carotid artery disease and varicose veins

Question 1

what is carotid artery disease?

Answer 1

Carotid artery disease refers to the build-up of atherosclerotic plaque in one or both common and internal carotid arteries, resulting in stenosis or occlusion.

Most carotid artery disease is asymptomatic, but it is also responsible for approximately 10-15% of ischaemic strokes, due to plaque rupture and/or atheroembolism.

Question 2

what is the pathphysiology of carotid artery disease ?

Answer 2

The pathophysiology of carotid artery disease is as for atheroma elsewhere, starting with a fatty streak, accumulating a lipid core and formation of a fibrous cap. The turbulent flow at the bifurcation of the carotid artery predisposes to this process specifically at this region

Question 3

what are the risk factors for carotid artery disease ?

Answer 3

age (≥65 years), 
smoking, 
hypertension, 
hypercholesterolaemia, 
obesity, 
diabetes mellitus, 
history of cardiovascular disease, 
and a family history of cardiovascular disease.

Question 4

what are the clinical features of carotid artery disease?

Answer 4

• Stroke in evolution = Progressive neurological deficit occurring over hours/days.
• Completed stroke = The stable end result of an acute stroke lasting Completed stroke over 24h.
• Crescendo TIA = Rapidly recurring TIA with increasing frequency, suggesting an unstable plaque with ongoing platelet aggregation and small emboli.

amaurosis fugax
internal capsular stroke
hemaniopia

carotid bruit

often asymptomatic

Question 5

what are the investigations in carotid artery disease?

Answer 5

stroke/TIA protocol if suspected

Duplex US of carotid
CT angiography

Question 6

what is the management of carotid artery disease ?

Answer 6

Medical management

• antiplatelet agent (e.g. aspirin, dipyridamole)
• smoking cessation
• optimization of BP and diabetes control
• statin
• Acute thrombolysis in CT-proven ischaemia indicated in specialized units if detected early.

Surgery

Carotid endarterectomy (CEA) 
-	 Offered to patients with symptomatic >70% stenosis of the ICA or >50% stenosis if recent TIA/CVA and high ABCD2 risk score (age, BP, clinical, duration, diabetes).

Question 7

what are varicose veins?

Answer 7

subcutaneous, tortuous, permanently dilated veins >3mm in diameter when measured in the standing position, however they may not be visible

Question 8

what are the clinical features of varicose veins?

Answer 8

pain
itching 
heaviness 
swelling 
oedema 
worse at end of the day or hot weather

Question 9

what are the complications of varicose veins ?

Answer 9

eczema 
phlebitis 
lipodermatoscelerosis 
ulceration 
bleeding

Question 10

what InV are done for varicose veins?

Answer 10

Duplex US
- assess for reversed flow, valve closure time >0.5 second indicative of reflux, >1.0 second indicates reflux in the deep system

Question 11

how can varicose veins be managed?

Answer 11

Medical

• microsclerotherapy or laser sclerotherapy
• foam sclerotherapy
• compression stockings

Surgical

• local stab avulsions
• saphenofemoral or saphenopopliteal disconnection
• endovenous laser therapy
• radiofrequency ablation