- What are the usual indications, in an otherwise fit person, for considering them for repair of an abdominal aortic aneurysm?
Indications for an abdomianl aortic aneurysm repair include:
- male with AAA>5.5cm
- female with AAA>5cm
- rapid growth of AAA of more than 1cm/year
- symptomatic AAA (abdominal pain, back pain or tenderness)
- AAA associated with peripheral arterial aneurysm ( iliac, femoral, or popliteal artery aneurysms) or symptomatic peripheral artery disease (eg, iliac occlusive disease) undergoing revascularization
- What are the features of a patient who presents with a rupturing Abdominal Aortic Aneurysm?
A typical clinical presentation will have features like:
- Sudden onset severe abdominal pain, radiating to the back
- Haemodynamic collapse – hypotension and tachycardia
- Pulsatile abdominal mass
- Distal embolization can cause acute limb ischemia
- retroperitoneal bleeds are more likely to present with the pt haemodynamically stable and back pain
- A 68 year-old man presents to ED with a one hour history of pain in the left side of his abdomen and mid back. It started suddenly, has not moved, and is getting worse. It is the worst pain he has experienced. He has a history of stable angina, managed with beta blockers and nitrates. On examination, he is pale, sweaty, has a pulse of 110 bpm, blood pressure of 100/65 mmHg, normal chest and cardiac exam. Abdominal exam reveals a tender mass in the epigastrium, which is pulsatile and expansile, peripheral pulses and neuro exam are normal.
- What is the diagnosis?
- What investigations and treatments are needed?
- The most likely diagnosis is a ruptured AAA.
Classical triad: severe abdominal pain radiating to the back + hypotension and tachycardia + pulsatile abdominal mass - Immediately notify senior ED staff and request immediate senior surgical referral, anaesthetics and ICU notification
attend to ABCs
- insert 2 x large bore peripheral IV cannulae,
- target SBP ~90 mmHg to maintain end organ perfusion (analogous to the permissive hypotension)
- cross-match 6+ units of blood, consider activation of massive transfusion protocol
- obtain FBC, UEC, coagulation profile, VBG and ECG
provide titrated analgesia (e.g. fentanyl or morphine)
Treatment is surgical. o Endovascular Aneurysm Repair (EVAR) - Most effective for ruptured AAA - Insertion of a stent using a guidewire and angiographic guidance o Open Repair
- What are the treatment options for an otherwise fit 75 year-old man who has been found to have a 6cm AAA (abdominal aortic aneurysm) on routine screening?
Elective surgical repair is indicated in a male patient with an AAA >5.5cm
Management options include:
- Conservative treatment - If the patient declines surgery or isn’t fit for surgery
- Endovascular Aneurysm Repair (EVAR)
- Open repair
Conservative treatment involves:
o Watchful waiting
o Cardiovascular risk reduction AND
o Antiplatelet therapy
EVAR:
- Percutaneous access via iliac/ femoral arteries
- Graft components delivered to wall off aneurysm from circulation
- Less invasive, better 30 day morbidity and mortality but similar long term outcomes
- Risk of occlusion, graft migration, late rupture
Open involves: Midline/ transverse incision Occlusion of vessels above and below Placement of prosthetic graft Associated risks with open: Acute renal failure Wound infection Aorto-duodenal fistulae Distal embolization Colonic ischaemia Graft infection Peri-operative bleeding
- What are the common complications of endovascular (stent) repairs of abdominal aortic aneurysms?
Complications can be categorise into:
- access site complications
- endograft complications
- systemic complications
Access site complications include:
- hematoma
- acute thrombosis of the accessed vessel
- distal embolization
- dissection
- pseudoaneurysm
- arteriovenous fistula
Endograft complications include:
- endoleak- persistent flow of blood into the aneurysm sac after device placement and indicates a failure to completely exclude the aneurysm
- endograft migration
- endograft infection
- kinking/ occlusion/ stent fractures / component separation
Systemic complications include: - Cardiopulmonary disease (e.g. Myocardial Infarction) - IV contrast complications Allergy Contrast nephropathy - Ischaemia – due to thrombosis, embolism, arterial dissection, obstruction related to positioning or kinking of the graft Renal Intestinal Lower limb Pelvic
- Post-implantation syndrome- fever, leukocytosis, elevated CRP
- What are the main indications for carotid endarterectomy (CEA, carotid surgery)?
