Skin ulcers are a common presentation to general practice – affecting 2-3 patients per 1000 per year, and can have several important causes:

• Venous ulcers
  • Due to venous blood stasis
• Arterial ulcers
  • A manifestation of peripheral vascular disease
• Mixed, venous and arterial ulcers
• Pressure sores and diabetic ulcers
  • Typically the result of excessive pressure to an area of skin, due to lack of sensation in this area from diabetic nephropathy
  • Also seen in immobile patients

Other rare causes can include:

• Autoimmune vasculitis – e.g. associated with rheumatoid arthritis, SLE
• Tropical disease
• TB
• Skin cancers
• Insect / spider bites

It is also important to differentiate between leg and foot ulcers as the causes are often very different:

• Leg ulcers
  • 65% are venous
  • 15% are arterial
  • 20% are other causes
• Foot ulcers
  • 70% are arterial
  • 5% are venous
  • 25% are other causes

Most ulcers are multifactorial, and important factors are obesity and sedentary life-style.

Treatment requires a multi-faceted approach. Regular wound dressings, and removal of dead sloughed tissues aids recovery. The use of moist dressings is important to create a physiological environment for healing. Wound swabs are often not useful as all chronic ulcers will become colonised with gram positive and gram negative bacteria.

Compression bandages are important in both treatment as prevention as they help to reduce venous stasis and promote blood flow.

Consider skin cancer, particularly SCC in any ulcer that fails to respond to treatment.

History

• Factors that make peripheral vascular disease (arterial ulcers) more likely:
  • Smoker or ex-smoker
  • Known cardiovascular disease (e.g. previous CVA or MI, history of coronary artery disease, angina)
  • History of claudication
• Past medical history
  • PVD
  • Diabetes
  • Rheumatoid arthritis, SLE or inflammatory bowel disease
• Drug history
  • Beta-blockers – can reduce peripheral blood flow
  • Steroids and NSAIDs – can reduce skin healing

Examination

• The most important part of the examination is checking the peripheral pulses!
  • Strong pulses throughout, indicate that arterial disease is unlikely
  • Absent pulses suggest arterial disease
• Ulcer location
  • Inside of the ankle and calf – likely venous ulcer
  • Areas of pressure – likely diabetic ulcer
  • Lateral foot and lower leg – likely arterial ulcer
  • Sun exposed areas – think about risk of skin cancers
• Appearance of the ulcer
  • Look at the wedge of the ulcer, and the base of the ulcer
  • A “punched out” ulcer refers to one that has clean straight edges and base – more likely arterial
  • An “undermined” lesion refers to a wide base of the ulcer, relative to the ulcer opening. Suggest pressure sores or diabetic ulcer
  • Lesions with raised edges suggest skin cancers (usually SCC or BCC)
  • Dry base of ulcer – suggests arterial disease
  • Moist base of ulcer – suggests venous disease

Venous vs arterial

Table adapted from a table in Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt

Pressure sores

Can be graded by severity:

• I – non-blanching erythema
• II – partial thickness ulceration
• III – full thickness ulceration
• IV – deel full thickness with extensive skin and tissue loss

Features:

• Slough at base
• Edges are “undermined” – i.e. the base is wider than the skin defect
• Can expand rapidly
• Often at sites of pressure – e.g. sacrum in bed bound patients, on sole of feet in mobile patients

Appearance

Arterial	“Punched out” Location: distal to ankle Surrounding skin often mottled to evidence of varicose veins and varicose eczema Painful – especially at night Associated PVD and / or risk factors
Venous	Location: proximal to ankle Surround skin might show haemosiderin deposition, varicose eczema or varicose veins May be infected (yellowish foul smelling discharge) Painless
Diabetic / neuropathic ulcer	Location: Pressure points – often on heel, tip of toes, between toes Painless Appearance often somewhat similar to arterial, but may lack other signs associated with PVD (e.g. pale cold foot, reduced pulses – may be normal)

Investigations

• Blood
  • FBC
  • U+Es
  • CRP
  • HbA1c or blood glucose
• Consider swab for MC+S
  • Useful in acute stages
  • In chronic ulcers – will often grow a variety of colonisation but not infective organisms
• Consider ABPI
  • ABPI – ankle-brachial pressure index
  • If <0.9 suggests arterial disease
• Doppler USS

