5. Definition:
• Peripheral artery disease is a narrowing of
the peripheral arteries serving the legs,
stomach, arms and head. (“Peripheral” in
this case means away from the heart).
• PAD most commonly affects arteries in the
legs.
• It has been estimated that 202 million
people worldwide have PAD.
• Patients with PAD die from a heart attack,
sudden cardiac arrest, or stroke.
6. Clinical Presentation of PAD
• Anatomical Location
• Mechanism of Injury
• Speed of Onset
• Collaterals
9. 1.A -Intermittent Claudication
• Fatigue, discomfort, cramping, or pain of vascular origin in the muscles of the
lower extremities( commonly localized to the thigh, hip, buttock and calf muscles)
that is consistently induced by exercise and consistently relieved by rest (within
10 min).
10. 1.B -Sever Limb Ischemia
Critical limb ischemia Sub-critical limb ischemia
Chronic recurrent foot pain at rest that requires
regular use of analgesics , nonhealing
wound/ulcers, or gangrene in 1 or both legs
Rest pain only
More then 2 weeks
PLUS ankle systolic blood pressure <50 mmHg PLUS ankle systolic blood pressure > 50 mmHg
11. Diagnostic Work Up
History or physical examination findings suggestive of PAD need to be
confirmed with diagnostic testing .
• Resting ABI (Ankle brachial Index)
• initial diagnostic test for PAD and may
be the only test required to establish
the diagnosis.
13. Cont.
• Exercise treadmill ABI (Ankle brachial Index)
• is useful in establishing the diagnosis of lower extremity PAD in the
symptomatic patient when resting ABIs are normal or borderline
• The TBI (Toe Brachial index)
• used to establish the diagnosis of PAD in the setting of non-
compressible arteries (ABI >1.40) and may also be used to assess
perfusion in patients with suspected CLI
• CT angiography, MR angiography, invasive angiography:
• are generally reserved for highly symptomatic patients in whom
revascularization is being considered
15. Drugs used for PAD
• Statin
• therapy modestly improves claudication symptoms in addition to
lowering lipid levels
• Antiplatelets: (aspirin,clopidogrel )
• Both of them are not effective in improving claudication
symptoms, but they are recommended to reduce the risk of
myocardial infarction, stroke, or vascular death in patients with
symptomatic PAD.
16. Cont.
• Cilostazol
• phosphodiesterase inhibitor suppresses platelet aggregation and is
a direct arterial vasodilator.
• It improves claudication symptoms
• increase maximal and pain-free walking distances in patients with
PAD by at least 50% compared with placebo
• Cilostazol does not affect overall mortality.
• contraindicated in patients with a history of heart failure.
• Cilostazol can be used safely with aspirin or clopidogrel
17. Surgical Indications
• Indication for angioplasty and bypass grafting :
• Absolute:
o Rest pain
o Non healing wounds or ulcers
• Relative :
o Pain affecting the patient quality of life
• Indication for amputation :
• Severe limb pain + no revascularization option.
• Limb gangrene.
• Life threatening infections.
18. 2- acute limb ischemia
• Acute (<2 wk) EMERGENCY
• Immediate referral to vascular surgery
20. Buergers Disease ( Thromboangiitis Obliterans ):
• The exact cause of Buergers disease is not known but it is almost always
linked to smoking .
• This disease affects the small and the medium sized vessels of the
extremities.
• Affected vessels are thrombosed and infiltrated by inflammatory cells
resulting in ischemia .
• Markers that are common in other vasculitis are usually negative or normal in
burger disease . Including ESR, CRP, ANA and RF.
• Most patients are men 75%
21. • Clinical features :
osymptoms are variable from person to person
( pain or tenderness in the arms or legs ,
numbness or tingling , skin ulcers or gangnere
in digits , discoloration) symptoms may worse
with stress or exposure to cold.
