VASCULAR SURGERY-EMQ-28

Theme: Vascular procedures to the carotid artery

A Right carotid endarterectomy

B Left carotid endarterectomy

C Right carotid artery stenting

D Left carotid artery stenting

E No surgical/endovascular intervention

For each of the scenarios below, choose the most appropriate treatment option from the list above. Each option may be selected once,
more than once or not at all.

Scenario 1

An 85-year-old patient has no symptoms and a 90% stenosis of the left and a 40% stenosis of the right internal carotid artery.

No surgical/endovascular intervention Correct answer

Carotid endarterectomy is indicated for patients with a symptomatic (ie transient ischaemic attack [TIA] or amaurosis fugax) > 70% stenosis of an
internal carotid artery. With regard to asymptomatic but significant internal carotid artery stenosis, a recent randomised trial has shown that surgery
will reduce the risk of stroke from around 12% to 6% over a 5-year period. Most surgeons would therefore not operate on patients with asymptomatic
stenosis who are 80 years of age or older. Carotid stenting is still an experimental procedure and its use is confined to randomised clinical trials;
previous series have shown an unacceptably high stroke rate with carotid stenting compared with surgery.

Scenario 2

An 80-year-old patient complains of amaurosis fugax in the left eye with an 80% stenosis of the right and a 50% stenosis of the left internal carotid
artery.

No surgical/endovascular intervention Correct answer

In this case, the symptoms are not in the territory of the significantly stenosed carotid artery. It is important to remember that amaurosis fugax
(transient, sudden loss of vision) should occur on the same side as the significantly diseased artery, whilst sensory or motor loss in the limbs should
occur contralateral to the diseased artery.

Scenario 3

A 60-year-old patient has no significant past medical history and a 90% stenosis of the left and a 60% stenosis of the right internal carotid artery.

Left carotid endarterectomy Correct answer

As noted for case 1, with regard to asymptomatic but significant internal carotid artery stenosis (> 70% stenosis), recent findings have indicated that
surgery will reduce the risk of stroke from around 12% to 6% over a 5-year period. It could therefore be beneficial to perform left carotid
endarterectomy in this 60-year-old patient.

Scenario 4

A 72-year-old patient complains of recurrent episodes of loss of function of the left upper limb lasting for a few minutes to an hour with 90% stenosis
of both internal carotid arteries.

Right carotid endarterectomy Correct answer

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In this case, the 90% stenosis of the right carotid artery correlates with recurrent transient loss or impairment of function in the contralateral (left)
upper limb. Since symptoms that correlate with significant impairment of the left carotid artery are not being experienced, most surgeons would
consider it appropriate, in a patient of this age, to carry out endarterectomy of the right carotid artery only.

Scenario 5

A 79-year-old patient has made a good recovery from a right-sided cerebrovascular accident and has been found to have a complete occlusion of
the right and a 40% stenosis of the left internal carotid artery.

No surgical/endovascular intervention Correct answer

When assessing patients for carotid surgery, it is important to make sure that their symptoms correlate with the significantly stenosed side. This is
not the case in this patient. Carotid endarterectomy is performed to prevent stroke secondary to embolisation for carotid plaque. If the artery is
occluded, there is no flow and there can therefore be no embolisation. Surgery is thus not indicated for occluded internal carotid arteries.

THEME: LOWER-LIMB ULCERATION

ASquamous cell carcinoma

B Hypertensive ulcer (Martorell syndrome)

C Pyoderma gangrenosum

D Neuropathic ulcer

E Vasculitic ulcer

F Necrobiosis lipoidica

G Sickle cell disease

H Venous ulcer

I Basal cell carcinoma

J Erythema nodosum

For each of the case descriptions below, select the most appropriate diagnosis from the list above. Each option may be used once, more
than once, or not at all.

Scenario 1

A 54-year-old woman with known inflammatory bowel disease presents with a large nodulopustular ulcerating lesion over her right anterior shin. It
has a blue overhanging necrotic edge. Her ankle–brachial pressure indices are normal.

Pyoderma gangrenosum Correct answer

Pyoderma gangrenosum (PG) are recurring nodulopustular ulcers commonly affecting the legs, abdomen and face. They are tender and have a red
or blue overhanging necrotic edge. They heal with cribriform scars. Over 50% of patients with PG have associated underlying active or quiescent
systemic disease – such as inflammatory bowel disease, seronegative rheumatoid arthritis, a lymphoproliferative disease, autoimmune hepatitis or
Wegener’s granulomatosis. The diagnosis of PG is primarily clinical and by exclusion of other causes of cutaneous ulcerations with a similar
appearance; skin histology may help. Treatment is usually with immunosuppressants and corticosteroids.

Scenario 2

A 57-year-old woman with varicose veins presents with a large ulcer over her left medial malleolus. This is associated with surrounding
lipodermatosclerosis and eczema. The ankle–brachial pressure index in this leg is 1. The patient is moderately obese.

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Venous ulcer Correct answer

Venous ulcers may develop spontaneously or following minor trauma. There may be a history of varicose veins, deep venous thrombosis, chronic
venous insufficiency, poor calf-muscle function or arteriovenous fistulae. Other factors predisposing to venous ulceration include obesity, all risk
factors for deep-vein thrombosis, a family history of varicose veins and a history of leg fracture. In long-term venous insufficiency, the skin undergoes
changes (atrophy and variable pigmentation), with the dermis and subcutaneous tissue becoming indurated and fibrosed; this is termed
lipodermatosclerosis. Venous eczema (erythema, scaling, weeping and itching) is a common feature associated with such ulceration; this is distinct
from cellulitis. The ankle–brachial pressure indices are normal in patients with classic venous ulceration.

Scenario 3

A 59-year-old man presents with ulceration over the tips of his toes in his left foot and a large ulcer over his right heel. He also complains of
paraesthesias in both feet. The ankle–brachial pressure indices are 1.05 on the right and 1.2 on the left. On neurological assessment, proprioception
and vibration sense are reduced.

Neuropathic ulcer Correct answer

Neuropathic ulcers can result from peripheral sensory neuropathy secondary to diabetes mellitus. The other causes of altered sensory neuropathy
leading to neuropathic ulcers include spinal cord injuries, spina bifida, tabes dorsalis, syringomyelia, alcohol abuse and leprosy. Neuropathic ulcers
are common at the sites of pressure or repeated trauma. The usual sites in the lower limb are the heads of the metatarsals, the interdigital clefts, the
heel (calcaneum) and the lateral malleolus. In diabetic patients, the ankle–brachial pressure indices may be falsely elevated even in those with major
vessel disease. This is due to calcification of the vessel walls and medial sclerosis. Neurological assessment may reveal altered sensation including
proprioception and two-point discrimination in the foot or toes, reduced vibration sense and absent ankle jerks.

Scenario 4

A 30-year-old woman of Jamaican origin presents with a 4-month history of painful ulceration over her right shin. Ankle–brachial pressure indices are
normal. The patient has mild splenomegaly. Her haemoglobin is 9.2 gm/dl.

