Vascular Surgery

Question 1

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

Answer 1

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.

Question 2

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

Answer 2

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

Question 3

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

Answer 3

Arrange a duplex scan

Sapheno-popliteal junction incompetence must be imaged prior to starting treatment

Question 4

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

Answer 4

Acute mesenteric embolus

Although mesenteric infarct may raise the lactate the pH may be raised often secondary to vomiting.

Question 5

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

Answer 5

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.

Question 6

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

Answer 6

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.

Question 7

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

Answer 7

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.

Question 8

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

Answer 8

Squamous cell carcinoma

If, after many years, an ulcer becomes heaped up and irregular, with rolled edges then suspect a squamous cell carcinoma.

Question 9

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

Answer 9

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.

Question 10

In which of the following operations are Skew flaps created?

	Hindquarter amputation
	Above knee amputation
	Gritti- Stokes amputation
	Below knee amputation
	Symes amputation

Answer 10

Below knee amputation

This is one variant of a below knee amputation. The Burgess flap is the other commonly practised approach

Question 11

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

Answer 11

<0.4

Rest pain is typically associated with low ABPI values.

Question 12

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

Answer 12

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.

Question 13

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

Answer 13

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.

Question 14

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

Answer 14

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.

Question 15

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

Answer 15

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.

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

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.

Question 18

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

Answer 18

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.

Question 19

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

Answer 19

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.

Question 20

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

Answer 20

The most likely diagnosis is a carotid body tumour and it is likely to be of the hyperplastic type.

Question 21

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

Answer 21

A below knee amputation is the best option here. The foot is non salvageable. However, she may ambulate with a prosthesis.

Question 22

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

Answer 22

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.

Question 23

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

Answer 23

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.

Question 24

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

Answer 24

> 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.

Question 25

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 ```

Answer 25

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.

Question 26

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 ```

Answer 26

Marjolin's ulcer is a squamous cell carcinoma occurring at sites of chronic inflammation or previous injury.

Question 27

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

Answer 27

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.

Question 28

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 ```

Answer 28

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

Question 29

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 ```

Answer 29

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

Question 30

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

Answer 30

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.

Question 31

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 ```

Answer 31

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.

Question 32

A 32 year old male is noted to have a tender mass in the right groin area. There are also red streaks on the thigh, extending from a small abrasion. What is the most likely explanation? ``` Lymphadenitis Saphena varix Femoral artery aneurysm Abscess Incarcerated hernia ```

Answer 32

Lymphadenitis The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes.

Question 33

Which of the ABPI measurements shown below is most likely to be found in a 45 year old man who develops calf pain after walking 600 yards. It resolves during periods of rest. >1.2 1. 0 0. 7 0. 5 0. 3

Answer 33

0.7 Since this is a long claudication distance it may be that only a minor lesion is present. Whilst resting ABPI may be normal, they are usually abnormal following exercise.

Question 34

A 78 year old man develops sudden onset abdominal pain and almost immediately afterwards passes a large amount of diarrhoea. What is the most appropriate investigation? ``` Abdominal x-ray CT angiogram Abdominal MRI scan Abdominal USS Rigid sigmoidoscopy ```

Answer 34

CT angiogram Sudden onset of abdominal pain followed by forceful evacuation are the classical presenting features of acute mesenteric infarction. This is best investigated by CT angiography, which has a sensitivity of 95% for the diagnosis.

Question 35

A 66 year old man is referred via the aneurysm screening programme with an abdominal aortic aneurysm measuring 4.4 cm. Apart from well controlled type 2 DM he has no other co-morbidities. What is the best course of action? ``` AAA repair during next 48 hours USS in 6 months CT aortic angiogram MRI aortic angiogram Discharge from the programme ```

Answer 35

USS in 6 months At this point continue with ultrasound surveillance.

Question 36

A 78 year old man presents with left sided rest pain in his leg and a non healing arterial leg ulcer on the same leg. Imaging shows normal right leg vessels, on the left side there is a long occlusion of the external iliac artery that is unsuitable for stenting. He has a significant cardiac history. What is the most appropriate treatment option? ``` Aorto-bifemoral bypass Axillo-bifemoral bypass Femoro-femoro cross over graft Femoro-distal bypass Amputation ```

Answer 36

Femoro-femoral cross over grafts are an option for treatment of iliac occlusions in patients with significant co-morbidities and healthy contralateral vessels. In reality, the idealised situation presented here seldom applies and the opposite vessels usually have some disease and one must be careful not to damage the healthy side.

