Category 10, Items 29 and 30
A 30-year-old otherwise healthy woman has the acute onset of severe low back pain, and loss of sensation and then motor function of both lower extremities. On physical examination, she is somewhat tachycardic at a regular rate of 100, although blood pressure is 95/70 on the right upper extremity and 105/70 on the left. She is anxious and has no pulses or Doppler signals in the femoral or distal vessels. She is insensate to pinprick from L-4 and deep tendon reflexes are also absent. Abdominal examination demonstrates no abnormal abdominal masses and bowel sounds are present.
A chest film and an EKG are normal. Her WBC count is 14,400 with no shift. SMA-7 and SMA-12 are normal. Serum creatinine is 0.9. A Foley catheter yields 0.5 mL/kg/hour. The angiogram shown is obtained.
29. Which of the following statements is TRUE?
Angiography is the most expedient and readily available method of confirming the diagnosis
This condition is the most common lethal catastrophe involving the aorta
Aortic rupture is the most common cause of death but occurs late in the course, and careful surveillance of aortic diameter is required for optimal timing of operation
No specific therapy is required for patients with only chest or back pain as the initial event
Because it is rare and causes of death are insidious (renal failure, bowel infarction), the diagnosis is difficult to establish and overall mortality is 40%
30. The first step for this particular patient’s problem should be
bilateral femoral thromboembolectomy of the iliac arteries
left axillo-bifemoral bypass grafting
aorto-bifemoral bypass graft with superior mesenteric artery reconstruction
reconstruction of the ascending aorta
placement of a right iliac artery stent and femoro-femoral bypass
Select the one lettered answer that is BEST for each item.
For the answers and a critique of items 29 and 30 see page 310.
Footnotes
(Reproduced by permission from SESAP No. 11 2002–2004 Syllabus, Volume 2. For enrolment in the Surgical Education and Self-Assessment Program, please apply to the American College of Surgeons, 633 North St. Clair St., Chicago IL 60611-3211, USA; tel 312 202-5000; fax 312 202-5001; email postmaster{at}facs.org)