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Year 3 Breast and Vascular Surgery > Carotid Artery disease and Aneurysms > Flashcards

Carotid Artery disease and Aneurysms Flashcards

1
Q

Pathogenesis of Carotid Artery Disease

A
  • Turbulent flow promotes atherosclerosis and plaque formation
  • Plaque rupture → complete occlusion or distal emboli
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2
Q

Investigations of carotid artery disease

A

Bloods - FBC, U+Es, Clotting, lipid profile and glucose
ECG - AF
Duplex carotid Doppler - if post TIA do to rule out CVD
MRI angiography

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3
Q

Mx of carotid artery disease

A

Conservative:
• Aspirin or clopidogrel
• Control risk factors

Surgical: Endarterectomy
• Symptomatic - Perform w/i 2wks of presentation

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4
Q

Endarterectomy

A

Surgical procedure to remove the atheromatous plaque material, or blockage

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5
Q

Complications of Endarterectomy

A 
• Stroke or death
• HTN
• Haematoma
• MI
• Nerve injury:
- Hypoglossal: ipsilateral tongue deviation
- Great auricular: numb ear lobe
- Recurrent laryngeal: hoarse voice
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6
Q

Advantages and disadvantages of stenting

A 
Benefits:
•  Less invasive: 
• ↓ hospital stay
• ↓ risk of infection
• ↓ risk of CN injury

Disadvantages:
• ↑ stroke risk, pts. >70yrs

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7
Q

Aneursym

A

Abnormal dilatation of a blood vessel >50% of its normal diameter

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8
Q

Classification of aneurysms

A
  • True Aneurysm
  • False Aneurysm
  • Dissection
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9
Q

True Aneurysm

A

Dilatation of a blood vessel involving all layers of the wall and is >50% of its normal diameter

  • Fusiform: e.g AAA
  • Saccular: e.g Berry aneurysm
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10
Q

False Aneurysm

A

Collection of blood between the media and adventitia layers that communicates with the vessel lumen.

Usually iatrogenic: puncture, cannulation

Pulsatile lump which is tender and painful

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11
Q

Dissection

A

Vessel dilatation caused by intima separating from the media to form a channel within the vessel wall.

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12
Q

Causes of aneurysms

A

Congenital:

  • ADPKD → Berry aneurysms
  • Marfan’s, Ehlers-Danlos

• Acquired

  • Atherosclerosis
  • Trauma: e.g. penetrating trauma
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13
Q

Complications of aneurysms

A
  • Rupture
  • Thrombosis
  • Distal embolisation
  • Pressure: DVT
  • Fistula (IVC, intestine)
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14
Q

Popliteal Aneurysm

A

Presentation:
• Very easily palpable popliteal pulse
• may be bilateral
• can cause acute limb ischaemia

Mx:
• Acute: embolectomy or fem-distal bypass
• Stable:
-  Elective grafting + tie off vessel
- Stenting
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15
Q

AAA presentation

A

• Usually asymptomatic

Symptoms:
• Back pain or umbilical pain radiating to groin
• Acute limb ischaemia
• Blue toe syndrome: distal embolisation
• Acute rupture

Examination:
• Expansile mass just above the umbilicus
• Bruits may be heard
• Tenderness + shock suggests rupture

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16
Q

Mx of AAA

A
  • 3- 4.4 cm - annual USS
  • 4.5 - 5.4cm - 3 monthly USS

Risk factor reduction:

  • smoking cessation
  • blood pressure control
  • statin and aspirin therapy
  • weight loss

Surgical
• Aim to treat aneurysm before it ruptures
• Open or endovascular aneurysm repair

If > 5.5 do CY scan with contrast for surgical planning

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17
Q

Indications for AAA surgery

A
  • Symptomatic (back pain = imminent rupture)
  • Diameter >5.5cm
  • Rapidly expanding: >1cm/yr
  • Causing complications- emboli
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18
Q

Screening AAA

A

UK men offered one-time USS screen at 65yrs

19
Q

Risk factors for AAA rupture

A
  • ↑BP
  • Smoker
  • Female
  • Strong FH
20
Q

Presentation of AAA rupture

A

• Sudden onset severe abdominal pain
- Radiates to back or flanks
• Collapse → shock
• Expansile abdominal mass

21
Q

Mx of AAA rupture

A

Surgical emergency:
• High flow O2
• 2 x large bore cannulae
- Give fluid if shocked but keep SBP <100mmHg
- Give O- blood if desperate
- Blood: FBC, U+E, clotting, amylase, G+S 10u, crossmatch
• Instigate the major haemorrhage protocol
• Call vascular surgeon, anaesthetist and warn theatre
• Analgesia
• Abx prophylaxis: cef + met
• Urinary catheter + CVP line

