Vascular Surgery Flashcards
A 28 year old female has suffered from diffuse abdominal pain for the past 2 weeks since she was started on the contraceptive pill. The pain has increased significantly over the post 10 hours and has been associated with vomiting. A pregnancy test is negative. What is the most likely diagnosis?
Mesenteric venous thrombosis Acute mesenteric embolus Chronic mesenteric ischaemia Ruptured ectopic pregnancy Inflammatory bowel disease
Mesenteric venous thrombosis is the likely underlying cause and an angiogram is the sensible step as it will also facilitate the identification of areas of infarcted bowel , similar to that which may occur in the leg when massive DVT is present.
A 72 year old man collapses with sudden onset abdominal pain. He has been suffering from back pain recently and has been taking ibuprofen. What is the most likely cause?
Acute mesenteric artery embolus Peritonitis due to peptic ulcer disease Ruptured abdominal aortic aneurysm Bleeding Dieulafoy lesion Pancreatitis
Ruptured abdominal aortic aneurysm
The key feature here is the sudden nature of the collapse, this suggests a significant intra abdominal catastrophe. The history of back pain is also suggestive of recent aneurysm expansion
A 40 year old lady presents to the surgical clinic with symptoms related to varicose veins. She has noticed that these first developed when she was pregnant. On examination, she has a truncal varicosity of the medial leg, there are no ulcers or skin changes. A hand held Doppler examination demonstrates sapheno popliteal junction reflux. What is the most appropriate course of action?
Offer the patient sapheno-popliteal junction ligation Offer the patient foam sclerotherapy of the sapheno-popliteal junction Offer the patient laser ablation of the sapheno-popliteal junction Arrange contrast venography Arrange a duplex scan
Arrange a duplex scan
Sapheno-popliteal junction incompetence must be imaged prior to starting treatment
A 79 year old lady develops sudden onset of abdominal pain and collapses, she has passed a large amount of diarrhoea. In casualty her pH is 7.35 and WCC is 18. What is the most likely cause?
Mesenteric venous thrombosis Acute mesenteric embolus Acute on chronic mesenteric ischaemia Vasculitis Myocardial infarct
Acute mesenteric embolus
Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting.
The medical team refer a 72 year old lady with a bilateral swollen legs. Deep vein thrombosis has been excluded and there is no response to diuretics. On further questioning, the patient reveals that she was born with the swelling in both of her legs. What is the most likely diagnosis?
Lymphoedema tarda Meige's disease Filariasis Lymphoma Milroy's disease
Milroy’s disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige’s disease develops AFTER birth.
A 65 year old diabetic female presents with a painless ulcer at the medial malleolus, it has been present for the past 16 years. On examination, she has evidence of truncal varicosities and a brownish discolouration of the skin overlying the affected area. What is the most likely cause?
Chronic obliterative arterial disease Superficial venous insufficiency Deep venous insufficiency Mixed ulcer Neuropathic ulcer
Superficial venous insufficiency
Venous ulcers are usually associated with features of venous insufficiency. These include haemosiderin deposition and varicose veins. Neuropathic ulcers will tend to present at sites of pressure, which is not typically at the medial malleolus.
A 52 year old obese lady reports a painless grape sized mass in her groin area. She has no medical conditions apart from some varicose veins. There is a cough impulse and the mass disappears on lying down. What is the most likely cause?
Femoral hernia Inguinal hernia Saphena varix False aneurysm of the femoral artery Arteriovenous malformation
The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge during coughing/sneezing. A blue discolouration may be noted.
A 79 year old retired teacher has had an ulcer for 15 years. It is at the medial malleolus and has associated lipodermatosclerosis of the lower limb. The ulcer base is heaped up and irregular. What is the most likely diagnosis?
Basal cell carcinoma Superficial venous insufficiency Squamous cell carcinoma Mixed ulcer Chronic obliterative arterial disease
Squamous cell carcinoma
If, after many years, an ulcer becomes heaped up and irregular, with rolled edges then suspect a squamous cell carcinoma.
A 22 year old professional tennis player attends the emergency department with a swollen painful right arm. On examination, his fingers are dusky. What is the most appropriate investigation?
