Arterial Disease Flashcards
What is carotid artery disease? How will it present?
Build up of atherosclerotic plaques 1+ common & internal carotid arteries -> stenosis/ occlusion
- Mostly asymptomatic
- Causes 10-15% of ischaemic strokes due plaque rupture/ atheroembolism
- TIA (<24hrs)
May Carotid bruit neck auscultation
Pathophysiology of atheromas
Fatty streak -> lipid core -> fibrous cap
Proliferation SM cells, foam cells -> EC lipid -> fibrosis, necrosis, inflammatory cells, cholesterol clefts -> disruption internal lamina then media -> in growth BVs -> plaque fissuring (cracking cap)
How is carotid artery disease classified?
Radiologically - degree of stenosis
Mild - <50% diameter reduction
Moderate - 50-69%
Severe - 70-99%
Total occlusion
Differentials for carotid artery disease
- carotid dissection - <50yrs, CT disorder, precipitated trauma
- thrombotic occlusion CA - imaging different
- fibromuscular dysplasia - stenosis angiopathy hypertrophy vessel wall, <50yrs, females, focal neurological deficit
- vasculitis - giant cell arteritis/ Takayasu’s arteritis, systemic
Hypoglycaemia, Todd’s paresis, subdural haematomma, SOL, VST, MS
How would you investigate someone suspected of carotid artery disease?
Suspected stroke - UrGeNT non-contrast CT head
Also:
- bloods (FBC, U&Es, clotting, lipid profile, glucose)
- ECG (A fib)
Thrombectomy to my considered CT contrast angiography
Post diagnosis I stroke/ TIA:
Duplex USS - degree stenosis
Lesions within CA - Ct angiography
Acute management of carotid artery disease/ suspected stroke
High flow O2
Blood glucose optimised (4-11mmol)
Swallowing screen assessment
- I stroke IV alteplase (admitted <4.5hrs symptoms onset + meet inclusion criteria), 300mg aspirin
✅thrombectomy + consider IV thrombolysis - H stroke correction coagulate the + neurosurgery referral (potential clot evacuation)
Long term management stroke/ TIA
Anti-platelets (aspirin 300mg OD 2 weeks -> clopidogrel 75mg OD)
Statin (atorvastatin)
Management hypertension/ DM/ smoking
Exercise
WL
Speech and language therapy
Physiotherapy
Occupation t
Carotid endarterectomy - all acute non-disabling with symptomatic carotid stenosis 50-99% ~ remove atheroma + damaged intima
Oxford stroke classification
Classification Description Signs and Symptoms
Total Anterior Circulation Stroke (TACS) (20%) Large cortical stroke in middle or anterior cerebral artery areas Must have all of:
Motor weakness or sensory deficit of -¥2/3 areas (face, arm, leg)
Homonymous hemianopia
High cortical dysfunction (dysphasia, dyspraxia, or neglect)
Partial Anterior Circulation Stroke (PACS) (35%) Cortical stroke in middle or anterior cerebral artery areas Will present with either:
2/3 TACS criteria
Limited motor or sensory deficit (1 of leg, arm or face)
High cortical dysfunction alone
Lacunar Stroke (LACS) (20%) Occlusion of the deep penetrating arteries Will present with any of:
Pure motor -¥2/3 areas (face, arm, leg)
Pure sensory -¥2/3 areas (face, arm, leg)
Pure sensorimotor -¥2/3 areas (face, arm, leg)
Ataxic hemiparesis
Posterior Circulation Stroke (POCS) (25%) Occlusion of vertebrobasilar or PCA circulation, affecting brainstem, cerebellum, or occipital lobe Variety of presentations can occur, typically:
Ipsilateral CN palsy with contralateral motor or sensory defects
Bilateral motor or sensory deficits
Isolated homonymous hemianopia
Cerebellar dysfunction
What is an AAA? Risk factors?
Dilation abdominal aorta >3cm
(Aneurysm dilation >50%)
1/70 men >65yrs
RFs: Atherosclerosis Trauma Infection CT disorder Inflammatory disease Smoking Hypertension Hyperlipidemia FH Male Older (DM negative)
Most AAAs are asymptomatic, how are they picked up? If they do have symptoms what would they be?
Incidental finding or screening (NAAASP) abdo USS men 65yrs (>5.5cm -> CT contrast)
Symptomatic: Abdo pain Back/ loin pain Distal embolisation -> limb ischaemia Aortoenteric fistula Pulsatile mass Retroperitoneal haemorrhage signs rare
Rupture - abdo/ back/ lion pain, shock, syncope
Management of AAAs
<5.5cm monitored duplex USS
3-4.4cm yearly scan
4.5-5.4 3 monthly
Reduce cvs factors
Surgery >5.5cm / expanding >1cm yr / symptomatic
- open repair clamping, segment removed, prosthetic graft
- endovascular repair graft via femoral arteries & fixing stent across (higher rates reintervention & rupture)
What is the most important complication of an endovascular repair for AAAs? How can you classify it?
Endovascular leaking
Incomplete seal around aneurysm -> blood leaks around graft
Often asymptomatic - regular surveillance
-> rupture
Type 1 - leak graft end, inadequate seal
Type 2 - sac filling from branch vessel, most resolve
Type 3 - leak through defect in graft, resolves cessation anticoags
Type 5 - continued expansion aneurysm without leak imaging
Complications of AAA
Rupture - pain, syncope, vomiting, pulsatile mass
Retroperitoneal leak
Classic triad (50%): flank/ back pain, hypotension, pulsatile mass
80% rupture posteriorly retroperitoneal space
Embolisation
Aortoduodenal fistula
Management of ruptured AAA
Suspected: High flow O2 IV access Urgent bloods (FBC U&Es clotting crossmatch min 6U) Shock treated carefully (BP <100mmHg) Transferred vascular unit Unstable - open surgical repair Stable - ct angiogram
What does the wall of an artery consist of? Where is the tear in an arterial dissection? How might it spread?
