Clinical SBAs
Clinical Vascular: (17 questions)

Questions

• 1
  A previously well 55-year old woman presents with an acutely painful leg. The leg is weak, sensation is reduced and pulses are absent. What is the most appropriate initial action to be taken by the junior doctor in A&E?
  Difficulty: Medium     Topic: Acutely painful leg with reduced sensation
  a

  Give alteplase

  b

  Contact the vascular consultant on-call

  c

  Immediate fasciotomy

  d

  Full anti-coagulation with heparin and warfarin

  e

  Monitor each 15minutes for deterioration
  Explanation: Acute limb ischaemia can be due to thrombosis or embolism. The features are: severe pain, absent pulses, altered sensation, loss of movement, pale and cold. Treatment depends on the cause, emboli are treated with surgical emoblectomy or thrombolysis; angioplasty may be performed for thrombosis. Alteplase may be part of the management but assessment by a vascular surgeon should occur first. Fasciotomy is used for compartment syndrome. Heparin and warfarin anticoagulation is the treatment for a DVT. Monitoring is important but this patient required immediate intervention to restore perfusion to the limb.
• 2
  Which of the following is not a cause of lymphoedema?
  Difficulty: Hard     Topic: Lymphoedema
  a

  Gonorrhoea infection

  b

  Lymph node clearance

  c

  Milroy's syndrome

  d

  Yellow nail syndrome

  e

  Filariasis
  Explanation: Gonorrhoea most frequently causes urethritis but can also cause septic arthritis. It may cause inguinal lymphadenopathy but will not cause lymphoedema. Lymphoedema is a relatively rare surgical complication even with full lymph node clearance for breast cancer. It occurs from damage to draining lymphatics. Milroy's syndrome is a congenital lymphatic malformation causing asymmetrical lower limb oedema. Yellow nail syndrome is a rare condition of lymphoedema, chylous pleural effusions and dystrophic yellow nails. Filariasis is a parasitic infection that can cause gross lymphoedema.
• 3
  A 67-year old woman presents with dilated, tortuous veins in the distribution of the short saphenous vein. What investigation must be performed pre-operatively?
  Difficulty: Medium     Topic: Dilated short saphenous vein
  a

  Ambulatory venous pressures

  b

  CT scan

  c

  Duplex ultrasound scan

  d

  MR venogram

  e

  Venography
  Explanation: Treatment of short saphenous disease involves ligation of the sapheno-popliteal junction. The position of this may vary and therefore duplex USS is always recommended prior to surgery. Ambulatory venous pressures are rarely measured. CT scans are not part of the investigation venous disease. MR venograms may be used to look at central venous disease (e.g. IVC stenosis). Venography is the gold standard for assessing venous disease but is rarely required due to use of duplex USS.
• 4
  A 61-year old man is recovering from a right hemi-arthroplasty and develops a painful, swollen, erythematous calf. Which of the following is not a risk factor for this condition?
  Difficulty: Medium     Topic: Painful, red calf
  a

  Obesity

  b

  Diabetes

  c

  Polycythaemia rubra vera

  d

  Heart failure

  e

  Nifedipine
  Explanation: This man has a deep vein thrombosis, a common post-operative complication and patients should receive prophylaxis with LMWH and compression stockings. Nifedipine is a calcium channel blocker used for hypertension that causes diuretic-resistant pedal oedema but not DVT. Virchow's triad describes the risk factors: endothelial damage, hypercoagulability and stasis of flow. Obesity, diabetes, and PRV all increase blood viscosity. Heart failure predisposes to stasis therefore increases risk.
• 5
  A 55-year old man is incidentally found to have an abdominal aortic aneurysm. Ultrasound shows a diameter of 4.8cm. What is the most appropriate management?
  Difficulty: Hard     Topic: AAA management
  a

  Endovascular repair

  b

  Open graft repair

  c

  USS each 6 months

  d

  CT scan each 9 months

  e

  Monthly physical examination
  Explanation: Risk of rupture increases greatly with size, especially above 5.5cm. If >5.5cm, the risk of rupture is greater than the risk posed by surgery, so treatment is recommended Endovascular repair is favoured due to lower mortality however some may require open repair. If <5.5cm then an ultrasound scan should be done each 6 months to monitor its size. CT is a more expensive alternative, because it also would need to be done twice-yearly which would also cause excessive radiation exposure. Physical examination is not reliable.
• 6
  A 78-year old woman presents with intermittent calf pain. Femoral and popliteal pulses are present but foot pulses are absent. What is the most likely location of her disease?
  Difficulty: Easy     Topic: Intermittent calf pain
  a

  Common iliac artery

  b

  External iliac artery

  c

  Femoral artery

  d

  Popliteal artery

  e

  Posterior tibial artery
  Explanation: Ischaemic pain is experienced in the muscle group immediately inferior to the affected vessel. Calf pain usually is due to disease below the level of the popliteal artery, this is almost certainly the case here because of present popliteal pulse. Presence or absence of foot pulses are not hard signs for PVD as their absence may be physiological and some patients have significant disease despite pulses present. Catheter angiography is the gold standard investigation.
• 7
  A 45-year old lady present with an ulcer on her medial calf. It is shallow with sloping sides. What other feature would not support the diagnosis?
  Difficulty: Medium     Topic: Shallow leg ulcer
  a

