Aneurysms & Carotid Artery Surgery - Presentation, Investigation & Therapy Flashcards Preview

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Flashcards in Aneurysms & Carotid Artery Surgery - Presentation, Investigation & Therapy Deck (91):
1

What is aneurysm disease?

Dilation of all layers of the aorta leading to an increase in diameter of >50% (abdominal aorta > 3.5cm)

2

What is dilation of all layers of the aorta leading to an increase in diameter of >50% (abdominal aorta > 3.5cm) called?

Aneurysm

3

What is the aetiology of aneurysm disease?

Degenerative disease

Connective tissue disease (such as Marfan's disease)

Infection (such as mycotic aneurism)

4

What are some risk factors for degenerative abdominal aortic aneurism?

Male sex

Age

Smoking

Hypertension

Family history

5

What is the prevalence of abdominal aneurysm in the UK?

3%

6

What can be said about abdominal aneurysm always presenting with symptoms?

It often does not have any presentations and so is asymptomatic

7

What is used to detect dangerous swelling of the aorta?

Abdominal aortic aneurysm screening

8

When are men invited to abdominal aortic aneurysm screening?

When they turn 65

9

What is the criteria for screening to be used in general?

Definable disease

Prevalance

Severity of disease

Natural history

Reliable detection

Early detection confers advantage

Treatment options are available

Cost

Feasibility

Acceptability

10

What are the potential outcomes for screening?

Normal aorta (discharged)

Small abdominal aortic aneurysm, 3-4.4cm (invited for annual ultrasound)

Medium abdominal aortic aneurysm,4.5-5.5cm (incited for 3 monthly ultrasound scan)

Large abdominal aortic aneurysm, >5.5cm

11

What is classified as a small abdominal aortic aneurysm?

3-4.4cm

12

How often do people with a small abdominal aortic aneurysm getting an ultrasound?

Once a year

13

What is classified as a medium abdominal aortic aneurysm?

4.5-5.5cm

14

How often do people with a medium abdominal aortic aneurysm get an ultrasound?

Once every 3 months

15

What is classified as a large abdominal aortic aneurysm?

More than 5.5cm

16

What is the presentation of abdominal aortic aneurysm when it is impending rupture?

Increasing backpain

Tender abdominal aorta

17

What is the presentation of abdominal aortic aneurysm once it has ruptured?

Abdominal/back/flank pain

Painful pulsatile mass

Haemodynamic instability

Hypoperfusion

18

What are some unusual presentations of abdominal aortic aneurysm?

Distal embolism

Aortocaval fistula

Aortoenteric fistula

Ureteric occlusion

Duodenal obstruction

19

What are questions to ask when deciding how to manage an asymptomatic patient?

Is the aneurysm a size to consider repair?

Is the patient a candidate for repair?

Is the aneurysm suitble for endovascular or open repair?

20

How does the risk of rupture change with aneurysm size?

It increases

21

What is patient fitness determined by?

Full history and examination

Bloods

ECG

ECHO

Pulmonary function tests (PFT)

Myocardial perfusion scan (MPS)

Cardiopulmonary exercise testing

End of the bad test

Patient preferance

22

What does ECHO stand for?

Echocardiogram

23

What is an echocardiogram (ECHO)?

Ultrasound used to make pctures of heart valves and chambers

24

What is an ultrasound used to make pctures of heart valves and chambers called?

Echocardiogram

25

What does PFTs stand for?

Pulmonary function tests

26

What are pulmonary function tests?

Non-invasive tests that show how well the lungs are working

27

What are non-invasive tests that show how well the lungs are working called?

Pulmonary function tests

28

What does MPS stand for?

Myocardial perfusion scan

29

What is a myocardial perfusion scan?

Uses radioactive substance to show blood flow to the heart

30

What uses radioactive substance to show blood flow to the heart?

Myocardial perfusion test

31

What does CPEX stand for?

Cardiopulmonary exercise testing

32

What is cardiopulmonary exercise testing?

Tests the function of the heart and lungs as a combined unit

33

What tests the function of the heart and lungs as a combined unit?

Cardiopulmonary exercise testing

34

What is used to determine if the aneurysm is suitible for endovascular or open repair?

Ultrasound

CT/MRI

35

What are the advantages of ultrasound?

No radiation

No contrast

Cheap

36

What are the disadvantages of ultrasound?

Operator dependent

Inadequate for surgical planning

37

What are the advantages of CT/MRI?

Quick

Not operator dependent

Necessary for surgical planning (shows detailed anatomy)

38

What are the disadvantages of CT/MRI?

Contrast

Radiation

39

What are the treatment options of abdominal aortic aneurysm?

Conservative

Endovascular repair

Open repair

40

What is endovascular repair?

Using a small graft guided by an X-ray

41

42

What is open repair?

Large incision and then graft inserted

43

What are some potential consequences of open repair?

Wound infection

Bleeding

Pain

Scar

Damage to veins or nerves

44

What are some potential consequences of endovascular repair?

Wound infection

Bleeding

Pain

Scar

Contrast

Radiation

Endoleak

45

What is endoleak?

Persistant blood flow outside of the lumen of an endoluminal graft but within the aneurysm sac, caused by an incomplete seal of the aneurysm sac

46

Compare open vs vascular repair?