Sickle cell disease Correct answer

Sickle cell disease is an hereditary haemolytic anaemia occurring mainly among those of Afro-Caribbean origin. The haemoglobin S molecule
crystallises during reduced blood oxygen tension, causing vascular occlusion. Depending on the affected vessel, patients may have bone or joint
pain, priapism, neurological abnormalities or skin ulcers. The ulceration is due to occlusion of the cutaneous microcirculation, leading to ischaemia
and skin breakdown. In dark-skinned individuals, there may be a non-specific increase in melanin pigmentation around the ulcer, which, if over the
ankle region, may be confused with the discoloration caused by haemosiderin around a venous ulcer. Anaemia and splenomegaly are recognised
features of sickle cell disease

Theme: Lower limb ischaemia

A Surgical embolectomy

B Femoral–popliteal bypass graft

C Angioplasty

D Correct risk factors and conservative management

E Aorta–femoral bypass graft

Select the most appropriate option above for the treatment of the patients below. Each option may be used once, more than once or not at
all.

Scenario 1

A 55-year-old man presenting with a sudden onset of severe pain in his left foot and calf. There is no preceding history of intermittent claudication.
He is unable to move his foot which is now mottled and cold. There are absent pulses below his left knee but a palpable femoral pulsation.
Electrocardiogram (ECG) reveals Q waves with sinus rhythm.

Surgical embolectomy Correct answer

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Scenario 2

A 75-year-old man presents to the outpatient clinic with right buttock and thigh pain after walking 100 yards. He is a smoker of 30 cigarettes per day
with poor cardiac history (3 previous MIs, hypertension and left ventricular failure). Ankle brachial Doppler pressure ratio in the right leg is 0.3 and
that on the left 0.6. Arteriogram shows an isolated 3 cm 80% stenosis in the right common iliac artery with good run-off. There is evidence of 40%
stenosis in the left superficial femoral artery with well-developed collaterals.

Angioplasty Correct answer

Scenario 3

A 65-year-old man has been admitted to the emergency department; when you see him he presents with pain in his foot while at rest. Investigation
reveals 10 cm (superficial femoral artery (SFA) block. The patient has given up smoking and on examination has a good constitution and is
otherwise fit and well.

Femoral–popliteal bypass graft Correct answer

Theme: Lower limb ischaemia

A Femoropopliteal bypass

B Percutaneous balloon angioplasty

C Femorodistal bypass

D Below knee amputation

E Tissue plasminogen activator infusion (intra-arterial)

F Fasciotomy

G No treatment but recommend lifestyle changes

For each of the presentations below, select the most likely single treatment from the options listed above. Each option may be used once,
more than once or not at all.

Scenario 1

A 73-year-old diabetic woman presents with critical ischaemia of the right lower leg. Angiography reveals extensive disease of the superficial
femoral, popliteal and tibial arteries. Pulse-generated run-off assessment indicates a good run-off in the posterior tibial artery.

Femorodistal bypass Correct answer

Femorodistal bypass

Femorodistal bypass using an autogenous vein graft is the treatment of choice in this patient. The absence of images of the posterior tibial, anterior
tibial and common peroneal arteries on angiography films must not be accepted as evidence of their occlusion.

Scenario 2

A 72-year-old man presents with a 4-h history of acute ischaemia of the left leg. Clinical examinations demonstrate signs of acute ischaemia with no
evidence of gangrene. There is no neurological deficit. An urgent angiogram reveals a complete occlusion of the distal superficial femoral artery
probably due to thrombosis.

Tissue plasminogen activator infusion (intra-arterial) Correct answer

Tissue plasminogen activator infusion (intra-arterial)

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Intra-arterial thrombolysis with tissue plasminogen activator (TPA) or streptokinase is the treatment of choice in this patient in view of the short
history (4 h), absence of neurological deficit and angiographic findings.

Scenario 3

A 57-year-old smoker presents with intermittent claudication of the right calf. The claudication distance is 70 m. Angiography reveals a 12 cm
stenosis with run off in the proximal superficial femoral artery.

No treatment but recommend lifestyle changes Correct answer

No treatment but recommend lifestyle changes

BMT and lifestyle. This is single level disease and femoro-distal is not indicated. Femoro-popliteal or angioplasty are options but are unlikely to be
popular at this stage.

Scenario 4

A 21-year-old motorcyclist presents with multiple injuries following a road traffic accident. Clinical examination reveals a critically ischaemic right
lower leg. The right dorsalis pedis pulse is feeble. The right calf is tense and swollen. The intracompartmental pressure is 55 mmHg. Angiography
shows no discontinuity of the arterial tree.

Fasciotomy Correct answer

Fasciotomy

This patient has the compartment syndrome. Urgent fasciotomy is indicated in order to save his right leg.

Theme: The painful lower limb

A Atherosclerosis

B Buerger’s disease

C Chronic venous insufficiency

D Degenerative joint disease

E Deep venous thrombosis

F Embolus

G Polymyalgia rheumatica

H Polymyositis

I Raynaud’s disease

J Ruptured Baker’s cyst

K Sciatica

L Scleroderma

M Septic arthritis

N Superficial thrombophlebitis

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From the list above, select the most likely diagnosis for the following patients who all present with pain in the lower limb. The items may
be used once, more than once, or not at all.

Scenario 1

A 32-year-old man with a long history of intravenous drug abuse attends The Emergency Department with a 4-h history of very severe pain in his left
leg. On examination, the patient is in sinus rhythm. The limb is pale and cold compared to the other side, and only the femoral pulse is present.
Pulses are normal contralaterally.

Embolus Correct answer

F – Embolus

The scenario describes several of the classic clinical features associated with acute limb ischaemia as a result of arterial embolism (pain,
paraesthesia, paralysis, pale, perishing with cold, pulseless). An embolus is the passage of matter from one part of the circulation to another through
a vascular lumen. The commonest sources of arterial emboli arise in the heart (thrombus in atrial appendage secondary to atrial fibrillation), from
mural thrombus on a myocardial infarct, from aneurysms and atherosclerotic plaques. Peripheral emboli may also arise from the heart valves.
Previously, acute endocarditis on a rheumatic heart valve was an important source, but is now rare. More commonly, peripheral emboli occur
secondary to acute bacterial endocarditis after intravenous drug abuse with contaminated needles, as in the clinical case described.

Scenario 2

A 54-year-old woman is referred to clinic with limb pain. She describes a dull ache that is worse at the end of the day, and that affects the right side
more than the left. She has a past history of deep venous thrombosis. On examination, varicose veins are evident in the distribution of the long
sapheous system, and there is brown pigmentation of the skin of the lower third of both legs. There is also a small ulcer superior to the medial
malleolus.

