Los elementos principales de UNETE

Questions

1. Buerger’s test 164

2. Ankle–brachial pressure index 164

3. Severe limb ischaemia 164

4. Lower limb pain 165

5. Intermittent claudication 165

6. Deep vein thrombosis 165

7. Leg ulcers 166

8. Amaurosis fugax 166

9. Investigation of amaurosis fugax 166 10. Trendelenburg’s tourniquet test 167

11. Carotid endarterectomy 167

12. Abdominal aortic aneurysm 167

13. Elective abdominal aortic aneurysm repair 168

14. Varicose veins 168

15. Venous embolism prophylaxis 168

16. Acute upper limb pain 169

17. Critical limb ischaemia 169

18. Postoperative complications of carotid

endarterectomy 169

19. Diagnosis of acute lower limb pain 170 20. Management of acute lower limb pain 170 21. Investigation of an aortic dissection 170

22. Raynaud’s syndrome 170

23. Popliteal aneurysms 171

24. Vascular anatomy 171

25. Branches of external carotid artery 172

Answers 173

QUESTIONS

1. Buerger’s test

You are asked by your colleague to see an elderly patient in clinic who has a positive Buerger’s test. From the list of options below, select the most likely reason for a positive Buerger’s test.

A. Venous insufficiency of the upper limbs B. Arterial insufficiency of the lower limbs C. Venous insufficiency of the lower limbs D. Arterial insufficiency of the upper limbs E. None of the above

2. Ankle–brachial pressure index

As part of the peripheral vascular examination, you are asked to record the ankle–brachial pressure index of the patient. Which one of the following values reflects a normal ankle–brachial pressure index?

A. Between 0.9 and 0.6 B. Greater than 1.3 C. Between 0.6 and 0.3 D. Greater or equal to 1.0 E. Less or equal to 0.3

3. Severe limb ischaemia

You are asked to see a 67-year-old woman admitted with severe limb ischaemia.

Your senior colleague asks you to examine the patient and report your findings.

What are the two most likely clinical features that suggest the patient has severe limb ischaemia?

A. Pulselessness and pain B. Paraesthesia and paralysis C. Perishingly cold limb and pallor D. Pallor and pain

E. Paraesthesia and pallor

4. Lower limb pain

A 55-year-old man, with a positive smoking history, presents to you in outpatient clinic with pain in the lower leg which is brought on by walking. The pain is cramping in nature, well localized to the left calf only, and is relieved by rest. The patient has noticed that his walking distance has progressively decreased because of the cramps in the left calf. There are no abnormal findings on physical examination. What is the most appropriate way to investigate the patient’s symptoms?

A. Measure the ankle–brachial pressure index B. Angiography

C. Radiograph of the lower limbs D. Ultrasound

E. None of the above

5. Intermittent claudication

A 60-year-old woman has been diagnosed as having claudication of the lower limbs. The patient is a smoker and has hyperlipidaemia for which she is taking a

‘statin’. You are asked to discuss with the patient the treatment options available to her. From the list below, choose the recommended treatment option for this patient.

A. Angioplasty B. Amputation C. Thrombectomy

D. Increasing exercise and quitting smoking

E. Continue with the cholesterol-lowering medication and follow up in outpatients in 3 months

6. Deep vein thrombosis

You are told by your colleague that a 44-year-old woman, who underwent elective right hip replacement, is suspected of having deep vein thrombosis of the left calf.

You are asked to carry out a pretest clinical probability score (Wells score) and a D-dimer test. Which is the most likely scenario where deep vein thrombosis can be excluded from your list of differential diagnoses?

A. Wells score of 4 and a positive D-dimer result B. Wells score of 2 and a negative D-dimer result C. Wells score of 0 and a negative D-dimer result D. Wells score of 3 and a positive D-dimer result E. None of the above

7. Leg ulcers

A 65-year-old man presents for the first time to your clinic with a painless wound in his right leg, which has been present for over 2 months. On examination you notice a 3 cm ¥ 4 cm leg ulcer in the gaiter area of the right leg, covering the medial malleolus. The shallow bed of the ulcer is covered with granulation tissue, which is surrounded by sloping edges. There is no history of trauma. From the list below, choose the most likely diagnosis.

A. Arterial leg ulcer B. Neuropathic ulcer C. Venous ulcer D. Traumatic ulcer E. Neoplastic ulcer

8. Amaurosis fugax

Your colleague consults you with regard to a 56-year-old patient who has suffered an episode of amaurosis fugax. From the list below, choose the most likely site of pathology which may give rise to amaurosis fugax.