- If patient is symptomatic: 1 or more ischemic event in the past 6 months or stenosis >50% (the bigger the occlusion -99%, more benefit)
- If patient is asymptomatic: occlusion >80% is shown to be beneficial than medical management.
- If patient has life expectancy >5years for male, >10 years for female
Absolute contraindication is if there is asymptomatic complete occlusion on contralateral side.
- A 71 year-old man presented to the ED with weakness and numbness in his left arm. These symptoms started suddenly two hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, he is a lifelong smoker. Physical exam is normal, other than the numbness.
- What is the likely diagnosis?
- What investigations are needed?
- The most likely diagnosis is Transient Ischemic Attack (TIA) of the right MCA.
A TIA a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow, which renders the brain ischemic in the area producing the symptom.
Ddx include: stroke, seizures, space occupying lesion
- Necessary Ix include:
- Bloods: FBC, UEC, BGL, PT/ APTT (Concurrent liver disease/ anti-coagulated), fasting lipids
- ECG
- Non-contrast CT (exclude haemorrhage)
- Diffusion weighted MRI
- Vascular imaging: Carotid doppler US, CTA/ MRA (angiography)
- A 71 year old man presents to the ED with weakness and numbness in his left arm. These symptoms started suddenly two hours ago. His vision was not affected, and the numbness and weakness is getting better. He has no other symptoms, he is a lifelong smoker. Physical exam is normal, other than the numbness.
- What is the likely diagnosis?
- What are the risk factors for this disease?
- The most likely diagnosis is Transient Ischemic Attack (TIA) of the right MCA.
A TIA a sudden onset of a focal neurologic symptom and/or sign lasting less than 24 hours, brought on by a transient decrease in blood flow, which renders the brain ischemic in the area producing the symptom. - Risk factors for this disease are:
- Non-modifiable
o Increasing age
o Male
o FHx (premature CVA)
- Lifestyle o Smoking o Obesity o Lack of exercise o Western diet - Disease o Previous TIA/stroke o Hypercoagulable state (Factor V Leiden, Protein C/S Deficiency, Antithrombin III deficiency) o Diabetes Mellitus o Hypertension o Dyslipidaemia o Other Atherosclerotic disease such as Coronary Artery Disaese or Peripheral Artery Disaese e.g. Carotid Stenosis o AF o Valvular Heart Disease
- Medications
o OCP
- A 65 year-old man presents to the ED with an eight hour history of abdominal severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50 mmHg. His temperature is 37.5°C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderatley raised CRP at 40, a near normal amylase and the rest are normal. His aterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of - 6.5, and a PaCO2 of 3.5.
- What does the arterial blood gas show?
- What is the most likely diagnosis?
- How should he be managed?
- The arterial blood gas shows metabolic + lactic acidosis with partial respiratory compensation.
- The likely diagnosis is acute mesenteric ischemia (a type of ischemic bowel disease) due to classic triad of severe abdominal pain + AF + old age.
Acute mesenteric ischemia occurs mostly due to arterial compromise (embolism, thrombosis) in superior mesenteric artery. Hence, blood in stool, increase in lactate and CRP, pain
- • Initial resuscitation (ABCDE, supplemental O2, IV access, IV fluids)
• NBM
• NGT decompression
• Analgesia
• Call: intervention radiologist and vascular/ general surgeon
• Empirical Abx: Ceftriaxone + Metronidazole
• Investigations: o FBC, UEC, VBG (done) o ECG o Erect CXR and Supine AXR o Mesenteric angiography/ CTA
• Definitive management:
- The traditional treatment of acute mesenteric arterial embolism is early surgical laparotomy with embolectomy since it provides rapid treatment and allows direct inspection of the bowel
o Endovascular therapy can also include balloon angioplasty with arterial stent placement
o Any infarcted bowel should be resected
- You are the ED intern on duty. You are asked to see and treat a 75 year-old man who has presented with sudden onset of pain in his left leg. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal.
