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Vascular Surgery by Emi > Carotids (extra) > Flashcards

Carotids (extra) Flashcards

1
Q

How do you determine proximal stenosis in CCA

A

dampened velocities and spectral broadening in ICA

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2
Q

How do you determine distal occlusion and high grade stenosis in ICA

A

dampened velocities and low EDV in ICA

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3
Q

What are characteristics of post stenotic waveform in ICA

A

low velocity wave form with delayed upstroke (parvus tardus)

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4
Q

Carotid preocclusive thump

A

short narrow peak with no flow through diastoly

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5
Q

absent bilateral diastolic flow in carotids

A

cardiac disfunction

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6
Q

carotid dissection classification

A

1) minimal injury or irregular intima
2) dissection with raised intimal flap / IMH with luminal narrowing >25% / Intraluminal thrombosis
3) PSA
4) vessel occlusion or complete thrombosis
5) vessel transection

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7
Q

Shamblin classification

A

1) localized to carotid bifurcation
2) partially surround ECA and ICA
3) completely encases ECA and ICA

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8
Q

common carotid division

A

upper border of thyrdoi cartillage

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9
Q

external carotid artery branches

A

1) ascending pharyngeal
2) superior thyroid
3) lingual
4) facial
5) occipital
6) posterior auricular
7) terminal branches: superficial temporal and maxillary

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10
Q

segments of vertebral artery

A

1) from subclavian to C6 foramina
2) through foramina of C6 - C2
3) from C2 foramen transversarium to dura mater
4) pierces through the dura mater to formed basillary artery

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11
Q

familial carotid body tumor gene

A

succinyl dehydrogenase

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12
Q

Fontaine’s sign

A

carotid body tumor will move left to right but not up and down

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13
Q

Hollenhorst plaque

A

cholesterol crystal embolization to retinal circulation, incidental, not associated with increased risk of stroke

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14
Q

> 30% in stent carotid stenosis

A

> 150cm/s

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15
Q

> 50% in stent carotid stenosis

A

> 220cm/s

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16
Q

> 80% in stent carotid stenosis

A

> 325cm/s

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17
Q

criteria for ICA occlusion

A

bidirectional flow in ICA stump and externalization or high resistance flow patterns in ipsilateral CCA with absent, decreased or reversed flow in diastole

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18
Q

Indirect carotid stenosis criteria

A

1) decreased EDV in CCA or ICA in presence of distal lesion
2) internalization of ECA
3) reversal of flow in ophtalmic artery
4) anterior cross filling via anterior communicating artery
5) posterior communicating artery flow
6) increased flow pulsatility in unilateral CCA
7) decreased flow pulsatility in unilateral MCA
8) abnormal flow acceleration and pulsatility transmission index (MCA)

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19
Q

Stent deformity or re-stenosis criteria

A

1) b-mode >30% narrowing
2) focal velocity increase >150cm/sec and stenotic to pre-stenotic PSV ratio of 1:>=2
3. evidence of plaque or thrombus formation

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20
Q

Bowhunter’s syndrome

A

positional posterior insufficiency caused by dynamic compromise of dominant left vertebral artery –> transient dizziness when looking upwards with head rotated

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21
Q

Vertebral artery stenosis

A

PSV >= 2 (ratio of the stenotic to pre or post stenotic area)

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22
Q

Normal carotid values

A

ICA PSV <125
ICA EDV <40
ICA/CCA <2

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23
Q

50-69% carotid stenosis

A

ICA PSV 125-230
ICA EDV 40-100
ICA/CCA 2-4

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24
Q

70-79% carotid stenosis

A

ICA PSV >230
ICA EDV 100-125
ICA/CCA 2-4

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25
Q

80-89% carotid stenosis

A

ICA PSV >230
ICA EDV >125
ICA/CCA >4

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26
Q

Costocervical trunk branches

A

deep cervical

superior intercostal

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27
Q

thyrocervical trunk branches

A

inferior thyroid
suprascapular
ascending cervical
transverse cervical

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28
Q

parts of ICA

A
  1. cervical
  2. petrous
  3. lacetum
  4. cavernous
  5. clinoid
  6. ophtalmic
  7. communicating
  8. terminal branches: anterior cerebral and middle cerebral
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29
Q

