Vascular Surgery Flashcards
A wheelchair bound 78 year old woman with ischaemic heart disease secondary to long smoking history and longstanding type II diabetes presents with rest pain and a non healing ulcer on the dorsum of her foot. Angiogram shows reasonable superficial femoral artery and iliacs. At the level of the popliteal artery there is an occlusion. Below this there is a short area of patent posterior tibial artery and this reconstitutes lower down the leg to flow to the foot. What is the best treatment option?
Long sub intimal angioplasty Femoro-distal bypass graft with PTFE Above knee amputation Below knee amputation Axillo-femoral bypass
Above knee amputation
A femoro-distal bypass graft would carry a high risk of failure and risk of peri-operative myocardial infarct. This lady would be well suited to primary amputation as she is not ambulant.
A 48 year old woman is admitted with sepsis secondary to an infected diabetic foot ulcer. She has a necrotic and infected forefoot with necrosis of the heel. There is a boggy indurated swelling anterior to the ankle joint. Pulses are normal. What is the best course of action?
Above knee amputation Amputation of the foot Below knee amputation Incision and drainage of pus Application of 4 layer bandages
Below knee amputation
A 76 year old man presents acutely (two hours after onset) with a painful right arm (he is right handed). On examination, he has a cool right forearm and absent radial and brachial pulses. A duplex scan shows an embolus occluding the brachial artery. What is the most appropriate course of action?
Administration of therapeutic low molecular weight heparin
Brachial embolectomy without fasciotomy
Intra arterial thrombolysis
Systemic thrombolysis
Brachial embolectomy with fasciotomy
Brachial embolectomy without fasciotomy
Options to treat upper limb embolic events include either anticoagulation or surgery. Background arterial lesions are very rarely present in the upper limb so embolectomy is usually successful. Anticoagulation with intravenous unfractionated heparin is a reasonable alternative. However, note that low molecular weight heparin is not used in this setting as it’s difficult to control perioperatively.
Which of the following is not a feature of a Charcot foot?
Bounding foot pulses in the early phases
Often occurs in the complete absence of trauma
Erythema of the foot in the early phase
Autonomic neuropathy
Peripheral neuropathy
Often occurs in the complete absence of trauma
Do not confuse the early phase of Charcot foot with cellulitis
Trauma (even if only minor) is a prerequisite. Patients cannot usually recall the traumatic event. The associated neuropathy means that patients continue to walk on the affected foot with subsequent deformity developing over time.
Which of the ABPI measurements shown below is most likely to be found in a 43 year old lady with long standing diabetes who complains of foot pain. It is worse at night and during minor exercise.
> 1.0
- 9
- 3
- 5
- 7
> 1.0
Diabetes may be complicated by vessel calcification and neuropathic pain. Therefore individuals may present with pain which is atypical for claudication both in terms of its tempo of onset and location.
A 74 year old man presents with a painful right leg. The pain developed suddenly the preceeding evening. However, he wondered if it might resolve overnight, instead, it has got worse. On examination, his right leg is cold and white with diminished distal sensation. A CT angiogram shows a thrombus occluding the external iliac artery with no atheromatous disease. What is the most appropriate course of action?
Femoral embolectomy and below knee fasciotomy
Femoral embolectomy alone
Femoral popliteal bypass graft without fasciotomy
Femoral embolectomy with above and below knee fasciotomy
Femoro-femoro cross over graft with above and below knee fasciotomy
Femoral embolectomy and below knee fasciotomy
Delayed limb re-perfusion = Risk of compartment syndrome
Delayed surgery for limb ischaemic carries a risk of re-perfusion injury and compartment syndrome. Where surgery is delayed beyond 6 hours, most surgeons would perform a fasciotomy at the same time as the embolectomy. However, whilst the compartments below the knee are vulnerable, its very rare for this to occur in the thigh and so, as a rule, the thigh is not treated in this manner.
Which of the ABPI measurements shown below is most likely to be found in a 45 year old man who develops calf pain after walking 600 yards. It resolves during periods of rest.
> 1.2
- 0
- 7
- 5
- 3
0.7
Since this is a long claudication distance it may be that only a minor lesion is present. Whilst resting ABPI may be normal, they are usually abnormal following exercise.
A 78 year old man presents with left sided rest pain in his leg and a non healing arterial leg ulcer on the same leg. Imaging shows normal right leg vessels, on the left side there is a long occlusion of the external iliac artery that is unsuitable for stenting. He has a significant cardiac history. What is the most appropriate treatment option?