Question 37

A 52 year old lady develops lower leg swelling following redo varicose vein surgery. There is evidence of swelling of the left leg up to the knee. The overlying skin appears healthy. What is the best management option? ``` Homans operation Multilayer compression bandages High dose frusemide High dose bumetanide Lymphovenous anastomosis ```

Answer 37

Multilayer compression bandages Unfortunately, lymphoedema may complicate redo varicose vein surgery (in 0.5% of cases). As the presentation is mild, she should be managed using compression hosiery. Diuretics do not help in cases of true lymphoedema and a dramatic response suggests an alternative underlying cause.

Question 38

A 67 year old patient is due to undergo a femoro-popliteal bypass graft. Which heparin regime should the surgeon ask for prior to cross clamping the femoral artery? Single therapeutic dose of low molecular weight heparin on the ward prior to coming to theatre Single therapeutic dose of low molecular weight heparin the night before surgery Dose of 10,000 units of unfractionated heparin prior to induction of anaesthesia Dose of 3,000 units of unfractionated heparin, 3 minutes prior to cross clamping Dose of 30,000 units of unfractionated heparin, 3 minutes prior to cross clamping

Answer 38

As a rule most vascular surgeons will administer approximately 3,000 units of systemic heparin 3-5 minutes prior to cross clamping to help prevent further intra arterial thromboses. A dose of 30,000 units is given prior to going on cardiopulmonary bypass. Heparin given at induction will cause bleeding during routine dissection.

Question 39

An 18 year old lady presents with extensive varicose veins of her left leg. There is associated port wine staining. What is the most likely diagnosis? ``` Type 1 diabetes Osler syndrome Gardner's syndrome Proteus syndrome Klippel-Trenaunay-Weber syndrome ```

Answer 39

A less common cause of venous insufficiency is Klippel-Trenaunay-Weber (KTW) syndrome, which involves port-wine stains, varicose veins, and bony or soft-tissue hypertrophy.

Question 40

Which operation below is an amputation of the lower limb in which the femoral condyles are removed and the patella retained? ``` Transfemoral amputation Gritti Stokes amputation Symes amputation Below knee amputation with Burgess flap Below knee amputation with Skew flap ```

Answer 40

This is a Gritti - Stokes amputation. During a Gritti - Stokes operation the patella is conserved and swung posteriorly to cover the distal femoral surface.

Question 41

A 66 year old man has been suffering from weight loss and develops severe abdominal pain. He is admitted to hospital and undergoes a laparotomy. At operation, the entire small bowel is infarcted and only the left colon is viable. What is the most likely explanation? Mesenteric venous thrombosis Acute on chronic mesenteric ischaemia Acute embolus to the inferior mesenteric artery Acute embolus affecting the coeliac axis Arcuate ligament compression syndrome

Answer 41

This man is likely to have underlying chronic mesenteric vascular disease. Only 15% of emboli will occlude SMA orifice leading to entire small bowel infarct. The background history of weight loss also favors an acute on chronic event.

Question 42

Which of the interventions listed below would not be conventional treatment for a venous ulcer? ``` Compression bandages Limb elevation to control oedema Optimisation of glycaemic control of diabetic Use of skin grafts in selected cases Excision and closure in selected cases ```

Answer 42

Most venous ulcers are managed with compression bandages. Skin grafting is sometimes used. However, ulcer excision is not standard practice and closure would be impossible.

Question 43

A 23 year old man presents with intermittent symptoms of altered sensation in his arm and discomfort when he uses his hands. He works as an electrician and his symptoms are worst when he is fitting light fixtures. What is the most likely cause? ``` Cervical rib Axillary artery embolus Axillary vein thrombosis Raynaud's Atheroma of the subclavian artery ```

Answer 43

Compression of the thoracic outlet by the fibrous band of the rib can result in both neurological and circulatory compromise. When manual tasks are performed in which the hand works overhead the signs and symptoms will be maximal and this is the basis of Adsons test.