Chronic venous insufficiency Correct answer

C – Chronic venous insufficiency

Chronic venous insufficiency describes a spectrum of disease of the lower limb veins in which venous return is chronically impaired by reflux,
obstruction, or calf pump failure. This results in sustained venous hypertension, which is associated with clinical complications such as oedema,
eczema, lipodermatosclerosis and ulceration. Varicose veins are usually characteristic of this condition, and provide visual confirmation of venous
reflux. However, the absence of visible varicose veins does not exclude the presence of significant superficial reflux. The pain associated with this
condition tends to be worse following prolonged periods of standing (gravitational effects/calf pump not functional), and is relieved by rest and
elevation of the affected limb. In the case described (and most commonly) the insufficiency is secondary to previous venous obstruction of the deep
veins by thrombosis (DVT).

Scenario 3

A 28-year-old man of Chinese origin with a history of calf pain induced by exercise presents to The Emergency Department with gangrene of the left
great toe. He reports a history of preceding calf pain induced by exercise. He is a heavy smoker, but has no other risk factors for atherosclerosis.
Examination reveals absent pedal pulses on the affected side.

Buerger’s disease Correct answer

B – Buerger’s disease

Buerger’s disease (thromboangiitis obliterans) almost exclusively affects young men in their early 20s or 30s who are heavy smokers. It is
particularly common in men of Jewish, Arab, Indian and Chinese origin. It has previously been considered as a variant of accelerated atherosclerosis
but most now regard it as a separate disease process. It involves progressive obliteration of distal, medium-sized arteries of the lower limb,
characterised by transmural round cell infiltration associated with intimal proliferation. Collagen is laid down around the vessels, encasing them in a
thick fibrous coat. Patients usually present with distal gangrene, often preceded by a history of claudication. Popliteal pulses are usually preserved,
but pedal pulses are absent. Arteriography shows normal proximal vessels and distal occlusions with ‘corkscrew’ collaterals. Biopsy of the occluded
vessel provides histological confirmation of the diagnosis.

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Theme: Ulceration in the lower limb

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A Arteriovenous fistula

B Ischaemic ulcer

C Necrobiosis lipoidica

D Neoplastic ulcer

E Neuropathic ulcer

F Pyoderma gangrenosum

G Self-inflicted

H Sickle cell disease

I Syphilis

J Traumatic ulcer

K Tuberculosis

L Vasculitic ulcer

M Venous ulcer

The following scenarios describe patients with leg ulceration. From the above list of causes of ulceration, choose the most appropriate
answer. Each item may be used once, more than once, or not at all.

Scenario 1

A 55-year-old diabetic man presents with a large painless ulcer on the sole of his foot. On examination, the ulcer appears deep with healthy
surrounding skin. The foot feels warm and his ankle-brachial pressure index is 0.8.

Neuropathic ulcer Correct answer

E – Neuropathic ulcer

These ulcers occur in denervated tissue and result from local ischaemia, usually caused by non-perceived local trauma. They are characteristically
painless and have a good blood supply (although diabetic neuropathy being a common cause may also lead to large-vessel atherosclerosis,
resulting in a mixed picture of arterial and neuropathic ulceration). The causes of neuropathic ulceration may be divided into peripheral nerve lesions
and spinal cord lesions. The former consist of diabetes, nerve injuries and leprosy, while spina bifida, tabes dorsalis and syringomyelia comprise the
second group.

Scenario 2

A 27-year-old man presents with abdominal pain, bloody diarrhoea and weight loss. On examination he is noted to have some areas of necrotising
ulceration surrounded by erythema over his legs, which are acutely painful.

Pyoderma gangrenosum Correct answer

F – Pyoderma gangrenosum

This man may have undiagnosed ulcerative colitis. The lesions at first resemble boils, which subsequently break down to form necrotic ulcers with
purple edges. Pyoderma gangrenosum is also associated with rheumatoid arthritis, multiple myeloma and leukaemia.

Scenario 3

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A 60-year-old lady presents with brown discoloration of both calves and a large left medial malleolar ulcer. A central raised patch of friable, irregular,
nodular growth is noted.

Neoplastic ulcer Correct answer

D – Neoplastic ulcer

This woman has a Marjolin’s ulcer or a squamous cell carcinoma arising from chronic inflammation in a long-standing benign ulcer or scar. This
commonly occurs in a venous ulcer making constant review of such patients important.

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Theme: The swollen lower limb

A Angio-oedema

B Congestive cardiac failure

C Chronic renal failure

D Chronic liver failure

E Chronic venous insufficiency

F Deep venous thrombosis

G Factitious oedema

H Klippel–Trenaunay syndrome

I Malabsorption

J Malnutrition

K Milroy’s disease

L Obesity

M Primary lymphoedema

N Secondary lymphoedema

O Venous obstruction

The following patients all present with swelling affecting the lower limb. From the list above, select the most likely diagnosis. The items
may be used once, more than once, or not at all.

Lymphoedema is an accumulation of tissue fluid secondary to a fault in the lymphatic system (abnormalities of lymph formation or lymph clearance).
This may be primary, in the absence of other causes, or secondary to malignant disease, surgery (eg post-radical mastectomy/groin dissection),
radiotherapy or infection (filariasis, pyogenic tuberculosis). The differential diagnosis of lymphoedema includes other causes of tissue oedema, which
may be broadly classified as:

• systemic disorders, eg cardiac/renal/liver failure, hereditary angiooedema, etc

• venous disorders, eg post-thrombotic syndrome, extrinsic compression (pregnancy/tumour/retroperitoneal fibrosis), Klippel–Trenaunay
syndrome
• miscellaneous disorders, eg arteriovenous malformations, factitious oedema etc.

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Scenario 1

A 21-year-old woman is referred to clinic with a history of intermittent oedema of the face and extremities. Her mother also suffers with similar
symptoms.

Angio-oedema Correct answer

A – Angio-oedema

Hereditary angio-oedema is inherited as an autosomal dominant condition. It arises as a result of a deficiency in the complement system regulation,
and is characterised by recurrent attacks of swelling of the face and extremities that subsequently resolve. The oedema is often associated with
erythema.

Scenario 2

A 14-year-old boy is referred to clinic for assessment of varicose veins and associated swelling of his left leg. As he enters the consultation room you
note that he has a ‘short-leg’ gait. His varicose veins are large and do not lie in a typical distribution.

Klippel–Trenaunay syndrome Correct answer

2 H – Klippel–Trenaunay syndrome

This syndrome is characterised by dilated veins, associated with bony and soft tissue deformity, elongation of the limb, capillary naevi and limb
oedema. There are no arterial abnormalities. The diagnosis is suggested as varicose veins are present since birth or early childhood, and are often
present on the outside of the leg, not the inner side where most varicose veins appear.

Scenario 3

A 48-year-old woman presents with a history of unilateral swelling of the right leg. There is no history of venous obstruction. Her general practitioner
has sent copies of recent full blood counts, urea & electrolytes, and liver function tests, all of which are normal. Isotope lymphography demonstrates
delayed transit of radionuclide on the right side.

Primary lymphoedema Correct answer

M – Primary lymphoedema

Primary lymphoedema may be classified as:

• congenital – when it occurs soon after birth (and is hereditary in some cases; Milroy’s disease)
• praecox – presenting up to the age of 35 years
• tarda – when it presents over the age of 35 years, as in this case.

