Carotid Artery disease and Aneurysms

Question 1

Pathogenesis of Carotid Artery Disease

Answer 1

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

Question 2

Investigations of carotid artery disease

Answer 2

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

Question 3

Mx of carotid artery disease

Answer 3

Conservative:
• Aspirin or clopidogrel
• Control risk factors

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

Question 4

Endarterectomy

Answer 4

Surgical procedure to remove the atheromatous plaque material, or blockage

Question 5

Complications of Endarterectomy

Answer 5

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

Question 6

Advantages and disadvantages of stenting

Answer 6

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

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

Question 7

Aneursym

Answer 7

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

Question 8

Classification of aneurysms

Answer 8

• True Aneurysm
• False Aneurysm
• Dissection

Question 9

True Aneurysm

Answer 9

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

Question 10

False Aneurysm

Answer 10

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

Question 11

Dissection

Answer 11

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

Question 12

Causes of aneurysms

Answer 12

Congenital:

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

• Acquired

• Atherosclerosis
• Trauma: e.g. penetrating trauma

Question 13

Complications of aneurysms

Answer 13

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

Question 14

Popliteal Aneurysm

Answer 14

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

Question 15

AAA presentation

Answer 15

• 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

Question 16

Mx of AAA

Answer 16

• 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

Question 17

Indications for AAA surgery

Answer 17

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

Question 18

Screening AAA

Answer 18

UK men offered one-time USS screen at 65yrs

Question 19

Risk factors for AAA rupture

Answer 19

• ↑BP
• Smoker
• Female
• Strong FH

Question 20

Presentation of AAA rupture

Answer 20

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

Question 21

Mx of AAA rupture

Answer 21

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

Question 22

Aortic Dissection presentation

Answer 22

• 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

Question 23

Type A aortic dissection

Answer 23

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

Question 24

Type B aortic dissection

Answer 24

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

Question 25

Investigations of aortic dissection

Answer 25

* 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

Question 26

Mx of aortic dissection

Answer 26

• 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

Question 27

Degree of Stenosis

Answer 27

Mild <50% Moderate 50-69% Severe 70-99% Total Occlusion 100%

Question 28

Risk factors

Answer 28

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

Question 29

When is carotid endarterectomy done

Answer 29

Stenosis of more than 50%

Question 30

Mx of acute stroke

Answer 30

High flow oxygen Blood glucose optimisation Swallowing screen CT scan Ischaemic - IV alteplase within 4.5 hrs of onset and aspirin Haemorrhagic - neurosurgery

Question 31

Long term mx of stroke

Answer 31

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

Question 32

Investigations for AAA

Answer 32

USS | CT with contrast - 5.5 cm

Question 33

DVLA and AAA

Answer 33

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

Question 34

When is aortic aneurysm surgically managed

Answer 34

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

Question 35

Complications of EVAR

Answer 35

Endovascular leak

Question 36

Acute and chronic aortic dissection

Answer 36

Acute: diagnosed ≤14 days Chronic: diagnosed > 14 days

Question 37

Presentation of aortic dissection

Answer 37

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

Question 38

Ix for psuedoaneurysms

Answer 38

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

Question 39

Mx of psuedoaneurysms

Answer 39

USS guided compression - do not insert needle - surgical ligation - bypass graft if ischaemic

Question 40

Where do most AAA rupture

Answer 40

Posteriorly into the retroperitoneal space

Question 41

Is rapid correction of hypotension required in this pt

Answer 41

No as will exacerbate bleed - can cause clots to spread Aim for < 100 mmHg systolic - permissive hypotension

Question 42

Which nerves can be damaged during a carotid endarterectomy

Answer 42

Glossopharyngeal- most common Hypoglossal Vagus

Question 43

Pseudoaneurysms

Answer 43

Aetiology: - IVDU or trauma Pathophysiology: - tear between tunica media and adventitia

Question 44

Highest risk of rupture

Answer 44

Pseudoanuerysm