Tunica intima- endothelium, elastic membrane
Tunica media - smooth muscle
Tunica adventitia - external elastic membrane
Tear intima layer -> blood flow between & split intima & media
Can progress distally/ proximal/ both - anterograde -> iliac arteries, retrograde -> aortic valve (cardiac tamponade)
Chronic >14days
How can aortic dissections be classified?
Anatomically 2 systems
Debakey:
Type 1 - originates ascending aorta -> aortic arch
<65yrs, highest mortality (1% per hr)
Type 2 - confined ascending aorta
Elderly, atherosclerotic disease + hypertension
Type 3 - distal subclavian artery in descending aorta
a. Extends distally -> diaphragm
b. Extends beyond diaphragm into abdo aorta
Stanford classification:
A - debakey types 1 + 2, ascending aorta can propagate aortic arch + descending aorta
B - not involving ascending aorta, includes debakey type 3
Risk factors for aortic dissection?
Hypertension Atherosclerotic disease Male Ct disorders (Marfan’s, Ehler’s-danios syndrome) Bicuspid aortic valve 50-70yrs
A man presents with testing chest pain radiating to the back. Clinical sings include tachycardia, hypotension, new aortic regurgitation murmur & reduced urine output. What are your differentials? What other signs might there be? How would you investigate?
Aortic dissection
Signs end-organ hypoperfusion (reduced urine output, paraplegia, lower limb ischaemia, abdo pain secondary ischaemia, deterioration consciousness)
- CT angiogram
Transoesophageal echo maybe
MI - ECG, troponin
PE - dyspnoea, ABG hypoxia, CTPA/ V/Q scan
Pericarditis - ECG ST⬆️, pericardial rub auscultation
MSK back pain
How would you manage aortic dissection?
✅urgent initial assessment
✅ high flow O2
✅IV access (2 large bore cannulas)
✅fluid resus cautiously (110mmGh, rupture just for cerebral perfusion)
Type A - surgically, removal ascending aorta & synthetic graft
Type B uncomplicated - medically, IV beta blockers (labetalol) Or CCB
Type B + rupture/renal,visceral,limb ischaemia/refectory pain/ uncontrollable hypertension - surgery
Lifelong antihypertensives + imaging (1,3,12 months -> 6-12 month intervals)
What is the most common complication of chronic type B aortic dissections?
What are other complications of aortic dissections?
Aneurysm
✅ endovascular repair
- rupture Regurgitation MI Cardiac tamponade Stroke/ paraplegia Mortality 20% before hospital
Define a thoracic aortic aneurysm
What segments of the aorta can they involve?
Aneurysm - persistent, abnormal dilation of an artery to 1.5X normal diameter
Ascending aorta/ aortic root 60%
Aortic arch 10%
Descending aorta 40%
Thoracoacromial aorta 10%
Rarer, higher mortality - abdo aort aneurysms
Aetiology of thoracic aortic aneurysms
Degradation of tunica media -> dilates -> wall tension rises -> dilates
- CT disorders e.g. MS, EDS
- bicuspid aortic valve (tuners)
- trauma
- aortic dissection
- aortic arteritis
- tertiary syphilis
Mean rate 1-2mm/yr
Typically thoracic aneurysms are asymptomatic and found incidentally. If they are symptomatic what is the most common presentation and how does it change depending on site of aneurysm? What are some other potential symptoms?
Pain
Ascending aorta - anterior chest
Aortic arch - neck
Descending aorta - between scapulae
Back pain, hoarse voice, distempered neck veins, ❤️F symptoms, dyspnoea/ cough
-> rupture/ dissection
How would you diagnose a thoracic aneurysm?
CXR - widened mediastinal silhouette, enlarged aortic knob, tracheal deviation?
- CT chest + contrast
Transoesophageal echocardiograohy (TOE) - concurrent aortic insufficiency/ dissection, routine marfan’s & susoected THoracic aortic disease
Pre-op: routine bloods, G&S, ECG, CXR
Management of thoracic aneurysm
Confirmed - medical (ramipril, atorvastatin, aspirin) + investigations - statin Antiplatelet BP controlled Smoking cessation
Surgical: depends location
What is the name for the condition causing syncope or neurological deficits (vertigo, diplopia, dysphagia, dysarthria, visual loss) when blood supply to the affected arm is increased through exercise?
Explain the pathophysiology of it
Subclavian steal syndrome - rare
- Secondary proximal stenosing lesion*/ occlusion in subclavian artery (typically left 3X)
- to compensate increased O2 demand in arm blood is drawn from collateral circulation -> reversed blood flow in ipsilateral vertebral artery (or internal thoracic)
- > cerebral + upper limb features (arm claudication)
*atherosclerosis, vasculitis, thoracic outlet syndrome, complications surgery
You suspect subclavian steal syndrome, how will you investigate?
Duplex USS - retrograde flow affected vertebral artery with exercise
- routine CXR
Definitive:
- CT angiography or MR angiography
What are the three grades of disease severity for subclavian steal syndrome?
Pre-subclavian steal - reduced anterograde vertebral flow
Intermittent alternating flow - antegrade flow occurs in diastolic phase & retrograde in systolic
Advanced disease - permanent retrograde flow
How to manage subclavian steal syndrome
Conservative: Anti-platelet Statin Smoking WL Diabetic control
Surgical:
Endovascular
bypass - longer/ distal occlusion
Percutaneous angioplasty
From which artery does the right subclavian A branch from.
Brachiocephalic
