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MyPasTest: MRCS A Online - Jan Exam 2015

30. Systemic Surgery- Vascular Surgery (38Qs)

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Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital

Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: [email protected]

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01. A 78-year-old lifelong smoker presents with a punched out deep ulcer on the ball of his foot. On examination the foot is cool and hairless and sensation is reduced. The Dorsalis Pedis and Posterior Tibial pulse are difficult to feel. What is the likely aetiology? Select one answer only.

Arterial « YOUR ANSWER (Correct Answer)

Diabetic

Infective

Malignant

Venous. This patient has peripheral arterial disease with typical deep punched out ulcers. The limb has signs of chronic ischaemia with absent pulses. These ulcers usually occur in pressure areas such as the ball of the foot or heel. 02. Theme: level of arterial disease and location of symptoms A Aorto-iliac occlusion B External iliac/common femoral occlusion C Superficial femoral artery occlusion D Crural vessel occlusion E Aorto-iliac occlusion and superficial femoral artery occlusion. For each of the patients below, choose the most likely level of arterial disease from the list above. Each option may be selected once, more than once or not at all. Scenario 1 Rest pain and foot ulcers A - Aorto-iliac occlusion« YOUR ANSWER E - Aorto-iliac occlusion and superficial femoral artery occlusion« CORRECT ANSWER. Scenario 2 Impotence B - External iliac/common femoral occlusion« YOUR ANSWER A - Aorto-iliac occlusion« CORRECT ANSWER. Scenario 3 Calf claudication C - Superficial femoral artery occlusion« CORRECT ANSWER.

Scenario 4 Thigh claudication D - Crural vessel occlusion« YOUR ANSWER B - External iliac/common femoral occlusion« CORRECT ANSWER. Scenario 5 Buttock claudication E - Aorto-iliac occlusion and superficial femoral artery occlusion« YOUR ANSWER A - Aorto-iliac occlusion« CORRECT ANSWER. Claudication pain usually occurs in the muscle group just distal to the diseased artery. Tissue loss

usually only results when there is disease at more than one level.



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02. Theme: supra-aortic arterial surgey A Carotid-carotid bypass B Carotid-subclavian bypass C Carotid endarterectomy D Superficial temporal artery-middle cerebral artery bypass E Thoracic-outlet decompression. For each of the pathologies below, choose the procedure from the list above that may be required to deal with the condition. Each option may be selected once, more than once or not at all. Scenario 1 Subclavian steal syndrome A - Carotid-carotid bypass« YOUR ANSWER B - Carotid-subclavian bypass« CORRECT ANSWER. Scenario 2 Amaurosis fugax B - Carotid-subclavian bypass« YOUR ANSWER C - Carotid endarterectomy« CORRECT ANSWER. Scenario 3 Unilateral 95% stenosis of the carotid bifurcation C - Carotid endarterectomy« CORRECT ANSWER. Scenario 4 Paget–Schroetter syndrome (axillary vein thrombosis) D - Superficial temporal artery-middle cerebral artery bypass« YOUR ANSWER E - Thoracic-outlet decompression« CORRECT ANSWER. Scenario 5 Endovascular repair of a thoracic aneurysm where the landing zone involves the origin of the left carotid artery (ie the origin of the left carotid artery is covered by the stent graft) E - Thoracic-outlet decompression« YOUR ANSWER A - Carotid-carotid bypass« CORRECT ANSWER.

Superficial temporal artery to middle cerebral artery bypass is now an obsolete procedure. Carotid

endarterectomy is indicated for both symptomatic and asymptomatic internal carotid artery stenosis

70%. Stenting of thoracic aneurysms is becoming preferable to open surgery due to its much lower

peri-/post-operative mortality. If the aneurysm is close to the origins of the left subclavian and left

carotid vessels, these may be covered by the stent as long as a carotid–carotid bypass is performed

before stenting, thereby preventing a left cerebrovascular accident. The left subclavian can usually be

covered without impunity. Paget–Schroetter syndrome (axillary vein thrombosis) is likely to recur

unless the thoracic outlet is decompressed.

04. A 72-year-old man is transferred to your vascular centre with a suspected AAA. Fast scan at the initial hospital emergency department showed a 9cm suspected aneurysm. Vital signs are as follows; heart rate 100, Blood pressure 117 systolic, 02sats 94% on room air. What is the next appropriate step? Select one answer only.

CT scan« YOUR ANSWER (Correct Answer)

Elective repair



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Theatre for emergency EVAR

Theatre for emergency open repair

Repeat Fast Scan.

This patient has a AAA and at present is relatively haemodynamically stable. Preferably when the

surgical team is alerted to this transfer, radiology should be alerted to be on standby. Once the patient

is rapidly assessed in the emergency department and if haemodynamically stable and appears safe to

do so as in the case above, an urgent CT scan should be performed. This allows confirmation of

diagnosis of the aneurysm and potential complication – leak or rupture and allows the vascular

surgeon to review the anatomy including the neck of the aneurysm as this aids planning for surgical

intervention including potential suitability for EVAR which if available can be performed in the

emergency setting if the patient is stable. Clearly if the patient is haemodynamically unstable and a

ruptured AAA is suspected, the vascular consultant should be informed and there should be no delay

to theatre.

05. THEME: LOWER-LIMB ULCERATION A Squamous cell carcinoma B Hypertensive ulcer (Martorell syndrome) C Pyoderma gangrenosum D Neuropathic ulcer E Vasculitic ulcer F Necrobiosis lipoidica G Sickle cell disease H Venous ulcer I Basal cell carcinoma J Erythema nodosum. For each of the case descriptions below, select the most appropriate diagnosis from the list above. Each option may be used once, more than once, or not at all.

Scenario 1 A 54-year-old woman with known inflammatory bowel disease presents with a large nodulopustular ulcerating lesion over her right anterior shin. It has a blue overhanging necrotic edge. Her ankle–brachial pressure indices are normal. A - Squamous cell carcinoma« YOUR ANSWER C - Pyoderma gangrenosum« CORRECT ANSWER.

Pyoderma gangrenosum (PG) are recurring nodulopustular ulcers commonly affecting the legs, abdomen and face. They are tender and have a red or blue overhanging necrotic edge. They heal with cribriform scars. Over 50% of patients with PG have associated underlying active or quiescent systemic disease – such as inflammatory bowel disease, seronegative rheumatoid arthritis, a lymphoproliferative disease, autoimmune hepatitis or Wegener’s granulomatosis. The diagnosis of PG is primarily clinical and by exclusion of other causes of cutaneous ulcerations with a similar appearance; skin histology may help. Treatment is usually with immunosuppressants and corticosteroids. Scenario 2 A 57-year-old woman with varicose veins presents with a large ulcer over her left medial malleolus. This is associated with surrounding lipodermatosclerosis and eczema. The ankle–brachial pressure index in this leg is 1. The patient is moderately obese.



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B - Hypertensive ulcer (Martorell syndrome) « YOUR ANSWER H - Venous ulcer« CORRECT ANSWER. Venous ulcers may develop spontaneously or following minor trauma. There may be a history of varicose veins, deep venous thrombosis, chronic venous insufficiency, poor calf-muscle function or arteriovenous fistulae. Other factors predisposing to venous ulceration include obesity, all risk factors for deep-vein thrombosis, a family history of varicose veins and a history of leg fracture. In long-term venous insufficiency, the skin undergoes changes (atrophy and variable pigmentation), with the dermis and subcutaneous tissue becoming indurated and fibrosed; this is termed lipodermatosclerosis. Venous eczema (erythema, scaling, weeping and itching) is a common feature associated with such ulceration; this is distinct from cellulitis. The ankle–brachial pressure indices are normal in patients with classic venous ulceration. Scenario 3 A 59-year-old man presents with ulceration over the tips of his toes in his left foot and a large ulcer over his right heel. He also complains of paraesthesias in both feet. The ankle–brachial pressure indices are 1.05 on the right and 1.2 on the left. On neurological assessment, proprioception and vibration sense are reduced. C - Pyoderma gangrenosum« YOUR ANSWER D - Neuropathic ulcer« CORRECT ANSWER. Neuropathic ulcers can result from peripheral sensory neuropathy secondary to diabetes mellitus. The other causes of altered sensory neuropathy leading to neuropathic ulcers include spinal cord injuries, spina bifida, tabes dorsalis, syringomyelia, alcohol abuse and leprosy. Neuropathic ulcers are common at the sites of pressure or repeated trauma. The usual sites in the lower limb are the heads of the metatarsals, the interdigital clefts, the heel (calcaneum) and the lateral malleolus. In diabetic patients, the ankle–brachial pressure indices may be falsely elevated even in those with major vessel disease. This is due to calcification of the vessel walls and medial sclerosis. Neurological assessment may reveal altered sensation including proprioception and two-point discrimination in the foot or toes, reduced vibration sense and absent ankle jerks. Scenario 4 A 24-year-old woman of Jamaican origin presents with a 4-month history of painful ulceration over her right shin. Ankle–brachial pressure indices are normal. The patient has mild splenomegaly. Her haemoglobin is 9.2 gm/dl. D - Neuropathic ulcer« YOUR ANSWER G - Sickle cell disease« CORRECT ANSWER. Sickle cell disease is an hereditary haemolytic anaemia occurring mainly among those of Afro-Caribbean origin. The haemoglobin S molecule crystallises during reduced blood oxygen tension, causing vascular occlusion. Depending on the affected vessel, patients may have bone or joint pain, priapism, neurological abnormalities or skin ulcers. The ulceration is due to occlusion of the cutaneous microcirculation, leading to ischaemia and skin breakdown. In dark-skinned individuals, there may be a non-specific increase in melanin pigmentation around the ulcer, which, if over the ankle region, may be confused with the discoloration caused by haemosiderin around a venous ulcer. Anaemia and splenomegaly are recognised features of sickle cell disease. 06. Theme: Lower limb ulceration A Basal cell carcinoma B Erythema nodosum C Hypertensive ulcer (Martorell’s ulcer) D Necrobiosis lipoidica E Neuropathic ulcer F Pyoderma gangrenosum