• Treatment :
oThe most essential part of treatment is to
avoid all tobacco nicotine products. even one
cigarette a day can worsen the disease
• Prognosis :
o40-50% of patient with Buergers disease will
end by amputation if continue smoking
22. Raynaud’s phenomenon
• Vasospasm of the digital arteries ( finger / toes) .
• symptoms are usually provoked by exposure to cold
temperatures or emotional stress or cold or frozen
drink.
• primary’ or ‘secondary’ Raynaud’s
• Primary Raynaud’s :
• Idiopathic
• most common among young women usually < 30 years old.
• Secondary Raynaud’s:
• Secondary to other disease or medication e.g. SLE, RA,
SCLERODERMA
• may be suspected if the onset occurs later in life (particularly
in a man) or if the symptoms are only in one hand or foot.
23. • Primary Raynaud’s is usually diagnosed based on symptoms.
• Symptoms include color changes in the fingers or toes upon exposure to cold.
• Not everyone with Raynaud’s will see all three of these color changes.
• Depending on the situation, blood tests may be ordered to help determine
whether the Raynaud’s is primary or secondary.
24. Management
• the cornerstone of treatment for Raynaud’s
is avoiding exposure to cold
• keeping warm
• avoiding smoking
• limiting caffeine
• and reducing stress
• severe cases calcium channel blockers (nifedipine)
25. MCQ
• What is the most appropriate initial intervention for an elderly male
who complains of leg pain with walking and at night who is found to
have weak pulses in bilateral lower extremities and a reduced ankle-
brachial index?
A. Lifestyle modification
B. Anticoagulation with warfarin
C. Angioplasty
D. Compression stockings
26. • Answer is A
• The initial management of peripheral arterial disease involves lifestyle
modification such as smoking cessation, which is essential, a healthy diet and
an exercise plan.
• Cilostazol can be prescribed, which is a phosphodiesterase inhibitor and is
effective PAD.
• Surgery and stenting are treatment for patients who fail noninvasive therapy
or who have severe limb ischemia.
• Compression stockings are contraindicated in PAD but are useful in peripheral
venous insufficiency.
27. MCQ
• Which of the following findings would indicate critical peripheral
arterial disease?
A. Ankle-brachial index greater than 1.3
B. Ankle-brachial index less than 0.8
C. Ankle-brachial index less than 0.3
D. No palpable posterior tibial pulse
28. • Answer is C
• The ratio of blood pressure of the arm to the foot is used to assess peripheral
vascular disease.
• An ankle-brachial index of less than 0.3 indicates critical ischemia.
• A reading greater than one most likely signifies calcification of the leg vessel.
• Toe pressures can be used in this situation.
29. MCQ
Which of the following is the following is the next step in managing in
a patient with claudication who has failed a smoking cessation,
cilostazol, and walking-trial therapy?
A. Popliteal artery angioplasty
B. Lower extremity compression stockings
C. Femoral-popliteal bypass
D. Angiography
30. • Answer is D
• Angiography is an invasive imaging technique with radiopaque dye under
fluoroscopy. It is the gold standard test for peripheral artery disease.
• It should be used with caution in patients with renal disease due to contrast
toxicity.
• Carbon dioxide angiography can be used as safer contrast agent in patients
with renal disease
• Diagnostic imaging should be performed prior to surgical bypass
34. Definition:
• Aortic dissection is relatively uncommon, but potentially
fatal event resulting in the separation of the layers of the
Tunica Media by blood producing a false lumen.
• More common in males (50–70 years of age).
• Death from aortic dissection can be related to :
o rupture of the dissection into the pericardium precipitating cardiac tamponade, acute
dissection into the aortic valve leading to severe aortic regurgitation, obstruction of the
coronary artery and myocardial infarction, and end-organ failure due to abdominal aortic
branch vessel obstruction.
• Mortality related to aortic dissection remains high at 25 to 30 percent.
35.
36. The two main anatomic classifications used to describe aortic
dissection are the DeBakey and Stanford (Daily) systems.
