Vascular Surgery - Lange

Question 1

A 56-year-old male has history of leg pain at rest. Patient also has history of severe coronary artery diseases. He cannot walk two flights of steps without getting short of breath. He underwent evaluation and was noted to have complete
aortoiliac occlusive disease. He needs surgery. Which one of the following options is acceptable?

(A) Aortobililiac bypass
(B) Aortobifemoral bypass
(C) Aortoiliac angioplasty and stent
placement
(D) Axillobifemoral bypass
(E) Axilloiliac

Answer 1

Axillobifemoral bypass

• The treatment goal in these patients is to reestablish blood flow to the lower extremity.
• The treatment is based on the findings at angiogram. All the treatment options are valid and are used in treatment of the aortoocclusive
• disease.
• Patients with short-segment (TASCA) stenosis in common iliac artery are treated with angioplasty and/or stent placement and the patency results are expected to be comparable to surgery.
• In patients with long-segment stenosis and good risk patient treatment options would include aortobifemoral bypass.
• These procedures are long lasting. The long-term patency rates are reported to be 65–90%.
• Axillobifemoral bypass is utilized in patients with high risk and poor general
• condition.
• The patency rates for this group vary between 50–85% in 5 years.
• The patient described would be an ideal candidate for axillobifemoral bypass

Question 2

What are the acceptable reasons to operate on abdominal aortic aneurysms in 65 year old female with a 5-cm infrarenal aneurysm?

• Presence of aneurysm
• Aneurysm with intramural thrombus
• Asymptomatic aneurysm 5.5cm
• Associated 2cm iliac aneurysm
• Patient with splenic artery aneurysm 1.5 cm

Answer 2

Asymptomatic aneurysm 5.5cm

• Current indication for repair of abdominal aortic aneurysm in female patients (with acceptable risk) includes aneurysm size 5 cm in
• Any aneurysm with associated complication should be treated ; just the presence of intramural thrombus does not justify repair
• Asymptomatic 5.5cm aneurysm should be treated in all patients, male or female - at acceptable cardiac risk.
• Patients with 2cm aneurysm of iliac artery without any symptoms should be observed - as the risk of surgery is higher than risk of observation till they reach 4 cm.
• In patients, not in child bearing age, 1.5 cm splenic aneurysm could be observed.

Question 3

An 89-year-old male presents with asymptomatic 8-cm abdominal aneurysm. He has a recent history of myocardial infarction (MI) and is not a candidate for coronary artery bypass. What should the treatment options include?

(A) Conservative treatment observation
(B) Computerized axial tomography (CAT) scan to evaluate eligibility for endovascular repair
(C) Open repair without any further workup
(D) Axillofemoral bypass and coil embolization of aneurysm
(E) b-blocker therapy

Answer 3

CAT scan to evaluate eligibility for endovascular repair

• An 8-cm aneurysm carries significant mortality which exceeds 50% in 1 year from aneurysm related death if observation or medical management is chosen as treatment option.
• It would be appropriate, if the neck size is greater than 1.5 cm and diameter is less than 26 mm, without any significant thrombus or calcification in the neck. This patient does well at least on mid term follow-up.
• They have lower perioperative morbidity compared to traditional open repair.
• Open repair with given cardiac history would carry high morbidity and morotality.
• b-blocker therapy would be indicated for his cardiac condition but is not a standard therapy for aneurysm.

Question 4

A70-year-old male underwent an open abdominal aortic aneurysm repair for ruptured aneurysm. He was stable during the procedure. In intensive care unit he was noted to have no urine output and was also noted to have large bloody bowel movement on first postoperative day. The next step for investigation includes:

(A) Reexploration
(B) Arterial blood gas evaluation for acidosis
(C) CAT scan abdomen
(D) Sigmoidscopy/colonoscopy
(E) Antibiotics and hydration

Answer 4

Sigmoidoscopy/Colonoscopy

• Mortality associated with aortic aneurysm is usually around 0–3%. A ruptured AAA carries mortality in range of 60–80% depending on presentation.
• Risk of large-bowel ischemia with ruptured AAA is about 10%. The first investigation with patients where colonic ischemia is suspected is to perform sigmoidoscopy.
• All other investigations may be done but none of them would be the primary investigation for the suspected pathology.

Question 5

A 69-year-old man was noted to have abdominal pain in left flank with severe hypotension and pulsatile mass in abdomen. He was taken to the operating room after he coded in the emergency room. Which of the following statements regarding ruptured abdominal aortic aneurysm is TRUE?

(A) 10% of patient with ruptured aneurysm reach the Hospital.
(B) Mortality is about 10%.
(C) Aortic control is usually obtained by thoracotomy.
(D) It cannot be treated by endovascular means.
(E) Mortality following a code for ruptured AAA is 100%.

Answer 5

Mortality following a code for ruptured AAA is 100%

• Ruptured AAA carries a mortality of 40–50%. It is true that only 50% of all ruptured AAA reaches the hospital.
• Free peritoneal rupture carries a very high mortality.
• Thoracotomy is not the standard approach for proximal aortic control.
• Ruptured AAA can be treated with endovascular grafts.
• Preoperative hypotension is a good predictor of poor outcome but cardiac arrest is associated with 100% mortality in most of the studies.

Question 6

A 82-year-old female presented with history of loss of vision in right eye for about 15 minutes and it cleared up. She has a history of diabetes and hypertension. She had which showed old infarct on right side. Carotid duplex showed that patient had 99% carotid artery stenosis. Which one of the following statements is TRUE?

(A) 60% chance that extra cranial carotid artery stenosis is the cause of transient ischemic attack (TIA).
(B) It is always due to platelet emboli.
(C) 25% may be intracranial bleed.
(D) 0.5 to 10% may have cardiac and other causes of TIA.
(E) It is always due to thrombosis.

Answer 6

60% chance that extra cranial carotid artery stenosis is the cause of the TIA

• Neurological events are associated with extracranial carotid artery in about 60%.
• Fourty percent may have extracranial/intracranial cause for neurological events, which includes cardiac emboli, arch of aorta as source of emboli;
  intracranial bleed may be more than just a TIA.
• It is not always that platelet emboli are the cause of TIA, it could be due to atheroma.
• It is not always attributed to thrombus.

Question 7

A 63-year-old male was noted to have a recent TIA. Patient was having recurrent episodes of TIA despite of being on aspirin and clopidogrel bisulfate. He does have a history of unstable angina. His workup includes magnetic resonance angiography (MRA) and carotid duplex. What are the appropriate treatment options?