Question 44

During short saphenous vein surgery for varicose veins which of the following nerves is particularly at risk? ``` Sural nerve Popliteal nerve Tibial nerve Femoral nerve Saphenous nerve ```

Answer 44

Sural nerve Short Saphenous Vein Originates at the 5th digit where the dorsal vein merges with the dorsal venous arch of the foot, which attaches to the great saphenous vein. It passes around the lateral aspect of the foot (inferior and posterior to the lateral malleolus) and runs along the posterior aspect of the leg (with the sural nerve)

Question 45

A 22 year old intravenous drug user is found to have a femoral abscess. The nursing staff contact the on call doctor as the patient has a temperature of 39oC. He is found to have a pan systolic murmur loudest at the left sternal edge at the 4th intercostal space. What is the most likely underlying lesion? ``` Aortic regurgitation Mitral regurgitation Aortic stenosis Tricuspid stenosis Tricuspid regurgitation ```

Answer 45

Tricuspid regurgitation Intravenous drug users are at high risk of right sided cardiac valvular endocarditis. The character of the murmur fits with a diagnosis of tricuspid valve endocarditis.

Question 46

A 21 year old badminton player attends A&E with a painful, swollen right arm. He is right handed. Clinically he has dusky fingers and his upper limb pulses are present. An axillary vein thrombosis is confirmed. What is the best acute treatment to achieve vein patency? ``` Intravenous heparin Warfarin Catheter directed tPA Low molecular weight heparin Aspirin ```

Answer 46

Heparin and warfarin prevent propagation of the clot. Chronic axillary-subclavian vein thrombosis (ASVT) rarely responds to thrombolytics and generally is better treated either conservatively with warfarin.

Question 47

A 23 year old man presents with a brachial artery embolus. A cervical rib is suspected as being the underlying cause. From which of the following vertebral levels do they most often arise? ``` C7 C5 C4 C3 C2 ```

Answer 47

They usually arise from C7.

Question 48

A 57 year old lady has suffered from lymphoedema for many years. The left leg is swollen to the mid thigh. Severe limb deformity has developed as a result of process and in spite of compression hosiery. Lymphoscintography shows no patent lymphatics in the proximal leg. The overlying skin is healthy. Which of the following options would give the best long term outcome? ``` Multilayer compression bandages Charles operation Homans operation Long term loop diuretic therapy Amputation ```

Answer 48

Homans operation Surgery is indicated in less than 10% of cases. However, severe deformity is one of the indications for surgery. Lymphovenous anastomosis is indicated where the proximal lymphatics are not patent. When the overlying skin is healthy (and limb deformity a problem), a Homans procedure is a reasonable first line operative option.

Question 49

A 73 year old man with rest pain and ulceration of the foot undergoes a femoro-distal bypass graft with a PTFE graft. At the end of the procedure there are good distal foot pulses and a warm pink foot. Over the ensuing 60 days the foot becomes progressively cooler and the pulses diminish. What is the most likely underlying explanation for this process? ``` Embolus Neo-intimal flap Neo-intimal hyperplasia Polyarteritis Steal syndrome ```

Answer 49

Neo-intimal hyperplasia PTFE may induce neo-intimal hyperplasia with subsequent occlusion of the distal anastomosis. In more proximal arterial bypass surgery the process of neo-intimal hyperplasia is not sufficient to cause anastomotic occlusion. However, distal bypasses are at greater risk and if vein cannot be used as a conduit then the distal end of the PTFE should anastomosed to a vein cuff to minimise the risk of neo-intimal hyperplasia.

Question 50

Which of the following is not a typical feature of a chronic venous leg ulcer? Heaped raised borders if the ulcer has been present more than 5 years Evidence of surrounding lipodermatosclerosis Irregular shape to the ulcer 20% of cases will have a previous history of deep vein thrombosis Haemosiderin deposits in surrounding skin

Answer 50

The borders of the ulcer are often well defined even though they may be irregular. Heaped or raised borders should raise suspicion of a marjolins ulcer.

