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Vascular Surgery by Emi > Carotids (extra) > Flashcards

Carotids (extra) Flashcards

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1
Q

How do you determine proximal stenosis in CCA

A

dampened velocities and spectral broadening in ICA

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2
Q

How do you determine distal occlusion and high grade stenosis in ICA

A

dampened velocities and low EDV in ICA

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3
Q

What are characteristics of post stenotic waveform in ICA

A

low velocity wave form with delayed upstroke (parvus tardus)

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4
Q

Carotid preocclusive thump

A

short narrow peak with no flow through diastoly

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5
Q

absent bilateral diastolic flow in carotids

A

cardiac disfunction

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6
Q

carotid dissection classification

A

1) minimal injury or irregular intima
2) dissection with raised intimal flap / IMH with luminal narrowing >25% / Intraluminal thrombosis
3) PSA
4) vessel occlusion or complete thrombosis
5) vessel transection

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7
Q

Shamblin classification

A

1) localized to carotid bifurcation
2) partially surround ECA and ICA
3) completely encases ECA and ICA

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8
Q

common carotid division

A

upper border of thyrdoi cartillage

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9
Q

external carotid artery branches

A

1) ascending pharyngeal
2) superior thyroid
3) lingual
4) facial
5) occipital
6) posterior auricular
7) terminal branches: superficial temporal and maxillary

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10
Q

segments of vertebral artery

A

1) from subclavian to C6 foramina
2) through foramina of C6 - C2
3) from C2 foramen transversarium to dura mater
4) pierces through the dura mater to formed basillary artery

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11
Q

familial carotid body tumor gene

A

succinyl dehydrogenase

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12
Q

Fontaine’s sign

A

carotid body tumor will move left to right but not up and down

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13
Q

Hollenhorst plaque

A

cholesterol crystal embolization to retinal circulation, incidental, not associated with increased risk of stroke

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14
Q

> 30% in stent carotid stenosis

A

> 150cm/s

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15
Q

> 50% in stent carotid stenosis

A

> 220cm/s

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16
Q

> 80% in stent carotid stenosis

A

> 325cm/s

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17
Q

criteria for ICA occlusion

A

bidirectional flow in ICA stump and externalization or high resistance flow patterns in ipsilateral CCA with absent, decreased or reversed flow in diastole

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18
Q

Indirect carotid stenosis criteria

A

1) decreased EDV in CCA or ICA in presence of distal lesion
2) internalization of ECA
3) reversal of flow in ophtalmic artery
4) anterior cross filling via anterior communicating artery
5) posterior communicating artery flow
6) increased flow pulsatility in unilateral CCA
7) decreased flow pulsatility in unilateral MCA
8) abnormal flow acceleration and pulsatility transmission index (MCA)

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19
Q

Stent deformity or re-stenosis criteria

A

1) b-mode >30% narrowing
2) focal velocity increase >150cm/sec and stenotic to pre-stenotic PSV ratio of 1:>=2
3. evidence of plaque or thrombus formation

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20
Q

Bowhunter’s syndrome

A

positional posterior insufficiency caused by dynamic compromise of dominant left vertebral artery –> transient dizziness when looking upwards with head rotated

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21
Q

Vertebral artery stenosis

A

PSV >= 2 (ratio of the stenotic to pre or post stenotic area)