(A) Carotid endarterectomy for 50% carotid stenosis on MRA
(B) Carotid endarterectomy for 60% stenosis on MRA without any treatment of
unstable angina

(C) Carotid endarterectomy for 90% stenosis with coronary artery bypass graft
(CABG) at the same time
(D) Start patient on heparin therapy and treat conservatively for carotid stenosis of 80%
(E) Coronary angiogram with possible coronary intervention and simultaneous carotid angiogram and angioplasty and stenting

Answer 7

Start patient on heparin therapy and treat conservatively for carotid stenosis of 80%

• Asymptomatic carotid artery stenosis is only treated surgically if it is greater than 70% stenosis.
• The risk reduction with surgical treatment is favorable with 70% stenosis when compared to nonoperative treatment.
• Any symptomatic stenosis is an indication for surgical intervention including ulcerated plaque.
• Any amount of stenosis with unstable angina would need appropriate
• workup for cardiac risk prior to carotid intervention.
• Carotid endarterectomy and CABG are viable options if they are left main disease and have undergone coronary angiogram.
• In this patient the most appropriate treatment is option to perform coronary angiogram and possible carotid stenting if feasible.
• Role of anticoagulation to prevent recurrent TIA is not well established.
• Aspirin and clopidogrel bisulfate are appropriate options for TIA.

Question 8

A 62-year-old man had right carotid endarterectomy 7 years ago. Now he has presented with 80% stenosis on the same side. He has no symptoms
from the stenosis. He has carotid artery stenosis on the opposite side of 80%. He does not have any history of TIA. What is the appropriate treatment for the patient?

(A) Medical management with aspirin
(B) Carotid artery redo surgery and patch angioplasty
(C) Angiogram and angioplasty and stenting
(D) Left carotid endarterectomy
(E) Antiocoagulation of the patient to prevent stroke

Answer 8

Left carotid endarterectomy

• Recurrent stenosis is secondary to intimal hyperplasia but it occurs in first two years.
• If more than two years, it is progression of disease and it does not carry high risk for embolization, so it is reasonable to observe it.
• It is also a surgery which carries higher stroke rate and morbidity with nerve injury which is in range of 7%.
• Patient is treated with antiplatelet therapy which includes aspirin and clopidogrel bisulfate.
• Anticoagulation with warfarin is not a standard therapy. It is appropriate to treat the opposite side with 80% carotid stenosis.
• Angiogram and angioplasty is an option but if the stenosis is significant and symptomatic.
• Priority in this case would be to treat the opposite side.

Question 9

A 60-year-old male patient with bilateral carotid artery stenosis 90%, with history of right-sided weakness with resolution of symptoms in 15 minutes. How would you treat the patient?

(A) Right carotid endarterectomy
(B) Left carotid endarterectomy
(C) Right carotid angioplasty and stenting
(D) Start patient on aspirin
(E) Start patient on heparin

Answer 9

**Left carotid endarterectomy **

• The treatment for symptomatic carotid artery stenosis greater than 70% is carotid endarterectomy.
• Since patient has left cerebral symptoms, it would be appropriate to treat that side first.
• Patient would need bilateral carotid endarterectomy but symptomatic side would be the first one to be operated.
• Heparin has no significant role in preventing stroke.
• Aspirin is a part of therapy but would not constitute a primary modality for treatment.

Question 10

A 72-year-old patient is noted to have neurological deficit following elective carotid endarterectomy in recovery room. What is the most appropriate treatment at this time?

(A) Carotid duplex
(B) CAT scan of brain
(C) Angiogram of cerebral vessels
(D) Heparin drip
(E) Exploration of the same side

Answer 10

Exploration of the same side

• In recovery room, the immediate approach would be to explore the patient.
• The cause for immediate stroke is usually technical and is most likely reversible if treated early on.
• All investigations are valid options once the technical cause is addressed and it would not be a primary option.

Question 11

A 63-year-old man has had a cyanotic painful left fourth toe for 2 days. The dorsalis pedis and posterior tibial arteries are palpable on both sides. There is no history of cardiac or vascular disease. What is the most likely diagnosis?

(A) Cardiac embolus
(B) Atheroembolism
(C) Lupus vasculitis
(D) Digital atherosclerosis
(E) Raynaud’s syndrome

Answer 11

Atheroembolism

• All the listed conditions may result in isolated digital ischemia. In this age group, atheroembolism is the most likely diagnosis in a man.
• The atheroma is derived from an occult aortic aneurysm or a proximal ulcerative atherosclerotic lesion.
• This plaque or ulcer can be any part of the vascular tree proximal to the ischemic toe.
• Cardiac emboli also are common in this age group but are a less likely cause in the absence of previous MI, arrhythmia, or valvular disease.

Question 12

A 40-year-old chronic smoker presents with ulceration of the tip of the right second, third, and fourth toes. He gives a history of recurrent migratory superficial phlebitis of the feet occurring a few years ago. Physical examination findings are remarkable for absent bilateral posterior tibial and dorsalis pedis pulses with palpable popliteal pulses. What is the single most important step in management?

(A) Multiple toe amputations
(B) Long-term anticoagulant therapy
(C) Immediate operative intervention
(D) Angiography followed by bypass surgery
(E) Cessation of smoking

Answer 12

Cessation of smoking

• This patient suffers from thromboangiitis obliterans (Buerger’s disease), a disease found most frequently in white men between 20 and 40 years of age.
• It is a form of panvasculitis involving the artery, vein, and nerve.
• Heavy tobacco smoking is strongly associated with this disease.
• Early in the course of the disease, there is involvement of the superficial veins, producing recurrent migratory superficial
• phlebitis.
• The distribution of arterial involvement is usually segmental, involving the peripheral arteries. In the lower extremities, the disease occurs generally beyond the popliteal arteries and distal to the forearm in the upper extremities.
• As long as ulceration or gangrene is confined to a digit, amputation should be postponed as long as possible unless rest pain or infection cannot be otherwise controlled.
• Bypass surgery is rarely indicated, and long-term anticoagulation has not been of much benefit.
• The most important aspect of treatment is cessation of smoking, which can halt progression of the disease.

Question 13

A middle-aged man is found to have a small pulsating mass at the level of the umbilicus during a routine abdominal examination. What is the best initial test to establish the diagnosis?

(A) Aortography
(B) Ultrasound
(C) Computed tomography (CT)
(D) Magnetic resonance imaging (MRI)
(E) Plain films of the abdomen

Answer 13

Ultrasound

• Although aortography, CT, and MRI can all establish the diagnosis of abdominal aortic aneurysm, ultrasound remains the best screening test.
• It is the preferred method for making the initial diagnosis, because it is reliable, inexpensive, and noninvasive.
• Aortography is used infrequently because of the small but definite risk it entails and because diagnosis can be made by other means.
• Once the aneurysm meets the criteria for repair, then a CT scan is done preoperatively to establish the true size and to delineate the aneurysm more accurately.
• Plain films of the abdomen are inaccurate in establishing the diagnosis.

Question 14

A 58-year-old woman is found to have a right carotid bruit on routine examination. She is completely asymptomatic. A carotid duplex scan and carotid arteriogram (Fig. 10–1) reveal a right carotid stenosis. Which of the following
statements is true?

