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.
Which one of the following is least associated with Tetralogy of Fallot?
Right ventricular outflow tract obstruction Overriding aorta Pan systolic murmur Left-to-right shunt Right ventricular hypertrophy
Left-to-right shunt
Right-to-left shunting is characteristic of Fallot’s. In some patients there can be bidirectional shunting (if there is mild pulmonary stenosis) and a few patients can even have pink tetralogy when there is a predominant shunt from left to right due to minimal infundibular stenosis.
A 57 year old lady has suffered from lymphoedema for many years. The left leg is swollen to the mid thigh. Severe limb deformity has developed as a result of process and in spite of compression hosiery. Lymphoscintography shows no patent lymphatics in the proximal leg. The overlying skin is healthy. Which of the following options would give the best long term outcome?
Multilayer compression bandages Charles operation Homans operation Long term loop diuretic therapy Amputation
Homans operation
Surgery is indicated in less than 10% of cases. However, severe deformity is one of the indications for surgery. Lymphovenous anastomosis is indicated where the proximal lymphatics are not patent. When the overlying skin is healthy (and limb deformity a problem), a Homans procedure is a reasonable first line operative option.
A 65 year old man presents, for the first time, with pain at the back of his calves when he mobilises 10 metres. He is known to have hypertension. What is the most appropriate investigation?
Arterial duplex scan MRI angiogram DSA angiogram Aortic USS Knee x-ray
Arterial duplex scan
An arterial duplex should be performed first, before progression to an angiography.
Which of the following features are not typically seen in a venous stasis ulcer?
Located above the medial malleolus Haemosiderin deposits Variable scarring Exophytic granulation tissue Varicose veins
Exophytic granulation tissue
Whilst the base of the ulcer may be lined by granulation tissue, this is seldom exophytic. One of the concerns would be that this represents a malignant transformation.
A 34 year old man presents with varicose veins and it is suspected that these are part of the Klippel-Trenaunay syndrome. Which of the following is not a characteristic of this condition?
Presence of varicose veins Gigantism of a limb Long saphenous vein involvement Port wine stains with clear borders Low flow rates through capillary anomalies
Long saphenous vein involvement
The Klippel-Trenaunay vein is a large, lateral, superficial vein sometimes seen at birth. This vein begins in the foot or the lower leg and travels proximally until it enters the thigh or the gluteal area. Otherwise, varicosities may not be clinically evident until the child begins to ambulate.
Varicosities may be extensive, though they often spare the saphenous distribution. They are seen below the knee, laterally above the knee, and occasionally in the pelvic region. Varicosities may affect the superficial, deep, and perforating venous systems.
Flow rates through the vascular anomalies are low flow rates in contrast to Parkes Weber syndrome where high flow rates are seen.
Surgical exploration has demonstrated atresia and agenesis of deep veins, compression due to fibrous bands, aberrant arteries, abnormal muscles, or venous sheaths.
Rarely, varicosities have been found in the bladder, the colon, and the pulmonary vessels
A thin 72 year old lady has a 3 week history of postprandial abdominal pain that is centrally located. She has episodic diarrhoea and occasionally has passed blood PR. She has a history of ischaemic heart disease and marked renal impairment from ACE inhibitor usage. What is the most appropriate investigation?
Colonoscopy Duplex ultrasound scan of abdomen CT angiogram CT scan without contrast Measurement of faecal calprotectin
Duplex ultrasound scan of abdomen
She is likely to have mesenteric vascular disease. Proximal SMA disease would be the most serious variant. Ideally a CT angiogram would be the best test but with her impaired renal function and low BMI, make a duplex of the SMA is a reasonable first line investigation. Gut peristalsis may impair acquisition of magnetic resonance images.
A 38 year old lady is troubled by lymphoedema that occurred following a block dissection of the groin for malignant melanoma many years previously. Despite therapy with compression bandages she has persistent lower leg swelling impairing her activities of daily living. She has no evidence of recurrent malignancy. Lymphoscintography demonstrates occlusion of the groin lymphatics. However, the distal lymphatic system appears healthy. Which of the following options could be considered?
Lymphovenous anastomosis Homans procedure Charles procedure Loop diurectic therapy long term Amputation
Lymphovenous anastomosis
In young patients with proximal disease and healthy distal lymphatics a lymphovenous anastomosis may be considered. Such cases are rare.
A 52 year old lady develops lower leg swelling following redo varicose vein surgery. There is evidence of swelling of the left leg up to the knee. The overlying skin appears healthy. What is the best management option?
Homans operation Multilayer compression bandages High dose frusemide High dose bumetanide Lymphovenous anastomosis
Multilayer compression bandages
Unfortunately, lymphoedema may complicate redo varicose vein surgery (in 0.5% of cases). As the presentation is mild, she should be managed using compression hosiery. Diuretics do not help in cases of true lymphoedema and a dramatic response suggests an alternative underlying cause.
