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Arterial Diseases Flashcards

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1
Q

What is carotid artery disease?

A

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

Usually asymptomatic but responsible for 10-15% of ischaemic strokes

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2
Q

What is the radiological classification of carotid artery disease?

A

Mild - <50%
Moderate 50-69%
Severe - 70-99%
Total occlusion

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3
Q

How may Carotid artery disease present?

A

Focal neurological deficit:
TIA - including amaurosis fugax
Stroke

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4
Q

List some differential diagnosis for carotid artery disease?

A
  • Carotid dissection - often younger then 50 with underlying connective tissue disorder, potentially precipitated by trauma or sudden neck movement
  • Thrombotic Occlusion of Carotid artery
  • Fibromuscular dysplasia
  • Vasculitis

-hypoglycaemia, subdural haematoma

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5
Q

What initial investigation is ordered for a stroke?

A

Urgent non-contrast CT head

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6
Q

What other investigations would you do for a pt with stroke?

A

Bloods - FBC, U&Es, Clotting, lipid profile and glucose
ECG - AF

CT head contrast angiography for thrombectomy

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7
Q

How can carotid arteries be screened for after stroke or TIA?

A

Duplex ultrasound scans

CT angiography

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8
Q

What is the acute management of suspected stroke?

A

High flow oxygen
Blood glucose optimised
Swallowing screen assessment

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9
Q

Initial management of ischeamic stroke?

A

IV alteplase, if pt admitted 4.5 hrs of symptom onset and meet inclusion criteria and 300mg aspirin

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10
Q

Initial management of haemorrhaging stroke?

A

Correct an coagulopathy and referral to neurosurgery

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11
Q

What is the long term management with known stroke or TIA?

A

Anti-platelet - 300mg aspirin for 2 weeks OD and then clopidogrel 75mg OD
Statin - high dose
Aggressive management of hypertension and DM
Lifestyle

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12
Q

Who should be consider for a carotid endarterectomy (CEA)?

A

Pt with non-disabling stroke/TIA who have symptomatic carotid stenosis between 50-99%

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13
Q

Complications of stroke?

A 
Dysphagia 
Seizures 
Ongoing spasticity 
Bladder/bowel incontinenece 
Depression/anxiety 
Cognitive decline
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14
Q

Definition of AAA?

A

Dilation of abdominal aorta greater then 3 cm

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15
Q

What are the risk factors of AAA?

A

Smoking, hypertension, hyperlipideamia, family history and male gender + increasing age

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16
Q

How do AAA present?

A

Most are asymptomatic and usually incidental finding

But symptomatic present with:

Abdominal pain
Back/loin pain
Distal embolisation

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17
Q

At what age are men invited to national AAA screening (NAAASP)?

A

65

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18
Q

What is the main differential diagnosis for AAA?

A

Renal colic

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19
Q

What investigations are appropriate for AAA?

A

Initial ultrasound scan

Then follow-up CT scan with contrast warranted if threshold of 5.5cm

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20
Q

What is the management of AAA less then 5.5 cm?

A
  1. 0-4.4cm - yearly ultrasound
  2. 5-5.4cm - 3 monthly ultrasound

Optimise CVD risk factors - including statin and aspirin therapy

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21
Q

When is surgery consider in AAA?

A

AAA >5.5cm
AAA expanding at >1cm/yr
Symptomatic AAA in person who is otherwise fit

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22
Q

What are the two types of surgery for AAA?

A

Open repair

Endovascular repair (EVAR)

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23
Q

What is a complication of EVAR?

A

Endoleaks

Often asymptomatic and need monitoring via ultrasound

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24
Q

What is the major complication of AAA?