The Stanford system is more widely used and classifies dissections
into:
Type A: involve the ascending aorta and may involve the arch.
Type B: anything below the origin of the Left Subclavian Artery.
Ascending aortic dissections are almost twice as common as
descending dissections.
The right lateral wall of the ascending aorta is the most common
site.
37. Clinical Features:
• Clinically, aortic dissection presents as a two-step process:
• The first event is the interruption of the intima
• which is associated with severe pain
• The second event sets in when the pressure exceeds a critical
limit and rupture occurs
o Abrupt sharp high-intensity chest pain at the onset is the
most specific characteristic of aortic dissection.
o It has been described as stabbing, tearing, or ripping in
nature.
• Severe chest pain is more common with type A dissections
• Back pain and abdominal pain are more common in type B
dissection.
38. Clinical Features and Complications:
• Physical examination:
oIncreased catecholamine levels from anxiety and pain.
oTachycardia and hypotension result from aortic rupture, pericardial
tamponade, acute aortic valve regurgitation, or even acute
myocardial ischaemia
oAbsent pulses in the extremities and a diastolic murmur of aortic
regurgitation may also be present.
oSyncope, stroke, and other neurological manifestations secondary to
malperfusion syndrome may develop.
39. Risk factors for aortic dissection:
• Vascular
inflammation
o Giant cell arteritis
o Takayasu arteritis
o Syphilis
• Deceleration trauma
o Accident
o Fall from height
• Iatrogenic factors
o Catheter/Instrument
intervention
o Aortic surgery
• Cross-clamp or
side clamp
• Graft
anastomosis
o Cannulation site
• Long standing arterial hypertension
(Most Common Cause)
o Advanced age
o Smoking
o Dyslipidaemia
o Cocaine
• Connective tissue disorders
o Hereditary fibrillinopathies
• Marfan’s syndrome
• Ehlers-Danlos syndrome
• Turner’s syndrome
o Hereditary vascular diseases
• Bicuspid aortic valve
• Coarctation
• Aortic aneurysm
• Pregnancy
40. Diagnosis:
• an immediate ECG to exclude acute myocardial infarction
• Biochemical markers of myocardial damage may help in the diagnosis if the ischemic changes
are confused with those related to MI
• The most promising biochemical marker for diagnosing acute aortic dissection
o is an elevated circulating smooth muscle myosin heavy chain protein; this is released from
damaged aortic medial smooth muscle
• Transthoracic echocardiography (TTE) is easily available and the ascending aorta and aortic
arch can be visualized well.
o TOE images the entire thoracic aorta except for the most distal ascending aorta and a part
of the arch obscured by the trachea or right main bronchus.
• CT with Iodine Contrast Gold standard – can see the entire aorta
• Magnetic Resonance Angiogram (100% sensitive and specific) but invasive and takes time to
perform
41. Management:
• The primary goal is to reduce the force of left ventricular contraction without
compromising perfusion, thus reducing shear forces and preventing further extension
of the dissection or possible rupture
• The patient should be cared for in a critical care environment (ABC)
• Acute type A and complicated type B dissections should be managed surgically
• Depending on the urgency, coexisting medical conditions should be investigated and
treated.
• Pain should be treated with adequate analgesics.
• For uncomplicated Type B dissections medical therapy maybe initiated:
o BP titration to about 110–120 mm Hg systolic with IV metoprolol, or labetalol first. Sodium
nitroprusside for further control of blood pressure, calcium channel blockers or beta-
blockers
42. Prognosis and Follow-up:
• Aortic rupture, cardiac tamponade, circulatory failure, stroke, or visceral
ischaemia are the most common causes of death.
• Once the patient is discharged, medical follow-up with a focus on tight blood
pressure control should be performed regularly.
• Serial aortic imaging surveillance is recommended.
• The overall 10 yrs. mortality is about 55% in treated patients.