What are you going to do?
Most likely diagnosis is acute limb ischemia.
I would take Hx, examination, investigations and plan management.
In terms of history,
- Ask about pain – SOCRATES
- 6 P’s of ischemic limb – Pain, Pallor, Pulselessness, Paraesthesia, Perishingly cold, Paralysis
- Trauma history
- Coronary artery disease
- Atherosclerotic risk; smoking, lipids, DM, HTN, AF, recent MI, Fam hx
O/E,
- Inspect for loss of hair, pulselessness, pallor, coldness, oedema, tenderness
- Examine sensation and movement/power
- Also perform CV exam
IX,
- Ankle-brachial index (ABI) is first line, if <0.9 is indicative of PVD
- Toe-brachial index (TBI) if ABI not possible
- ECG
- Doppler U/S
- CT angiogram
Mx:
• Contact vascular surgeon
Tx requires urgent assessment for viability of the limb + give antiplatelet, analgesia, anticoags
For viable limbs – they are revascularized using endovascular or thrombolytic method or surgical thrombectomy
For non-viable limbs – they are amputated
- You are the ED intern on duty. You have seen a 75 year-old man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal.
- What is the likely diagnosis
- What may have caused it
- what are you going to do?
- Acute Limb Ischemia
2.
Aetiology:
• Embolism
o Cardiac causes : AF, valvular vegetation, LV thrombus secondary to LV dysfunction,
o Non-cardiac: Atherosclerotic embolus, aneurysmal
• Thrombosis (most common for lower limb)
o Thrombosis of native vessel (atherosclerosis or aneurysm)
o Occlusion of a bypass graft
• Trauma
o Blunt
o Penetrating
• Rarer causes:
o Vasculitis
o Aortic dissection
- Confirm the diagnosis with necessary investigaions, call for vascular surgeons, supportive care and definitive treatment based on assessment.
Ix- ankle-brachial pressure index (ABPI), duplex doppler USS, CTA
- supportive care; protect limb with heel pad, dont elevate, analgesia
- UFH IV bolus + IV heparin infusion
• Definitive treatment:
o Thrombolysis – viable limb
o Surgical revascularisation/embolectomy – threatened limb
o Amputation – non-viable limb
- You are the ED intern on duty. You have seen a 75 year-old man with a painful left leg of sudden onset. He has a cardiac history (AF and hypertension) and he smoked for 60 years. On examination he has a left cold leg from mid thigh downwards with no palpable pulses below the femoral pulse. His right leg is normal.
What are the clinical signs that you will assess to determine whether the leg is salvageable, or that it is beyond help and needs amputation?
Likely diagnosis is acute limb ischemia.
The limb is non-viable if there are signs of tissue loss, sensory loss, nerve damage.
The limb is viable if it has none of these and artery anatomy is defined.
The clinical signs to determine are:
- No capillary refill
- if the Doppler results are audible or inaudible
- Complete motor/sensory deficit
- Paralysis
- Tissue loss/gangrene
- A 54 year-old insulin diabetic presents to the ED complaining of increasing pain in her right foot that has been developing over one week. It is worse at night, partially relieved by hanging her foot over the side of the bed. Her right great toe has become swollen, red in parts and discoloured in others. She is febrile (37.7°C), pulse 86 regular, BP 130/80 mmHg, blood glucose 13.2 mmol/L. Femoral pulses are present bilaterally, but no distal pulses can be felt below this, the right great toe is erythematous with a large fluctuant swelling at the base.
- What does this clinical appearance suggest?
- What investigations are needed?
- What treatment is needed?”
- This suggests a peripheral vascular disease which is now critical limb ischemia due to resting pain. An abscess has formed in the great toe and patient’s DM is poorly managed (BSL 13.2).