Aorto-bifemoral bypass
Axillo-bifemoral bypass
Femoro-femoro cross over graft
Femoro-distal bypass
Amputation
Femoro-femoro cross over graft
Femoro-femoral cross over grafts are an option for treatment of iliac occlusions in patients with significant co-morbidities and healthy contralateral vessels. In reality, the idealised situation presented here seldom applies and the opposite vessels usually have some disease and one must be careful not to damage the healthy side.
A 79 year old retired teacher has had an ulcer for 15 years. It is at the medial malleolus and has associated lipodermatosclerosis of the lower limb. The ulcer base is heaped up and irregular. What is the most likely diagnosis?
Basal cell carcinoma Superficial venous insufficiency Squamous cell carcinoma Mixed ulcer Chronic obliterative arterial disease
Squamous cell carcinoma
If, after many years, an ulcer becomes heaped up and irregular, with exophytic edges then suspect a squamous cell carcinoma.
Which of the following changes are most likely to be identified in the aortic wall of a 38 year old lady with a Marfans syndrome and a dissecting aortic aneurysm?
Transmural aortitis Cystic medial necrosis Foamy macrophages Dense dystrophic calcification None of the above
Cystic medial necrosis
Cystic medial necrosis ( or cystic medial degeneration) occurs when basophils and mucoid material lie in between the intimal elastic fibres of the aorta. It is typically found in the aortic degeneration of Marfans syndrome, but may also be seen in aortic degeneration in older adults.
An 84 year old lady is admitted with an infected diabetic foot. An x-ray shows osteomyelitis of her calcaneum. She has a fixed flexion deformity of her knee, but normal pulses. What is the best course of action?
Above knee amputation Below knee amputation Application of 4 layer bandages Hyperbaric oxygen therapy Debridement of foot bones and application of VAC
Above knee amputation
Consider above knee amputation in patients with fixed flexion deformity.
This patient will not be able to walk with a below knee amputation, therefore an above knee amputation would be preferable, as it guarantees better healing the short term.
Which of the interventions listed below would not be conventional treatment for a venous ulcer?
Compression bandages
Limb elevation to control oedema
Optimisation of glycaemic control of diabetic
Use of skin grafts in selected cases
Excision and closure in selected cases
Excision and closure in selected cases
Most venous ulcers are managed with compression bandages. Skin grafting is sometimes used. However, ulcer excision is not standard practice and closure would be impossible.
An unusually tall 43 year old lady presents to the surgical clinic with bilateral inguinal hernias. She develops chest pain and collapses. As part of her investigations a chest x-ray shows evidence of mediastinal widening. What is the most likely underlying diagnosis?
Pulmonary embolus Aortic dissection Tietze syndrome Boerhaaves syndrome Myocardial infarct
Aortic dissection
Marfans syndrome may present with a variety of connective tissue disorders such as bilateral inguinal hernia. They are at high risk of aortic dissection, as in this case.
A 54 year old man presents to the vascular clinic with severe rest pain and an ulcer on his right foot that is not healing. On examination he has bilateral absent femoral pulses. Imaging demonstrates a bilateral occlusion of the common iliac arteries that is not suitable for stenting. What is the most appropriate intervention?
Aorto-bifemoral bypass Axillo-bifemoral bypass Bilateral transfermoral amputation Femoro-femoro cross over graft Femoro-popliteal bypass
Aorto-bifemoral bypass
In a young patient consideration should be given to aorto-bifemoral bypass grafts as these have the best long term functional outcome compared with an axillo-bifemoral bypass graft.
A 22 year old man is referred to the surgical clinic. He has been complaining of varicose veins for many years. On examination he has extensive varicosities of the right leg, there are areas of marked port wine staining. The saphenofemoral junction is competent on doppler assessment. The most likely underlying diagnosis is:
Deep vein thrombosis
Klippel-Trenaunay syndrome
Varicose veins due to sapheno-popliteal junction incompetence
Sturge - Weber syndrome
Angiosarcoma
Klippel-Trenaunay syndrome
Sturge - Weber syndrome is a an arteriovenous malformation affecting the face and CNS, the peripheral vessels are not affected. Simple varicose veins should not typically be associated with port wine staining, nor should a DVT or angiosarcoma.
An 83 year old lady is admitted from a nursing home with infected lower leg ulcers. She underwent an attempted long superficial femoral artery sub initimal angioplasty 2 weeks previously. This demonstrated poor runoff below the knee. What is the best course of action?
Below knee amputation with Burgess flap Below knee amputation with skew flaps Transfemoral amputation Gritti Stokes amputation Wound debridement
Transfemoral amputation
The best option here is to opt for early amputation or simply palliate the patient. Above knee surgery would be needed, attempts to offer a below knee amputation would probably fail.