Question 51

A 74 year old man presents with a painful right leg. The pain developed suddenly the preceeding evening. However, he wondered if it might resolve overnight, instead, it has got worse. On examination, his right leg is cold and white with diminished distal sensation. A CT angiogram shows a thrombus occluding the external iliac artery with no atheromatous disease. What is the most appropriate course of action? Femoral embolectomy and below knee fasciotomy Femoral embolectomy alone Femoral popliteal bypass graft without fasciotomy Femoral embolectomy with above and below knee fasciotomy Femoro-femoro cross over graft with above and below knee fasciotomy

Answer 51

Femoral embolectomy and below knee fasciotomy Delayed surgery for limb ischaemic carries a risk of re-perfusion injury and compartment syndrome. Where surgery is delayed beyond 6 hours, most surgeons would perform a fasciotomy at the same time as the embolectomy. However, whilst the compartments below the knee are vulnerable, its very rare for this to occur in the thigh and so, as a rule, the thigh is not treated in this manner.

Question 52

Which of the following is not a typical feature of an arterial leg ulcer? ``` Well demarcated edges A grey - white base to the ulcer Men are affected more than women Painful Ankle swelling ```

Answer 52

Ankle swelling is often absent. If present it may be due to mixed arteriovenous disease. With mixed disease the arterial component is treated first.

Question 53

A 65 year old man presents with expressive dysphasia and right sided weakness over 4 hours. His symptoms have now completely resolved. A CT scan of his head is normal. What is the most useful investigation? ``` Arch aortogram Arterial duplex scan 24 hour cardiac tape Implantation of a reveal device MRI brain ```

Answer 53

Arterial duplex scan This patient has had a transient ischaemic attack. He urgently needs carotid duplex scanning to assess if he needs a carotid endarterectomy.

Question 54

Which of the ABPI measurements shown below is most likely to be found in a 43 year old lady with long standing diabetes who complains of foot pain. It is worse at night and during minor exercise. >1.0 0. 9 0. 3 0. 5 0. 7

Answer 54

>1.0 Diabetes may be complicated by vessel calcification and neuropathic pain. Therefore individuals may present with pain which is atypical for claudication both in terms of its tempo of onset and location.

Question 55

A 66 year old man is admitted with severe angina. There is a lesion of the proximal left anterior descending coronary artery. Which of the following would be the most suitable conduit for bypass? ``` Long saphenous vein Short saphenous vein Cephalic vein Internal mammary artery Thoraco-acromial artery ```

Answer 55

The internal mammary artery is an excellent conduit for coronary artery bypass. It has better long term patency rates than venous grafts. The thoraco-acromial artery is seldom used.

Question 56

An 84 year old lady is admitted with an infected diabetic foot. An x-ray shows osteomyelitis of her calcaneum. She has a fixed flexion deformity of her knee, but normal pulses. What is the best course of action? ``` Above knee amputation Below knee amputation Application of 4 layer bandages Hyperbaric oxygen therapy Debridement of foot bones and application of VAC ```

Answer 56

Above knee amputation This patient will not be able to walk with a below knee amputation, therefore an above knee amputation would be preferable, as it guarantees better healing the short term.

Question 57

Which of the following types of lymphedema is congenital? ``` Meiges' disease Milroy's disease Lymphoedema tarda Lymphoedema following surgery Lymphoedema due to venous insufficiency ```

Answer 57

Milroy's disease is congenital. Meiges' develops after birth.

Question 58

Concerning proximal aortic dissection (Debakey types 1 and 2/ Stanford type A) which statement is false? The intimal tear is typically >50% of the aortic circumference It is usually treated using an endovascular approach They have a 50% mortality in the first 2 days Arch reconstructions may require deep hypothermic circulatory arrest Target systolic pressure of around 110mmHg should be maintained

Answer 58

It is usually treated using an endovascular approach Usually open surgery is required for these lesions as customised grafts are not usually available for this type of repair yet.

