Vascular Surgery

Question 1

What is the definition of an abdominal aneurysm?

Answer 1

Dilatation of the aorta greater than 3cm

Question 2

What are some risk factors for AAA?

Answer 2

Smoking, hypertension, hyperlipidaemia, family history, male gender, increasing age

Question 3

How do patients present with an abdominal aortic aneurysm?

Answer 3

Often asymptomatic and found as incidental finding or through screening.
Can present with non-specific abdo/back pain, pulsation and expansile mass.

Question 4

What screening are patient offered for AAA and from what age?

Answer 4

At 65 men are offered a screening ultrasound scan

Question 5

What imaging can be used to diagnose AAA?

Answer 5

Ultrasound- usually initial imaging

CT angiogram can be used to guide elective surgery as gives more detailed picture

Question 6

How big would an AAA be to fit into the different categories of small, medium and large aneurysms?

Answer 6

Small: 3-4.4cm
Medium: 4.5-5.4cm
Large: >5.5cm

Question 7

How would you manage a patient with an AAA less than 5.5cm?

Answer 7

3-4.4cm ultrasound yearly
4.5-5.4cm ultrasound every 3 months
Reduce cardiovascular risk factors

Question 8

How would you manage a large AAA (>5.5cm)?

Answer 8

Consider surgery- either open or endovascular repair

Question 9

How might a ruptured abdominal aortic aneurysm present?

Answer 9

Symptoms: Severe abdo pain radiating to back or groin, collapse, LOC
Signs: tender, pulsation and expansile abdo mass, haemodynamic instability

Question 10

What does permissive hypotension refer to in ruptured AAA management?

Answer 10

Aiming for lower than normal BP when fluid resuscitating to not increase blood loss

Question 11

How will you manage suspected AAA rupture if the patient is unstable?

Answer 11

Transferred to theatre right away

High flow O2, IV access, urgent bloods with group and save 6units

Question 12

How will you manage suspected AAA rupture in stable patient?

Answer 12

CT angiogram

High flow O2, IV access, urgent bloods with group and save 6units

Question 13

What is an aortic dissection?

Answer 13

Tear in the intimal layer of aortic wall, causing blood to flow between tunica intima and media

Question 14

Which of anterograde or retrograde aortic dissections can result in cardiac tamponade?

Answer 14

Retrograde dissections

Question 15

Which 2 classifications systems are used for aortic dissections?

Answer 15

Stanford classification

DeBakey classification

Question 16

What are some risk factors for aortic dissection?

Answer 16

Hypertension, atherosclerosis, connective disorders, bicuspid aortic valve

Question 17

What is a characteristic presentation of a patient with aortic dissection?

Answer 17

Symptoms: Tearing chest pain radiating to the back
Signs: tachycardia, hypotension, new aortic regurgitation murmur

Question 18

Which imaging is recommended for diagnosis of aortic dissection?

Answer 18

CT angiogram

Question 19

If a 60 year old man with a background of hypertension presents with sudden onset tearing chest pain, what would be your top differential?

Answer 19

Aortic dissection

Question 20

How does the location of an aortic dissection affect where the patient feels the pain?

Answer 20

Pain more likely in anterior chest when ascending aorta affected
Pain more likely to be felt in the back when descending aorta affected

Question 21

What is peripheral arterial disease?

Answer 21

Narrowing of the peripheral arteries, reducing blood supply to the limb/peripheries

Question 22

What is intermittent claudication?

Answer 22

A crampy/achy pain in the calf or thigh occurring during exertion and relieved by rest

Question 23

What is the end stage of peripheral arterial disease?

Answer 23

Critical limb ischaemia

Question 24

What are some feature of critical limb ischaemia? (6P’s)

Answer 24

Burning pain at rest (worse at night)

Pallor, pulseless, paralysis, perishing cold, parasthesia

Question 25

What causes leriche syndrome?

Answer 25

Occlusion of distal aorta or proximal common iliac artery

Question 26

What is the clinical triad in Leriche syndrome?

Answer 26

Thigh/buttock claudication
Absent femoral pulses
Male impotence

Question 27

What is Buerger’s test?

Answer 27

Laying a patient supine, lift their leg- it will become pale if peripheral arterial disease present
Then get patient sitting up with legs hanging over end of the bed- if PAD is present the legs will go blue then a dark red colour

Question 28

What are the non-surgical management options of intermittent claudication?

Answer 28

Lifestyle changes, exercise training

Medication: Statin, clopidogrel, 5-HT2 receptor antagonist (peripheral vasodilator)

Question 29

What surgical options are used to manage critical limb ischaemia?

Answer 29

Angioplasty and stenting, endartectomy, bypass surgery

Question 30

A young male smoker presents with painful blue discolouration of his fingertips. What would be your top vascular differential?

Answer 30

Buerger disease (thromboangiitis obliterans)

Question 31

What is the main component of management of Buerger’s disease?

Answer 31

Smoking cessation

Question 32

Why would you not try to actively re-warm an acutely ischaemic limb?

Answer 32

This would enhance tissue damage

Question 33

What are some features of venous insufficiency?

Answer 33

Oedema, brown pigmentation, lipodermatosclerosis, eczema

Question 34

Where do arterial ulcers commonly occur?

Answer 34

Toes and heel

Question 35

What can cause ulcers to occur at stoma sites and is associated with IBD?

Answer 35

Pyoderma gangrenosum

Question 36

What would be management of an AAA that has grown at a rate of more than >1cm/year?

Answer 36

2 week wait referral for surgery

Question 37

Which out of arterial and neuropathic ulcers are more likely to be painless?

Answer 37

Neuropathic