Vascular Surgery

Question 1

Features of intermittent claudication

Answer 1

Aching or burning in the leg muscles following walking
Symptoms relieved within minutes of stopping
Pain not present at rest

Question 2

Features of critical limb ischaemia

Answer 2

Progressive symptoms from intermittent claudication
Rest pain present in foot/leg >2 weeks
Patients often hang legs out of bed at night to ease pain
Ulceration
Gangrene

Question 3

What ABPI is suggestive of critical limb ischaemia

Answer 3

<0.5

Question 4

What are the 6 P’s of acute limb ischaemia?

Answer 4

Pale
Pulseless
Painful 
Paralysed 
Paresthesia 
Perishingly cold

Question 5

How would you interpret the results of an ABPI

Answer 5

> 1 normal
0.6-0.9 - claudication symptoms
0.3-0.6 - pain at rest e.g, critical limb ischaemia
<0.3 - impending acute limb ischaemia

(>1.2 may be present in diabetic patients due to calcification of vessels)

Question 6

Management of peripheral arterial disease

Answer 6

Lifestyle - stop smoking, diet, exercise
Manage comorbitidies- e.g, HTN, diabetes
Medical management - atorvastatin 80mg + clopidogrel 75mg
Surgical management - angioplasty and stenting, bypass surgery

Question 7

At what ABPI level would compression banding for venous ulcers be acceptable in a patient with peripheral arterial disease

Answer 7

> 0.8

Otherwise there is a risk of reduced blood supply to the foot

Question 8

Presentation of abdominal aortic aneurysm

Answer 8

Often asymptomatic
Symptoms of peripheral vascular disease
Non specific abdominal pain/back pain
Palpable expansile pulsation in abdomen

Question 9

What is the screening programme for AAA’s?

Answer 9

Single USS abdomen for all males aged 65

Question 10

How is screening for AAA’s monitored depending on results

Answer 10

Normal (<3cm) - no further action 
Small aneurysm (3-4.4cm) - rescan every 12 months 
Medium aneurysm (4.4-5.4cm) - rescan every 3 months 
Large aneurysm (>5.5cm) - refer to vascular surgery for intervention

Question 11

Which patients with AAA’s are managed surgically?

Answer 11

Symptomatic patients e.g, abdominal/back pain
Aneurysm diameter >5.5cm
Rapidly enlarging aneurysm >1cm/year

Question 12

How are patients with abdominal aortic aneurysms managed surgically?

Answer 12

Elective endovascular aneursym repair (EVAR)

This is where a stent is placed into the abdominal aorta via the femoral artery to prevent blood from collecting in the aneurysm

Question 13

What is the main complication of elective endovascular aneurysm repair (EVAR)

Answer 13

Endo-leak

Where the stent fails to exclude blood from the aneurysm
This usually presents without symptoms on routine follow up after surgery

Question 14

Features of venous ulcer

Answer 14

Usually present above the ankle
Painless
Oedema
Hyperpigmentation of skin - haemosiderin deposits
Lipodermatosclerosis (inflammation of fat under the skin) - presents as hard, red skin
Varicose eczema

Question 15

Causes of venous ulcers

Answer 15

Occur due to pooling of blood and waste products in the skin due to venous insufficiency

Varicose veins
DVT
Phlebitis

Question 16

Management of venous ulcers

Answer 16

Compression banding (must exclude arterial disease first)
Skin grafting - if ulcer fails to heal after 12 weeks

Question 17

Features of arterial ulcers

Answer 17

Usually present on pressure areas - toes or heels 
Painful to touch 
Cold to touch 
Gangrene 
No palpable pulses

Question 18

Management of arterial ulcers

Answer 18

Good wound care - debridement, cleaning, dressing
Abx if infected
Tissue viability nurse input
Plastic surgery input for severe ulcers

Question 19

Features of neuropathic ulcers

Answer 19

Seen in diabetic patients
On plantar surface of foot
Occur due to pressure

Question 20

Management of neuropathic ulcers

Answer 20

Cushioned shoes - to reduce callous formation