Pathology

Arterial ulcers

• Insufficient arterial blood supply due to peripheral vascular disease
• Management is aimed at improving peripheral arterial blood supply

Venous disease

• Typically due to thrombophlebitis – venous inflammation and clots
• Associated with venous stasis – poor blood flow through the veins
• May have a history of DVT or varicose veins
• Causes chronic venous hypertension, which may lead to skin discolouration – dark, copper coloured skin – as a result of hyperpigmentation
• Often very slow to heal – especially if treated without compression
• Usually not painful
  • If they are associated with pain, this can often be relieved by raising the legs

Management

Arterial ulcers

• This should involve treating the underlying arterial insufficiency
• Usually this would be a referral to a vascular surgeon, for work-up for treatments to re-establish blood flow
• For more info, see management of peripheral vascular disease

Venous Ulcers

Ulcer heal better when occluded, and kept in a moist environment.

Principles of management

• Nursing care:
  • Regular dressing changes
  • Removal of slough and necrotic tissue
  • Keep wound moist
  • AVOID the use of anti-septics, which are toxic to cells and slow healing
    • Wash iff any antiseptics after 5 minutes
  • Cleaning should beamingly performed with saline
  • Dressings – are complicated – loads of different types, for slightly different purposes. Ask the nurse!
• Antibitoics
  • Are usually not indicated
  • Only useful if there is surrounding cellulitis
• Compression
  • Use a firm, elastic compression bandage
  • From the base of the toes to just below the knee
• Elevation
  • Elevate the affected limb
  • Aim for 60 minute BD, plus elevation overnight
  • Above the level of the heart
  • Aids venous drainage
• Medication review – avoid drugs that can affect healing
  • Steroids
  • NSAIDs
  • Beta-blockers
  • Smoking!
• Exercise
  • Encourage early ambulation and exercise
  • Helps to improve the pump action of the calf muscle which aids venous return
• Severe cases
  • May need surgery to treat varicose veins
• Prevention
  • Continue to use compression
  • Regular exercise
  • Use of emollients for varicose eczema
  • If BMI >25, then encourage weight loss
  • Smoking cessation

Pressure sores

• Management
  • Relieve the pressure!
  • Daily wound cleaning with saline and dressings
  • Vitamin C 500mg BD
  • Antibiotics
    • Are usually not indicated
    • Only useful if there is surrounding cellulitis
  • Negative pressure therapy
    • May be useful for non-healing wounds
  • Optimise nutritional status
  • Surgical wound debridement may be required in some cases
• Prevention
  • Particularly important in hospitals and residential care homes
  • Turning of patients every 2 hours
  • Daily skin checks for areas of pressure
  • Special mattresses – e.g. air filled – which may periodically change pressure in the mattress to change the areas of pressure on the patient
  • Control urinary and feral incontinence
  • Good general hygiene

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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• Hypertension
• Dyslipidaemia
  • High LDL and low LDL levels
• Diabetes
• Obesity
• FHx of arterial disease
  • Significant if a first degree relative had MI before the age of 55
• Smoking
• Age
• Male gender

Epidemiology

• Affects about 10-15% of the population
• Usually CAD (coronary artery disease) is also present. About 75% of patients will also have symptomatic CAD. In the other group of patients it is believed the CAD is masked by PVD, as the PVD prevents patients from exerting themselves to a degree which would initiate symptoms of CAD.

Presentation

The classical presentation involves:

• Pain in the calves on walking, relieved by rest
  • This pain is also known as claudication
  • The pain can occur anywhere along the leg, and down into the foot
  • Many patients do NOT present with classic claudication – often because they are not doing enough activity to induce the symptoms – particularly if they have another comorbidity that limits their activity.
• Pain may also occur when legs are raised (e.g. in bed), and abate when legs are lowered (e.g. by sitting)

The main differential is “spinal claudication” caused by impingement of the caudal equina by a spinal stenosis. This also classically causes pain in the back of the legs on exertion.

