Vascular

1- ischemic leg:
a) golden periods 4-16 hrs
b) nerves are first structure to be damage
c) angiogram is done in all pt
d) parasthesia pts are more critical than those with pain
2- Below the inguinal ligament, where is the femoral artery
a) medial
b) lateral
c) anterior
d) posterior
e)midpoint
3- Varicose veins will affect all the following except :
a)short saphenous vein.
b)long saphenous veins.
c)popliteal vein
deep vein
d)perforaters.
-Varicose vein can be in all veins, EXCEPT:
a) Long saphenous vein
b) Shod saphenous vein
c) Poploteal vein
d) Perforators
Varicose veins and spider veins are normal veins that have dilated under the influence of increased
venous pressure.
4-Multiple ulcers on the medial aspect of the leg with redness and tenderness around it are
most likely:
a) Venous ulcers.
b) Ischemic ulcers. Pale ulcers
c) Carcinoma.
5- All can complicate excision of abdominal aortic aneurysm, except:
a) Paraplegia
b) Renal failure
c) Hepatic failure
d) Leg ischemia
Presentation
Asymptomatic: Most patients present without an asymptomatic pulsatile abdominal mass (see Image 5). The
aortic bifurcation is located just above the umbilicus. Occasionally, an overlying mass (pancreas or stomach)
may be mistaken for an AAA. An abdominal bruit is nonspecific for a nonruptured aneurysm. Patients with
popliteal artery aneurysms frequently have AAAs (25-50%).
Rupture: Persons with AAAs that have ruptured may present in many ways. The most typical manifestation of
rupture is abdominal or back pain with a pulsatile abdominal mass. However, the symptoms may be vague,
and the abdominal mass may be missed. Symptoms may include groin pain, syncope, paralysis, or flank mass.
The diagnosis may be confused with renal calculus, diverticulitis, incarcerated hernia, or lumbar spine disease.
Peripheral emboli: Atheroemboli from small AAAs produce livedo reticularis of the feet or blue toe syndrome

Acute aortic occlusion: Occasionally, small AAAs thrombose, producing acute claudication.
Aortocaval fistulae: AAAs may rupture into the vena cava, producing large arteriovenous fistulae. In this case,
symptoms include tachycardia, congestive heart failure (CHF), leg swelling, abdominal thrill, machinery-type
abdominal bruit, renal failure, and peripheral ischemia.
Aortoduodenal fistulae: Finally, an AAA may rupture into the fourth portion of the duodenum. These patients
may present with a herald upper gastrointestinal bleed followed by an exsanguinating hemorrhage.
Physical examination
Bilateral upper extremity blood pressures are discernible in patients with AAAs. Hypertension may trigger a workup
for renal artery stenosis. Unequal blood pressures (>30 mm Hg) indicate subclavian artery stenosis, and perioperative
monitoring is important.
Cervical bruits may indicate carotid artery stenosis. Abdominal examination includes palpation of the aorta and an
estimation of the size of the aneurysm. Bruits may indicate the presence of renal or visceral artery stenosis; a thrill is
possible with aortocaval fistulae.
Regarding the peripheral pulses, palpate femoral popliteal and pedal pulses (dorsalis pedis or posterior tibial) to
determine if an associated aneurysm (femoral/popliteal) or occlusive disease exists. Flank ecchymosis (Grey Turner
sign) represents retroperitoneal hemorrhage.
With respect to rectal aspects of the physical examination, guaiac-positive stool is present with associated colon cancer.
Most persons with AAAs are asymptomatic. Patients may describe a pulse in the abdomen and may actually feel a
pulsatile mass. At times, AAAs may cause symptoms from local compression, including early satiety, nausea, vomiting,
urinary symptoms, or venous thrombosis from venous compression. Back pain can be caused by erosion of the AAA
into adjacent vertebrae. Other symptoms include abdominal pain, groin pain, embolic phenomenon to the toes, and
fever. Transient hypotension should prompt consideration of rupture because this finding can progress to frank shock
over a period of hours. Temporary loss of consciousness is also a potential symptom of rupture.
Most clinically significant aneurysms are palpable upon routine physical examination; however, the sensitivity of the
technique is based on the experience of the examiner, the size of the aneurysm, and the size of the patient. In a recent
study, 38% of AAA cases were detected based on physical examination findings, while 62% were detected incidentally
based on radiologic studies obtained for other reasons.
Complications of operation

Death - 1.8-5% if elective and 50% if ruptured

Pneumonia - 5%
Myocardial infarction - 2-5%
Groin infection - Less than 5%
Graft infection - Less than 1%
Colon ischemia - Less than 1% if elective and 15-20% if ruptured
Renal failure related to preoperative creatinine level, intraoperative cholesterol embolization, and hypotension
Incisional hernia - 10-20%
Bowel obstruction
Amputation from major arterial occlusion
Blue toe syndrome and cholesterol embolization to feet
Impotence in males - Erectile dysfunction and retrograde ejaculation (>30%)
Paresthesias in thighs from femoral exposure (rare)
Lymphocele in groin - Approximately 2%
Late graft enteric fistula

6- Varicose veins:
a. Are merely a cosmetic problem.
b. Require ultrasonography for diagnosis.
c. May be effectively treated with elastic stockings.
d. Lead to ulceration of the skin.
e. Are cured for the life of the patient by surgical excision.
7- The key pathology in the pathophysiology of venous ulceration is:
a. The presence of varicose veins.
b. Incomplete valves causing high venous pressure.
c. Transudation of serum proteins.
d. Hemosiderin deposition.
e. Subcutaneous fibrosis.

