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luminal diameter > 4.0 cm but < 5.0 cm should lead to restriction of the Class 1 Medical Assessment,
whilst a diameter > 5.0 cm should lead to denial. Regular follow-up is mandatory, with careful control of
the blood pressure.
In view of the relatively poor outcome in patients with aortic aneurysm after surgery, only the best risk
subjects in whom coronary artery disease has been excluded may be considered for restricted
certification. In applicants with a forme fruste3 of Marfan’s syndrome and in whom the
echocardiographic dimensions of the heart and great vessels remain within the normal range, any valvar
regurgitation, whether aortic or mitral, should be minimal before restricted certification may be
considered subject to indefinite subsequent review.
PERIPHERAL VASCULAR DISEASE
Peripheral vascular disease powerfully predicts the presence of a generalized arteriopathy that is likely to
involve the coronary and cerebral circulations. The discovery of absent (lower) limb pulses, with or
without symptoms suggestive of intermittent claudication, should always provoke full cardiovascular
review. In 84 consecutive patients with peripheral vascular disease but no cardiac symptoms followed for
a mean of 66 months, more than two-thirds had significant coronary artery disease on angiography and
their mean left ventricular ejection fraction was reduced at 44 per cent. There were 23 events in the
follow-up period. Dipyridamole stress thallium MPI was a significant predictor of outcome. In general
terms, the younger the age of onset, the worse the outcome. The presence of peripheral vascular disease
following coronary artery surgery is associated with a significantly higher mortality. On account of the
co-morbid risk of a coronary event associated with peripheral vascular disease all such applicants should
at least undergo pharmacological stress thallium MPI. If abnormal, certification should be denied unless a
subsequent coronary angiogram satisfies the standard requirements for minor coronary artery disease (see
above).
1 Marfan’s syndrome: a congenital disorder of connective tissue characterized by abnormal length of extremities,
especially fingers and toes, subluxation of the lens, cardiovascular abnormalities (commonly dilation of the
ascending aorta) and other deformities. After Antonin Bernard Jean Marfan, French paediatrician (1858-1942).
2 Ehler-Danlos syndrome: a group of inherited disorders of the connective tissue. The major manifestations include
hyperextensible skin and joints, easy bruisability, poor wound healing, and orthopaedic and ocular defects. After
Edvard Ehlers, Danish dermatologist (1863-1937) and Henri A. Danlos, French dermatologist (1844-1912).
3 forme fruste: a partial, arrested, or inapparent form of the disease (French ‘unfinished form’).
ICAO Preliminary Unedited Version — October 2008 III-1-44
Indefinite supervision is required, and class 1 Medical Assessment must be restricted to multicrew
operations.
VENOUS THROMBOSIS
A number of factors predispose to deep venous thrombosis, with consequent risk of pulmonary embolism.
In spite of the attention of the news media that deep venous thrombosis has attracted recently, it is rare or
very rare in otherwise fit aircrew. The risk is enhanced in the thrombophilic syndromes (factor V Leiden;
deficient protein S and C and anti-thrombin). Occult malignancy may also be associated. Following an
episode, recurrence is common - 20 per cent at five years which will require long term treatment with
warfarin. Aspirin is not a substitute.
Once diagnosed, deep venous thrombosis is normally treated with warfarin for 3 - 6 months which
precludes certification until one week after this medication is discontinued.
Pulmonary embolism
Pulmonary embolism is an important complication of deep venous thrombosis and is now often
investigated by spiral computed tomography (CT) scanning. This procedure has taken over from
ventilation/perfusion (V/Q) scanning.
Pulmonary angiography may be performed if the pulmonary artery pressure is also to be measured. It is
essential to secure the diagnosis in view of the risk of recurrence although this is low in the absence of
risk factors. Warfarin is the mainstay of treatment. This medication disbars from any form of certification
in many States due to the risk of haemorrhage which is in addition to any risk from the underlying
condition. New direct thrombin inhibitors are under trial. These do not require follow-up of the
prothrombin time and may have a lower rate of haemorrhagic complication. They are not yet generally
available.
Following pulmonary embolus, the pulmonary artery pressure must be shown to be normal before
medical certification can be considered. Good Doppler signals may enable a non-invasive assessment of
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Manual of Civil Aviation Medicine 1(102)