FUN FACT:

Claudication comes from the latin “to limp”, which itself derives from the Emperor Claudius – whom it was said walked with a limp

Examination

• Elevating the leg may cause it to go pale and cold, as well as causing pain.
  • Beuger’s angle <20’ – the leg will go pale and cold upon raising it 20’ off the couch.
• Increased vascular filling time – Upon lowering, the leg may become hot and red as reperfusion occurs. Perfusion time tends to be reduced (>15s)
• Oedema is not usually present
• There may be evidence of poor skin health due to poor perfusion, such as ulcers, dry scaly skin, cool peripheries and reduced capillary refill time
• Check the pulse in the foot (posterior tibial and dorsals pedis)
  • Palpable pulses indicate low likelihood of peripheral vascular disease
  • Absent pulses represent an increased chance of peripheral vascular disease
  • If you are unable to locate a pulse by hand, you can use a doppler probe to assess if significant blood flow is present in the artery
  • For more information, see Peripheral Vascular Exam

  

  An example of a doppler probe used for assessing peripheral pulses

Classification

Claudication – this is limb pain (inc aching, cramping and tired feeling of the legs) upon exertion. It most commonly occurs in the calves, but may also be present in the feet, thighs, buttocks and even arms. The distance a patient can walk before they experience symptoms is known as the claudication distance.

• Claudication could be thought of as ‘angina’ of the limbs
• Pain is usually relieved by rest
• As peripheral vascular disease progresses, the distance that a patient can walk reduces.

Can cause claudication / buttock pain at rest
Burning pain at night, due to elevation (which reduces limb perfusion), and is relieved by hanging the legs over the side of the bed (very poor prognostic sign!)
Patients may have:

• ‘Punched out’ ischaemic ulcers – usually on the toes and heels, rarely higher up the limb. These tend to occur after a localised traumatic event. They are often painful, but diabetic and alcoholic patients may not have pain.
• Gangrene – often black necrotic gangrenous tissue surrounds the punched out ulcer lesions. Infection of this areas can occur (wet gangrene).
• Reduced / absent peripheral pulses – start distally, and work your way up until you find the pulse
• Skin atrophy – in chronic disease
• Hair loss – in chronic disease
• Cyanosis
• Excessive sweating – due to overactivity of the sympathetic nerves
• Erectile Dysfunction – Leriche syndrome – the result of distal aortic disease. Other features of the syndrome are buttock pain, and pale, cold legs. Surgery may be useful to reduce symptoms in these patients
• Amputation – may be necessary in patients with very severe disease. Usually only performed in patients with severe unremitting leg pain + gangrene, to prevent sepsis. Amputation should be performed as distally as possible, ideally below the knee, as this provides the greatest flexibility with prosthetic replacement limbs, but must be high enough to provide sufficient perfusion to allow healing of the stump.  In many cases, above the knee amputation is likely to heal better.
  • Phantom limb pain is common, and usually treated with gabapentin. This is often used prophylactically, as this improves efficacy.

Investigations

The diagnosis can be made on the basis of a suggestive history and examination, in conjunction with an ABPI <0.9.

After diagnosis is made, typically a patient may be referred to the vascular team for further investigation, which would typically include a CT angiogram of the lower limb.

• Arterial duplex ultrasound is an alternative to CT angio but is highly dependent on operator skill

ABPI – Ankle-Brachial pressure index

This is a measure of the ratio of the blood pressure in the ankle vs the arm. As peripheral vascular disease affects the legs more than the arms, it can be used as an indicator of reduced arterial blood flow in the legs.

