Vascular

Question 1

A 62-year-old non-insulin dependent diabetic man has presented with a penetrating plantar ulcer of his left foot.
On examination he has no palpable pulses below the level of the femoral artery. The ulcer on his foot is necrotic and oozing pus. He is also noted to have a second large ulcer on the posterior aspect of his left leg.
An angiogram is performed which shows patent vessels to the distal popliteal artery. No vessels are seen distal to the trifurcation.

Answer 1

Robinson (skew flap)
This man requires a below knee amputation. Two operations exist:

The Burgess long posterior flap
The skew flap technique, as described by Kingsley Robinson.
A controlled clinical trial of the two techniques showed no difference in healing rates, with a slightly earlier limb fitting and mobilisation with skew flaps.

A long posterior flap is not an option for this man due to the ulcer on the posterior aspect of the lower leg.

Question 2

A 39-year-old type 1 insulin dependent diabetic has presented to the vascular clinic with a right inter-digital ulcer between the second and third toe. He has been treated with oral antibiotics. A plain radiograph revealed osteomyelitis six months before.
On examination all pulses in the right leg are palpable. A repeat radiograph confirms marked destruction of the head of the third metatarsal.

Answer 2

Ray
This man requires amputation of the toe and metatarsal (Ray amputation). This amputation is useful in diabetic gangrene when osteomyelitis has developed.

Question 3

A 78-year-old man with extensive peripheral vascular disease has previously undergone a right above knee amputation.
He presented to the vascular clinic six weeks previously with critical ischaemia of his left foot. He underwent a femoro-distal bypass which was unsuccessful. His left lower leg is no longer viable. He has been wheel chair bound following his first amputation.

Answer 3

Gritti-Stokes (knee disarticulation)
Gritti-Stokes knee disarticulation, or above knee amputation, is indicated for this patient. Because he is wheel chair bound as a single amputee he is unlikely he rehabilitate as a double amputee. If he undergoes a second above knee amputation, he will loose the pendulum affect of the left (unamputated) leg, which makes transferring from the wheel chair difficult.

A through knee disarticulation is a quick procedure in a sick patient, and leaves the patient with the pendulum effect due to the longer stump.

Question 4

A 73-year-old man presents to the emergency unit with a fever and history of being unwell over the preceding six weeks. On examination he is found to have a warm pulsatile mass in the epigastrium. A CT scan confirms a 6.2 cm infra-renal abdominal aortic aneurysm. An abdominal ultrasound scan performed the previous year showed no evidence of an aneurysm. Blood cultures are positive for Staphylococcus.

Answer 4

Mycotic aneurysm
Mycotic. A mycotic aneurysm develops from infection in a native artery. Infection develops in the wall of the artery weakening the media causing the artery to become aneurysmal. The condition occurs more commonly in atheroscelortic arteries as these already have a weakened resistance to infection. If reconstruction is attempted, it should be with vein grafts or antibiotic bonded grafts.

Question 5

A 29-year-old female presents on the medical take as an emergency. She has suffered with malaise, fever and arthralgia for a month. She is found to be hypertensive and is now complaining of abdominal pain following food. On examination she has a pulsatile/expansile mass in the epigastrium.

Answer 5

Takayasu’s disease
Takayasu’s aortitis is an inflammatory process which is transmural and granulomatous and if left untreated will lead to occlusion through fibrosis. The male: female ratio is 1:7, affecting younger adults. The commonest presentation affects the arch vessels and abdominal aorta. This young woman has developed a focal aneurysm due to disruption of the media. Her hypertension is due to renovascular involvement. The abdominal pain is due to mesenteric ischaemia. She should be treated at least in the acute phase with high dose steroids with or without methotrexate or cyclophosphamide.

Question 6

A 38-year-old man is referred by his GP to the vascular outpatients with a palpable mass in the epigastrium. He has suffered with joint hypermobility since childhood. His brother died of a ruptured abdominal aneurysm aged 42 years. On examination he is of normal height, with marked scarring over his knees and elbows. An ultrasound scan confirms a thoraco-abdominal aneurysm.

Answer 6

Ehlers-Danlos syndrome
Ehlers-Danlos. Ehlers-Danlos type IV is associated with aneurysm formation. The case is more likely to represent Ehlers-Danlos than Marfan’s as he is of normal height, and suffers with joint hypermobility and poor healing, all hallmarks of Ehlers-Danlos.

Question 7

A 66-year-old man presents to the vascular outpatients clinic with buttock and thigh claudication on the right. He has a claudication distance of 50 m. He is an ex-smoker of six months.
On examination all pulses in the left leg are palpable with no pulses palpable on the right. An angiogram is performed which shows a 10 cm occlusion of the right common and external iliac arteries, with no other abnormalities detected.

Answer 7

Femoro-femoral bypass
This man requires a left to right femoro-femoral bypass graft (or ilio-femoral bypass from the external iliac artery to give better flow dynamics and avoid one femoral incision [higher infection rates with groin versus abdominal incisions]). Another option would be an angioplasty plus a stent (angioplasty alone for such a long occlusion would not work).

An aorto-bifemoral bypass is a very major reconstruction, which is unnecessary as the aorta and left iliac system are healthy.

Question 8

A 72-year-old man with marked peripheral vascular disease presents to the vascular outpatients clinic. He has previously undergone bilateral femoro-popliteal bypasses, both of which have occluded. He continues to smoke. He is now complaining of bilateral rest pain. On examination no pulses are palpable in either leg. An angiogram reveals no options for angioplasty, stenting or arterial reconstruction.

Answer 8

Lumbar sympathectomy
This man is at risk of losing both legs. A lumbar sympathectomy involves excision of the second and third lumbar ganglia. This can be performed laparoscopically. Chemical sympathectomy is more practical and less invasive, particularly as the results are so poor.

The indications for lumbar sympathectomy are

Rest pain
Digital ischaemia
Ischaemic ulceration.
Lumbar sympathectomy often fails to produce any symptomatic improvement. Any benefit may only be temporary.

Question 9

A 78-year-old woman presents to the vascular outpatients clinic with bilateral buttock pain. She has a claudication distance of 50 m but usually gets breathless before achieving this distance. She suffers with stable angina, having had a myocardial infarction six years previously.
An angiogram reveals a severely narrowed aorta with multiple stenotic lesions in both iliacs. Both femoral arteries are patent with good run off below the knees.

