Vascular SAQs 4

Question 1

Someone is fainting and you find he has a bruit in his neck.

a) Diagnosis?

Answer 1

Carotid Artery Stenosis + TIA/Stroke*

*Potentially could be Syncope (cerebral hypoperfusion)

Question 2

Someone is fainting and you find he has a bruit in his neck.

a) What investigations?

Answer 2

CT Head: Rule out Haemorrhagic stroke
ECG: AF?
Echo: Thrombus?
Duplex USS of Carotid: assess narrowing or CT/MRI Angiogram

Question 3

Someone is fainting and you find he has a bruit in his neck.

a) Management?

Answer 3

If TIA:
Clopidogrel or Aspirin + Dipyridamole

If Stroke:
Thrombolysis if <4.5 hours

Medical:
Antiplatelet: Clopidogrel/ Aspirin
Address other cardiovascular RFs

*Medical therapy for Carotid Stenosis: Antiplatelet + address cardiac RFs

Question 4

Someone is fainting and you find he has a bruit in his neck.

a) Surgical intervention? Indications?

Answer 4

Symptomatic patients, with ipsilateral stenosis >70%: Carotid Endarterectomy

Question 5

Abdominal Aortic Aneurysm: Patient with pulsatile swelling

a) What 6 managements?

Answer 5

Regular USS abdomen monitoring: Assess Size
Address risk factors: Stop Smoking, Rigorous Blood Pressure Control
Doxycycline, ACEi, Statin, Aspirin: Some evidence for reducing expansion rate
CT Abdomen: Assess Size and visceral arterial involvement
When >5.5cm consider for elective surgical repair (open/EVAR)
Assess Performance Status: ECG, CXR, Spirometry
Cross Match if surgery planned

Question 6

Abdominal Aortic Aneurysm: Patient with pulsatile swelling

a) What investigations would you do? And what is the findings on each?

Answer 6

USS Abdomen: Focal Dilation of the Aorta - Diameter >3cm
CT abdomen: Foacl Dilation of the Aorta - Diameter >3cm + involvement of visceral arteries. Signs of impending rupture: crescent sign, draped aorta sign, retroperitoneal haematoma (Rupture)

Question 7

Abdominal Aortic Aneurysm: Patient with pulsatile swelling

  c) Becomes more drowsy and confused. What is the diagnosis?

Answer 7

Ruptured Aortic Aneurysm

Question 8

Abdominal Aortic Aneurysm: Patient with pulsatile swelling

a) How would you treat?

Answer 8

ABC
Call for Vascular Surgeon + Anaesthetist
IV Access
FBC (Hb), Cross Match
Keep diastolic BP <100
Take patient to theatre
Prophylactic Anitbiotics: Cefuroxime + Metronidazole
Surgical clamping of the aorta above leak + graft insertion

Question 9

Abdominal Aortic Aneurysm: Patient with pulsatile swelling

  e) If shadow found on CXR, would you give him the same treatment?

Answer 9

Elective surgical repair would not be justified.

Treatment for rupture is as normal.