With the patient lying flat on the couch:

• Measure the blood pressure in both arms and take the highest value
• Measure the blood pressure in both ankles and take the highest value
  • Instead of the stethoscope, use a Doppler ultrasound probe to measure the pressure over the posterior tibial artery – record the pressure when your hear the first ‘whoosh’
• Using only systolic values, divide the ankle pressure by the brachial pressure
• A normal value is >1
• A value of <0.9 is pathological for limb ischaemia (PVD). The lower the number, the greater the degree of PVD
• Pain at rest – ABPI = <0.6
• High Risk of gangrene – ABPI – <0.3, or ankle systolic pressure <55mmHg
• CAUTION – in very severe arteriosclerosis the vessels are incompressible, and thus falsely high readings may be obtained (e.g. an ABPI >1.3)

Investigate for Diabetes

Bloods

• HbA1c
• Lipids
• U+E’s
• ESR/CRP – to exclude arteritis
• ECG – to check for cardiac involvement
• Platelets and clotting

Arterial imaging

• Should be performed to assess the extent of the disease
• E.g. CT angiography (aka arteriography), DSA (digital subtraction arteriography), colour duplex imaging

Differentials

The most likely differential diagnosis is a neurological cause – typically compression of the spinal cord due to spinal stenosis – sometimes referred to as neurogenic claudication. This can cause a similar pattern of pain on activity in the buttocks, radiating down the legs, alleviated by rest.

• PVD – pain starts in calf and typically radiates up the leg
• Neurogenic claudication – pain typically starts in the buttock and radiates down the leg

Management

A diagnosis of peripheral vascular disease is confirmation that the patient has cardiovascular disease. Thus, as well as treating the peripheral vascular disease, many of the treatments are aimed at reducing other complications of cardiovascular disease (such as stroke and MI).

The aim of PVD treatment is to improve the walking distance and lower limb circulation.

• There are no medications that are proven to improve the symptoms of intermittent claudication
• Walking therapies – can be as effective as surgery at improving symptoms

Medical management

All patients should be given:

• Statin (e.g. atorvastatin 40mg nocte) regardless of cholesterol levels
• Control hypertension – for example an ACE-inhibitor (e.g. ramipril 5mg daily) or a calcium channel blocker (e.g. amlodipine 5mg daily)
  • β-blockers should be avoided, but are typically safe unless PAD is very severe
• Antiplatelet agent –  aspirin 100mg daily or clopidogrel 75mg daily – can improve claudication distance and reduce other symptoms.

Lifestyle factors

• Stop smoking
• Lose weight – aim for BMI 18.5 – 24.9
• Increase exercise – e.g. 30-60 mins, 5x week – often undervalued as a treatment. May increase the claudication distance, and improve QoL. Thought to be beneficial by increasing collateral circulation, improved endothelial compliance (i.e. better vasodilation to overcome the lumen narrowing and improve blood flow), decreased blood viscosity.
  • May be as effective as surgery
  • Explain to patients to walk until limits by claudication, rest until symptoms resolve, and then try again
  • If patients find stopping in the street frequently embarrassing – try recommending they do their exercises at a shopping mall – where frequent stopping is more socially acceptable!
  • 1/3 of patients will improve
  • 1/3/ will stay the same
  • 1/3/ will get worse
• Symptom management
  • Raising the pillow 4-6 inches can help keep the legs below heart level and reduce leg pain at night
  • Avoid cold weather if possible
  • Foot care – encourage self inspection daily for lesions, with prompt treatment. Careful washing of the feet everyday with thorough drying

Control of risk factors

• Screen for and treat diabetes if present
• Patients with known cardiovascular disease are automatically considered high risk for diabetes

Surgical Interventions

Surgical treatments are typically reserved for patients with very severe symptoms or where tissue destruction is present.

Indications for specialist referral include:

• Lifestyle limiting claudication
• Pain at rest
• Gangrene

Percutaneous Transluminal angioplasty – PTA – is useful for short lesions (usually <5cm) in big arteries. A balloon is used to widen the artery, which in some cases, may be enough on its own. In many cases, a stent is also placed. Particularly useful in iliac artery disease (successful in 75-90% of patients), and also successful in 50-70% of thigh and calf disease patients.