A 72 year old man present in the vascular clinic with calf pain present on walking 100 yards. He is an ex-smoker and lives alone. On examination, he has reasonable leg pulses. His right dorsalis pedis pulse gives a monophasic doppler signal with an ankle brachial pressure index measurement of 0.7. All other pressures are acceptable. There is no evidence of ulceration or gangrene. What is the best course of action?
Conservative management with medical therapy and exercise Angioplasty Arterial bypass surgery with PTFE graft Arterial bypass surgery with vein graft Watch and wait
Conservative management with medical therapy and exercise
Structured exercise programmes combined with medical therapy will improve many patients. Should his symptoms worsen or fail to improve then a more comprehensive work up should be considered.
A 22 year old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39oC. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space. What is the most likely underlying lesion?
Aortic regurgitation Mitral regurgitation Aortic stenosis Tricuspid stenosis Tricuspid regurgitation
Tricuspid regurgitation
Intravenous drug users are at high risk of right sided cardiac valvular endocarditis. The character of the murmur fits with a diagnosis of tricuspid valve endocarditis.
An 83 year old woman is admitted with a left intertrochanteric neck of femur fracture. On examination, the patient is found to have an ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries. Her ECG is normal. What is the most likely lesion?
Mitral valve stenosis Aortic valve sclerosis Aortic valve regurgitation Tricuspid valve stenosis Mitral valve regurgitation
Aortic valve sclerosis
The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic stenosis, however as there is no radiation of the murmur to the carotids and the ECG is normal, this is less likely.
Which of the following is not a typical feature of an arterial leg ulcer?
Well demarcated edges A grey - white base to the ulcer Men are affected more than women Painful Ankle swelling
Ankle swelling
Ankle swelling is often absent. If present it may be due to mixed arteriovenous disease. With mixed disease the arterial component is treated first.
A 71 year old man presents with a painful lower calf ulcer, mild pitting oedema and an ABPI of 0.3. What is the most likely cause?
Mixed ulcer Deep venous insufficiency Chronic obliterative arterial disease Squamous cell carcinoma Neuropathic ulcer
Chronic obliterative arterial disease
Painful ulcers associated with a low ABPI are usually arterial in nature. The question does not indicate that features of chronic venous insufficiency are present. Patients may have mild pitting oedema as many vascular patients will also have ischaemic heart disease and elevated right heart pressures. The absence of more compelling signs of venous insufficiency makes a mixed ulcer less likely.
An 18 year old lady presents with extensive varicose veins of her left leg. There is associated port wine staining. What is the most likely diagnosis?
Type 1 diabetes Osler syndrome Gardner's syndrome Proteus syndrome Klippel-Trenaunay-Weber syndrome
Klippel-Trenaunay-Weber syndrome
A less common cause of venous insufficiency is Klippel-Trenaunay-Weber (KTW) syndrome, which involves port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.
Which operation below is an amputation of the lower limb in which the femoral condyles are removed and the patella retained?
Transfemoral amputation Gritti Stokes amputation Symes amputation Below knee amputation with Burgess flap Below knee amputation with Skew flap
Gritti Stokes amputation
This is a Gritti - Stokes amputation. During a Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.
A 74 year old lady has a long standing venous leg ulcer overlying her medial malleolus. Which of the following statements relating to the management of this condition is false?
Pentoxifylline may speed ulcer healing
Treatment with daily low dose flucloxacillin may speed ulcer healing
Multilayer bandages may provide compression equivalent to 40mmHg
Large ulcers may be considered for skin grafting
They should not be treated with compression stockings if the ankle / brachial pressure index is 0.4
Treatment with daily low dose flucloxacillin may speed ulcer healing
Routine use of antibiotics is not advised as this may predispose to resistant organisms. Pentoxifylline was subjected to a Cochrane review in 2007 and shown to improve healing rates.
A 62 year old diabetic man presents with long standing plantar ulcer he has clinical evidence of a charcot foot. What is the most likely diagnosis?
Mixed ulcer Chronic obliterative arterial disease Neuropathic ulcer Squamous cell carcinoma Deep venous insufficiency
Neuropathic ulcer
Plantar ulcers in association with peripheral neuropathy are often neuropathic. They classically occur at pressure points.
A 21 year old badminton player attends A&E with a painful, swollen right arm. He is right handed. Clinically he has dusky fingers and his upper limb pulses are present. An axillary vein thrombosis is confirmed. What is the best acute treatment to achieve vein patency?
Intravenous heparin Warfarin Catheter directed tPA Low molecular weight heparin Aspirin
Catheter directed tPA
Heparin and warfarin prevent propagation of the clot. Chronic axillary-subclavian vein thrombosis (ASVT) rarely responds to thrombolytics and generally is better treated conservatively with warfarin.
