Arterial Diseases of Extremities Flashcards
Clinical disorder characterized by stenosis or occlusion in the aorta or arteries of the limbs.
PA
Leading cause of PAD in patients >40 years old
Atherosclerosis
Primary site of involvement in PAD in 80-90% of symptomatic patients
Popliteal arteries
Primary site of involvement in PAD in 30% of symptomatic patients
abdominal aorta and iliac arteries
PAD lesions occure preferentially at ___
arterial branch points
which are sites of increased turbulence, altered shear stress, and intimal injury
Involvement of the distal vasculature is most common in __
elderly individuals and patients with diabetes mellitus.
The most typical symptom of PAD is ____
intermittent claudication
The site of claudication in PAD is ____.
distal to the location of the occlusive lesion.
[PAD] Symptoms are far more common in the_____extremities because of the higher incidence of obstructive lesions in the former region.
lower than in the upper
Critical limb ischemia symptoms
Rest pain
Feeling of cold or numbness in the foot and toes.
Symptoms worsen at night when legs are horizontal and improve when legs are dependent.
Persistent rest pain in severe cases.
Important physical findings of PAD include decreased or absent pulses ____[proximal/distal] to the obstruction, the presence of bruits over the narrowed artery, and muscle atrophy.
Normal ABI:
1-1.4
Borderline ABI: 0.91–0.99.
0.91-0.99
Abnormal ABI diagnostic of PAD
<0.9
[PAD] It is not be used for routine diagnostic testing, but are performed before potential revascularization
Magnetic resonance angiography (MRA), computed tomographic angiography (CTA), and conventional catheter-based angiography
[PAD] The prognosis is worse in patients who ____
Smoke cigarettes
Diabetes mellitus.
[PAD] PTA and stenting of the ___ artery are associated with higher success rates than are PTA and stenting of the femoral and popliteal arteries.
iliac
There is no definitive medical therapy for critical limb ischemia. T/F
T
[PAD] Drug-coated balloons and drug-eluting stents have lower/higher restenosis rates than PTA and bare metal stents respectively.
lower
[PAD] The most frequently used procedure is the _____ using knitted Dacron grafts.
aortobifemoral bypass
Which of the following is the most common cause of peripheral arterial disease (PAD) in patients older than 40 years?
A) Vasculitis
B) Trauma
C) Atherosclerosis
D) Fibromuscular dysplasia
C
In PAD, which group has the highest prevalence of atherosclerotic disease?
A) Patients aged 20–40 years
B) Patients aged 40–50 years
C) Patients in their 60s and 70s
D) Patients older than 80 years
C
Which risk factor is most associated with an increased risk of developing PAD?
A) Hyperthyroidism
B) Smoking
C) Vitamin D deficiency
D) Hypotension
B
Intermittent claudication, a hallmark symptom of PAD, typically presents as:
A) Persistent pain in the legs, relieved by exercise.
B) Pain, cramping, or fatigue in the muscles during exercise, relieved by rest.
C) Pain only during rest, aggravated by walking.
D) Generalized leg swelling without pain.
B
In patients with PAD, which site of claudication is associated with aortoiliac disease?
A) Calf only
B) Buttock, hip, thigh, and calf
C) Sole of the foot only
D) Groin
B
Calf- femoral popliteal disease
What is the normal range for the ankle-brachial index (ABI) in patients without PAD?
A) 0.60–0.80
B) 0.81–0.90
C) 0.91–0.99
D) 1.00–1.40
D
Which class of medications is recommended for reducing the risk of cardiovascular events in patients with PAD?
A) Proton pump inhibitors
B) Calcium channel blockers
C) Statins
D) NSAIDs
C
Which of the following combinations is effective in improving cardiovascular and limb outcomes in patients with PAD but is associated with an increased risk of bleeding?
A) Warfarin and aspirin
B) Rivaroxaban (low dose) and aspirin
C) Clopidogrel and ticagrelor
D) Statin and ezetimibe
B
In supervised exercise training programs for PAD patients, what is the minimum recommended duration per session?
A) 15 minutes
B) 20 minutes
C) 30 minutes
D) 60 minutes
C
Which medication has been shown to increase walking distance in PAD patients by 40–60% and improve quality of life?
A) Cilostazol
B) Pentoxifylline
C) Warfarin
D) Digoxin
A
For which of the following scenarios is surgical revascularization most appropriate in a PAD patient?