It has been suggested that these groups represent different parts of the same spectrum of disease, which has been attributed to aplasia, hypoplasia,
or hyperplasia of the lymph vessels. Once other causes of oedema have been excluded, the diagnosis of primary lymphoedema may be confirmed
using isotope lymphography, computed tomography scanning, magnetic resonance imaging, or contrast lymphangiography. The aims of treatment
are to reduce limb swelling and weight, reduce the risk of infection, and improve function. This may be achieved using conservative measures
(elevation/compression of affected limb). Surgical intervention involves debulking (of excess skin and subcutaneous tissue) or bypass procedures
(where regional blockade of lymphatics is evident).

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Theme: Management of peripheral vascular disorders

A Above-knee amputation

B Aortofemoral bypass

C Atherosclerosis risk factor reduction

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D Below-knee amputation

E Femorodistal bypass

F Femorofemoral bypass

G Femoropopliteal bypass

H Intraluminal stenting

I Long saphenous vein surgery

J Percutaneous thrombolytic thromboembolectomy

K Percutaneous transluminal angioplasty

L Sclerotherapy

M Short saphenous vein surgery

N Surgical thromboembolectomy

The following are descriptions of patients with peripheral vascular disorders. Please select the most appropriate treatment from the above
list. The items may be used once, more than once, or not at all.

Scenario 1

A 57-year-old man presents with left-sided cramping calf pain after walking approximately 100 metres. Examination of both lower limbs reveals no
significant abnormalities.

Atherosclerosis risk factor reduction Correct answer

C – Atherosclerosis risk factor reduction

This patient has intermittent claudication, a symptom of chronic lower limb atherosclerosis. Initial management involves: risk factor reduction,
including cessation of smoking, lipid-lowering drugs, anti-platelet medication, good diabetic control if appropriate; regular exercise as part of a
supervised exercise programme and weight loss. Surgical intervention is only indicated when the patient has disabling claudication, critical limb
ischaemia, ulcers, or gangrene. The two main options are: percutaneous angioplasty (preferable) or bypass surgery.

Scenario 2

A 64-year-old man presents with sudden onset of severe left-sided calf pain. On examination his left foot is pale and cold; on the affected side he
has no palpable pulses below the femoral pulse. He is currently recovering from a recent cerebrovascular accident.

Surgical thromboembolectomy Correct answer

N – Surgical thromboembolectomy

This patient has a classic presentation of acute lower ischaemia, with four of the six Ps: pallor, pulselessness, paraesthesia, paralysis, ‘perishing’
cold and pain. Percutaneous thrombolytic thromboembolectomy is the treatment of choice unless contraindicated, as in this scenario, in which case
the patient should procede to surgical thromboembolectomy. Contraindications to thrombolysis include: cerebrovascular accident within the past 2
months, recent surgery, or previous thrombolytic therapy.

Scenario 3

A 37-year-old woman presents with prominent unsightly leg veins, which cause discomfort on prolonged standing. Examination reveals tortuous
dilated subcutaneous veins along the medial aspect of the right calf; tourniquet tests indicate that when tied around the upper thigh and again just

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above the knee, the varicosities refill upon standing; however, when tied just below the knee they are controlled. She is currently taking oral
contraception.

Short saphenous vein surgery Correct answer

M – Short saphenous vein surgery

This patient has a classic presentation of symptomatic varicose veins. Injection sclerotherapy is not applicable, first as it is contraindicated in those
taking oral contraceptives, and second as it only provides short-term benefit in those with major incompetence of either long or short saphenous
veins. The tourniquet test clearly indicates short saphenous incompetence, hence the need for short saphenous ligation and stripping. General
consensus would suggest that duplex scanning should be performed to confirm the diagnosis and to site the junction for surgery (this is not
necessary for long-saphenous disease unless the veins are recurrent).

Theme: ankle brachial pressure index (ABPI)

A 1.1
B 0.7
C 0.4
D 0.1
E Incompressible

For each of the patients below, choose the most likely ABPI value from the list above. Each option may be selected once, more than once
or not at all.

Clinical presentation: ankle brachial index

· normal > 0.90

· claudication 0.50–0.90

· rest pain 0.21–0.49

· tissue loss < 0.20

• > 1.25, commonly seen in diabetics.

Scenario 1

Walks unlimited distances

1.1 Correct answer

Scenario 2

Poorly controlled diabetic with ingrowing toe nail

Incompressible Correct answer

Scenario 3

Claudicates at 200 yards

0.7 Correct answer

Scenario 4

Rest pain both day and night, as well as gangrene of the first and second toes

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0.1 Correct answer

Scenario 5

Rest pain at night but no ulcers or gangrene

0.4 Correct answer

Theme: Aortic bypass grafting

A Aortobifemoral bypass

B Axillobifemoral bypass

C Femoral-to-femoral crossover

D Left iliac angioplasty

E Left iliac angioplasty and femoral crossover

For each of the patients described below, select the procedure of choice from the list of options above. Each option may be used once,
more than once, or not at all.

An aortobifemoral bypass graft has the highest patency rate of any bypass procedures to the femoral vessels. An axillobifemoral bypass
graft should only be considered in the very high-risk surgical patient who has critical ischaemia. It should not be performed in patients
with claudication.

Scenario 1

A 50-year-old man has a 50-yard (~45 m) claudication distance, with complete occlusion of the lower aorta, with patent femoral vessels.

Aortobifemoral bypass Correct answer

A – Aortobifemoral bypass

Scenario 2

A 79-year-old man with emphysema requires home oxygen. He has complete occlusion of the aorta, with patent femoral vessels. His toes appear
gangrenous and dusky.

Axillobifemoral bypass Correct answer

B – Axillobifemoral bypass

Scenario 3

A 43-year-old postman, otherwise fit and well, who is a non-smoker presents with acute onset claudication in both feet – he is determined to go back
to work. He has an aortic bifurcation block with good femoral run-off on both sides.

Aortobifemoral bypass Correct answer

A – Aortobifemoral bypass

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Theme: Lower limb ischaemia

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A Below-knee amputation

B Fasciotomy

C Femorodistal bypass

D Femoropopliteal bypass

E Lifestyle changes only

F Percutaneous balloon angioplasty

G Tissue plasminogen activator (TPA) infusion (intra-arterial)

For each of the presentations below, select the most likely single treatment from the options listed above. Each option may be used once,
more than once, or not at all.

Scenario 1

A 65-year-old man presents with intermittent claudication of the left calf. His claudication distance is 50 yards (~45 m). Angiography demonstrates a
1.5-cm stenosis of the left superficial femoral artery.

Percutaneous balloon angioplasty Correct answer

F – Percutaneous balloon angioplasty

Percutaneous balloon angioplasty is particularly suitable for localised stenoses and short occlusions. Lesions in the larger proximal vessels (above
knee) are technically easier to treat, with fewer complications and better long-term results.

Scenario 2

A 73-year-old diabetic presents with critical ischaemia of the right lower leg. Angiography reveals extensive disease of the superficial femoral,
popliteal and tibial arteries. Pulse-generated, run-off assessment indicates a good run-off in the posterior tibial artery.