- Investigations needed are:
- FBC, CRP, ESR
- BSL, HbA1c
- abscess swap & culture
- Ankle brachial index
- Doppler U/S on lower limb
- CT angiogram
- X-Ray (complication can cause osteomyelitis) - • Vascular consult regarding revascularisation or amputation and appropriate treatment
• Incision and drainage of the abscess
o Empirical Abx: flucloxacillin
• Diabetic management: endocrinology and podiatry review, as well as other allied health staff for diabetic care
- What factors will a vascular surgeon consider when planning treatment for peripheral vascular disease in a patient’s foot?
The main factors to consider are viability, severity, patient’s age and comorbidities.
The foot is decided whether it is viable or not by assessing the tissue necrosis, nerve damage, sensory/motor loss.
All patients should have aggressive risk factor modification
- Smoking cessation
- BP control, lipid control
- Diabetes control -medication compliance
All patient with diagnosis should be started on medication
- Anticoagulation (heparin)
- Antiplatelet (aspirin or clopidogrel alone)
- Analgesia (opioid and paracetamol)
For moderate and disabling claudication patients medical therapy and exercise program are started. If this fails they are assessed for anatomy definition and surgical revascularisation.
For critical ischemic limbs, urgent revascularisation (balloon angioplasty with stenting or bypass grafting) should be done and consider amputation if required due to non-viable limb.
- How does a vascular surgeon decide the level of amputation if one becomes necessary for peripheral vascular disease?
The level of the amputation is dictated by the extent of the disease, healing potential of the stump, and rehabilitation potential of the patient. The decision is made through physical examination and objective testing.
On physical examination, they should have arterial pulse just proximal to the level of amputation to ensure healing. Should be inspected for gangrene/ulcers, infections, pulselessness, pallor, coldness and all affected limb should be amputated.
Objective testing include, ankle pressures, toe pressures, transcutaneous oximetry, skin perfusion pressure (measurement of Skin Perfusion Pressure is with laser Doppler a non-invasive test.)
- What anatomical levels are commonly used for amputations in the lower limb for peripheral vascular disease?
Above knee amputation (femoral)
- Bone transected 12-15cm (1/3) above knee, this is common in end stage PVD
Below knee amputation (tibial)
- Good for prosthetic fitting
- Tibia transected 12cm below tibial tuberosity with posterior flap
Through knee
- Requires wide stump, unpopular
Syme’s ankle disarticulation (malleolar)
- Only used in trauma and diabetics, prosthetic is difficult
Lisfrank or Chopart- midfoot amputation
Transmetatarsal
- For diabetics, gangrene toes
- A 59 year-old woman presents to the ED with pain and tingling in her right hand and forearm. It started suddenly four hours ago. It has improved, and the pain is gone, but the numbness remains. There is no history of trauma and no previous episodes. She has no significant medical history, but is waiting to see a cardiologist for “palpitations”. On examination the right hand and forearm are cool to touch. The radial and ulnar arterial pulses are absent on that side, pulses elsewhere are normal. Sensation is mildly reduced, but she has full range of movement in the hand.
- What is the likely diagnosis?
- What investigations are needed?”
- Acute upper limb ischemia due to sudden onset of pain, no identifiable trauma, decrease in sensation, post AF and (pulselessness, paraesthesia, perishingly cold, pain).
Differentials can include cubital tunnel, carpal tunnel, compartment syndrome.
2. Ix: • Bloods: FBC, UEC, BSL, lipids, ESR/CRP, Coags • ECG • Duplex Doppler USS upper limb • CTA/ conventional angiography • Echocardiography
- A 59 year-old woman presents to the ED with pain and tingling in her right hand and forearm. It started suddenly four hours ago. It has improved, and the pain is gone, but the numbness remains. There is no history of trauma and no previous episodes. She has no significant medical history, but is waiting to see a cardiologist for “palpitations”. On examination the right hand and forearm are cool to touch. The radial and ulnar arterial pulses are absent on that side, pulses elsewhere are normal. Sensation is mildly reduced, but she has full ranges of movement in the hand.