(A) Operative treatment is indicated if the stenosis is greater than 80%, even if the patient is asymptomatic.
(B) The incidence of stroke can be decreased by prophylactic carotid endarterectomy in patients with as little as 40% stenosis.
(C) Aspirin is always a superior treatment to surgery regardless of the degree of stenosis.
(D) If symptoms eventually develop, they are invariably TIAs, not stroke.
(E) Neither surgery nor aspirin is indicated, because the patient is asymptomatic.

Answer 14

Operative treatment is indicated if the stenosis is greater than 80%, even if the patient is asymptomatic.

• Operative treatment is indicated if the diameter of the stenosis is greater than 60%, even if the patient is asymptomatic. The value of prophylactic carotid endarterectomy, for hemodynamically significant carotid stenosis, decreases
• the incidence of subsequent cerebral ischemic events if performed with morbidity and mortality rates under 4%.
• Several studies including asymptomatic carotid artery surgery (ACAS) have shown that surgical treatment is superior to medical management if the stenosis is 60% or greater.
• The ACAS trial has shown the benefits of surgical treatment over medical management if the stenosis is greater than 60%.
• However,there are no data to support the use of carotid endarterectomy in asymptomatic patients with stenosis of less than 60%.
• If ischemic events eventually develop, stroke can be the presenting symptom.

Question 15

A 57-year-old male smoker is referred to you because of two episodes of right upper extremity weakness over the past 6 months, each lasting for 10–15 minutes. Findings on CT scan of the head are negative. An angiogram shows a 75% stenosis of the left carotid artery. What is the most appropriate treatment?

(A) Antiplatelet therapy
(B) Oral anticoagulants
(C) Carotid endarterectomy
(D) Carotid artery bypass to vertebral system
(E) Surgery only if a stroke develops

Answer 15

Carotid endarterectomy

• This patient is experiencing recurrent left hemispheric TIA with a hemodynamically significant stenosis of the left carotid artery.
• This is clearly an indication for surgery because operative management is superior to aspirin in symptomatic carotid bifurcation disease with stenosis greater than 70%.
• Oral anticoagulants may decrease the incidence of TIAs but not of completed strokes, and they are associated with a considerable risk of hemorrhage.
• Carotid endarterectomy, and not carotid artery bypass, is the surgical procedure of choice.
• Surgical treatment must be performed before and not after major neurologic deficits are produced from cerebral infarction.

Question 16

A 24-year-old man complains of progressive intermittent claudication of the left leg. On examination, the popliteal, dorsalis pedis, and posterior tibial pulses are normal; but they disappear on dorsiflexion of the foot. What is the most likely diagnosis?

(A) Embolic occlusion
(B) Thromboangiitis obliterans
(C) Atherosclerosis obliterans
(D) Popliteal artery entrapment syndrome
(E) Cystic degeneration of the popliteal artery

Answer 16

Popliteal artery entrapment syndrome

• Popliteal artery entrapment syndrome consists of intermittent claudication caused by an abnormal relation of that artery to the muscles, usually the medial head of the gastrocnemius muscle.
• As a consequence of developmental abnormalities, the popliteal artery may be compressed by the medial head of the gastrocnemius muscle, resulting in ischemia of the leg at an unusually early age.
• On examination, the pulses may be diminished or absent, but they may also be normal and be made to disappear on dorsiflexion of the foot.
• Angiography is essential to establish the diagnosis.

Question 17

Four days after undergoing hysterectomy, a 30- year-old woman develops phlegmasia cerulea dolens over the right lower extremity. What is the most appropriate treatment?

(A) Bed rest and elevation
(B) Systemic heparinization
(C) Venous thrombectomy
(D) Prophylactic vena caval filter
(E) Local urokinase infusion

Answer 17

Venous thrombectomy

• Phlegmasia cerulae (blue) dolens, indicates that major venous obstruction has occurred.
• The standard treatment for postoperative thrombosis includes bed rest and anticoagulation.
• Venous thrombectomy may be indicated when impending gangrene is noted.
• Vena caval filters are inserted in patients with established pulmonary emboli, but they may be considered as a prophylactic measure when iliofemoral thrombosis is massive.
• They are also inserted as an adjunct to venous thrombectomy along with creation of an arteriovenous fistula to prevent the venous system from rethrombosing.
• Thrombolysis of major venous thrombi requires placement of a multihole pigtail catheter inside the thrombus and administration of tPA, including systemic heparinization and is therefore contraindicated postoperatively.

Question 18

A 21-year-old woman is referred to your office because of multiple lower extremity varicose veins. She has large varicosities in the distribution of the long saphenous vein. What is the next step in management?

(A) A ligation and stripping operation
(B) Ligation of both the long and short saphenous system

(C) Sclerotherapy
(D) Duplex evaluation along with clinical correlation as an essential initial step
(E) Compression stockings and anticoagulation therapy

Answer 18

Duplex evaluation along with clinical correlation as an essential initial step

• A through clinical evaluation followed by a venous duplex examination are the two most important steps in managing varicose vein of
  the lower extremity.
• An asymptomatic patient without complications of phlebitis, ulceration,
  or hemorrhage should be treated with compression stocking.
• Duplex evaluation will help map the valvular incompetence of the superficial and deep system including the perforators that guide the extent of the initial surgical intervention, and also investigate if these are primary or secondary varicosities.
• Sclerotherapy is an alternative to surgery but in the presence of saphenofemoral, saphenopopliteal, or perforator reflux is associated with a high incidence of recurrence and complications.

Question 19

A 45-year-old woman undergoes cardiac catheterization through a right femoral approach. Two months later, she complains of right lower extremity swelling and notes the appearance of multiple varicosities. On examination, a bruit is heard over the right groin. What is the most likely diagnosis?

(A) Femoral artery thrombosis
(B) Superficial venous insufficiency
(C) Arteriovenous (AV) fistula
(D) Pseudoaneurysm
(E) Deep vein insufficiency

Answer 19

Arteriovenous (AV) Fistula

• A traumatic AV fistula results from a penetrating injury to adjacent artery and vein, permitting blood flow from the injured artery into the vein.
• The iatrogenic injury in this case occurred during cardiac catheterization.
• Femoral artery thrombosis results in signs of limb ischemia. A bruit is usually not heard with venous insufficiency.
• Traumatic pseudoaneurysm presents as an enlarging pulsating mass.
• Once the diagnosis of AV fistula is made, an angiogram is performed, and surgical repair (division of the fistula and reconstruction of the artery and preferably of the injured vein as well) is carried out.

Question 20

A young basketball player develops an acute onset of subclavian vein thrombosis (effort thrombosis) after heavy exercise. What is the next step in management?

(A) Active exercise of the limb
(B) Anti-inflammatory drugs
(C) Thrombolytic therapy
(D) Antibiotics
(E) First-rib resection

Answer 20

Thrombolytic Therapy

• Effort thrombosis also called Paget-von-Schroetter syndrome is the development of thrombosis of the axillary-subclavian vein as a result of injury or compression.
• It occurs primarily in young athletes and is disabling
• When these patients are seen early thrombolytic therapy is the first step in management and is followed by a venogram to detect correctable lesions,
• If effort thrombosis is associated with thoracic outlet syndrome - then thrombolytic therapy should be followed by cervical rib resection
• If the condition is chronic thrombolytic therapy might not be successful; these patients usually respond to limb elevation and anticoagulation.

