Hypotension, Aneurysms, Varicose Veins, Dissection

Question 1

What is aortic dissection associated with?

Answer 1

HTN
Trauma 
Bicuspid aortic valve 
Marfans/ Ehlers 
Pregnancy 
Syphilis 
Males 60-80

Question 2

S+S aortic dissection

Answer 2

Severe radiating chest pain
Tearing/ ripping pain
Aortic regurg
Varying pulse

Question 3

Investigations for ?aortic dissection

Answer 3

ECG
CT angiogram - diagnosticUSS if urgent
CXR - widened mediastinum, larger aortic knuckle, pleural effusion, deviated trachea
ECHO (TOE)

Question 4

Management of type A aortic dissection

Answer 4

Keep systolic 100-120

Needs surgery

Question 5

Management of type B aortic dissection

Answer 5

Conservative management

Reduce BP - labetalol

Question 6

Complications of aortic dissection

Answer 6

Backward tear - aortic incompetence/ regurg

Forward tear - unequal arm pulses/ BP

Question 7

What is aortic dissection?

Answer 7

Tear in intimal layer of aortic wall, causing blood to flow between tunica intima + media
Progressing distally = anterograde
Progressing proximally = retrograde

Question 8

What is the DeBakery classification?

Answer 8

For aortic dissection
Type 1- originates in the ascending aorta and propagates at least to the aortic arch
Type 2- confined to ascending aorta
Type 3 - originates distal to subclavian artery in the descending aorta

Question 9

What is the stanford classification?

Answer 9

For aortic dissection
Group A- DeBakey 1+2 (ascending aorta +/- aortic arch/descending aorta)
Group B- DeBakey 3 (no involvement of ascending aorta)

Question 10

What is an aneurysm?

Answer 10

Artery with dilatation >50% of its original diameter

AAA: >3cm dilatation

Question 11

True vs false aneurysms

Answer 11

True = abnormal dilatations involving all of wall
False = only involves adventitia

Question 12

Investigations for ?AAA

Answer 12

USS to diagnose

CT with contrast if >5.5cm

Question 13

Medical management of AAA - what is it + when is it appropriate

Answer 13

If AAA asymptomatic + <5.5cm
Monitor via duplex USS (3-4cm = yearly, 5-5.4cm 3 monthly)
Reduce CV RF

Question 14

Surgical management of AAA

Answer 14

If >5.5cm, expanding >1cm per year or symptomatic
Open or endovascular repair
Disqualified from driving if >6.5cm

Question 15

UK screening for AAA

Answer 15

Abdo USS for men in 65th year

Question 16

Classical features of ruptured AAA

Answer 16

Flank/ back pain, hypotension, pulsatile abdo massVomiting, syncope

Question 17

Management of ruptured AAA

Answer 17

Crossmatch, treat shock but keep BP <100, surgery

Question 18

What is the definition of postural hypotension?

Answer 18

Drop of greater than 20 systolic

Question 19

Causes of postural hypotension

Answer 19

Venous pooling: severe varicose veins, prolonged standing
Impaired tone: diabetic neuropathy, Shy-Drager syndrome
Reduced tone: prolonged bed rest
Hypovolaemia: dehydration, exsanguination
Drugs: hypotensive agents, levodopa
Addisonian disease: Addisons, hypopituitarism, abrupt cessation of steroids

Question 20

Pathology of aneurysms

Answer 20

Degradation of elastic lamellae, leukocytic infiltrate, enhanced proteolysis + smooth muscle cell loss

Question 21

What is the normal diameter of the aorta?

Answer 21

2cm

Question 22

RF for AAA

Answer 22

Fam hx
Males
Increasing age 
HTN
COPD
Hyperlipidemia

Question 23

How does an unruptured AAA present?

Answer 23

Incidental finding on examination of scans
Pain in back, abdo, loin or groin
Pulsatile abdo swelling
Distal embolisation producing features of limb ischaemia
Ureterohydronephrosis
Retroperitoneal fibrosis

Question 24

Types of AAA surgical repair

Answer 24

Open repair 
Endovascular repair (using stent-graft system)

Question 25

What are varicose veins?

Answer 25

Dilated, tortuous superficial veins, an indication of lower extremity venous insufficiency

Question 26

Pathology of varicose veins

Answer 26

Caused by incompetent valves in affected vein, causing reflux of blood + high venous pressure

Question 27

RF for varicose veins

Answer 27

``` Increasing age Fam hx Females Pregnancy Obesity Prolonged standing or sitting Hx of DVT ```

Question 28

S+S of varicose veins

Answer 28

Pain, aching, discomfort, swelling, heaviness, itching

Question 29

Complications of varicose veins

Answer 29

Bleeding, thrombophlebitis, DVT, venous skin changes, ulceration

Question 30

Management of varicose veins

Answer 30

Lifestyle advice, elevate legs and avoid sitting/ standing for long periods Refer to secondary care Consider compression stockings