Aneurysms and Carotid Surgery

Question 1

what is an aneurysm?

Answer 1

dilatation of all layers of the aorta leading to an increase in diameter of >50%

Question 2

what is the tunica intima made from?

Answer 2

endothelial cells

Question 3

what is the tunica media made from?

Answer 3

smooth muscle cells

Question 4

what is the tunica externa made form?

Answer 4

collagen and connective tissue

Question 5

what causes aneurysm?

Answer 5

> degenerative disease
connective tissue disease
infection

Question 6

what are the risk factors for aneurysm?

Answer 6

> male
> age
> smoking
> hypertension
> family history
> diabetes

Question 7

when are men in England invited for an aortic aneurysm screen?

Answer 7

the year they turn 65

Question 8

what happens if someone has a small (3-4cm) abdominal aortic aneurysm?

Answer 8

they will be invited for annual USS scans

Question 9

what happens if someone had a medium (4.5-5.5cm) abdominal aortic aneurysm?

Answer 9

they will be invited for 3 month USS scan

Question 10

how large is a large abdominal aortic aneurysm?

Answer 10

> 5.5cm

Question 11

what would the symptoms of an AAA that is about to rupture be?

Answer 11

increasing back pain and a tender abdominal aortic aneurysm

Question 12

what are the symptoms of a ruptured abdominal aortic aneurysm?

Answer 12

> abdominal/back pain
painful pulsatile mass
haemodynamic instability
hypoperfusion

Question 13

what are some unusual presentation of abdominal aortic aneurysm?

Answer 13

> distal embolization
> aortocaval fistula
> aortoenteric fistula
> ureteric occlusion
> duodenal obstruction

Question 14

what is aortocaval fistula?

Answer 14

when the aneurysm erodes into the vena cava

Question 15

what is an aortoenteric fistula?

Answer 15

when the aneurysm erodes into the bowel

Question 16

at what size of aneurysm would surgery be considered?

Answer 16

5.5cm

Question 17

name some things that would be done to test patients fitness for surgery

Answer 17

> full history and examination
> bloods
> ECG
> ECHO
> PFTs
> MPs
> CPEX

Question 18

what are the pros of a ultrasound scan?

Answer 18

> no radiation
no contrast
cheap

Question 19

what are the problems with ultrasound scanning?

Answer 19

> operator dependant

> inadequate for surgical planning

Question 20

what are the pros of a CTA/MRA?

Answer 20

> quick
not operator dependant
necessary for surgery planning

Question 21

what are the problems with CTA/MRA?

Answer 21

> contrast (patients often have renal failure)

> radiation

Question 22

what are the three treatment options for an abdominal aortic aneurysm?

Answer 22

> conservative
endovascular repair
open repair

Question 23

what general complications can there be with open repair of an AAA?

Answer 23

> wound infection
bleeding
pain
scar

Question 24

what technical complications can there be with open repair of an AAA?

Answer 24

> damage to bowel, uterus, nerves
> incisional hernia
> graft infection
> distal emboli
> renal failure
> colonic ischaemia

Question 25

what patient factors can cause complications in open surgery of an AAA?

Answer 25

> MI > Stroke > Death > DVT/PE

Question 26

what technical complications can there be with endovascular repair of an AAA?

Answer 26

``` > endoleak > femoral artery dissection > rupture > distal emobli > damage to femoral vein ```

Question 27

why does an repaired AAA need ongoing surveillance?

Answer 27

blood can leak from the top end, from the branches or between the two pieces of graft.

Question 28

what happens in an emergency open repair?

Answer 28

they go straight to theatre and a laparotomy from the xiphisternum to the pubic symphysis is performed. there is a massive transfusion protocol. they are kept awake to the last moment as they are using their abdominal muscles to keep tamponade

Question 29

what is the definition of a transient ischaemic attack?

Answer 29

focal CNS disturbance caused by vascular events such as micro-emboli and occlusion leading to cerebral ischaemia. symptoms last less than 24 hours and there is no permanent neurological problems.

Question 30

define stroke

Answer 30

clinical syndrome consisting of rapidly developing clinical signs 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.

Question 31

name three causes of stroke

Answer 31

> cerebral infarction > primary intracerebral haemorrhage > subarachnoid haemorrhage

Question 32

``` which of the following is not a factor for carotid atherosclerosis: > smoking > previous deep vein thrombosis > hypertension > obesity ```

Answer 32

previous deep vein thrombosis as it is a venous disease

Question 33

how would you diagnose a stroke?

Answer 33

> history > examination > CT scan > carotid ultrasound scan

Question 34

what affect does the radius of the vessel have on the velocity of the fluid within it?

Answer 34

as the radius decrease the velocity increases

Question 35

how is the brain still perfused if the right main internal carotid artery is blocked?

Answer 35

the circle of willis

Question 36

a male with confirmed TIA has a carotid doppler (right internal artery has a 90% stenosis). what management can be given?

Answer 36

carotid endarterectomy.

Question 37

what is a carotid endarterectomy?

Answer 37

and incision is made to open the carotid artery and the plaque is removed. the artery is closed.

Question 38

what complications could occur from a carotid endarterectomy?

Answer 38

``` > wound infection > bleedings > scar > anaesthetic risk > nerve damage ```

Question 39

what can cause a perioperative stroke in a carotid endarterectomy?

Answer 39

> plaque rupture > hypoperfusion > virchows triad

Question 40

what other surgical procedure can be offered other than carotid endarterectomy?

Answer 40

stenting