Cardiology #11 (AAA, AD, PAD, Buerger's)

Question 1

MC site of abdominal aortic aneurysm

Answer 1

Infrarenal

Question 2

Main modifiable risk factor for AAA

Answer 2

Smoking

Question 3

Other risk factors for AAA

Answer 3

Age > 60 years
Caucasians
Males
Hyperlipidemia
Atherosclerosis
Connective tissue disorder (Marfan)
Syphilis
HTN

Question 4

On the other hand, what are some protective factors against AAA

Answer 4

Female gender
DM
Moderate alcohol use
Non-Caucasian race

Question 5

Symptoms of AAA

Answer 5

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)

Question 6

What are some symptoms of AAA if the aneurysm has ruptured?

Answer 6

Abdominal, flank, or back pain
Abdominal bruit
Pulsatile mass
Hypotension
Syncope
Flank ecchymosis

Question 7

Best diagnostic studies in a 1) hemodynamically stable patient and 2) a hemodynamically unstable patient

Answer 7

1) stable: CT scan with IV contrast
2) unstable: focused bedside US

Question 8

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.

Answer 8

True

Question 9

Best initial test to monitor progression of AAA in an asymptomatic patient with suspected AAA

Answer 9

Abdominal US

Question 10

Who should be screened, one time, for AAA?

Answer 10

Via abdominal US, men 65-75 years of age who have ever smoked. One time.

Question 11

If the AAA is ruptured, what is the treatment?

Answer 11

-Immediate surgical repair (end-vascular stent graft or open repair)

Question 12

What is the size of the AAA that is considered for immediate surgical repair

Answer 12

> or equal to 5.5 cm or 0.5 cm expansion in 6 months

-Even if the patient is asymptomatic

Question 13

What are the other recommendations for sizes of AAA?

Answer 13

> 4.5 cm: vascular surgeon referral
4-4.5 cm: US every 6 months
3-4 cm: US every 1 year

Question 14

What is the most common type, also with the highest mortality, of aortic dissection?

Answer 14

Ascending (near the aortic arch or left subclavian)

Question 15

Most important risk factor for aortic dissection

Answer 15

Hypertension

Question 16

Other risk factors for aortic dissection

Answer 16

Age > 50
Men
Family history
Turner’s Syndrome
Collagen disorders (Marfan, Ehlers-Danlos)
Pregnancy

Question 17

Symptoms of aortic dissection

Answer 17

-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

Question 18

On chest radiograph, what is seen in aortic dissection?

Answer 18

Widened mediastinum (may be normal in 10% so does not rule out)

Question 19

What are the most common imaging modalities used in diagnosing an aortic dissection?

Answer 19

CT angiogram
MR angiogram
TEE

Question 20

When is surgical intervention pursued with aortic dissection?

Answer 20

In acute proximal (proximal to left subclavian artery) OR distal with complications (impending rupture, vital organ involvement)

Question 21

What is the treatment for a descending/distal (distal to left subclavian artery) aortic dissection?

Answer 21

Nonselective BB (Labetalol) with Sodium nitroprusside added if needed; Nicardipine

Systolic BP lowered to goal of 100-120 mmHg within 20 minutes

Question 22

Regarding the Stanford classification for aortic dissection, what is Stanford A and what is Stanford B?

Answer 22

-Stanford A: involves ascending aorta and possibly descending aorta
-Stanford B: involves descending aorta without involvement of ascending aorta

Question 23

MC symptom of PAD

Answer 23

Intermittent claudication (lower extremity pain with ambulation)

Question 24

MC artery involved in PAD and the associated area of claudication

Answer 24

Popliteal artery: lower calf, ankle, and foot

Question 25

What is Leriche's Syndrome (associated with PAD)

Answer 25

-Triad of 1) claudication (buttock, thigh pain), 2) impotence, and 3) decreased femoral pulses

Question 26

If the femoral artery or branches is associated with PAD, where is the area of claudication?

Answer 26

Thigh, upper calf

Question 27

What are some physical exam findings of a patient with PAD?

Answer 27

-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)

Question 28

What is the most useful screening test in a patient with PAD?

Answer 28

Ankle brachial index

Question 29

What ABI is positive for PAD?

Answer 29

Positive if ABI < 0.90 (0.50 is severe). Normal ABI: 1 -1.2

Question 30

If the ABI is > 1.2, what doest that mean?

Answer 30

Possible non compressible (calcified) vessels: may give false reading

Question 31

What is the GOLD STANDARD for PAD?

Answer 31

Arteriography: only performed if revascularization is planned though

Question 32

Treatment for PAD

Answer 32

-Supportive (first line): exercise, smoking cessation (greatest benefit), foot care -Platelet inhibitors: Cilostazol MOST EFFECTIVE MEDICAL THERAPY, Aspirin, Clopidogrel -Revascularization: Percutaneous transluminal angioplasty

Question 33

What is Thromboangiitis Obliterans (Buerger's Disease)?

Answer 33

Nonatherosclerotic inflammatory small and medium vessel vasculitis, leading to vasocclusive phenomena

Question 34

Who should you suspect Buerger's Disease in (what kind of patient)?

Answer 34

Young smokers with distal extremity ischemia/ischemia ulcers or gangrene of digits

Question 35

Risk factors for Buerger's Disease

Answer 35

-Strongly associated with smoking -Young men, 20-45 years old -India, Asia, and Middle East

Question 36

Triad of symptoms associated with Buerger's Disease

Answer 36

-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)

Question 37

How do you diagnose Buerger's Disease with an Allen's Test?

Answer 37

-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

Question 38

What is seen on aortography in a patient with Buerger's Disease?

Answer 38

Corkscrew collaterals

Question 39

However, what is the gold standard for a patient with Buerger's Disease?

Answer 39

Biopsy

Question 40

What is the treatment for Buerger's Disease?

Answer 40

-Smoking/tobacco cessation (cornerstone of management) -Wound care -Amputation if gangrene progresses -CCB for Raynaud's -Iloprost

Question 41

What is Iloprost and how does it help treat Buerger's Disease?

Answer 41

-Prostaglandin analog that may help with critical limb ischemia while smoking cessation is in progress