ABDOMINAL AORTIC ANEURYSM Fast Facts - Aneurysm: permanent dilation of an artery with an increase in diameter >50% (1.5 normal size) - Ectasia: diameter increased <50% - Infrarenal aorta most common - Male aortas are 20% larger than female - If there is a ƉŽƉůŝƚĞĂůĂŶĞƵƌLJƐŵ͕LJŽƵŵƵƐƚůŽŽŬĨŽƌ͕ŽƚŚĞƌǁŝƐĞŝƚ͛Ɛmalpractice - Familial component: screen for any first degree relative Cause/Pathogenesis - Atherosclerosis in most cases - Increased collagen:elastin - Inflammation - Chlamydia/syphilis - Higher rupture risk in emphysema patients - Ehlers-Danlos Clinical Manifestations - Most are asymptomatic o incidental finding on imaging/abdominal surgery - Back/flank/abdominal pain - Abrupt onset 10/10 pain - Hypotension - Shock - Pulsatile abdominal mass - 25% are ruptured Diagnostic Methods 1. Physical: AAA ~5cm to palpate 2. XR: ĐĂŶĞƐƚĂďůŝƐŚĚŝĂŐŶŽƐŝƐ͕ĐĂŶ͛ƚƚĞůůLJŽƵŵƵĐŚŽĨĂŶLJƚŚŝŶŐĞůƐĞ 3. US: Accurate, not good for thoracic/suprarenal, not accurate for rupture 4. CT: radiation, good visualization, nephrotoxic 5. MRI: better at visualizing 6. Aortography: GOLD STANDARD, rarely used, CTA less invasive Operate/Follow Up - If AAA <4.5 cm and asymptomatic repeat US in 6 mo o if unchanged, return in 1 year - If AAA >4.5 cm repeat US 1 year - If 5cm, >1cm growth in 1 year, or if there are any symptoms (regardless of size)
operate - Once ruptured, mortality is 100% (said 90% at beginning so idk) Treatment No cure, we want to decrease rupture ƌŝƐŬďLJ͙ - Control BP - No heavy lifting (>15 lbs) - Stop smoking - Ambulation - Antiplatelet - 3 surgical approaches o Oblique: retroperitoneal, avoids juggling organs Prior to surgery - Cardiac eval, pulmonary function test, type & screen Post-Op Must monitor indefinitely Repeat CT @ - 1 month - 6 month - 1 year - yearly PERIPHERAL VASCULAR DISEASE OF THE LOWER EXTREMITIES General Considerations - 70% stenosis operate Causes of ASPVD - Genetics - Tobacco use - HTN - DM - HLD - Increased homocysteine - Female (estrogen, smaller arteries) Pathophysiology of LEOD - Diabetic patient
more susceptible to ischemia
higher risk of amputation o neuropathy, decreased arterial flow/resistance to infection o Charcot joint Symptoms - Intermittent claudication o cold calves/feet, presents similar to compartment syndrome o Paralysis, pulseless, pain, pallor, paresthesia, poikilothermy (cold) - Leriche Syndrome: pain in buttocks due to aorta/aortoiliac disease - Rest pain - Ischemia/gangrene Physical Exam - Bruit - Thrills (bruit you can feel) - cold skin - capillary refill - ulcers - Pulse exam (0: no feel, 1: barely there, 2: good/normal) - Monofilament testing: always do on DM pts, checks neuropathy Diagnosing - ABI
Doppler LE Arterial
Angiogram
surgical intervention - Segmental limb pressure/ABI o Pressure legs > arms o 1.0 Normal o >1.3: calcification, ignore this o <0.9: PAD <0.5 ʹ severe <0.4 ʹ pain at rest <0.3 ʹ ischemia/gangrene - Duplex scanning o Triphasic: good arterial flow o Biphasic/Monophasic: bad flow - Contrast study o Gold Standard: Aortogram with runoffs o CT/MRA ʹ pay attn to renal function - Angiograms (See below)
operate - Once ruptured, mortality is 100% (said 90% at beginning so idk) Treatment No cure, we want to decrease rupture ƌŝƐŬďLJ͙ - Control BP - No heavy lifting (>15 lbs) - Stop smoking - Ambulation - Antiplatelet - 3 surgical approaches o Oblique: retroperitoneal, avoids juggling organs Prior to surgery - Cardiac eval, pulmonary function test, type & screen Post-Op Must monitor indefinitely Repeat CT @ - 1 month - 6 month - 1 year - yearly PERIPHERAL VASCULAR DISEASE OF THE LOWER EXTREMITIES General Considerations - 70% stenosis operate Causes of ASPVD - Genetics - Tobacco use - HTN - DM - HLD - Increased homocysteine - Female (estrogen, smaller arteries) Pathophysiology of LEOD - Diabetic patient
more susceptible to ischemia
higher risk of amputation o neuropathy, decreased arterial flow/resistance to infection o Charcot joint Symptoms - Intermittent claudication o cold calves/feet, presents similar to compartment syndrome o Paralysis, pulseless, pain, pallor, paresthesia, poikilothermy (cold) - Leriche Syndrome: pain in buttocks due to aorta/aortoiliac disease - Rest pain - Ischemia/gangrene Physical Exam - Bruit - Thrills (bruit you can feel) - cold skin - capillary refill - ulcers - Pulse exam (0: no feel, 1: barely there, 2: good/normal) - Monofilament testing: always do on DM pts, checks neuropathy Diagnosing - ABI
Doppler LE Arterial
Angiogram
surgical intervention - Segmental limb pressure/ABI o Pressure legs > arms o 1.0 Normal o >1.3: calcification, ignore this o <0.9: PAD <0.5 ʹ severe <0.4 ʹ pain at rest <0.3 ʹ ischemia/gangrene - Duplex scanning o Triphasic: good arterial flow o Biphasic/Monophasic: bad flow - Contrast study o Gold Standard: Aortogram with runoffs o CT/MRA ʹ pay attn to renal function - Angiograms (See below)