Question 59

A 63 year old man who previously smoked 20 cigarettes a day and has newly diagnosed type II diabetes. He presents with rest pain. A diagnostic angiogram demonstrates occlusion of the distal superficial femoral artery continuing below the knee. He has reasonable posterior tibial artery below this level which branches to give good runoff to the foot. He has varicose veins. Which of the strategies presented below is most appropriate? Femoro-distal bypass graft using long saphenous vein Femoro-above knee popliteal bypass graft using PTFE Femoro-distal bypass graft using PTFE Femoro-distal bypass graft using PTFE and Miller cuff Above knee amputation

Answer 59

Femoro-distal bypass graft using PTFE and Miller cuff This man needs a bypass operation. Using PTFE alone will not give a good result as sub intimal hyperplasia will give poor outcome early. Using a vein cuff (Miller cuff) at the end of a PTFE graft will improve the situation. Varicose veins means that vein cannot be reliably used as a conduit. However, the construction of a Miller vein cuff can be done with vein from another anatomical site.

Question 60

A 67 year old male is diagnosed as having a 7cm infra renal abdominal aortic aneurysm. What is the likely risk of rupture over the next 5 years? ``` <10% 20% 25% 75% 35% ```

Answer 60

Risks of abdominal aortic aneurysm rupture (over 5 years): 5-5.9cm = 25% 6-6.9cm= 35% 7cm and over = 75% Aneurysms greater than 5cm in diameter on USS should be formally assessed using CT scanning with arterial phases to delineate anatomy and facilitate surgical planning.

Question 61

A 54 year old man presents to the vascular clinic with severe rest pain and an ulcer on his right foot that is not healing. On examination he has bilateral absent femoral pulses. Imaging demonstrates a bilateral occlusion of the common iliac arteries that is not suitable for stenting. What is the most appropriate intervention? ``` Aorto-bifemoral bypass Axillo-bifemoral bypass Bilateral transfermoral amputation Femoro-femoro cross over graft Femoro-popliteal bypass ```

Answer 61

Aorto-bifemoral bypass In a young patient consideration should be given to aorto-bifemoral bypass grafts as these have the best long term functional outcome compared with an axillo-bifemoral bypass graft.

Question 62

A 24-year-old female is referred to the acute surgical team as she is noted to have an absent left radial pulse. Apart from some dizziness and lethargy, the patient does not have any features suggestive of an acute ischaemic limb. Blood tests are as follows: Na+ 136 mmol/l K+ 4.1 mmol/l Urea 2.3 mmol/l Creatinine 77 µmol/l ESR 66 mm/hr What is the most likely diagnosis? ``` Turner's syndrome Takayasu's arteritis Kawasaki disease Coarctation of the aorta Breast carcinoma with local spread ```

Answer 62

Takayasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches Females> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase

Question 63

A 62 year old diabetic man presents with long standing plantar ulcer he has clinical evidence of a charcot foot. What is the most likely diagnosis? ``` Mixed ulcer Chronic obliterative arterial disease Neuropathic ulcer Squamous cell carcinoma Deep venous insufficiency ```

Answer 63

Neuropathic ulcer Plantar ulcers in association with peripheral neuropathy are often neuropathic. They classically occur at pressure points.

Question 64

A 65 year old man presents, for the first time, with pain at the back of his calves when he mobilises 10 metres. He is known to have hypertension. What is the most appropriate investigation? ``` Arterial duplex scan MRI angiogram DSA angiogram Aortic USS Knee x-ray ```

Answer 64

An arterial duplex should be performed first, before progression to an angiography.

Question 65

A 32 year old woman attends clinic for assessment of varicose veins. She has suffered for varicose veins for many years and can trace their development back to when she suffered a complex tibial fracture. On examination she has marked truncal varicosities with a long tortuous long saphenous vein. What is the most appropriate next step? Arrange a venogram Arrange a venous duplex scan List her for a trendelenberg procedure List her for injection foam sclerotherapy List her for multiple avulsion phlebectomies

Answer 65

Arrange a venous duplex scan This lady is likely to have deep venous incompetence as she will have been immobilised for her tibial fracture and may well have had a DVT. A duplex scan is mandatory prior to any form of surgical intervention. A venogram would provide similar information but is more invasive.

Question 66

A 21 year old post man notices leg pain after 5 minutes walking during his round. It improves 3 minutes after stopping. Clinically he is noted to have reduced hair of the lower limbs and his calf muscles appear atrophied. There is a weak popliteal pulse, but it is still present when the knee is fully extended. What is the most likely diagnosis? ``` Occlusive arterial disease caused by atherosclerosis Popliteal fossa entrapment Cerebral vascular accident Diabetes mellitus Adductor canal compression syndrome ```

Answer 66

Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle. The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended.