A) Mild intermittent claudication
B) Stable PAD without rest pain
C) Critical limb ischemia
D) Asymptomatic PAD
C
Which surgical intervention for aortoiliac disease in PAD patients has the highest long-term patency rate?
A) Axillofemoral bypass
B) Femorofemoral bypass
C) Aortobifemoral bypass with Dacron graft
D) Aortoiliac endarterectomy
C
Which preoperative test is most appropriate to stratify cardiac risk in a PAD patient with poor functional capacity before vascular surgery?
A) Coronary angiography
B) Radionuclide myocardial perfusion imaging
C) Ankle-brachial index
D) Duplex ultrasonography
B
A hyperplastic disorder that typically affects medium-size and small arteries, but it can also affect larger arteries.
Fibromuscular dysplasia
[Fibromuscular Dysplasia] The most common type of medial dysplasia and is characterized by alternating areas of thinned media and fibromuscular ridges.
Medial fibroplasia
The ____ arteries are the limb arteries most likely to be affected by fibromuscular dysplasia.
iliac
“String of beads” appearance caused by thickened ridges and thin less-involved portions
Fibromuscular dysplasia
Fibromuscular dysplasia most commonly affects which type of arteries?
A) Large arteries only
B) Medium-size and small arteries
C) Capillaries and arterioles
D) Veins
B
What is the most common histologic subtype of fibromuscular dysplasia?
A) Intimal fibroplasia
B) Medial fibroplasia
C) Perimedial fibroplasia
D) Adventitial hyperplasia
B
Which treatment options are appropriate for patients with fibromuscular dysplasia and debilitating symptoms or threatened limbs?
A) Statins and aspirin therapy
B) Corticosteroids and immunosuppressants
C) Percutaneous transluminal angioplasty (PTA) and surgical reconstruction
D) Endarterectomy and bypass grafting
C
Inflammatory occlusive vascular disorder affecting small and medium-size arteries and veins.
Thromboangiitis Obliterans (Buerger’s Disease)
The clinical features of thromboangiitis obliterans often include a triad of ____
claudication of the affected extremity
Raynaud’s phenomenon
migratory superficial vein thrombophlebitis.
Although the cause of thromboangiitis obliterans is not known, there is a definite relationship to ____ in patients with this disorder.
cigarette smoking
Buerger’s Disease disorder primarily affects ___
distal vessels
calves and feet
forearm and hand
[Buerger’s Disease] The diagnosis can be confirmed by ____and pathologic examination of an involved vessel.
excisional biopsy
What is a characteristic triad of clinical features in thromboangiitis obliterans?
A) Claudication, migratory superficial vein thrombophlebitis, and Raynaud’s phenomenon
B) Claudication, hypertension, and tachycardia
C) Migratory superficial vein thrombophlebitis, Raynaud’s phenomenon, and digital ischemia
D) Hypertension, claudication, and digital ulcers
A
What is the most important intervention in managing thromboangiitis obliterans?
A) Anticoagulation therapy
B) Glucocorticoid therapy
C) Complete cessation of tobacco use
D) Long-term antibiotics
C
Which finding is characteristic of thromboangiitis obliterans on conventional arteriography?
A) Proximal atherosclerotic plaques
B) Smooth, tapering segmental lesions in distal vessels with collateral formation
C) Diffuse calcifications in large arteries
D) Aneurysms of the major proximal vessels
B
Which of the following is true regarding the pathologic changes in thromboangiitis obliterans?
A) The internal elastic lamina is disrupted in the early stages.
B) Neutrophil infiltration is replaced by mononuclear cells and fibroblasts in later stages.
C) The disease predominantly involves the intimal layer of the vessels.
D) Giant cell arteritis is a hallmark feature of the early phase.
B
_____ occurs when arterial occlusion results in the sudden cessation of blood flow to an extremity.
Acute limb ischemia
Principal causes of acute arterial occlusion include ___
embolism
thrombus in situ
arterial dissection and trauma.
[ALI] In the lower extremities, emboli lodge most frequently in the _____
femoral artery,
[ALI] Once the diagnosis is made, the patient should be anticoagulated with intravenous ____ to prevent propagation of the clot and recurrent embolism.
heparin
[ALI] Intraarterial thrombolytic therapy with recombinant tissue plasminogen activator, reteplase, or tenecteplase is most effective when acute arterial occlusion is recent (< ___weeks) and caused by a thrombus in an atherosclerotic vessel, arterial bypass graft, or occluded stent.