Chest X-ray Arterial duplex scan CT angiogram Venous duplex scan Venous Doppler test
Venous duplex scan
This patient has an axillary vein thrombosis. It classically presents with pain and swelling of an effort induced limb. Duplex scan is needed to exclude a thombus.
In which of the following operations are Skew flaps created?
Hindquarter amputation Above knee amputation Gritti- Stokes amputation Below knee amputation Symes amputation
Below knee amputation
This is one variant of a below knee amputation. The Burgess flap is the other commonly practised approach
Which of the ABPI measurements shown below is most likely to be found in an 83 year old man with rest pain?
0.6-0.8 <0.4 >1.2 1.0 0.5
<0.4
Rest pain is typically associated with low ABPI values.
A 72 year old man present in the vascular clinic with calf pain present on walking 100 yards. He is an ex-smoker and lives alone. On examination, he has reasonable leg pulses. His right dorsalis pedis pulse gives a monophasic doppler signal with an ankle brachial pressure index measurement of 0.7. All other pressures are acceptable. There is no evidence of ulceration or gangrene. What is the best course of action?
Conservative management with medical therapy and exercise Angioplasty Arterial bypass surgery with PTFE graft Arterial bypass surgery with vein graft Watch and wait
Conservative management with medical therapy and exercise
Structured exercise programmes combined with medical therapy will improve many patients. Should his symptoms worsen or fail to improve then a more comprehensive work up should be considered.
A wheelchair bound 78 year old woman with ischaemic heart disease secondary to long smoking history and longstanding type II diabetes presents with rest pain and a non healing ulcer on the dorsum of her foot. Angiogram shows reasonable superficial femoral artery and iliacs. At the level of the popliteal artery there is an occlusion. Below this there is a short area of patent posterior tibial artery and this reconstitutes lower down the leg to flow to the foot. What is the best treatment option?
Long sub intimal angioplasty Femoro-distal bypass graft with PTFE Above knee amputation Below knee amputation Axillo-femoral bypass
A femoro-distal bypass graft would carry a high risk of failure and risk of peri-operative myocardial infarct. This lady would be well suited to primary amputation as she is not ambulant.
A 24 year old lady presents with a history of severe epigastric pain that is worse post prandially. On examination, the abdomen is soft and non tender with no palpable masses, there is a bruit in the epigastrium. Imaging with USS shows no gallstones and an OGD is normal. What is the most likely diagnosis?
Sphincter of oddi dysfunction Irritable bowel syndrome Median arcuate ligament syndrome Mesenteric vein thrombosis GORD
Median arcuate ligament syndrome is largely a diagnosis of exclusion. The classic signs of epigastric pain with an audible bruit are only found in a minority. Where the condition is suspected, the diagnosis is usually apparent on duplex scanning (in thin patients) or with CT angiography.
A 72 year old man has a CT scan for abdominal discomfort and the surgeon suspects abdominal aortic disease. It reveals a 6.6cm aneurysm with a 3.5cm neck and it continues to involve the right common iliac. The left iliac is occluded. He is hypertensive and has Type 2 DM which is well controlled. What is the best course of action?
Abdominal aortic aneurysm repair in next 48 hours Abdominal aortic aneurysm repair in 6 weeks time Review in outpatients in 3 months Endovascular aortic aneurysm repair in 48 hours Discharge the patient
Abdominal aortic aneurysm repair in next 48 hours
Assuming he is fit enough. This would be a typical ‘open ‘ case as the marked iliac disease would make EVAR difficult. Tender aneurysms require urgent surgery.
A 34 year old teacher attends A&E with a swollen leg. She has been in England for 2 weeks having previously lived in the Democratic Republic of the Congo. She lives in an area prevalent with mosquitoes and where there is poor sanitation. What is the most likely diagnosis?
Meige's disease Lymphoma Milroy's disease Filariasis Malaria
Filariasis is caused by the nematode Wuchereria bancrofti, which is mainly spread by mosquito. The oedema can be gross leading to elephantitis. Treatment is with diethylcarbamazine.
A 23 year old male suffering from hepatitis C presents with right groin pain and swelling. On examination, there is a large abscess in the groin. Adjacent to this is a pulsatile swelling. There is no cough impulse. What is the most likely diagnosis?