• PTA is not good for long lesions. These are more likely to occur in diabetic patients.
• Selection of patients is usually based on arterial imaging.
• PTA can result in thrombus formation and subsequent embolisation
• Reccurrence is about 30% at 3 years

Surgery – thromboendarterectomy and bypass grafting

• Is suitable for some patients. These are usually those with an obvious blockage, where the distal vessel is still filled by collateral vessels (indicating that the distal vessel is still in good shape) – similar to the indications for PTA – however patients must be able to tolerate surgery. May be used in those in whom PTA was not successful.
• These patients may receive a bypass graft. These are usually made from venous tissue, but prosthetic structures are also used.
  • Aspirin improves the longevity / patency of prosthetic grafts
  • Warfarin may be required after graft surgery in venous grafts
• Sympathectomy may be used to relieve pain. This can be chemical or surgical, but as they are equally effective, and generally used in those who can’t tolerate other surgery, chemical sympathectomy is much more widely performed. Particularly useful in diabetic patients.

Other Interventions

Limb Compression

• May help those with severe disease who are not candidates for surgery.
• Inflatable cuffs are placed over the limb and inflated rhythmically for a period of 1-2 hours, several days per week
• This is thought to improve both venous and arterial flow, thus reducing symptoms, but evidence is poor

Flashcard

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy
• Peripheral Vascular Disease – Health Pathways

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• introduce yourself
• wash your hands
• check you’ve got the right patient

Inspection

• Is the patient in any pain?
• Check around the bed
  • Mobility aids
  • O2
  • Cigarettes
  • Medication
• Look for any general signs – e.g. heart failure, cyanosis, pallor

Hands

• Tar staining
• Palmar xanthomas
• Capillary return – Press for at least 2-3 seconds – then check the return appears within 2 seconds
• Radial pulse – comment on the rate, rhythm and character. Also check for radio-radial delay – this is a sign of co-arctation of the aorta.
• Do the blood pressure in BOTH arms

Face

• Eyes – look for xanthelasma, arcus and conjunctival pallor
• Mouth – look for central cyanosis and angular stomatitis
• Caroitd pulse – check it and comment on the character!

Abdomen

• Look for obvious pulsations and masses
• Look for scars
• Check the AA – is it pulsatile (normal) or expansile (abnormal). The aorta bifurcates at approximately the level of the umbilicus

Leg inspection

• Swelling
• Discoloration
• Scars
• Dressings
• Pallor
• Missing hair / nails / toes
• Ulcers
• Dry skin
• Just have a good look and feel of the legs and toes. Make sure you look between the toes and lift up the feet.
• Compare the temperature with the back of your hand – do this at 3 separate places on each leg

Leg palpation

• Temperature – compare both legs using the back of your hand. Compare in several different places
• Sensation – ask the patient to close their eyes, and then touch them in a couple of different places on their feet. Ask them to say where/when they feel it
• Capillary refill – same as for the hands
• Pulses – check that these are normal / absent / reduced – comment on what you find
  • Dorsalis pedis
  • Posterior tibial
  • Popliteal – take the weight of the patients legt with both hands and feel into the popliteal fossa
  • Femoral

• Lift up the legs for 30s to 1 min, and see if they go pale
• If they do, then ask the patient to then sit up and drop the leg over the side of the bench. If the leg then turns red/purple then this is a positive test and the patients has reflex hyperaemia which is present when there is poor peripheral circulation
• Reflex hyperaemia occurs when there is dilation of the peripheral blood vessels when the leg is raised in response to the fall in bp. Then when the leg is lowered, the massively dilated blood vessels suddenly fill causing the leg to go a red/purple colour

Auscultation

• Renal bruit
• Femoral bruit
• Aortic bruit
• Carotid bruit

To finish

• Thank the patient
• Aks if they have any questions
• Allow them to re-dress in private
• Mention any further possible tests:
  • FBC – anaemia
  • U+E’s – renal failure
  • Blood sugar – diabetes

References

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Varicose veins…

• Are tortuous dilated superficial veins
• Are different to reticular veins or telangiectasia
• Are caused by weak vein walls causing dilation and valve incompetence
• Are often symptomless
• Are investigated with Doppler venous scanning.
• Can be left untreated, compressed, injected or operated on
• Often recur

Epidemiology and Aeitiology

• Affect 40% of men and 32% of women
  • However, a higher proportion of women present with varicose veins, possibly due to the cosmetic effect veins have, or because they appear earlier than in males
• Risk factors:
  • ↑Age
  • Pregnancy
  • ↑ No. of pregnancies
  • Long periods of standing – e.g. occupation as a teacher, shop assistant, surgeon(!) etc
  • Family History

Pathophysiology

1. The presence of valves, which prevent back-flow of blood distally
2. The deep venous system is assisted by pressures generated by muscles, noticeably the calf muscles.

