vascular

Question 1

fournier gangrene affects what fascia

Answer 1

deep fascia
Fournier’s gangrene is essentially necrotizing fasciitis of the perineum and it is a surgical emergency because it can cause rapid and uncontrollable necrosis of tissue and ultimately death by overwhelming sepsis if not treated promptly

Question 2

most common site for peripheral arterial disease

Answer 2

femoral artery - producing pain in the calves on exertion

Question 3

what are varicose veins

Answer 3

Varicose Veins are dilated and tortuous superficial veins, most often affecting the lower limb. They occur due to incompetence of the valves between the deep and superficial venous systems, resulting in retrograde flow and pooling of blood in the superficial venous system.

Question 4

features of varicose veins

Answer 4

Visible superficial veins
Pain
Cramping or heaviness
Oedema
Venous ulcers may be present
Discolouration due to increased haemosiderin deposits
Haemorrhage

Question 5

tx for varicose veins

Answer 5

Treatment not required unless bleeding, pain, ulceration, thrombophlebitis or significant psychological morbidity
Lifestyle modification
Reduce long periods of standing
Elevate lower limbs when possible
Support stockings
Weight loss
Walking
Radiofrequency ablation: destruction of the endothelium of the vein via high temperature catheter
Endovenous laser ablation: destruction of the vein using laser
Injection sclerotherapy: Injection of sclerosant substance at several points in the vein, leading to occlusion
Surgery: avulsion therapy or stripping of the vein

Question 6

Chronic dull pain, discomfort, pruritus with skin changes (hemosiderin, oedema) suggest

Answer 6

chronic venous insuffiency
dilated tortuous veins are suggestive of varicose veins due to venous valve incompetence. As venous pressure rises, the veins become varicose and leak inflammatory substances into the interstitium. Duplex ultrasonography can pick up bidirectional blood flow in the superficial veins instead of unilateral blood flow from the superficial to the deep system.

Question 7

diagnostic test for PAD

Answer 7

Computerised tomography angiography

Question 8

varicose veins diagnostic test

Answer 8

Duplex ultrasonography

Question 9

when do we use ABPI for PAD

Answer 9

ABPI is used to evaluate peripheral arterial disease which present as claudication pain and absent peripheral pulses. In a patient with chronic venous insufficiency, ABPI should be done to exclude PAD but it is not the diagnostic test for venous insufficiency.

Question 10

lipodermatosclerosis

Answer 10

Lipodermatosclerosis refers to changes in the skin of the lower legs

Question 11

superficial thrombophlebitis refers to thrombus formation in superficial venous vasculature most commonly in lower limb veins what is mx

Answer 11

Compression stockings

Question 12

Dry gangrene is a complication

Answer 12

of criticlal limb ischaemia

Dry gangrene is a complication of critical limb ischaemia. The blood supply to the toe has become so poor that the lack of oxygen and nutrients has led to necrosis of the tissue. There is usually a clear delineation between the dead and living tissue. Dry gangrene is not infected

Question 13

wet gangrene tx

Answer 13

debridement and amputuation and borad IV abx

Question 14

what is buergers disease

Answer 14

Buerger’s disease is a non-atherosclerotic vasculitis caused by occlusion in small and medium-sized arteries. in men

Question 15

how does buergers disease present

Answer 15

It typically presents as an acutely ischaemic limb, without a background of peripheral claudication.

Question 16

what investigations would you do for burgers disease

Answer 16

Arterial Doppler will confirm the absence of peripheral pulses in the affected limb. Further imaging (such as with arterial duplex or CT/MR angiography) will show non-atherosclerotic occlusion. Martorell’s sign on arterial duplex describes the ‘corkscrew’-shaped collateral vessels characteristic of Buerger’s disease.

Question 17

mx for buergers disease

Answer 17

Management is with smoking cessation ± vasoactive medication (such as nifedipine).

Question 18

most likley cause of acute limb ischaemia

Answer 18

AF

The most likely aetiology for acute limb ischaemia is an embolus of cardiac origin, particularly in the absence of previous intermittent claudication due to atherosclerotic peripheral artery disease (PAD). The most likely explanation in this scenario is a cardiac thrombus in the myocardium due to AF, throwing off an embolus that has now lodged into the popliteal trifurcation of the right leg, producing ischaemic symptoms.

Question 19

first line management in acute limb ischameia

Answer 19

IV heparin - slow clot propagation so it can be determind if embolic or thrombotic cause( inactivates the thrombin)

Question 20

‘Inverted champagne bottle’ appearance (tapering of legs above the ankle)

Answer 20

venous ulcer commonly shin

arterial pressure points

Question 21

PAD only MR angio if confrimed first test you can do is

Answer 21

ABPI

Question 22

management of venous ulcer

Answer 22

compression bandaging - do ABPI first to avoid exacerbating PAD

Question 23

what is wet gangrene

Answer 23

In wet gangrene the necrotic area is poorly demarcated from the surrounding tissue and patients are pyrexial/septic.