Answer 9

Axillo-bifemoral bypass
An extra-anatomic bypass is indicated in this patient to restore blood flow to both femoral arteries. Aorto-bifemoral bypass grafts have a better long term patency rate but this patient is less likely to survive such an invasive procedure.

The question asked you to choose a vascular procedure. In reality this patient’s severe breathlessness means that her quality of life and walking distance are not going to be improved very much, if at all, by any operation.

Claudication is not a life or limb threatening condition so the best management for her would be best medical treatment alone. There would then be no operative risks to worry about. Primum non nocere.

Question 10

A 55-year-old lorry driver presents to the vascular outpatients clinic complaining of left calf claudication. He has a claudication distance of approximately 400 m. He continues to smoke. On examination all pulses are palpable.

Answer 10

Behaviour modification programmes
Behaviour modification programme - this man has a sedentary life style and he continues to smoke. His employment is not compromised by his claudication. With stopping smoking, increased exercise and control of hypercholesterolaemia it is likely that his symptoms will remain stable or improve.

Question 11

A 59-year-old insulin dependant diabetic presents 2 weeks post MI to the vascular unit. He suffers with bilateral rest pain and has developed an area of dry necrosis on his right foot. His ABPI on the right is 0.3 and 0.45 on the left. A CT angiogram shows long occlusions of the posterior tibial and anterior tibial arteries in the right leg.

Answer 11

Chemical sympathectomy
This is a difficult problem. This man is suffering critical ischaemia, that is,rest pain for more than two weeks, ulceration or gangrene or ankle systolic blood pressure of less than 50 mm Hg. Normally this man would be offered reconstructive surgery depending on the angiogram findings. However, as he has had an MI within two weeks he has a high risk of a further MI under anaesthetic. Iloprost is contraindicated within 6 months of myocardial infarction. Iloprost is a prostacyclin analogue given by intravenous infusion. Improvements are usually only temporary.

Question 12

A 51-year-old postman presents to the vascular outpatients clinic complaining of left calf claudication. His claudication distance is approximately 100 m. He is an ex-smoker of two years. On examination he has a palpable femoral pulse on the left with no foot pulses being palpable. An arterial duplex scan confirms a 25cm occlusion of the left superficial femoral artery. He refuses a femoro-popliteal bypass, as he is concerned that he may loose his job.

Answer 12

Naftidrofuryl oxalate
Cilostazol (pletal) was thought to be more effective than Naftidrofuryl oxalate (Praxilene) but NICE recommends only naftidrofuryl oxalate. Most vascular surgeons advise patients with claudication to avoid surgery and modify their behaviour rather than take expensive medication. However, the surgeon in this case has offered surgery as the patient’s employment is severely impacted by his claudication.

Question 13

A 45-year-old woman presents to the emergency unit with a swollen right leg two weeks following a total abdominal hysterectomy. She complains of an extreme bursting pain from the leg. On examination the leg has a blue discolouration. A venous duplex scan confirms an extensive iliofemoral deep vein thrombosis (DVT).

Answer 13

Phlegmasia caerula dolens
Phlegmasia caerula dolens. Severe and extensive iliofemoral DVT causes a swollen and painful leg, which is typically pale/erythematous, a syndrome known as phlegmasia alba dolens. Phlegmasia caerula dolens (as described above) results when the thrombosis extends to the venular and capillary levels with secondary development of acute arterial ischaemia. Fifty percent of these patients will go on to develop venous gangrene.

Question 14

A 49-year-old woman presents to the vascular outpatients clinic with a longstanding swollen left leg. She reports that the swelling developed after the birth of her last child, 14 years ago. On examination there is moderate swelling of the left leg, which is non-pitting, with no pigmentation present. The right leg is normal to examination. A venous duplex shows an occluded left superficial femoral vein. The superficial venous system is dilated. No valvular incompetence is seen.

Answer 14

Post-phlebtic syndrome
Post-phlebitic syndrome. This woman has developed chronic venous insufficiency from a DVT that was not diagnosed or treated 14 years ago. Post-phlebitic syndrome is also referred to as post-thrombotic syndrome. DVT management should not only be aimed at preventing clot propagation/pulmonary embolus but also at the prevention of this syndrome

Question 15

A 59-year-old woman presents to the vascular outpatients clinic with longstanding bilateral varicose veins. The skin on both lower legs has become indurated and tender. She describes that the skin changes developed from dry scaly skin over both gaitor areas, which was extremely itchy, which resulted in her scratching continually. The legs have a brown discolouration.

Answer 15

Lipodermatosclerosis
Lipodematosclerosis. The patient has given a classical description of the development of venous lipodermatosclerosis. The pigmentation is due to both melanin and haemosiderin deposits. Ulceration may develop spontaneously or from minor trauma.

Question 16

A 39-year-old man was recently diagnosed with renal failure and has been placed on the renal transplant list. He works as a computer programmer and is keen to return to work. He is therefore keen to undergo continuous peritoneal dialysis. A silastic non-irritant double cuffed catheter has been placed in the peritoneal cavity by means of a long subcutaneous tunnel.

Answer 16

Tenkoff
Tenkoff continuous ambulatory peritoneal dialysis (CAPD) has the advantage of being relatively cheap, simple to set up, and relatively easy to run. Disadvantages are obesity due to glucose absorption, peritonitis and catheter failure (approximately 50% in three years). CAPD is used in young adults expected to be transplanted within two years, elderly and diabetics where vascular access is difficult. Initially, catheters (Trocath) were passed blindly into the abdomen with a trochar, Tenkoff type catheters have now superseded these.

Question 17

A 69-year-old man is two days post emergency open abdominal aortic aneurysm repair. He suffers with ischaemic heart disease having undergone a coronary artery bypass grafting two years ago. Following his aneurysm repair, he was transferred to the intensive care unit. Monitoring has shown a rising CVP which has been put down to a failing myocardium by the cardiologist.

Answer 17

Swan-Ganz
A CVP line alone will not provide information on cardiac function. A pulmonary artery balloon flotation catheter (now a historical technique but one that demonstrates understanding of cardiac physiology) is a multiple lumen catheter with an inflatable balloon just proximal to the tip. When the catheter is correctly placed, the balloon is inflated and the pressure at the tip reflects the pressure in the left atrium. Changes of pressures at the tip reflect changes in intravascular volume, filling pressure and left ventricular function.