Femorodistal bypass Correct answer

C – Femorodistal bypass

Femorodistal bypass using an autogenous vein graft is the treatment of choice in the second patient. Absence of contrast in the posterior tibial,
anterior tibial and common peroneal arteries on angiography films must not be accepted as evidence of their occlusion.

Scenario 3

A 72-year-old man presents with a 4-hour history of acute ischaemia of the left leg. Clinical examination demonstrates signs of acute ischaemia with
no evidence of gangrene, mottling or neurological deficit. An urgent angiogram reveals a complete thrombotic occlusion of the distal superficial
femoral artery.

Tissue plasminogen activator (TPA) infusion (intra-arterial) Correct answer

G – Tissue plasminogen activator (TPA) infusion (intra-arterial)

Intra-arterial thrombolysis with TPA is the treatment of choice in the third patient in view of the short history (4 hours), angiographic findings and
absence of neurological deficit.

Scenario 4

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A 57-year-old smoker has a history of intermittent claudication of his right calf. His claudication distance is 0.5 mile (~0.8 km). Angiography reveals a
12-cm stenosis in the proximal superficial femoral artery. This has had no effect on his lifestyle, work or social activities.

Lifestyle changes only Correct answer

E – Lifestyle changes only

The initial treatment of intermittent claudication is correction of risk factors, such as diabetes, hypertension, smoking and exercise. Younger non-
smokers should have a thrombotic screen performed on presentation. Critical ischaemia is defined by rest-pain of at least 2 weeks’ duration that
requires regular adequate analgesia, or ulceration or gangrene of the foot or toes with an ankle pressure of < 50 mmHg or a toe pressure of < 30
mmHg.

Scenario 5

A 21-year-old motorcyclist presents with multiple injuries following a road traffic accident. Clinical examination reveals a critically ischaemic right
lower leg. The right dorsalis pedis pulse is weak. His right calf is tense and swollen. The intracompartmental pressure is 55 mmHg. Angiography
shows no discontinuity of the arterial tree.

Fasciotomy Correct answer

B – Fasciotomy

The fifth patient has compartment syndrome. Urgent fasciotomy is indicated in order to save his right leg.

Theme: Lower limb venous disease

A Compression bandaging

B Elevation, rest, NSAIDs and antibiotics

C Emergency surgery

D IV heparin

E Warfarinisation

For each of the patients described below, select the treatment of choice from the list of options above. Each option may be used once,
more than once, or not at all.

Scenario 1

A woman has thrombosed varicose veins and cellulitis.

Elevation, rest, NSAIDs and antibiotics Correct answer

B – Elevation, rest, NSAIDs and antibiotics

The woman with thrombosed varicose veins and cellulitis should be treated with elevation, rest, NSAIDs and antibiotics.

Scenario 2

A woman develops a swollen and tender left leg 5 days after surgery.

IV heparin Correct answer

D – IV heparin

14
One should also suspect a deep-vein thrombosis in a patient with a swollen and tender leg post-operatively. It is best to perform some imaging
(duplex Doppler study) before commencing treatment for this second scenario.

Scenario 3

A 64-year-old woman, who is a known case of venous insufficiency, presents with hypotension and profuse bleeding from the medial malleolus of the
right leg. Conservative treatment has failed.

Emergency surgery Correct answer

C – Emergency surgery

A patient with venous insufficiency and profuse bleeding from an ulcer should have emergency surgery to stop the bleeding.

Theme: Carotid artery disease

A Carotid angiogram

B Carotid Doppler

C CT scan

D ECG

What initial investigation would you perform for each of the patients listed below? Each option may be used once, more than once, or not
at all.

Scenario 1

A 71-year-old man presents with a normal pulse, left carotid bruit and left TIAs.

Carotid Doppler Correct answer

B – Carotid Doppler

Thirty per cent of carotid bruits heard on auscultation are not because of carotid stenosis. The initial investigation that should be performed here is a
Doppler ultrasound scan. This may be followed by digital subtraction angiography or magnetic resonance angiography (MRA), but many centres will
rely on colour duplex Doppler alone if performed by an experienced operator.

Scenario 2

A 71-year-old man presents with a normal pulse, left carotid bruit and a dense left hemiplegia.

CT scan Correct answer

C – CT scan

In cases where a persistent neurological deficit has occurred a CT scan must be carried out initially to exclude a space-occupying lesion.

Theme: Vascular tumours

A Angiosarcoma

B Chemodectoma

C Leiomyomas

15
D Glomus jugulare tumour

E Kaposi’s sarcoma

Match the most appropriate feature above with the list below. Each option may be used once, more than once, or not at all.

Scenario 1

Carotid artery

Chemodectoma Correct answer

B – Chemodectoma

Chemodectomas originate from paraganglionic cells at the carotid bifurcation. If untreated, 5% metastasise within 10 years.

Scenario 2

Rapid growing, bulky

Angiosarcoma Correct answer

A – Angiosarcoma

Angiosarcomas usually develop in the extremities. Although they are radiosensitive and respond to chemotherapy, radical amputation is still advised.

Scenario 3

Blue-red macule with HIV

Kaposi’s sarcoma Correct answer

E – Kaposi’s sarcoma

A Kaposi’s sarcoma is a haemangiosarcoma, treated with a combination of chemo- and radiotherapy.

Scenario 4

Buzzing sensation in head

Glomus jugulare tumour Correct answer

D – Glomus jugulare tumour

A glomus jugulare tumour arises at the jugular bulb. Excision is associated with palsies of cranial nerves X, XI and XII. It should not be confused with
a glomus tumour, which is the only true benign blood vessel tumour (cavernous haemangiomas are dilated blood spaces with thin walls, and port-
wine stains/telangiectasias are capillary malformations). Most glomus tumours occur on the upper limbs, especially the digits.

4831

Theme: Leg ulcers

A Arterial

B Diabetic

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C Neoplastic

D Postphlebitic

E Venous

For each of the patient scenarios below, select the aetiology of the most likely ulcer from the above list. Each option may be used once,
more than once, or not at all.

Leg ulcers often have multiple aetiologies. The aetiology is usually apparent from taking a clear history and identifying the site of the ulcer. The most
common causes of leg ulcers are venous, mixed, arterial, neuropathic, vasculitic (including rheumatoid arthritis) and neoplastic. Venous and
postphlebitic ulcers tend to be situated in the gaiter area and have sloping edges.

Arterial ulcers have punched-out edges and often occur at pressure areas at the extremities, eg toes.

Diabetic ulcers often occur at the site of trauma or ill-fitting shoes. Neoplastic ulcers have raised, rolled or everted edges and may occur anywhere.

Scenario 1

A 72-year-old woman presents with a 2-year history of an intermittently healing, shallow ulcer above the right medial malleolus. The surrounding skin
has a brown discoloration. Ten years previously, she was involved in an RTA and sustained pelvic fractures, which were treated with traction and
bedrest.