  A history of DVT

  b

  Pain rated 9/10

  c

  Lipodermatosclerosis

  d

  Bilateral pedal oedema

  e

  Bleeding with minor trauma
  Explanation: Venous ulcers occurs from chronic venous insufficiency and are the most common lower limb ulcer. They may be slightly painful and are tender, but are not severely painful unlike vasculitic or most ischaemic ulcers. Deep vein insufficiency may occur secondary to DVT and contributes to venous congestion. Lipodermatosclerosis is deposition of haemosiderin in the subcutaneous tissues, followed by inflammation, fibrosis and contracture. Oedema is common with venous disease. The ulcers are well perfused so bleed readily.
• 8
  What is a major risk factor for venous thromboembolism?
  Difficulty: Medium     Topic: VTE risk factors
  a

  Adenocarcinoma

  b

  Factor V Leiden mutation

  c

  Long-haul flights

  d

  Obesity

  e

  Oral oestrogen contraceptive use
  Explanation: The most recent guidance for assessment of risk of PE (from the British Thoracic Society) groups risk factors in major and minor. Major factors are: previous VTE, malignant, recent surgery, recent fracture, varicose veins, immobility and late pregnancy. Minor risk factors include: thrombophilias (e.g. factor V Leiden), obesity, HRT and OCP use, long-haul travel and central venous catheterisation. Adenocarcinomas, especially upper GI, are associated with high risk of VTE.
• 9
  A 55-year old woman presents with a 12-hour history of an acutely painful leg that she cannot move. Pulses are absent and there is fixed mottling of the skin. What is the most appropriate management?
  Difficulty: Medium     Topic: Acutely painful leg with mottled skin
  a

  Limb amputation

  b

  Full anti-coagulation with heparin and warfarin

  c

  Immediate fasciotomy

  d

  Give alteplase

  e

  Monitor each 15minutes for deterioration
  Explanation: This woman has experienced acute limb infarction 12-hours ago and the limb is no longer viable. Fixed mottling of the skin, a long history and muscle stiffening/fibrosis suggest that the limb has irreversibly infarcted therefore amputation is required to avoid gangrene. Heparin and warfarin anticoagulation is the treatment for a DVT. A fasciotomy is used for compartment syndrome. Alteplase may be given sometimes for acute limb ischaemia but only during early presentation. She is unlikely to acutely deteriorate given the long history.
• 10
  An 82-year old man presents to A&E in shock. He suffers from angina but is complaining of severe abdominal pain that does not localise. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Non-localising abdominal pain
  a

  Acute pancreatitis

  b

  Ruptured abdominal aortic aneurysm

  c

  Myocardial infarction

  d

  Spontaneous bacterial peritonitis

  e

  Chronic mesenteric ischaemia
  Explanation: In an elderly patient presenting with shock and abdominal pain, a ruptured abdominal aortic aneurysm must be excluded. History of arterial disease (especially PVD) or hypertension increases the risk of aneurysms. Rupture may cause epigastric pain that radiates to the back or it may be non-localising and intermittent if leaking but not yet ruptured. Acute pancreatitis causes local peritonitis. MI very rarely presents as abdominal pain, most in diabetics. SBP almost occurs with a history of ascites. Chronic ischaemia causes pain post-meals or haematochezia.
• 11
  A 60-year old man presents with intermittent calf claudication. What clinical feature would be most suggestive of critical limb ischaemia?
  Difficulty: Medium     Topic: Calf claudication
  a

  Absent pulses

  b

  Going red with dependency

  c

  Buerger's angle of 40 degrees

  d

  ABPI of 0.7

  e

  Pain at rest
  Explanation: Worrying signs are those of critical ischaemia: ulceration and pain at rest or night when the limb is horizontal. These suggest that urgent treatment is required to reduce the risk of infarction. The remaining features listed are all consistent with peripheral vascular disease. Absent pulses is a useful sign but doesn't indicate severity. Redness on dependency (the 'sunset sign') occurs in moderate disease. A Buerger's angle of <15-20 degrees is more worrying. ABPI of 0.7 suggests mild disease.
• 12
  A man presents with impotence and bilateral intermittent buttock claudication. On examination femoral pulses are absent. Where is the lesion most likely to be?
  Difficulty: Medium     Topic: Impotence and buttock claudication
  a