Question 21

A middle-aged man undergoes a left below knee amputation for left-foot gangrene secondary to arterial occlusive disease. Which of the following statements is true after the belowknee amputation?

(A) There is less efficient function than after a through-knee amputation.
(B) Stump prognosis can be judged by transcutaneous oxygen monitoring.
(C) Poor prognosis is inevitable if Doppler fails to record a pulse at that level.
(D) The fibula and tibia are of equal length.
(E) The level of transection is 5 cm above the medial malleolus

Answer 21

Stump prognosis can be judged by transcutaneous oxygen monitoring

• Stump prognosis can be judged by transcutaneous oxygen monitoring. Doppler is not fully reliable to select the level of transection, because it cannot calculate the quantity of vascular flow.
• Transcutaneous oxygen (PO2 >40 mm Hg) offers a fairly accurate prediction of a favorable result; although, Doppler fails to confirm a patient pulse at the level of transection.
• On the other hand, a duplex evaluation with blood flow of more than 50 cm/s is also a fairly accurate predictor for stump prognosis.
• The level of transection is 13–15 cm below the level of the medial condyle of the tibia.

Question 22

A 72-year-old retired banker complains of left leg intermittent claudication while playing golf. An angiogram shows occlusion of the superficial femoral artery and reconstitution of the popliteal artery below the knee. What is the
treatment of choice?

(A) A vigorous exercise program
(B) Endarterectomy of the superficial femoral artery
(C) Femoropopliteal bypass with expanded polytetrofluoroethylene (PTFE) graft
(D) In situ femoropopliteal bypass
(E) Femoropopliteal bypass with reversed saphenous vein graft

Answer 22

A vigorous exercise program

• If claudication is the only symptom, elective vascular reconstruction is considered only if claudication is disabling and interferes with day-to-day activity.
• Because the risk of gangrene occuring in a patient who has only claudication is small - this alone does not constitute a clear cut indication for operation
• Vigorous exercise programs have resulted in marked improvement in claudicants.
• Revascularization surgery is usually reversed for rest pain or tissue loss (non-healing ulcer, gangrene).
• Addition of a phosphodiastraze inhibitor, cilostazol (pletal), or pentoxiphyline (trental) can help increase the claudication distance.
• It should also be kept in mind that an angiogram is not indicated for claudication.
• An initial evaluation with noninvasive vascular studies is the investigation of choice
• Angiogram is only requested if the decision is made to intervene surgically

Question 23

A 40-year-old patient undergoes a CT scan of the abdomen for nonspecific abdominal pain. A splenic artery aneurysm is incidentally identified. What is true of the splenic artery aneurysm?

(A) It requires splenectomy for optimal treatment.
(B) It is more common in men.
(C) It is caused by atherosclerosis in most cases.
(D) It may rupture during pregnancy.
(E) It is rarely calcified on an abdominal x-ray.

Answer 23

It may rupture during pregnancy

• Splenic artery aneurysms are rare and are most frequently caused by medial necrosis
• Small asymptomatic aneurysms caused by atheroscerlosis are more commonly incidental findings at autopsy.
• Larger (>3cm) aneurysms predominate in women and characteristically rupture during late pregnancy.
• Rupture may be preceded by an initial warning bleed into the retroperiotenum with massive bleeding following after 1 or 2 days.

Question 24

A 70-year-old man with a long-standing history of diabetes develops gangrene of the right second toe. What is true of his diabetic foot?

(A) Dorsalis pedis and posterior tibial arteries are always absent.
(B) Gangrene of the toe always requires urgent below-knee amputation.
(C) Arterial reconstruction is invariably required.
(D) His right femoral artery is most probably occluded or stenosed.
(E) Trophic ulcers are sharply demarcated.

Answer 24

Trophic ulcers are sharply demarcated

• Patients with diabetic foot may have localised arterial occlusion involving the popliteal artery and its branches usually sparing the femoral artery
• Although patients have gangrene of the toes, there may be a palpable pulse in the foot.
• In the presence of localized disease, trophic ulcers and even gangrene of the toes respond to local foot care and major vascular reconstruction or amputations are not required
• The trophic ulcers have punched sides
• Patients may not realise the gravity of localised gangrene with spreading cellulitis which develops because of the neurotropic nature of the lesions with the absence of pain sensation

Question 25

Eleven years after undergoing right modified radical mastectomy, a 61-year-old woman develops raised red and purple nodules over the right arm. What is the most likely diagnosis?

(A) Lymphangitis
(B) Lymphedema
(C) Lymphangiosarcoma
(D) Hyperkeratosis
(E) Metastatic breast cancer

Answer 25

Lymphangiosarcoma

• Lymphangiosarcoma is a rare complication of long-standing lymphedema, most frequently described in a patient who has previously undergone radical mastectomy (Stewart-Treves syndrome).
• It usually presents as blue, red, or purple nodules with satellite lesions.
• Early metastasis, mainly to the lung, may develop if it is not recognized early and widely excised.
• Lymphedema is a complication of radical mastectomy and presents as diffuse swelling and nonpitting edema of the limb.
• Lymphangitis and hyperkeratosis are complications of lymphedema.

Question 26

Four days after undergoing subtotal gastrectomy for stomach cancer, a 58-year-old woman complains of right leg and thigh pain, swelling and redness, and has tenderness on examination. The diagnosis of deep vein thrombosis is entertained. What is the initial test to establish the diagnosis?

(A) Venography
(B) Venous duplex ultrasound
(C) Impedance plethysmography
(D) Radio-labeled fibrinogen
(E) Assay of fibrin/fibrinogen products

Answer 26

Venous duplex ultrasound

• The most accurate method of confirming the diagnosis of venous thrombosis is the injection of contrast material to visualize the venous system (venography).
• However, this method is invasive and time consuming and must be done in the radiology suite.
• Venous duplex ultrasound is noninvasive, can be done bedside, and has a sensitivity and specificity of 96 and 100%, respectively.
• The other methods listed are used less often in certain selected patients.

Question 27

A middle-age woman has right leg and foot nonpitting edema associated with dermatitis and hyperpigmentation. The diagnosis of chronic venous insufficiency is made. What is the treatment of choice?