Postphlebitic Correct answer

D – Postphlebitic

Scenario 2

A 68-year-old man presents with a deep, painless ulcer beneath the heel of his right foot, which has gradually deteriorated in the two months since
his admission for pneumonia. The ulcer is surrounded by wet macerated skin and culture has grown MRSA and Pseudomonas species.

Diabetic Correct answer

B – Diabetic

Scenario 3

A 94-year-old man presents with a deep, painful ulcer at the tip of his great toe. He has gradually been getting less mobile over the last few months
and the pain in his toe prevents him from sleeping.

Arterial Correct answer

A – Arterial

Theme: Carotid artery disease

A Carotid angiography

B Carotid duplex

C CT head

D MRI head

E Right carotid endarterectomy

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F Left carotid endarterectomy

For each of the patients described below, select the most likely intervention from the list of options above. Each option may be used once,
more than once, or not at all.

Patients with carotid territory TIAs, amaurosis fugax or a stroke (with subsequent recovery), and a > 70% stenosis should be offered endarterectomy.
The risks of the operation are less than the risk of suffering a disabling stroke, providing the operation is performed within 6 months of the stroke.
Endarterectomy should carry a mortality of < 2%, and a 1-2% risk of stroke. It is normally too late to operate on completely occluded arteries.
Patients with lesser degrees of stenosis should be given antiplatelet drug therapy.

A young patient with optic neuritis and foot drop should first have an MRI scan of the brain to look for demyelinating disease.

Scenario 1

A patient has a resolving right-sided CVA. A carotid duplex shows 99% stenosis of the left internal carotid artery and a completely occluded right
internal carotid artery.

Left carotid endarterectomy Correct answer

F – Left carotid endarterectomy

Scenario 2

A 30-year-old patient with optic neuritis develops foot drop.

MRI head Correct answer

D – MRI head

Scenario 3

A resolving recent left-sided hemiparesis with 90% right internal carotid artery stenosis.

Right carotid endarterectomy Correct answer

E – Right carotid endarterectomy

Theme: Varicose veins

A Compression and warfarin

B Elevation and NSAIDs

C IV heparin

D Varicose vein surgery

For each of the patients described below, select the most likely intervention from the list of above options. Each option may be used once,
more than once, or not at all.

Scenario 1

A 54-year-old man presents with varicose veins and a bleeding varicose ulcer.

Varicose vein surgery Correct answer

D – Varicose vein surgery

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Varicose veins must be dealt with surgically if they are suspected of causing an ulcerating lesion that is bleeding intermittently – this should be done
promptly.

Scenario 2

A 30-year-old woman presents with varicose veins and an acute episode of thrombophlebitis.

Elevation and NSAIDs Correct answer

B – Elevation and NSAIDs

Episodes of thrombophlebitis are best treated by elevation, analgesics (NSAIDs are useful) and external elastic support

Scenario 3

A 45-year-old woman presents with varicose veins and a swollen leg. Duplex confirms a DVT.

IV heparin Correct answer

C – IV heparin

On confirmation of a DVT, patients should be started on intravenous heparin as soon as possible. Intravenous heparin has been the mainstay of
treatment; however, patients are frequently treated with low-molecularweight heparins on an outpatient basis before starting warfarin therapy.
Warfarin therapy aims to prevent the formation of clots; heparin aims to prevent their propagation and dispersal.

Theme: Lower limb ischaemia

A Angioplasty

B Aortofemoral bypass graft

C Correct the risk factors and provide conservative treatment

D Femoropopliteal bypass graft

E Surgical embolectomy

Select the most appropriate option above for the treatment of the patients below. Each option may be used once, more than once, or not
at all.

Scenario 1

A 55-year-old man presents with a sudden onset of severe pain in his left foot and calf. There is no preceding history of intermittent claudication but
he experienced a myocardial infarction two weeks ago. He is unable to move his foot, which is now mottled and cold. There are absent pulses below
his left knee but a palpable femoral pulse. ECG reveals Q waves with sinus rhythm.

Surgical embolectomy Correct answer

E – Surgical embolectomy

The first patient is likely to have had a mural thrombus post MI that has embolised to his leg. He may also have been in atrial fibrillation previously.
As he has critical ischaemia, surgical embolectomy is indicated.

Scenario 2

A 75-year-old man presents to the outpatient clinic with right buttock and thigh pain when walking 100 yards. He smokes 30 cigarettes per day and
has a poor cardiac history (three previous MIs, hypertension and left ventricular failure). Ankle brachial Doppler pressure ratio in the right leg is 0.3

19
and that on the left 0.6. An arteriogram shows an isolated 3 cm 80% stenosis in the right common iliac artery with good run-off. There is evidence of
40% stenosis in the left superficial femoral artery with well-developed collaterals.

Angioplasty Correct answer

A – Angioplasty

Angioplasty is useful for short stenoses. This has better results for proximal stenosis above the inguinal ligament. For occluded vessels the
procedure is now possible in specialist centres using cutting-balloon or subintimal angioplasty techniques.

Scenario 3

A 65-year-old man presents with pain in his foot when at rest. He has given up smoking and is otherwise fit and well. Angiography shows a 10-cm
block in the superficial femoral artery with good distal run-off.

Femoropopliteal bypass graft Correct answer

D – Femoropopliteal bypass graft

A patient with rest pain has critical ischaemia and needs urgent intervention. A 10-cm stenosis is too long for a successful angioplasty. A good distal
run-off would allow distal bypass grafting. The SFA is the commonest site for lower limb atherosclerosis because the vessel narrows as it passes
through the adductor hiatus.

4836Theme: 5-year graft patency rates

A Aortobifemoral graft

B Axillofemoral graft

C Femoral–femoral crossover graft

D Femoropopliteal PTFE graft patency (below knee)

E Reversed vein femoropopliteal graft

For each of the percentages below, select the most likely single graft from the options listed above. Each option may be used once, more
than once, or not at all.

Patency rates are related to the force and volume of the inflow and the runoff away from the graft. If the run-off is poor then blood that
passes into the graft will be functionless; therefore, flow will be greatly reduced so leading to graft occlusion and failure. Synthetic grafts
used below the inguinal ligament are vastly inferior to vein grafts.

Scenario 1

70%

Reversed vein femoropopliteal graft Correct answer

E – Reversed vein femoropopliteal graft

Scenario 2

80%

Femoral–femoral crossover graft Correct answer

C – Femoral–femoral crossover graft

20
Scenario 3

60%

Axillofemoral graft Correct answer

B – Axillofemoral graft

Scenario 4

35%

Femoropopliteal PTFE graft patency (below knee) Correct answer

D – Femoropopliteal PTFE graft patency (below knee)

Scenario 5

90%

Aortobifemoral graft Correct answer

A – Aortobifemoral graft

4837

Theme: Lower limb ulceration

A Basal cell carcinoma

B Erythema nodosum

C Hypertensive ulcer (Martorell’s ulcer)

D Necrobiosis lipoidica

E Neuropathic ulcer

F Pyoderma gangrenosum

G Sickle cell disease

H Squamous cell carcinoma

I Vasculitic ulcer

J Venous ulcer

For each of the following profiles, select the most likely cause of the ulcer from the above list. Each option may be used once, more than
once, or not at all.

