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General Surgery > Vascular - Arterial Disease > Flashcards

Vascular - Arterial Disease Flashcards

1
Q

What is carotid artery disease?

A

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

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2
Q

What is the main risk of carotid artery disease?

A

Ischaemic stroke

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3
Q

Recap - what is the process of atherosclerosis?

A
  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.
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4
Q

What about the carotid artery predisposes it to atherosclerotic changes?

A

Turbulent flow at the bifurcation.

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5
Q

List 8 risk factors for carotid artery disease:

A 
Age >65 years 
Hypertension 
Hypercholesterolaemia 
Smoking 
Obesity 
Diabetes 
PMH of CVD 
FH of CVD
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6
Q

What are the symptoms of carotid artery disease?

A

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

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7
Q

Why can even severe unilateral carotid artery disease be asymptomatic?

A

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

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8
Q

What initial investigations are performed if stroke is suspected?

A

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

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9
Q

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

A

First - Duplex USS

CT angiography may then be done to better assess

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10
Q

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

A

4.5 hours from symptom onset and after haemorrhage ruled out

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11
Q

What drug is used from thrombolysis?

A

IV alteplase

recombinant tissue plasminogen activator

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12
Q

When should mechanical thrombectomy be considered in ischaemic strokes?

A

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

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13
Q

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

A

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.

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14
Q

What antiplatelet regime is typically used post-stroke?

A

2 weeks aspirin 300mg oral or rectal OD

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

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15
Q

What statin is typically used post-stroke?

A

high dose atorvastatin (20-80mg OD)

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16
Q

What is a CEA?

A

Carotid Endarterectomy

Removal of atheroma in carotid artery via incision in artery wall

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17
Q

What are the indications for CEA?

A

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

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18
Q

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

A

Carotid dissection

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19
Q

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

A

Fibromuscular dysplasia

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20
Q

What type of systemic conditions can also cause carotid stenosis?

A

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

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21
Q

What is an aneurysm?

A

Dilatation of blood vessel > 50% normal diameter

22
Q

What is an AAA?

A

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

23
Q

Symptoms of AAA

A

Most asymptomatic and found incidentally

If symptomatic - abdo/back/loin pain

24
Q

Classical examination finding for AAA

A

Pulsatile abdominal mass

25
Q

Is there screening done for AAA?

A

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

26
Q

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

A

Ruptured AAA

27
Q

What investigations are used for suspected AAA?

A

First line - USS

If confirmed - CT with contrast when at 5.5cm to determine suitability for procedures

28
Q

What is the threshold for surgical intervention of a AAA?

A

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

29
Q

How would a triple A < 5.5cm be managed

A 
Monitor with USS 
Smoking cessation 
BP control 
Statin 
Aspirin 
Weight loss/exercise
30
Q

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

A

Annually

31
Q

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

A

every 3 months

32
Q

What are the limitations to driving with a AAA?

A

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

33
Q

What are the surgical treatment options for AAA?

A

Open repair

Endovascular repair

34
Q

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

A

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

35
Q

What is the management of ruptured AAA?

A

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

36
Q

What are the layers of the arterial wall?

A

Tunica intima
Tunia media
Tunica adventitia

37
Q

What is an aortic dissection?

A

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

38
Q

What is anterograde vs retrograde aortic dissections?

A

Anterograde - tear from origin point towards iliac arteries

Retrograde - tear from origin point towards aortic valve

39
Q

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

A

Connective tissue disorders (Marfan’s, Ehlers Danlos)

Male sex

40
Q

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

A

Atherosclerosis
Hypertension
Male sex

41
Q

Classical symptom of aortic dissection

A

Tearing chest pain radiating to the back

42
Q

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

A

Aortic dissection

43
Q

What cardiac murmur is typically associated with aortic dissection?

A

Aortic regurgitation

44
Q

What imaging modality is preferred in aortic dissection?

A

CT angiogram

45
Q

What is the surgical management option for aortic dissection?

A

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

46
Q

What is the medical management option for aortic dissection?

A

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

47
Q

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

A

Ascending aorta

48
Q

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

A

Arch of the aorta

49
Q

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

A

Descending aorta

50
Q

What imaging modality is preferred in thoracic aortic aneurysm?

A

CT with contrast

General Surgery (3 decks)

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