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Aortic Aneurysm

• An abnormal widening or ballooning of a section of an artery due to weakness in the wall of the blood vessel.
• Abdominal aortic aneurysm is the most common place.
  • Below the renal vessels and usually involving the bifurcation.
  • < 3cm
  • Usually men over 70 years old

Causes & Risk Factors

• Damage to the blood vessels
• CAD
• Smoking
• HTN
• Hyperlipidemia
• Weakness of the lining of the blood vessels may be congenital
  • Marfan’s syndrome
  • Ehlers Danlos type IV

Clinical Presentation

• Most aneurysms are asymptomatic
• Pain
  • Substernal abdominal and radiating to the back
  • Tearing pain radiating to the back = rupture
• Hoarse voice secondary to constriction of the recurrent laryngeal nerve
• Dyspnea
• Cough
• Dysphagia

Physical Exam Findings

• You may feel a pulsatile mass for an abdominal aortic aneurysm

Labs & Studies

• U/S
  • Best study for abdominal aneurysms
• CT/MRI
  • Thoracic aneurysm
• Aortography

Treatment

• Blood pressure control is the primary concern
• Smoking cessation
• Surgical repair
  • The risk of rupture at 5.0 cm to 5.0 cm is 5–10% per year

Giant Cell Arteritis

• Inflammation of the arteries
• The temporal artery is the most common artery involved so the name temporal arteritis is sometimes used interchangeably with giant cell arteritis.
• Usually occurs in patients older than 55
• 50% will have polymyalgia rheumatica (multiple joint pain)

Clinical Presentation

• Jaw claudication – pain in jaw while chewing
• Headache
• Scalp tenderness
• Visual problems including blurred vision, diplopia, complete loss of vision etc
• Fever

Physical Exam Findings

• Temporal artery may be
  • Normal
  • Tender
  • Enlarged
  • Pulseless
• Fundal exam
  • ischemic optic neuritis with pallor and edema of the optic disk
  • scattered cotton-wool patches
  • small hemorrhages

Labs & Studies

• Blood work
  • Liver function tests
    • Alk phos elevated
  • C reactive protein is elevated
  • Sed rate elevated
  • Platelets may be low
• Biopsy of temporal artery is the gold standard for diagnosis
• U/S may show a halo sign

Treatment

• High dose prednisone 40–60 mg po daily for 1–2 months followed by tapering
• Aspirin 81 mg may help reduce risk of stroke and blindness etc.

Peripheral Arterial Disease (PAD)

• Also known as peripheral vascular disease (PVD)or peripheral vascular disorder (PVD)

Causes

• Atherosclerosis

Clinical Presentation

• Claudication
  -Painful, tired feeling when walking
• Ischemia in lower extremities
  • Numbness
  • Tingling
  • Ulcers
• Erectile dysfunction

Physical Exam Findings

• Weakened pulses
• Dependent rubor – when foot is dependent it turns dusky color
• Atrophic skin
  • Hairless
  • Shiny
  • Ulcers (PAINFUL)
• Paresthesia
• OCCLUSION – the 7 Ps
  • Pain
  • Pallor
  • Pulselessness
  • Paresthesias
  • Poikilothermia (cold)
  • Paralysis

Labs & Studies

• Doppler U/S flow studies
• Ankle brachial index
  • 1–1.2 is normal
  • < 0.9 is diagnostic
  • < 0.4 is severe
• Arteriography may be necessary
• CT/MRI angiography

Treatment

• Lifestyle modifications including progressive exercise
• Medications
  • Antiplatelet
    • Aspirin 81 mg daily
  • ACEI – vasodilators
• Surgical intervention
  • Endovascular stenting and angioplasty
  • Bypass grafting
    • Aorto-femoral bypass
    • Fem-fem bypass
    • Axillo-fem bypass

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