Scenario 1

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A 54-year-old lady with known inflammatory bowel disease presents with a large nodulo-pustular ulcerating lesion over her right anterior shin. It has
a blue overhanging necrotic edge. The arterial blood pressure index (ABPI) is normal.

Pyoderma gangrenosum Correct answer

F – Pyoderma gangrenosum

Pyoderma gangrenosum is recurring nodulo-pustular ulceration that commonly affect the legs, abdomen and face. The ulcers are tender with a red-
blue overhanging necrotic edge and they heal with cribriform scars. Pyoderma gangrenosum is associated with inflammatory bowel disease, acute
leukaemia, polycythaemia rubra vera, autoimmune hepatitis, Wegener’s granulomatosis and myeloma.

Scenario 2

A 57-year-old obese lady with varicose veins presents with a large ulcer over her left medial malleolus. This is associated with surrounding
lipodermatosclerosis and eczema. The ABPI in this leg is 1.05.

Venous ulcer Correct answer

J – Venous ulcer

Venous ulcers may develop spontaneously or following a minor injury. Risk factors include past history of varicose veins and deep-venous
thrombosis (DVT); all causes of varicose veins or DVT may therefore predispose to venous ulceration. Venous incompetence leads to a high venous
pressure which causes pericapillary fibrin deposition, white cell activation and increased production of free radicals. All these factors contribute to
skin breakdown, causing ulceration. These ulcers usually lie proximal to the medial or lateral malleolus, although they may extend to the ankle or
dorsum of the foot. Lipodermatosclerosis frequently accompanies long-standing venous incompetence. Increased exudates leads to venous eczema,
excoriation of the surrounding skin, itch and worsening of the ulcer.

Scenario 3

A 59-year-old man presents with ulceration over the distal tips of three toes in his left foot and over his right heel. He also complains of paraesthesia
in both his feet. The ABPI is 1.02 on the right and 1.16 on the left. On neurological assessment, proprioception and vibration sense are reduced.

Neuropathic ulcer Correct answer

E – Neuropathic ulcer

Neuropathic ulcers can result from peripheral sensory neuropathy secondary to diabetes mellitus. The other causes for altered sensory neuropathy,
leading to neuropathic ulcers include: spinal cord injuries, spina bifida, tabes dorsalis, syringomyelia, alcohol abuse and leprosy. Neuropathic ulcers
are common at the sites of pressure or repeated trauma. The usual sites in the lower limb are the head of the metatarsals, interdigital clefts, heel
(calcaneum) and the lateral malleolus. In diabetic patients, the arterial blood pressure index (ABPI) may be falsely elevated, because of calcification
of the vessel walls and medial sclerosis, even in those with major vessel disease. Neurological assessment of the foot and toes may reveal altered
sensation including proprioception and two-point discrimination, reduced vibration sense and absent ankle jerks.

Scenario 4

A 30-year-old Afro-Caribbean lady presents with a 4-month history of a painful ulcer over her right shin. ABPIs are normal. She is anaemic and has
mild splenomegaly.

Sickle cell disease Correct answer

G – Sickle cell disease

Sickle cell disease is hereditary haemolytic anaemia occurring mainly among those of Afro-Caribbean origin. The haemoglobin ‘S’ molecule
crystallises during reduced blood oxygen tension causing vascular occlusion. Depending on the affected vessel, patients may have bone or joint
pain, priapism, neurological abnormalities, skin ulcers. Ulceration is due to occlusion of the cutaneous microcirculation, leading to ischaemia and skin
breakdown. In dark-skinned individuals, there may be a non-specific increase in melanin pigmentation around the ulcer which, if over the ankle
region, may be confused with haemosiderin discoloration around a venous ulcer.

Theme: level of arterial disease and location of symptoms

22
A Aorto-iliac occlusion
B External iliac/common femoral occlusion
C Superficial femoral artery occlusion
D Crural vessel occlusion
E Aorto-iliac occlusion and superficial femoral artery occlusion

For each of the patients below, choose the most likely level of arterial disease from the list above. Each option may be selected once,
more than once or not at all.

Claudication pain usually occurs in the muscle group just distal to the diseased artery. Tissue loss usually only results when there is disease at more
than one level.

Scenario 1

Rest pain and foot ulcers

Aorto-iliac occlusion and superficial femoral artery occlusion Correct answer

Scenario 2

Impotence

Aorto-iliac occlusion Correct answer

Scenario 3

Calf claudication

Superficial femoral artery occlusion Correct answer

Scenario 4

Thigh claudication

External iliac/common femoral occlusion Correct answer

Scenario 5

Buttock claudication

Aorto-iliac occlusion Correct answer

Theme: type of intervention

A Best medical treatment and exercise

B Angioplasty and stenting
C Aorto-bifemoral graft
D Axillo-bifemoral graft
E Amputation

For each of the patients below, choose the most appropriate management from the list above. Each option may be selected once, more
than once or not at all.

Patients with claudication do not require radiological/surgical intervention unless it interferes with their life style and they are willing to accept the
small but significant risks associated with the procedures involved. Iliac angioplasty/stenting does achieve very good results with low complication
rates in those patients with short occlusions. Patients with critical limb ischaemia require revascularisation to prevent them from loosing their leg in
the near future. What they are offered depends on the length of the occlusion (surgery vs angioplasty) and on their level of fitness (aortic vs extra-
anatomical bypass). Patients who are unlikely to walk in the future may be better managed with a primary amputation.

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Scenario 1

A 60-year-old patient; no significant past medical history; bilateral rest pain; complete occlusion of both common and external iliac arteries

Aorto-bifemoral graft Correct answer

Scenario 2

An 82-year-old patient; bed-bound secondary to right-sided cerebro-vascular accident; extensive gangrene of right foot; complete occlusion of both
common and external iliac arteries

Amputation Correct answer

Scenario 3

A 79-year-old patient; history of coronary heart disease and impaired renal function; bilateral gangrenous toes; complete occlusion of both common
and external iliac arteries

Axillo-bifemoral graft Correct answer

Scenario 4

A 70-year-old patient; sedentary life style; claudicates at 400 yards; short occlusions of both common iliac arteries

Best medical treatment and exercise Correct answer

Scenario 5

A 79-year-old patient; enthusiastic golfer; claudicates at 100 yards; short occlusions of both common iliac arteries

Angioplasty and stenting Correct answer

Theme: medications used in those patients with peripheral vascular disease

A Cilostazol
B Aspirin
C Clopidogrel
D Simvastatin
E Losartan

For each of the statements below, choose the most appropriate drug from the list above. Each option may be selected once, more than
once or not at all.