In the case of varicose veins it is the former of these two mechanisms that is usually the problem. It used to be thought that valve incompetence, resulting in blood pooling/stasis was the cause of the dilated vein, however that hypothesis has become out of favour, and the current thinking is that weakness in the vein wall causes dilation of the vein. If this occurs around a valve, then the cusps of the valve will no longer meet in the middle and the valve will become incompetent, resulting in backflow of blood, and therefore inadequate drainage. The most common valves involved are those around the saphenofemoral junction (in the groin), however they can occur in other places for example the junction between the short saphenous vein and the popliteal vein.

Presentation

Complications

History and examination

Investigations

Treatment

Flashcard

References

• Murtagh’s General Practice. 6th Ed. (2015) John Murtagh, Jill Rosenblatt
• Oxford Handbook of General Practice. 3rd Ed. (2010) Simon, C., Everitt, H., van Drop, F.
• Beers, MH., Porter RS., Jones, TV., Kaplan JL., Berkwits, M. The Merck Manual of Diagnosis and Therapy

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An aneurysm is an artery that has a localised dilation, with a permanent diameter of >1.5x that expected of the particular artery.
True Aneurysm – the wall of the artery forms the wall of the aneurysm

• The most frequently involved arteries are; in decreasing incidence: abdominal aorta, iliac, popliteal, femoral and thoracic aorta

False aneurysm – aka – pseudoaneurysm – other surrounding tissues form the wall of the aneurysm

• These most commonly occur in the femoral artery following femoral artery puncture. If there is inadequate pressure to the entry site of the puncture, then blood can spill out and form a haematoma. Eventually the surrounding soft tissue will form the wall of the aneurysm.
• I think – the difference between this and a true haematoma is that in a pseudoaneurysm there is still communication between the lumen and the fluid collection, but in a haematoma, there is either no connection, or just a one way ‘leakage’ of fluid..

• Fusiform describes a shape that is tapered at both ends (a bit like a raindrop with a pointy bit at both ends), whilst sac-like describes a more rounded characteristic.

Aetiology

• Hypertension
• Smoking
• Age
• Diabetes
• Obesity
• High LDL levels
• Sedentary lifestyle
• Genetic factors – are more important in aneurysmal disease than in atherosclerotic disease, although they have a role in both.
  • 10% of cases have a first-order relative also with the condition

• Co-arctation of the aorta
• Marfan’s syndrome, and other connective tissue disorders
• Previous aortic surgery
• Pregnancy (particularly 3^rd trimester)
• Trauma
• Incidence increases with age – 5% of men over 60 have one
• Occur 3-5x more often in men than women

Complications

• Elective repair of aneurysms before rupture is comparatively safe
• Repair after rupture has very high mortality

General Features of aortic aneurysm

Often symptomless, and discovered incidentally (examination, AXR, ultrasound, CT)

• Mean age of presentation – 65
• Often discovered on AXR – about 65% of cases are sufficiently calcified to show up on radiograph
• Ultrasound is usually used to ‘stage’ the aneurysm. It is accurate at assessing the site of the aneurysm, and easy to follow up cases to asses development. CT is more accurate, and particularly useful at looking at the surround structures (e.g. to see if there is any compression) but more expensive, thus is usually used only for pre-op assessment.

Risk of dissection (bursting). Risk increases with the diameter of the aneurysm
A source of thrombus formation, which can embolise to the lower limbs

• Rarely, may be completely occluded by thrombus

Management of aortic aneurysm

The nice guidelines state that an aortic aneurysm of greater than 5.5cm in diameter should be treated. Below this size, the risk of dissection is outweighed by the risk of surgery.

• At 5.5cm the annual risk of rupture is 25%
• At 6.5cm it is 35%
• At >7cm it is 75%

In some cases, symptomatic aneurysms of smaller size may be operated on.

• Pain is thought to be a risk factor for rupture
• Thrombo-embolus is also an indication for surgery – and can prevent limb-loss.