A

Rupture

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25
What are less common complications of AAA?
Retroperitoneal leak Embolisation Aortoduodenal fistula
26
What is the management of rupture AAA?
High flow O2, IV access and urgent bloods(FBC, U&Es, clotting) with cross match Shock should be treated carefully as raising BP may dislodge any clot and make bleeding worse so aim for BP <=100mmHg If pt unstable immediate open surgical repair If stable they require CT angiogram to determine whether aneurysm sutible for endovasular repair.
27
Between which two layers does an aortic dissection occur?
Tunic intima and tunica media
28
How is acute and chronic aortic dissection distinguished?
Acute <=14 days | Chronic >14 days
29
Who is more likely to get an aortic dissection?
Men People with connective tissue disorders Age 50-70
30
What are the two types of dissections in aortic dissections?
Anterograde | Retrograde - can cause bleeding into aortic valve and cardiac tamponade
31
What are the clinical features of aortic dissection?
Tearing chest pain radiating to the back - may be subtle Most common signs - tachycardia, hypotension, new aortic regurgitation murmur or signs of end-organ hypo perfusion.
32
What are the differential diagnosis for aortic dissection?
MI PE Pericarditis MSK pain
33
Which two systems classify aortic dissections anatomically?
DeBakey | Stanford
34
What are the risk factors for aortic dissection?
``` Hypertension Atherosclerotic disease Male gender Connective tissue disorder Biscuspid aortic valve ```
35
What investigations should be performed for suspected aortic dissection?
``` Baseline bloods (FBC, U&Es, LFTs, troponin, coagulation) with cross match of a least 4 units ABG, ECG ``` CT angiogram to diagnose, could also use trans oesophageal ECHO
36
What is the management for aortic dissections?
A-E assessment - O2, IV access, fluid resuscitation(caution) Type A Stanford - surgically - worse prognosis if untreated Type B - Medically Life-long antihypertensives, surveillance imaging
37
What does surgery involve for type A Stanford aortic dissections?
Removal of ascending aorta and replacement with synthetic graft. May require aortic valve repair and re-implantation of add it all branches of aorta.
38
When does a type B stanford aortic dissection require surgical intervention?
Rupture Renal,visceral or limb ischemia Uncontrolled hypertension
39
What is the most common complication of a chronic type B Stanford aortic dissection?
Aneurysm
40
Name some complications of aortic dissections?
``` Aortic rupture Aortic regurgitation MI Cardiac tamponade Stroke or paraplegia ```
41
In which pts can using an ABPI be problematic?
Pts with oedema, ulcers/fibrosis/scaring, calcium in wall of arteries Leads to false reading
42
If ABPI is not reliable then what can be done instead?
Lift pts leg and measure height at which sound on Doppler disappears and convert to mmHg - this is called pole test
43
What does the buerger test look for examination?
Critical ischaemia
44
What is the normal ABPI?
0.8-1.1
45
What is intermittent claudication?
Pain on walking, comes on quicker when walking fast and worse when walking uphill Pain relieved on rest/standing still
46
What is rest pain?
Severe pain when going to bed often in the foot and have to get out of bed and walk around. This is sign of critical ischaemia
47
What is the difference between pain felt on spinal stenosis and intermittent claudication?
Pain not relieved by standing alone in spinal stenosis but my be relived by rest Leaning forward may help in spinal stenosis Spinal stenosis affects both legs usually
48
What are the levels of intermittent claudication?
Mild : walking distance >300m, single stenosis Moderate : walking stenosis 100-200m, severe stenosis/occlusion Severe : walking distance 50-100m, occlusion Rest pain : block at two levels - Occlusion + severe stenosis/occlusion
49
What are the different scenarios for PVD?
Infrarenal aorta - younger pts, slight weakness in legs when walking Iliac disease - common iliac - buttock pain, external iliac - thigh pain Femoropopliteal disease - calf pain Run-off disease - changes in foot - usually seen in diabetes and hard to treat
50
How does diabetic foot disease present?
Neuropathic pain - shooting/burning pain in feet Toenail infection - acute paronychia Interdigital infection - begins and fungal and develops to bacteria Pressure ulcer - MT head, Dorsal PIP joint, tips of toes - rubbing on shoes due to subluxation Charcot mid foot deformity ulcer - losses sensation, planter arch can collapse Heel linear fissure ulcer - dry skin due to autonomic neuropathy Wet gangrene/deep planter space infection
51
What are some components of diabetic foot disease?
Reduced immune function Sensory/autonomic/motor neuropathy Peripheral vascular disease - accelerated atherosclerotic, calcium deposits Endothelial dysfunction