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G Sickle cell disease H Squamous cell carcinoma I Vasculitic ulcer J Venous ulcer. For each of the following profiles, select the most likely cause of the ulcer from the above list. Each option may be used once, more than once, or not at all. Scenario 1 A 54-year-old lady with known inflammatory bowel disease presents with a large nodulo-pustular ulcerating lesion over her right anterior shin. It has a blue overhanging necrotic edge. The arterial blood pressure index (ABPI) is normal. A - Basal cell carcinoma « YOUR ANSWER F - Pyoderma gangrenosum« CORRECT ANSWER. Pyoderma gangrenosum is recurring nodulo-pustular ulceration that commonly affect the legs, abdomen and face. The ulcers are tender with a red-blue overhanging necrotic edge and they heal with cribriform scars. Pyoderma gangrenosum is associated with inflammatory bowel disease, acute leukaemia, polycythaemia rubra vera, autoimmune hepatitis, Wegener’s granulomatosis and myeloma. Scenario 2 A 57-year-old obese lady with varicose veins presents with a large ulcer over her left medial malleolus. This is associated with surrounding lipodermatosclerosis and eczema. The ABPI in this leg is 1.05. B - Erythema nodosum « YOUR ANSWER J - Venous ulcer« CORRECT ANSWER. Venous ulcers may develop spontaneously or following a minor injury. Risk factors include past history of varicose veins and deep-venous thrombosis (DVT); all causes of varicose veins or DVT may therefore predispose to venous ulceration. Venous incompetence leads to a high venous pressure which causes pericapillary fibrin deposition, white cell activation and increased production of free radicals. All these factors contribute to skin breakdown, causing ulceration. These ulcers usually lie proximal to the medial or lateral malleolus, although they may extend to the ankle or dorsum of the foot. Lipodermatosclerosis frequently accompanies long-standing venous incompetence. Increased exudates leads to venous eczema, excoriation of the surrounding skin, itch and worsening of the ulcer. Scenario 3 A 59-year-old man presents with ulceration over the distal tips of three toes in his left foot and over his right heel. He also complains of paraesthesia in both his feet. The ABPI is 1.02 on the right and 1.16 on the left. On neurological assessment, proprioception and vibration sense are reduced. C - Hypertensive ulcer (Martorell’s ulcer) « YOUR ANSWER E - Neuropathic ulcer« CORRECT ANSWER. Neuropathic ulcers can result from peripheral sensory neuropathy secondary to diabetes mellitus. The other causes for altered sensory neuropathy, leading to neuropathic ulcers include: spinal cord injuries, spina bifida, tabes dorsalis, syringomyelia, alcohol abuse and leprosy. Neuropathic ulcers are common at the sites of pressure or repeated trauma. The usual sites in the lower limb are the head of the metatarsals, interdigital clefts, heel (calcaneum) and the lateral malleolus. In diabetic patients, the arterial blood pressure index (ABPI) may be falsely elevated, because of calcification of the vessel walls and medial sclerosis, even in those with major vessel disease. Neurological assessment of the foot and toes may reveal altered sensation including proprioception and two-point discrimination, reduced vibration sense and absent ankle jerks.



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Scenario 4 A 30-year-old Afro-Caribbean lady presents with a 4-month history of a painful ulcer over her right shin. She mentions that she does not have a functioning spleen. ABPIs are normal. D - Necrobiosis lipoidica « YOUR ANSWER G - Sickle cell disease« CORRECT ANSWER. Sickle cell disease is hereditary haemolytic anaemia occurring mainly among those of Afro-Caribbean origin, often involving functional asplenia from childhood. The haemoglobin ‘S’ molecule crystallises during reduced blood oxygen tension causing vascular occlusion. Depending on the affected vessel, patients may have bone or joint pain, priapism, neurological abnormalities, skin ulcers. Ulceration is due to occlusion of the cutaneous microcirculation, leading to ischaemia and skin breakdown. In dark-skinned individuals, there may be a non-specific increase in melanin pigmentation around the ulcer which, if over the ankle region, may be confused with haemosiderin discoloration around a venous ulcer. 07. Theme: Lower limb venous disease A Compression bandaging B Elevation, rest, NSAIDs and antibiotics C Emergency surgery D Subcutaneous low molecular weight heparin E Warfarinisation. For each of the patients described below, select the treatment of choice from the list of options above. Each option may be used once, more than once, or not at all.

Scenario 1 A woman has thrombosed varicose veins and cellulitis. A - Compression bandaging« YOUR ANSWER B - Elevation, rest, NSAIDs and antibiotics« CORRECT ANSWER.

The woman with thrombosed varicose veins and cellulitis should be treated with elevation, rest,

NSAIDs and antibiotics.

Scenario 2 A woman develops a swollen and tender left leg 5 days after surgery. B - Elevation, rest, NSAIDs and antibiotics« YOUR ANSWER D - Subcutaneous low molecular weight heparin« CORRECT ANSWER.

One should also suspect a deep-vein thrombosis in a patient with a swollen and tender leg post-operatively. It is best to perform some imaging (duplex Doppler study) before commencing treatment for this second scenario. Scenario 3 A 64-year-old woman, who is a known case of venous insufficiency, presents with hypotension and profuse bleeding from the medial malleolus of the right leg. Conservative treatment has failed. C - Emergency surgery« CORRECT ANSWER. C – Emergency surgery A patient with venous insufficiency and profuse bleeding from an ulcer should have emergency surgery to stop the bleeding. 08. Theme: Leg ulcers A Arterial B Diabetic



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C Neoplastic D Postphlebitic E Tuberculous. For each of the patient scenarios below, select the aetiology of the most likely ulcer from the above list. Each option may be used once, more than once, or not at all. Scenario 1 A 72-year-old woman presents with a 2-year history of an intermittently healing, shallow ulcer above the right medial malleolus. The surrounding skin has a brown discoloration. Ten years previously, she was involved in an RTA and sustained pelvic fractures, which were treated with traction and bedrest. A - Arterial« YOUR ANSWER D - Postphlebitic« CORRECT ANSWER. Scenario 2 A 68-year-old insulin-dependent diabetic man presents with a progressively worsening deep, painless ulcer beneath the heel of his right foot, which has gradually deteriorated in the past two months. The ankle appears deformed, and the ulcer is surrounded by wet macerated skin and culture has grown MRSA and Pseudomonas species. Strong pedal pulses are present on examination. B - Diabetic« CORRECT ANSWER. Scenario 3 A 94-year-old man presents with a deep, painful ulcer at the tip of his great toe. He has gradually been getting less mobile over the last few months and the pain in his toe prevents him from sleeping. C - Neoplastic« YOUR ANSWER A - Arterial« CORRECT ANSWER. Leg ulcers often have multiple aetiologies. The aetiology is usually apparent from taking a clear

history and identifying the site of the ulcer. The most common causes of leg ulcers are venous, mixed,

arterial, neuropathic, vasculitic (including rheumatoid arthritis) and neoplastic. Venous and

postphlebitic ulcers tend to be situated in the gaiter area and have sloping edges.Arterial ulcers have

punched-out edges and often occur at pressure areas at the extremities, eg toes.Diabetic ulcers often

occur at the site of trauma or pressure points. In the question above, the presence of strong pedal

pulses excludes an arterial aetiology for the ulcers, while the ulcer location and Charcot-type joint

suggest a neuropathic component (in this case, secondary to poorly controlled diabetes). Neoplastic

ulcers have raised, rolled or everted edges and may occur anywhere.