(A) Vein stripping
(B) Pressure-gradient stockings
(C) Skin grafting
(D) Perforator vein ligation
(E) Valvuloplasty

Answer 27

Pressure gradient stockings

• The mainstay of treatment of chronic venous insufficiency and its complication, venous stasis ulceration, is conservative management.
• Elastic stocking support, frequent elevation of the legs, and avoidance of prolonged sitting and standing is used for venous insufficiency in the absence of ulceration.
• If venous stasis ulcers develop, then paste boots (e.g., Unna’s boots) are used along with appropriate bed rest and foot elevation until the ulcer heals.
• Patients whose ulcers fail to heal after such conservative management may need perforator vein ligation.
• Skin grafting should be considered for chronic stasis ulcers that are large, and perforator incompetance has been treated.
• Venous reconstruction procedures, including valvuloplasty, can be useful for a selected group of patients, especially those with venous claudication to less than half a block, that have been treated with all the procedures above, including stripping and ligation.
• Unlike previous opinions, superficial venous stripping and ligation is not always contraindicated in the presence of chronic venous insufficiency and even previous history of deep vein thrombosis.

Question 28

A 55-year-old woman has bilateral leg edema associated with thick, darkly pigmented skin. A Trendelenburg’s test is done, and results are interpreted as positive/positive. What does this patient have?

(A) Competent varicose veins/competent perforators
(B) Competent varicose veins/incompetent perforators
(C) Deep vein thrombosis (DVT)
(D) Incompetent varicose veins/competent perforators
(E) Incompetent varicose veins/incompetent perforators

Answer 28

**Incompetent varicose veins/incompetent perforators **

• The Trendelenburg’s test is a two-part test used to access the competency of the superficial and perforating veins. The legs are elevated to evacuate the veins, and pressure is applied to the saphenofemoral junction either by hand or tourniquet.
• The four possible results are:
  
  • (a) negative/ negative response if there is gradual filling of veins from below and continued slow filling after release of pressure, indicating absence of incompetent superficial and perforating veins;
  • (b) negative/positive response if there is gradual filling of veins from below while there is rapid retrograde filling after release of pressure, indicating incompetent superficial veins only
  • (c) positive/negative response if there is rapid initial filling of the veins from below while only continued slow filling after the release of pressure, indicating incompetent perforators only and
  • (d) positive/positive response if there is rapid filling of the saphenous vein before and after release of pressure, indicating incompetent superficial and perforating veins.

Question 29

A middle-aged man known to have peptic ulcer disease is admitted with upper gastrointestinal (GI) bleeding. During his hospital stay, he develops DVT of the left lower extremity. What is the most appropriate management?

(A) Anticoagulation
(B) Observation
(C) Thrombolytic therapy
(D) Inferior vena cava (IVC) filter
(E) Venous thrombectomy

Answer 29

Inferior Vena Cava Filter

• The main treatment of DVT is adequate anticoagulation.
• However, if pulmonary embolism develops during anticoagulant therapy or if there is contraindication to anticoagulation, the insertion of an IVC filter is indicated either to prevent occurrence of or to offer prophylaxis against recurrence of pulmonary embolism (Fig. 10–4).
• Observation alone leaves the patient unprotected against pulmonary embolism, and operative thrombectomy is reserved for limb salvage in the presence of impending venous gangrene.
• Obviously, if anticoagulation is contraindicated (as in the patient presented), thrombolytic therapy cannot be used.

Question 30

A 70-year-old executive is complaining of three-block intermittent claudication of both legs. What is the percentage chance of his developing limb-threatening gangrene?

(A) Less than 10%
(B) 20%
(C) 45%
(D) 60%
(E) More than 75%

Answer 30

Less than 10%

• The relatively benign course of intermittent claudication has been well established. The risk of gangrene developing within 5 years in an extremity with claudication as the only symptom is only about 5%. The patient must be encouraged to stop smoking, to exercise, and be placed on a diet that lowers cholesterol.

Question 31

Thirty-six hours after undergoing an abdominal aortic aneurysm repair, a 70-year-old woman develops abdominal distension associated with bloody diarrhea. What is the most likely diagnosis?

(A) Aortoduodenal fistulas
(B) Diverticulitis
(C) Pseudomembranous enterocolitis
(D) Ischemic colitis
(E) Acute hepatic failure

Answer 31

Ischemic colitis

• The occurrence of bowel movements during the first 24–72 hours after repair of an abdominal aortic aneurysm (especially if the hemoccult test is positive), should raise suspicion for ischemic colitis.
• It may develop as a result of interruption of flow to the inferior mesenteric artery with inadequate collateral circulation from either the superior mesenteric artery or the iliac arteries.
• Aortoduodenal fistula is a late complication of aneurysm repair.
• Pseudomembranous enterocolitis occurs late in the postoperative course.

Question 32

A 65-year-old man is referred to you because of an incidental finding of a 3-cm left popliteal aneurysm (Fig. 10–2). The patient is completely asymptomatic and has normal pulses. How should the aneurysm be treated?

(A) It should be observed.
(B) It should be repaired because it may lead to spontaneous rupture.
(C) It should be repaired only if it is larger than 5 cm.

(D) It should be repaired because of its tendency to either undergo thrombosis or embolize distally.
(E) It should be repaired because of its tendency to cause nerve compression if it enlarges.

Answer 32

It should be repaired because of its tendency to either undergo thrombosis or embolize distally

• Popliteal aneurysms are usually arteriosclerotic and are bilateral in at least 50% of cases.
• Any popliteal aneurysm twice the size of the normal artery is an indication for surgical repair.
• Although often asymptomatic and small, they should be treated surgically because of their propensity to produce limb-threatening ischemia related to thrombosis or embolism.
• Spontaneous rupture and/or nerve compression are rare complications of a popliteal aneurysm.
• The ideal repair consists of ligation of the aneurysm, including its branches and a bypass to the open distal vessels.

Question 33

A 72-year-old woman falls at home after an episode of dizziness. She had been complaining of low-back pain for 3 days before the fall. In the emergency department, she is hypotensive and has cold, clammy extremities. A pulsating mass is palpable on abdominal examination. Following resuscitation, the next step in the management should involve which of the following?

(A) Peritoneal lavage
(B) Immediate abdominal exploration

(C) CT scan of the abdomen
(D) Abdominal aortogram
(E) Abdominal ultrasound

Answer 33

Immediate abdominal exploration

• The presence of acute vascular collapse with history of abdominal or flank pain and associated pulsating abdominal mass is characteristic of a ruptured abdominal aneurysm.
• Operation should be performed as quickly as possible, because the first priority is to control the hemorrhage.
• No time should be lost in obtaining diagnostic studies, because these patients often crash in the radiology suite.
• These patients should not be resuscitated aggressively, because an increase in systolic pressure will only cause more intra-abdominal hemorrhage.

Question 34

A 60-year-old man complains of dizziness, vertigo, and mild right-arm claudication. On physical examination, there is decreased pulse and blood pressure of the right upper extremity. What is the treatment of choice?

