Vascular

Question 1

1. What is an Aortic Dissection? Pathophysiology
2. What are the causes / risk factors of aortic dissection?
3. What are the two classifications of Aortic Dissection?
4. What is a Stanford A and B Aortic Dissection?
5. What are the baseline investigations for an Aortic Dissection?
6. What are complications of an Aortic Dissection?
7. How do you manage a Stanford A dissection?
8. How do you manage a Stanford B dissection?

Answer 1

1. Refers to when the tunica intima tears away from tunica media. High blood pressure flowing through the aorta then tunnels between the intima and media, separating both layers. Over time, blood pools between layers increasing the diameter creating a false lumen
2. Chronic HTN (stress, coarctation), weakened aortic valve (Marfan’s, Ehler’s Danlos), Aneurysms, Noonan’s, Turner’s, Syphillis
3. Stanford, De-Bakey
4. Stanford A refers to a dissection proximal to L subclavian artery (proximal) vs. Stanford B refers to a dissection distal to L subclavian artery
5. FBC (may show anaemia), U&Es (needed prior contrast), ECG (may be normal or show ST depression), Group & Save and Cross Match (for blood transfusions), VBG (access Hb, lactate), CXR (widened mediastinum, aortic knuckle), CT angiogram (intimal flap)
6. Pericardial Tamponade, Aortic regurgitation as the dissection extends proximally, Renal failure, Stroke
7. Blood Transfusion, IV Labetalol, Urgent surgical repair
8. Conservative management, i.e. IV Labetalol

Question 2

1. What is an abdominal aortic aneurysm?
2. What is a true and false aortic aneurysm?
3. How are AAA’s screened?
4. What are the causes of AAAs?
5. How often should AAA’s be monitored?

Answer 2

1. Abnormal dilatation of the abdominal aorta
2. True = all 3 layers are involved, false = 1 layer involved
3. One-off abdominal US for men aged 65
4. HTN, diabetes, smoking, Marfan’s disease
5. If < 3cm, normal, if 3 - 4.4cm then rescan every 12 months, if 4.4 - 5.4 then rescan every 3 months, if above > 5.5cm then refer within 2 weeks for vascular surgery

Question 3

Peripheral Arterial Disease

1. What are the symptoms of Intermittent Claudication?
2. What are the symptoms of Critical Limb Ischaemia?
3. What are the features of Acute Limb Ischaemia?
4. What are some important investigations for PAD?
5. Outline the results of an ABPI?
6. What is the conversative, medical and surgical management of Peripheral Arterial Disease?

Answer 3

1. Aching and burning following walking, can walk for certain distance before symptoms come on, relieves on rest within minutes, no symptoms at rest
2. Rest pain in foot for >2 weeks, ulceration, gangrenous, may hang legs out of bed
3. Pain, pulseless, perishingly cold, paralysed, paresthesia, pallor
4. ABPI, Duplex Ultrasound, Magnetic resonance angiogaphy

5. 
> 1.3 = Non compressible arteries
1.0 = Normal
0.6 - 0.9 = Claudication
0.3 - 0.6 = Rest Pain
< 0.3 = Impending

6. Conversative: Smoking cessation, alcohol cessation, exercise training, weight loss

Medical: Atorvastatin 80mg, Clopidogrel, Aspirin 75mg, BP control, Nafidrofuryl Oxalate, Cilostazole (on BNF)

Surgical: Bypass surgery, Angioplasty, Stenting, Amputation