09. Theme: Management of peripheral vascular disorders A Above-knee amputation B Aortofemoral bypass C Atherosclerosis risk factor reduction D Below-knee amputation E Femorodistal bypass F Femorofemoral bypass G Femoropopliteal bypass H Intraluminal stenting I Long saphenous vein surgery J Percutaneous thrombolytic thromboembolectomy K Percutaneous transluminal angioplasty L Sclerotherapy M Short saphenous vein surgery



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N Surgical thromboembolectomy. The following are descriptions of patients with peripheral vascular disorders. Please select the most appropriate treatment from the above list. The items may be used once, more than once, or not at all. Scenario 1 A 57-year-old man presents with left-sided cramping calf pain after walking approximately 100 metres. Examination of both lower limbs reveals no significant abnormalities. A - Above-knee amputation« YOUR ANSWER C - Atherosclerosis risk factor reduction« CORRECT ANSWER. This patient has intermittent claudication, a symptom of chronic lower limb atherosclerosis. Initial management involves: risk factor reduction, including cessation of smoking, lipid-lowering drugs, anti-platelet medication, good diabetic control if appropriate; regular exercise as part of a supervised exercise programme and weight loss. Surgical intervention is only indicated when the patient has disabling claudication, critical limb ischaemia, ulcers, or gangrene. The two main options are: percutaneous angioplasty (preferable) or bypass surgery. Scenario 2 A 64-year-old man presents with sudden onset of severe left-sided calf pain. On examination his left foot is pale and cold; on the affected side he has no palpable pulses below the femoral pulse. He is currently recovering from a recent cerebrovascular accident. B - Aortofemoral bypass« YOUR ANSWER N - Surgical thromboembolectomy« CORRECT ANSWER.

This patient has a classic presentation of acute lower ischaemia, with four of the six Ps: pallor, pulselessness, paraesthesia, paralysis, ‘perishing’ cold and pain. Percutaneous thrombolytic thromboembolectomy is the treatment of choice unless contraindicated, as in this scenario, in which case the patient should procede to surgical thromboembolectomy. Contraindications to thrombolysis include: cerebrovascular accident within the past 2 months, recent surgery, or previous thrombolytic therapy. Scenario 3 A 37-year-old woman presents with prominent unsightly leg veins, which cause discomfort on prolonged standing. Examination reveals tortuous dilated subcutaneous veins along the lateral aspect of the right calf; tourniquet tests indicate that when tied around the upper thigh and again just above the knee, the varicosities refill upon standing; however, when tied just below the knee they are controlled. She is currently taking oral contraception. C - Atherosclerosis risk factor reduction« YOUR ANSWER M - Short saphenous vein surgery« CORRECT ANSWER. This patient has a classic presentation of symptomatic varicose veins. Injection sclerotherapy is not applicable, first as it is contraindicated in those taking oral contraceptives, and second as it only provides short-term benefit in those with major incompetence of either long or short saphenous veins. The tourniquet test clearly indicates short saphenous incompetence, hence the need for short saphenous ligation and stripping. General consensus would suggest that duplex scanning should be performed to confirm the diagnosis and to site the junction for surgery (this is not necessary for long-saphenous disease unless the veins are recurrent). 10. Theme: Carotid artery disease A Carotid angiogram B Carotid Doppler C CT scan D ECG.



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What initial investigation would you perform for each of the patients listed below? Each option may be used once, more than once, or not at all. Scenario 1 A 71-year-old man presents with a normal pulse, left carotid bruit and left TIAs. A - Carotid angiogram« YOUR ANSWER B - Carotid Doppler« CORRECT ANSWER. Thirty per cent of carotid bruits heard on auscultation are not because of carotid stenosis. The initial investigation that should be performed here is a Doppler ultrasound scan. This may be followed by digital subtraction angiography or magnetic resonance angiography (MRA), but many centres will rely on colour duplex Doppler alone if performed by an experienced operator. Scenario 2 A 71-year-old man presents with a normal pulse, left carotid bruit and a dense left hemiplegia. B - Carotid Doppler« YOUR ANSWER C - CT scan« CORRECT ANSWER. In cases where a persistent neurological deficit has occurred a CT scan must be carried out initially to exclude a space-occupying lesion. 11. Theme: Ulceration in the lower limb A Arteriovenous fistula B Ischaemic ulcer C Necrobiosis lipoidica D Neoplastic ulcer E Neuropathic ulcer F Pyoderma gangrenosum G Self-inflicted H Sickle cell disease I Syphilis J Traumatic ulcer K Tuberculosis L Vasculitic ulcer M Venous ulcer. The following scenarios describe patients with leg ulceration. From the above list of causes of ulceration, choose the most appropriate answer. Each item may be used once, more than once, or not at all. Scenario 1 A 55-year-old diabetic man presents with a large painless ulcer on the sole of his foot. On examination, the ulcer appears deep with healthy surrounding skin. The foot feels warm and his ankle-brachial pressure index is 0.8. A - Arteriovenous fistula« YOUR ANSWER E - Neuropathic ulcer« CORRECT ANSWER. These ulcers occur in denervated tissue and result from local ischaemia, usually caused by non-perceived local trauma. They are characteristically painless and have a good blood supply (although diabetic neuropathy being a common cause may also lead to large-vessel atherosclerosis, resulting in a mixed picture of arterial and neuropathic ulceration). The causes of neuropathic ulceration may be



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divided into peripheral nerve lesions and spinal cord lesions. The former consist of diabetes, nerve injuries and leprosy, while spina bifida, tabes dorsalis and syringomyelia comprise the second group. Scenario 2 A 27-year-old man presents with abdominal pain, bloody diarrhoea and weight loss. On examination he is noted to have some areas of necrotising ulceration surrounded by erythema over his legs, which are acutely painful. B - Ischaemic ulcer« YOUR ANSWER F - Pyoderma gangrenosum« CORRECT ANSWER. This man may have undiagnosed ulcerative colitis. The lesions at first resemble boils, which subsequently break down to form necrotic ulcers with purple edges. Pyoderma gangrenosum is also associated with rheumatoid arthritis, multiple myeloma and leukaemia. Scenario 3 A 60-year-old lady presents with brown discoloration of both calves and a large left medial malleolar ulcer that has developed over many years. A central raised patch of friable, irregular, nodular growth is noted. C - Necrobiosis lipoidica« YOUR ANSWER D - Neoplastic ulcer« CORRECT ANSWER. This woman has a Marjolin’s ulcer or a squamous cell carcinoma arising from chronic inflammation in a long-standing benign ulcer or scar. This commonly occurs in a venous ulcer making constant review of such patients important. 12. Theme: Aortic bypass grafting A Aortobifemoral bypass B Axillobifemoral bypass C Femoral-to-femoral crossover D Left iliac angioplasty E Left iliac angioplasty and femoral crossover. For each of the patients described below, select the procedure of choice from the list of options above. Each option may be used once, more than once, or not at all. Scenario 1 A 50-year-old man has a 50-yard (~45 m) claudication distance, with complete occlusion of the lower aorta, with patent femoral vessels. A - Aortobifemoral bypass« CORRECT ANSWER.

Scenario 2 A 79-year-old man with emphysema requires home oxygen. He has complete occlusion of the aorta, with patent femoral vessels. His toes appear gangrenous and dusky. B - Axillobifemoral bypass« CORRECT ANSWER.

Scenario 3 A 43-year-old postman, otherwise fit and well, who is a non-smoker presents with acute onset claudication in both feet – he is determined to go back to work. He has an aortic bifurcation block with good femoral run-off on both sides. C - Femoral-to-femoral crossover« YOUR ANSWER A - Aortobifemoral bypass« CORRECT ANSWER. An aortobifemoral bypass graft has the highest patency rate of any bypass procedures to the femoral

vessels. An axillobifemoral bypass graft should only be considered in the very high-risk surgical

patient who has critical ischaemia. It should not be performed in patients with claudication.



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13. A 76-year-old woman attends for review of an ulcer that appeared 2 weeks ago over the medial aspect of her lower left leg. This is shallow with sloping edges. On examination there is hyperpigmentation of surrounding skin. She takes warfarin for a previous recurrent DVT. What is the likely diagnosis? Select one answer only.

Arterial Ulcer« YOUR ANSWER

Marjolin’s Ulcer

Post-Phelbitic Ulcer« CORRECT ANSWER

Neuropathic Ulcer

Vasculitic Ulcer

This patient has a venous ulcer as a consequence of poor venous flow after previous DVT. The

hyperpigmentation is lipodermatosclerosis from haemosiderin deposition. Typically venous ulceration

affects the ‘gaiter’ area in the lower medial third of the lower limb. The ulcers have gently sloping

edges, are shallow and flat with granulation tissue with healing or slough on the base.

14. Theme: Management of arterial disease A Percutaneous angioplasty B Femoropopliteal bypass graft C Emergency aortoiliac bypass graft D Endovascular stent graft E Below-knee amputation.

For each of the clinical scenarios below select the most appropriate action. Each option may be used once, mor than once, or not at all.