The cardiac output/index can be calculated by using a thermodilution technique. Placement of Swan-Ganz catheters is associated with a number of major complications. Transoesophageal echocardiography is now the standard method of cardiac physiological assessment.

Question 18

A 52-year-old woman has recently undergone a left mastectomy and axillary node clearance for a node positive grade III invasive ductal carcinoma. The oncologist has recommended chemotherapy. A double lumen catheter with a single cuff is placed in the right subclavian vein under local anaesthetic.

Answer 18

Hickmann line
Hickmann line. Most chemotherapies are given at intervals over a number of weeks. Many of the agents are highly irritant and are required to be given centrally where there is high flow. The most commonly used catheter for this purpose is a Hickmann line. The cuff is placed just under the skin preventing the catheter from becoming dislodged. The double lumen has the advantage of allowing blood samples to be taken as well as drug administration.

Question 19

A 59-year-old man is undergoing a femoro-distal bypass graft for critical ischaemia. A venous conduit is used. The vascular surgeon wants to avoid a size mismatch between the ends of the conduit to be anastomosed. A valvulotome cutting knife is pulled back through the graft to disrupt the valves in the vein lumem.

Answer 19

In-situ
Insitu grafting is the method of choice for vessels around the knee or near the foot. The vein tributaries are ligated and the upper end is then freed and mobilised from the femoral vein which is oversewen. The vein is then anastomosed to the artery. The clamps are then divided and the vein is allowed to distend proximal to the first competent valve. The valvulotome is then passed up the vein to the distended segment and is then gently withdrawn disrupting the valves one by one. The distal end is then anastomosed to the artery.

Question 20

A 67-year-old man presents to the vascular outpatients clinic with right foot rest pain and bilateral short distance claudication. He underwent a coronary artery bypass grafting two years before in which the long saphenous vein was harvested from the right leg. He unfortunately developed an extensive iliofemoral DVT in the left leg in the postoperative period following the CABG. A vascular procedure is planned on his right leg.

Answer 20

PTFE
This man has no leg veins available to act as a conduit. Most commonly a PTFE graft is used. However, there is a lower patency rate at one year with synthetic grafts compared to venous grafts. Some vascular surgeons recommend harvest of arm veins when leg veins are not available.

Question 21

A 63-year-old man presents to the physicians following a transient ischaemic attack, on examination he has a fever. Initial blood cultures grew Streptococcus. An abdominal CT scan showed a 5.7 cm infrarenal abdominal aortic aneurysm, there are signs the aneurysm may be mycotic.

Answer 21

Impregnated
The diagnosis of a mycotic organism can only be definitely made when organisms are cultured from the aneurysm wall. As the aneurysm is greater than 5.5 cm, it requires repair. If a synthetic graft is to be used it should be impregnated with antibiotics. The patient will require a prolonged course of iv antibiotics based on cultures pre-operatively and for at least two weeks post-operatively. Some surgeons still advocate a two-stage approach with an axillo-bifemoral graft being formed first and then ligation of the abdominal aorta a number of weeks later.

Question 22

A 39-year-old female secretary presents to the vascular outpatients clinic with an intermittently cold left hand. She is right hand dominant. She complains that her left hand becomes painful after minimal typing or other light duties. Recently the symptoms have become worse. Radial and ulnar pulses are present on the left but are reduced compared to the right. She has a positive Roos test (aka elevated stress test - slow repetitive finger clenching in the ‘surrender’ position, that is, replicates the symptoms in less than three minutes. On examination she has a palpable mass in the left neck.

Answer 22

Thoracic outlet syndrome
Thoracic outlet syndrome - the mass in the neck represents a cervical rib. The subclavian artery can be compressed between the clavicle and either a cervical rib or band or scalenus anterior. Symptoms range from asymptomatic through to incapacitating ischaemia. A chest radiograph should be performed to identify any cervical ribs and a duplex scan should be performed at rest and in the Roos position/test.

Question 23

A 75-year-old man is being nursed on the coronary care unit following a recent myocardial infarction (MI). He is found to have a cold right hand. He has had no previous similar symptoms. On examination neither the ulnar or radial pulses are palpable.

Answer 23

Embolic
Embolic. The most likely diagnosis is embolic as he is likely to have developed a mural thrombus following his recent MI. The diagnosis is confirmed by an arterial duplex of the arm and an echocardiogram. If he has signs of acute ischaemia, he will require an embolectomy or thrombolysis.

Question 24

A 32-year-old man presents to the vascular outpatients clinic with recurrent paronychias and signs of digital ischaemia. He also complains of claudication type pain from both legs. He smokes 20 cigarettes a day.

Answer 24

Buerger’s disease
Buerger’s disease - the condition is also known as thromboangiitis obliterans, the symptoms are characterised by segmental occlusions of small and medium sized arteries of the arms and legs. The condition was traditionally more common in young men who smoked from the Middle East or Indian sub-continent. However, the incidence is now also increasing in women and older men due to the increased incidence of smoking in these groups.

Question 25

A 76-year-old man presents to the vascular outpatients clinic. He describes ‘drop attacks’ usually following excessive use of his right arm. He also complains of worsening vertigo, diplopia, dysphagia and dysarthria. On examination all pulses are palpable. A supraclavicular bruit is heard on the right. An arterial duplex scan identified a significant stenosis of the right subclavian artery.

Answer 25

Steal syndrome
Steal syndrome - this is a classical description of subclavian steal syndrome. Vertebrabasilar symptoms develop when exercising the affected limb, as there is a reversal of flow in the vertebral artery on the side of the stenosis, which acts as a collateral to supply blood to the ischaemic arm ‘stealing’ blood from the circle of Willis and cerebral arteries. Duplex scanning shows reversal of flow in the vertebral artery on exercise.

Question 26

A 74-year-old woman presents to the vascular outpatients clinic with hoarness, back pain and venous congestion of the left neck. On examination she has a pulsatile mass in the left supraclavicular fossa and an audible bruit. Clinically she has Horner’s syndrome on the left. A chest radiograph shows a left mediastinal shadow.

Answer 26

Aneurysm
Aneurysm - this woman has an intrathoracic subclavian artery aneurysm. Subclavian artery aneurysms represent 1% of all peripheral aneurysms. Intrathoracic aneurysms are mostly asymptomatic. Distal embolisation is seen in two thirds of patients with extrathoracic subclavian aneurysms. Steal syndrome may be seen with larger aneurysms.

