Vascular Surgery Examination

Question 0

What are the pressure points on the foot?

Answer 0

Heel and ball of the foot; in between the toes

Question 1

What should you look for on inspection?

Answer 1

Scars from previous surgery
Signs of peripheral arterial disease
Loss of hair
Pallor
Shiny skin
Cyanosis
Dry skin
Scaling
Deformed toe nails
Ulcers
Gangrene
Inspect pressure points

Question 2

What is indicated by cool peripheries

Answer 2

Ischaemia

Question 3

What is suggested by the presence of bruits?

Answer 3

Arterial disease

Question 4

What is indicated by an expansile pulsitile abdominal mass?

Answer 4

AAA until proven otherwise

Question 5

How is lower limb ischaemia classified?

Answer 5

I: Asymptomatic
II: Intermittent claudication
III: Night/rest pain
IV: Tissue loss (ulceration/gangrene)

Question 6

What is indicated by a cyanosed, warm foot which is not infected?

Answer 6

Venous disease

Question 7

If the foot is oedematous, what does this suggest about the origin of claudication pain?

Answer 7

It is venous

Question 8

If pulses are reduced or absent what does this suggest about the origin of claudication pain?

Answer 8

It is arterial

Question 9

What are the common causes of acute limb iscaemia?

Answer 9

1. Embolic- usually cardiac in origin
2. Thrombotic- with occlusion of narrowed athersclerotic arterial segment
3. Compartment syndrome- there is increased pressure in a fascial compartment often followin trauma which compromises the perfusion and viability of the compartmental structures

Question 10

What is the common cardiac association with embolic limb ischaemia?

Answer 10

Atrial fibrillation

Question 11

How does a TIA differ from a stroke?

Answer 11

TIA: symptoms last 24 hours

Question 12

What is the difference between embolic and thrombotic ischaemia in terms of onset and severity

Answer 12

Embolic: sudden acute onset (seconds or minutes) with no history of claudication. Ischaemia is profound as there are no pre-existing collaterals

Thrombotic: Insidious onset over hours or days with history of claudication. The ischaemia is less severe due to pre-existing collaterals

Question 13

What is the most common misdiagnosis for an AAA?

Answer 13

Renal colic- a man >60 with renal colic should be considered to have a ruptured AAA unless proven otherwise

Question 14

What is Raynaud’s syndrome?

Answer 14

Digital ischaemia induced by cold

Question 15

What are the three phases of Raynaud’s disease/syndrome?

Answer 15

1. Pallor: due to digital artery spasm and/or obstruction
2. Cyanosis: due to deoxygenation of static venous blood
3. Redness: due to reactive hyperaemia

Question 16

Why is it important to esquire into sexual activity in patients presenting with some types claudication?

Answer 16

Men with guteal claudication due to internal iliac disease invariably suffer from erectile dysfunction. Patients are often extremely concerned by this symptom but are too embarrassed to mention it

Question 17

Describe Buerger’s test

Answer 17

With the patient lying supine, stand at the foot of the bed. Raise the patient’s feet and support the legs at 45° to the horizontal for 2-3 minutes.

Then ask the patient to sit up and hang his or her legs over the edge of the bed. Watch the patient’s feet for another 2-3 minutes.

Pallor on elevation (with emptying or ‘guttering’ of the superficial veins), followed by reactive hyperaemia (rubor) on dependency, is a positive test and implies significant PAD.

Question 18

Which pulses should be measured in the arms and neck?

Answer 18

Carotid, brachial, radial

Question 19

Why should blood pressure be measured in both arms? What is a normal difference?

Answer 19

It is measured in both arms to look for subclavian artery disease (subclavian steal syndrome)

Discrepancy of 10mmHG or less is normal

If the discrepancy is greater than this the higher value is the true pressure

Question 20

Which pulses are you palpating for in the legs?

Answer 20

Femoral
Popliteal
Posterior tibial
Dorsalis perdis

Question 21

How should you feel for the popliteal pulse?

Answer 21

Flex the patients knee to 30 degress and, with your thumb in front of the knee and two fingers behind, press firmly in the midline over the popliteal artery.

Question 22

How should you feel for the posterior tibial pulse?

Answer 22

Feel 2cm below and 2cm behind the medial malleolus using the pads of your index, middle and ring fingers

Question 23

How should you feel for the dorsalis pedis pulse?

Answer 23

Using the pads of your index, middle and ring fingers, feel in the middle of the dorsum of the foot, just lateral to the tendon of extensor hallucis longus

Question 24

Where should you listen for bruits?

Answer 24

``` Neck region (carotids) Abdomen (renal and aortic) Groin (femoral) ```

Question 25

How is an ABPI measurement carried out?

Answer 25

Use a hand-held Doppler and a sphygmomanometer. The probe is held in turn over the three pedal arteries (posterior tibial, dorsalis pedis, perforating peroneal) while inflating a blood pressure cuff round the ankle. The pressure at which the Doppler signal disappears is the systolic pressure in that artery as it passes under the cuff. The ratio of the highest pedal artery pressure to the highest brachial artery pressure is the ABPI. Normally the ABPI is >1.0 when the patient is supine. Typical values in claudication and critical limb ischaemia are <0.4 respectively. Absolute values may be less informative than the trend over time.

Question 26

What four things do you palpate for in an arterial exam?

Answer 26

Temperature CRT Peripheral pulses Abdominal aorta

Question 27

What do you inspect for during a venous system physical examination?

Answer 27

Colour changes, selling and superfical venous dilatation and tortuosity

Question 28

What do you palpate for during a venous system physical examination?

Answer 28

Differences in temperature Pitting oedema (see how far up the leg the oedema extends)

Question 29

If a patient has pitting oedema in their leg, what should you look for next?

Answer 29

Raised JVP- indicates cardiac disease or pulmonary hypertension is causing oedema

Question 30

What is indicated by ulcers around the medial malleolus?

Answer 30

Venous disease

Question 32

What is suggested by warm varicose veins?

Answer 32

Infection

Question 33

What is indicated by tender, firm varicose veins?

Answer 33

Thrombosis

Question 34

What are the two main venous junctions in the leg?

Answer 34

``` Saphenofemoral junction (SFJ) Saphenopopliteal junction (SPJ) ```

Question 35

What causes pigmentation in venous insufficiency?

Answer 35

Deposition of haemosiderin in the skin from breakdown of extravasated blood

Question 36

What is demonstrated by the cough impulse?

Answer 36

Palpate over the SFJ and then SPJ whil asking the patient to cough. If there is incompetence at either of these junctions it will be felt as an impulse beneath your finger

Question 37

What is the Trendelenburg test?

Answer 37

Ask the patient to sit on the edge of the examination couch and elevate the limb as far as is comfortable for the patient. Then empty the superficial veins by 'milking' the leg. With the patient's leg still elevated, press with your thumb over the saphenofemoral junction. A high thigh tourniquet can be used instead of digital pressure Ask the patient to stand while you maintain pressure over the saphenofemoral junction If saphenofemoral junction is present, the patients varicose veins will not fill until the pressure from the tourniquet is removed. This demonstrates the level of reflux

Question 38

What is the likely cause of a pulsitile mass below the umbilicus?

Answer 38

iliac artery aneurysm

Question 39

What should be done if a popliteal artery is unexpectedly easy to palpate?

Answer 39

Abdominal ultrasound to exclude AAA

Question 40

Why is bandaging for leg ulcers initially contraindicated?

Answer 40

1 in 5 patients with a venous ulcer will have significant arterial disease. Bandaging for leg ulcer is therefore contraindicated unless there is evidence of adequate arterial circulation following ABPI measurement