Aneurysms and Carotid Surgery- Presentation, Investigation and Therapy Flashcards
1
Q
What is aneurysm disease?
A
Dilatation of all layers of the aorta leading to an increase in diameter >50%
2
Q
What is the size of an abdominal aortic aneurysm?
A
> 3cm
3
Q
Where are the most common sites of aneurysms?
A
- Infrarenal
- Aorta
4
Q
What are the causes of aneurysm disease?
A
- Degenerative disease
- Connective tissue disease
- Infection
5
Q
Give an example of a connective tissue disease that can lead to aneurysm disease?
A
Marfan’s disease
6
Q
What are the risk factors for degenerative AAA disease?
A
- Male
- Age
- Smoking
- Hypertension
- Family history
7
Q
How can aneurysms present?
A
- Asymptomatic
- Through AAA screeing
- Symptomatic
8
Q
What are the criteria or screening programmes?
A
- Definable disease
- Prevalence
- Severity of disease
- Natural history
- Reliable detection confers advantage
- Treatment options available
- Cost
- Feasibility
- Acceptability
9
Q
What are the 4 outcomes after screening?
A
- Normal aorta= discharges
- Small AAA (3-4.4cm)= invited for annual USS scans
- Medium AAA(4.5-5.5cm)= invited for 3 monthly USS scans
- Large AAA(>5.5cm)= sent to the nearest vascular surgeon for work up
10
Q
When will an AAA present?
A
- Impending rupture
- Rupture
11
Q
What are the symptoms of impending rupture?
A
- Increasing back pain
- Tender AAA
12
Q
What are the symptoms of a ruptured AAA?
A
- Abdo/back/flank pain
- Painful pulsatile mass
- Haemodynamic instability
- Hypoperfusion
13
Q
What are unusual presentations of AAA?
A
- Distal embolization
- Aortocaval fistula
- Aortoenteric fistula
- Uretic occlusion
- Duodenal obstruction
14
Q
What are the 3 questions to think about when it comes to management of asymptomatic patients?
A
- Is the aneurysm a size to consider repair?
- Is the patient a candidate for repair?
- Is the aneurysm suitable for endovascular or open repair?
15
Q
How does risk of rupture vary with aneurysm size?
A
As the size of aneurysm increases so does the risk or rupture
16
Q
How is patient fitness assessed?
A
- Full history and eamination
- Bloods
- ECG
- ECHO
- PFTs
- Myocardial perfusion tests
- CPEX
- End of bed test
- Patient preference
17
Q
What 2 imaging techniques can be used in the investigation of AAA?
A
- Ultrasound
- CT
18
Q
What are the advantages of CT?
A
- Quick
- Not operator dependent
- Necessary for surgical planning as it provides detailed anatomy
19
Q
What are the disadvantages of CT?
A
- Contrast
- Radiation
20
Q
What are the advantages of ultrasound?
A
- No radiation
- NO contrast
- Cheap
21
Q
What are the disadvantages of ultrasound?
A
- Operator dependent
- Inadequate for surgical planning
22
Q
What are the 3 options for treatment/ management?
A
- Conservative
- Endovascular repair
- Open repair
23
Q
Why may a conservative approach be used?
A
- Patient/ aneurysm not fir for repair
- Patients wishes
24
Q
What must be planned if a conservative approach is taken?
A
Event of rupture
25
What are the general complications in open repair?
- Wound infection/ dehiscence
- Bleeding
- Pain
- Scar
26
What are the technical complications in open repair?
- Damage to bowel, ureters, veins, nerves
- Incisional hernia
- Graft infection
- Distal emboli
- Renal failure
- Colonic ischaemia
27
What are the patient factor complications in open surgery?
- DVT/PE
- MI
- Stroke
- Death
28
What are the general complications in endovascular repair?
- Wound infection
- Bleeding/ haematoma
- Pain
- Scar
- Reaction to contrast/ kidney injury
- Radiation
29
What are the technical complications in endovascular repair?
-Endoleak
-Femoral artery dissection/ pseudo aneurysm
-Rupture
-Distal emboli/ ischaemia/ colonic ischaemia
Damage to femoral vein/ nerve
30
What are the patient factor complications in endovascular repair?
- DVT/ PE
- MI
- Stroke
- Death
31
What is endoleak?
When the is blood leaking into the aneurysm sac
32
What are the types of endoleak?
