Vascular surgery

Question 1

What is peripheral arterial disease

Answer 1

narrowing of the arteries supplying the limbs and the periphery, reducing the blood supply to these areas

Question 2

What are the three main patterns of presentation in patients with peripheral arterial disease?

Answer 2

• Intermittent claudication
• Critical limb ischaemia
• Acute limb-threatening ischaemia

Question 3

What are the features of acute limb ischaemia

Answer 3

6 P’s:
* Pallor
* Pulseless
* Pain
* Paralysis
* Paraesthesia
* “Perishing with cold”

Question 4

What is the initial investigation for Acute Limb-Threatening Ischaemia?

Answer 4

• Handheld arterial Doppler examination
• If Doppler signals are present, ankle-brachial pressure index (ABI) should be obtained

Question 5

What are factors suggesting a thrombus in Acute Limb-Threatening Ischaemia?

Answer 5

• Pre-existing claudication with sudden deterioration
• No obvious source for emboli
• Reduced or absent pulses in contralateral limb
• Evidence of widespread vascular disease (e.g., MI, stroke, TIA, previous vascular surgery)

Question 6

What are factors suggesting an embolus in Acute Limb-Threatening Ischaemia?

Answer 6

• Sudden onset of painful leg (< 24 hours)
• No history of claudication
• Clinically obvious source of embolus (e.g., AF, recent MI)
• No evidence of peripheral vascular disease (normal pulses in contralateral limb)
• Evidence of proximal aneurysm (e.g., abdominal or popliteal)

Question 7

What is the initial management of Acute Limb-Threatening Ischaemia?

Answer 7

• ABC approach
• Analgesia: IV opioids
• Intravenous unfractionated heparin
• Vascular review

Question 8

What are the definitive management options for Acute Limb-Threatening Ischaemia?

Answer 8

• Intra-arterial thrombolysis
• Surgical embolectomy
• Angioplasty
• Bypass surgery
• Amputation (for irreversible ischaemia)

Question 9

What are the features of Intermittent Claudication?

Answer 9

• Aching or burning in the leg muscles following walking
• Patients can walk a predictable distance before symptoms start
• Symptoms are usually relieved within minutes of stopping
• Not present at rest

Question 10

What is involved in the assessment of Intermittent Claudication?

Answer 10

• Check the femoral, popliteal, posterior tibialis, and dorsalis pedis pulses
• Check Ankle-Brachial Pressure Index (ABPI)
• Duplex ultrasound (first-line investigation)
• Magnetic Resonance Angiography (MRA) prior to intervention

Question 11

What are the features of Critical Limb Ischaemia?

Answer 11

• Rest pain in foot for more than 2 weeks
• Ulceration
• Gangrene
• Patients may hang their legs out of bed at night to ease the pain

Question 12

What is the Ankle-Brachial Pressure Index (ABPI)?

Answer 12

the ratio of the systolic blood pressure in the lower leg to that in the arms. Lower blood pressure in the legs (ABPI < 1) is an indicator of peripheral arterial disease

Question 13

How is Ankle-Brachial Pressure Index interpretated

Answer 13

> 1.2: may indicate calcified, stiff arteries. This may be seen with advanced age or PAD
1.0 - 1.2: normal
0.9 - 1.0: acceptable
< 0.9: likely PAD
< 0.5 indicates severe disease, urgent referral

Question 14

Which comorbidities should be treated in patients with Peripheral Arterial Disease (PAD)?

Answer 14

Hypertension
Diabetes mellitus
Obesity
Smoking

Question 15

Non-pharmacological management of peripheral arterial disease

Answer 15

• stop smoking
• exercise training - supervised exercise programme

Question 16

Pharmacological management of peripheral arterial disease

Answer 16

• all patients should be taking Atorvastatin 80 mg and clopidogrel 75mg
• naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life

Question 17

What are the treatment options for severe PAD or critical limb ischaemia?

Answer 17

• Endovascular revascularization (e.g., percutaneous transluminal angioplasty, possibly with stent placement)
• Surgical revascularization (e.g., surgical bypass with autologous vein or prosthetic material, endarterectomy)
• Amputation (for patients not suitable for other interventions)

Question 18

When are endovascular techniques typically used in PAD treatment?

Answer 18

For short segment stenosis (< 10 cm), aortic iliac disease, and high-risk patients

Question 19

When are open surgical techniques typically used in PAD treatment?

Answer 19

For long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery, and purely infrapopliteal disease.