Aspirin inhibits prostaglandin synthesis to prevent the formation of platelet-aggregating substance thromboxane A2. Clopidogrel blocks the
adenosine phosphate (ADP) receptors, which prevents fibrinogen binding to the receptor. These decrease the ability of platelet adhesion and
aggregation. Simvastatin and the other statins reduce cholesterol biosynthesis, mainly in the liver, where they are selectively distributed, by inhibiting
HMG–CoA reductase. Cilostazol is said to be a phosphodiesterase inhibitor. This increases the levels of cyclic AMP thereby decreasing platelet
function, relaxing vascular smooth muscle and increasing lipoprotein lipase activity. It is contraindicated in those patients with ischaemic heart
disease.

Scenario 1

Angiotensin–II receptor antagonist

Losartan Correct answer

Scenario 2

Stabilises atheromatous plaque

24
Simvastatin Correct answer

Scenario 3

Reduces serum levels of LDL cholesterol

Simvastatin Correct answer

Scenario 4

Cyclo-oxygenase inhibitor

Aspirin Correct answer

Scenario 5

Phosphodiesterase inhibitor

Cilostazol Correct answer

Theme: supra-aortic arterial surgey

A Carotid-carotid bypass
B Carotid-subclavian bypass
C Carotid endarterectomy
D Superficial temporal artery-middle cerebral artery bypass
E Thoracic-outlet decompression

For each of the pathologies below, choose the procedure from the list above that may be required to deal with the condition. Each option
may be selected once, more than once or not at all.

Superficial temporal artery to middle cerebral artery bypass is now an obsolete procedure. Carotid endarterectomy is indicated for both symptomatic
and asymptomatic internal carotid artery stenosis >70%. Stenting of thoracic aneurysms is becoming preferable to open surgery due to its much
lower peri-/post-operative mortality. If the aneurysm is close to the origins of the left subclavian and left carotid vessels, these may be covered by the
stent as long as a carotid–carotid bypass is performed before stenting, thereby preventing a left cerebrovascular accident. The left subclavian can
usually be covered without impunity. Paget–Schroetter syndrome (axillary vein thrombosis) is likely to recur unless the thoracic outlet is
decompressed.

Scenario 1

Subclavian steal syndrome

Carotid-subclavian bypass Correct answer

Scenario 2

Amaurosis fugax

Carotid endarterectomy Correct answer

Scenario 3

Unilateral 95% stenosis of the carotid bifurcation

Carotid endarterectomy Correct answer

Scenario 4

25
Paget–Schroetter syndrome (axillary vein thrombosis)

Thoracic-outlet decompression Correct answer

Scenario 5

Endovascular repair of a thoracic aneurysm where the landing zone involves the origin of the left carotid artery (ie the origin of the left carotid artery
is covered by the stent graft)

Carotid-carotid bypass Correct answer

Theme: Vascular

A Computed tomography (CT)

B Carotid Doppler ultrasonography
C ECG
D Carotid angiogram

What initial investigation would you perform for each of the clinical scenarios below? Each option may be used once, more than once, or
not at all.

Thirty per cent of carotid bruits heard on auscultation are not due to carotid stenosis. The initial investigation that should be performed is
a Doppler ultrasound scan in patient 1. In cases where a persistent neurological deficit has occurred a CT scan must be carried out
initially to exclude a space-occupying lesion.

Scenario 1

A 71-year-old man with left carotid bruit and normal pulse and left transient ischaemic attacks (TIAs).

Carotid Doppler ultrasonography Correct answer

Scenario 2

A 71-year-old man with left carotid bruit and normal pulse plus a dense left hemiplegia.

Computed tomography (CT) Correct answer

Theme: Lower limb venous disease

A Elevation and non-steroidal anti-inflammatory drugs (NSAIDs)

B Urgent surgery
C Intravenous (iv) heparin
D Compression bandaging
E Treatment with warfarin

For each of the patients described below, select the most likely diagnosis from the list of options above. Each option may be used once,
more than once or not at all. You may believe that more than one diagnosis is possible but you should choose the ONE most likely
diagnosis.

Scenario 1

A 54-year-old woman with thrombosed varicose veins and cellulitis.

Elevation and non-steroidal anti-inflammatory drugs (NSAIDs) Correct answer

Elevation and non-steroidal anti-inflammatory drugs (NSAIDs)

In a patient with thrombosed varicose veins and cellulitis, the treatment should be elevation, rest and NSAIDs.

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Scenario 2

A 49-year-old lady, 5 days post-left hip replacement, with a swollen, red and tender left leg.

Intravenous (iv) heparin Correct answer

Intravenous (iv) heparin

In this patient, a diagnosis of deep vein thrombosis should be considered. It is best to perform some imaging before commencing treatment.

Scenario 3

A 70-year-old man with long history of venous ulcer over the medial malleolus.

Compression bandaging Correct answer

Compression bandaging

A 70-year-old man with a poorly healing venous ulcer should be treated with appropriate compression bandaging.

Scenario 4

A 64-year-old woman, with known history of venous insufficiency, presents with hypotension and profuse bleeding from the medial malleolus of her
right leg.

Urgent surgery Correct answer

Urgent surgery

A patient with venous insufficiency with profuse bleeding from an engorged vein (long saphenous vein in this case) should have urgent surgery to
stop the bleeding.

5716

Theme: Management of arterial disease

A Percutaneous angioplasty
B Femoropopliteal bypass graft
C Emergency aortoiliac bypass graft
D Endovascular stent graft
E Below-knee amputation

For each of the clinical scenarios below select the most appropriate action. Each option may be used once, mor than once, or not at all.

Scenario 1

A 56-year-old man with a necrotic arterial ulcer on his shin has an angiogram. This reveals a solitary, short segment, distal superficial femoral artery
(SFA) occlusion with single-vessel run-off on that side.

Percutaneous angioplasty Correct answer

Short segment superficial femoral artery (SFA) occlusions are usually very amenable to angioplasty, and restoration of distal circulation is likely to
allow the necrotic ulcer to heal with close supervision.

Scenario 2

A 60-year-old man is found to have a right iliac aneurysm at angiography. However, during the procedure the aneurysm is ruptured by the guidewire.
The patient becomes hypotensive

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Endovascular stent graft Correct answer

There is already a catheter sheath in place, and a straight covered stent graft is kept close to hand in such procedures for exactly this reason.

Scenario 3

Angiography of a 56-year-old male shows disease involving a long segment of the SFA on the same side as a foot with a gangrenous-looking toe.

Femoropopliteal bypass graft Correct answer

Traditionally a femoropopliteal bypass would be considered but long-segment occlusions of SFA and also popliteal artery are being treated with
endovascular stenting. The foot is likely to still be viable and non-resolving digital gangrene may require only local amputation.

Scenario 4

A 35-year-old male involved in a road traffic accident has a grossly comminuted compound fracture of his right tibia with no distal pulses felt. His
lower leg and foot are very cold to feel and white. He is otherwise stable but in a lot of pain.

Below-knee amputation Correct answer

This difficult case shows a non-salvageable lower limb which if left will only become necrotic, gangrenous and cause much more life-threatening
problems. It is literally life or limb and, by deciding early, the level of amputation can be restricted to below knee.

5741

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