Question 27

A 40-year-old woman has been referred from the upper GI clinic to the vascular outpatients clinic. She was investigated for dysphagia that has been present since childhood. A barium swallow showed an oblique indentation in the anterioposterior view. An OGD showed a pulsatile mass narrowing the lumen.

Answer 27

Aberrant
Aberrant - this woman is more likely to have an aberrant (congenital anomaly) subclavian artery and not an aneurysm, as the symptoms have been present since childhood. Aberrant subclavian arteries are common, being found in 1% of post-mortem examination. They were also a common incidental finding when arch aortograms were used to assess carotid artery disease. They are usually asymptomatic and rarely require surgery.

Question 28

A 75-year-old man undergoing an open repair of a 6 cm aortic aneurysm is found at operation to have a 3.5 cm aneurysm of his right common iliac artery. Which method of repair should be chosen?

Answer 28

Trouser graft
Whereas isolated abdominal aortic aneurysms are repaired using a straight (tube) graft, aneurysms which involve both the aorta and iliac arteries are repaired using a bifurcated (trouser) graft. The grafts which are made from Dacron are anastomosed at the infrarenal neck in an end to end fashion and in the iliacs in either an end to end or end to side fashion.

Question 29

A 78-year-old man has collapsed at home. When reviewed in the resuscitation room he is pale and has a blood pressure of 90/60 mmHg. Examination of his abdomen reveals a pulsatile expansile mass in the epigastium. As he is haemodynamically unstable he is transferred to the operating theatre for emergency repair of his suspected ruptured abdominal aortic aneurysm. How should the aorta be approached?
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Answer 29

Transabdominal approach
The transabdominal approach through an extended midline incision is the standard approach for a ruptured aortic aneurysm. This approach gives good exposure of the aortic neck and iliac vessels. A disadvantage of this approach is that the small bowel mesentery requires dissection off the aorta. The retroperitoneal approach gives better access to the supra-renal aorta, but takes longer to both position the patient and to expose the aorta. The retro-peritonael approach also has the disadvantage of poor access to the contralateral (right) iliac.

Question 30

An 81-year-old frail woman has been under six monthly review in the vascular outpatients clinic with an abdominal aortic aneurysm, which is steadily increasing in size. Her most recent ultrasound scan has shown the aneurysm to have increased from 5.3 to 5.9 cm. She suffers with exertional angina and moderate obstructive lung disease. She is keen for intervention. What would be the optimal method of repair in this patient?

Answer 30

Endovascular aortic stent
This woman is at increased risk of rupture as her aneurysm is increasing in size rapidly and is greater than 5.5 cm. She is frail with multiple co-morbidities and is therefore unlikely to survive an open aneurysm repair. An endoluminal aortic stent is therefore the most realistic option for her.

Question 31

A 48-year-old insulin dependant diabetic with a 30 pack year history of smoking presents with infected necrosis of his hallux. An angiogram shows patent vessels to the below knee popliteal then occlusion with refilling of the anterior tibial at the level of the ankle, feeding the dorsalis pedis and pedal arch.

Answer 31

Popliteal – pedal bypass
Popliteal-pedal bypass. This man has tissue loss with severe infragenicular disease. A “suck it and see” amputation of his hallux may work, but has the real risk of accelerating the tissue destruction in his foot and ultimately leading to limb loss. A popliteal-pedal bypass will take blood from an area of good flow to the point where it is required and although a technically difficult operation gives this man the best chance of limb salvage.

Question 32

A 60-year-old smoker presents with intermittent claudication and completes a treadmill test where he covers 180 metres before stopping with cramp in his right calf; his ABPI falls from 0.67 to 0.32 in the affected leg. A duplex scan shows a 10 cm block in his superficial femoral artery. In addition to addressing risk factors and stopping smoking what else should he undergo?

Answer 32

Exercise therapy
Exercise therapy. This man needs to address his risk factors and stop smoking for improvement in his cardiovascular profile, but his walking is a quality of life problem since he covered 180 metres. Although one could perform an angioplasty or surgery it is not currently indicated; he should gain good symptomatic improvement from an exercise programme and in addition to improving his general health this has no iatrogenic risks associated with it.

Question 33

A 60-year-old gentleman undergoes routine and uneventful repair of his abdominal aortic aneurysm; he is noted to have prominent popliteal pulses and a duplex ultrasound reports right popliteal aneurysm of 2.8 cm diameter, left popliteal aneurysm of 1.5 cm diameter.
What should he be offered once he has recovered from his aortic surgery?

nsider intervention.

Answer 33

Right femoral-popliteal bypass and tie off aneurysm
Right femoral-popliteal bypass and tie off aneurysm.

The problem with popliteal aneurysms is that they thrombose and in doing so take out the run-off which often leads to limb loss, although occasionally they do rupture and bleed. In view of this, vascular surgeons intervene electively by bypass, tie off the vessel above and below the aneurysm with a double tie of a non-absorbable suture such as nylon.

The left popliteal is still quite small at the moment and so one would follow this up and if it grew to a diameter greater than 2.5 cm consider intervention

Question 34

A 68-year-old man presents with sudden onset short distance (20 yard) claudication in the left leg with a previous background of normal activity.
His left foot is cool, but does have capillary refill and sensation; movement of the toes is preserved. He has a good femoral pulse but nil below. Angiography shows a thrombosed left popliteal artery with single vessel run-off below the knee and duplex confirms the suspicion of an underlying (thrombosed) popliteal aneurysm. What should he be offered?

Answer 34

Conservative therapy with exercise. This man’s aneurysm has thrombosed and in doing so has left him with an ischaemic limb surviving on a single vessel. The options now are a distal bypass, thrombolysis or wait and see.

Thrombolysis is not without risk in a gentleman of this age and can worsen the situation by causing an ischaemia/reperfusion event resulting in compartment syndrome; also it can dislodge a clot which then takes out the remaining single vessel.

Aggressive reconstructive femoral-distal bypass is usually reserved for critical ischaemia (rest pain, inability to sleep, tissue loss) and involves extensive dissection.

In the acute phase patients often improve as collaterals form and so the initial plan for this gentleman should be to encourage mobilisation and reassess his function - since he is only a few days from thrombosis and has a viable limb; he will probably improve with time which would thus result in avoiding surgery.