Saphena varix False aneurysm of the femoral artery True aneurysm of the femoral artery Incarcerated hernia Reactive lymphadenopathy
False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall.
A 71 year old man presents with a painful lower calf ulcer, mild pitting oedema and an ABPI of 0.3. What is the most likely cause?
Mixed ulcer Deep venous insufficiency Chronic obliterative arterial disease Squamous cell carcinoma Neuropathic ulcer
Chronic obliterative arterial disease
Painful ulcers associated with a low ABPI are usually arterial in nature. The question does not indicate that features of chronic venous insufficiency are present. Patients may have mild pitting oedema as many vascular patients will also have ischaemic heart disease and elevated right heart pressures. The absence of more compelling signs of venous insufficiency makes a mixed ulcer less likely.
A 63 year old man is admitted with rest pain and foot ulceration. An angiogram shows a 3 cm area of occlusion of the distal superficial femoral artery with 3 vessel run off. His ankle - brachial pressure index is 0.4. What is the most appropriate course of action?
Conservative management with medical therapy and exercise Arterial bypass surgery using PTFE Arterial bypass surgery using vein Primary amputation Angioplasty
Short segment disease and good run off with tissue loss is a compelling indication for angioplasty. He should receive aspirin and a statin if not already taking them.
A 60 year old Tibetan immigrant is referred to the surgical clinic with a painless neck swelling. On examination, it is located on the left side in the anterior triangle. There are no other abnormalities to find. What is the most likely diagnosis?
Carotid body tumour Submandibular gland calculus Carotid artery aneurysm Fibromatosis colli Laryngeal cancer
The most likely diagnosis is a carotid body tumour and it is likely to be of the hyperplastic type.
A 48 year old woman is admitted with sepsis secondary to an infected diabetic foot ulcer. She has a necrotic and infected forefoot with necrosis of the heel. There is a boggy indurated swelling anterior to the ankle joint. Pulses are normal. What is the best course of action?
Above knee amputation Amputation of the foot Below knee amputation Incision and drainage of pus Application of 4 layer bandages
A below knee amputation is the best option here. The foot is non salvageable. However, she may ambulate with a prosthesis.
An 89 year old man presents with hypotension and collapse and is found by the staff in the toilet of his care home. He is moribund and unable to give a clear history. He had suffered a cardiac arrest in the ambulance but has since been resuscitated and now has a Bp of 95 systolic. He has an obviously palpable AAA. What is the best course of action?
Immediate CT scanning of the abdominal aorta Immediate laparotomy Immediate endovascular aortic aneurysm repair Palliation USS of aorta
The fact that he is frail (care home resident) and has already suffered a cardiac arrest means that attempts at surgery will invariably fail. At 89 years of age the functional outcomes were it to be ‘successful’ would be very poor. Palliation is therefore the best option, imaging will not change this management decision.
A 35 year old Singaporean female attends a varicose vein pre operative clinic. On auscultation, a mid diastolic murmur is noted at the apex. The murmur is enhanced when the patient lies in the left lateral position. What is the most likely underlying lesion?
Pulmonary valve stenosis Aortic valve stenosis Aortic sclerosis Mitral valve stenosis Tricuspid regurgitation
A mid diastolic murmur at the apex is a classical description of a mitral stenosis murmur. The most common cause is rheumatic heart disease. Complications of mitral stenosis include atrial fibrillation, stroke, myocardial infarction and infective endocarditis.
A 77 year old morbidly obese man with type 2 diabetes presents with leg pain at rest. His symptoms are worst at night and sometimes improve during the day. He has no areas of ulceration. Which of the ABPI measurements shown below is most likely to be found?
1.0 >1.2 0.3 0.7 0.5
> 1.2
Type 2 diabetics may have vessel calcification. This will result in abnormally high ABPI readings. Pain of this nature in diabetics is usually neuropathic and if a duplex scan is normal then treatment with an agent such as duloxetine is sometimes helpful.
A 76 year old man presents acutely with a painful right arm (he is right handed). On examination, he has a cool right forearm and absent radial and brachial pulses. A duplex scan shows thrombus occluding the brachial artery. What is the most appropriate course of action?
