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Vascular Surgery > Arterial Diseases > Flashcards

Arterial Diseases Flashcards

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
Q

What are less common complications of AAA?

A

Retroperitoneal leak
Embolisation
Aortoduodenal fistula

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26
Q

What is the management of rupture AAA?

A

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.

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27
Q

Between which two layers does an aortic dissection occur?

A

Tunic intima and tunica media

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28
Q

How is acute and chronic aortic dissection distinguished?

A

Acute <=14 days

Chronic >14 days

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29
Q

Who is more likely to get an aortic dissection?

A

Men
People with connective tissue disorders
Age 50-70

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30
Q

What are the two types of dissections in aortic dissections?

A

Anterograde

Retrograde - can cause bleeding into aortic valve and cardiac tamponade

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31
Q

What are the clinical features of aortic dissection?

A

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.

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32
Q

What are the differential diagnosis for aortic dissection?

A

MI
PE
Pericarditis
MSK pain

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33
Q

Which two systems classify aortic dissections anatomically?

A

DeBakey

Stanford

34
Q

What are the risk factors for aortic dissection?

A 
Hypertension 
Atherosclerotic disease 
Male gender
Connective tissue disorder 
Biscuspid aortic valve
35
Q

What investigations should be performed for suspected aortic dissection?

A 
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
Q

What is the management for aortic dissections?

A

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
Q

What does surgery involve for type A Stanford aortic dissections?

A

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
Q

When does a type B stanford aortic dissection require surgical intervention?

A

Rupture
Renal,visceral or limb ischemia
Uncontrolled hypertension

39
Q

What is the most common complication of a chronic type B Stanford aortic dissection?

A

Aneurysm

40
Q

Name some complications of aortic dissections?

A 
Aortic rupture 
Aortic regurgitation 
MI
Cardiac tamponade 
Stroke or paraplegia
41
Q

In which pts can using an ABPI be problematic?

A

Pts with oedema, ulcers/fibrosis/scaring, calcium in wall of arteries

Leads to false reading

42
Q

If ABPI is not reliable then what can be done instead?

A

Lift pts leg and measure height at which sound on Doppler disappears and convert to mmHg - this is called pole test

43
Q

What does the buerger test look for examination?

A

Critical ischaemia

44
Q

What is the normal ABPI?

A

0.8-1.1

45
Q

What is intermittent claudication?

A

Pain on walking, comes on quicker when walking fast and worse when walking uphill

Pain relieved on rest/standing still

46
Q

What is rest pain?

A

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
Q

What is the difference between pain felt on spinal stenosis and intermittent claudication?

A

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
Q

What are the levels of intermittent claudication?

A

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
Q

What are the different scenarios for PVD?

A

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
Q

How does diabetic foot disease present?

A

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
Q

What are some components of diabetic foot disease?

A

Reduced immune function
Sensory/autonomic/motor neuropathy
Peripheral vascular disease - accelerated atherosclerotic, calcium deposits
Endothelial dysfunction

52
Q

What is the treatment for diabetic foot disease?

A 
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
Q

What is acute limb ischaemia?

A

Sudden decrease in limb perfusion the threatens the viability of the limb

54
Q

What are the three main aetiologies of acute limb ischaemia?

A

Embolisation - most common, source may be AF, post-MI, mural-thrombus, AAA or prosthetic valve.
Thrombus in situ - plaque ruptures
Trauma - compartment syndrome

55
Q

What are the 6Ps of acute limb ischaemia?

A 
Pain
Pallor
Pulselessness 
Parasthesia 
Perishingly cold 
Paralysis
56
Q

What is a sensitive sign for embolitic occlusion in acute limb ischaemia?

A

Normal, pulsatile contralateral limb

57
Q

What is the clinical categories for acute limb ischaemia?

A

Rutherford classification:

I-viable
IIA-marginally threatened
IIB-immediately threatened
III-irreversible

58
Q

What are the differential diagnosis for acute limb ischaemia?

A

Critical chronic limb ischaemia
Acute DVT
Spinal cord or peripheral nerve compression

59
Q

What investigations would you do in acute limb ischaemia?

A

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
Q

What is the time when irreversible limb damage starts to occur in acute limb ischaemia?

A

6 hours

61
Q

What is the initial management of someone with acute limb ischaemia?

A

High flow 02

IV access - therapeutic dose heparin or bolus dose then heparin infusion

62
Q

What is the conservative management for acute limb ischaemia?

A

Consider in Rutherford 1 and 2a

Prolonged course of heparin + regular assessment to determine effectiveness through APPT and clinical review

63
Q

What are the surgical options for acute limb ischaemia cause by embolisation?

A

Embolectomy
Local intra -arterial thrombolysis
Bypass surgery

64
Q

What are the surgical options for acute limb ischaemia if cause is thrombotic disease?

A

Local intra-arterial thrombolysis
Angioplasty
Bypass surgery

65
Q

What options are available for irreversible acute limb ischaemia?

A

Urgent amputation

Palliative approach

66
Q

What is some with acute limb ischaemia at risk of after surgery?

A

Ischemia reperfusion syndrome

67
Q

What is the long term management for acute limb ischemia after treatment?

A

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
Q

What is involved in reperfusion injury after an acute limb ischaemia?

A 
Compartment syndrome 
Damaged muscle cells release: 
K+ ions 
H+ ions 
Myoglobin - AKI
69
Q

What is an early symptom of chronic limb ischaemia?

A

Intermittent claudication and walking a fixed distance (claudication distance)

70
Q

What is the Fontaine classification of chronic leg ischaemia?

A

Stage I - asymptomatic
Stage II - intermittent claudication
Stage III - ischaemic rest pain
Stage IV - ulceration or gangrene or both

71
Q

What is leriche syndrome?

A

Peripheral arterial disease affecting the aortic bifurcation- specifically presents with buttock/thigh pain and associated erectile dysfunction.

72
Q

How is critical limb ischaemia defined?

A

Ischaemia rest pain greater then 2 weeks
Presence of ischaemic lesions or gangrene
ABPI <0.5

73
Q

What are the differential diagnosis for a patient with chronic limb ischaemia?

A

Spinal stenosis

Acute limb ischaemia

74
Q

What are the investigations for chronic limb ischaemia?

A 
ABPI - quantify severity  
Doppler ultrasound 
CT angiography or MR angiography 
Cardiovascular risk assessment 
If under 50 do thrombophila screen
75
Q

What is the medical management for chronic limb ischaemia?

A 
Lifestyle advice 
Statin therapy 
Anti-platelet therapy 
Optimise diabetes control 
Supervised exercise programme
76
Q

When can surgical intervention be offer in chronic limb ischaemia?

A

When risk factor modification has been discussed
Supervised exercise has failed to improve symptoms

Any pt with critical limb ischaemia

77
Q

What are the surgical options for chronic limb ischaemia?

A

Angioplasty
Bypass grafting
Combination of two
Amputation for severe cases

78
Q

What are complications of chronic limb ischaemia?

A

Sepsis - infected gangrene
Acute-on-chronic ischaemia
Amputation
Reduced mobility and quality of like

79
Q

What is the immediate management for some who has had a open AAA?

A

ICU

80
Q

What are the complication after an AAA open repair?

A

Most commonly cardiac event

Haemorrhage, resp failure, renal failure, embolisation, ureteric injury, impotence, graft infection

Vascular Surgery (3 decks)

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