Obviously if the limb deteriorates then bypass is indicated.

Question 35

A 32-year-old lady with systemic lupus erythematosus (SLE) presents to the Emergency department with a one day history of sharp, right sided chest pain made worse by deep inspiration. She had her varicose veins stripped nine days ago.

Answer 35

Pulmonary embolism
Pulmonary embolism occurs following dislodgement of venous thrombi, generally from the iliac or the femoral vein, and their subsequent impaction in the pulmonary vasculature. Risk factors include surgery (primarily orthopaedic and gynaecological), immobility, smoking, oral contraceptive pill and malignancy. In addition, this lady has antiphospholipid syndrome which in conjunction with a short period of immobility (due to surgery) and stress has resulted in pulmonary embolism.

Question 36

A 70-year-old hypertensive, obese man is brought to the emergency department with central chest pain with the pain radiating to his back between the scapular blades. His BP is 190/120 mmHg in the right arm and 110/90 mmHg in the left.

Answer 36

Dissecting thoracic aortic aneurysm
Dissection of a thoracic aortic aneurysm causes severe tearing chest pain radiating to the back. The signs and symptoms can be varied depending on the branches of the aorta involved in the dissection. A difference in the pulse pressure between the arms is thus a common, but not an invariable sign. The other complications of this condition include hemiplegia, acute limb ischaemia, and myocardial infarction (may occur if the coronary arteries are involved at the aortic root).

Question 37

A 63-year-old gentleman presents with severe retrosternal chest pain following a bout of heavy drinking. His pulse is 128/min, blood pressure 100/88 mmHg, and examination of his abdomen reveals mild guarding and rigidity.

Answer 37

Perforation of the oesophagus

Spontaneous perforation of the oesophagus (Boerhaave’s syndrome) occurs due to severe barotraumas as seen when a patient vomits against a closed glottis. The pressure in the oesophagus rapidly increases and the oesophagus perforates at its weakest point (lower third). The usual history is that of a patient experiencing severe chest or upper abdominal pain following a heavy meal or a bout of drinking (usually binge). Haematemesis may or may not be present. This condition may be misdiagnosed as a myocardial infarction or perforated peptic ulcer. There may be surprising amount of upper abdominal rigidity even without any peritoneal contamination.

Question 38

A 39-year-old male pedestrian was knocked over by a car. On examination there is a car tyre mark over the knee, the tibia is exposed over a wide area and obviously fractured at more than one site, the lower leg soft tissue is badly mutilated, no pulses are palpable below the femoral artery.

Answer 38

Above knee amputation
This limb is unviable attempted preservation will result in tissue necrosis and sepsis. The decision to amputate a limb following trauma, should only be made after a thorough examination of the limb by both a senior orthopaedic and a senior vascular surgeon.

Question 39

A 68-year-old man has presented with left foot rest pain. A CT angiogram shows complete occlusion of the left common and external iliac arteries. The right common iliac artery is also occluded, with reconstitution at the iliac bifurcation. The common femoral and distal arteries are relatively normal on both sides.

Answer 39

Aorto-bifemoral bypass
This man has severe symptomatic peripheral arterial disease and requires reconstructive surgery. A femoro-femoral crossover bypass is not an option as the donor (right)artery is diseased (angioplasty + stent of the right common iliac artery could be followed by a femoro-femoral crossover but this is not on the list of options). An axillo-femoral bypass has a high occlusion rate and should only be performed in patients who are unlikely to tolerate more extensive surgery. Therefore, an aorto-bifemoral bypass graft is the best option from the list. This is a major surgical intervention, which carries a 2% mortality rate.

Question 40

A 72-year-old woman presents with disabling short distance claudication (20m) of the left calf muscles. She continues to smoke 20 cigarettes a day. An arterial duplex reveals a 25 cm occlusion of the left superficial femoral artery. The flow reconstitutes in the proximal popliteal artery with good three vessels run off.

Answer 40

Femoro-popliteal bypass
This woman has a symptomatic occlusion of the superficial femoral artery with good reconstitution of the flow distal to the occlusion. At 25 cm the occlusion is too long to attempt angioplasty (although these limits are often exceeded as angioplasty techniques improve) and therefore the procedure of choice (from this list) is ideally a femoro-popliteal bypass with a vein graft.

Question 41

A 64-year-old woman with known venous insufficiency presents to her general practitioner with a 24 hour history of pain and increased exudate from her right leg ulcer. On examination, the area surrounding the ulcer is red, warm and painful. The ABPI in this leg is 1.02. She says that she feels well in herself.

Answer 41

Rest, oral antibiotics and simple analgesics
This patient has got cellulitis, probably from infection in the ulcer. Since it is only 24 hours old and the patient is systemically well, the most appropriate treatment at this stage would be rest, oral antibiotics (usually flucloxacillin since infection in such instances is caused due to Staphylococcus aureus) and simple analgesics.

Question 42

A 38-year-old woman presents to the surgical outpatient clinic with an eight week history of an ulcer on her left leg. On examination, the ulcer is over the medial malleolus and has gentle sloping edges. The peripheral pulses are palpable and her ABPI is 1.

Answer 42

High-grade compression bandaging
This is a classical presentation of a simple venous leg ulcer. Such ulcers are usually over the medial malleolus and have gentle sloping edges. Since the peripheral circulation is good with a normal ABPI, the most appropriate treatment would be high compression. This could be in the form of elastic or inelastic compression bandages or tubular bandages (Tubigrip).

Question 43

A 66-year-old woman in the orthopaedic ward complains of pain and swelling in her left calf. On examination, her temperature is 37.8°C. The left calf is red and tender, and feels warm to touch. She had undergone a left total hip replacement eight days ago.

Answer 43

Therapeutic SC low molecular weight heparin (LMWH)
This patient is very likely to have a deep venous thrombosis (DVT). It is classically seen 7-10 days post-surgery. The patient complains of pain and swelling in the affected leg (calf). Examination may reveal a warm, red, tender calf with an increase in the calf girth. Treatment should begin on the basis of the clinical diagnosis. Duplex scanning is necessary to confirm or rule out the diagnosis. Once the diagnosis is confirmed, treatment with therapeutic LMWH (clexane) should be continued, followed by warfarinisation.