2
[ALI] Surgical revascularization is preferred when r toration of blood flow must occur within ____ to prevent limb loss or when symptoms of occlusion have been present for ____
24 h
> 2 weeks.
Which cardiac condition is a major source of arterial emboli leading to acute limb ischemia?
A) Atrial fibrillation
B) Sinus bradycardia
C) Patent ductus arteriosus
D) Mitral valve prolapse
A
atrial fibrillation; acute myocardial infarction; ventricular aneurysm; cardiomyopathy; infectious and marantic endocarditis; thrombi associated with prosthetic heart valves; and atrial myxoma.
What is the initial treatment for a patient with suspected acute limb ischemia?
A) Aspirin therapy
B) Intravenous heparin
C) Surgical revascularization
D) Antibiotic therapy
B
Intraarterial thrombolytic therapy is most effective when the acute arterial occlusion has been present for:
A) <12 hours
B) <24 hours
C) <1 week
D) <2 weeks
D
Surgical revascularization is preferred in which of the following scenarios?
A) Symptoms of arterial occlusion for <2 weeks
B) Small distal vessel occlusion
C) Restoration of blood flow needed within 24 hours to prevent limb loss
D) Patient with contraindications to anticoagulation therapy
C
Which of the following is true regarding the management of acute limb ischemia caused by cardiac thromboembolism?
A) Long-term anticoagulation is contraindicated.
B) Anticoagulation is unnecessary if thrombolysis is successful.
C) Long-term anticoagulation is indicated to prevent recurrence.
D) Endovascular therapy alone is curative for all patients.
C
In this condition, multiple small deposits of fibrin, platelets, and cholesterol debris embolize from proximal atherosclerotic lesions or aneurysmal sites.
Atheroembolism
Blue toe syndrome
Atheroembolism
Atheroembolism primarily results from embolization of which of the following?
A) Fibrin, platelets, and cholesterol debris
B) Fat and bone marrow
C) Leukocytes and fibrinogen
D) Proteins and calcium deposits
A
Which clinical feature is most characteristic of atheroembolism?
A) Widespread petechial rash
B) Livedo reticularis and “blue toe” syndrome
C) Ulceration of proximal arteries
D) Acute, diffuse limb swelling
B
What diagnostic finding supports the diagnosis of atheroembolism?
A) Evidence of aortic aneurysm on CTA
B) Cholesterol crystals on skin or muscle biopsy
C) Negative Doppler studies for distal emboli
D) Prolonged clotting times
B
This is a symptom complex resulting from compression of the neurovascular bundle (artery, vein, or nerves) at the thoracic outlet as it courses through the neck and shoulder.
Thoracic Outlet Compression Syndrome
Venous compression may cause thrombosis of the subclavian and axillary veins; this is often associated with effort and is referred to as _____
Paget-Schroetter syndrome.
[TOCS] Cervical ribs, abnormalities of the scalenus anticus muscle, proximity of the clavicle to the first rib, or abnormal insertion of the pectoralis minor muscle may compress the _____ as these structures pass from the thorax to the arm.
subclavian artery, subclavian vein, and brachial plexus
[TOCS]Depending on the structures affected, thoracic outlet compression syndrome is divided into these 3 forms
arterial, venous, and neurogenic
This form of compression in TOCS have the following symptoms: shoulder and arm pain, weakness, and paresthesias
Neurogenic
This form of compression in TOCS have the following symptoms: shoulder and arm pain, weakness, and paresthesiasThis form of compression in TOCS have the following symptoms: claudication,
Raynaud’s phenomenon,
ischemic tissue loss or gangrene.
Arterial
This form of compression in TOCS is associated with Paget Schroetter Syndrome
Venous
Provocative Maneuvers [TOCS]
Abduction and External Rotation Test:
Arm abducted 90°; shoulder externally rotated.
Scalene Maneuver:
Extension of neck and rotation of head toward affected side.
Costoclavicular Maneuver:
Posterior rotation of shoulders.
Hyperabduction Maneuver:
Arm raised 180°.
Thoracic Outlet Compression Syndrome results from compression of which of the following structures?
