Aortic aneurysms and Carotid Artery Disease

Question 1

What is an aortic aneurysm?

Answer 1

Dilatation of all layers of the aorta, leading to an increase in diameter of > 50% (AA > 3cm)

Question 2

What causes an aneurysm?

Answer 2

Degenerative disease (atheroma)
Connective tissue disease (i.e. Marfan)
Infection (mycotic aneurysm)

Question 3

What are risk factors for AAA disease?

Answer 3

Male 
Age 
Smoking 
Hypertension 
FH

Question 4

What are the symptoms of impending AAA?

Answer 4

Asymptomatic
Increasing back pain
Tender AAA

Question 5

What are AAA screening?

Answer 5

Detects dangerous swelling of the aorta (ultrasound scan of men > 65)

Question 6

What is a false aneurysm?

Answer 6

Dilatation of the T adventitia of an artery and not all layers like an aneurysm

Question 7

What is the outcome if screening for AAA shows aorta is 3-4.4 cm (small aneurysm)?

Answer 7

Annual USS scans

Question 8

What is the outcome if screening for AAA shows aorta is 4.5-5.5 cm (medium aneurysm)?

Answer 8

3 monthly USS scans

Question 9

What is the outcome if screening for AAA shows aorta is >5.5 cm (large aneurysm)?

Answer 9

Treatment offered

Question 10

What are the symptoms of a ruptured AAA?

Answer 10

Abdo/back/flank pain
Painful pulsatile mass
Haemodynamic instability (abnormal blood flow)
Hypoperfusion (shock)

Question 11

What less common presentations of a ruptured AAA?

Answer 11

Distal embolisation
Aortocaval fistula 
Aortaenteric fistula 
Ureteric occlusion 
Duodenal obstruction

Question 12

What is an aortocaval fistula?

Answer 12

Abnormal connection between aorta and IVC, caused by AAA

Question 13

What is an aortoenteric fistula?

Answer 13

A connection between the aorta and oesophagus, intestines or stomach, can be caused by AAA

Question 14

What are 3 things to consider for an asymptomatic AAA?

Answer 14

Is aneurysm a size to consider repair?
Is the patient a candidate for repair?
Is aneurysm suitable for endovascular or open repair?

Question 15

What are the tests carried out to determine patient fitness for AAA repair?

Answer 15

Full history and exam 
Bloods: FBC, U+Es
ECG 
Echo
PFT
Myocardial perfusion scan 
Cardio-pulmonary exercise test

Question 16

What are the pros and cons of using USS for assessing AAA?

Answer 16

No radiation 
No contrast 
Cheap 
BUT 
Operator dependent 
Inadequate for surgical planning

Question 17

What are the pros and cons of using CTA/MRA for assessing AAA?

Answer 17

Quick 
not operator dependent 
Necessary for surgical planning - detailed anatomy 
BUT 
Uses contrast and radiation

Question 18

When is conservative treatment of AAAs used?

Answer 18

Patient or aneurysm not fit for repair

Consider event of rupture

Question 19

What are the 2 surgical procedure for AAA repair?

Answer 19

Endovascular repair

Open repair

Question 20

What are the general complications of open repair of AAA?

Answer 20

Wound infection
Bleeding
Pain
Scar

Question 21

What are the technical complications of open repair of AAA?

Answer 21

Damage to bowel, ureters, veins, nerves 
Incisional hernia 
Graft infection 
Distal emboli 
Renal failure 
Colonic ischaemia

Question 22

What are the patient factors for complications of open and endovascular repair of AAA?

Answer 22

DVT/PE
MI
Stroke
Death

Question 23

What are the general complications of endovascular repair of AAA?

Answer 23

Same of open repair, as well as:
Contrast causes kidney injury
Radiation

Question 24

What are the technical complications of endovascular repair of AAAs?

Answer 24

Endoleak 
Femoral artery dissection/pseudoaneurysm 
Rupture 
Distal emboli/ischaemia 
Damage to femoral vessels

Question 25

What is the management for symptomatic AAA?

Answer 25

ABCDE History Examination CTA

Question 26

What is ABCDE management?

Answer 26

``` Airway obstruction Breathing Circulation Disability Exposure ```

Question 27

What is a TIA?

Answer 27

Focal CNS disturbance by vascular events such as micro emboli and occlusion, leading to cerebral ischaemia - lasts less then 24hrs

Question 28

What is a stroke?

Answer 28

Rapidly developing signs of disturbance of cerebral function, lasting more than 24hrs or leading to death, with no other causes than vascular origin

Question 29

What are causes of a stroke (/TIA)?

Answer 29

``` AF Carotid atheroma rupture/thrombus Endocarditis MI Carotis artery trauma/dissection IVDA Haematological disorder (i.e. sick cell disease) ```

Question 30

How is diagnosis made for stroke (/TIA)?

Answer 30

History Examination: Neuro, cardiac, auscultate carotids CT Carotid USS

Question 31

What happens to the velocity of flow in a vessel as radius decreases (Poiseullie's Law)?

Answer 31

As radius of a vessel decreases (i.e. stenosis), velocity increases

Question 32

What is the best medical therapy for stroke?

Answer 32

``` Smoking cessation Control of HPT Antiplatelet Statin (lower cholesterol) Diabetic control ```

Question 33

What is a carotid doppler test?

Answer 33

Test that uses high-frequency sound waves to measure the amount of blood flow through your arteries and veins

Question 34

How is a TIA confirmed?

Answer 34

Left sided symptoms | Carotid doppler: right internal artery occluded

Question 35

What are surgical methods that can be used to prevent a stroke?

Answer 35

Carotid endarecomy to remove plaque | Stenting

Question 36

What are the possible complications of a carotid endarectomy?

Answer 36

``` Wound infection Bleeding Scar Anaesthetic risk Nerve damage Perioperative stroke (plaque rupture or hypo perfusion) ```

Question 37

When is surgery considered as prophylaxis for stroke?

Answer 37

Men with 50-69% stenosis | Asymptomatic stenosis > 70%