A. Vertebrobasilar artery territory B. Carotid artery territory

C. Posterior communicating artery territory D. Spinal artery territory

E. Anterior communicating artery territory

9. Investigation of amaurosis fugax

You have decided to investigate the symptom experienced by the patient in Question 8. From the list below, select the most appropriate investigation that you would order first to investigate the site of pathology.

A. Magnetic resonance angiography B. Digital subtraction angiography

C. Computed tomography scan of the head and neck D. Duplex ultrasound scanning

E. None of the above

10. Trendelenburg’s tourniquet test

You are told that a 45-year-old woman, who presented to the vascular surgery clinic, has a positive tourniquet test in the left leg. On the basis of the information conveyed to you, from the list below, choose the most likely diagnosis that is associated with a positive tourniquet test.

A. Varicose veins B. Chronic leg ischaemia C. Deep vein thrombosis D. Arterial ulcer

E. Acute leg ischaemia

11. Carotid endarterectomy

You are in the vascular surgery outpatient clinic explaining the indications for undergoing carotid endarterectomy to a patient. From the list below, select the most likely scenario where carotid endarterectomy is likely to be indicated.

A. Symptomatic carotid artery stenosis of between 50 per cent and 60 per cent

B. Asymptomatic carotid artery stenosis of between 70 per cent and 80 per cent

C. Asymptomatic carotid artery stenosis of between 50 per cent and 60 per cent

D. Symptomatic carotid artery stenosis of between 70 per cent and 80 per cent

E. None of the above

12. Abdominal aortic aneurysm

You see a 65-year-old man in your clinic, who is being monitored for an abdominal aortic aneurysm. The patient smokes 20 cigarettes a day and has a 25-year history of poorly controlled hypertension. From the list below, select the most appropriate investigation that can be used to monitor the progression of this patient’s condition.

A. Computed tomography scan of the abdomen B. Angiography

C. Abdominal plain film radiography D. Magnetic resonance imaging E. Ultrasound

13. Elective abdominal aortic aneurysm repair

During a ward round you are asked about the conditions that must be met in order to qualify a patient for elective abdominal aortic aneurysm repair. From the list below, select the most likely abdominal aortic aneurysm size that warrants elective repair providing the patient is fit for surgery.

A. Greater than 5.0 cm B. Greater than 5.5 cm C. Less than 5.0 cm D. Greater than 4.5 cm E. Less than 5.5 cm

14. Varicose veins

A 41-year-old woman, diagnosed with varicose veins in the left leg, presents to your clinic with a 2-month history of severe pain in the left leg on prolonged standing. The patient is obese and the pain has affected her working and social lifestyle and she asks you about the most effective treatment option. From the list below, choose the most effective treatment option that you would discuss with this patient.

A. Use of compression stockings B. Injection sclerotherapy C. Surgery

D. Weight loss E. None of the above

15. Venous embolism prophylaxis

A 55-year-old woman, who is obese and has a positive smoking history, is to have varicose vein surgery in the next 12 hours. Your senior colleague asks you to ensure that deep vein thrombosis prophylaxis is commenced. From the list below, choose the most appropriate form of deep vein thrombosis prophylaxis that you would use.

A. Low-molecular-weight heparin B. Warfarin

C. Aspirin D. Clopidogrel E. None of the above

16. Acute upper limb pain

You see a 50-year-old woman with a history of atrial fibrillation, who presents to the emergency department with a sudden onset of pain in the left forearm. The pain started 3 hours ago, and has been increasing in intensity since. On examination, the left forearm is cold and pale. The left axillary pulse is present but distal pulses are absent. Movement and sensation are intact in the left hand. There is no history of trauma. What is the most appropriate next step in this patient’s management?

A. Commence a heparin infusion and send the patient to theatre for vascular intervention

B. Give analgesia and manage the patient in the emergency department C. Administer oral aspirin and send the patient to theatre for vascular

intervention

D. Request an angiogram

E. Request anteroposterior and lateral plain radiographs of the left forearm

17. Critical limb ischaemia

You see a 60-year-old man with a history of coronary heart disease and hyperlipidaemia in your clinic. The patient has found it increasingly hard to walk due to the gradual increase in intensity of the cramping pain he experiences in his right leg on walking and which is relieved by resting a few minutes. In addition, he tells you that cramps have started to occur at night when he is sleeping. On examination of the right leg, you notice that there is a ‘punched out’ ulcer at the right heel. The right posterior tibial and dorsalis pedis pulses are weak. You suspect that this patient has critical limb ischaemia. What is the most appropriate next line investigation that would support your diagnosis?