Scenario 1 A 56-year-old man with a necrotic arterial ulcer on his shin has an angiogram. This reveals a solitary, short segment, distal superficial femoral artery (SFA) occlusion with single-vessel run-off on that side. A - Percutaneous angioplasty« CORRECT ANSWER. Short segment superficial femoral artery (SFA) occlusions are usually very amenable to angioplasty, and restoration of distal circulation is likely to allow the necrotic ulcer to heal with close supervision.

Scenario 2 A 60-year-old man is found to have a right iliac aneurysm at angiography. However, during the procedure the aneurysm is ruptured by the guidewire. The patient becomes hypotensive B - Femoropopliteal bypass graft« YOUR ANSWER D - Endovascular stent graft « CORRECT ANSWER.

There is already a catheter sheath in place, and a straight covered stent graft is kept close to hand in such procedures for exactly this reason. Scenario 3 Angiography of a 56-year-old male shows disease involving a long segment of the SFA on the same side as a foot with a gangrenous-looking toe. C - Emergency aortoiliac bypass graft« YOUR ANSWER B - Femoropopliteal bypass graft« CORRECT ANSWER. Traditionally a femoropopliteal bypass would be considered but long-segment occlusions of SFA with good distal run-off, and also popliteal artery are being treated with endovascular stenting. The foot is likely to still be viable and non-resolving digital gangrene may require only local amputation.



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Scenario 4 A 35-year-old male involved in a road traffic accident has a grossly comminuted compound fracture of his right tibia with no distal pulses felt. His lower leg and foot are very cold to feel and white. He is otherwise stable but in a lot of pain. D - Endovascular stent graft « YOUR ANSWER E - Below-knee amputation« CORRECT ANSWER This difficult case shows a non-salvageable lower limb which if left will only become necrotic, gangrenous and cause much more life-threatening problems. It is literally life or limb and, by deciding early, the level of amputation can be restricted to below knee. 15. Theme: type of intervention A Best medical treatment and exercise B Angioplasty and stenting C Aorto-bifemoral graft D Axillo-bifemoral graft E Amputation. For each of the patients below, choose the most appropriate management from the list above. Each option may be selected once, more than once or not at all. Scenario 1 A 60-year-old patient; no significant past medical history; bilateral rest pain; complete occlusion of both common iliac and external iliac arteries A - Best medical treatment and exercise« YOUR ANSWER C - Aorto-bifemoral graft« CORRECT ANSWER Scenario 2 An 82-year-old patient; bed-bound secondary to right-sided cerebro-vascular accident; extensive gangrene of right foot; complete occlusion of both common and external iliac arteries B - Angioplasty and stenting« YOUR ANSWER E - Amputation« CORRECT ANSWER Scenario 3 A 79-year-old patient; history of coronary heart disease and impaired renal function; bilateral gangrenous toes; complete occlusion of both common iliac and external iliac arteries C - Aorto-bifemoral graft« YOUR ANSWER D - Axillo-bifemoral graft« CORRECT ANSWER Scenario 4 A 70-year-old patient; sedentary life style; claudicates at 400 yards; short occlusions of both common iliac arteries D - Axillo-bifemoral graft« YOUR ANSWER A - Best medical treatment and exercise« CORRECT ANSWER Scenario 5 A 79-year-old patient; enthusiastic golfer; claudicates at 100 yards; short occlusions of both common iliac arteries E - Amputation« YOUR ANSWER B - Angioplasty and stenting« CORRECT ANSWER Patients with claudication do not require radiological/surgical intervention unless it interferes with their life style and they are willing to accept the small but significant risks associated with the procedures involved. Iliac angioplasty/stenting does achieve very good results with low complication rates in those patients with short



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occlusions. Patients with critical limb ischaemia require revascularisation to prevent them from losing their leg in the near future. What they are offered depends on the length of the occlusion (surgery vs angioplasty) and on their level of fitness (aortic vs extra-anatomical bypass). Patients who are unlikely to walk in the future may be better managed with a primary amputation. 16. The medical team ask you to review a patient on the ward who has developed a swollen painful pale oedematous leg. Looking through the notes you see the patient was diagnosed with a deep vein thrombosis last week. Pulses are present. Which is the likely diagnosis? Select one answer only.

Atherosclerotic Ischaemia« YOUR ANSWER

Deep Vein Thrombosis

LymphodemaTarda

Phlegmasia Alba Dolens« CORRECT ANSWER

Phelgmasia Cerulea Dolens. This condition is related to extensive complicated deep vein thrombosis. The deep venous system is totally occluded and must rely on the superficial venous system. However, this superficial system is now under pressure of high flow from the arterial system which leads to a painful oedematous white leg (‘alba’ meaning white). If this progresses all venous outflow is occluded leading to cerulean dolens – here the arterial supply is impeded and ischaemia and gangrene occur. Thrombolysis is an effective treatment but needs to be undertaken with caution. 17. Theme: Vascular A Computed tomography (CT) B Carotid Doppler ultrasonography C Transthoracic echocardiogram D Carotid angiogram. What initial investigation would you perform for each of the clinical scenarios below? Each option may be used once, more than once, or not at all. Scenario 1 A 71-year-old man with left carotid bruit and normal pulse and left transient ischaemic attacks (TIAs). A - Computed tomography (CT)« YOUR ANSWER B - Carotid Doppler ultrasonography« CORRECT ANSWER Scenario 2 A 71-year-old man with left carotid bruit and normal pulse plus a dense left hemiplegia. B - Carotid Doppler ultrasonography« YOUR ANSWER A - Computed tomography (CT)« CORRECT ANSWER

Thirty per cent of carotid bruits heard on auscultation are not due to carotid stenosis. The initial

investigation that should be performed is a Doppler ultrasound scan in patient 1. In cases where a

persistent neurological deficit has occurred a CT scan must be carried out initially to exclude a space-

occupying lesion.

18. Theme: The swollen lower limb A Angio-oedema B Congestive cardiac failure



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C Chronic renal failure D Chronic liver failure E Chronic venous insufficiency F Deep venous thrombosis G Factitious oedema H Klippel–Trenaunay syndrome I Malabsorption J Malnutrition K Milroy’s disease L Obesity M Primary lymphoedema N Secondary lymphoedema O Venous obstruction. The following patients all present with swelling affecting the lower limb. From the list above, select the most likely diagnosis. The items may be used once, more than once, or not at all. Scenario 1 A 21-year-old woman is referred to clinic with a history of intermittent oedema of the face and extremities. Her mother also suffers with similar symptoms. A - Angio-oedema« CORRECT ANSWER

Hereditary angio-oedema is inherited as an autosomal dominant condition. It arises as a result of a deficiency in the complement system regulation, and is characterised by recurrent attacks of swelling of the face and extremities that subsequently resolve. The oedema is often associated with erythema.

Scenario 2 A 14-year-old boy is referred to clinic for assessment of varicose veins and associated swelling of his left leg. As he enters the consultation room you note that he has a ‘short-leg’ gait. His varicose veins are large and do not lie in a typical distribution. B - Congestive cardiac failure« YOUR ANSWER H - Klippel–Trenaunay syndrome« CORRECT ANSWER This syndrome is characterised by dilated veins, associated with bony and soft tissue deformity, elongation of the limb, capillary naevi and limb oedema. There are no arterial abnormalities. The diagnosis is suggested as varicose veins are present since birth or early childhood, and are often present on the outside of the leg, not the inner side where most varicose veins appear. Scenario 3 A 48-year-old woman presents with a history of unilateral swelling of the right leg. There is no history of venous obstruction. Her general practitioner has sent copies of recent full blood counts, urea & electrolytes, and liver function tests, all of which are normal. Isotope lymphography demonstrates delayed transit of radionuclide on the right side. E - Chronic venous insufficiency« YOUR ANSWER M - Primary lymphoedema« CORRECT ANSWER Primary lymphoedema may be classified as:

1. congenital – when it occurs soon after birth (and is hereditary in some cases; Milroy’s disease) 2. praecox – presenting up to the age of 35 years 3. tarda – when it presents over the age of 35 years, as in this case.

It has been suggested that these groups represent different parts of the same spectrum of disease, which has been attributed to aplasia, hypoplasia, or hyperplasia of the lymph vessels. Once other causes of oedema have been excluded, the diagnosis of primary lymphoedema may be confirmed



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using isotope lymphography, computed tomography scanning, magnetic resonance imaging, or contrast lymphangiography. The aims of treatment are to reduce limb swelling and weight, reduce the risk of infection, and improve function. This may be achieved using conservative measures (elevation/compression of affected limb). Surgical intervention involves debulking (of excess skin and subcutaneous tissue) or bypass procedures (where regional blockade of lymphatics is evident).