43. Intramural hematoma
Aortic IMH is an entity within the spectrum of AAS, in which a
• hematoma develops in the media of the aortic wall in the
absence of an False Lumen and intimal tear
• This entity may account for 10 – 25% of AAS.
• Has two types : A & B
• (Type A) involvement of the ascending aorta and aortic arch 30% &
10% respectively
• (Type B) involves the descending thoracic aorta 60–70%
Pain is characteristic of IMH, whereas malperfusion and pulse deficit are much
less likely than with classic AoD.
44. Diagnosis
• CT and MRI
• are the gold standard for diagnosis and classification of intramural
hematoma.
• Transthorasic Echocardiography (TTE):
• inadequate because of its low sensitivity
• TTE cannot be used as the sole imaging technique in patients with
suspected
45. Management
• Type A intramural haematoma
Surgery is required in most of Type A IMHs.
• Type B intramural haematoma
Medical treatment is the initial approach to this condition
46. Penetrating aortic ulcer
• Penetrating aortic ulcer (PAU) is defined as ulceration of an aortic
atherosclerotic plaque penetrating through the internal elastic lamina
into the media.
• Such lesions represent 2 – 7% of all AAS.
• typical patient is elderly (usually over 65 years of age) and has
hypertension and diffuse atherosclerosis, who presented with chest
or back pain but without signs of aortic regurgitation or malperfusion.
• Type A: progressive aortic enlargement and development of saccular or
fusiform aneurysms, which is particularly accelerated in the ascending aorta
• Type B: The most common location of PAU is the middle and lower
descending thoracic aorta
47. Diagnostic Imaging
• Contrast-enhanced CT
• is the technique of choice for diagnosis of PAU.
• the classic appearance of the lesion is a
mushroom-like outpouching of the aortic
lumen with overhanging edges
48. Management
in the presence of AAS related to PAU, the aim of treatment is to
prevent aortic rupture and progression to acute AD.
indications for intervention:
• include recurrent and refractory pain
• signs of contained rupture (rapidly growing aortic ulcer)
• associated periaortic hematoma
• pleural effusion.
In all patients with PAU, medical therapy including pain relief and
blood pressure control is recommended.
49. MCQ
• When a transesophageal echocardiogram is done to diagnose an
aortic dissection, what is the critical finding that leads to a
diagnosis?
A. An enlarged aorta
B. An incompetent aortic valve
C. An intimal flap
D. Left ventricular function
50. • Answer is C
• A transesophageal echocardiogram (TEE) is done to identify the intimal flap
and thus helps to distinguish the dissection from an ordinary aortic aneurysm.
• TEE is as accurate as MRI or CT in terms of sensitivity and specificity. Also, it
can be done at the bedside.
• The important drawbacks of TEE are the possibility of operator inexperience
and false positive results due to movement artifacts.
• TEE also cannot be performed in patients with varices or esophageal stricture.
51. MCQ
• A patient presents to the emergency department with chest pain
radiating to the back. The pain started suddenly and has not subsided.
The patient is diaphoretic but is not vomiting. Pulses are present and
equal. Which test should be used first to confirm the suspected
diagnosis?
A. Chest x-ray
B. Aortogram
C. EKG
D. Transesophageal echocardiogram
52. • Answer is D
• The most important diagnosis to rule out is aortic dissection. Chest x-ray findings are
nonspecific; however, it may help in determining the need for further workup.
• With ongoing chest pain, the best test is transesophageal echocardiogram (TEE). If
the patient is stable, an alternative is a CT scan. If the patient is unstable, TEE can be
done in the operating room.
• Aortography is used only when the diagnosis by the above tests is uncertain.
• The pain of aortic dissection is at times difficult to distinguish from angina or an
acute myocardial infarction. Patients often present with unequal radial pulses and
blood pressure differences in both arms with a dissection. Any patient presenting to
the emergency department with chest pain should have blood pressures in both
arms taken and recorded. A stat portable chest x-ray can be obtained to look for a
widened mediastinum.
