Aorta/ Peripheral Vascular Disease

Question 1

Diagnosis of coarctation of the aorta

Answer 1

Diagnosis: CoA is generally confirmed by two-dimensional and Doppler transthoracic echocardiography. In adolescents, adults, and some pediatric cases, cardiovascular magnetic resonance imaging (CMR) or computed tomography angiography (CTA) are used as a complementary diagnostic tool. CMR and CTA define the location and length of obstruction and identify collateral vessels and other associated lesions such as aortic dilatation.

Question 2

Treatment of symptomatic carotid artery stenosis

Answer 2

Symptomatic =
- Ipsilateral amaurosis fugax
- Contralateral motor/ sensory symptoms
- Aphasia

Mild Stenosis (<50%) - Medical management
Symptomatic (>50%) - CEA
Asymptomatic(>70%) - CEA

•For women with recently symptomatic carotid stenosis of 50 to 69 percent, we suggest medical management rather than CEA (Grade 2B).

•For patients with total or near total occlusion of the symptomatic ipsilateral internal carotid artery, we suggest medical management rather than CEA or CAS (Grade 2B).

●For patients selected for treatment with CEA, we suggest that CEA be performed within two weeks (but not within the first two days) of the last symptomatic event rather than a later time (Grade 2B). Observational evidence suggests that CEA in the first 48 hours after stroke onset is associated with increased risk compared with CEA performed 3 to 14 days after symptom onset.

●For select patients with recently symptomatic carotid stenosis of 70 to 99 percent, we suggest CAS rather than CEA if any of the following conditions are present (Grade 2C):

•A carotid lesion that is not suitable for surgical access
•Radiation-induced stenosis
•Clinically significant cardiac, pulmonary, or other disease that greatly increases the risk of anesthesia and surgery

Question 3

Definitions and Treatment of acute limb ischemia
- Viable
- Threatened
- Irreversible

Answer 3

I. Viable: limb not immediately threatened; no sensory loss; no muscle weakness; audible arterial and venous Doppler.
II. Threatened: mild to moderate sensory or motor loss; inaudible arterial Doppler; audible venous Doppler.
III. Irreversible: major tissue loss or permanent nerve damage inevitable; profound sensory loss, anesthetic; profound muscle weakness or paralysis (rigor); inaudible arterial and venous Doppler.

Viable = Revascularization (Urgent) + anticoagulation
Threatened = Emergent Revascularization + anticoagulation
Irreversible = Amputation

Question 4

Treatment indication for Coarctation of the Aorta

Answer 4

• Arm/ leg peak to peak gradient >=20 mmHg,
• Arm/ leg peak to peak >= 10 mmGh and collateral flow or decreased LV function or Aortic regurgitation.

For patients with discrete CoA who weigh ≥25 kg (ie, large enough to allow use of an adult-size stent), we suggest transcatheter intervention with stent placement rather than surgical repair or balloon angioplasty without stent placement (Grade 2C).