Lymphoedema is an accumulation of tissue fluid secondary to a fault in the lymphatic system

(abnormalities of lymph formation or lymph clearance). This may be primary, in the absence of other

causes, or secondary to malignant disease, surgery (eg post-radical mastectomy/groin dissection),

radiotherapy or infection (filariasis, pyogenic tuberculosis). The differential diagnosis of

lymphoedema includes other causes of tissue oedema, which may be broadly classified as:

1. systemic disorders, eg cardiac/renal/liver failure, hereditary angiooedema, etc 2. venous disorders, eg post-thrombotic syndrome, extrinsic compression

(pregnancy/tumour/retroperitoneal fibrosis), Klippel–Trenaunay syndrome 3. miscellaneous disorders, eg arteriovenous malformations, factitious oedema etc.

19. Theme: Lower limb venous disease A Elevation, non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics B Urgent surgery C Low molecular weight heparin D Compression bandaging E Treatment with warfarin. For each of the patients described below, select the most likely treatment from the list of options above. Each option may be used once, more than once or not at all. You may believe that more than one treatment is possible but you should choose the ONE most likely treatment. Scenario 1 A 54-year-old woman with thrombosed varicose veins and cellulitis. A - Elevation, non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics« CORRECT ANSWER Elevation, non-steroidal anti-inflammatory drugs (NSAIDs) and antibiotics In a patient with thrombosed varicose veins and cellulitis, the treatment should be elevation, rest, NSAIDs and antibiotics. Scenario 2 A 49-year-old lady, 5 days post-left hip replacement, with a swollen, red and tender left leg. B - Urgent surgery« YOUR ANSWER C - Low molecular weight heparin« CORRECT ANSWER In patients with a high clinical suspicion of DVT, therapeutic low molecular weight heparin should be commenced, and urgent imaging (e.g. venous duplex imaging) should be organised. Scenario 3 A 70-year-old man with long history of venous ulcer over the medial malleolus. C - ILow molecular weight heparin« YOUR ANSWER D - Compression bandaging« CORRECT ANSWER A 70-year-old man with a poorly healing venous ulcer should be treated with appropriate compression bandaging. Scenario 4



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A 64-year-old woman, with known history of venous insufficiency, presents with hypotension and profuse bleeding from the medial malleolus of her right leg. D - Compression bandaging« YOUR ANSWER B - Urgent surgery« CORRECT ANSWER A patient with venous insufficiency with profuse bleeding from an engorged vein (long saphenous vein in this case) should have urgent surgery to stop the bleeding. 20. Theme: Lower limb ischaemia A Angioplasty B Aortofemoral bypass graft C Correct the risk factors and provide conservative treatment D Femoropopliteal bypass graft E Surgical embolectomy. Select the most appropriate option above for the treatment of the patients below. Each option may be used once, more than once, or not at all. Scenario 1 A 55-year-old man presents with a sudden onset of severe pain in his left foot and calf. There is no preceding history of intermittent claudication but he experienced a myocardial infarction two weeks ago. He is unable to move his foot, which is now mottled and cold. There are absent pulses below his left knee but a palpable femoral pulse. ECG reveals Q waves with sinus rhythm. A - Angioplasty« YOUR ANSWER E - Surgical embolectomy« CORRECT ANSWER. The first patient is likely to have had a mural thrombus post MI that has embolised to his leg. He may also have been in atrial fibrillation previously. As he has acute limb ischaemia, surgical embolectomy is indicated. Scenario 2 A 75-year-old man presents to the outpatient clinic with right buttock and thigh pain when walking 100 yards. He smokes 30 cigarettes per day and has a poor cardiac history (three previous MIs, hypertension and left ventricular failure). Ankle brachial Doppler pressure ratio in the right leg is 0.3 and that on the left 0.6. An arteriogram shows an isolated 3 cm 80% stenosis in the right common iliac artery with good run-off. There is evidence of 40% stenosis in the left superficial femoral artery with well-developed collaterals. His symptoms have persisted despite best medical care. B - Aortofemoral bypass graft« YOUR ANSWER A - Angioplasty« CORRECT ANSWER. Angioplasty is useful for short stenoses. This has better results for proximal stenosis above the inguinal ligament. For occluded vessels the procedure is now possible in specialist centres using cutting-balloon or subintimal angioplasty techniques. Scenario 3 A 65-year-old man presents with pain in his foot when at rest. He has given up smoking and is otherwise fit and well. Angiography shows a 10-cm block in the superficial femoral artery with good distal run-off. C - Correct the risk factors and provide conservative treatment« YOUR ANSWER D - Femoropopliteal bypass graft« CORRECT ANSWER A patient with rest pain has critical ischaemia and needs urgent intervention. A 10-cm stenosis is too long for a successful angioplasty. A good distal run-off would allow distal bypass grafting. The SFA is



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the commonest site for lower limb atherosclerosis because the vessel narrows as it passes through the adductor hiatus. 21. Theme: Carotid artery disease A Carotid angiography B Carotid duplex C CT head D MRI head E Right carotid endarterectomy F Left carotid endarterectomy. For each of the patients described below, select the most likely intervention from the list of options above. Each option may be used once, more than once, or not at all. Scenario 1 A patient has resolving right-sided hemiplegia following a CVA. A carotid duplex shows 99% stenosis of the left internal carotid artery and a completely occluded right internal carotid artery. A - Carotid angiography« YOUR ANSWER F - Left carotid endarterectomy« CORRECT ANSWER

Scenario 2 A 30-year-old patient with optic neuritis develops foot drop. B - Carotid duplex« YOUR ANSWER D - MRI head« CORRECT ANSWER Scenario 3 A resolving recent left-sided hemiparesis with 90% right internal carotid artery stenosis. C - CT head« YOUR ANSWER E - Right carotid endarterectomy« CORRECT ANSWER

Patients with carotid territory TIAs, amaurosis fugax or a stroke (with subsequent recovery), and a >

70% stenosis should be offered endarterectomy. The risks of the operation are less than the risk of

suffering a disabling stroke, providing the operation is performed within 6 months of the stroke.

Endarterectomy should carry a mortality of < 2%, and a 1-2% risk of stroke. It is normally too late to

operate on completely occluded arteries. Patients with lesser degrees of stenosis should be given

antiplatelet drug therapy. A young patient with optic neuritis and foot drop should first have an MRI

scan of the brain to look for demyelinating disease.

22. A 15-year-old girl attends the vascular clinic with recent right leg swelling. On examination she has confluent swelling to the thigh with pitting oedema. Examination of the groin and abdomen is unremarkable, as is ultrasound of the abdomen and groin. Lymphatic abnormality was seen on lymphoscintigraphy. Which is the likely diagnosis? Select one answer only.

Kippel-Trenaunay Syndrome« YOUR ANSWER

Lymphoedema Praecox« CORRECT ANSWER

LymphodemaTarda

Milroy Disease

Secondary Lymphoedema.



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This is primary lymphoedema that occurs after puberty and before the age of 35 years. It is more

common in females than males. It is the recent diagnosis in the 15 year old female which makes this

diagnosis most likely in this female along with any obvious aetiology. Kippel-Trenaunay Syndrome

causes limb hypertrophy - characterised with a capillary haemangioma, venous malformations and

varicosities that can be superficial or deep involving muscle, bone and viscera and limb abnormalities

with limb lengthening.Lymphoedema Praecox, Tarda and Milroy Disease are all example of primary

lymphoedema. Milroy is congentiallymphoedema. Praecox occurs before the age of 35 and usually

around puberty. Tarda is primary lymphoedema occurring after the age of 35. Secondary

lymphoedema occurs as a consequence of another aetiology or surgery.

23. You are called to see an 8-year-old girl admitted overnight following an emergency open reduction and internal fixation of her right supracondylar fracture. She is complaining of severe pain and tingling in her right hand. On examination there is pain on passive flexion of the hand. Which is the likely diagnosis? Select one answer only.

Arteriovenous Malformation« YOUR ANSWER

Axillary Vein Thrombosis

Axillary Artery Aneurysm

Compartment Syndrome« CORRECT ANSWER

Secondary Lymphoedema. This occurs when tissue pressure in a closed muscle compartment is greater than the perfusion

pressure and leads to muscle and nerve ischemia. This can readily occur after supracondylar

fractures. Passive flexion of the muscle induces pain is a reliable sign. Pressure in the compartment

must be released. In this case you must immediately split the hard plaster of paris cast to reduce the

pressure on the limb. However, if this does not help the symptoms, the patient would require an

urgentfasciotomy to release the muscle compartment pressure. Serious consequences arise if

compartment syndrome is missed with necrosis of the nerve and muscles resulting in ischaemic

contractures – in the upper limb this is classically Volkmann’s Ischemic Contracture.

24. A 64-year-old smoker attends for review due to intermittent pain in the back of the right calf on walking. After 30 yards she needs to stop and rest to ease the pain. Which is her likely ABPI value? Select one answer only.

>1« YOUR ANSWER

1

0.95 – 0.5« CORRECT ANSWER

0.5 – 0.3

<0.2. This patient has intermittent claudication. Ankle Brachial Pressure Index (ABPI) aids assessment of

peripheral arterial disease and aids the assessment of severity in the legs.

ANKLE BP systolic / Brachial BP Systolic = ABPI >1 common in diabetic patients due to calcified

arteries obscuring the true result so is unreliable.