53. MCQ
• A 65-year-old hypertensive male presents with an acute episode of
chest pain that is tearing in nature and radiates to his back. What is
the most likely diagnosis?
A. Left ventricular rupture
B. Aortic dissection
C. Mitral valve endocarditis
D. Cardiac tumor with acute hemorrhage
54. • Answer is B
• Aortic dissection occurs 3 times more frequently than abdominal aortic aneurysm
rupture. There are two main classification systems based on the location of the
dissection. These include the DeBakey system and the Stanford system. The most
widely accepted system is Stanford, subdividing dissection into proximal and distal.
Type A is proximal to left subclavian artery. Type B is distal to left subclavian artery.
• Ascending thoracic aortic dissection requires emergent surgical intervention.
Untreated, more than half of patients die in the first 48 hours. The mortality rate is
even higher when the aortic root and coronary artery are involved.
• Marfan syndrome, Ehlers-Danlos syndrome, and other connective tissue disorders
make the aorta prone to dissection. Pregnancy and hypertension are also significant
risk factors.
• Aortic dissection presents with severe sharp pain which is tearing in nature. Only
10% of patients with dissections do not have pain. Some patients describe only a lack
of energy and present with hypotension. Neurologic deficits can occur and include
syncope, hoarseness, and Horner syndrome.
56. Aortic Aneurysm
• aneurysm is a localized or diffuse dilation of an artery with a diameter at least
50% greater than the normal size of the artery and it can occur anywhere in the
human aorta
• most common complication remains life-threatening rupture with hemorrhage.
• Arteriosclerotic (degenerative) disease is the most common cause of thoracic
aneurysms.
• the prevalence of aortic aneurysms probably exceeds 3-4% in individuals older
than 65 years
• Death from aneurysmal rupture is one of the 15 leading causes of death in most
series.
57. Risk factors
• smoking,
• Chronic obstructive pulmonary disease (COPD),
• Hypertension.
• atherosclerosis
• male gender,
• older age,
• high body mass index
• bicuspid or unicuspidal aortic valves,
• genetic disorders, and
• family histst degree relative with aortic disease.
58. Symptoms
• Usually Asymptomatic and discovered accidentally.
• Pain may be acute, implying impending rupture or dissection, or
chronic, from compression or distention
• Ascending aortic aneurysms anterior chest pain.
• Distended neck veins Large ascending aortic aneurysms may cause
superior vena cava obstruction manifesting.
• Ascending aortic aneurysms develop aortic insufficiency
• Aortic Arch Aneurysms pain radiating to the neck
• Hoarseness from stretching of the recurrent laryngeal nerves
59. Cont.
• Descending thoracic aneurysms more likely cause back pain localized
between the scapulae.
• Descending thoracic aneurysms and thoracoabdominal aneurysms may
compress the trachea or bronchus and cause dyspnea, stridor, wheezing,
or cough Compression of the esophagus results in dysphagia.
• in abdominal aortic aneurysm palpation of a pulsatile mass around
the level of the umbilicus, Abdominal auscultation may reveal the
presence of a bruit.
• Erosion into surrounding structures may result in hemoptysis,
hematemesis, or GI bleeding. Erosion into the spine may cause back pain
or instability.
60. Work up
• most often asymptomatic and the diagnosis is made following imaging
performed for other diseases or for screening Aortic aneurysms
• Once aortic dilation is suspected, based on echocardiography and/or chest X-
ray, CT or MRI (with or without contrast) is required to adequately visualize
the entire aorta and identify the affected parts.
• CT angiography is Gold Standard for Aortic aneurysms evaluation.
61. Complication
The most common complications of AAs are acute rupture and dissection
Treatment
• all aneurysms must be treated with risk-factor reduction
• Strict control of hypertension.