Question 44

A 72-year-old man is seen in the vascular clinic with a popliteal artery aneurysm.
If you were to operate on the patient which structure would you expect to see immediately superficial and in contact with the aneurysm?

	 Gastrocnemius tendon
	 Popliteal vein
	 Small saphenous vein
	 Superficial fascia
	 Sural nerve

Answer 44

popliteal vein

From superficial to deep, the structures can be remembered as nerve, vein artery.

The popliteal artery therefore lies deepest in the popliteal fossa with the popliteal vein its superficial relation.

The small saphenous vein enters the roof of the fossa before joining the popliteal vein.

The boundaries of the popliteal fossa are

Superolaterally the biceps tendon
Superomedially the semitendinosus and semimembranosus and
Inferiorly the heads of gastrocnemius.

Question 45

A 77-year-old man is brought to the emergency department with a two hour history of severe peri-umbilical pain radiating to the back.
On examination, he is anxious, pale, sweaty and mildly cyanosed. His pulse rate is 126/min and blood pressure is 80/60 mmHg. Abdominal examination reveals a slightly tender mass just to the left of the umbilicus. Bowel sounds are normal. His bilateral femoral pulses are very feeble.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Acute diverticulitis
Acute pancreatitis
Adhesive small bowel obstruction
Perforated sigmoid colon
Ruptured abdominal aortic aneurysm

Answer 45

Ruptured abdominal aortic aneurysm

Abdominal aortic aneurysm, the commonest aortic aneurysm, is more common in males than females.

The other risk factors include

Smoking
Hypertension
A positive family history
Increasing age.
Rupture of abdominal aortic aneurysm is commonly seen in men over 60 years of age.

These aneurysms most often rupture into the retroperitoneal space, resulting in epigastric/peri-umbilical pain, with the pain radiating to the back or lumbar region, a pulsatile abdominal mass and signs of hypovolaemic shock.

In the case of leaking abdominal aortic aneurysm, these classical symptoms may not be present, or may be delayed (until rupture).

Although an abdominal ultrasound, CT or an MRI scan may be indicated to diagnose or assess the progress of an abdominal aortic aneurysm, a diagnosis of rupture is usually made clinically.

The above investigations may, however, be indicated if a diagnosis of leaking aneurysm is suspected (when the patient is stable enough to undergo any of the above investigations).

Immediate surgery to identify the rupture and stem the blood loss is imperative in cases of ruptured aneurysm. Delay in diagnosis and/or treatment may be fatal.

Question 46

A 68-year-old man with a past medical history of myocardial infarction and hyperparathyroidism is brought into the emergency department. He is complaining of severe abdominal pain and is unable to keep still. The pain is radiating to his back.
His initial observations reveal a blood pressure of 106/70 mmHg, a pulse of 108/min and saturations of 84% on air. You go to see him in the trolley bay area.
What is the most likely diagnosis?
(Please select 1 option)
	 Diverticular disease
	 Renal stone made of calcium phosphate
	 Renal stone made of oxalate
	 Renal stone made of urate
	 Rupturing abdominal aortic aneurysm

Answer 46

Rupturing abdominal aortic aneurysm

The diagnosis to think of first is a rupturing abdominal aortic aneurysm. This should always be considered in the differential diagnosis of renal colic.

In this case

The nature of the pain (radiating to the back)
Hypotension and
Previous history of vascular disease
mean that this possible diagnosis should not be overlooked.

Question 47

A 65-year-old man presents as an emergency with tearing back pain believed by the general practitioner to be renal colic. This is his first episode of such pain.
Past medical history includes hypertension and hypercholesterolaemia and he is a current smoker of 30 cigarettes a day. Dipstick testing of his urine is normal.
On assessment in the emergency unit he has a pulse of 82 beats per minute and a blood pressure of 138/90 mmHg and, as there is no house officer available, he is provided with analgesia and is sent to the urology ward for clerking. Before he is assessed he becomes acutely unwell with a blood pressure of 106/68 mmHg and a pulse of 120 beats per minute.
What is the likely diagnosis?
(Please select 1 option)
Acute pancreatitis
Perforated duodenal ulcer
Pyelonephritis
Renal colic
Ruptured aortic aneurysm

Answer 47

Ruptured aortic aneurysm CorrectCorrect
This is a classic scenario and emphasises the importance of obtaining an accurate history. The presence of an aneurysm must be excluded in any patient who presents with back pain.

In this case, there is a strong cardiovascular history which, along with male gender, is typical of that of a patient with an aortic aneurysm. Furthermore, the nature of the pain and absence of haematuria tends to count against renal colic.

The other classic mimic for aortic aneurysm is lower abdominal pain radiating to the testicle.

Question 48

A 78-year-old male presents with an hour history of an acutely cold, painful, left lower limb.
On examination he has a radial pulse of 98 beats per minute irregular and there are no pulses palpable in the left lower limb. The skin is pale but not mottled. The patient is able to move his left toes, ankle and knee.
Which of the following would be the most appropriate management for this patient?
(Please select 1 option)
Aspirin
Aspirin and clopidogrel
Embolectomy
Heparinisation
Thrombolysis

Answer 48

embolectomy

This man has developed an acutely ischaemic limb due to an embolus lodging in the origin of the femoral artery.

The embolus is most likely to have originated from the left atrium as he is in atrial fibrillation.

Acute limb ischaemia results from a complete occlusion of a proximal artery in the absence of collaterals resulting in the classic presentation of: pain, paralysis, paraesthesia, pallor, pulselessness and a perishingly cold limb.

Initial management is emergency balloon catheter embolectomy under local or general anaesthetic. Limb salvage is reported to be 70% with a 22% mortality.

Intra-arterial thrombolysis is usually reserved for patients who have thrombosed a diseased segment of artery or have occluded a lower limb bypass graft (venous or synthetic).

Following embolectomy the patient is usually heparinised and warfarin commenced if the patient remains in atrial fibrillation to prevent recurrence.

Question 49

A 68-year-old male is found to have an asymptomatic infra-renal abdominal aortic aneurysm on an ultrasound scan for bladder outflow obstruction.
What diameter of aneurysm is an indication for intervention in an asymptomatic patient?
(Please select 1 option)
	 ≥4.0 cm
	 ≥4.5 cm
	 ≥5.0 cm
	 ≥5.5 cm
	 ≥6.0 cm

Answer 49

> 5.5cm
Abdominal aortic aneurysm may cause symptoms due to pressure on surrounding structures, although the majority are asymptomatic at diagnosis.