A) Axillary nerve and lymphatic vessels
B) Neurovascular bundle (artery, vein, or nerves)
C) Large thoracic veins only
D) Intercostal arteries and veins
B
Which type of thoracic outlet compression is most likely to cause thrombosis of the subclavian or axillary veins, often associated with effort?
A) Neurogenic
B) Venous
C) Arterial
D) Mixed neurovascular
B
Which symptom is most characteristic of arterial Thoracic Outlet Compression Syndrome?
A) Persistent shoulder pain and paresthesia
B) Raynaud’s phenomenon and claudication
C) Severe chest pain and dyspnea
D) Swelling of the arm and neck veins
B
The abduction and external rotation test for diagnosing arterial TOCS involves which maneuver?
A) Arm raised above the head at 180°
B) Arm abducted to 90° with external shoulder rotation
C) Head rotated to the opposite side while extending the neck
D) Arms placed behind the back with shoulders pushed forward
B
Which of the following is true regarding neurophysiologic testing in neurogenic Thoracic Outlet Compression Syndrome?
A) Electromyograms and nerve conduction studies are highly sensitive.
B) Normal test results exclude the diagnosis.
C) Abnormal results may indicate brachial plexus involvement.
D) Neurophysiologic testing is contraindicated during acute symptoms.
C
What is the first-line management for most patients with Thoracic Outlet Compression Syndrome?
A) Surgical removal of the first rib
B) Avoidance of symptom-provoking positions and shoulder girdle exercises
C) Long-term anticoagulation therapy
D) Immediate thrombolysis
B
Surgical intervention in Thoracic Outlet Compression Syndrome, such as first rib removal or scalenus anticus muscle resection, is indicated in which scenario?
A) Persistent mild symptoms
B) Severe ischemia or debilitating symptoms refractory to conservative management
C) Isolated paresthesias with normal imaging
D) Minimal venous compression on provocative testing
B
This typically affects young athletic men and women when the gastrocnemius or popliteus muscle compresses the poplieteal artery and causes intermittent claudication
Popliteal Artery Entrapment
Provocative maneuvers the check pulse for Popliteal Artery Entrapment
Ankle dorsiflexion
Plantar Flexion
The most common peripheral aneurysm
Popliteal artery aneurysms
The most common clinical presentation of popliteal artery aneurysm
limb ischemia
How is popliteal artery aneurysm detected
Palpaption
What are the indications for repair of popliteal artery aneurysms
Symptomatic aneurysm
Diameter exceeds 2-3cm
Compression of a large arteriovenous fistula may cause reflex slowing of the heart rate
Nicoladoni-Branham sign
Which demographic is most commonly affected by popliteal artery entrapment?
A) Elderly women with diabetes
B) Young athletic men and women
C) Middle-aged men with hypertension
D) Sedentary individuals over 50 years old
B
What is the primary mechanism causing intermittent claudication in popliteal artery entrapment?
A) Atherosclerotic plaque formation
B) Compression of the popliteal artery by the gastrocnemius or popliteus muscle
C) Embolization of cholesterol debris
D) Vasospasm of the popliteal artery
B
Which diagnostic test is most appropriate to confirm popliteal artery entrapment?
A) Electromyography (EMG)
B) Duplex ultrasonography, CTA, MRA, or conventional angiography
C) Ankle-brachial index measurement
D) Chest X-ray
B
Which clinical maneuver may reveal an abnormality in popliteal artery entrapment?
A) Ankle dorsiflexion and plantar flexion
B) Straight leg raise test
C) Costoclavicular maneuver
D) Treadmill stress test
A
Approximately what percentage of popliteal artery aneurysms are bilateral?
A) 25%
B) 50%
C) 75%
D) 90%
B
What is the most common clinical presentation of a popliteal artery aneurysm?
A) Rupture of the aneurysm
B) Limb ischemia secondary to thrombosis or embolism
C) Compression of adjacent structures
D) Claudication without ischemia
B
Which diagnostic test is most appropriate to confirm the presence of a popliteal artery aneurysm?
A) Magnetic resonance angiography (MRA)
B) Duplex ultrasonography
C) Computed tomography angiography (CTA)
D) Chest X-ray
B
Which of the following is an indication for surgical repair of a popliteal artery aneurysm?
