Aorta and PAD clinical

Question 1

What is an aneurysm?

ii. what is the difference between a true and a false aneurysm

Answer 1

An artery with a dilation >50% of its original diameter

an aorta >1.5 times expected size, which is generally defined as aorta >3cm

ii. true aneurysm involves all layers of arterial wall a false one doesn’t

Question 2

What are the causes of an abdominal aorta aneurysm?

Answer 2

Atheroma

trauma

hypertension

smoking

genetics (marfans)

Question 3

What are the signs and symptoms of ruptured AAA?

Answer 3

Intermittent or continuos abdominal pain (radiates to back,illiac fossae or groin)

collapse and shock

pulsatile

may be tachycardic/hypotensive

Question 4

How do you diagnose ruptured AAA?

Answer 4

Abdominal US

CT

Question 5

How do you manage ruptured AAA?

Answer 5

Surgical repair: open or endovascular.

Infra renal: EVAR (enter from femoral artery). Endovascular aortic repair

Supra renal: TVAR (enter from thoracic aorta). thoracic endovascular aortic repair

screening programme:

Should be offered to all men > 65.

Thought to be safe to monitor all aneurysms <5.5cm in size.

In aneurysms >5.5cm, surgical repair should be offered but mortality can be up to 50%.

Question 6

What are the signs and symptoms of unruptured AAA?

Answer 6

often asymptomatic

May be picked up incidentally on abdominal exam.

On examination: pulsatile abdominal mass.

Question 7

How do you diagnose unruptured AAA?

Answer 7

abdominal US

CT

Question 8

How do you manage unruptured AAA

Answer 8

screening programme

elective surgery : if >5.5cm

Question 9

what is aortic dissection?

Answer 9

It is the splitting within the tunica media . This creates a false lumen where blood now travels through - very dangerous.

Question 10

What are the risk factors of aortic dissection?

Answer 10

Hypertension.

Trauma including surgery.

Connective tissue disease: Marfans. associated with aortic root dilation. causes aortic regurgitation

Inherited diseases: Turners syndrome. associated with coarcation of aorta

Question 11

What are the signs and symptoms of aortic dissection?

Answer 11

sudden chest pain (+/-) radiation to back

Radial – radial pulse delay.

Unequal BP between both arms

Question 12

How do you diagnose and manage aortic dissection?

Answer 12

Diagnostic investigation: CT or MRI or TOE (transeophageal echocardiogram)

Management:
Analgesia.

B blockers – reduce cardiac output and amount of blood being forced into the dissection. or CCB if B blockers are contraindicated

Open or endovascular repair.

Question 13

What are the categories for the symptoms of Peripheral artery disease?

ii. which stages suggest critical limb ischaemia

Answer 13

Stage I – asymptomatic

Stage II – intermittent claudication

Stage III – rest pain/nocturnal pain

Stage IV – necrosis/gangrene.

ii. stage 3/4

Question 14

What do people complain of if they have intermitten claudication?

Answer 14

Cramping pain in the calf, thigh or buttock after walking for a given distance and is relieved by rest

Question 15

What are the symptoms of critical limb ischaemia? (severe form of PAD)

Answer 15

Ulceration, gangrene and foot pain at rest

burning pain at night relieved by hanging legs over side of bed

Question 16

What are arterial ulcers?

Answer 16

Punched out ulcer that are usually small and circular.

Found on the lateral surface of the ankle.

Intensely painful.

Question 17

What are the signs of peripheral arterial disease (PAD)

Answer 17

absent femoral, popliteal or foot pulses

cold white legs

atrophic skin

punched out (arterial ulcers)

buerger’s angle (angle that leg goes pale when raised off the couch)

Question 18

How do you diagnose PAD?

Answer 18

Ankle brachial pressure index: To calculate it divide ankle pressure/brachial pressure

1. 0.9-1.2 - normal
2. 0.4-0.85 - claudication
3. 0.-0.4 - severe

Duplex ultrasound scanning. (first line)

Invasive- MR angiography, CT angiography

Question 19

What can effect the ABPI ratio?

Answer 19

calcified vessels due to diabetes and chronic renal failure

doppler signal.

Question 20

How do you manage PAD?

Answer 20

1. Slowing down progression
   e. g. stop smoking, lipid lowering, antiplatelets treating hypertension diabetes
2. exercise: 30 mins three times a week
3. surgical:

Stenting.
Bypass graft.- inflow and outflow bypass
Sympathectomy.
Amputation.

Question 21

What are the causes of acute limb ischaemia?

Answer 21

Thrombosis - more likely from vasculopaths causing emboli and thrombosis to complete occlusion

Question 22

What are the signs and symptoms of acute limb ischaemia?

Answer 22

6 P’s

Pale

pulseless

painful

paralysed

paraesthetic

perishingly cold

Question 23

How do you mange acute limb ischaemia?

Answer 23

urgent open surgery or angioplasty

anticoagulate with heparin and look for source of emboli

Question 24

What conditions can increase the deep vein pressure?

Answer 24

1. deep valve incompetence

2. deep vein obstruction.

Question 25

What are the signs and symptoms of chronic venous disease?

Answer 25

Varicose veins

pain
cramps

tingling

heaviness

restless

oedema

venous eczema

ulcers

chronic venous insuffiency:

haemosiderin: iron deposits which give legs red brown colour
lipodermatoscerosis: causes skin to swell and harden

Question 26

What are varicose veins?

Answer 26

Dilated, tortuous superficial veins, due to the abnormal transmission of deep vein pressure

Question 27

What are the risk factors of varicose veins?

Answer 27

prolonged standing

obesity

pregnancy

family history

contraceptive pill

Question 28

What investigations can be used for chronic venous disease?

Answer 28

Duplex scan

State of the deep veins (occlusions or incompetence)

Saphenofemoral or saphenopopliteal incompetence

Question 29

How do you manage chronic venous disease?

Answer 29

education - exercise don’t stand on legs to long and weight loss
treat underlying cause

1. Endovenous (Duplex guided)
   Foam sclerotherapy - chemical
2. Endovenous (Duplex guided)
   Endovenous ablation- mechanical-physical

surgical- removal of vein