what parts of ICA have branches

A

petrous
cavernous
ophtalmic
communicating

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30
Q

what are the branches of petrous ICA

A

vidian

caroticotympanic

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31
Q

what are the branches of cavernous ICA

A

meningohypophyseal

inferolateral trunk

32
Q

what are the branches of ophtalmic ICA

A

ophtalmic

superior hypophyseal

33
Q

what are the branches of communicating ICA

A

posterior communicating

anterior choroidal

34
Q

sound of carotid bruit with 50-69% stenosis

A

low pitched
short
systemic
gruff

35
Q

sound of high grade stenosis bruit

A

high pitched, soft

36
Q

extracranial carotid artery aneurysm

A

if untreated 50% risk of stroke and death

>2cm absolute indication for operation

37
Q

NASCAT trial results

A
  1. 70-99% any ipsilateral stroke reduction: 9% vs 26% at 2 years
  2. 50-69% any ipsilateral stroke reduction: 16 vs 22% at 5 years (p=0.045)
  3. <50%: no benefit
  4. near occlusion: no benefit
38
Q

timing of CEA:

A
  1. TIA - next elective schedule
  2. non disabling stroke (minor fixed deficit or TIA with small CTA / MR stroke): 48h - 2 weeks
  3. major hemispheric stroke: 4 weeks at least
  4. crescendo TIA or stroke in evolution - urgent CEA (but increased perioperative risk)
39
Q

ACAS trial

A

asymptomatic patients with stenosis >60%, 1662 patients randomized
Endpoint: stoke and death
5% in surgery group and 11% with any medical management
risk reduction of 53%

40
Q

EVA 3s trial

A

2006, stopped before completion
symptomatic patients with severe disease
EPD was not always used
30 day stroke rate: 3.9 in CEA and 9.6 in CAS

41
Q

SPACE trial

A

symptomatic patients

Endpoint was stroke and death. EPD used 27% of time
No difference in end point between groups

recurrent stenosis: 4.6 in CEA and 10.7% in CAS
Failed to prove CAS was not inferior

42
Q

ICSS trial

A

symptomatic patients

stroke, MI, or death: 5.2 in CEA and 8.2 in CAS

43
Q

what’s the difference of new area brain infarctions between CAS and CEA

A

50% in CAS and 17% in CEA

44
Q

CREST trial

A 
symptomatic and asymptomatic patients, 
endpoint: combined stroke, MI and death
composit endpoint: 4.5% CEA and 5.2 in CAS (not statistically different), but if you took out MI, CEA is statistically better
CEA only higher in MI
patients over 70 did better with CEA
younger patients did better with stent
women did worse with stenting
45
Q

What’s the pathology of stroke

A

85% due to cerebral infarction

46
Q

Technique for stump pressure measurement in the carotid

A

Clamp CCA and ECA leaving ICA open, and then measure pressure

47
Q

Results of CREST trial for CEA patch vs no patch

A

66% patch and 29%primary closure, eversoion excluded

Priprocedural outcomes: statistically significant increase in stroke and death in the no patch group
More restenosis

48
Q

Mechanism for postoperative stroke in carotid

A

Embolization
Unsatisfactory technical result —> thromboembolism
Uncontrolled hypertension
Inadequate cerebral perfusion intraoperatively

49
Q

Proven indications for carotid endarterectomy

A

Symptomatic: hemispheric or mononuclear TIA or stroke, providing m&m <6%, 70-99% stenosis both genders, for men also 50-69%
Asymptomatic: providing surgical m&m <2.3%, 60-99% stenosis

50
Q

What lesions have higher risk of stroke with carotid stenting

A

Long lesions (1.2 cm), dysynchronous or sequential lesions, lesions distal to carotid bulb

51
Q

SAPPHIRE trial

A

Randomized prospective controlled for patients at high risk for endarterectomy
Asymptomstic patients >80%, symptomatic >50%
70% if patients were asymptomstic and high risk - critique: should have been managed medically
1 year endpoint (stoke and death) 12.2% in CAS and 20.1% in CEA. More pronounced in asymptomstic patients.

52
Q

High anatomical risk for CEA

A 
Previous CEA with recurrent stenosis
Prior radiation therapy to neck
Previous ablative neck surgery
Lesion at C2
Lesion below the clavicle
Contralatetal vocal cord palsy / laryngectomt
Tracheostomy aroma
Contralateral occlusion (?)
Immobile neck
Tandem lesion
53
Q

How do you anchor exchange wire with carotid stenting

A

Use external carotid artery

54
Q

What does fluoro field include for carotid atenting

A

Arch and guide wire tip

Usually best in LAO

55
Q

High risk for CAS?