A) Asymptomatic aneurysm with a diameter of 1 cm
B) Symptomatic aneurysm or diameter exceeding 2–3 cm
C) Non-palpable femoral pulse
D) Evidence of mild claudication only
B
What is the defining feature of an arteriovenous fistula?
A) Direct communication between a vein and a capillary
B) Bypass of the capillary bed between an artery and a vein
C) Compression of veins by surrounding tissue
D) Venous thrombosis leading to ischemia
B
Which clinical finding is commonly associated with arteriovenous fistula?
A) Persistent pallor of the extremity
B) Pulsatile mass with a thrill and a systolic-diastolic bruit
C) Blanching of the skin with pressure
D) Cold, dry skin over the fistula
B
Which long-term complication may result from a large arteriovenous fistula?
A) Aortic dissection
B) High-output heart failure
C) Chronic arterial occlusion
D) Pulmonary hypertension
B
Which diagnostic test is most appropriate for identifying a suspected arteriovenous fistula at the site of catheter access?
A) Duplex ultrasonography
B) Ankle-brachial index
C) Electrocardiography
D) Echocardiography
A
Compression of a large arteriovenous fistula causing reflex slowing of the heart rate is referred to as which sign?
A) Nicoladoni-Branham sign
B) Raynaud’s sign
C) Allen’s sign
D) Tinel’s sign
A
What is the hallmark clinical feature of Raynaud’s phenomenon?
A) Persistent cyanosis of the extremities
B) Triphasic color change: blanching, cyanosis, and rubor
C) Diffuse swelling of the hands and feet
D) Ulceration and gangrene in all cases
B
Which of the following triggers is most commonly associated with Raynaud’s phenomenon?
A) Exposure to heat
B) Cold exposure or emotional stress
C) High-altitude environments
D) Vigorous exercise
B
What is the primary pathophysiologic mechanism behind the pallor observed in Raynaud’s phenomenon?
A) Venous congestion
B) Vasospasm of the digital arteries
C) Increased capillary permeability
D) Vasodilation of peripheral vessels
B
What percentage of patients with systemic sclerosis experience Raynaud’s phenomenon?
A) 10–20%
B) 30–40%
C) 80–90%
D) 100%
C
Which class of medications is first-line therapy for severe Raynaud’s phenomenon?
A) Beta-blockers
B) Calcium channel blockers
C) Corticosteroids
D) Anticoagulants
B
Which of the following best differentiates primary Raynaud’s phenomenon from secondary Raynaud’s phenomenon?
A) Primary Raynaud’s has normal nailfold capillary findings.
B) Primary Raynaud’s is associated with connective tissue diseases.
C) Secondary Raynaud’s involves episodic rather than persistent symptoms.
D) Secondary Raynaud’s is unrelated to underlying conditions.
A
In Raynaud’s phenomenon, the hyperemic phase following cold exposure is associated with which clinical finding?
A) Cyanosis of the affected digits
B) Blanching and pallor
C) Bright red color (rubor) and throbbing pain
D) Diffuse edema of the affected extremity
C
Which of the following is a common secondary cause of Raynaud’s phenomenon?
A) Hypertension
B) Polycythemia vera
C) Systemic lupus erythematosus (SLE)
D) Diabetes mellitus
C
What is the defining characteristic of acrocyanosis?
A) Persistent cyanosis of the hands and feet due to arterial occlusion
B) Episodic blanching and cyanosis of the digits triggered by cold exposure
C) Persistent cyanosis caused by arterial vasoconstriction and capillary/venule dilation
D) Cyanosis of the digits due to embolization
C
Which of the following distinguishes primary acrocyanosis from Raynaud’s phenomenon?
A) Episodic nature of symptoms
B) Cyanosis extends proximally from the digits and is persistent
C) Pain and ulceration are common in acrocyanosis
D) Primary acrocyanosis is associated with systemic diseases
B
Which demographic is most commonly affected by primary acrocyanosis?
A) Men over 50 years old
B) Women under 30 years old
C) Children under 10 years old
D) Men with connective tissue disorders
B
What is the appropriate management for primary acrocyanosis?
A) Anticoagulant therapy
B) Warm clothing and avoidance of cold exposure
C) Sympathetic nerve block
D) Immediate surgical intervention
B
Which of the following is a potential cause of secondary acrocyanosis?
A) Atherosclerosis
B) Antiphospholipid antibodies
C) Hyperthyroidism
D) Iron deficiency anemia
B
What is the defining clinical appearance of livedo reticularis?