  Distal aorta

  b

  Common iliac arteries

  c

  Median sacral artery

  d

  External iliac arteries

  e

  Internal iliac arteries
  Explanation: Leriche's syndrome is bilateral intermittent buttock claudication, loss of distal limb pulses and failure of erection due to severe atherosclerosis at the bifurcation of the aorta. It is most common in patients with multiple risk factors for peripheral vascular disease. Endovascular stenting is the most common treatment for this condition. External iliac disease causes quadriceps claudication and internal iliac disease may cause impotence.
• 13
  A 47-year old obese woman present to her GP with dilated, tortuous veins in the distribution of the long saphenous vein. Which of the following tests would be least appropriate?
  Difficulty: Easy     Topic: Dilated, tortuous leg veins
  a

  Trendelenburg’s test

  b

  Doppler ultrasound

  c

  Tourniquet test

  d

  Palpating for a cough impulse

  e

  Thomas' test
  Explanation: Thomas' test is used on the hip to demonstrate a fixed flexion deformity, most commonly due to osteoarthritis. With the patient lying flat, when the lumbar lordosis is removed, the affected leg rises. Trendelenburg's test examines competency at the sapheno-femoral junction (SFJ). With the patient lying flat, blood is emptied out of the leg, then pressure is placed on the SFJ. The patient is then asked to stand, if the varicosities do not refill then incompetence at the SFJ was the cause. If the veins do re-fill then there is incompetence elsewhere, though the SFJ may still also be incompetent. Doppler USS is more reliable than clinical tests; it is used on all patients. The tourniquet test examines the level of incompetence in a similar method to the Trendelenburg test. A tourniquet is moved down the leg until the level of incompetence is found; the veins do no re-fill on standing. A cough impulse may be transmitted by an incompetent sapheno-femoral junctio
• 14
  A 68-year old man with chronic kidney disease with intermittent claudication is found to have an ankle brachial pressure index of 1.4. Which is the most accurate interpretation?
  Difficulty: Easy     Topic: ABPI
  a

  The claudication is from spinal stenosis

  b

  The pain is due to peripheral neuropathy

  c

  The ABPI reading does not reflect tissue perfusion

  d

  His symptoms are from vascular spasm, not atheroma

  e

  He has good lower limb perfusion
  Explanation: CKD increases the risk of atherosclerosis and peripheral vascular disease. An ABPI of 1.4 is not physiological, it occurs due to calcification of the arterial media that resists compression and gives a false-high blood pressure. This occurs in diabetes, CKD and especially during dialysis. Due to this, we cannot draw conclusions from the investigation therefore all the other options could be correct and further investigation is required. If arterial disease were suspected then angiography could be performed.
• 15
  A 58-year old diabetic smoker attends his GP complaining of nocturnal leg pain with relief by hanging it over the side of the bed. What is the most appropriate initial investigation?
  Difficulty: Medium     Topic: Nocturnal leg pain
  a

  Monofilament examination of foot sensation

  b

  Venous Doppler

  c

  Contrast angiography

  d

  Ankle-brachial pressure index (ABPI)

  e

  Urea and electrolytes
  Explanation: This man has peripheral vascular disease with ischaemic pain at night because the leg relies on gravity to aid its perfusion. ABPI compares ankle pressure with the best of either arm blood pressure where a ratio of 1-1.2 is normal. In the absence of arterial calcification it is a good indicator of perfusion, where 0.9-0.6 shows impaired perfusion and a limb at risk of infarction would be <0.3.
• 16
  A 76-year old man with a chronic venous ulcer has a biopsy performed which demonstrates malignant squamous cell transformation. What is the best term to describe this?
  Difficulty: Medium     Topic: Chronic venous ulcer
  a

  Marjolin ulcer

  b

  Richter's transformation

  c

  Buerger's disease

  d

  Bazin's disease

  e

  Zollinger-Ellison syndrome
  Explanation: Marjolin ulcers are squamous cell carcinomas that arise in previous chronic ulcers. They present as a change in appearance that spreads with hard, raised edges. Metastases occur in 5-10% and prognosis is poor for these patients but it is otherwise good. Richter's describes transformation of CLL into acute lymphoblastic leukaemia. Buerger's disease (thromboangiitis obliterans) is the presence of severe arterial and venous thromboses in young smokers. Bazin's disease is fat necrosis with ulceration and an overlying rash. Zollinger-Ellison syndrome is a gastrin-secreting tumour that causes multiple upper GI ulcers.
• 17
  A 65-year old presents with a wound on his left leg. He has bilateral pedal oedema. There is an ulcer on the left leg immediately superior to the medial malleolus that has shallow irregular sides. What is the most likely underlying pathology?
  Difficulty: Easy     Topic: Shallow leg ulcer
  a

  Chronic ischaemia

  b

  Infection

  c

  Malignancy

  d

  Acute infarction

  e

  Venous congestion
  Explanation: 70% of all leg ulcers are venous. They are warm, have sloping irregular edges with granulation tissue and slough. The most common location is adjacent and superior to the medial malleolus. Features of chronic venous congestion may also be present: oedema, lipodermatosclerosis, atrophie blanche, haemosiderin deposition and eczema. Ischaemic ulcers occur at the peripheries. Infection causes spreading erythema or pus formation. Malignant ulcers have rolled edges. Infarction does not cause ulcers acutely.