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22
Q

Normal carotid values

A

ICA PSV <125
ICA EDV <40
ICA/CCA <2

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23
Q

50-69% carotid stenosis

A

ICA PSV 125-230
ICA EDV 40-100
ICA/CCA 2-4

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24
Q

70-79% carotid stenosis

A

ICA PSV >230
ICA EDV 100-125
ICA/CCA 2-4

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25
80-89% carotid stenosis
ICA PSV >230 ICA EDV >125 ICA/CCA >4
26
Costocervical trunk branches
deep cervical | superior intercostal
27
thyrocervical trunk branches
inferior thyroid suprascapular ascending cervical transverse cervical
28
parts of ICA
1. cervical 2. petrous 3. lacetum 4. cavernous 5. clinoid 6. ophtalmic 7. communicating 8. terminal branches: anterior cerebral and middle cerebral
29
what parts of ICA have branches
petrous cavernous ophtalmic communicating
30
what are the branches of petrous ICA
vidian | caroticotympanic
31
what are the branches of cavernous ICA
meningohypophyseal | inferolateral trunk
32
what are the branches of ophtalmic ICA
ophtalmic | superior hypophyseal
33
what are the branches of communicating ICA
posterior communicating | anterior choroidal
34
sound of carotid bruit with 50-69% stenosis
low pitched short systemic gruff
35
sound of high grade stenosis bruit
high pitched, soft
36
extracranial carotid artery aneurysm
if untreated 50% risk of stroke and death | >2cm absolute indication for operation
37
NASCAT trial results
1. 70-99% any ipsilateral stroke reduction: 9% vs 26% at 2 years 2. 50-69% any ipsilateral stroke reduction: 16 vs 22% at 5 years (p=0.045) 3. <50%: no benefit 4. near occlusion: no benefit
38
timing of CEA:
1. TIA - next elective schedule 2. non disabling stroke (minor fixed deficit or TIA with small CTA / MR stroke): 48h - 2 weeks 3. major hemispheric stroke: 4 weeks at least 4. crescendo TIA or stroke in evolution - urgent CEA (but increased perioperative risk)
39
ACAS trial
asymptomatic patients with stenosis >60%, 1662 patients randomized Endpoint: stoke and death 5% in surgery group and 11% with any medical management risk reduction of 53%
40
EVA 3s trial
2006, stopped before completion symptomatic patients with severe disease EPD was not always used 30 day stroke rate: 3.9 in CEA and 9.6 in CAS
41
SPACE trial
symptomatic patients Endpoint was stroke and death. EPD used 27% of time No difference in end point between groups recurrent stenosis: 4.6 in CEA and 10.7% in CAS Failed to prove CAS was not inferior
42
ICSS trial
symptomatic patients | stroke, MI, or death: 5.2 in CEA and 8.2 in CAS
43
what's the difference of new area brain infarctions between CAS and CEA
50% in CAS and 17% in CEA
44
CREST trial
``` symptomatic and asymptomatic patients, endpoint: combined stroke, MI and death composit endpoint: 4.5% CEA and 5.2 in CAS (not statistically different), but if you took out MI, CEA is statistically better CEA only higher in MI patients over 70 did better with CEA younger patients did better with stent women did worse with stenting ```
45
What’s the pathology of stroke
85% due to cerebral infarction
46
Technique for stump pressure measurement in the carotid
Clamp CCA and ECA leaving ICA open, and then measure pressure
47
Results of CREST trial for CEA patch vs no patch
66% patch and 29%primary closure, eversoion excluded Priprocedural outcomes: statistically significant increase in stroke and death in the no patch group More restenosis
48
Mechanism for postoperative stroke in carotid
Embolization Unsatisfactory technical result —> thromboembolism Uncontrolled hypertension Inadequate cerebral perfusion intraoperatively
49
Proven indications for carotid endarterectomy
Symptomatic: hemispheric or mononuclear TIA or stroke, providing m&m <6%, 70-99% stenosis both genders, for men also 50-69% Asymptomatic: providing surgical m&m <2.3%, 60-99% stenosis
50
What lesions have higher risk of stroke with carotid stenting
Long lesions (1.2 cm), dysynchronous or sequential lesions, lesions distal to carotid bulb
51
SAPPHIRE trial
Randomized prospective controlled for patients at high risk for endarterectomy Asymptomstic patients >80%, symptomatic >50% 70% if patients were asymptomstic and high risk - critique: should have been managed medically 1 year endpoint (stoke and death) 12.2% in CAS and 20.1% in CEA. More pronounced in asymptomstic patients.