3 fold reduction in operative mortality for endovascular vs open

Improved quality of life initially with endovascular

Quality of life improvements lost with increase reintervention and surveillance for endovascular repair

No difference in overall mortality

47

What is the process of managing someone who is symptomatic?

ABCDE (first aid)

History, check records

Examination

Maybe coronary CT angiography

48

What does CTA stand up for?

CT angiography

49

What is a CT angiography?

CT along with intravenous contrast to obtain 3D pictures of the moving heart and great vessels

50

What can occur after a CTA in an emergency?

Emergency open repair or emergency endovascular repair

51

What should be remembered about exposure to abdominal aortic aneurysm patients?

It will be as an incidental finding through screening or sympomatic

52

What is the treatment as the aneurysm gets bigger?

Always curveillance until the abdominal aorta reaches 5.5 cm, then assess the patient for surgery and decide if open repair or endovascular repair

53

What is carotid disease?

Plaque builds up in the carotid arteries

54

What is atherosclerosis of the carotid arteries associated with?

Transient ischaemic attacks and ischaemic stroke

55

Who are the symptoms of stroke managed by?

Stroke teams

56

Who is involved with the management of carotid disease other than stroke teams?

Vascular surgeons to prevent further events

57

What does TIA stand for?

Transient ischaemic attacks

58

What is a transient ischaemic attack?

Focal CNS disturbance caused by vascular events such as microemboli and occlusion, leading to cerebral ischaemia, symptoms are less than 24 hours and there is no permanent neurological damage

59

What is focal CNS disturbance caused by vascular events such as microemboli and occlusion, leading to cerebral ischaemia, symptoms are less than 24 hours and there is no permanent neurological damage called?

Transient ischaemic attack

60

61

What is a stroke?

Clinical syndrome consisting of rapidly developing clinical signs of focal or global disturbance of cerebral function, symptoms lasting more than 24 hours or leading to death, with no apparent origin other than vascular

62

What is clinical syndrome consisting of rapidly developing clinical signs of focal or global disturbance of cerebral function, symptoms lasting more than 24 hours or leading to death, with no apparent origin other than vascular called?

Stroke

63

64

What are possible causes of stroke?

Cerebral infarction (84%)

Primary intracerebral haemorrhage (10%)

Subarachnoid haemorrhage (6%)

65

What can cause cerebral infarction?

Atrial fibrillation

Carotid atherosclerotic plaque rupture/thrombosis

Endocarditis

Myocardial infarction

Carotid artery trauma/dissection

Drug abuse

Haemotological disorder

66

What are some risk factors for carotid artery atherosclerosis?

Smoking

Diabetes

Family history

Male sex

Previous deep vein thrombosis

Hypertension

Hyperlipidaemia/hypercholesterolaemia

Obesity

Age

67

Are females or males more susceptible to carotid artery atherosclerosis?

Males

68

What does the diagnosis of carotid plaque involve?

History

Examination:

neurological
cardiac
auscultate carotids

Investigations

CT
carotid ultrasound scan

69

What investigations are used to diagnose carotid plaque?

CT

Carotid ultrasound scan

70

How does the velocity of blood change as the radius of a vessel changes?

As the radius decreases the velocity increases

71

What is the velocity of blood through the carotid at <50% stenosis?

<125cm/s

72

What is the velocity of blood at 50-69% stenosis?

>125 cm/s

73

What is the velocity of blood as 70-79% stenosis?

>270cm/s

74

What is the end diastolic velocity of blood at 80-99% stenosis?

End diastolic velocity

75

What does the mangement of carotid plaques involve?

Medical therapy

Carotid doppler

76

What does the medical therapy for carotid plaque involve?

Smoking cessation

Control of hypertension

Antiplatelet

Statin

Diabetic control

77

What is carotid doppler?

Imaging test that uses ultrasound to examine the carotid arteries

78

How is the brain still perfused even if the carotid arteries are blocked?

Circle of Willis

79

When the carotid arteries are blocked, what is the further risk of stroke?

Emboli being showered from high velocity causing distal ischaemia

80

What is performed if the occlusion of the carotid artery is severe enough?

Carotid endarterectomy

81

What is an endarterectomy?

Surgical procedure to removed the atheromatous plaque material, or blockage in the lining of an artery

82

What is a surgical procedure to removed the atheromatous plaque material, or blockage in the lining of an artery?

Endarterectomy

83

What are some potential complications of endarterectomy?

General (wound infection, bleeding, scar, anaesthetic risks)

Nerve damage

Perioperative stroke

84

What is a treatment option for carotid plaques other than endarterectomy?

Stenting

85

What is stenting?

Insertion of a small mesh tube to treat weak arteries and restored blood flow through a narrow or blocked artery

86

What is insertion of a small mesh tube to treat weak arteries and restored blood flow through a narrow or blocked artery called?

Stenting

87

What is NNT?

Number of patietns needed to treat to prevent 1 additional bad outcome

88

How does the NNT for stenting change with time?

Increases exponentially (is 5 for within 2 weeks but 125 for longer than 12 weeks)

89

What does CEA stand for?

Carotid andarterectomy

90

What is the management for asymptomatic patients with carotid plaque?

CEA should be considered when high grade stenosis

CEA may be of more benefit for males patients <70 years

CEA should only be performed by operators with a low (<3%) perioperative stroke or death rate

91

When should carotid surgery be offered to all symptomatic patients?

When stenosis is >70%

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