(A) Anticoagulation
(B) Repair of coarctation of the aorta
(C) Ligation of vertebral artery
(D) Carotid endarterectomy
(E) Carotid subclavian bypass

Answer 34

Carotid subclavian bypass

• The clinical picture presented is that of a subclavian artery stenosis resulting in subclavian steal syndrome, represented by vertebrobasilar symptoms and extremity ischemia.
• The symptoms are due to a decrease of posterior circulation (vertebral artery) blood flow. Claudication occurs more commonly than ischemic findings.
• Most patients have no triggering events, and the symptoms are not readily reproducible.
• Carotid subclavian bypass restores the circulation beyond the stenotic area and corrects the steal syndrome.
• Ligation of the vertebral artery will correct the steal syndrome but will not improve the circulation of the arm.
• Anticoagulation has no role in the treatment of this entity.
• Other treatment options include subclavian artery transposition, axilloaxillary bypass, and subclavian artery angioplasty.
• Coarctation of the aorta results in pulse and pressure difference between the upper and lower extremities

Question 35

An 18-year-old man develops a painful, swollen leg while training for the New York Marathon. There is tenderness in the calf and ecchymosis is present. What is the most likely diagnosis?

(A) Cellulitis
(B) DVT
(C) Superficial thrombophlebitis
(D) Tear of the plantaris muscle
(E) Medical lemniscus tear

Answer 35

**Tear of the plantaris muscle **

• Spontaneous thrombophlebitis in this age group is unlikely. Plantaris or gastrocnernius tear may occur during physical exertion involving running or walking, causing a sharp pain in this region.
• After resolution of a hematoma in this region, it may be difficult to exclude cellulitis if there is any question that the integrity of the skin has been damaged.
• In superficial thrombophlebitis, there is tenderness along the distribution of the long or short saphenous veins. A tear of the medial lemniscus of the knee joint is detected by tenderness over the medical aspect of the knee joint during flexion and internal rotation of the knee joint (McMurray sign).

Question 36

Next two flashcards share same clinical stem:

Four days after suffering MI, a 78-year-old woman suddenly develops severe diffuse abdominal pain. Her electrocardiogram (ECG) shows atrial fibrillation. On examination, the abdomen is soft, minimally tender, and slightly distended. Hyperactive bowel sounds are present.

What is the most likely diagnosis?

(A) Mesenteric embolus
(B) Nonocclusive ischemic disease
(C) Perforated peptic ulcer
(D) Congestive heart failure (CHF)
(E) Digoxin toxicity

Answer 36

Mesenteric embolus

• Patients with atrial fibrillation are more likely to develop emboli to different sites throughout the body.
• Nonocclusive ischemic disease is characterized by spasm of the major mesenteric arterial vessels, with a characteristic beading effect.
• Early recognition may result in improvement with direct intra-arterial infusion of papaverine (which causes vasodilation), thus avoiding operative intervention.

Question 37

The most appropriate initial examination consists of which of the following?

(A) Gastrografin upper GI series
(B) White blood cell (WBC) counts and serial
abdominal examination

(C) Colonoscopy
(D) Diagnostic peritoneal lavage
(E) Angiography

Answer 37

Angiography

• Clinical findings of peritoneal irritation and leukocytosis in patients with suspected visceral ischemia indicate necrosis of ischemic bowel.
• Immediate arteriography is required to establish the diagnosis and initiate treatment to restore circulation before massive bowel infarction, acidosis, and possible perforation occur.
• The most likely diagnosis is a mesenteric embolus arising from the heart, especially in the presence of atrial fibrillation.
• The catheter should be left in place to allow papaverine infusion to an area of borderline ischemic bowel.

Question 38

A 28-year-old woman has new-onset hypertension and a bruit on abdominal examination. An arteriogram shows fibromuscular dysplasia (FMD) of the right renal artery. What is the best treatment option?

(A) Aortorenal saphenous vein bypass
(B) Patch angioplasty of the renal artery
(C) Percutaneous transluminal angioplasty (PTA)
(D) Transaortic renal endarterectomy
(E) Hepatorenal bypass

Answer 38

Percutaneous transluminal angioplasty

• Among all causes of renovascular hypertension, FMD responds best to angioplasty.
• Intermediate results of PTAfor FMD are similar to those of bypass. PTA has lower morbidity, causes less discomfort, and is less expensive.
• Recurrence can be treated by repeated PTA.

Question 39

Next three flash cards have same clinical stem

A 60-year-old man with a history of atrial fibrillation is found to have a cyanotic, cold right lower extremity.

The embolus is most probably originating from which of the following?

(A) An atherosclerotic plaque
(B) An abdominal aortic aneurysm
(C) Heart
(D) Lungs
(E) Paradoxical embolus

Answer 39

**Heart **

The heart is the origin of about 90% of lower extremity emboli. The causes are usually mitral stenosis, atrial fibrillation, or MI. A rare source of left atrial emboli is a left atrial myxoma. The remaining 10% arise from ulcerated plaques in the aorta or peripheral arteries. Paradoxical emboli arising from the venous system may reach the arterial circulation through a patent foramen ovale.

Question 40

Which is the most common site at which an arterial embolus lodges?

(A) Aortic bifurcation
(B) Popliteal artery
(C) Tibial arteries
(D) Common femoral artery
(E) Iliac artery

Answer 40

Common femoral artery

• Arterial emboli usually lodge proximal to bifurcations, the most common site being the common femoral artery.

Question 41

What is the most appropriate management?

(A) Embolectomy
(B) Lumbar sympathectomy
(C) Bypass surgery
(D) Amputation
(E) Arteriography

Answer 41

**Embolectomy **

• Once the diagnosis is made clinically, heparin is administered intravenously to prevent the development of thrombi distal to the embolus.
• Then embolectomy can be done in most instances under local anesthesia.
• Arteriography to confirm what is already clinically apparent only delays the needed surgical procedure.
• If there is a doubt, duplex evaluation will help confirm the diagnosis. Lumbar sympathectomy locks are of dubious value.
• In patients who have known occlusive disease, absent pulses in the contralateral extremity, absence of clinical features of hyperacute ischemia would be best managed by an angiogram and thrombolytic infusion.

Question 42

An elderly patient with ischemic rest pain is found to have combined aortoiliac and femoropopliteal occlusive disease. What is the treatment of choice?

(A) Aortofemoral bypass
(B) Femoropopliteal bypass
(C) Aortofemoral and femoropopliteal bypass
(D) Lumbar sympathectomy
(E) Vasodilator therapy

Answer 42

Aortofemoral bypass

• Patients with combined segmental occlusive disease require correction of proximal hemodynamically significant disease before distal (infrainguinal) bypass. Only about 20% of patients undergoing aortofemoral reconstruction in the presence of superficial femoral artery occlusion will subsequently require femoropopliteal bypass.
• Combined procedures should be reserved for patients with severe lifethreatening ischemia.
• Lumbar sympathectomy and vasodilator therapy are ineffective in treating severe arterial occlusive disease.

Question 43

A 66-year-old woman has a 5.5-cm infrarenal abdominal aortic aneurysm. What is the most common manifestation of such an aneurysm?

