Case 18- AAA

Question 1

AAA screening outcomes

Answer 1

<3cm- normal no further action required
3-4.4cm- rescan in 12 months
4.5-5.4cm- rescan in 3 months
>5.5cm- refers within 2 weeks to vascular surgery.

Question 2

Investigations for DIC

Answer 2

FBC- thrombocytopenia
D dimer- raised
Clotting profile- prolonged APTT, prothrombin and bleeding time
Blood film- schistocytes (microangiographic haemolytic anaemia)

Question 3

Older male presents with renal colic

Answer 3

Treat as ruptured AAA

Question 4

Ischaemic bowel disease

Answer 4

Encompasses a heterogenous group of disorders caused by acute or chronic processes arising from occlusive or non occlusive aetiologies, resulting in decreased blood flow to the GI tract

Question 5

Acute mesenteric ischameia

Answer 5

Typically an embolus resulting in occlusion of an artery which supplies the small bowel. Severe, sudden abdominal pain and very little exam findings. Suspect in a patient with known/ new AF.

Question 6

Chronic mesenteric ischaemia

Answer 6

Colicky, intermittent abdominal pain. Think of as intestinal angina

Question 7

Ischaemic colitis

Answer 7

An acute but transient (non-fulminant such as acute mesenteric ischaemia) compromise in blood flow to the large bowel- doesn’t cause tissue gangrene. Can occur after abdominal surgery

Question 8

Sx of ischaemic bowel disease

Answer 8

Abdominal pain, melaena, haematochezia, diarrhoea, abdominal tenderness, weight loss, abdominal bruit, signs of shock

Question 9

Differentials for ischaemic bowel disease

Answer 9

Infective colitis, ulcerative colitis, large bowel obstruction, acute pancreatitis, gastroenteritis

Question 10

Aspirin and the coagulation profile

Answer 10

Only prolongs the bleeding time. All else normal

Question 11

Waterhouse Friderichsen syndrome

Answer 11

Adrenal infarcts which lead to adrenal insufficiency during DIC

Question 12

Acute limb ischaemia

Answer 12

Sudden lack of blood flow to a limb. Caused by embolism or thrombus- the 6 P’s

Question 13

Critical (Chronic) Limb ischaemia

Answer 13

Advanced stage of PAD- triad of ischaemic rest pain, arterial insufficiency ulcers, gangrene. Usually have pink lower limbs due to well developed collateral circulation
Often hang legs out of the bed, and ABPI typically below 0.5

Question 14

Fontaine classification of PAD

Answer 14

1- asymptomatic PAD
2- pain on exertion (claudication)
3- ischaemic pain at rest
4- necrosis, gangrene, ulcers

Question 15

Acute limb ischaemia Sx

Answer 15

Pain 
Pallor
Pulse less ness
Paralysis
Paraesthesia 
Perishingly old

Question 16

Differentials of PAD

Answer 16

Spinal stenosis, arthritis, symptomatic Bakers cyst, nerve root compression

Question 17

Red flags for PAD

Answer 17

Ischaemic rest pain
Ulcers
Gangrene

NB- ask about 6 P’s?

Question 18

TRALI Transfusion Associated Lung Injury

Answer 18

Sudden dyspnoea, hypoxia, hypotension, fever

Supportive treatment, IV fluids and vasopressors

Question 19

TRACO Transfusion associated circulatory overload

Answer 19

Dyspnoea
Orthopnoea
Peripheral oedema
Rapid hypertension

Diuretics

Question 20

AAA Screening

Answer 20

One off USS when 65

Question 21

Management following AAA Screening

Answer 21

Low rupture risk (asymptomatic, less than 5.5cm)- observe, modify risk factors

High rupture risk (symptomatic, greater than 5.5cm, rapidly enlarging (more than 1cm/year))- refer within 2 weeks to vascular surgery for probable intervention