- Type I: from above or below the graft
- Type II: from a branch
- Type III: at the graft joint
- Type IV: through the graft
- Type V: unknown origin
33
What management should a symptomatic patient receive?
- ABCDE
- History, check records
- Examination
- CT
34
How should an emergency open repair be carried out?
- Straight to theatre
- Massive transfusion protocol
- Prep abdomen, rapid anaesthetic
- Laparotomy xiphisternum to pubic symphysis
- Occlude the aorta proximally
35
What needs to be considered before emergency EVAR?
- Anatomical suitability
| - Logistics
36
How do you examine a patient for and AAA?
- Use 2 hands either side to check if there is a pulsatile expanding mass
- Check above umbilicus
37
What is atherosclerosis of the carotid arteries associated with?
- Ischaemic attacks
| - Ischaemic strokes
38
Who manages the symptoms of strokes?
Stroke teams
39
Who is involved in the management of carotid disease to prevent further events?
-Vascular surgeons
40
TIA
Focal CNS disturbance caused by vascular events such as microemboli and occlusion, leading to cerebral ischaemia. Symptoms last less than 24 hrs and there are no permanent neurological sequelae
41
Stroke
Clinical syndrome consisting od rapidly developing clinical signs of focal or global disturbance of cerebral function, lasting more than 24 hrs or leading to death, with no apparent cause other than that vascular origin
42
What are the 3 main cause of stroke/TIA?
- Cerebral infarction
- Primary intracerebral haemorrhage
- Subarachnoid haemorrhage
43
What can cause a cerebral infarction?
- AF
- Carotid atherosclerosis plaque rupture/ thrombus
- Endocarditis
- MI
- Carotid artery trauma/ dissection
- Drug abuse
- Haematological disorder
44
What are the 3 components of Virchow's triad?
- Coaguability
- Flow
- Vessel wall
45
What are the risk factor for carotid artery atherosclerosis?
- Smoking
- Diabetes
- Family history
- Male
- Hypertension
- Hyperlipidaemia/ hypercholesterolemia
- Obesity
- Age
46
How is a diagnosis of carotid artery disease made?
- History
- Examination
- CT
- Carotid ultrasound
47
What is involved in examination for carotid artery disease?
- Neurological
- Cardiac
- Auscultate carotids
48
What is involved in the neurological examination for carotid artery disease?
Contralateral:
- Paralysis
- Paresis
- Visuopatial neglect
- Dysphasia
Ipsilateral:
-Amaurosis fugax symptoms
49
What happens to the velocity as the radius of a vessel decreases?
Increases
50
How can velocity indicate degree of stenosis?
- <125cm/s: <50% stenosis
- >125cm/s: 50-69% stenosis
- >270cm/s: 70-79% stenosis
- End diastolic velocity> 140cm/s: 80-99% stenosis
51
What best medical therapy management is there for carotid artery disease?
-Smoking cessation
-Control of hypertension
-Antiplatelet
-Statin
Diabetic control
52
How does the brain remain perfused on both side/
Circle of Willis
53
Where does risk of further stroke arise from?
Emboli being showered from high velocity flow in a diseased carotid artery, causing distal ischaemia
54
When is there no risk of emboli?
No flow
55
What may prevent stroke if you have a severely narrowed carotid artery?
Carotid endarterectomy
56
What are the branches of the external carotid artery?
- Posterior auricular
- Occipital
- Facial
- Lingual
- Ascending pharyngeal
- Superior thyroid
57
What complications may there be form endarterectomy?
- Wound infection
- Bleeding
- Scar
- Anaesthetic risks
- Nerve damage
- Perioperative stroke
58
What nerves may damaged during endarterectomy?
- Glossopharyngeal nerve
- Hypoglossal nerve
- Vagus nerve
59
What may cause a perioperative stroke?
- Plaque rupture
- Hypoperfusion
- Virchow's triad
60
Who should be treated for carotid artery disease according to current guidelines?
Asymptomatic patients with 60-99% stenosis who are under 75 yrs old
61
Why is there a clear benefit for treatment in women with a higher grade stenosis?
-There is a higher operative risk in women and a more rapid reduction in the risk of stroke recurrence on medical therapy in women
62
Who requires BMT?
All patients
63
When should surgery be considered for men with carotid artery disease?
50-69% stenosis