Question 67

Which of the following is not a feature of a Charcot foot? Bounding foot pulses in the early phases Often occurs in the complete absence of trauma Erythema of the foot in the early phase Autonomic neuropathy Peripheral neuropathy

Answer 67

Often occurs in the complete absence of trauma Trauma (even if only minor) is aprerequisite. Patients cannot usually recall the traumatic event. The associated neuropathy means that patients continue to walk on the affected foot with subsequent deformity developing over time.

Question 68

A 34 year old man presents with varicose veins and it is suspected that these are part of the Klippel-Trenaunay syndrome. Which of the following is not a characteristic of this condition? ``` Presence of varicose veins Gigantism of a limb Long saphenous vein involvement Port wine stains with clear borders Arteriovenous fistulae ```

Answer 68

Long saphenous vein involvement The Klippel-Trenaunay vein is a large, lateral, superficial vein sometimes seen at birth. This vein begins in the foot or the lower leg and travels proximally until it enters the thigh or the gluteal area

Question 69

Which of the following statements related to coronary artery bypass surgery is true? Late graft stenosis is mainly associated with saphenous vein grafts Is indicated if there is stenosis > 70% of the right coronary artery The left atrium is cannulated during the procedure The CHADS score is used to assess peri operative risk Cardioplegia is always undertaken at a 37 degrees

Answer 69

Late graft stenosis is mainly associated with saphenous vein grafts Indications are: 1. Left main stem stenosis or equivalent (proximal LAD and proximal circumflex) 2. Triple vessel disease 3. Diffuse disease unsuitable for PCI The right atrium is cannulated. The CHADS score assesses whether a patient should be warfarinised if they have atrial fibrillation. Cardioplegia can be undertaken at cold or warm temperatures.

Question 70

A 73 year old man develops sudden onset abdominal pain and collapses. On examination he has a tender pulsatile mass in his upper abdomen. He has a blood pressure of 90/60mmHg and pulse rate of 105 beats per minute. Which of the following intravenous fluid regimens is most appropriate, whilst waiting for operative repair? 1 Litre of pentastarch over 15 minutes 1 litre of Hartmans solution over 4 hours 1 litre of gelofusin over 30 minutes 1 litre of Hartmans solution over 30 minutes 1 litre of blood over 15 minutes

Answer 70

1 litre of Hartmans solution over 4 hours This man will have a contained haematoma and is awaiting surgery. Rapid, high volume infusions may cause this to dislodge with disastrous consequences

Question 71

An 83 year old woman is admitted with a left intertrochanteric neck of femur fracture. On examination, the patient is found to have an ejection systolic murmur loudest in the aortic region. There is no radiation of the murmur to the carotid arteries. Her ECG is normal. What is the most likely lesion? ``` Mitral valve stenosis Aortic valve sclerosis Aortic valve stenosis Tricuspid valve stenosis Mitral valve regurgitation ```

Answer 71

The most likely diagnosis is aortic sclerosis. The main differential diagnosis is of aortic stenosis, however as there is no radiation of the murmur to the carotids and the ECG is normal, this is less likely.

Question 72

A 73 year old woman collapses with sudden onset of abdominal pain and she passes a large amount of diarrhoea. On admission, she is vomiting repeatedly. She has recently been discharged from hospital following a myocardial infarct but recovered well. What is the most likely cause? Acute superior mesenteric artery embolus Acute inferior mesenteric artery embolus Pancreatitis Infection with clostridium difficile Myocarditis

Answer 72

Acute superior mesenteric artery embolus Sudden onset of abdominal pain and forceful bowel evacuation are features of acute mesenteric infarct. The SMA is more likely to be involved than the IMA and that makes this the most likely diagnosis. Severe vomiting is not commonly seen with clostridium difficile infection.