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1. 1 Normal

2. 0.95 -0.5 Intermittent Claudication

3. 0.5 -0.3 Rest Pain

4. <0.2 Gangrene.

25. Theme: ankle brachial pressure index (ABPI) A 1.1 B 0.7 C 0.4 D 0.1 E Incompressible. For each of the patients below, choose the most likely ABPI value from the list above. Each option may be selected once, more than once or not at all. Scenario 1 Walks unlimited distances A - 1.1« CORRECT ANSWER. Scenario 2 Poorly controlled diabetic with Charcot ankle arthropathy B - 0.7« YOUR ANSWER E - Incompressible« CORRECT ANSWER. Scenario 3 Claudicates at 200 yards C - 0.4« YOUR ANSWER B - 0.7« CORRECT ANSWER. Scenario 4 Rest pain both day and night, as well as gangrene of the first and second toes D - 0.1« CORRECT ANSWER. Scenario 5 Rest pain at night but no ulcers or gangrene E - Incompressible« YOUR ANSWER C - 0.4« CORRECT ANSWER.

Clinical presentation: ankle brachial index· normal > 0.90· claudication 0.50–0.90· rest pain 0.21–0.49·

tissue loss < 0.20

> 1.25, commonly seen in diabetics.

26. A 79-year-old woman presents with an ulcer over the medial aspect of her lower right leg. Although she has had this for months, recently it has become increasingly painful. The edges of the ulcer have become raised and thickened. What is the most likely diagnosis? Select one answer only.

Marjolin’s Ulcer« YOUR ANSWER

Post-Phlebitic Ulcer

Traumatic Ulcer

Vascular Ulcer



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Vasculitic Ulcer. This is a Marjolin’s Ulcer, in which a chronic venous ulcer has undergone malignant change. This is a

type of squamous cell carcinoma and is diagnosed by the description of change in a longstanding

ulcer that is tender with thickened edges. Diagnosis is by biopsy.

27. Theme: 5-year graft patency rates A Aortobifemoral graft B Axillofemoral graft C Femoral–femoral crossover graft D Femoropopliteal PTFE graft patency (below knee) E Reversed vein femoropopliteal graft. For each of the percentages below, select the most likely single graft from the options listed above. Each option may be used once, more than once, or not at all. Scenario 1 70% A - Aortobifemoral graft« YOUR ANSWER E - Reversed vein femoropopliteal graft« CORRECT ANSWER. Scenario 2 80% B - Axillofemoral graft« YOUR ANSWER C - Femoral–femoral crossover graft« CORRECT ANSWER. Scenario 3 60% C - Femoral–femoral crossover graft« YOUR ANSWER B - Axillofemoral graft« CORRECT ANSWER. Scenario 4 35% D - Femoropopliteal PTFE graft patency (below knee)« CORRECT ANSWER. Scenario 5 90% E - Reversed vein femoropopliteal graft« YOUR ANSWER A - Aortobifemoral graft« CORRECT ANSWER.

Patency rates are related to the force and volume of the inflow and the runoff away from the graft. If

the run-off is poor then blood that passes into the graft will be functionless; therefore, flow will be

greatly reduced so leading to graft occlusion and failure. Synthetic grafts used below the inguinal

ligament are vastly inferior to vein grafts.

28. The medical team ask for a vascular opinion on a 62 year old woman who has lower limb ulceration and a persistent cough. On examination, multiple ulcerations that are irregular, friable with an undermined edge and a bluish tinge are seen on both lower limbs. Pulses are present. CXR shows a cavitational lesion in the right upper lobe. What is the likely aetiology of these ulcers? Select one answer only.

Arterial « YOUR ANSWER



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Infective« CORRECT ANSWER

Post-Phlebitic

Vasculitis

Venous. This patient has Tuberculosis. Usually respiratory or bone disease is concurrent. The description of the ulcers are typical for tuberculous ulceration. 29. Theme: medications used in those patients with peripheral vascular disease. A Cilostazol B Aspirin C Clopidogrel D Simvastatin E Losartan. For each of the statements below, choose the most appropriate drug from the list above. Each option may be selected once, more than once or not at all. Scenario 1 Angiotensin–II receptor antagonist A - Cilostazol« YOUR ANSWER E - Losartan« CORRECT ANSWER. Scenario 2 Stabilises atheromatous plaque B - Aspirin« YOUR ANSWER D - Simvastatin« CORRECT ANSWER. Scenario 3 Reduces serum levels of LDL cholesterol C - Clopidogrel« YOUR ANSWER D - Simvastatin« CORRECT ANSWER. Scenario 4 Cyclo-oxygenase inhibitor D - Simvastatin« YOUR ANSWER B - Aspirin« CORRECT ANSWER. Scenario 5 Phosphodiesterase inhibitor E - Losartan« YOUR ANSWER A - Cilostazol« CORRECT ANSWER.

Aspirin inhibits prostaglandin synthesis to prevent the formation of platelet-aggregating substance

thromboxane A2. Clopidogrel blocks the adenosine phosphate (ADP) receptors, which prevents

fibrinogen binding to the receptor. These decrease the ability of platelet adhesion and aggregation.

Simvastatin and the other statins reduce cholesterol biosynthesis, mainly in the liver, where they are

selectively distributed, by inhibiting HMG–CoA reductase. Cilostazol is said to be a

phosphodiesterase inhibitor. This increases the levels of cyclic AMP thereby decreasing platelet



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function, relaxing vascular smooth muscle and increasing lipoprotein lipase activity. It is

contraindicated in those patients with ischaemic heart disease.

30. Theme: Lower limb ischaemia A Surgical embolectomy B Femoral–popliteal bypass graft C Angioplasty D Correct risk factors and conservative management E Aorta–femoral bypass graft. Select the most appropriate option above for the treatment of the patients below. Each option may be used once, more than once or not at all. Scenario 1 A 55-year-old man presenting with a sudden onset of severe pain in his left foot and calf. There is no preceding history of intermittent claudication. He is unable to move his foot which is now mottled and cold. There are absent pulses below his left knee but a palpable femoral pulsation. Electrocardiogram (ECG) reveals Q waves with sinus rhythm. A - Surgical embolectomy« CORRECT ANSWER. In the absence of precipitating factors this gentleman has probably dislodged a proximal embolus which is now blocking the popliteal artery. He may have had a paroxysm of AF which has now resolved. The treatment of choice is a surgical embolectomy and anticoagulation. Scenario 2 A 75-year-old man presents to the outpatient clinic with right buttock and thigh pain after walking 100 yards. He is a smoker of 30 cigarettes per day with poor cardiac history (3 previous MIs, hypertension and left ventricular failure). Ankle brachial Doppler pressure ratio in the right leg is 0.3 and that on the left 0.6. Arteriogram shows an isolated 3 cm 80% stenosis in the right common iliac artery with good run-off. There is evidence of 40% stenosis in the left superficial femoral artery with well-developed collaterals. His Symptoms have persited despite lifestyle modification. C - Angioplasty« CORRECT ANSWER. As this gentleman has good distal run, off, a short segment stenosis, multilevel disease and intermittent claudication, angioplasty is the treatment of choice in the first instance. If this doesn’t work he may have to proceed to bypass grafting. In either event he should be counselled strongly to stop smoking and start an appropriate anti-platelet agent. Scenario 3 A 65-year-old man has been admitted to the emergency department; when you see him he presents with pain in his foot while at rest. Investigation reveals 10 cm (superficial femoral artery (SFA) block. The patient has given up smoking and on examination has a good constitution and is otherwise fit and well. B - Femoral–popliteal bypass graft« CORRECT ANSWER. This gentleman has critical ischaemia with a long segment stenosis. A fem-pop bypass would be in his best interests. 31. Theme: Varicose veins A Compression and warfarin B Elevation and NSAIDs



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C LMW heparin D Varicose vein surgery. For each of the patients described below, select the most likely intervention from the list of above options. Each option may be used once, more than once, or not at all. Scenario 1 A 54-year-old man presents with varicose veins and a bleeding varicose ulcer. A - Compression and warfarin« YOUR ANSWER D - Varicose vein surgery« CORRECT ANSWER. Varicose veins must be dealt with surgically if they are suspected of causing an ulcerating lesion that is bleeding intermittently – this should be done promptly. Scenario 2 A 30-year-old woman presents with varicose veins and an acute episode of thrombophlebitis. B - Elevation and NSAIDs« CORRECT ANSWER. Episodes of thrombophlebitis are best treated by elevation, analgesics (NSAIDs are useful) and external elastic support. Scenario 3 A 45-year-old woman presents with varicose veins and a swollen leg. Duplex confirms a DVT. C - LMW heparin« CORRECT ANSWER. On confirmation of a DVT, patients should be started on LMW heparin as soon as possible assuming there are no contraindications. This is continued until warfarin therapy can be instigated and made theraputic. Warfarin therapy aims to prevent the formation of clots; heparin aims to prevent their propagation and dispersal. 32. Theme: Investigation of carotid artery disease A Carotid angiography B CT scan of head C Duplex Doppler ultrasound of carotid arteries D Magnetic resonance angiography (MRA) E Near-infrared spectroscopy F Transcranial Doppler ultrasound. From each of the statements below, select the most appropriate investigation from the above list. Each option may be used once, more than once, or not at all. Scenario 1 What should be the initial investigation in a 65-year-old man presenting with an episode of amaurosis fugax affecting his right eye? B - CT scan of head« YOUR ANSWER C - Duplex Doppler ultrasound of carotid arteries« CORRECT ANSWER. Duplex Doppler ultrasound of the carotid arteries is the initial investigation of choice for carotid stenosis. It is the quickest and safest investigation for amaurosis fugax. Subsequently, carotid angiography (digital subtraction angiography) or MRA may be used to confirm the duplex findings. Scenario 2