8- Lymphedema is diagnosed most effectively by:

a. A complete history and physical exam.
b. Duplex ultrasonography.
c. Lymphoscintigraphy.
d. Lymphangiography.
e. Magnetic resonance imaging.
Lymphedema is an abnormal collection of protein-rich fluid in the interstitium due to a defect in the lymphatic drainage
network. Lymphedema most commonly affects the extremities, but it can involve the face, genitalia, or trunk.
Numerous causes, both primary and secondary in nature, have been identified for this condition.
Imaging Studies
Imaging is not necessary to make the diagnosis, but it can be used to confirm it, to assess the extent of involvement,
and to determine therapeutic intervention.

Lymphangiography is an invasive technique that can be used to evaluate the lymphatic system and its patency.
Although it was once thought to be the first-line imaging modality for lymphedema, it is now rarely used
because of the potential adverse effects.
Lymphoscintigraphy is the new criterion standard to assess the lymphatic system. It allows for detailed
visualization of the lymphatic channels with minimal risk. The anatomy and the obstructed areas of lymphatic
flow can be assessed.
Ultrasonography can be used to evaluate the lymphatic and venous systems. Volumetric and structural changes
are identified within the lymphatic system. Venous abnormalities such as deep vein thrombosis can be
excluded based on ultrasonography findings.
MRI and CT scanning can also be used to evaluate lymphedema. These radiologic tests can be helpful in
confirming the diagnosis and monitoring the effects of treatment. They are also recommended when
malignancy is suspected.

9- Splenectomy does not have a role in the management of patients with hemolytic anaemia
due to:
a. Spherocytosis.
b. Elliptocytosis.
c. Pyruvate kinase deficiency.
d. Glucose- 6-phosphate dehydrogenase deficiency.
e. Sickle cell anaemia.
10-Risk of DVT can be decreased by these measures except:
a) discontinue oral contraceptives 7-10 days before surgery
b) daily intake of 1mg warfarin for 10 days
c) early ambulation after major surgery
d) intermittent pneumatic device intraoperative
e) administration of Dextran 70
oral contraceptives should be stopped at least 3-4 weeks before surgery
Prevention of deep venous thrombosis (DVT) has long been studied in a variety of clinical situations with varying
degrees of success.
Primary prophylaxis is directed toward acting on one or more components of the Virchow triad, affecting blood
flow, coagulation, or vessel wall endothelium. Studies have also addressed the timing for the initiation of
prophylaxis and the duration.
Surgical patients undergoing general anesthesia have been extensively studies as described earlier with fatal PE
rates ranging from 0.1-0.8% for all patients29,30 and up to 7% of patients undergoing surgery for fractured hips. 31
Many different forms of therapy have been evaluated in this group.

Intermittent pneumatic leg compression devices work by effectively increasing venous blood flow and
activating the fibrinolytic system.
Studies in cardiac surgery and neurosurgical patients have shown a distinct improvement in the incidence of deep
venous thrombosis (DVT) without the added risk of bleeding. 32,33 However, the effect is less impressive in higherrisk patients, and compliance can be difficult.
Anticoagulants represent another form of primary prophylaxis against venous thrombosis that has been
extensively studies in recent years. The effectiveness of heparin has been established by numerous randomized
clinical trials. Subcutaneous heparin of 5000 units given twice daily has been shown to not only decrease the
incidence of deep venous thromboses (DVTs) but also prevents fatal PE. In one multicenter international trial, fatal
PE was decreased from 0.7% to 0.1%.34
Vitamin K antagonists such as warfarin have also been shown to be an effective form of primary prophylaxis in
high-risk patients. Therapy is often initiated the night prior to surgery; however, the anticoagulation effects of
warfarin do not begin until the third day of use, preventing the propagation of clinically important thrombosis with
less postoperative bleeding complications. Low-molecular weight heparin (LMWH) has been shown to be superior
to both heparin and warfarin in high-risk patients such as those suffering from multitrauma and postorthopedic
surgery.35 Equivalent results were seen in general surgery patients and medical patients. 36,37
Timing and duration of prophylactic agents has also been determined to have a significant effect the development
of deep venous thrombosis. Early prophylaxis in surgical patients with LMWH has been associated with significant
reductions in postoperative venous thrombosis. Studies have shown that initiation of therapy within 8 hours of
surgery has the greatest effect and is currently recommended by the American College of Chest Physicians. 38
Additional recommendations by the ACCP for extended out-of-hospital prophylaxis have been made based on
multiple randomized studies that have demonstrated an additional 7-10 days of anticoagulation decrease
venous thrombosis rates without major bleeding issues.