Question 22

ABPI

Answer 22

BP legs/ BP arms

1.2+ calcified arteries (esp. diabetics)- refer
1-1.2 normal
0.9-1 acceptable
<0.9 signifies likely disease, less than 0.5 requires urgent referral

Compression bandaging can be used if ABPI is greater than 0.8

Question 23

3 stages of peripheral arterial disease

Answer 23

Intermittent claudication
Critical limb ischaemia
Acute limb threatening ischaemia

Question 24

Features of intermittent claudication

Answer 24

Aching or burning in legs following walking
Walk predictable distances before the symptoms start
Relieved within minutes of stopping
Not present at rest

Question 25

Investigations for intermittent claudication

Answer 25

Cardio vascular examination, observations 
ABPI
Bloods- diabetes, infection etc.
Doppler USS
MR angiogram of lower limb

Question 26

6 P’s of acute limb threatening ischaemia

Answer 26

Pale
Pulseless 
Painful
Paralysed 
Paraesthesis
Poikilothermia

Question 27

Acute limb ischaemia due to thrombus

Answer 27

Pre existing claudication with sudden deterioration
No obvious emboli source
Reduced or absent pulses in contra lateral limb
Vasculopaths (widespread vascular disease)

Question 28

Acute limb ischaemia due to embolus

Answer 28

Sudden onset painful leg
No history of claudication
Obvious source of embolus eg. AF, recent MI
No evidence of PAD (normal pulses in contra lateral limb)

Question 29

Management of acute limb threatening ischaemia

Answer 29

Initial management- IV heparin (esp.if delay for surgery), codeine, paracetamol, vascular review

Definitive management- Thrombolysis, thrombectomy, bypass surgery, amputation at last resort

Question 30

Management of PAD

Answer 30

Supportive- address co morbidities eg. Smoking, HTN, DM, obesity, exercise training
Medical- statin (80mg atorvastatin), clopidogrel (preference to aspirin)
Surgical- angioplasty, stenting, bypass, amputation

NB- naftidrofuryl oxalate is a vasodilator used in patients with poor QOL

Criteria for surgery;

• endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
• open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

Question 31

Superficial thrombophlebitis

Answer 31

Inflammation associated with thrombosis of a superficial vein, typically the long saphenous vein of the leg (usually non infective but it can be infective in nature)

Managed with compression stockings (ABPI first) and NSAIDs
USS to exclude DVT

Question 32

Management of varicose veins

Answer 32

Conservative- leg elevation, weight loss, regular exercise, graduated compression stockings
Refer to secondary care- pain, discomfort, swelling, bleeding, skin changes secondary to venous insufficiency, superficial thrombophlebitis, active or healed venous leg ulcer
Surgical- ligation, stripping, endothermic ablation, sclerotherapy

Question 33

Subclavian steal syndrome

Answer 33

Stenotic lesion of the subclavian artery

Decreased cerebral blood flow, syncope

Question 34

Diabetic foot disease

Answer 34

Secondary to neuropathy (reduced sensation) and PAD (ABPI)

Question 35

Leriche syndrome

Answer 35

Male patients;

Claudication of the buttocks and thighs
Atrophy of the musculature of the legs
Impotence (due to paralysis of the L1 nerve)

Question 36

Intermittent claudication vs critical ischaemia

Answer 36

Pain at rest suggests critical ischaemia

Question 37

Buerger’s disease

Answer 37

(also known as thromboangiitis obliterans)- a small and medium vessel vasculitis that is strongly associated with smoking.

Features;
extremity ischaemia
intermittent claudication
ischaemic ulcers
superficial thrombophlebitis
Raynaud's phenomenon

Question 38

Coarctation of the aorta signs on x ray

Answer 38

notching of the inferior border of the ribs

Question 39

Coarctation of the aorta signs on x ray

Answer 39

notching of the inferior border of the ribs

Question 40

Neuropathic ulcers

Answer 40

Usually a normal ABPI (caused by neuropathy not PAD)