Page 1369 - TNFlipTest

Toronto Notes 2019 Aortic Disease
• pharmacotherapy
■ antiplatelet agents (e.g. Aspirin, clopidogrel)
■ statin and ACEI/ARB for global cardiovascular protection since patients with PAD are at increased
risk for CAD and CVD
■ cilostazol (cAMP-phosphodiesterase inhibitor with antiplatelet and vasodilatory effects): improves
walking distance for some patients with claudication (not available in Canada) • surgical
■ indications: severe lifestyle impairment, vocational impairment, critical ischemia ■ revascularization
◆ endovascular (angioplasty ± stenting)
◆ endarterectomy: removal of plaque and repair with patch (usually distal aorta or common/deep
femoral)
◆ bypass graft sites: aortofemoral, axillofemoral, femoropopliteal, distal arterial
◆ graft choices: saphenous vein graft (reversed or in situ), synthetic (polytetrafluoroethylene graft
(e.g. Gore-Tex® or Dacron®)
◆ amputation: if not suitable for revascularization, persistent serious infections/gangrene,
unremitting rest pain that is poorly controlled with analgesics
Prognosis
• claudication:conservativetherapy:60-80%improve,20-30%staythesame,5-10%deteriorate,5%will require intervention within 5 yr, <4% will require amputation
• forpatientswithcriticallimbischemia,at2yr:25%riskofmortality(secondarytoCVA/MI),25%risk of bilateral limb amputation, 25% risk of unilateral limb amputation, 25% without complications, 33% 5 yr survival rate
Vascular Surgery VS5
Differential Diagnosis of Lower Extremity Pain
Vascular
• Atherosclerotic disease
• Fibromuscular dysplasia
• Popliteal entrapment syndrome
• Venous claudication/hypertension
Neurogenic
• Neurospinal disease (e.g. spinal stenosis) • Complex regional pain syndrome
• Radiculopathies
• Diabetic neuropathy
MSK
• Osteoarthritis
• Rheumatoid arthritis/connective tissue
disease
• Remote trauma
Aortic Disease
Anterior midline
1. Ascending aorta 2. Right coronary 3. Left coronary
4. Arch of aorta
5. Braciocephalic
6. Right subclavian
7. Right common carotid 8. Left common carotid 9. Left subclavian
10. Descending aorta Thoracic:
11. Esophageal
12. Posterior intercostal 13. Subcostal
14. Superior phrenic
Abdominal: 15. Celiac
16. Left gastric
17. Common hepatic 18. Splenic
19. Superior mesenteric 20. Inferior phrenic
21. Superior suprarenal 22. Middle suprarenal 23. Renal
24. Gonadal
25. Lumbar
26. Inferior mesenteric 27. Median sacral
28. Common iliac
7 6
5
2
8
9
10
3 11
14
Lateral
Posterolateral
4
20
1
17
15
19
16 18
21 22
23
12
25
24 26
13
©Amy Cao 2019
28 27
Figure 3. Aortic anatomy
Aortic Dissection
Definition
Type A
• tearinaorticintimaallowingbloodtodissectintothemedia
• Stanfordclassification:TypeA(involvetheascendingaorta)vs.TypeB(distaltoleftsubclavianartery) • acute<2wk(initialmortality1%perhrforTypeAdissections)
• chronic>2wk
Etiology
• mostcommon:HTN
• other:connectivetissuedisease(e.g.Marfan’s,Ehlers-DanlostypeIV),cysticmedialnecrosis,
atherosclerosis, congenital conditions (e.g. coarctation of aorta, bicuspid aortic valves, patent ductus arteriosus), infection (e.g. syphilis), trauma, arteritis (e.g. Takayasu’s)
Type B
Figure 4. Stanford classification of aortic dissection
© Ken Vanderstoep