Question 73

A 52 year old male attends the stroke unit with dizziness and vertigo while playing tennis. He is known to have hypertension and a previous myocardial infarct. He now complains of right arm pain. What is the most likely diagnosis? ``` Posterior circulation infarct Vertebrobasilar aneurysm Dissection of thoracic aorta Subclavian steal syndrome Left middle cerebral artery infarct ```

Answer 73

Subclavian steal syndrome characteristically presents with posterior circulation symptoms, such as dizziness and vertigo, during exertion of an arm. There is subclavian artery steno-occlusive disease proximal to the origin of the vertebral artery and is associated with flow reversal in the vertebral artery. Management involves percutaneous transluminal angioplasty or a stent.

Question 74

A 73 year old lifelong heavy smoker presents to the vascular clinic with symptoms of foot ulceration and rest pain. On examination, her foot has areas of gangrene and pulses are impalpable. Which of the ABPI measurements shown below is most compatible with this process? >1.2 1. 0 0. 3 0. 8 0. 5

Answer 74

0.3 This is critical limb ischaemia. Values of 0.3 are typical in this setting and urgent further imaging is needed. Debridement of necrosis prior to improving arterial inflow carries a high risk of limb loss.

Question 75

A 38 year old lady is troubled by lymphoedema that occurred following a block dissection of the groin for malignant melanoma many years previously. Despite therapy with compression bandages she has persistent lower leg swelling impairing her activities of daily living. She has no evidence of recurrent malignancy. Lymphoscintography demonstrates occlusion of the groin lymphatics. However, the distal lymphatic system appears healthy. Which of the following options could be considered? ``` Lymphovenous anastomosis Homans procedure Charles procedure Loop diurectic therapy long term Amputation ```

Answer 75

In young patients with proximal disease and healthy distal lymphatics a lymphovenous anastomosis may be considered. Such cases are rare

Question 76

An 83 year old lady with a significant cardiac history is admitted with rest pain and bilateral leg ulcers. Imaging demonstrates bilateral occlusion of both common iliac arteries that are unsuitable for stenting. What is the most appropriate intervention? ``` Femoro-femoral cross over graft Axillo-bifemoral bypass graft Bilateral trans femoral amputations Aorto-bifemoral bypass graft Femoro-distal bypass ```

Answer 76

In patients with major cardiac co-morbidities the safest option is to choose an axillo-bifemoral bypass graft. The long term patency rates are less good than with aorto-bifemoral bypass grafts, however, the operation is less major.

Question 77

A 19 year old lady presents with recurrent episodes of pain in her hands. She notices that her symptoms are worst in cold weather. When she gets the pain she notices that her hands are very pale, they then become dark blue in colour. What is the most likely diagnosis? ``` Axillary artery embolus Brachial artery embolus Raynauds disease Cervical rib Rheumatoid ```

Answer 77

Raynauds disease is characterised by a series of colour changes and discomfort is often present. The young age at presentation coupled with the absence of a smoking history (in most cases) makes occlusive disease unlikely.

Question 78

An 80 year old lady is brought to the emergency department by her carers. She has been unwell for the past few days. On examination, she has a cold, pulseless leg with fixed mottling, below the knee. A duplex scan shows a stenosis of the profunda femoris and popliteal artery with no flow distal to this. What is the most appropriate course of action. ``` Femoro-femoro cross over graft Axillo- femoral bypass graft Trans femoral amputation Gritti Stokes amputation Administration of intravenous unfractionated heparin ```

Answer 78

Trans femoral amputation Fixed mottling is a sign of an unsalvageable limb and mandates either amputation or palliation. A through knee amputation (Gritti Stokes) is unlikely to heal in this setting.

Question 79

A 74 year old lady has a long standing venous leg ulcer overlying her medial malleolus. Which of the following statements relating to the management of this condition is false? Pentoxifylline may speed ulcer healing Treatment with daily low dose flucloxacillin may speed ulcer healing Multilayer bandages may provide compression equivalent to 40mmHg Large ulcers may be considered for skin grafting They should not be treated with compression stockings if the ankle / brachial pressure index is 0.4

Answer 79

Treatment with daily low dose flucloxacillin may speed ulcer healing Routine use of antibiotics is not advised as this may predispose to resistant organisms. Pentoxifylline was subjected to a Cochrane review in 2007 and shown to improve healing rates.