• Cessation of smoking is recommended
• Statin used for overall cardiovascular risk reduction
62. Treatment
• treatments are based on size or growth rate and symptoms
indications for surgical treatment :
• Aortic size - Ascending aortic diameter ≥5.5 cm or twice the diameter of the
normal contiguous aorta; descending aortic diameter ≥6.5 cm; subtract 0.5
cm from the cutoff measurement in the presence of Marfan syndrome, family
history of aneurysm or connective tissue disorder, bicuspid aortic valve, aortic
stenosis, dissection, patient undergoing another cardiac operation; growth
rate ≥1 cm/year
• Symptomatic aneurysm
• Traumatic aortic rupture
63. Cont.
• indications for surgical treatment :
• Acute type B aortic dissection with associated rupture, leak, distal
ischemia
• Pseudoaneurysm
• Large saccular aneurysm
• Mycotic aneurysm
• Aortic coarctation
• Bronchial compression by aneurysm
• Aortobronchial or aortoesophageal fistula
64. Ruptured AAA
• Ruptured AAA triad:
• SEVERE ABDOMIN/BACK PAIN
• PULSATILE ABDOMNAL MASS
• HYPOTENTION
• triad may be incomplete or absent, and
misdiagnosis can occur in up to 60% of cases
• IMMEDIATE REFERRAL
65. Screening USPSTF
• Because AAA is most often clinically silent, screening can improve
detection. Ultrasonography has a high sensitivity and specificity (95% and
nearly 100%, respectively)
67. MCQ
Which statement about abdominal aortic aneurysms (AAAs) is false?
A. Majority are due to atherosclerosis
B. Most AAAs present with abdominal pain
C. The majority of AAAs occur below the renal arteries
D. Aneurysms that are 3 to 3.5 cm do not need surgery
68. • Answer is B
• Over 95% of abdominal aortic aneurysms (AAAs) are due to atherosclerosis.
However, other contributing factors may include hypertension,
hyperlipidemia, and smoking.
• The majority of AAAs are asymptomatic. Only ruptured AAAs cause
abdominal pain.
• Most AAAs occur below the renal arteries and often end at the bifurcation of
the iliac arteries.
• Small aneurysms less than 3.5 cm do not need surgery. Once a year, follow-up
with ultrasound may be required
69. MCQ
• In a patient with a leaking abdominal aortic aneurysm, what is the
most frequent finding on physical exam?
A. Flank ecchymosis
B. Distended abdomen
C. Displaced pulsatile mass
D. Lower extremity hypertension
70. • Answer is A
• In patients with a frank rupture, the patient will be in shock with low blood
pressure and absent distal pulses.
• In patients who have a leak, the most common complaint is back pain. The
reason for the back pain is that 95% of leaks start in the left posterior corner
just below the take-off of the left renal artery. That is often the weakest point
in the aorta.
• In a patient with a leak, the blood pressure is usually normal and even the
groin pulses may be palpable. One may feel the pulsatile mass.
• Leaking aneurysm of the aorta are tracking blood usually into the
retroperitoneum causing flank ecchymosis.
71. MCQ
• In a 65 year old suspected of having an abdominal aortic aneurysm,
what is the diagnostic test of choice?
A. Gray-scale and Doppler ultrasound
B. CT angiography
C. Angiogram
D. Magnetic resonance angiography
72. • Answer is A
• Ultrasound is by far the best test for an abdominal aortic aneurysm suspected
on a clinical exam.
• Other radiological tests show excellent sensitivity and specificity but are more
expensive, more time-consuming, and cannot be performed portably if
necessary.
• Ultrasound is easily available and very reliable. It is more challenging,
however, in the very obese.
• In assessing an abdominal aortic aneurysm, it is important to determine origin
(above or below renal arteries), length, extension, if any, into one or both iliac
arteries, and maximum transverse diameter.