(A) Abdominal or back pain
(B) Acute leak or rupture
(C) Incidental finding on abdominal examination
(D) Atheroembolism
(E) Spontaneous thrombosis

Answer 43

Incidental finding on abdominal examination

• Most patients are unaware of their abdominal aneurysm until it is incidentally discovered by their physician. The importance of careful deep palpation of the abdomen cannot be overemphasized.
• On occasion, these aneurysms may expand, causing abdominal or back pain, and may even leak or rupture, mimicking other acute intra-abdominal conditions.
• Signs and symptoms of acute ischemia in the lower extremities are rare and usually follow thrombosis or embolization from an abdominal aneurysm.

Question 44

A 72-year-old man complains of bilateral thigh and buttock claudication of several months duration. He was told by his physician that the angiogram revealed findings indicating that he has Leriche syndrome. What does this patient have?

(A) Abdominal aortic aneurysm
(B) Aortoiliac occlusive disease
(C) Iliac artery aneurysm
(D) Femoropopliteal occlusive disease
(E) Tibial occlusive disease

Answer 44

Aortoiliac occlusive disease

• Leriche syndrome consists of the manifestations of aortoiliac occlusive disease and includes thigh and buttock claudication, atrophy of the leg muscles, diminished femoral pulses, and impotence in men.

Question 45

A young woman develops a left femoral arteriovenous fistula a few months after a stab wound to the groin. Which of the following physiological changes (Nicoladoni-Branham sign) is elicited on physical examination?

(A) Appearance of CHF when the artery proximal to the fistula is compressed
(B) Slowing of the pulse rate when the fistula is compressed
(C) A rise in the pulse rate when the artery distal to the fistula is compressed
(D) A bruit heard only after the fistula is occluded
(E) Absent dorsalis pedis after leg is elevated

Answer 45

Slowing of the pulse rate when the fistual is compressed

• The Nicoladoni-Branham sign can be elicited in some patients with an AV fistula.
• Occlusion of the fistula or the artery proximal to the fistula may result in slowing of the heart rate.
• By this compression, the peripheral resistance is increased, venous return is decreased, and the pulse rate falls.

Question 46

A young patient sustains blunt trauma to his right knee that results in acute thrombosis of his popliteal artery. Which tissue is most sensitive to ischemia?

(A) Muscle
(B) Nerve
(C) Skin
(D) Fat
(E) Bone

Answer 46

Nerve

• Peripheral nerve endings are the tissues most sensitive to anoxia in the extremity.
• Therefore, paralysis and paresthesia are most important when evaluating an extremity with acute arterial occlusion.
• The second most sensitive tissue is the muscle.
• This is why an extremity with paralysis and paresthesia will develop gangrene if circulation is not restored.
• Gangrene is less likelyto occur if signs of ischemia are present, but motor and sensory functions are intact.

Question 47

A 24-year-old male cyclist undergoes repair of both popliteal artery and vein following a gunshot wound to the right knee. Thirty-six hours postoperatively, there is increasing swelling of the leg and foot, and the patient complains of increasing foot pain and inability to move his toes. His pedal pulses are palpable. What is the most immediate next step that should be
undertaken?

(A) Arteriography
(B) Leg and foot elevation
(C) Fasciotomy
(D) Venography
(E) Immediate reexploration of the popliteal
space

Answer 47

Fasciotomy

• Compartment syndrome can occur following repair of vascular injuries, especially if ischemia time is more than 6 hours or if there have been substantial periods of shock.
• Other instances include the combination of arterial and venous injury and the presence of concomitant soft-tissue crush injury or bone fracture.
• Compartment swelling and tenderness, pain disproportionate to the physical findings, paresthesia, and weakness are all clinical signs of compartment syndrome and require urgent surgical decompression.
• A palpable pulse does not rule out the presence of a compartment syndrome, because compartment pressures are high, even before loss of a palpable pulse.

Question 48

A homeless elderly man is brought to the emergency department after sustaining frostbite to both feet. What is the most appropriate immediate management?

(A) Slow rewarming at room temperature
(B) Amputation of the gangrenous toes
(C) Rapid rewarming with warm water
(D) Rapid rewarming with hot water or dry heat
(E) Thorough debridement of blisters and devitalized tissue

Answer 48

Rapid rewarming with warm water

• Rapid warming of the injured tissue is the most important aspect of treatment.
• The frozen tissue should be placed in warm water, with a temperature in the range of 40.8–44.8ºC.
• Dry heat or hot water carries the risk of thermal injury because of decreased sensation in the injured part.
• Opening of blisters and debridement of devitalized tissue are contraindicated.
• Demarcation of gangrenous areas should be carefully observed, often for several weeks, before amputation is performed.
• The extremity should be elevated, tetanus prophylaxis should be administered as indicated, and antibiotics should be given in the presence of open wounds

Question 49

What is true of carotid body tumours?

(A) They most frequently present as a painless neck mass.
(B) They arise from endothelial cells.
(C) They are usually hypovascular.
(D) They frequently manifest with a stroke.
(E) They are usually treated by embolization.

Answer 49

Most frequently present as a painless neck mass

• Carotid body tumors are usually 3–4 mm in size and are located at the carotid bifurcation.
• They arise from nests of chemoreceptor cells of neuroectodermal origin (carotid body).
• In normal individuals, the carotid body responds to a fall in PO2 and pH and to a rise in PCO2 and temperature to cause an increase in cardiac contraction, heart rate, and respiratory rate.
• Carotid body tumors are uncommon, slow growing, and highly vascular. Although large tumors may cause compression of the vagus or hypoglossal nerves, most tumors present as a palpable painless mass at the carotid bifurcation.
• The treatment is definitely excision whenever possible.

Question 50

A middle-aged man complains of short distance claudication in the right thigh. The angiogram shows a right common iliac artery stenosis of 90% over a short segment. What is the treatment of choice?

(A) Aortofemoral bypass
(B) Left-to-right fermorofemoral bypass
(C) Iliofemoral bypass
(D) PTA and stent placement
(E) Axillofemoral bypass

Answer 50

PTA and Stent Replacement

• PTA is technically successful in approximately 90% of iliac lesions with good patency rates.
• It is more successful for single short stenoses rather than multiple long stenosis or occlusions.
• The advantages of PTA is that it is less invasive than surgery, has a lower initial cost, has a shorter hospital stay, and lower morbidity, enables an earlier return to full activity, and the procedure can be repeated without an increase in morbidity or a decrease in clinical result.
• It is particularly useful for patients who are at high operative risks. The ideal procedure would be and angioplasty and stent placement.

Question 51

A 65-year-old man with hypertension and a blood pressure of 190/105 mm Hg has unilateral renal artery stenosis. What is the best diagnostic test to determine the physiologic significance of the lesion?

(A) Aortography
(B) Renal scan
(C) Renal ultrasound
(D) Renal vein renin assay
(E) Rapid-sequence intravenous pyelogram

Answer 51

Renal vein renin assay

• Aortography and renal ultrasound can detect the presence of renal artery stenosis, but they do not determine the functional significance of the lesion.
• IVP is not a sensitive enough test to detect the presence of renal artery stenosis. A renal scan can show decreased flow (uptake) or decreased
• function of the affected kidney, but it, too, lacks sensitivity.
• The assessment of renal vein renin levels is a good diagnostic test to determine the physiologic significance of renal artery stenosis.
• It indicates whether the stenosis is significant enough to decrease the glomerular filtration rate and cause the release of renin. In addition, the opposite kidney should have suppression of renin secretion.

