Carotid Artery Disease Flashcards
A patient with coronary artery bypass is at high risk of?
Stroke, TIA, !! carotid artery stenosis
The most common site for coronary artery disease is at what level?
At the bifurcation of common carotid artery at C2/C3
What are the RF for coronary artery disease?
Define Asymptomatic Coronary artery disease
Define Symptomatic
***Same side stroke (haemorrhagic/ischaemic), TIA, or just hypoperfusion
What is Dysarthria?
Slurred speech specifically due to weakness in muscle control causing problems articulating
What are the signs and symptoms of Coronary Artery Disease
How specific is carotid bruit at indicating carotid artery stenosis?
Not specific and not a good indicator, but still done on exam
What guidelines are used for the diagnostic criteria and management algorithms used in carotid artery disease
What is the diagnostic criteria for coronary artery disease?
ESVS - European Society for Vascular Surgery
> 50% stenosis confirmed by 2 imaging modalities according to the ESBS
What is the new gold standard imaging for coronary artery disease?
What was the old one?
Why has the new one replaced the old one? (2)
New: Carotid CT/MR Angiography
Old: Carotid Angiography
Carotid angiography is invasive and itself carries a 1% risk of stroke
List the relevant investigations for carotid artery disease, indicating specifically the diagnostic criteria
What is/are the definitive management of carotid artery disease?
Carotid Endarterectomy (CEA)
Carotid artery stenting (CAS)
Carotid artery bypass (not in algorithm, but used to be used)
To perform any of the surgical management for a patient with carotid artery disease, what should the surgeon make sure of? (especially if the patient is asymptomatic)
For any surgery you should !! weigh the risks and benefits of performing!!
1) Life Expectancy >5yrs (adequate)
2) Favourable anatomy
3) Patient conditions and comorbidities
4) Patient already on BMT
Anything vascular, what meds?
Statin Nightly + DAPT (clopidogrel 75mg, Aspirin 75mg) OD
The ESVS guidelines state the BMT (best medical therapy) should be given to all patients with coronary artery disease. What is included in the BMT? (specifics)
Conservative and medical management
If a patient had a stroke and on carotid CT angiography, >50% stenosis is found. Ideally, within how long should the surgery be performed?
How long after the event (stroke, TIA, cerebral hypoperfusion) will the patient still be considered symptomatic?
After performing the surgery what is the followup plan for all patients?
Surgery within 2 weeks of event ideally
Patient is considered symptomatic for 6 months
Post-op duplex in 6 weeks
What is the full management algorithm according to ESVS guidelines
BMT Best medical therapy
CEA = carotid endarterectomy
CAS = Carotid Artery Stenting
!!!!!!! Post-op Duplex in 6 weeks (must include)
What is contained within the carotid sheath?
Common carotid artery (medial)
Internal Jugular Vein (Lateral)
Vagus Nerve (posterior, in between them)
Deep cervical LN
At what level is the carotid body?
At the bifurcation => C2/C3
The facial vein drains into what vein
Ligating this vein, as part of carotid endarterectomy will lead to? What covers it when trying to access the common carotid?
Does the carotid sheath cover it?
Drains into the common facial vein which drains into the internal jugular vein
cutting it leads to nothing, thats why we cut it
The platysma covers it but the carotid sheath does not
The incision for carotid endarterectomy is where?
Along the anterior border of the SCM
As part of carotid endarterectomy, 3 arteries are clamped. What are they and list them in the correct order of clamping
1st Common carotid artery
2nd Internal Carotid artery
3rd External Carotid artery
Once youve clamped the arteries what are the chances a stroke occurs?
What is the cause of the stroke in that case?
What is done to assess if the risk of stroke is likely intraoperatively?
If the risk of stroke is deemed too high what is done in this case?
There is a 1/6 chance stroke will occur on clamping.
This stroke is due to cerebral hypoperfusion
Stump pressures are taken to assess the risk of stroke and if it is deemed to high, a shunt is formed proximal to the clamp on the common carotid to distal to the internal carotid artery clamp
Which artery is stump pressures taken from?
Is this done before or after clamping?
What pressure is considered sufficient?
If a shunt is needed, what is it made of?
Stump pressure are performed on the internal carotid artery after clamping
>50mmHg is considered sufficient
The shunt is typically made of Silicone or PVC (polyvinyl chloride)
Once carotid endarterectomy is done, What is the patch made of? which is better and why?
bovine or Dacron patch is used. The bovine one is preferable due to reduced risk of infection
Damage to the carotid body intraoperatively will cause what?
Damage to the carotid body causes:
1) BP fluctuations
2) Blunted response to hypoxia
3) Rarely, Sleep-disordered breathing
Recall: The carotid body serves 2 functions
1) Barometer for BP
2) Chemoreceptor for blood oxygen levels
What needs to be done in the immediate post-operative period after carotid endarterectomy
Monitor BP (Carotid body causing fluctuations in BP)
Observe for Haematoma compromising airway (presents like strap haematoma)
What are the contraindications to carotid endarterectomy?
Explain the full procedure of carotid endarterectomy like you would in a long case including post-op
What nerves are in the vicinity of carotid artery surgey?
Vagus nerve CN X (incl. recurrent laryngeal)
Hypoglossal nerve CNXII
What are the specific complications of carotid endarterectomy?
Stroke and MI are both complications of CEA and CAS. Which of the complications is more likely to occur for each surgery
CEA -> MI (cuz CEA prevents stroke)
CAS -> Stroke (cuz stents prevent MIs)
Who performs carotid artery stenting?
IR
Who inserts the carotid artery stent?
Interventional radiology
