Vascular - Arterial Disease

Question 1

What is carotid artery disease?

Answer 1

Build up of atherosclerotic plaque in one of or both common and internal carotid arteries.

Question 2

What is the main risk of carotid artery disease?

Answer 2

Ischaemic stroke

Question 3

Recap - what is the process of atherosclerosis?

Answer 3

1. High LDL levels cause oxidisation of LDLs which are engulfed by monocytes in the arterial lining
2. Monocytes swell into foam cells and accumulate to form the fatty streak.
3. Fibrous cap formed over a lipid core.
4. Platelet aggregation and thrombus formation.

Question 4

What about the carotid artery predisposes it to atherosclerotic changes?

Answer 4

Turbulent flow at the bifurcation.

Question 5

List 8 risk factors for carotid artery disease:

Answer 5

Age >65 years 
Hypertension 
Hypercholesterolaemia 
Smoking 
Obesity 
Diabetes 
PMH of CVD 
FH of CVD

Question 6

What are the symptoms of carotid artery disease?

Answer 6

Asymptomatic until development of focal neurological deficit (TIA or stroke)

Question 7

Why can even severe unilateral carotid artery disease be asymptomatic?

Answer 7

Collateral blood supply from contralateral internal carotid and vertebral arteries via the circle of willis

Question 8

What initial investigations are performed if stroke is suspected?

Answer 8

Urgent non-contrast head CT
Bloods - FBC, U+Es, clotting, lipids, glucose
ECG - specifically assess for AF
Swallow screen assessment

Question 9

If stroke is confirmed, what investigations should be performed to assess the carotid arteries?

Answer 9

First - Duplex USS

CT angiography may then be done to better assess

Question 10

What is the time cut off for commencement of stroke thrombolysis?

Answer 10

4.5 hours from symptom onset and after haemorrhage ruled out

Question 11

What drug is used from thrombolysis?

Answer 11

IV alteplase

recombinant tissue plasminogen activator

Question 12

When should mechanical thrombectomy be considered in ischaemic strokes?

Answer 12

Where there is confirmed occlusion of the proximal anterior circulation on CT angiography.

Question 13

What long term management should a patient who has had a stroke be on?

Answer 13

Lifestyle - weight management, diet and exercise
Smoking cessation
Antiplatelet therapy - aspirin for 2 week then clopidogrel
Statin
Hypertension or DM management if applicable
SALT if dysphagia or dysphasia.

Question 14

What antiplatelet regime is typically used post-stroke?

Answer 14

2 weeks aspirin 300mg oral or rectal OD

Followed by long term e.g. 75mg clopidogrel oral OD

Question 15

What statin is typically used post-stroke?

Answer 15

high dose atorvastatin (20-80mg OD)

Question 16

What is a CEA?

Answer 16

Carotid Endarterectomy

Removal of atheroma in carotid artery via incision in artery wall

Question 17

What are the indications for CEA?

Answer 17

Patients who have had stroke or TIA with symptomatic 50-99% carotid stenosis

Question 18

Carotid artery disease which typically occurs in younger men with connective tissue disease and a history of trauma or sudden neck movement:

Answer 18

Carotid dissection

Question 19

Non-atheromatous carotid artery disease in young women, also commonly occurs in renal arteries:

Answer 19

Fibromuscular dysplasia

Question 20

What type of systemic conditions can also cause carotid stenosis?

Answer 20

Vasculitis (e.g. giant cell or takayasu’s arteritis)

Question 21

What is an aneurysm?

Answer 21

Dilatation of blood vessel > 50% normal diameter

Question 22

What is an AAA?

Answer 22

Abdominal aortic aneurysm - dilatation of abdominal aorta of >3cm

Question 23

Symptoms of AAA

Answer 23

Most asymptomatic and found incidentally

If symptomatic - abdo/back/loin pain

Question 24

Classical examination finding for AAA

Answer 24

Pulsatile abdominal mass

Question 25

Is there screening done for AAA?

Answer 25

Yes - men in the UK are offered a screening USS at 65 years

Question 26

Patient presents with hypotension, back pain, and pallor, what diagnosis are you most concerned with?

Answer 26

Ruptured AAA

Question 27

What investigations are used for suspected AAA?

Answer 27

First line - USS | If confirmed - CT with contrast when at 5.5cm to determine suitability for procedures

Question 28

What is the threshold for surgical intervention of a AAA?

Answer 28

Any 1 of: >5.5cm Expanding by >1cm per year Symptomatic

Question 29

How would a triple A < 5.5cm be managed

Answer 29

``` Monitor with USS Smoking cessation BP control Statin Aspirin Weight loss/exercise ```

Question 30

How often are monitoring USS performed on a AAA of 3.0-4.4cm?

Answer 30

Annually

Question 31

How often are monitoring USS performed on AAA of 4.5-5.5cm?

Answer 31

every 3 months

Question 32

What are the limitations to driving with a AAA?

Answer 32

Alert DVLA and suspended from driving when >6.5 until surgically repaired

Question 33

What are the surgical treatment options for AAA?

Answer 33

Open repair | Endovascular repair

Question 34

What is the main complication which may occur from endovascular repair of AAA?

Answer 34

Endovascular leaking - incomplete seal formed around the graft meaning blood can leak around it

Question 35

What is the management of ruptured AAA?

Answer 35

High flow O2 Wide bore IV access Urgent bloods and crossmatch minimum 6 units Treat shock carefully (BP <100) so as to not precipitate further bleeding Transfer to vascular unit for surgical repair - unstable -> open, stable -> CT to assess best option

Question 36

What are the layers of the arterial wall?

Answer 36

Tunica intima Tunia media Tunica adventitia

Question 37

What is an aortic dissection?

Answer 37

Tear in the intima causing bleeding between the tunica intima and media

Question 38

What is anterograde vs retrograde aortic dissections?

Answer 38

Anterograde - tear from origin point towards iliac arteries Retrograde - tear from origin point towards aortic valve

Question 39

What are the main risk factors for younger patients and aortic dissection?

Answer 39

Connective tissue disorders (Marfan's, Ehlers Danlos) | Male sex

Question 40

What are the risk factors for older patients with aortic dissection?

Answer 40

Atherosclerosis Hypertension Male sex

Question 41

Classical symptom of aortic dissection

Answer 41

Tearing chest pain radiating to the back

Question 42

Tachycardia, hypotension, and new onset cardiac murmur are signs of...

Answer 42

Aortic dissection

Question 43

What cardiac murmur is typically associated with aortic dissection?

Answer 43

Aortic regurgitation

Question 44

What imaging modality is preferred in aortic dissection?

Answer 44

CT angiogram

Question 45

What is the surgical management option for aortic dissection?

Answer 45

Removal of ascending aorta and replacement with synthetic graft, reinsertion of all branches into the graft

Question 46

What is the medical management option for aortic dissection?

Answer 46

Management blood pressure with IV labetalol (2nd line CCB)

Question 47

Which anatomical region of the aorta is associated with pain in the anterior chest in thoracic aortic aneurysm?

Answer 47

Ascending aorta

Question 48

Which anatomical region of the aorta is associated with pain in the neck in thoracic aortic aneuryms?

Answer 48

Arch of the aorta

Question 49

Which anatomical region of the aorta is associated with pain between the scapula in thoracic aortic aneurysm?

Answer 49

Descending aorta

Question 50

What imaging modality is preferred in thoracic aortic aneurysm?

Answer 50

CT with contrast