74. Coarctation of the Aorta
• Coarctation of the aorta (CoA) is congenital heart
• defects accounts for 5-8% of all congenital heart defects
• Physical examination will show
• higher blood pressure in the arms than in the legs
• Radio-femoral delay
• EKG will show LVH
• CXR will show notching of ribs
• Diagnosis is made by echo
• Treatment is balloon angioplasty with stent placement
or surgical correction
• commonly associated with Turner syndrome
• Coarctation of aorta
• Bicuspid aortic valve
75. Chest X- Ray Findings
• Early :
• cardiomegaly,
• pulmonary edema
• other signs of congestive heart failure (CHF)
• Late:
• inverted "3" sign
• Rib notching
Inferior Rib notching
76. MCQ
• A 16-year-old girl has coarctation of the aorta. With which of the
following lesions is this most likely associated?
A. Atrial septal defect
B. Bicuspid aortic valve
C. Pulmonary valve regurgitation
D. Lower extremity hypertension
77. • Answer is B
• Coarctation of the aorta is a rare heart defect accounting for 5 to 8% of all
congenital heart defects.
• It may occur as an isolated defect or in association with other lesions, most
commonly ventricular septal defect and bicuspid aortic valve.
• Coarctation of the aorta often presents with upper extremity hypertension
and radial-femoral pulse delay.
• The disorder can be surgically treated but endovascular techniques are also
being applied.
78. MCQ
• Coarctation of the aorta is typically associated with which of the
following?
A. Atrial septal defect
B. Ventricular septal defect
C. Aortic regurgitation
D. Pulmonary valve regurgitation
79. • Answer is B
• Bicuspid aortic valve is often seen in patients with other left-sided obstructive
lesions. Bicuspid aortic valves often become stenotic.
• Bicuspid aortic valve is commonly seen in patients with coarctation of the
aorta and interrupted aortic arch.
• Coarctation is also commonly associated with a ventricular septal defect.
• Often, endovascular stenting can be used to treat coarctation.
80. MCQ
• A 17-year-old male is seen with elevated blood pressure. He has a
significant radial-femoral delay in his pulses. Of the following, what
would be found on further investigation?
A. Arachnodactyly
B. Positive darkfield microscopy test
C. Rib notching on chest x-ray
D. Systolic ejection murmur
81. • Answer is C
• Aortic coarctation will often reveal a prominent aortic knob and an
indentation of the proximal descending aorta on chest x-ray (CXR).
• CXR also shows rib notching along the inferior rib surface due to enlargement
of the intercostal arteries in coarctation, the result of increased collateral
flow.
• In the past, barium esophagography was performed to demonstrate the
classic "E" or "reverse 3" sign representing compression above and below the
coarctation. With the development CT and MRI, barium esophagrams are no
longer used for this purpose.
• A gradient greater than 20 mmHg indicates the need for intervention.
82. MCQ
• Coarctation of aorta is not typically associated with which of the
following?
A. Ventricular septal defect
B. Bicuspid aortic valve
C. Patent ductus arteriosus
D. Atrial septal defect
83. • Answer is D
• Coarctation of aorta accounts for 5% to 8% of congenital heart defects.
• It is most commonly associated with bicuspid aortic valve, ventricular septal
defect, and patent ductus arteriosus.
• Coarctation of the aorta often presents with upper extremity hypertension
and radial-femoral pulse delay.
• The disorder can be surgically treated, but endovascular techniques are also
being applied.
85. Categories of Mesenteric Ischemia
• Acute mesenteric arterial embolus:
• 40-50% cases, consider atrial fibrillation and endocarditis as sources
• Emboli lodge in the superior mesenteric artery (SMA)
• supplies the distal half of the duodenum to the proximal two-thirds
of the transverse colon
• Mesenteric Thrombosis:
• 20-35% cases, thrombosis of previously atherosclerotic vessel.
• MI of the gut
• Dissection or inflammation in<5% cases
• Mesenteric Venous Thrombosis:
• 5-15% cases, secondary to hypercoagulable state: Antithrombin-III, protein C or S deficiency,
Factor V Leiden, pancreatitis, trauma, polyarteritis nodosa
• Non-occlusive:
• 5-15% cases, occurs secondary to low perfusion states, both a cause of sepsis and result of
hypotension sepsis, any hypoperfusion, CHF, recent surgery, hemodialysis
86. Presenting symptoms
• Acute mesenteric arterial embolus:
• acute onset of abdominal pain put out of proprtion to physical examination N/V , blood in
stool.
