Tips to diagnose Pneumothorax

                                           

Coarctation of Aorta

 *  Actiology

-  Congenital narrowing of a segment of aorta.

-  The commonest site is below the subclavain artery base i.e. at its junction with the descending aorta.

 

*  Haemodynamics

-  Blood flow and B.P. in the lower part of the body are decreased.

-  B.P. in the upper part of the body is elevated: {Mechanical- Renal Ischaemia.}

-  Collaterals develop between the branches of the aorta above and below the coarctation, most important are the intercostal branches of the internal mammary artery with intercostal branches of the descending aorta.

Collaterals around the scapula may also develop.

-  Left ventricular hypertrophy & lateral failure.

-  Common associated congenital anomalies:

        Bicuspid aortic valve.

        Congenital aneurysms of circle of Willis.

        Turner's syndrome.

 

*  Symptoms:

-  Intermittent claudication (ischaemia of the lower limbs).

-  Headache & Epistaxis (Hypertension).

-  Pain around shoulders, (Dilated collaterals).

 

*  General Signs

-  Weak delayed femoral pulse with low B.P in the lower limbs.

-  Strong pulsations in the upper limbs and carotids with high brachial B.P.

-  Dilated pulsating collaterals especially intercostal arteries which can be seen in the inter-scapular region posteriorly (Suzman sign).

 

  Precordial/ PRECARDIAL Examination:

Left ventricular hypertrophy with heaving apex.

  Ausculations:

(A) Aortic Area:

-  Accentuated second aortic sound.

-  Systolic ejection murmur.

-  Early diastolic murmur may be heard.

(A.R. due to hypertension & bicuspid aortic valve).

(B) Over site of coarctation:

i.e. Left intraclavicular region (anteriorly) & Left inter scapular region (posteriorly).

Harsh systolic ejection murmur.

(C) Over all the collaterals on the back of the chest:

Continuous murmur

  Investigations

1)      ECG: Left ventricular hypertrophy

2)      CXR, C.T. Scan chest with enhancement:

        Left ventricular enlargement.

        Dilated ascending aorta, sometimes with double aortic knuckle.

Rosler Sign:

Notching of the lower borders of the ribs posteriorly (erosion by collaterals).

 

3.   Aortography, Subtraction Digital Angiography:

Shows the exact site and extent of the coarctation.

Complications:

-  SBE, either on the coarctation or on the bicuspid aortic valve.

-  Left ventricular failure

-  Dissecting aortic aneurysm.

-  Subarachnoid haemorrhage.

 

Treatment:

-  Prophylactic against SBE.

-  Medical for complications

-  Surgical repair of the coarctation.

......END