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’dOn 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