A 19 year old lady presents with recurrent episodes of pain in her hands. She notices that her symptoms are worst in cold weather. When she gets the pain she notices that her hands are very pale, they then become dark blue in colour. What is the most likely diagnosis?
Axillary artery embolus Brachial artery embolus Raynauds disease Cervical rib Rheumatoid
Raynauds disease
Raynauds disease is characterised by a series of colour changes and discomfort is often present. The young age at presentation coupled with the absence of a smoking history (in most cases) makes occlusive disease unlikely.
An 83 year old lady with a significant cardiac history is admitted with rest pain and bilateral leg ulcers. Imaging demonstrates bilateral occlusion of both common iliac arteries that are unsuitable for stenting. What is the most appropriate intervention?
Femoro-femoral cross over graft Axillo-bifemoral bypass graft Bilateral trans femoral amputations Aorto-bifemoral bypass graft Femoro-distal bypass
Axillo-bifemoral bypass graft
In patients with major cardiac co-morbidities the safest option is to choose an axillo-bifemoral bypass graft. The long term patency rates are less good than with aorto-bifemoral bypass grafts, however, the operation is less major.
A 73 year old male presents with a collapse and is brought to the emergency department. On examination, he has a cold, painful left hand and forearm. What is the most likely cause?
Occlusion of the brachial artery due to atheroma
Occlusion of the axillary artery due to atheroma
Axillary vein thrombosis
Cervical rib
Brachial artery embolus
Brachial artery embolus
Atheroma is very rare in the upper limb vessels
The most likely event is one of embolism, because of the acute nature of the condition there is no time for the development of a collateral circulation so the limb is usually pale and painful. Emboli usually occur as a result of atrial fibrillation. Fast atrial fibrillation can cause syncope and an acute embolus.
A 32 year old woman attends clinic for assessment of varicose veins. She has suffered from varicose veins for many years and can trace their development back to when she suffered a complex tibial fracture. On examination, she has marked truncal varicosities with a long tortuous long saphenous vein. What is the most appropriate next step?
Arrange a venogram
Arrange a venous duplex scan
List her for a trendelenberg procedure
List her for injection foam sclerotherapy
List her for multiple avulsion phlebectomies
Arrange a venous duplex scan
This lady is likely to have deep venous incompetence as she will have been immobilised for her tibial fracture and may well have had a DVT. A duplex scan is mandatory prior to any form of surgical intervention. A venogram would provide similar information but is more invasive.
A 40 year old lady presents to the surgical clinic with symptoms related to varicose veins. She has noticed that these first developed when she was pregnant. On examination, she has a truncal varicosity of the medial leg, there are no ulcers or skin changes. A hand held Doppler examination demonstrates sapheno popliteal junction reflux. What is the most appropriate course of action?
Offer the patient sapheno-popliteal junction ligation
Offer the patient foam sclerotherapy of the sapheno-popliteal junction
Offer the patient laser ablation of the sapheno-popliteal junction
Arrange contrast venography
Arrange a duplex scan
Arrange a duplex scan
Sapheno-popliteal junction incompetence must be imaged prior to starting treatment
A 23 year old man presents with a brachial artery embolus. A cervical rib is suspected as being the underlying cause. From which of the following vertebral levels do they most often arise?
C7 C5 C4 C3 C2
C7
They usually arise from C7.
A cervical rib is due to which of the following?
Hyperplasia of the annulus fibrosus
Proliferation of the nucleus pulposus
Fusion of the transverse processes of the 6th and 7th cervical vertebrae
An accessory cervical vertebra
Elongation of the transverse processes of the 7th cervical vertebra
Elongation of the transverse processes of the 7th cervical vertebra
Cervical ribs occur as a result of the elongation of the transverse process of the 7th cervical vertebra. It is usually a fibrous band that attaches to the first thoracic rib.
A 63 year old man is admitted with rest pain and foot ulceration. An angiogram shows a 3 cm area of occlusion of the distal superficial femoral artery with 3 vessel run off. His ankle - brachial pressure index is 0.4. What is the most appropriate course of action?
Conservative management with medical therapy and exercise Arterial bypass surgery using PTFE Arterial bypass surgery using vein Primary amputation Angioplasty
Angioplasty
Short segment disease and good run off with tissue loss is a compelling indication for angioplasty. He should receive aspirin and a statin if not already taking them.
A 63 year old man who previously smoked 20 cigarettes a day and has newly diagnosed type II diabetes. He presents with rest pain. A diagnostic angiogram demonstrates occlusion of the distal superficial femoral artery continuing below the knee. He has reasonable posterior tibial artery below this level which branches to give good runoff to the foot. He has varicose veins. Which of the strategies presented below is most appropriate?