Question 24

gold satndard would be magenic resonance angiogrpahy when do you do CT angio
MRA great for CKD as no chance of contrast

Answer 24

only if MRA CI

Question 25

sx and rf for AAA

Answer 25

US of AAA

Question 26

A 71-year-old man presents to the emergency department with an a painful left leg and is subsequently diagnosed with acute limb ischaemia.

Which of the following would point to an embolic rather than thrombotic cause for the patient’s presentation?

Answer 26

Onset over minutes

Acute limb ischaemia due to embolic obstruction tends to produce symptoms over minutes; patients can typically point out the precise time they started to develop symptoms. Thrombosis-induced acute limb ischaemia on the other hand develops over hours to days.

Question 27

An ulcer with a rolled edge appearance should raise suspicion of

Answer 27

BCC

Question 28

what is ABPI

what do diabetics have

Answer 28

It is a ratio of the highest ankle systolic blood pressure over the highest brachial blood pressure. A lower index suggests a narrowing of the lower limb blood vessels. Note: diabetic patients may have artificially high ABPI values as their arteries are not easily compressible due to calcification

Question 29

double amputee potnetial with ischaemic limb do you offer below or above knee amputation

Answer 29

below as above would make less stable

Question 30

carotid artery stenosis of 70-99%,

Answer 30

Patients should undergo carotid endarterectomy if there is carotid artery stenosis of 70-99%, with symptoms of an ischaemic event such as a Stroke or TIA in the corresponding vascular territory

as well as
Anti-platelet agents (first line is clopidogrel 75mg)
Cholesterol lowering therapy
Blood pressure control
Lifestyle advice

Question 31

mx of intermittent claudication

Answer 31

supervised exercise programme - promotes collateral vessel formation

Question 32

mx ischaemic legs

Answer 32

lifestyle
antiplatelettherapy
statin
diabetes
bp
pain relief iwth naftidofuryl oxalate - vasodialtor that can alleviate the pain

Question 33

biggest RF for AAA

Answer 33

smoking

Question 34

arterial ulcers located where

Answer 34

distal extremities and pressure points, bony promenince.

Question 35

under 50% carotid stenosis what do you do

Answer 35

antiplatlet therapy

Question 36

pain starts below the knee what artery occluded

Answer 36

Left femoro-popliteal artery

Question 37

A 72-year-old man attends for follow-up after his visit complaining of exertional pain in the calves, relieved by rest. The GP suspects the patient has intermittent claudication and orders ankle–brachial pressure index (ABPI) investigations.

The ABPI comes back at 1.4 (normal 0.8–1). Subsequent imaging with Duplex ultrasound confirms the presence of significant anatomical stenoses bilaterally.

Which of the following conditions in the patient’s background is most likely to explain the misleading ABPI?

Answer 37

Diabetes mellitus

An ABPI of greater than 1.3 may suggest the presence of arterial calcification, usually due to diabetes mellitus or end-stage renal failure. In such patients, the ABPI is not a reliable indicator of peripheral artery disease and further investigations (such as toe–brachial pressure indices) are warranted.

further investigations such as toe-brachial pressure indices are needed

Question 38

difference between chronic, acute and critical limb ischaemia

Answer 38

Acute limb ischaemia is a surgical emergency, caused by a sudden lack of blood flow to the limb. Cx thromboembolism. need RF. Symptoms are the 6Ps: Pain, Pulselessness, Pallor, Paraesthesia, Paralysis, Perishing with cold.
CT angiography is needed to confirm the diagnosis. Urgent surgical assessment is needed to determine the viability of the limb. If the limb is viable, revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.
Over this time, or if revascularisation fails, or the limb is deemed non-viable, amputation is the only option

Chronic limb ischaemia presents with cramping pain the lower limbs after walking a certain distance and is relieved by rest. Like with angina, it’s brought on by increased oxygen demand of the myocytes that cannot be met, the onset of the pain is predictable (with exercise) and symptoms are relieved by rest. Calf claudication is due to narrowing in the femoral vessels, hence the popliteal, dorsalis pedis and posterior tibial pulses are weaker

Critical limb ischaemia consists of a triad of ischaemic pain at rest (burning pain that is worse at night when the leg is elevated, and relieved by hanging the leg off the bed), arterial ulcers, and gangrene. Critical limb ischaemia is a worsening of chronic limb ischaemia to the point where the limb may receive permanent damage and has all the same risk factors as chronic limb ischaemia

Question 39

CT angiography is needed to confirm the diagnosis of acute limb ischameia . Urgent surgical assessment is needed to determine the viability of the limb. If the limb is viable what happens revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.

if the limb is not viable what happens

Answer 39

revascularisation procedure (e.g. angioplasty) need to be performed within 4-6 hours of onset to save the limb.
and within how long

Over this time, or if revascularisation fails, or the limb is deemed non-viable, amputation is the only option

Question 40

A 60 year old male complains of worsening cramping pain in his buttocks and legs. He used to be able to walk to the grocery store, but now has to stop intermittently due to pain. He also reports that he has difficulty getting erections these days. His past history is significant for hypertension and hyperlipidaemia.

Examination shows loss of hair and decreased temperature in the lower legs. The femoral pulses are not felt. The genital examination reveals no abnormalities.