Abdominal aortic aneurysms primarily affect men over 65 years, with a prevalence of 5%.

Approximately 70% of presenting abdominal aortic aneurysms are detected before rupturing, and are treated electively with 30% presenting as a rupture or with distal embolisation.

Evidence supports surgical intervention when an abdominal aortic aneurysm is =5.5 cm in maximal diameter, although this is subject to the patient’s health and fitness for surgery.

Surgical intervention may be indicated if the patient develops acute onset of pain in the aneurysm, as this may represent imminent rupture of the aneurysm.

Question 50

An otherwise fit 80-year-old lady presents with an eight hour history of acutely ischaemic right arm with severe pain in the hand and fingers. She is right handed. There was no history of pain or restricted movement prior to this current episode.
She has a history of atrial fibrillation for which she has been prescribed digoxin and takes appropriate medications for hypertension. On examination the hand is very cold and pale but some movement and sensation are preserved. There is a good axillary artery pulse but distal pulses are impalpable.

What is the correct management?
(Please select 1 option)
	 Arrange a duplex scan
	 Book an outpatient appointment for vascular surgery
	 Commence heparin
	 Embolectomy
	 Thrombolysis

Answer 50

Embolectomy

This lady has an acute limb occlusion.

Upper limb ischaemia is most commonly due to emboli followed by trauma and atherosclerotic occlusions are rare. Whilst the hand is currently viable it will not remain so for long.

It is likely that the embolus will have lodged at the level of the brachial artery and so surgical exploration and embolectomy using a Fogarty catheter is the correct treatment.

Intraoperative thrombolysis may help treat distal material not removed by the catheter.

Question 51

An 85-year-old lady falls whilst out shopping and injures her left upper limb.
She attends the Emergency department and an x ray confirms a fracture of the shaft of her humerus. Whilst being assessed in casualty it is noted that her forearm pulses are weak on the side of the fracture.
Which artery is she likely to have damaged?
(Please select 1 option)
Axillary
Brachial
Radial
Subclavian
Ulnar

Answer 51

The brachial artery winds around the midshaft of the humerus and is subject to trauma when the humeral shaft is fractured. The damage may range from pressure occlusion through mural contusion with secondary thrombosis, to partial or complete transection.

The nature of the damage should be assessed by means of an arteriogram and appropriate surgery in combination with fracture fixation should be undertaken.

Question 52

A 34-year-old footballer presents to the Emergency department with an acutely swollen left knee. Examination reveals tenderness and effusion over the antero-lateral aspect of the joint. There is full range of passive movements and the radiograph shows no fracture.

Answer 52

Hamarthrosis of knee joint

Tears of the gastrocnemius and soleus muscle fibres are due to sudden unaccustomed exercise.

The pain may accompany underlying haemorrhage within the muscle belly.

Question 53

A 39-year-old female teacher is persuaded to take part in a staff-student tennis match. She has not undertaken any regular exercise in the last 10 years. While running for a ball, she experiences sudden, severe pain in her right calf and is unable to play any longer. On examination, Simmonds’ test is negative.

Answer 53

Torn calf muscle

Simmonds’ test is positive if the Achilles tendon is ruptured (reduced plantar flexion of the ankle on squeezing the calf muscle). Rest, elevation and ice packs are usually sufficient to treat this condition. Physiotherapy may be required after the acute symptoms subside.

Question 54

A 68-year-old man undergoes surgery for perforated diverticular disease. One week later he develops pain and swelling in his left calf. This is associated with mild pyrexia.

Answer 54

Deep venous thrombosis

Hospitalisation and immobility increase the incidence of deep venous thrombosis. The other risk factors include

Increasing age
Pregnancy
Oral contraceptive pill
Surgery especially orthopaedic or pelvic
Malignancy
Past history of DVT and thrombophilia.
Clinical features include

Redness
Swelling
Pain
Calf tenderness
Dilated superficial veins (sometimes) and
Low grade pyrexia.
These signs and symptoms usually develop after 7-10 days post-operatively.

Question 55

A 15-year-old boy presents to his GP with a three month history of swelling and ache in his right lower thigh. The symptoms are worse at night and often keep him awake. There is no history of trauma. He is afebrile with no local tenderness or problem with joint movements.

Answer 55

Bone tumour

Tumours of the bone are important causes of progressive pain in the limbs in the absence of injury, particularly in children and young adults.

Acute swellings within the knee joint after trauma, without fractures, are usually due to damage to the cruciate ligaments or the menisci.

If the pain is severe and the joint movements are restricted, aspiration of the knee joint (either medial or lateral approach, depending on the effusion) under local anaesthetic will relieve the acute symptoms.

Question 56

To avoid a size mismatch at the anastomosis of a venous conduit.

Answer 56

In situ
In-situ grafting is the method of choice for vessels around the knee or near the foot. The vein tributaries are ligated and the upper end is then freed and mobilised from the femoral vein which is over-sewn. The vein is then anastomosed to the artery. The clamps are then divided and the vein is allowed to distend proximal to the first competent valve. The valvulotome is then passed up the vein to the distended segment and is then gently withdrawn disrupting the valves one by one. The distal end is then anastomosed to the artery.

Question 57

A femoro-popliteal bypass in a patient with marked varicose veins.

Answer 57

PTFE

Most commonly a polytetrafluoroethylene (PTFE) graft is used when no venous conduit is available. However, there is a lower patency rate at one year with synthetic grafts compared to venous grafts. Some vascular surgeons recommend harvest of arm veins when leg veins are not available.

Question 58

Infra-renal mycotic abdominal aortic aneurysm.

Answer 58

Impregnated

The patient requires a synthetic graft for repair of the abdominal aortic aneurysm; the graft should be impregnated with antibiotics. The patient will require a prolonged course of IV antibiotics based on cultures pre-operatively and for at least two weeks post-operatively.

Some surgeons still advocate a two-stage approach with an axillo-bifemoral graft being formed first and then ligation of the abdominal aorta a number of weeks later.

Question 59

A 4-year-old female presents with longstanding bilateral lower limb swelling.

Answer 59

Milroy’s disease

Lymphoedema is an excessive accumulation of interstitial fluid as a result of defective lymphatic drainage.

