Iliaca aneurysma

Izolált Ilica communis aneurysma ritka. AAA-val előfordulása 20%.

Tünetek: székrekedés, vizelet retenció, uro-infekció, hematuria, hasi fájdalom.

Indikációk:

Ilica communis aneurysma >3 cm átmérő: gyorsabban növekszik,, mint a 3 cm alattiak

– 3 és3.5 cm átmérő között 6 havonta Uh kontroll

–  Ilica communis aneurysma 3.5 cm és 4 cm között elektív műtét, ha a beteg jó általános állapotban van

– minden tünetes ICAA indikáció műtétre

– ICAA 4 cm fölött: opus

– 5 cm fölött sürgősségi műtét

Thrombózis profilaxis terhességben

ACOG thromboprophylaxis recommendations

 

©2015 UpToDate®
ACOG recommended thromboprophylaxis for pregnancies complicated by inherited thrombophilias*
Clinical scenario Antepartum management Postpartum management
Lower-risk thrombophilia¶ without previous VTE Surveillance without anticoagulation therapy Postpartum anticoagulation therapy for patients with additional risks factorsΔ
Low-risk thrombophila with a family history (first-degree relative) of VTE Surveillance without anticoagulation therapy Postpartum anticoagulation therapy or intermediate-dose◊ LMWH/UFH
Low-risk thrombophilia¶ with a single previous episode of VTE – not receiving long-term anticoagulation therapy Prophylactic or intermediate-dose LMWH/UFH or surveillance without anticoagulation therapy Postpartum anticoagulation therapy or intermediate-dose LMWH/UFH
High-risk thrombophilia§ without previous VTE Surveillance without anticoagulation therapy, or prophylactic LMWH or UFH Postpartum anticoagulation therapy
High-risk thrombophilia§ with a single previous episode of VTE or an affected first-degree relative – not receiving long-term anticoagulation therapy Prophylactic, intermediate-dose, or adjusted-dose LMWH/UFH regimen Postpartum anticoagulation therapy, or intermediate or adjusted-dose LMWH/UFH for six weeks (therapy level should be at least as high as antepartum treatment)
No thrombophilia with previous single episode of VTE associated with transient risk factor that is no longer present – excludes pregnancy- or estrogen-related risk factor Surveillance without anticoagulation therapy Postpartum anticoagulation therapy¥
No thrombophilia with previous single episode of VTE associated with transient risk factor that was pregnancy- or estrogen-related Prophylactic-dose LMWH or UFH¥ Postpartum anticoagulation therapy
No thrombophilia with previous single episode of VTE without an associated risk factor (idiopathic) – not receiving long-term anticoagulation therapy Prophylactic-dose LMWH or UFH¥ Postpartum anticoagulation therapy
Thrombophilia or no thrombophilia with two or more episodes of VTE – not receiving long-term anticoagulation therapy Prophylactic or therapeutic-dose LMWHOR

Prophylactic or therapeutic-dose UFH

Postpartum anticoagulation therapyOR

Therapeutic-dose LMWH/UFH for six weeks

Thrombophilia or no thrombophilia with two or more episodes of VTE – Receiving long-term anticoagulation therapy Therapeutic-dose LMWH or UFH Resumption of long-term anticoagulation therapy
LMWH: low molecular weight heparin; UFH: unfractionated heparin; VTE: venous thromboembolism.
* Postpartum treatment levels should be greater or equal to antepartum treatment. Treatment of acute VTE and management of antiphospholipid syndrome are addressed elsewhere.
¶ Low-risk thrombophilia: factor V Leiden heterozygous; prothrombin G20210A heterozygous; protein C or protein S deficiency.
Δ First-degree relative with a history of a thrombotic episode before age 50 years, or other major thrombotic risk factors (eg, obesity, prolonged immobility).
◊ Intermediate dosing is variably defined in the literature. The American College of Chest Physicians has defined it as a pregnancy LMWH regimen of enoxaparin 40 mg or dalteparin 5000 units given every 12 hours. In UpToDate, intermediate dosing refers to prophylactic LMWH dosing that is increased as the pregnancy progresses and the patient’s weight increases, up to a maximum dose of enoxaparin 1 mg/kg once daily.
§ High-risk thrombophilia: antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; factor V Leiden homozygous or prothrombin G20210A mutation homozygous.
¥ Surveillance without anticoagulation therapy is supported as an alternative approach by some experts.
Reproduced with permission from: ACOG Practice Bulletin #138. Thromboembolism in pregnancy. Obstet Gynecol 2013; 122:706. DOI:10.1097/01.AOG.0000433981.36184.4e. Copyright © 2013 American College of Obstetricians and Gynecologists. Unauthorized reproduction of this material is prohibited.
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Carotid stenosis measuring

Methods for measuring stenosis

meth for measure

 

 

Society of Radiologists in Ultrasound (SRU) consensus

PSV = peak systolic velocity

EDV = end diastolic velocity

ICA = internal carotid artery

CCA = common carotid artery

normal:
ACI PSV  <125 cm/sec

and no plaque or intimal thickening is visible sonographically

ACI/ACC PSV ratio <2.0 and ACI EDV <40 cm/sec

<50% ACI stenosis:

ACI PSV <125 cm/sec and plaque or intimal thickening is visible sonographically
additional criteria include ICA/CCA PSV ratio <2.0 and ICA EDV <40 cm/sec

50-69% ACI stenosis:

ACI PSV is 125-230 cm/sec and plaque is visible sonographically

additional criteria include ACI/ACC PSV ratio of 2.0-4.0 and ICA EDV of 40-100 cm/sec

>/= 70% ICA stenosis but less than near occlusion:

ACI PSV is >230 cm/sec and visible plaque and luminal narrowing are seen at gray-scale and colour Doppler ultrasound

additional criteria include ACI/ACC PSV ratio >4 and ACI EDV >100 cm/sec

near occlusion of the ACI:
velocity parameters may not apply, since velocities may be high, low, or undetectable
diagnosis is established primarily by demonstrating a markedly narrowed lumen at colour or power Doppler ultrasound

total occlusion of the ICA:
no detectable patent lumen at gray-scale US and no flow with spectral, power, and colour Doppler ultrasound. There may be compensatory increased velocity in the contralateral carotid

Sonographic NASCET Index

This study proposed the incorporation of distal ICA flow velocity information on the conventional carotid Doppler study improving the diagnostic accuracy of PSV 1.