• abdominal pain put out of proprtion to physical examination It is intense and constant,
does not increase with palpation and initially does not result in abdominal wall rigidity or
other peritoneal signs. Later course of disease peritoneal signs will occur
• Severe abdominal pain
• Rebound tenderness
• Involuntary guarding
• Tenderness on percussion
• Acute mesenteric arterial thrombosis:
• usually presents as intermittent pain that becomes constant (intestinal angina) , food
fear because the pain becomes intense after eating.
• mesenteric venous thrombosis:
• These patients may present with diarrhea, and a longer history of pain.
• Non-occlusive mesenteric ischemia:
• altered mental status , abdominal pain and critically ill.
88. Work up
• Lab
• CBC and deferential leukocytosis
• Lactate normal lactate—cannot rule in or out
• D-dimer Normal D-dimer—makes less likely but does not rule out
• Coagulation profile
• Amylase and lipase
• Renal function test
• Liver function test
Neither D-dimer nor lactate is sensitive enough to rule out disease if
negative.
89. Cont.
Imaging :
• Plain film
• Pneumoperitoneum, gas in portal vein , bowel dilation, ileus, which is
• often misinterpreted as mechanical bowel obstruction)though
pneumatosis in severe cases.16
• Normal AXR does not rule out mesenteric ischemia
• 25% of patients with AMI have a normal AXR16
Portal vein gas pneumoperitoneum
illuis
90. Cont.
CT Angiography
• the imaging study of choice for diagnosis with a sensitivity and
specificity of over 90%.
• Early :Ascites, bowel wall thickening, mesenteric edema
• Late CT Findings:
• pneumatosis portalis portal vein gas/ mesenteric vein.
• Pneumoperitoneum perforation of the bowel
• pneumatosis intestinalis gas in intestinal wall
• variable amounts of free fluid
91. management :
• ABC
• NPO
• fluid resuscitation
• broad spectrum IV antibiotics
• emergent surgical consultation
• AMI secondary to SMV thrombosis
• heparin infusion and to MICU
92. MCQ
• What is the "classic finding" with acute mesenteric ischemia?
A. Normal WBC
B. Involvement of the inferior mesenteric artery
C. Nausea and vomiting
D. Pain out of proportion to the physical exam
93. • Answer is D
• Acute mesenteric ischemia is usually due to decreased blood perfusion in the
superior mesenteric artery.
• Acute mesenteric ischemia is associated with heart failure, atherosclerosis,
atrial fibrillation, valvular disorders, amongst other conditions.
• Patients with acute mesenteric ischemia classically have abdominal pain "out
of proportion" to physical exam findings.
• Other features of acute mesenteric ischemia include elevated white blood cell
count, elevated lactate levels, or a history of bloody bowel movements.
Patients can present in many ways, with various physical exam findings and
subjective symptoms. It is important to keep mesenteric ischemia at the top
of the differential diagnosis in patients with risk factors.
94. MCQ
• A 76-year-old man with a history of atrial fibrillation, hypertension and prior
stroke presents with acute onset of diffuse abdominal pain and vomiting. On
examination, he is tachycardic and yelling in pain but his abdomen is soft with no
rebound or guarding. An acute abdominal series shows pneumatosis intestinalis.
Which of the following is the most likely site of acute mesenteric arterial
occlusion?
A. Celiac trunk
B. Inferior mesenteric artery
C. Left colic artery
D. Superior mesenteric artery
95. • Answer is D
• The majority of cases of acute mesenteric ischemia are the result of acute
arterial occlusion resulting from embolization from the heart. The superior
mesenteric artery is most frequently affected in acute arterial occlusion