Sugery is the treatment of choice. There are two options:
Open Laparotomy – the affected segment of aorta may be clamped and replaced by a prosthetic segment, (most common a Dacron graft). Graft failure is rare. In a variation of the treatment, the affected artery segment is bypassed.

• Complications are generally rare. There may be kidney problems, and sometimes paraplegia or ischaemic colitis. fistula formation with the small bowel can also occur but is rare. Infection is also rare.

Mortality

• 5-8% in elective asymptomatic AAA
• 10-20% for symptomatic emergency AAA
• 50% for ruptured AAA
• Long-term survival for most patients is almost identical to the general population

Endoluminal surgery – EVAR – Endovascular aneurysm repair – an aortic graft is inserted through the femoral artery, and up into the abdominal aorta. This method is generally preferred (lower mortality 1.2%) but many patients are not suitable. There must be at least 2.5cm normal aorta between the aneurysm and the renal arteries to securely fix the graft in place.

• complications with the actual graft are more common with the endoluminal technique than with open surgery. the graft can fail, or it may be moved, allowing blood to refill the aneurysm. Although, the risks of the procedure itself are far less than open surgery.
• Generally, rupture cannot be treated by the endoluminal method, although there are ongoing trials.

Dissection and Rupture of AA

Death rates from this rises with age:

• Age 55-59 – death rate is 12.5 per 100 000
• Age 80+ – death rate is 273 per 100 000

>75% with a ruptured AAA die – usually before getting to hospital.
Of those that do reach hospital, surgery has a 50% mortality rate. Thus only around 10% of those with a ruptured AAA will survive.

• Dissection is where blood escapes through the innermost layer of the wall of the artery, and prises apart the media, creating a new lumen. Sometimes, this lumen is absorbed back into the main lumen, creating a ‘double-barrelled aorta’. This may be stable, but may rupture. If it is close to the aortic valve (thoracic aortic aneurysm) it may compromise valve function.
• The dissection is sometimes able to track back all the way to the pericardium, and can cause haemopericardium.

Classification of dissecting AA

• Type A – 2/3 of cases. These involve the ascending aorta, and may also include the descending aorta
• Type B –affect the descending aorta only

Symptoms

Pain

• Sudden onset, severe pain. Often described as tearing¸ and usually radiates to the back.
• Pain usually follows the line of the dissection
• Ascending aorta – pain will be in the chest
• Descending aorta – pain often in the back

Collapse (due to hypotension)
Expansile (not pulsatile) mass in the abdomen
Shock
Hypotension
Tachycardia
Profound anaemia
Sudden death
Other signs may include:

• Testicular pain
• Symptoms similar to renal colic
• Symptoms similar to diverticulitis
• Non-specific back pain – this results from gradual erosion of the vertebral bodies in patients with long-standing aneurysm.
• If in doubt about the diagnosis; assume ruptured AA!

Investigations

• Mortality in dissection  is about 1% per hour
• This is much higher if it progresses to rupture!

Treatment

• Type A – require Emergency surgery – usually by open surgery (Dacron Graft). for further details see above : ‘Management of aortic aneurysm’
• Type B – often not quite as urgent as type A – depending on the individual case. Possibility to treat endoluminally, although open surgery is often still the treatment of choice.

Abdominal Aortic Aneurysm

Usually in the infrarenal segment of the aorta (80%)
These most commonly occur below the level of the renal artery
Features of pain:

• Rapid expansion or rupture will cause epigastric pain radiating to the back. Pain may also be present in the groin, iliac fossae and testicles.
• Can be a constant or intermittent pain
•  Be careful not to dismiss it as renal colic!

Thoracic Aortic Aneurysm

• Asymmetrical brachial/radial/carotid pulses if the dissection involves the aortic arch. Variable pattern depending on where the dissection is.
• BP may be different in each arm – under similar circumstances to the above.