The causes are divided into primary or secondary.

Primary lymphoedema has a male to female ratio of 1:3 and has no known cause, but one third of patients have a family history of the condition.

Secondary lymphoedema is more common than primary and occurs when the lymphatic channels become blocked due to an acquired cause.

Primary lymphoedema is classified into

Congenital when it occurs soon after birth (Milroy’s disease is the inherited form)

Question 60

A 28-year-old female presents with a longstanding swollen right lower limb. A lymphangiography shows hypoplasia of the right lower limb lymphatics.

Answer 60

Lymphoedema praecox

Lymphoedema praecox when presents before the age of 35 years
Lymphoedema tarda when it presents over the age of 35 years.

Primary lymphoedema is thought to be due to aplasia, hypolasia or hyperplasia of the lymphatic vessels during development.

Isotope lymphography is performed to confirm the diagnosis and to assess the prognosis for both limbs.

Treatment is aimed at reducing swelling and weight, reducing the risk of infection and improving function. Surgery (debulking or bypass procedures) is occasionally required in severe cases.

Question 61

A 48-year-old woman with recurrent left lower limb deep vein thrombosis presents with a longstanding swollen left lower limb.

Answer 61

Secondary lymphoedema

Secondary lymphoedema is more common than primary and occurs when the lymphatic channels become blocked due to an acquired cause.

Primary lymphoedema is classified into

Congenital when it occurs soon after birth (Milroy’s disease is the inherited form)
Lymphoedema praecox when presents before the age of 35 years
Lymphoedema tarda when it presents over the age of 35 years.
Primary lymphoedema is thought to be due to aplasia, hypolasia or hyperplasia of the lymphatic vessels during development.

Isotope lymphography is performed to confirm the diagnosis and to assess the prognosis for both limbs.

Treatment is aimed at reducing swelling and weight, reducing the risk of infection and improving function. Surgery (debulking or bypass procedures) is occasionally required in severe cases.

Question 62

Which of the following is true regarding the blood supply of the heart?
(Please select 1 option)
The anterior cardiac vein drains into the coronary sinus
The atrioventricular node is supplied by the left coronary artery
The circumflex artery is a branch of the right coronary artery
The inferior part of the left ventricle is supplied by the left coronary artery
The left coronary artery originates from the left posterior aortic sinus

Answer 62

The left coronary artery originates from the left posterior aortic sinus

The left coronary artery originates from the left posterior aortic sinus This is the correct answerThis is the correct answer
The left coronary artery arises from the left posterior aortic cusp and divides into the circumflex arteries and the left anterior descending (LAD) artery.

The right coronary artery arises from the anterior aortic sinus and supplies the right ventricle, part of the interventricular septum, the atrioventricular (A-V) node and in 85% of cases the inferior part of the left ventricle.

The right coronary artery provides a posterior interventricular branch and a marginal branch that anastomoses with the LAD at the apex.

The oblique vein, together with the small, middle and great cardiac veins, drains into the coronary sinus, which drains into the right atrium. The anterior cardiac vein drains directly into the right atrium.

Question 63

Which of the following is correct regarding abdominal aortic aneurysm?
(Please select 1 option)
Are more common in women
Can lead to paraplegia
Does not rupture until the diameter reaches 70 mm
Is associated with thinning of the tunica adventitia
May cause occlusion of the intercostal arteries

Answer 63

Can lead to paraplegia
The incidence of abdominal aortic aneurysm is about five times higher in men than women.

It causes thinning of the tunica media and tunica intima leading to atrophy.

The elastic fibres may be replaced with connective tissue material such as collgen.

Mural thrombosis is common and may fill the saccular aneurysm.

Abdominal aortic aneurysm may be associated with occlusion of the renal arteries or the iliac arteries which may lead to mesenteric ishaemia (‘mesenteric angina’).

Involvement of the vertebral arteries may lead to ischaemia of the spinal cord resulting in paraplegia.

Any aneurysm more than 50 mm in diameter has the potential to rupture, and hence regular surveillance (with ultrasound scan or CT) is indicated.

Ruptured abdominal aortic aneurysm carries a mortality in the range of 50-60%.

Question 64

With which of the following is reperfusion injury not associated?
(Please select 1 option)
Compartment syndrome
Hyperkalaemia
Oedema of the gastric and intestinal mucosa
Pneumonia
Renal failure

Answer 64

Pneumonia

Reperfusion injury results when free radicals and other inflammatory molecules are released into the circulation.

This usually happens when a vascular clamp is released and blood starts flowing down the vessel, thus washing away all the accumulated toxic particles.

This can affect various organs such as

The lungs (causing increased permeability of the pulmonary vasculature and sequestration of neutrophils)
Muscle (causing muscle breakdown leading to myoglobulinaemia and hyperkalaemia)
Kidneys (myoglobulin accumulation causing acute tubular necrosis leading to renal failure)
Osseo-facial compartments (leading to compartment syndrome) and
The gut (causes gastrointestinal oedema leading to increased gastrointestinal permeability and endotoxic shock).

Question 65

Which of the following is true regarding the primary cartilaginous joint?
(Please select 1 option)
Are surrounded by a capsule enclosing a joint cavity
Are very mobile
Attach ribs to their costal cartilage
Bone ends are covered by hyaline cartilage
Symphysis pubis and xiphisternal joint are examples

Answer 65

Attach ribs to their costal cartilage

All joints in the body could be broadly divided into

Fibrous
Cartilaginous (primary and secondary) and
Synovial (typical and atypical) joints.
Primary cartilaginous joints are formed when the bone meets (joins) a cartilage. They are quite immobile and very strong. The adjacent bone may fracture but the bone-cartilage interface very rarely separates.

All epiphyses and the ribs attaching to their costal cartilages are examples of primary cartilaginous joints.

In a synovial joint, the bone ends taking part are covered by hyaline cartilage and surrounded by a capsule enclosing a joint cavity. The capsule is lined internally by synovial membrane (containing synovial fluid) and the capsule is reinforced internally or externally or both by ligaments.

All limb joints fall in this category.

Symphysis pubis, xiphisternal joint and intervertebral discs are examples of secondary cartilaginous joints (fibrous tissue is present between the two cartilages).

In fibrous joints, the ends are simply joined by fibrous tissue and the movement is negligible. The bones of the vault of the skull are united by fibrous joints.