<15% stenosis:

deceleration spectral broadening with a peak systolic velocity (PSV) <125 cm/s

16-49% stenosis:
pansystolic spectral broadening with a PSV <125 cm/s

50-69% stenosis:

pansystolic spectral broadening with a PSV of >125 cm/s and

end diastolic velocity (EDV) <110 cm/s or ACI/ACC PSV ratio >2 but <4

70-79% stenosis:

pansystolic spectral broadening with PSV >270 cm/s
or
EDV >110 cm/s or ACI/ACC PSV ratio >4

 

80-99% stenosis: EDV >140 cm/s
complete occlusion: no flow; terminal thump

SVS co-morbidity score

Score                                                Description of score

Major components

Cardiac status

0                       Asymptomatic, with normal electrocardiogram

1                        Asymptomatic but with either remote myocardial infarction by                                                                 history (6 months), occult myocardial infarction by electrocardiogram, or                                      fixed defect on dipyridamole thallium or similar scan

2                        Any one of the following: stable angina, no angina but significant reversible                                  perfusion defect on dipyridamole thallium scan, significant silent ischemia                                  (1% of time) on Holter monitoring, ejection fraction 25% to 45%, controlled                                   ectopy or asymptomatic arrhythmia, or history of congestive heart failure that                              is now well compensated

3                      Any one of the following: unstable angina, symptomatic or poorly controlled                                  ectopy/arrhythmia (chronic/recurrent), poorly compensated or recurrent                                        congestive heart failure, ejection fraction less than 25%, myocardial infarction                            within 6 months

Pulmonary status

0                        Asymptomatic, normal chest radiograph, pulmonary function tests within 20%                             of predicted

1                         Asymptomatic or mild dyspnea on exertion, mild chronic parenchymal                                        radiograph changes, pulmonary function tests 65% to 80% of predicted

2                         Between 1 and 3

3                        Vital capacity less than 1.85 L, FEV1 less than 1.2 L or less than 35% of                                     predicted, maximal voluntary ventilation less than 50% of predicted, PCO2                                  greater than 45 mm Hg, supplemental oxygen use medically necessary, or                                  pulmonary hypertension

Renal status

0                        No known renal disease, normal serum creatinine level

1                        Moderately elevated creatinine level, as high as 2.4 mg/dL (212

2                        Creatinine level, 2.5 to 5.9  (522) mg/dL

3                        Creatinine level greater than 6.0 mg/dL, or on dialysis or with kidney                                            transplant

Minor components

Hypertension

0                        None (cutoff point, diastolic pressure usually lower than 90 mm Hg)

1                         Controlled (cutoff point, diastolic pressure usually lower than 90 mm Hg) with                              single drug

2                         Controlled with two drugs

3                          Requires more than two drugs or is uncontrolled

Age

0                            55 y

1                            55-69 y

2                            70-79 y

3                             80 y

 

 

Risk factor Weighting Score

Cardiac                     x4            12

Pulmonary                 x2             6

Renal                         x2             6

Hypertension              x1              3

Age                           x1              3

Maximum score*                      30

 

Morphologic state

Definition, grading, and categorization of an initial morphologic state

Attribute      Absent 0          Mild 1            Moderate 2         Severe 3

Aortic neck

Length (L) L>25 mm    15< L <25 mm    10 <L<15 mm    L <10 mm

Diameter (d) d <24 mm 24<d<26 mm 26<d<28 mm d<28 mm

Angle 150° 150° angle 135° 135° angle 120° Angle 120°

Calcification/thrombus 25% 25-50% 50% –

Aortic aneurysm

Angulation and tortuosity

Aortic tortuosity index (T) T 1.05 1.05 T 1.15 1.15 T 1.2 T 1.2

Aortic angle ( ) 160° to 180° 140° to 159° 120° to 139° 120°

Thrombus 0 25% 25%-50% 50%

Aortic branch vessels No vessels 1 lumbar/IMA 2 vessels 2 vessels

d 4 mm IMA d 4 mm

Pelvic perfusion Patent bilateral IIA Single IIA occlusion Single IIA occlusion Bilateral IIA occlusion Contralateral IIA 50% stenosis

Iliac artery

Calcification None 25% vessel length 25%-50% vessel length 50% vessel length

Diameter/occlusive disease

d 10 mm 8 d 10 mm 7 d 8 mm d 7 mm

No occlusive disease No stenosis 7 mm diameter or 3 cm long

Focal stenosis 7 mm diameter and 3 cm in length

Stenosis 7 mm diameter and 3 cm in length More than one focal stenosis 7 mm diameter

Angulation and tortuosity

Iliac tortuosity index (
)
1.25 1.25
1.5 1.5
1.6
1.6 Iliac angle () 160° to 180° 121° to 159° 90° to 120° 90°

Iliac artery sealing zone

Length (L) L 30 mm20 L30 mm10 L20 mm L 10 mm

Diameter (d) d 12.5 mm 12.5 d 14.5 mm 14.5 d 17 mm d 17 mm

IIA, Internal iliac artery; IMA, inferior mesenteric artery.