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Which is the most appropriate investigation for a 28-year-old woman who collapses with a possible dense, right-sided stroke? A - Carotid angiography« YOUR ANSWER B - CT scan of head« CORRECT ANSWER. The 28-year-old with the dense stroke is most likely to have had an intracranial bleed necessitating a CT of the brain. Scenario 3 Which is the most appropriate procedure for intraoperative monitoring during carotid endarterectomy? C - Duplex Doppler ultrasound of carotid arteries« YOUR ANSWER F - Transcranial Doppler ultrasound« CORRECT ANSWER. Transcranial Doppler measures the flow in the middle cerebral artery and is thus useful in the intraoperative monitoring and investigation of postendarterectomy neurological episodes. Duplex Doppler would also demonstrate patency of the carotid artery following endarterectomy. Nearinfrared spectroscopy measures intracerebral blood flow but is not currently used for intraoperative monitoring. 33. Theme: Lower limb ischaemia A Femoropopliteal bypass B Percutaneous balloon angioplasty C Femorodistal bypass D Below knee amputation E Tissue plasminogen activator infusion (intra-arterial) F Fasciotomy G No treatment but recommend lifestyle changes. For each of the presentations below, select the most likely single treatment from the options listed above. Each option may be used once, more than once or not at all. Scenario 1 A 73-year-old diabetic woman presents with critical ischaemia of the right lower leg. Angiography reveals extensive disease of the superficial femoral, popliteal and tibial arteries. Pulse-generated run-off assessment indicates a good run-off in the posterior tibial artery. A - Femoropopliteal bypass« YOUR ANSWER C - Femorodistal bypass« CORRECT ANSWER.

Femorodistal bypass using an autogenous vein graft is the treatment of choice in this patient. The absence of images of the posterior tibial, anterior tibial and common peroneal arteries on angiography films must not be accepted as evidence of their occlusion. Scenario 2 A 72-year-old man presents with a 4-h history of acute ischaemia of the left leg. Clinical examinations demonstrate signs of acute ischaemia with no evidence of gangrene. There is no neurological deficit. An urgent angiogram reveals a complete occlusion of the distal superficial femoral artery probably due to thrombosis. B - Percutaneous balloon angioplasty« YOUR ANSWER E - Tissue plasminogen activator infusion (intra-arterial)« CORRECT ANSWER.

Intra-arterial thrombolysis with tissue plasminogen activator (TPA) or streptokinase is the treatment of choice in this patient in view of the short history (4 h), absence of neurological deficit and angiographic findings.



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Scenario 3 A 57-year-old smoker presents with intermittent claudication of the right calf. The claudication distance is 70 m. Angiography reveals a 12 cm stenosis in the proximal superficial femoral artery with adequate distal run-off present. C - Femorodistal bypass« YOUR ANSWER G - No treatment but recommend lifestyle changes« CORRECT ANSWER BMT and lifestyle. This is single level disease and femoro-distal is not indicated. Femoro-popliteal or angioplasty are options but are unlikely to be popular at this stage. Scenario 4 A 21-year-old motorcyclist presents with multiple injuries following a road traffic accident. Clinical examination reveals a critically ischaemic right lower leg. The right dorsalis pedis pulse is feeble. The right calf is tense and swollen. The intracompartmental pressure is 55 mmHg. Angiography shows no discontinuity of the arterial tree. D - Below knee amputation« YOUR ANSWER F - Fasciotomy« CORRECT ANSWER This patient has the compartment syndrome. Urgent fasciotomy is indicated in order to save his right leg. 34. A worried mother brings her child to see you. He has just started walking and she has noticed that he has a gait abnormality as his right leg appears longer than the other. He has prominent varicosities on his right leg and a bluish ‘port-wine stain’ on his face. What is the likely diagnosis? Select one answer only.

Deep Vein Thrombosis« YOUR ANSWER

Kippel-Trenaunay Syndrome« CORRECT ANSWER

Milroy Disease

Popliteal Aneurysm

Secondary Lymphoedema. The aetiology of this condition is unknown characterised with a capillary haemangioma, venous malformations and varicosities that can be superficial or deep involving muscle, bone and viscera and limb abnormalities with limb lengthening or limb hypertrophy. Treatment is symptomatic.

35. Theme: Vascular procedures to the carotid artery

A Right carotid endarterectomy

B Left carotid endarterectomy

C Right carotid artery stenting

D Left carotid artery stenting

E No surgical/endovascular intervention.

For each of the scenarios below, choose the most appropriate treatment option from the list above.

Each option may be selected once, more than once or not at all.

Scenario 1 An 85-year-old patient has no symptoms and a 90% stenosis of the left and a 40% stenosis of the right internal carotid artery. A - Right carotid endarterectomy« YOUR ANSWER



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E - No surgical/endovascular intervention« CORRECT ANSWER Carotid endarterectomy is indicated for patients with a symptomatic (ie transient ischaemic attack [TIA] or amaurosis fugax) > 70% stenosis of an internal carotid artery. With regard to asymptomatic but significant internal carotid artery stenosis, a recent randomised trial has shown that surgery will reduce the risk of stroke from around 12% to 6% over a 5-year period. Most surgeons would therefore not operate on patients with asymptomatic stenosis who are 80 years of age or older. Carotid stenting is still an experimental procedure and its use is confined to randomised clinical trials; previous series have shown an unacceptably high stroke rate with carotid stenting compared with surgery. Scenario 2 An 80-year-old patient complains of amaurosis fugax in the left eye with an 80% stenosis of the right and a 50% stenosis of the left internal carotid artery. B - Left carotid endarterectomy« YOUR ANSWER E - No surgical/endovascular intervention« CORRECT ANSWER In this case, the symptoms are not in the territory of the significantly stenosed carotid artery. It is important to remember that amaurosis fugax (transient, sudden loss of vision) should occur on the same side as the significantly diseased artery, whilst sensory or motor loss in the limbs should occur contralateral to the diseased artery. Scenario 3 A 60-year-old patient has no significant past medical history and a 90% stenosis of the left and a 60% stenosis of the right internal carotid artery. C - Right carotid artery stenting« YOUR ANSWER E - No surgical/endovascular intervention« CORRECT ANSWER

Current guidelines (National Clinical Guideline for Stroke, 4th ed, 2012, Royal College of Physicians) dictate the following for asymptomatic carotid artery stenosis:

1. Screening for asymptomatic carotid stenosis should not be performed. 2. Surgery or angioplasty/stenting for asymptomatic carotid artery stenosis should not routinely

be performed unless as part of a randomised trial. 3. Carotid endarterectomy or stenting should not be performed routinely in patients with

asymptomatic carotid stenosis prior to coronary artery surgery. Scenario 4 A 72-year-old patient complains of recurrent episodes of loss of function of the left upper limb lasting for a few minutes to an hour with 90% stenosis of both internal carotid arteries. D - Left carotid artery stenting« YOUR ANSWER A - Right carotid endarterectomy« CORRECT ANSWER

In this case, the 90% stenosis of the right carotid artery correlates with recurrent transient loss or impairment of function in the contralateral (left) upper limb. Since symptoms that correlate with significant impairment of the left carotid artery are not being experienced, most surgeons would consider it appropriate, in a patient of this age, to carry out endarterectomy of the right carotid artery only. Scenario 5 A 79-year-old patient has made a good recovery from a right-sided cerebrovascular accident and has been found to have a complete occlusion of the right and a 40% stenosis of the left internal carotid artery. E - No surgical/endovascular intervention« CORRECT ANSWER When assessing patients for carotid surgery, it is important to make sure that their symptoms correlate with the significantly stenosed side. This is not the case in this patient. Carotid



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endarterectomy is performed to prevent stroke secondary to embolisation for carotid plaque. If the artery is occluded, there is no flow and there can therefore be no embolisation. Surgery is thus not indicated for occluded internal carotid arteries. 36. Theme: Vascular tumours A Angiosarcoma B Chemodectoma C Leiomyomas D Glomus jugulare tumour E Kaposi’s sarcoma. Match the most appropriate feature above with the list below. Each option may be used once, more

than once, or not at all.