52
High anatomical risk for CEA
``` Previous CEA with recurrent stenosis Prior radiation therapy to neck Previous ablative neck surgery Lesion at C2 Lesion below the clavicle Contralatetal vocal cord palsy / laryngectomt Tracheostomy aroma Contralateral occlusion (?) Immobile neck Tandem lesion ```
53
How do you anchor exchange wire with carotid stenting
Use external carotid artery
54
What does fluoro field include for carotid atenting
Arch and guide wire tip | Usually best in LAO
55
High risk for CAS?
``` Tortuous arch Calcified arch Diseased great vessels Tortuous carotid artery Pre occlusive lesion Heavy plaque burden Circumferential calcification Echolucent plaque ```
56
Which stents have more Neuro events for carotid stenting
Open cell. Plaque protrudes through the stent cells
57
Where does vertebral artery enter transverse foramen
Variable but most commonly at C6
58
How many patients have vertebral artery Origin at the Athens
6%
59
What’s the most common size of vertebral arteries compared to each other
85% asymmetrical with left side dominant in ⅔ cases
60
Vertebral artery branches
V1 - no branches V2- radiculo-medullary V3- posterior spinal artery, lateral recurrent artery V4- anterior spinal artery and PICA
61
What does lateral recurrent artery (of V3) anastomoses with
Ascending cervical and deep cervical artery
62
Vertebral artery compression mechanism
Bone compression by osteophytes, c7 transverse process, posterior laminate C1 Muscular compression by longus Colli or longus capitis Arterial kinks Neural by sympathetic chain
63
Surgical indications for proximal vertebral transposition
Ischemia from fixed stenosis / occlusion Embolism from proximal plaque Positional symptoms from compression Subclsvian steal
64
What do you have to divide in distal vertebra artery bypass to get to the target
Levantine scapulae | Anterior army’s if C2 nerve
65
Management of trachea-innominate fistula
Bleeding control with balloon/covered stent Immediately followed by left to right carotid to carotid bypass, Median sternotomy Ligation of the innominate artery Muscle flap to close the tracheal defect
66
In patients with carotid bulb lesion, intracranial ICA lesion and symptoms, what’s the tx algorithm
Just treat the bulb first. | Intracranial only if symptoms persist
67
Maneuvers to get distal exposure of ICA
``` Medial mobilization of the hypoglossal nerve NT intubation Division of posterior belly of digastric Resection of styloid process Anterior subluxation of the mandible ```
68
What’s stump syndrome and how do you treat it
Chronically occluded ICA with “stump” of ICA being an origin of emboli. Best results are in mononuclear amaurosis fugax Treatment - endarterectomy of CCA and ECA with transaction and ligation of ICA stump. Resolution of symptoms 83%, 7% additional improvement Overall neuro events 5% Mortality periop 3% due to stroke mainly
69
Radiation induced carotid disease
Unusual location | Extensive rather than focal
70
Maneuver most likely to injury glossopharyngeal nerve
Transaction of posterior belly of digastric muscle
71
How to manage traumatic carotid dissection
OR / endovascular if patient has worsening or fluctuating neuro symptoms Anticosgulation if no contraidication Antiplatelets if contraindication to anticoagulation
72
Intracranial aneurysm algorithm
If coexists with carotid disease each part should be treated separately Significant symptomatic carotid disease should be treated before aneurysm Asymptomstic aneurysm found incidentally maybe treated before asymptomstic carotid disease if the aneurysm is 8mm or larger
73
Complications associated with vertebral artery open repair
``` Horners 8-28% Chylothorax 5% Immediate thrombosis 4% Lymphocele 4% Vague and recurrent laryngeal nerve palsy 2% ```
74
Two independent predictors of poor outcome for asymptomstic carotid stenosis in dialysis patients
Age >70 Dialysis >2 years History of renal transplant is protective
75
When should you do a CEA after a TIA
3-14 days
76
Pre op studies for carotid body tumor
24 hour urin collection for metanephrines and catecholamines | 123 I-metaiodobenzylbuanidine scintigraphy or CT/MRI of chest and abdomen
77
What’s carotid sinus
Innervated by the nerve of Hering (of glossopharyngeal) | Barorrceptors that produce bradycardia and hypotension when stimulated by increased pressure

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