Which of the following is the most likely diagnosis?

Answer 40

Aortoiliac artery stenosis

Claudication pain in the buttock and thigh, erectile dysfunction and diminished/absent femoral pulses are hallmark features of aortoiliac artery stenosis, also known as Leriche syndrome.

Question 41

spinal stenosis sx

Answer 41

Spinal stenosis is caused by progressive narrowing of the spinal canal. It can manifest with cramping pain that typically involves the entire leg and would not cause absent limb pulses. The pain is usually relieved with bending forward, not with rest.

Question 42

critical limb ischaemia what do patients tend to do

Answer 42

Critical limb ischaemia consists of a triad of ischaemic pain at rest (burning pain that is worse at night when the leg is elevated, and relieved by hanging the leg off the bed), arterial ulcers and gangrene

Question 43

20 cigareetes a day for a year what pack year hisotry

Answer 43

1pack per year history

Question 44

what is a saphena varix

Answer 44

A saphena varix is a dilation of the saphenous vein at the saphenofemoral junction (ie. the point where the saphenous vein drains into the femoral vein in the groin). This patient’s lump has several features in keeping with saphena varix: the classic location, bluish tinge, disappearance when lying down and positive cough impulse test. The past medical history of varicose veins also makes this more likely.

Question 45

is diabetes protective against AAA

Answer 45

yes

Question 46

chronic limb ischaemia tx

Answer 46

Refer for supervised exercise, clopidogrel 75mg once daily, atorvastatin 80mg

This is the correct answer. The patient presents with clinical features consistent with chronic leg ischaemia. Patients should be considered for 2 hours of supervised exercise per week for 3 months. Cardiovascular risk should be managed with smoking cessation, weight management, high dose statin therapy, antiplatelet therapy (with clopidogrel), and management of blood pressure and diabetes

Question 47

common cause of acute limb ischaemia

Answer 47

AF

Question 48

mesothelioma

what other places can it affect

Answer 48

cancer of the serosal services - pleura (lining of the lung) - can also affect pericadium and perineum

Question 49

first line for superificial thrombophelbitis

Answer 49

NSAIDs. then stockings

Question 50

PAD when is angio recommended

Answer 50

Percutaneous transluminal angioplasty is only indicated if conservative measures have failed and disease is severe enough to affect the patient’s quality of life, or if the disease is limb-threatening. Angioplasty is indicated with single-segment diseases which can be widened by a balloon

Question 51

most common cause of aneurysm

Answer 51

artherosclerosis

Question 52

what do you put between pleura servies with mesolethioma

Answer 52

talkam powder

Question 53

asbestos related pleural disease

Answer 53

lesion associated with pleural effusion - exudate and blood stained - benign condtions but lead to thickening as an infalmmarty condtio
volume loss
pleural plaques - shows asbestos expsoure but no sx - paches of plaques due to calcfication of areas of pleura due to expsoure looks like fat worms as such
diffuse peural thickening - involves visceral pleura - around ribs, costophrenic angles results in restrictice disease

Question 54

A 59 year old male comes to the emergency department with severe abdominal and lower back pain. He has a background of type 2 diabetes mellitus and hypertension. He is a lifelong smoker. Observations shows that his pulse rate is 120 beats per min, blood pressure 70/50 mmHg, SpO2 92% on air and temperature of 37.5 degrees Celsius. There are no airway noises and the chest sounds clear. Abdominal examination reveals an expansile and pulsatile mass. His calves are soft and non-tender.

What is the most appropriate initial management?

Answer 54

Fluid resuscitation to bring systolic blood pressure to 90mmHg

This patient’s presentation is typical for ruptured abdominal aortic aneurysms (severe abdominal and lower back pain, tachycardia, hypotension, expansile mass). Immediate fluid resuscitation with 0.9% normal saline to raise blood pressure to 90mmHg (permissive hypotension) is immediate first line treatment to keep vital organs perfused until definitive measures can be done.

get BP up first before procedure

Question 55

Dilated pampiniform venous plexus

Answer 55

variocele

Question 56

A 49 year old woman presents to the emergency department with sudden excruciating pain of the left arm associated with numbness while she was doing house chores this morning. There is no previous history of trauma to the arm. On further questioning, she has intermittent episodes of palpitations over the last few weeks.

Examination shows cyanosis to the level of the elbow and her left hand feels cold to touch. The radial and ulnar pulses are absent. She has active range of movement in the hand but the sensation is mildly reduced. Her right upper extremities are normal.

Following initial resuscitation with high flow oxygen, fluids and analgesia, what is the next best step of management?

Answer 56

Intravenous heparin bolus followed by continuous infusion

This patient has an acute ischaemic arm (acute pain, paraesthesia, pallor, cold) likely secondary to arterial embolism. She has minimal sensory loss without any motor deficit, putting her at category 2a- marginally threatened limb according to Rutherford criteria. For patients with category 2a and below, conservative management with prolonged course of heparin may be attempted first.

Question 57

are people with asbestos related lung disease aviable for compensation

Answer 57

industrial injuries disablement benefit from departments of work and pensions for damages claim