Scenario 1 Carotid artery B - Chemodectoma« CORRECT ANSWER. B – Chemodectoma: Chemodectomas originate from paraganglionic cells at the carotid bifurcation. If untreated, 5% metastasise within 10 years. Scenario 2 Rapid growing, bulky A - Angiosarcoma« CORRECT ANSWER. Angiosarcomas usually develop in the extremities. Although they are radiosensitive and respond to chemotherapy, radical amputation is still advised. Scenario 3 Blue-red macule with HIV C - Leiomyomas« YOUR ANSWER E - Kaposi’s sarcoma« CORRECT ANSWER A Kaposi’s sarcoma is a haemangiosarcoma, treated with a combination of chemo- and radiotherapy. Scenario 4 Buzzing sensation in head D - Glomus jugulare tumour« CORRECT ANSWER A glomus jugulare tumour arises at the jugular bulb. Excision is associated with palsies of cranial nerves X, XI and XII. It should not be confused with a glomus tumour, which is the only true benign blood vessel tumour (cavernous haemangiomas are dilated blood spaces with thin walls, and port-wine stains/telangiectasias are capillary malformations). Most glomus tumours occur on the upper limbs, especially the digits. 37. Theme: Lower limb ischaemia A Below-knee amputation B Fasciotomy C Femorodistal bypass D Femoropopliteal bypass E Lifestyle changes only F Percutaneous balloon angioplasty



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G Tissue plasminogen activator (TPA) infusion (intra-arterial). For each of the presentations below, select the most likely single treatment from the options listed above. Each option may be used once, more than once, or not at all. Scenario 1 A 65-year-old man presents with intermittent claudication of the left calf. His claudication distance is 50 yards (~45 m). Angiography demonstrates a 1.5-cm stenosis of the left superficial femoral artery. A - Below-knee amputation« YOUR ANSWER F - Percutaneous balloon angioplasty« CORRECT ANSWER

Percutaneous balloon angioplasty is particularly suitable for localised stenoses and short occlusions. Lesions in the larger proximal vessels (above knee) are technically easier to treat, with fewer complications and better long-term results. Scenario 2 A 73-year-old diabetic presents with critical ischaemia of the right lower leg. Angiography reveals extensive disease of the superficial femoral, popliteal and tibial arteries. Pulse-generated, run-off assessment indicates a good run-off in the posterior tibial artery. B - Fasciotomy« YOUR ANSWER C - Femorodistal bypass« CORRECT ANSWER Femorodistal bypass using an autogenous vein graft is the treatment of choice in the second patient. Absence of contrast in the posterior tibial, anterior tibial and common peroneal arteries on angiography films must not be accepted as evidence of their occlusion. Scenario 3 A 72-year-old man presents with a 4-hour history of acute ischaemia of the left leg. Clinical examination demonstrates signs of acute ischaemia with no evidence of gangrene, mottling or neurological deficit. An urgent angiogram reveals a complete thrombotic occlusion of the distal superficial femoral artery. C - Femorodistal bypass« YOUR ANSWER G - Tissue plasminogen activator (TPA) infusion (intra-arterial)« CORRECT ANSWER.

Intra-arterial thrombolysis with TPA is the treatment of choice in the third patient in view of the short history (4 hours), angiographic findings and absence of neurological deficit. Scenario 4 A 57-year-old smoker has a history of intermittent claudication of his right calf. His claudication distance is 0.5 mile (~0.8 km). Angiography reveals a 12-cm stenosis in the proximal superficial femoral artery. This has had no effect on his lifestyle, work or social activities. D - Femoropopliteal bypass« YOUR ANSWER E - Lifestyle changes only« CORRECT ANSWER.

The initial treatment of intermittent claudication is correction of risk factors, such as diabetes, hypertension, smoking and exercise. Younger non-smokers should have a thrombotic screen performed on presentation. Critical ischaemia is defined by rest-pain of at least 2 weeks’ duration that requires regular adequate analgesia, or ulceration or gangrene of the foot or toes with an ankle pressure of < 50 mmHg or a toe pressure of < 30 mmHg. Scenario 5 A 21-year-old motorcyclist presents with multiple injuries following a road traffic accident. Clinical examination reveals a critically ischaemic right lower leg. The right dorsalis pedis pulse is weak. His right calf is tense and swollen. The intracompartmental pressure is 55 mmHg. Angiography shows no discontinuity of the arterial tree.



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E - Lifestyle changes only« YOUR ANSWER B - Fasciotomy« CORRECT ANSWER The fifth patient has compartment syndrome. Urgent fasciotomy is indicated in order to save his right leg. 38. Theme: The painful lower limb A Atherosclerosis B Buerger’s disease C Chronic venous insufficiency D Degenerative joint disease E Deep venous thrombosis F Embolus G Polymyalgia rheumatica H Polymyositis I Raynaud’s disease J Ruptured Baker’s cyst K Sciatica L Scleroderma M Septic arthritis N Superficial thrombophlebitis. From the list above, select the most likely diagnosis for the following patients who all present with pain in the lower limb. The items may be used once, more than once, or not at all. Scenario 1 A 32-year-old man with a long history of intravenous drug abuse attends The Emergency Department with a 4-h history of very severe pain in his left leg. On examination, the patient is in sinus rhythm. The limb is pale and cold compared to the other side, and only the femoral pulse is present. Pulses are normal contralaterally. A - Atherosclerosis « YOUR ANSWER F - Embolus « CORRECT ANSWER. The scenario describes several of the classic clinical features associated with acute limb ischaemia as a result of arterial embolism (pain, paraesthesia, paralysis, pale, perishing with cold, pulseless). An embolus is the passage of matter from one part of the circulation to another through a vascular lumen. The commonest sources of arterial emboli arise in the heart (thrombus in atrial appendage secondary to atrial fibrillation), from mural thrombus on a myocardial infarct, from aneurysms and atherosclerotic plaques. Peripheral emboli may also arise from the heart valves. Previously, acute endocarditis on a rheumatic heart valve was an important source, but is now rare. More commonly, peripheral emboli occur secondary to acute bacterial endocarditis after intravenous drug abuse with contaminated needles, as in the clinical case described. Scenario 2 A 54-year-old woman is referred to clinic with limb pain. She describes a dull ache that is worse at the end of the day, and that affects the right side more than the left. She has a past history of deep venous thrombosis. On examination, varicose veins are evident in the distribution of the long sapheous system, and there is brown pigmentation of the skin of the lower third of both legs. There is also a small ulcer superior to the medial malleolus. B - Buerger’s disease « YOUR ANSWER C - Chronic venous insufficiency « CORRECT ANSWER. Chronic venous insufficiency describes a spectrum of disease of the lower limb veins in which venous return is chronically impaired by reflux, obstruction, or calf pump failure. This results in sustained venous hypertension, which is associated with clinical complications such as oedema,



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eczema, lipodermatosclerosis and ulceration. Varicose veins are usually characteristic of this condition, and provide visual confirmation of venous reflux. However, the absence of visible varicose veins does not exclude the presence of significant superficial reflux. The pain associated with this condition tends to be worse following prolonged periods of standing (gravitational effects/calf pump not functional), and is relieved by rest and elevation of the affected limb. In the case described (and most commonly) the insufficiency is secondary to previous venous obstruction of the deep veins by thrombosis (DVT). Scenario 3 A 28-year-old man of Chinese origin with a history of calf pain induced by exercise presents to The Emergency Department with gangrene of the left great toe. He reports a history of preceding calf pain induced by exercise. He is a heavy smoker, but has no other risk factors for atherosclerosis. Examination reveals absent pedal pulses on the affected side. C - Chronic venous insufficiency « YOUR ANSWER B - Buerger’s disease « CORRECT ANSWER. Buerger’s disease (thromboangiitis obliterans) almost exclusively affects young men in their early 20s or 30s who are heavy smokers. It is particularly common in men of Jewish, Arab, Indian and Chinese origin. It has previously been considered as a variant of accelerated atherosclerosis but most now regard it as a separate disease process. It involves progressive obliteration of distal, medium-sized arteries of the lower limb, characterised by transmural round cell infiltration associated with intimal proliferation. Collagen is laid down around the vessels, encasing them in a thick fibrous coat. Patients usually present with distal gangrene, often preceded by a history of claudication. Popliteal pulses are usually preserved, but pedal pulses are absent. Arteriography shows normal proximal vessels and distal occlusions with ‘corkscrew’ collaterals. Biopsy of the occluded vessel provides histological confirmation of the diagnosis.

Editor: Dr Mohammed Shamsul Islam Khan

MBBS (CMC); FCPS-II (Neuro-Surgery)

Medical Officer, Clinical Neuro-Surgery

National Institute of Neuro-Sciences and Hospital

Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh.

Mobile: +880 1713 455 662, +880 1685 811979.

E-mail: [email protected]

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