Question 52

A young college student injures his left knee while playing football and is unable to bear weight. The provisional x-ray report indicates that there are no fractures seen. He is discharged home but presents the next morning to the emergency department with a severely swollen, painful left knee and severe pain in the foot. On examination, the foot is pale, cold, and pulseless. What is the most likely diagnosis?

(A) Traumatic deep vein thrombosis
(B) Gastrocnemius muscle tear
(C) Traumatic arteriovenous fistula

(D) Posterior knee dislocation with thrombosed popliteal artery

(E) Traumatic sciatic neuropathy

Answer 52

Posterior knee dislocation with thrombosed popliteal artery

• Normal radiographic findings in the presence of severe knee trauma should raise suspicion for posterior dislocation of the knee which is often associated with popliteal artery thrombosis.
• A careful vascular examnation should therefore be made in such a situation.
• The presence of pallor, pain and pulselessness (three of the five ps) is indicative of severe ischemia.
• This patient should undergo urgent exploration for vascular repair
• The other options are unlikely to cause the signs and symptoms presented.

Question 53

An elderly patient complains of recurrent episodes of amaurosis fugax. This is attributable to microembolization of which of the following?

(A) Facial artery
(B) Retinal artery
(C) Occipital artery
(D) Posterior auricular artery
(E) Superficial temporal artery

Answer 53

Retinal artery

• Amaurosis fugax, one type of TIA, is a manifestation of carotid bifurcation atherosclerotic disease.
• It is manifested by unilateral blindness, being described by the patient as a window shade across the eye, lasting for minutes or hours.
• It is caused by microemboli from a carotid lesion lodging in the retinal artery, the first intracerebral branch of the internal carotid artery.

Question 54

A 65-year-old woman television technician undergoes femoral embolectomy and leg fasciotomy. Following surgery, she is noted to have oliguria, and her urine is red. What is the most probable diagnosis?

(A) Hematuria secondary to heparin
(B) Embolus of the renal artery
(C) Myoglobinuria
(D) Retroperitoneal hematoma
(E) Hemoglobinuria

Answer 54

**Myoglobinuria **

• Patients with sudden severe ischemia are prone to “ischemia-reperfusion” syndrome.
• With revascularization, there is sudden release of the accumulated products of ischemia into the circulation; namely, potassium, lactic acid, myoglobin, and cellular enzymes.
• Hyperkalemia, metabolic acidosis, and myoglobinuria (red urine, clear plasma) are the key features of the syndrome.
• Renal tubular acidosis results in myoglobin deposition in the renal tubules.
• Anticipation and early recognition require the induction of diuresis with mannitol, alkalinization of the urine to avoid precipitation of myoglobin in the renal tubules, and correction of hyperkalemia.

Question 55

A 24-year-old woman on oral contraceptive pills develops an episode of deep vein thrombosis that is adequately treated with anticoagulation. She is at increased risk of developing which of the following?

(A) Recurrent foot infections
(B) Claudication
(C) Pulmonary embolism
(D) Postphlebetic syndrome
(E) Superficial varicose veins

Answer 55

Postphlebetic syndrome

• Despite receiving optimal treatment for DVT, approximately 50% of the patients will develop the post-thrombotic syndrome.
• The recanalization of the deep veins will result in deformity and subsequently incompetence of the affected venous valves.
• Although patients with DVT can develop infections secondary to edema, these are usually located about the ankle and resolve with adequate treatment.
• Patients adequately treated for DVT are not at increased risk of developing pulmonary embolus.
• Neither the arterial circulation nor the superficial venous system are affected by the development of DVT.
• Young patients with iliofemoral thrombosis are best managed by thrombolytic infusion, which has been shown to preserve valvular function and decrease the incidence of postphlebitic syndrome.

Question 56

A 72-year-old businessman undergoes a femoral to- posterior tibial in situ bypass graft for a nonhealing foot ulcer. During routine follow-up examination 4 years later, the graft is found to be occluded. The cause of his graft failure is most probably secondary to which of the following?

(A) Progression of atherosclerosis
(B) Technical error
(C) Retained valve in the conduit
(D) Venous aneurysm
(E) Intimal hyperplasia

Answer 56

**Progression of atherosclerosis **

• The causes of graft failure can be divided into early and late. Although early failure of vein grafts is usually attributed to either technical error or inadequate outflow tract, late failure is usually related to progressive proximal or distal atherosclerotic disease.
• Other less common causes of late graft failures include— local stenotic areas from trauma or endothelial damage, valve stenosis from fibrosis, and venous aneurysms and subsequent thrombosis.
• Intimal hyperplasia is a rare cause of late failure.

Question 57

A 60-year-old woman has an asymptomatic right carotid bruit. A carotid duplex scan shows no evidence of significant carotid bifurcation disease but reveals reversal of flow in the right vertebral artery. What is the most likely diagnosis?

(A) Stenosis of the origin of the common carotid artery
(B) Stenosis of the vertebral artery
(C) Stenosis of the subclavian artery
(D) Stenosis of the external carotid artery
(E) Stenosis of the intracranial portion of the internal carotid artery

Answer 57

Stenosis of the subclavian artery

• Occlusion or stenosis of the subclavian artery proximal to the origin of the vertebral artery results in the “subclavian steal” syndrome.
  In response to decreased pressure in the distal subclavian artery, especially in instances in which increased perfusion is needed, there is
  reversal of flow in the vertebral artery.
• The clinical picture is that of vertebrobasilar symptoms in association with upper extremity exercise.
• Although this phenomenon is sometimes seen on duplex scanning or angiography, evolution into a clinical syndrome is relatively rare.
• The other mentioned options do not result in retrograde
  flow in the vertebral artery.

Question 58

A newborn girl with family history of lymphedema is noted to have bilateral lower extremity swelling. What is the diagnosis?

(A) Secondary lymphedema
(B) Lymphedema praecox
(C) Milroy disease
(D) Lymphedema tarda
(E) Meigs’s syndrome

Answer 58

Milroy disease

• Lymphedema is classified by etiology—primary versus secondary.
• Primary lymphedema is divided into congenital, praecox, and tarda, depending on the age of onset.
• The diagnosis of Milroy disease is reserved for patients with familial lymphedema in which clinical factors are present at birth or noticed soon thereafter.
• Lymphedema is classified as praecox if the age of onset is between 1 and 35 years. Meigs’ disease is the familial form of primary lymphedema praecox. If the onset of primary lymphedema is after 35 years of age, it is called lymphedema tarda.
• Secondary lymphedema usually results from a disease process that causes obstruction of the lymphatic system.