A 
Tortuous arch
Calcified arch
Diseased great vessels
Tortuous carotid artery
Pre occlusive lesion 
Heavy plaque burden
Circumferential calcification 
Echolucent plaque
56
Q

Which stents have more Neuro events for carotid stenting

A

Open cell. Plaque protrudes through the stent cells

57
Q

Where does vertebral artery enter transverse foramen

A

Variable but most commonly at C6

58
Q

How many patients have vertebral artery Origin at the Athens

A

6%

59
Q

What’s the most common size of vertebral arteries compared to each other

A

85% asymmetrical with left side dominant in ⅔ cases

60
Q

Vertebral artery branches

A

V1 - no branches
V2- radiculo-medullary
V3- posterior spinal artery, lateral recurrent artery
V4- anterior spinal artery and PICA

61
Q

What does lateral recurrent artery (of V3) anastomoses with

A

Ascending cervical and deep cervical artery

62
Q

Vertebral artery compression mechanism

A

Bone compression by osteophytes, c7 transverse process, posterior laminate C1
Muscular compression by longus Colli or longus capitis
Arterial kinks
Neural by sympathetic chain

63
Q

Surgical indications for proximal vertebral transposition

A

Ischemia from fixed stenosis / occlusion
Embolism from proximal plaque
Positional symptoms from compression
Subclsvian steal

64
Q

What do you have to divide in distal vertebra artery bypass to get to the target

A

Levantine scapulae

Anterior army’s if C2 nerve

65
Q

Management of trachea-innominate fistula

A

Bleeding control with balloon/covered stent
Immediately followed by left to right carotid to carotid bypass,
Median sternotomy
Ligation of the innominate artery
Muscle flap to close the tracheal defect

66
Q

In patients with carotid bulb lesion, intracranial ICA lesion and symptoms, what’s the tx algorithm

A

Just treat the bulb first.

Intracranial only if symptoms persist

67
Q

Maneuvers to get distal exposure of ICA

A 
Medial mobilization of the hypoglossal nerve
NT intubation
Division of posterior belly of digastric
Resection of styloid process
Anterior subluxation of the mandible
68
Q

What’s stump syndrome and how do you treat it

A

Chronically occluded ICA with “stump” of ICA being an origin of emboli. Best results are in mononuclear amaurosis fugax
Treatment - endarterectomy of CCA and ECA with transaction and ligation of ICA stump.

Resolution of symptoms 83%, 7% additional improvement
Overall neuro events 5%
Mortality periop 3% due to stroke mainly

69
Q

Radiation induced carotid disease

A

Unusual location

Extensive rather than focal

70
Q

Maneuver most likely to injury glossopharyngeal nerve

A

Transaction of posterior belly of digastric muscle

71
Q

How to manage traumatic carotid dissection

A

OR / endovascular if patient has worsening or fluctuating neuro symptoms
Anticosgulation if no contraidication
Antiplatelets if contraindication to anticoagulation

72
Q

Intracranial aneurysm algorithm

A

If coexists with carotid disease each part should be treated separately
Significant symptomatic carotid disease should be treated before aneurysm
Asymptomstic aneurysm found incidentally maybe treated before asymptomstic carotid disease if the aneurysm is 8mm or larger

73
Q

Complications associated with vertebral artery open repair

A 
Horners 8-28%
Chylothorax 5%
Immediate thrombosis 4%
Lymphocele 4%
Vague and recurrent laryngeal nerve palsy 2%
74
Q

Two independent predictors of poor outcome for asymptomstic carotid stenosis in dialysis patients

A

Age >70
Dialysis >2 years

History of renal transplant is protective

75
Q

When should you do a CEA after a TIA

A

3-14 days

76
Q

Pre op studies for carotid body tumor

A

24 hour urin collection for metanephrines and catecholamines

123 I-metaiodobenzylbuanidine scintigraphy or CT/MRI of chest and abdomen

77
Q

What’s carotid sinus

A

Innervated by the nerve of Hering (of glossopharyngeal)

Barorrceptors that produce bradycardia and hypotension when stimulated by increased pressure

Vascular Surgery by Emi (15 decks)

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