Aortic aneurysms and Carotid Artery Disease Flashcards by Alice McQuade

4 possible causes of aneurysm disease

Degenerative
Connective Tissue Disease
Inflammatory Disease
Infection - mycotic aneurysm

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What connective tissue disease is associated with aneurysm disease?

Marfan’s
Ehler Danlos
Loey Dietz

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Risk factors for degenerative aneurysm disease

Male
Age
Smoking
Hypertension
Family History

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Presentation of aneurysm disease

ASYMPTOMATIC

Symptomatic - impending rupture: increasing back pain, tender AAA
Rupture: 
- abdo/back/flank pain
- painful pulsatile mass
-haemodynamic instability
- hypoperfusion

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Unusual presentation of aneurysm

Distal embolisation
Aortocaval fistula
Aortoenteric fistula
Ureteric occlusion
Duodenal obstruction

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Criteria for screening

Definable disease
Prevalence
Severity
Natural history
Reliable detection
Early detection confers advantage
Treatment options available
Cost effective
Feasability
Acceptability

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Screening for AAA

Single Ultrasound at age 65

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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

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Management for AAA

Assess patient fitness

Consider Endovascular or Open Repair

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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

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Imaging investigations required for AAA

Ultrasound

CTA/MRA

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Complications of endovascular repair

Endoleak
Femoral artery dissection
Contrast reaction

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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

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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

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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

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What is the mortality rate from Emergency Open Repair following symptomatic AAA?

30-50%

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What is Carotid disease?

Atherosclerosis of carotid arteries

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What consequential conditions are associated with Carotid Disease?

Transient ischaemic attack

Ischaemic stroke

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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