Femoro-distal bypass graft using long saphenous vein
Femoro-above knee popliteal bypass graft using PTFE
Femoro-distal bypass graft using PTFE
Femoro-distal bypass graft using PTFE and Miller cuff
Above knee amputation
Femoro-distal bypass graft using PTFE and Miller cuff
This man needs a bypass operation. Using PTFE alone will not give a good result as sub intimal hyperplasia will give poor outcome early. Using a vein cuff (Miller cuff) at the end of a PTFE graft will improve the situation. Varicose veins means that vein cannot be reliably used as a conduit. However, the construction of a Miller vein cuff can be done with vein from another anatomical site.
Which of the ABPI measurements shown below is most likely to be found in an 83 year old man with rest pain?
0.6-0.8 <0.4 >1.2 1.0 0.5
<0.4
Rest pain is typically associated with low ABPI values.
In which of the following operations are Skew flaps created?
Hindquarter amputation Above knee amputation Gritti- Stokes amputation Below knee amputation Symes amputation
Below knee amputation
This is one variant of a below knee amputation. The Burgess flap is the other commonly practised approach.
A 1-day-old baby girl is noted to become profoundly cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected. What is the most likely cause?
Transposition of the great arteries Coarctation of the aorta Patent ductus arteriosus Hypoplastic left heart Ventricular septal defect
Transposition of the great arteries
Congenital heart disease
Cyanotic: TGA most common at birth, Fallot’s most common overall
Acyanotic: VSD most common cause
It is important to be aware of common congenital cardiac abnormalities. The main differentiating factor is whether the patient is cyanotic or acyanotic. In the neonate, TGA is the most common condition presenting with profound cyanosis.
The other options are causes of acyanotic congenital heart disease
A 65 year old man presents with expressive dysphasia and right sided weakness over 4 hours. His symptoms have now completely resolved. An MRI scan of his head is normal. What is the most useful investigation?
Arch aortogram Arterial duplex scan 24 hour cardiac tape Implantation of a reveal device MRI brain
Arterial duplex scan
This patient has had a transient ischaemic attack. He urgently needs carotid duplex scanning to assess if he needs a carotid endarterectomy.
Concerning proximal aortic dissection (Debakey types 1 and 2/ Stanford type A) which statement is false?
The intimal tear is typically >50% of the aortic circumference
It is usually treated using an endovascular approach
They have a 50% mortality in the first 2 days
Arch reconstructions may require deep hypothermic circulatory arrest
Target systolic pressure of around 110mmHg should be maintained
It is usually treated using an endovascular approach
Usually open surgery is required for these lesions as customised grafts are not usually available for this type of repair yet.
A 66 year old female has long standing mixed arteriovenous ulcers of the lower leg. Over the past 6 months one of the ulcers has become much worse and despite a number of different topical therapies is increasing in size. What is the most likely diagnosis?
Neuropathic ulcer Mixed ulcer Deep venous insufficiency Marjolins ulcer Chronic obliterative arterial disease
Marjolins ulcer
Marjolin’s ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.
A 77 year old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration. Which of the ABPI measurements shown below is most likely to be found?
1.0 >1.2 0.3 0.7 0.5
> 1.2
Type 2 diabetics may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.
A 34 year old teacher attends A&E with a swollen leg. She has been in England for 2 weeks having previously lived in the Democratic Republic of the Congo. She lives in an area prevalent with mosquitoes and where there is poor sanitation. What is the most likely diagnosis?
Meige's disease Lymphoma Milroy's disease Filariasis Malaria
Filariasis
Filariasis is caused by the nematode Wuchereria bancrofti, which is mainly spread by mosquito. The oedema can be gross leading to elephantitis. Treatment is with diethylcarbamazine.
A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck swelling. On examination, it is located on the left side of the neck in the anterior triangle. There are no other abnormalities to find. What is the most likely diagnosis?
Carotid body tumour Submandibular gland calculus Carotid artery aneurysm Fibromatosis colli Laryngeal cancer
Carotid body tumour
The most likely diagnosis is a carotid body tumour and it is likely to be of the hyperplastic type.
A 45 year old man undergoes a surgical excision of a carotid body tumour. Histological analysis is most likely to demonstrate which of the following?
Paraganglionoma Fibromatosis colli Schwannoma Lipoma Neuroma
Paraganglionoma
Carotid body tumours are the commonest type of head and neck paraganglionoma.
Which of the following types of lymphedema is congenital?
Meiges' disease Milroy's disease Lymphoedema tarda Lymphoedema following surgery Lymphoedema due to venous insufficiency
Milroy’s disease
Milroy’s disease is congenital. Meiges’ develops after birth.