Pathology of aneurysm

• Smoking
• Family history
• Diabetes
• Hypertension
• Age
• Hyperlipidaemia

Most probably pathology

• There is ischaemia of the aortic media where there is an atherosclerotic plaque. This is as a result of release of macrophage enzymes (released when macrophages become activatived) that break down the elastic fibres (collagen and elastin)
• There is evidence that various genetic variants of collagen are more susceptible, and this probably accounts for the familial aspect of aneurysms.
• Where this ischaemia occurs there is loss of the normal elastic nature of the media, allowing it to expand.

Marfan’s syndrome

• Arachnodactyly – abnormally long and thin fingers in comparison to the palm. Fingers may also be bent backwards at the MCP to 180’ in some cases.
• Joint hypermobility
• Scoliosis – lateral curvature of the spine
• Chest deformity
• High arched palate
• Dislocation of lens in the eye
• Patients are usually tall and thin, with long limbs

Heart valve defects
Pre-disposes to aneurysms

• There is weakening of the media layer of the aorta, leading to dilation. In these cases, the dilatation typically occurs in the ascending aorta. There may also be valve defects (e.g. aortic regurg) which complicate the issue.
• In Marfan’s Syndrome, the root of the aorta is typically affected

Lung disorders
Dura disorders

Treatment of Marfan’s

β-blocker therapy – has been proven to reduce the rate/risk of dilatation of the aorta
Monitoring of aortic dilatation –via X-Ray, Echo, MRI or CT can be useful in patients with known Marfan’s. Usually patients are followed up with yearly echo to assess the size of the aorta. In some cases, elective replacement of the ascending aorta may be recommended, to prevent dissection but has a mortality of 5-10%.
Avoidance of endurance sports / activities
In pregnancy – as both pregnancy and Marfan’s are risk factors for AA, then during pregnancy, the aorta is closely monitored by 6 weekly echo’s.

• If the aortic root >4cm, ceasarian section should be considered
• β – blocker therapy is safe to continue during pregnancy

Prognosis

• Generally good, although less than the general population.
• Surgical interventions have increased the average life-expectancy by 13 years

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Acute limb ischaemia occurs when there is blockage of a peripheral artery, either from a thromboembolism, or sometimes from an embolic plaque. It frequently occurs on a background of peripheral vascular disease.

As the MI is to coronary artery disease, acute limb ischaemia is to peripheral vascular disease

• Thrombus in situ – 40%
• Emboli – 38%
• Angioplasty occlusion – 15%
• Trauma
• Compartment syndrome – rare

Signs and Symptoms

• Pulseless
• Paraesthesia
• Pain – muscles also become tender to palpation after about 6-8hours
• Paralysis
• Pallor
• Perishing cold
• Fixed mottling of the skin implies irreversibility
• BEWARE – hot red leg may sometimes be present, which can result in misdiagnosis of gout or cellulitis

Diagnosis

Treatment

• It is an EMERGENCY!
  • 22% of cases are fatal
  • 16% of cases result in amputation
• Thrombolytic agent e.g. tissue plasminogen activator (tPA)– most effective when given via local arterial catheter (Fogarty Catheter), particularly for occlusions <2 weeks. Therapy is usually given via the catheter for 8-24hr
• Open surgery / angioplasty – DON’T BE AFRAID TO DO THESE! – equally, don’t be afraid to do angiography in cases of an unsure diagnosis.
• The decision to opt for thrombolysis over surgery depends on risk assessment on an individual patient basis (i.e. risks of surgery vs risks of thrombolysis)
• You should use heparin anticoagulation after both surgery and thrombolysis!

• Look for a source of emboli – e.g. ultrasounds of aorta, popliteal and femoral arteries for signs of aneurysm
• Watch out for reperfusion injury – which can lead to compartment syndrome

Case Example

• 92 year old nursing home patient
• Painful left leg, sudden onset
• Deaf and dementia
• Comfortable after 5mg morphine (relatively small dose)
• BP 110/40 – probably slightly low
• HR 80 irregular
• RR 16
• Heart sounds normal
• Apyrexic
• Whole left leg is white and cold
• Some mottling from foot to just above knee
• Calf is very tender
• Can barely move right leg, but can wiggle toes. Cannot move left leg at all
• Pulses on the right are normal
• No palpable aortic aneurysm
• No obvious swelling of the leg

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