Vascular: Aortic Dissection, Abdominal Aortic Aneurysm, DVT, PE

Question 1

AD

• Pathophysiology
• Risk factors - which is the most significant one

Answer 1

Tear in tunica intima in aorta

• HTN!
• trauma
• bicuspid aortic valve
• Marfans, EDS, Turners, Noonans
• pregnancy

Question 2

AD

• Presentation
• Investigations and diagnosis

Answer 2

Severe chest pain => tearing between shoulder blades
Radio-radial/radio-femoral delay
Aortic regurgitation
HTN

Definitive - CAP CT angiography
-CXR - widened mediastinum

Question 3

AD

Classification and management

Answer 3

Stanford
A - ascending aorta <=> left subclavian - MORE COMMON
B - left subclavian <=> descending aorta

A - surgical repair => IV labetolol
B - IV labetolol and bed rest to prevent progression
-endovascular repair if severe

Question 4

AAA

• Pathophysiology
• Risk factors

Answer 4

AAA forms when wall is weakened and balloons

• HTN
• DM
• Smokers
• Conenctive tissue - Marfans, EDS

Question 5

AAA

• Presentation
• Investigations and diagnosis

Answer 5

Most are asymptomatic

• abdo/back/loin pain
• pulsatile mass
• rupture => shock, syncope

Definitive - abdo US
-CT angio to measure size

Question 6

AAA

• Management
• Screening

Answer 6

Asymptomatic and under 5.5cm => Duplex USS monitoring, address CV risk factors

• 3-4.4cm = yearly US
• 4.5-5.4cm = 3 monthly US

5. 5cm+/expanding 1cm+ every year/symptomatic => surgical repair
   - open or endovascular

Rupture
Immediate high flow O2
IV access - 2x large bore cannulas
Urgent bloods - FBC, U&E, clotting and crossmatch

Permissive hypotension - prevent excess blood loss

Transferred to vascular unit

• unstable => open surgical repair
• stable => CT angiogram to assess suitability for endovascular repair

65+ men

Question 7

DVT or PE

• risk factors and Wells Score
• presentation

Answer 7

Increased estrogen - female, pregnancy/postpartum, OCP

3 
-clinical signs of DVT - calf swelling, pain, redness
-no more likely diagnosis
1.5
-recent surgery, bedridden in last month
-past DVT
-tachycardia
1
-haemoptysis
-malignancy treatment in last 6 months

2+ = DVT likely
4+ = PE likely

Question 8

DVT

• investigations and diagnosis
• management

Answer 8

DVT likely => Leg US in 4hrs

• US :) => DOAC
• US :( => DD
• DD :) => US
• DD :( => alt diagnosis

DD + DOAC if US delayed => US within 24hrs

DVT unlikely => DD in 4hrs

• DD :) => US or interim DOAC
• DD :( => alt diagnosis

DVT provoked => 3months
DVT unprovoked => 6months

Question 9

PE

-presentation

Answer 9

More commonly presents with atypical symptoms
-always suspect if no other diagnosis more likely

Pleuritic pain, pleural rub
SOB/SOBOE
Hemoptysis
High RR, HR
Leg swelling, erythema

Question 10

PE

-investigations

Answer 10

PE likely => Immediate CTPA

• DOAC if delayed
• CTPA :) => diagnosis confirmed (O2, DOAC, Alteplase or embolectomy for massive PE, IVC filter for repeated)
• CTPA :( => DVT US

PE unlikely => DD within 4hrs

• DOAC if delayed
• DD :) => CTPA
• DD :( => stop AC

DD is a useful rule out test especially for
-those from the community