Aortic aneurysms and Carotid Artery Disease Flashcards
4 possible causes of aneurysm disease
Degenerative
Connective Tissue Disease
Inflammatory Disease
Infection - mycotic aneurysm
What connective tissue disease is associated with aneurysm disease?
Marfan’s
Ehler Danlos
Loey Dietz
Risk factors for degenerative aneurysm disease
Male Age Smoking Hypertension Family History
Presentation of aneurysm disease
ASYMPTOMATIC
Symptomatic - impending rupture: increasing back pain, tender AAA Rupture: - abdo/back/flank pain - painful pulsatile mass -haemodynamic instability - hypoperfusion
Unusual presentation of aneurysm
Distal embolisation Aortocaval fistula Aortoenteric fistula Ureteric occlusion Duodenal obstruction
Criteria for screening
Definable disease Prevalence Severity Natural history Reliable detection Early detection confers advantage Treatment options available Cost effective Feasability Acceptability
Screening for AAA
Single Ultrasound at age 65
Outcomes of screening for AAA
Normal - discharged
Small AAA - 3-4.4cm : annual US
Medium- 4.5-5.5cm - 3 monthly US
Large - >5.5 cm - Urgent referral within 2 weeks
Management for AAA
Assess patient fitness
Consider Endovascular or Open Repair
What investigations are required to assess patient fitness?
Full history and exam Bloods ECG ECHO PFTs Myocardial Perfusion Scan CPEX End of Bed Patient Preference
Imaging investigations required for AAA
Ultrasound
CTA/MRA
Complications of endovascular repair
Endoleak
Femoral artery dissection
Contrast reaction
Complications of open repair
Wound infection/dehiscence Bleeding Pain Scarring Damage to bowel/ureters/veins/nerves Incisional hernia Graft infection Distal emboli Renal failure Colonic ischaemia
DVT/PE
MI
Stroke
Death
Types of endoleak
I - proximal or distal leak in graft opening
II - retrograde flow into aneurysmal sac; inferior mesenteric or lumbar arteries
III - Issue in graft eg- fabric tear
IV- Porous graft
V- Tension
Management of symptomatic AAA
Emergency Open Repair
ABCDE, History, Examination, CTA
Massive transfusion protocol
Laparotomy xiphisternum to pubic symphysis
Occlude aorta proximally
Notify DVLA in any case of AAA greater than 6.5 cm
What is the mortality rate from Emergency Open Repair following symptomatic AAA?
30-50%
What is Carotid disease?
Atherosclerosis of carotid arteries
What consequential conditions are associated with Carotid Disease?
Transient ischaemic attack
Ischaemic stroke
What is a transient ischaemic attack?
Focal CNS disturbances due to vascular events eg microemboli and occlusion leading to cerebral ischaemia
Symptoms lasting less than 24 hours
No permanent neurological sequelae
At which point in carotid disease is surgery considered?
Greater than 70% stenosis
Causes of stroke
Cerebral infarction
Primary intracerebral haemorrhage
Subarachnoid haemorrhage
Instances of cerebral infarction
AF Carotid atherosclerotic plaque rupture/thrombosis Endocarditis MI Carotid artery trauma/dissection Drug abuse Haematological disorder
Virchow’s triad
Vessel Injury
Hypercoagulability
Flow
Branches of external carotid
Posterior auricular Occipital Facial Lingual Ascending Pharyngeal Superior Thyroid
Complications of carotid endarterectomy
Wound infection Bleeding Scar Anaesthetic risks Perioperative stroke
When might stenting be used instead of a carotid endarterectomy?
Inaccessible disease
- too high up for open surgery
- previous surgery and scarring
Which inflammatory disease is associated with AAA?
Takayasu’s aortitis
Differential diagnosis to AAA
Renal colic Diverticulitis IBD IBS GI haemorrhage Appendicitis Ovarian torsion Ovarian rupture Splenic infarction
Prevalence of AAA
1 in 70 Males over 65 y/o
3000 deaths per year
As well as duplex monitoring for asymptomatic management of AAA, what other factors must be addressed
Weight Exercise Smoking cessation Hypertension control Statin and aspirin therapy to be started
Management of ruptured AAA
High flow O2
IV Access
Urgent bloods - FBC, U& Es, clotting
Cross match for minimum 6U units
Aim to keep BP <100mmHg : Permissive hypotension
Transfer to vascular unit - vascular reg, consultant, anaesthetist, theatre and blood transfusion informed
If unstable - immediate transfer for open repair
If stable - CTA to determine EVAR or open
What is permissive hypotension?
In ruptured AAA blood pressure is kept below 100 mmHg to prevent excessive blood loss
Risk factors for carotid artery disease
Age Obesity Hypercholesterolaemia Hypertension Diabetes Smoking Family history Cardiovascular history
Examination findings of carotid artery disease
Symptoms of stroke
Carotid bruit
Why is carotid disease likely to be asymptomatic?
If unilateral - collateral circulation of ICA and vertebral arteries on opposite side due to circle of willis
What is amaurosis fugax?
Transient visual loss
Can occur in TIA
What are differentials for carotid artery disease?
Carotid dissection
Thrombotic occlusion of carotid artery
Fibromuscular dysplasia
Vasculitis
How is Vasculitis differentiated from carotid artery disease?
GCA or Takayasu’s would typically have other systemic symptoms
What is fibromuscular dysplasia?
Non-atheromatous stenotic angiopathy
Causes hypertrophy of the vessel wall
What other non cerebrovascular conditions must be considered when patient presents with symptoms of carotid artery disease?
hypoglycaemia Todd’s paresis* subdural haematoma space-occupying lesion venous sinus thrombosis post-ictal state multiple sclerosis
What is Todd’s paresis?
Unilateral motor paralysis following seizure
Investigations for carotid artery disease
CT head
Bloods - FBC, clotting, lipid profile, glucose, U&EsECG
For thrombectomy - CT head contrast angiiography
Follow-up investigations for carotid artery disease
Duplex USS
Complications of stroke
dysphagia, seizures, ongoing spasticity, bladder or bowel incontinence, and depression, anxiety, or cognitive decline.
First line investigation of Carotid Artery disease
Carotid US Doppler