Administration of therapeutic low molecular weight heparin Brachial embolectomy without fasciotomy Intra arterial thrombolysis Systemic thrombolysis Brachial embolectomy with fasciotomy
Brachial embolectomy without fasciotomy
Options to treat upper limb embolic events include either anticoagulation or surgery. Background arterial lesions are very rarely present in the upper limb so embolectomy is usually successful. Anticoagulation with intravenous unfractionated heparin is a reasonable alternative. However, note that low molecular weight heparin is not used in this setting as its difficult to control perioperatively.
A 66 year old female has long standing mixed arteriovenous ulcers of the lower leg. Over the past 6 months one of the ulcers has become much worse and despite a number of different topical therapies is increasing in size. What is the most likely diagnosis?
Neuropathic ulcer Mixed ulcer Deep venous insufficiency Marjolins ulcer Chronic obliterative arterial disease
Marjolin’s ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.
A 73 year old male presents with a collapse and is brought to the emergency department. On examination, he has a cold, painful left hand and forearm. What is the most likely cause?
Occlusion of the brachial artery due to atheroma Occlusion of the axillary artery due to atheroma Axillary vein thrombosis Cervical rib Brachial artery embolus
Brachial artery embolus
The most likely event is one of embolism, because of the acute nature of the condition there is no time for the development of a collateral circulation so the limb is usually pale and painful. Emboli usually occur as a result of atrial fibrillation. Fast atrial fibrillation can cause syncope and an acute embolus.
A 41 year old man is admitted with peritonitis secondary to a perforated appendix. He is treated with a laparoscopic appendicectomy but has a stormy post operative course. He is now developing increasing abdominal pain and has been vomiting. A laparotomy is performed and at operation a large amount of small bowel shows evidence of patchy areas of infarction. What is the most likely cause?
Mesenteric venous thrombosis Superior mesenteric artery embolus Acute on chronic mesenteric ischaemia Vasculitis Median arcuate ligament syndrome
Mesenteric vein thrombosis may complicate severe intra abdominal sepsis and when it progresses may impair bowel perfusion. The serosa is quite resistant to ischaemia so in this case the appearances are usually patchy
A thin 72 year old lady has a 3 week history of postprandial abdominal pain that is centrally located. She has episodic diarrhoea and occasionally has passed blood PR. She has a history of ischaemic heart disease and marked renal impairment from ACE inhibitor usage. What is the most appropriate investigation?
Colonoscopy Duplex ultrasound scan of abdomen CT angiogram CT scan without contrast Measurement of faecal calprotectin
She is likely to have mesenteric vascular disease. Proximal SMA disease would be the most serious variant. Ideally a CT angiogram would be the best test but with her impaired renal function and low BMI, make a duplex of the SMA is a reasonable first line investigation. Gut peristalsis may impair acquisition of magnetic resonance images
A 54 year old lady presents with recurrent right sided varicose veins. She underwent endovenous laser ablation 5 years previously. On examination, she has skin changes affected the medial lower leg. Imaging demonstrates re-canalization of the long saphenous vein and saphenofemoral junction incompetence. What is the most appropriate option?
Offer redo endovenous laser therapy Offer foam sclerotherapy Offer saphenofemoral disconnection, long saphenous stripping to above knee and avulsions as required Offer saphenofemoral disconnection, long saphenous stripping to below knee and avulsions as required Offer saphenofemoral junction ligation alone
Offer saphenofemoral disconnection, long saphenous stripping to above knee and avulsions as required
In the UK, NICE, suggest the use non operative measures such as endothermal ablation for first time varicose veins. Recurrences respond far less favourably and are best managed with surgery.
An 83 year old lady is admitted from a nursing home with infected lower leg ulcers. She underwent an attempted long superficial femoral artery sub initimal angioplasty 2 weeks previously. This demonstrated poor runoff below the knee. What is the best course of action?
Below knee amputation with Burgess flap Below knee amputation with skew flaps Transfemoral amputation Gritti Stokes amputation Wound debridement
Transfemoral amputation
The best option here is to opt for early amputation or simply palliate the patient. Above knee surgery would be needed, attempts to offer a below knee amputation would probably fail.