An 80 year old lady is brought to the emergency department by her carers. She has been unwell for the past few days. On examination, she has a cold, pulseless leg with fixed mottling, below the knee. A duplex scan shows a stenosis of the profunda femoris and popliteal artery with no flow distal to this. What is the most appropriate course of action.
Femoro-femoro cross over graft Axillo- femoral bypass graft Trans femoral amputation Gritti Stokes amputation Administration of intravenous unfractionated heparin
Trans femoral amputation
Fixed mottling is a sign of an unsalvageable limb and mandates either amputation or palliation. A through knee amputation (Gritti Stokes) is unlikely to heal in this setting.
Which of the following is not a typical feature of a chronic venous leg ulcer?
Heaped raised borders if the ulcer has been present more than 5 years
Evidence of surrounding lipodermatosclerosis
Irregular shape to the ulcer
20% of cases will have a previous history of deep vein thrombosis
Haemosiderin deposits in surrounding skin
Heaped raised borders if the ulcer has been present more than 5 years
The borders of the ulcer are often well defined even though they may be irregular. Heaped or raised borders should raise suspicion of a marjolins ulcer.
The medical team refer a 72 year old lady with a bilateral swollen legs. Deep vein thrombosis has been excluded and there is no response to diuretics. On further questioning, the patient reveals that she was born with the swelling in both of her legs. What is the most likely diagnosis?
Lymphoedema tarda Meige's disease Filariasis Lymphoma Milroy's disease
Milroy’s disease
Milroy’s disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige’s disease develops AFTER birth.
A 65 year old diabetic female presents with a painless ulcer at the medial malleolus, it has been present for the past 16 years. On examination, she has evidence of truncal varicosities and a brownish discolouration of the skin overlying the affected area. What is the most likely cause?
Chronic obliterative arterial disease Superficial venous insufficiency Vasculitis Mixed ulcer Neuropathic ulcer
Superficial venous insufficiency
Venous ulcers are usually associated with features of venous insufficiency. These include haemosiderin deposition and varicose veins. Neuropathic ulcers will tend to present at sites of pressure, which is not typically at the medial malleolus.
A 73 year old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination, her foot has areas of gangrene and pulses are impalpable. Which of the ABPI measurements shown below is most compatible with this process?
> 1.2
- 0
- 3
- 8
- 5
0.3
This is critical limb ischaemia. Values of 0.3 are typical in this setting and urgent further imaging is needed. Debridement of necrosis prior to improving arterial inflow carries a high risk of limb loss
A 35 year old Singaporean female attends a varicose vein pre operative clinic. On auscultation, a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position. What is the most likely underlying lesion?
Pulmonary valve stenosis Aortic valve stenosis Aortic sclerosis Mitral valve stenosis Tricuspid regurgitation
Mitral valve stenosis
A mid diastolic murmur at the apex is a classical description of a mitral stenosis murmur. The most common cause is rheumatic heart disease. Complications of mitral stenosis include atrial fibrillation, stroke, myocardial infarction and infective endocarditis.
A 23 year old man presents with intermittent symptoms of altered sensation in his arm and discomfort when he uses his hand. He works as an electrician and his symptoms are worst when he is fitting light fixtures. What is the most likely cause?
Cervical rib Axillary artery embolus Axillary vein thrombosis Raynaud's Atheroma of the subclavian artery
Cervical rib
Compression of the thoracic outlet by the fibrous band of the rib can result in both neurological and circulatory compromise. When manual tasks are performed in which the hand works overhead the signs and symptoms will be maximal and this is the basis of Adsons test.
A 43 year old lady presents with severe chest pain. Investigations demonstrate a dissecting aneurysm of the ascending aorta which originates at the aortic valve. What is the optimal treatment?
Endovascular stent Medical therapy with beta blockers Medical therapy with ACE inhibitors Sutured aortic repair Aortic root replacement
Aortic root replacement
Proximal aortic dissections are generally managed with surgical aortic root replacement. The proximal origin of the dissection together with chest pain (which may occur in all types of aortic dissection) raises concerns about the possibility of coronary ostial involvement (which precludes stenting). There is no role for attempted suture repair in this situation.
A 72 year old female is found to have a malignant lesion in her left arm. She had a mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left arm. What is the most likely cause of the malignancy?
Lymphangiosarcoma Lymphoma Myeloma Angiomyolipoma Giant cell tumour
Lymphangiosarcoma
Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
