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 ID: 480292
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Slide1
AAA and PVD
Emily Pallister and Sanjena MithraSlide2
The plan…
CasesBasic facts you probably already know!Finals style tasksSlide3
Objectives
To demonstrate common clinical presentations of PVD and AAATo revisit incidence, pathogenesis and management of PVD (Arterial and Venous, Ulcers) and AAATo revise the difference between acute and chronic limb ischaemiaTo consider approach to these cases in finalsSlide4
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: HypertensionSlide5
Questions…
Is this a typical presentation?How would you investigate/manage this patient?Slide6
Investigations and Management
Management:History and examinationBloods incl FBC, UE, G&S
Investigations – USS/CTECGConsider CPEX and ECHOEVAR/Open RepairSlide7
Aneurysms
Definition: Permanent dilation of artery to 2x normal diameterTrue Aneurysm:
All layers of arterial wall involvedDue to degeneration of elastic lamina and SM lossFalse Aneurysm: Blood collects around vessel wall communicating with lumen. Surrounding tissues form wall of aneurysm.Slide8
Some facts about AAA!
5% incidence over 60 y.o. Increases with age.5M:1FRisk of rupture <1%/yr when AAA <5.5cm
25%/yr when AAA >6cmSymptoms:Usually asymptomatic except when impending rupture – Severe epigastric pain radiating to back.
HR BP
HbSlide9
Peripheral Arterial Disease
Mild
ischaemiaCramping painCalf/thigh/buttockFixed 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 <0.3Slide10
Peripheral Arterial DiseaseSlide11
Case 2
45 yo gentleman admitted via A&E with dry necrotic right hallux.What else do you want to know about this patient?Slide12
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?Slide13
InvestigationsSlide14
Task
You decide that this patient would benefit from an angiogram. Explain the procedure to the patient and consent for the process.Slide15
Acute limb ischaemia
Embolic
(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
surgerySlide16
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 fibrosis
CEAP Key
C0
No
venous disease
C1
Telangectasia
/reticular veins
C2
Varicose veins <3mm
C3
Oedema
C4
Skin changes i.e.:
4a
– eczema +
haemosiderin
4b –
lipodermatosclerosis
C5
Healed venous ulcer
C6
Active venous ulcerSlide17
Case 3
87 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
Site
Duration
Regional
features e.g. pulses, CRT
Depth
Previous ulcers
Patients
general health
Base
Pain
Known
PVD
Slough
Diabetes
SmellSlide18
Ulcers
Complete loss of epidermis and part of dermisAffects 2% population
VenousArterialDiabetic/Neuropathic
Mixed
arterial and venous
70%
2%
(15% of diabetics)
15%
Painless
Painful
Painless
Red granulation
Dark necrotic
base
Deep.
I
nfected
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