A) Blanching of the skin with cold exposure
B) Mottled or netlike reddish-blue discoloration of the skin
C) Persistent cyanosis of the digits
D) Uniform erythema of the extremities
B
Which subtype of livedo reticularis is associated with irregular, disrupted mottling that does not improve with warming?
A) Primary livedo reticularis
B) Secondary livedo reticularis
C) Atrophie blanche en plaque
D) Livedo racemosa
D
Which of the following is a secondary cause of livedo reticularis?
A) Cold agglutinin disease
B) Antiphospholipid antibody syndrome
C) Peripheral artery disease
D) Polycythemia vera
B
What is the appropriate management for benign primary livedo reticularis?
A) Initiation of anticoagulation therapy
B) Immunosuppressive therapy
C) Reassurance and avoidance of cold environments
D) Biopsy and surgical excision
C
Which rare syndrome is associated with the coexistence of ischemic stroke and livedo reticularis?
A) Sneddon’s syndrome
B) Raynaud’s syndrome
C) Marfan’s syndrome
D) Ehlers-Danlos syndrome
A
What is the primary trigger for the development of pernio (chilblains)?
A) Heat exposure
B) Cold exposure
C) Physical trauma
D) High-altitude environments
B
Which clinical feature is most characteristic of pernio?
A) Persistent cyanosis of the fingers
B) Raised erythematous lesions on the toes or fingers associated with pruritus and burning
C) Triphasic color change (blanching, cyanosis, rubor)
D) Large, painful ulcers with gangrene
B
What is the most appropriate initial management for pernio?
A) Topical corticosteroids and systemic antibiotics
B) Avoidance of cold exposure and use of sterile dressings for ulcers
C) High-dose corticosteroids and anticoagulation therapy
D) Surgical debridement and vascular reconstruction
B
Which of the following is a histologic finding associated with pernio?
A) Proliferative endarteritis
B) Angiitis with intimal proliferation and perivascular infiltration of leukocytes
C) Dilated capillary loops with fibrin deposition
D) Necrotizing vasculitis with thrombus formation
B
Which pharmacologic treatment has shown potential benefit in managing symptoms of pernio?
A) Beta-blockers
B) Dihydropyridine calcium channel antagonists
C) Corticosteroids
D) Anticoagulants
B
What is the hallmark symptom of erythromelalgia?
A) Persistent cyanosis of the extremities
B) Burning pain and erythema of the extremities, often involving the feet
C) Triphasic color change triggered by cold exposure
D) Pulsatile mass with a systolic-diastolic bruit
B
Which genetic mutation is associated with inherited forms of erythromelalgia?
A) SCN9A mutation affecting the Nav1.7 voltage-gated sodium channel
B) Factor V Leiden mutation
C) JAK2 mutation associated with myeloproliferative disorders
D) COL3A1 mutation linked to Ehlers-Danlos syndrome
A
What is the most common underlying cause of secondary erythromelalgia?
A) Paraneoplastic syndrome
B) Myeloproliferative disorders such as polycythemia vera and essential thrombocytosis
C) Connective tissue diseases like systemic lupus erythematosus (SLE)
D) Neuropathies
B
Which factor most commonly exacerbates the symptoms of erythromelalgia?
A) Cold exposure
B) Warm environments and dependent positioning of the affected extremity
C) High-intensity exercise
D) Emotional stress
B
Which treatment option is most effective for erythromelalgia associated with myeloproliferative disorders?
A) Corticosteroids
B) Aspirin
C) Beta-blockers
D) Anticoagulation
B
What is the primary mechanism of tissue damage in frostbite?
A) Hyperemia and vasodilation
B) Freezing and vasoconstriction of tissues
C) Direct trauma to blood vessels
D) Immune-mediated inflammation
B
What is the recommended initial treatment for frostbite?
A) Massage and application of extreme heat to the affected area
B) Immersion of the affected part in a warm water bath (40°–44°C)
C) Immediate application of cold compresses to prevent swelling
D) Administering systemic corticosteroids
B
Which of the following interventions is contraindicated in the management of frostbite?
A) Sterile dressings for ulcerated areas
B) Massage of the affected area
C) Use of analgesics during rewarming
D) Antibiotics if there is evidence of infection
B
Massage, application of ice water, and extreme heat are contraindicated
