
Renal failure
Colonic ischaemia
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20
Q

Describe endovascular repair (EVAR) of aneurysms

A

Small incision in groin, where special instruments are inserted through a catheter in the femoral arteries to thread them up to the aneurysm. At aneurysm, surgeon places stent and graft to support aneurysm.

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21
Q

What are some complications of EVAR?

A 
Damage to veins/arteries/nerves on insertion
Rupture of aneurysm 
Endoleak
Femoral artery dissection/pseudoaneurysm
Distal emboli/ischaemia
22
Q

What could surgery on aneurysms lead to clinically?

A

DVT/PE
MI
Stroke
Death

23
Q

What are some general complications following both EVAR and open surgery?

A 
Wound infection
Bleeding
Pain
Scarring
(Radiation/contrast if used)
24
Q

What are endoleaks?

A

Blood leaks back into aneurysm sac following EVAR, 5 types:
I - gap between graft and vessel at seal
II- increased pressure forces blood out
III- defect or misalignment of endograft
IV - porosity of graft
V- permeability of graft allows transmission of pressure into sac

25
Q

What is a type I endoleak?

A

I - gap between graft and vessel at seal, requires urgent attention

26
Q

What is a type II endoleak?

A

II- increased pressure forces blood out

MOST COMMON

27
Q

What is a type III endoleak?

A

III- defect or misalignment of endograft, requires urgent attention

28
Q

What is a type IV endoleak?

A

IV - porosity of graft, occurs soon after procedure

29
Q

What is a type V endoleak?

A

V- permeability of graft allows transmission of pressure into sac

ENDOTENSION, controversial

30
Q

What is there a risk of in EVAR?

A

Incomplete removal of blood can lead to Abdominal compartment syndrome

31
Q

Why must you prep abdomen before surgery?

A

Acts as a tamponade normally, which is lost following anaesthetics

32
Q

What is atherosclerosis of the carotid arteries associated with clinically?

A

Transient ischaemic attacks

Stroke

33
Q

What can cause cerebral infarctions?

A 
AF
Carotid atheromatous plaque rupture
Endocarditis
MI
Carotid artery injury/dissection
Drug abuse
Haematological disorders e.g. sickle cell
Primary intracerebral haemorrhage
34
Q

What % of strokes are due to ischaemia?

A

84%

35
Q

What % of strokes are due to haemorrhage?

A

16% (primary intracerebral +subarachnoid haemorrhages)

36
Q

What is Virchows triad?

A

Three broad range of factors associated with thrombosis:
Hypercoagulability
Haemodynamic changes - stasis, turbulence
Endothelial damage/dysfunction

37
Q

What are some risk factors for carotid artery atherosclerosis?

A 
Smoking
Diabetes
Hypertension
Family history
Male sex
Previous DVT
Hyperlipidaemia
Hypercholesterolaemia
Obesity
Age
38
Q

How can we diagnose stroke?

A

History and examination
CT
Carotid USS - measure flow and direction

39
Q

What is poiseuilles law?

A

Flow depends on resistance and radius of the vessels

As radius decreases, velocity increases

40
Q

What therapy is suggested to those with carotids artery atherosclerosis?

A 
Smoking cessation
Control of hypertension
Antiplatelet agents e.g. aspirin, clopidogrel
Statins
Diabetic control

If severe:
Carotid endarterectomy
Stenting

41
Q

What is the circle of willis?

A

circulatory anastomosis that supplies blood to the brain and surrounding structures.

42
Q

Describe Carotid endarterectomy

A

clamp above and below diseased section, remove plaque and repair artery to create open channel

43
Q

What is the general rule with superficial and deep vessels?

A

Superficial - continue following bifurcation

Deep - end and supply area

44
Q

What are some complications of Carotid endarterectomy ?

A 
Wound infection 
Bleeding
Scarring
Anaesthetic risks
Nerve damage
45
Q

What are the nearby nerves that can be damaged during Carotid endarterectomy, and how would damage present?

A

Vagus nerve - PS control of lungs, GI tract

Hypoglosseal nerve - numb lips and tongue

Glossopharyngeal nerve - loss of voice

46
Q

What is the hypoglosseal nerve responsible for?

A

Lip and tongue innervation

47
Q

What is vagus nerve responsible for?

A

Parasympathetic control of hearts, lung, GI tract etc

48
Q

What is the glossopharyngeal nerve responsible for?

A

Voice

49
Q

What are some possible complications of Carotid endarterectomy?

A

Plaque rupture
Hypoperfusion
Clotting

50
Q

When should surgery be considered?

A

Symptomatic but 50-69% stenosis

Asymptomatic but >70% stenosis

Cardiovascular system 16/17 (40 decks)

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