AAA and PVD
Emily Pallister and Sanjena Mithra
The plan…
• Cases• Basic facts you probably already know!• Finals style tasks
Objectives
• To demonstrate common clinical presentations of PVD and AAA
• To revisit incidence, pathogenesis and management of PVD (Arterial and Venous, Ulcers) and AAA
• To revise the difference between acute and chronic limb ischaemia
• To consider approach to these cases in finals
Case 1
• 80 yo gentleman sent by GP to A&E. Had been investigated for right hip pain. Xray of right hip demonstrated no hip injury but GP noted calcified aneurysmal aorta.
• PMH: Hypertension
Questions…
• Is this a typical presentation?• How would you investigate/manage this
patient?
Investigations and Management
Management:1. History and examination2. Bloods incl FBC, UE, G&S3. Investigations – USS/CT4. ECG5. Consider CPEX and ECHO6. EVAR/Open Repair
Aneurysms
• Definition: Permanent dilation of artery to 2x normal diameter• True Aneurysm: All layers of arterial wall involvedDue to degeneration of elastic lamina and SM loss• False Aneurysm: Blood collects around vessel wall communicating with lumen. Surrounding tissues form wall of aneurysm.
Some facts about AAA!
• 5% incidence over 60 y.o. Increases with age.• 5M:1F• Risk of rupture <1%/yr when AAA <5.5cm
25%/yr when AAA >6cm
Symptoms:Usually asymptomatic except when impending rupture – Severe epigastric pain radiating to back. HR BP Hb
Peripheral Arterial Disease
Intermittent Claudication
Rest Pain
Critical
Ischaem
ia
- Mild ischaemia- Cramping pain- Calf/thigh/buttock- Fixed claudication
distance- ABPI 0.9-0.6
- Severe ischaemia
- Burning pain in foot
- Shorter distance- No tissue loss- Worse at night- ABPI 0.6-0.3
- Severe ischaemia + tissue loss
- Gangrene- Whole limb
threatened- Painful, cold,
numb- ABPI <0.3
Peripheral Arterial Disease
Inspection
Palpation
[Percussion]
Auscultation
Special Tests
Case 2
45 yo gentleman admitted via A&E with dry necrotic right hallux.
What else do you want to know about this patient?
Case 2 cont’d
On examination the gentleman has a pale, cold right leg with no distal pulses felt. He has no tissue loss. He reports long standing rest pain and is suffering a lot of pain currently. He has extensive smoking history but is not diabetic.
What will your initial investigations/management be?
How would you stage his PVD?
Investigations
Arterial Duplex DSA
MRA CTA
Task
You decide that this patient would benefit from an angiogram.
Explain the procedure to the patient and consent for the process.
Acute limb ischaemiaEmbolic (38%) Thrombotic (40%)
Embolus from heart in AF/MS or during MI
Includes thrombosis of aneurysm or embolus from
aneurysm
Complete occlusion Incomplete occlusion + collateralisation
Rapid onset Slower onset
Leg:Arm 3:1 Leg:Arm 10:1
Often no previous claudication Usually previous claudication
Artery soft to palpate Calcified artery
Diagnosis often clinical Diagnosis from angio
Treated with embolectomy/thrombolysis and
anticoagulation
Treated with angioplasty/bypass surgery
Peripheral Venous Disease
• Due to valvular incompetence or damage to veins.• Blood can’t drain from capillaries. Irritates skin ->
impairs 02 exchange -> tissue breakdown and fibrosisCEAP Key
C0 No venous disease
C1 Telangectasia/reticular veins
C2 Varicose veins <3mm
C3 Oedema
C4 Skin changes i.e.:4a – eczema + haemosiderin4b – lipodermatosclerosis
C5 Healed venous ulcer
C6 Active venous ulcer
Case 387 yo lady referred in from district nurses with extensive bilateral ulcers, worse on the right.
What questions do you want to ask us regarding the ulcers?
Any trauma? Surrounding tissue SiteDuration Regional features e.g.
pulses, CRTDepth
Previous ulcers Patients general health Base
Pain Known PVD Slough
Diabetes Smell
Ulcers
• Complete loss of epidermis and part of dermis• Affects 2% population
Venous Arterial Diabetic/Neuropathic
Mixed arterial and venous
70% 2% (15% of diabetics) 15%
Painless Painful Painless
Red granulation Dark necrotic base Deep. Infected
Oedematous edge Punched out Punched out/callus
Gaiter area Anterolat aspect of ankles and toes
At pressure points, between toes
Haemosiderin pigmentation
Cold and pale skin Foot maybe warm
Pulses present Pulses absent Pulses present
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