52
What is the treatment for diabetic foot disease?
``` Optimise glycemic control - BM<10 Drain pus & debride necrotic tissue Appropriate antibiotics Stop smoking Cardio protective medications Offload pressure areas Debride osteomyelitis bone Revascularistion - critical ischaemia Podiatry follow up ```
53
What is acute limb ischaemia?
Sudden decrease in limb perfusion the threatens the viability of the limb
54
What are the three main aetiologies of acute limb ischaemia?
Embolisation - most common, source may be AF, post-MI, mural-thrombus, AAA or prosthetic valve. Thrombus in situ - plaque ruptures Trauma - compartment syndrome
55
What are the 6Ps of acute limb ischaemia?
``` Pain Pallor Pulselessness Parasthesia Perishingly cold Paralysis ```
56
What is a sensitive sign for embolitic occlusion in acute limb ischaemia?
Normal, pulsatile contralateral limb
57
What is the clinical categories for acute limb ischaemia?
Rutherford classification: I-viable IIA-marginally threatened IIB-immediately threatened III-irreversible
58
What are the differential diagnosis for acute limb ischaemia?
Critical chronic limb ischaemia Acute DVT Spinal cord or peripheral nerve compression
59
What investigations would you do in acute limb ischaemia?
Routine bloods - groups and save, thrombophila screen (if <50yrs without known risk factors) ECG Doppler ultrasound CT angiography - GOLD STANDARD CT ateriogram - if limb consider salvageable
60
What is the time when irreversible limb damage starts to occur in acute limb ischaemia?
6 hours
61
What is the initial management of someone with acute limb ischaemia?
High flow 02 | IV access - therapeutic dose heparin or bolus dose then heparin infusion
62
What is the conservative management for acute limb ischaemia?
Consider in Rutherford 1 and 2a | Prolonged course of heparin + regular assessment to determine effectiveness through APPT and clinical review
63
What are the surgical options for acute limb ischaemia cause by embolisation?
Embolectomy Local intra -arterial thrombolysis Bypass surgery
64
What are the surgical options for acute limb ischaemia if cause is thrombotic disease?
Local intra-arterial thrombolysis Angioplasty Bypass surgery
65
What options are available for irreversible acute limb ischaemia?
Urgent amputation | Palliative approach
66
What is some with acute limb ischaemia at risk of after surgery?
Ischemia reperfusion syndrome
67
What is the long term management for acute limb ischemia after treatment?
Reduce CVD risk factors Treat underlying cause for limb ischemia E.g AF Anti-platelet agent If amputation has occurred- OT, Physio + long term rehabilitation plan
68
What is involved in reperfusion injury after an acute limb ischaemia?
``` Compartment syndrome Damaged muscle cells release: K+ ions H+ ions Myoglobin - AKI ```
69
What is an early symptom of chronic limb ischaemia?
Intermittent claudication and walking a fixed distance (claudication distance)
70
What is the Fontaine classification of chronic leg ischaemia?
Stage I - asymptomatic Stage II - intermittent claudication Stage III - ischaemic rest pain Stage IV - ulceration or gangrene or both
71
What is leriche syndrome?
Peripheral arterial disease affecting the aortic bifurcation- specifically presents with buttock/thigh pain and associated erectile dysfunction.
72
How is critical limb ischaemia defined?
Ischaemia rest pain greater then 2 weeks Presence of ischaemic lesions or gangrene ABPI <0.5
73
What are the differential diagnosis for a patient with chronic limb ischaemia?
Spinal stenosis | Acute limb ischaemia
74
What are the investigations for chronic limb ischaemia?
``` ABPI - quantify severity Doppler ultrasound CT angiography or MR angiography Cardiovascular risk assessment If under 50 do thrombophila screen ```
75
What is the medical management for chronic limb ischaemia?
``` Lifestyle advice Statin therapy Anti-platelet therapy Optimise diabetes control Supervised exercise programme ```
76
When can surgical intervention be offer in chronic limb ischaemia?
When risk factor modification has been discussed Supervised exercise has failed to improve symptoms Any pt with critical limb ischaemia
77
What are the surgical options for chronic limb ischaemia?
Angioplasty Bypass grafting Combination of two Amputation for severe cases
78
What are complications of chronic limb ischaemia?
Sepsis - infected gangrene Acute-on-chronic ischaemia Amputation Reduced mobility and quality of like
79
What is the immediate management for some who has had a open AAA?
ICU
80
What are the complication after an AAA open repair?
Most commonly cardiac event | Haemorrhage, resp failure, renal failure, embolisation, ureteric injury, impotence, graft infection

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