- What is the likely diagnosis?
- What are the common causes of this problem?
- How are they diagnosed?
- Acute upper limb ischemia
Most common cause for upper limb PVD is from emboli (different to LLI which is thrombosis)
- Commonly source is from cardio, after AF, valvular disease, MI, tumour (atrial myxoma)
Thrombosis
- Atherosclerosis of the native vessel
- Occlusion of a graft bypass
Trauma
- Blunt or penetrating trauma
- They are diagnosed with:
• History and examination
• Bloods: lipids (atherosclerosis), ESR/CRP (vasculitis)
• ECG (AF)
• Echocardiography (valvular heart disease, LV dysfunction, tumour)
• doppler USS/ CT (aneurysm)
• Vascular imaging: angiography/ CTA/ MRA
- A 59 year-old woman presents to the ED with pain and tingling in her right hand and forearm. It started suddenly four hours ago. It has improved, and the pain is gone, but the numbness remains. There is no history of trauma and no previous episodes. She has no significant medical history, but is waiting to see a cardiologist for “palpitations”. On examination the right hand and forearm are cool to touch. The radial and ulnar arterial pulses are absent on that side, pulses elsewhere are normal. Sensation is mildly reduced, but she has full ranges of movement in the hand.
- What is the likely diagnosis?
- What are the treatment options?
- Acute upper limb ischemia
- Treatment options include medical and surgical interventions.
- risk factor modification is considered – smoking cessation, diabetes control, BP control, lipid control increasing exercise, weight loss
Medical treatment is with Anticoagulation – UFH IV bolus + infusion
•Referral to a vascular surgeon for either: o Intra-arterial thrombolysis o Embolectomy o Angioplasty with stenting o Bypass grafting o Amputation
- Varicose Veins.
Q1. What two significant venous abnormalities are visible on this picture?
Q2. How should this patient be investigated?
Q3. What are the complications if the venous hypertension goes untreated.
Q4 What is the mainstay of treatment for this condition.
- dilated superficial veins (>3mm), twisting of veins.
- clinical examination (hx + exam), duplex ultrasound
- chronic venous insufficiency which causes stasis and complications such as varciose eczema, lipodermatosclerosis (inflammation of the layer of fat under the epidermis), venous leg ulcers
- Conservative approach (lifting leg up, exercise, compression stockings, ulcer wound management), surgical approach involves endovenous tx; sclerotherapy or ablation or surgical excision
- A 65 year-old man presents to the ED with an eight hour history of severe, generalised abdominal pain. Earlier in the day he passed fresh blood in his stool, there is no previous episodes of blood PR. His medical history included AF, diabetes mellitus and hypertension. He is a long term smoker. He is restless with pain. His pulse is 110 irregularly irregular. His BP is 90/50 mmHg. His temperature is 37.5°C. Abdominal examination shows acute pain but a soft, non-rigid abdomen. Rectal exam shows fresh blood mixed into normal stools. His venous blood tests show a normal Hb, slightly raised white cell count (neutrophilia), a moderately raised CRP at 40, a near normal amylase and the rest are normal. His arterial blood gases show a pH of 7.29, lactate of 9.4 and base deficit of (-6.5), and a PaCO2 of 3.5. 1. What does the arterial blood gas show?
- What is the most likely diagnosis?
- What are reasonable differential diagnoses?
- The arterial blood gas shows metabolic + lactic acidosis with partial respiratory compensation.
- The likely diagnosis is acute mesenteric ischemia (a type of ischemic bowel disease) due to classic triad of severe abdominal pain + AF + old age.
Acute mesenteric ischemia occurs mostly due to arterial compromise (embolism, thrombosis) in superior mesenteric artery. Hence, blood in stool, increase in lactate and CRP, pain
- Differentials include:
- AAA rupture
- Bowel obstruction
- Acute pancreatitis
- Diverticulitis
- Inflammatory bowel disease
- Infective colitis, gastroenteritis
