PVD, AAA and renal stones Dörthe and Jo

Case Study Bob, 70 years old 1 month history intermittent back pain

HPC Slumbosacral QDull achy sensation Sometimes sharp I5-7 /10 TIntermittent Varies in duration ALow back movement, standing, sitting, driving Partially relieved by tramadol RRadiates to posterior leg SNo morning stiffness No bowel/ bladder problem No lower limb weakness or tingling sensation No weight loss or fever No interruption to walking No recent trauma/heavy lifting

PMH/ Risk factors Risk factorImportance / Relevance Hypertension Hypercholesterolaemia Smoking Diabetes Atherosclerosis Age5% of population over 60 15% of population over 80 FHxGenetic in 10-20% of First degree relatives -Marfan’s -Ehler’s Danlos GenderMale to female ratio 6:1

Presenting complaint of AAA Aneurysm asymptomatic Increasing size epigastric or back pain Leak/ Rupture Testicular pain Collapse Abdominal pain

On Examination Feel above the umbilicus for aortic aneurysm If leaking or rupture Hypotension Tachycardia pallor Pulsatile mass Abdominal pain Back pain

Definition Abnormal dilatation of abdominal aorta over 2x the normal size (2cm) or enlargement over 3cm Most commonly affects infrarenal aorta 95% with iliac involvement in 30% 6000 deaths per year in england and wales

True or false aneurysm? True aneurysm – Dilatation of all three layers of vessel False aneurysm – Dilatation of artery not involving all three layers

Aetiology Atherosclerotic in 95% 5% inflammatory Others – Traumatic – Infective (mycotic aneurysm) – CTD – Ehler’s Danlos,Marfans

Pathophysiology Decrease of amount of medial and adventitial elastin Other possible places – Aorta – Iliac – Popliteal – Femoral arteries

Investigations Acute – CT scan, Bloods, ECG US for screening purposes ( over 65 ) AAA on AXR – eggshell appearance due to calcification aneurysm wall

Management Conservative – If asymptomatic – Under 5.5cm – Regular follow ups with US – Management of cardiovascular risk factors Surgical – Prosthetic graft placement – rewrapping of native aneurysm around to reduce incidence of enterograft fistula formation – Endovascular EVAR – placement stent through distant percutaneous access

Criteria for surgery 1.AAA over 5.5 cm 2.Rupture 3.Rapid growth 4.Embolisation of plaque 5.Symptomatic

Complications General Risk of rupture – Under 5cm – 4% – 5-7cm diameter – 7% – More than 7cm – 20% Rupture Distal embolus Sudden complete thrombosis Fistulae formation Infection Of surgery Elective mortality – under 4% Emergency surgery mortality 50% Haemorrhage Graft infection Thrombosis/embolism Colonic ischaemia Renal failure

Peripheral vascular disease

Definition Also called peripheral arterial disease Occlusive atherosclerotic disease in lower extremities Occlusion distal to aortic arch Up to 12% of 55-70year old affected Rare causes – vasculitis, Buerger’s disease

Atherosclerosis Atheromas containing cholesterol and lipid form within intima and inner media, often accompanied by ulceration and smooth muscle hyperplasia Risk factors – hypertension, smoking, diabetes, FHx, hypercholesterolaemia, high LDL, obesity

Smooth muscle hyperplasia and plaque deposition Growth factor release Platelets adhere Endothelial injury

Presentation Buttock, thigh, calf, foot On exercise, especially uphill Relieved by rest Claudication distance reproducible Intermittent claudication Critical ischaemia Worse at night Relieved by hanging leg out of bed Pain in foot, usually metatarsal Rest pain Absent femoral pulses Buttock claudication +- impotence Leriche’s syndrome

On examination Legs – Weak/ absent pulses – Reduced CRT – Cold, pale legs – Hair loss – Atrophic skin changes – Painful, punched out ulcers – pressure areas – venous ulceration – medial malleolus Also examine CVS

Investigations Handheld Doppler ABPI – Normal= 1, claudication <0.6, rest pain <0.4 Bloods –anaemia, ESR, thrombophilia screen, lipids ECG - ?CAD Arterial Duplex CT angiogram Angiogram

Cx of PVD Amputation Gangrene – Dry – dry necrosis of tissue without signs of infection – Wet – moist necrotic tissue with signs of infection Ulcers Risk of limb loss with claudication 5% per year Risk of limb loss with rest pain over 50% per year

Management – Conservative and Medical RF Smoking Exercise Weight Statins Anti HTN DM Mx Antiplatelets Aspirin Clopidogrel Vasodilators Naftidrofuryl oxalate

Surgical Management Indications – Disabling claudication – Critical ischaemia – Weak/absent femoral pulses Angioplasty +- stenting Surgical bypass graft

Prognosis High risk for all-risk mortality, especially cardiovascular 15% progress to critical ischaemia 50% improve 25% stabilise 20% worsen – 20% need intervention – 8% need amputation