Cardiology #11 (AAA, AD, PAD, Buerger's) Flashcards
MC site of abdominal aortic aneurysm
Infrarenal
Main modifiable risk factor for AAA
Smoking
Other risk factors for AAA
Age > 60 years
Caucasians
Males
Hyperlipidemia
Atherosclerosis
Connective tissue disorder (Marfan)
Syphilis
HTN
On the other hand, what are some protective factors against AAA
Female gender
DM
Moderate alcohol use
Non-Caucasian race
Symptoms of AAA
Most patients are asymptomatic; found incidentally on patients with palpable abdominal mass or abdominal bruit
-Abdominal flank or back pain. Abdominal bruit, pulsatile abdominal mass (unruptured)
What are some symptoms of AAA if the aneurysm has ruptured?
Abdominal, flank, or back pain
Abdominal bruit
Pulsatile mass
Hypotension
Syncope
Flank ecchymosis
Best diagnostic studies in a 1) hemodynamically stable patient and 2) a hemodynamically unstable patient
1) stable: CT scan with IV contrast
2) unstable: focused bedside US
True or False: Patients with known AAA who present with classic symptoms or signs of rupture can be taken to the operating room without preoperative imaging.
True
Best initial test to monitor progression of AAA in an asymptomatic patient with suspected AAA
Abdominal US
Who should be screened, one time, for AAA?
Via abdominal US, men 65-75 years of age who have ever smoked. One time.
If the AAA is ruptured, what is the treatment?
-Immediate surgical repair (end-vascular stent graft or open repair)
What is the size of the AAA that is considered for immediate surgical repair
> or equal to 5.5 cm or 0.5 cm expansion in 6 months
-Even if the patient is asymptomatic
What are the other recommendations for sizes of AAA?
> 4.5 cm: vascular surgeon referral
4-4.5 cm: US every 6 months
3-4 cm: US every 1 year
What is the most common type, also with the highest mortality, of aortic dissection?
Ascending (near the aortic arch or left subclavian)
Most important risk factor for aortic dissection
Hypertension
Other risk factors for aortic dissection
Age > 50
Men
Family history
Turner’s Syndrome
Collagen disorders (Marfan, Ehlers-Danlos)
Pregnancy
Symptoms of aortic dissection
-Chest pain: sudden, severe, tearing (ripping, knife like) chest/upper back pain radiating between scapulae
-Neck/jaw pain
-Unequal blood pressure in both arms
-Decreased peripheral pulses
-New onset aortic regurgitation if ascending type
On chest radiograph, what is seen in aortic dissection?
Widened mediastinum (may be normal in 10% so does not rule out)
What are the most common imaging modalities used in diagnosing an aortic dissection?
CT angiogram
MR angiogram
TEE
When is surgical intervention pursued with aortic dissection?
In acute proximal (proximal to left subclavian artery) OR distal with complications (impending rupture, vital organ involvement)
What is the treatment for a descending/distal (distal to left subclavian artery) aortic dissection?
Nonselective BB (Labetalol) with Sodium nitroprusside added if needed; Nicardipine
Systolic BP lowered to goal of 100-120 mmHg within 20 minutes
Regarding the Stanford classification for aortic dissection, what is Stanford A and what is Stanford B?
-Stanford A: involves ascending aorta and possibly descending aorta
-Stanford B: involves descending aorta without involvement of ascending aorta
MC symptom of PAD
Intermittent claudication (lower extremity pain with ambulation)
MC artery involved in PAD and the associated area of claudication
Popliteal artery: lower calf, ankle, and foot
What is Leriche’s Syndrome (associated with PAD)
-Triad of 1) claudication (buttock, thigh pain), 2) impotence, and 3) decreased femoral pulses
If the femoral artery or branches is associated with PAD, where is the area of claudication?
Thigh, upper calf
What are some physical exam findings of a patient with PAD?
-Decreased or absent pulses
-Decreased capillary refill
-Atrophic skin changes: muscle atrophy, thin/shiny skin, hair loss, thickened nails, cool limbs, areas of necrosis.
-Ulcers: lateral malleolar ulcers
-Pale on elevation, dependent rubor (dusky red with dependency)
What is the most useful screening test in a patient with PAD?
Ankle brachial index
What ABI is positive for PAD?
Positive if ABI < 0.90 (0.50 is severe).
Normal ABI: 1 -1.2
If the ABI is > 1.2, what doest that mean?
Possible non compressible (calcified) vessels: may give false reading
What is the GOLD STANDARD for PAD?
Arteriography: only performed if revascularization is planned though
Treatment for PAD
-Supportive (first line): exercise, smoking cessation (greatest benefit), foot care
-Platelet inhibitors: Cilostazol MOST EFFECTIVE MEDICAL THERAPY, Aspirin, Clopidogrel
-Revascularization: Percutaneous transluminal angioplasty
What is Thromboangiitis Obliterans (Buerger’s Disease)?
Nonatherosclerotic inflammatory small and medium vessel vasculitis, leading to vasocclusive phenomena
Who should you suspect Buerger’s Disease in (what kind of patient)?
Young smokers with distal extremity ischemia/ischemia ulcers or gangrene of digits
Risk factors for Buerger’s Disease
-Strongly associated with smoking
-Young men, 20-45 years old
-India, Asia, and Middle East
Triad of symptoms associated with Buerger’s Disease
-Distal extremity ischemia both upper and lower extremities (claudication in lower calf or arch of foot)
-Raynaud’s Phenomenon
-Superficial migratory thrombophlebitis (changing sites due to decrease in blood flow in medium and small arteries and veins)
How do you diagnose Buerger’s Disease with an Allen’s Test?
-Allens Test: delayed perfusion of radial and ulnar arteries
–clench fist tightly. Occlude both radial and ulnar arteries. Slowly release one artery and see how long it takes for other artery to perfuse the hand
What is seen on aortography in a patient with Buerger’s Disease?
Corkscrew collaterals
However, what is the gold standard for a patient with Buerger’s Disease?
Biopsy
What is the treatment for Buerger’s Disease?
-Smoking/tobacco cessation (cornerstone of management)
-Wound care
-Amputation if gangrene progresses
-CCB for Raynaud’s
-Iloprost
What is Iloprost and how does it help treat Buerger’s Disease?
-Prostaglandin analog that may help with critical limb ischemia while smoking cessation is in progress