• If stable + diagnosis certain: US or CT may be feasible

22
Q

Aortic Dissection presentation

A 
• Sudden onset, tearing chest pain
- Radiates through to the back
•Tachycardia and hypertension
• Distal propagation → occlusion of branches
- Unequal arm pulses and BP

• Proximal propagation

  • Aortic regurgitation
  • Tamponade

• Rupture into pericardial, pleural or peritoneal cavities

23
Q

Type A aortic dissection

A
  • Involves ascending aorta ± descending
  • Higher mortality due to probable cardiac involvement
  • Require surgery
24
Q

Type B aortic dissection

A
  • Involves descending aorta only: distal to left subclavian artery
  • Usually best managed conservatively
25
Q

Investigations of aortic dissection

A
  • Bloods: G+S, FBC, U+E, clotting, trop I
  • ABG
  • ECG: exclude MI
  • TTE / TOE: can use in haemodynamically unstable pts
  • CT - Gold standard but not suitable for unstable pts.
  • CXR
26
Q

Mx of aortic dissection

A

• Analgesia
• ↓SBP:
- Labetalol - keep sBP 100-110mmHg

  • Type A: open repair
  • Type B: conservative initially
  • Surgery if persistent pain or complications
  • Consider TEVAR if uncomplicated
27
Q

Degree of Stenosis

A

Mild <50%

Moderate 50-69%

Severe 70-99%

Total Occlusion 100%

28
Q

Risk factors

A

Age (≥65 years)
Smoking
Hypertension, Hypercholesterolaemia, Obesity
Diabetes mellitus
History of cardiovascular disease
Family history of cardiovascular disease.

29
Q

When is carotid endarterectomy done

A

Stenosis of more than 50%

30
Q

Mx of acute stroke

A

High flow oxygen
Blood glucose optimisation
Swallowing screen
CT scan

Ischaemic - IV alteplase within 4.5 hrs of onset and aspirin

Haemorrhagic - neurosurgery

31
Q

Long term mx of stroke

A

Anti-platelet therapy - aspirin 300mg for two weeks then clopidogrel 75mg OD

If not tolerated, trial combination therapy aspirin and dipyradimole

Statin therapy - atorvastatin 80mg

Aggressive management of hypertension and/or diabetes mellitus

Smoking cessation

Regular cardiovascular exercise and active lifestyle with weight loss

Referral to the Speech and Language Therapy (SALT) team is advised for any dysphagia or dysphasia

32
Q

Investigations for AAA

A

USS

CT with contrast - 5.5 cm

33
Q

DVLA and AAA

A

Any AAA >6.5cm requires notification to the DVLA and disqualifies from driving until repaired

34
Q

When is aortic aneurysm surgically managed

A

AAA >5.5cm
AAA expanding at >1cm/year
Symptomatic AAA

35
Q

Complications of EVAR

A

Endovascular leak

36
Q

Acute and chronic aortic dissection

A

Acute: diagnosed ≤14 days

Chronic: diagnosed > 14 days

37
Q

Presentation of aortic dissection

A

Tearing chest pain
Tachycardia Hypotension due to hypovalaemia
New aortic regurgitation murmur

Signs of end-organ hypoperfusion such as reduced urine output, paraplegia, lower limb ischaemia, abdominal pain

38
Q

Ix for psuedoaneurysms

A

Routine bloods (FBC, CRP, U&Es, clotting, Cross match

USS - turbulent forward and backward flow (termed “yin-yang sign) - gold standard

Blood culture

Pus MC+S

G+S with cross match

39
Q

Mx of psuedoaneurysms

A

USS guided compression - do not insert needle

  • surgical ligation
  • bypass graft if ischaemic
40
Q

Where do most AAA rupture

A

Posteriorly into the retroperitoneal space

41
Q

Is rapid correction of hypotension required in this pt

A

No as will exacerbate bleed - can cause clots to spread

Aim for < 100 mmHg systolic - permissive hypotension

42
Q

Which nerves can be damaged during a carotid endarterectomy

A

Glossopharyngeal- most common
Hypoglossal
Vagus

43
Q

Pseudoaneurysms

A

Aetiology:
- IVDU or trauma

Pathophysiology:
- tear between tunica media and adventitia

44
Q

Highest risk of rupture

A

Pseudoanuerysm

Year 3 Breast and Vascular Surgery (8 decks)

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