A. Computed tomography angiography B. Ankle–brachial pressure index C. Radiograph the lower limbs D. Magnetic resonance angiography E. None of the above

18. Postoperative complications of carotid endarterectomy

The most common postoperative complication associated with carotid endarterectomy is:

A. Surgical site infection B. Cranial nerve injury C. Stroke

D. Hypertension E. Patch rupture

19. Diagnosis of acute lower limb pain

You are asked to see a 56-year-old homeless man who presented to the emergency department with a severe pain in his right leg, which started over 6 hours ago. On examination, the right leg is pale in colour in comparison with the left leg, from below the knee to the toes. The right leg is cold and the popliteal, posterior tibial and dorsalis pedis pulses are absent. There is no sensation in the right leg and the patient is unable to flex the knee or move the toes due to fixed flexion deformities.

In addition, the patient is apyrexial and heart rate is 85 beats per minute and regular. What is the most likely diagnosis?

A. Critical limb ischaemia B. Acute limb ischaemia C. Intermittent claudication D. Necrotizing fasciitis E. Spinal claudication

20. Management of acute lower limb pain

From the list below, select the most appropriate treatment option for the patient in Question 19.

A. Percutaneous transluminal angioplasty B. Revascularization through endarterectomy C. Revascularization through bypass grafting D. Endoluminal stent grafting

E. Amputation

21. Investigation of an aortic dissection

From the list below, select the most appropriate investigation for the prompt diagnosis of an aortic dissection?

A. Electrocardiogram B. Echo cardiogram

C. Computed tomography scan D. Chest radiograph

E. Magnetic resonance imaging

22. Raynaud’s syndrome

Raynaud’s syndrome can be caused by which one of the following antihypertensives?

A. a-blockers

B. Angiotensin-converting enzyme inhibitors C. b-blockers

D. Calcium channel blockers E. Angiotensin receptor blockers

23. Popliteal aneurysms

In association with a diagnosed popliteal aneurysm, a patient is more likely to have:

A. A berry aneurysm B. A femoral aneurysm C. An aortic aneurysm D. A carotid artery aneurysm E. None of the above

24. Vascular anatomy

You are assisting a bypass grafting procedure in theatre. Your senior colleague asks you to show him where the common femoral artery arises. From the list below, choose the statement that best describes the anatomical landmark and course of the common femoral artery.

A. As the external iliac artery passes over the inguinal ligament, it becomes the common femoral artery and gives off the superficial femoral artery before continuing down to the thigh, medial to the femur, as the profunda femoris artery

B. As the internal iliac artery passes under the inguinal ligament, it becomes the common femoral artery and gives off the profunda femoris artery before continuing down to the thigh, medial to the femur, as the superficial femoral artery

C. As the external iliac artery passes under the inguinal ligament, it becomes the common femoral artery and gives off the profunda femoris artery before continuing down to the thigh, medial to the femur, as the superficial femoral artery

D. As the internal iliac artery passes over the inguinal ligament, it becomes the common femoral artery and gives off the profunda femoris artery before continuing down to the thigh, medial to the femur, as the superficial femoral artery

E. As the external iliac artery passes under the inguinal ligament, it becomes the common femoral artery and gives off the superficial femoral artery before continuing down to the thigh, medial to the femur, as the profunda femoris artery

25. Branches of external carotid artery

As the external carotid artery courses inferosuperiorly from the common carotid bifurcation, it gives off the first of seven of its arterial branches just below the greater cornu of the hyoid bone. From the list below, select the name of the first branch of the external carotid artery.

A. Ascending pharyngeal artery B. Facial artery

C. Lingual artery D. Maxillary artery E. Superior thyroid artery

ANSWERS

Buerger’s test

1 B Buerger’s test is used to assess the arterial supply to the lower limbs.

Classically this test is performed by raising the patient’s legs to about 45–50∞ above the horizontal plane. The legs are kept in this position for approximately 2 minutes. In the meantime, the time taken for the legs to show signs of pallor is noted; if rapid pallor occurs, this implies poor arterial supply. After a couple of minutes, the legs are allowed to hang dependently over the side of the examination couch or bed. The rate at which ‘colour is seen returning to the legs’ and the rate of venous refilling of the feet are compared and noted. If there is arterial insufficiency, after about 2–3 minutes, the foot on the affected side will develop an intense reactive hyperaemia (a dusky crimson colour) because of arterial vasodilatation resulting from the build up of anaerobic metabolites from when the legs are elevated. Buerger’s test may be positive in both of the lower limbs and it is vital that the lower limbs are well inspected before this test is performed so that effective comparisons in colour change can be made.

Ankle–brachial pressure index

2 D The ABPI is measured by dividing the highest systolic blood pressure measured in any ankle artery (either the dorsalis pedis or posterior tibial artery) by systolic pressure at the brachial artery. This test is performed using a Doppler and blood pressure cuff (sphygmomanometer). The cuff is inflated above the artery while the Doppler probe, connected to a pulse volume recorder, is placed just below or at the site of the artery. The cuff is gently deflated and the pressure, at which the first pulse sound is heard, is noted.

An ABPI greater or equal to 1.0 is usually normal. ABPI values between 0.9 and 0.6 usually suggest peripheral vascular occlusive disease such as intermittent claudication. This is progressive symptomatic arterial occlusion of the lower limbs due to atherosclerosis, resulting in pain on movement which is relieved by rest. Values between 0.6 and 0.3 usually suggest critical limb ischaemia and these patients usually have limb pain at rest. An ABPI less or equal to 0.3 implies impending gangrene of the affected limb.

Patients with diabetes may have ABPI of greater than 1.3 which implies that the lower limb arterial walls may be calcified and are incompressible.

Severe limb ischaemia

3 B The clinical signs and symptoms associated with acute limb ischaemia can be remembered using the list of ‘6 Ps’:

• Pain

• Pallor

• Pulselessness

• Perishingly cold

• Paraesthesia

• Paralysis

Paraesthesia and paralysis are late signs of severe limb ischaemia and urgent surgical intervention is required as these features threaten loss of the limb. Acute limb ischaemia results either from a thrombus in situ (~40 per cent of cases), an embolus (~38 per cent) or graft/angioplasty occlusion (~15 per cent) or trauma.

Lower limb pain

4 A The abdominal aorta and lower limb arteries are commonly affected in PVD. The main effect of PVD, of which the commonest cause is atherosclerosis, is to restrict blood flow to the limbs due to stenotic narrowing of the arterial lumen. Deterioration of arterial perfusion to the lower limbs cannot meet the increase in metabolic demand from muscles, which is commensurate with an increase in physical activity, resulting in ischaemia. Patients are usually asymptomatic until critical artery stenosis is attained. Critical artery stenosis occurs when 75 per cent of the cross-sectional area and 50 per cent of the vessel diameter is reached.

Intermittent claudication falls under the chronic limb ischaemia category, and can be clinically described as cramp-like pain experienced in the muscles of the leg on walking, which is alleviated in minutes on resting.

Cramp-like pain of intermittent claudication can be experienced in the calf, thigh or buttock muscles depending on the level at which the arterial occlusion is present.

The ABPI (for more information on ABPI, please refer to the answer to Question 2) is used as a first line diagnostic investigation for chronic limb ischaemia in patients presenting with symptoms of lower limb PVD. This test is non-invasive, quick and cheap and is usually performed in an outpatient clinic setting. Ultrasound scanning may reveal areas of focal arterial stenosis but cannot provide the clinician with an indication of the severity of the patient’s PVD. A plain film radiograph of the lower limbs may not reveal any abnormalities. Angiography is not used as a first line investigation in the initial stages of forming a diagnosis of PVD. It is used for surgical planning in patients who are to undergo surgical or radiological interventional revascularization.

Intermittent claudication

5 D A majority of patients who are initially diagnosed with vascular claudication will usually be counselled about their condition, and in most

cases no further treatment is required providing the claudication is not severe. Risk factors (e.g. hyperlipidaemia, smoking, poor exercise and obesity) are usually identified and the patient is asked to correct these as part of managing their condition. Exercise and smoking cessation are factors which, if taken up by the patient, will most likely improve symptoms of claudication as well as decreasing overall cardiovascular risk.

Structured exercise programmes are relatively cheap and safer than endovascular intervention (e.g. percutaneous transluminal angioplasty) and surgery, and have shown to be beneficial if followed for at least 6 months. Patients are asked to walk to near maximum pain tolerance as well as increasing their maximum walking distance; compliance is usually a confounding factor.

Where claudication is concerned, percutaneous transluminal angioplasty and surgery are usually offered to patients after careful assessment of long-term efficacy of intervention, balanced by procedural risks and costs. These are patients who have severe claudication that has major implications on their social and working lifestyle (e.g. if the patient is unable to work or unable to look after themselves without help).

Deep vein thrombosis

6 B Venous stasis, potential injury to the vessel wall, and/or a hypercoagulable state are the three classic causes of venous thrombus formation described by Virchow (also known as Virchow’s triad). The legs are common sites for the development of DVT.

There are two main types of DVT: below knee and above knee. Below knee DVTs occur most frequently in the calf veins, with those in the soleal

There are two main types of DVT: below knee and above knee. Below knee DVTs occur most frequently in the calf veins, with those in the soleal

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