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SU27.1-8 | Vascular and Lymphatic Surgery — Practice Quiz
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A 62-year-old smoker describes cramping pain in the calf that comes on reproducibly after walking about 200 metres and is relieved within minutes of rest. There is no pain at rest and no tissue loss. Where does he sit on the spectrum of chronic occlusive arterial disease?
Correct. Reproducible exertional muscle pain relieved by rest, without rest pain or tissue loss, is intermittent claudication — the mildest stage of the occlusive arterial spectrum.
Occlusive arterial disease is one continuum: claudication (exertional, relieved by rest) → nocturnal rest pain → tissue loss/gangrene.
The spectrum runs claudication → rest pain → tissue loss. Exertional pain relieved by rest, with no rest pain, is claudication.
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A diabetic patient with critical lower-limb ischaemia has an Ankle-Brachial Pressure Index (ABPI) measured at 1.3. Why is this falsely reassuring value misleading in this patient?
Correct. In diabetics and renal patients, medial calcification makes the ankle vessels non-compressible, so the cuff records a falsely normal or high ABPI (>1.3) despite severe ischaemia.
ABPI <0.9 = arterial disease; ABPI >1.3 = falsely high from non-compressible calcified vessels (diabetes, renal failure) and must not reassure.
An ABPI normally <0.9 indicates disease; but a falsely HIGH ABPI (>1.3) from non-compressible, medially calcified vessels can mask severe ischaemia in diabetics/renal patients.
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A 30-year-old man who smokes heavily presents with distal ischaemia of the fingers and toes, superficial thrombophlebitis and digital ulceration; angiography shows segmental occlusion of small and medium distal vessels with sparing of proximal arteries. Atherosclerotic risk factors are otherwise absent. Which diagnosis fits best?
Correct. Buerger's disease (thromboangiitis obliterans) is a non-atherosclerotic inflammatory occlusion of distal small/medium vessels in young heavy smokers, with digital ischaemia and thrombophlebitis; absolute smoking cessation is the key treatment.
Buerger's disease = young heavy smoker + distal small/medium-vessel inflammatory occlusion; smoking cessation is essential.
Distal small/medium-vessel occlusion in a young heavy smoker without atherosclerotic risk factors is Buerger's disease, not large-vessel atherosclerosis.
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A 24-year-old typist describes that when exposed to cold her fingers first turn white, then blue, then red on rewarming, with normal hands between episodes and no ulceration. A screen for connective-tissue disease is negative. What is the classic triphasic colour sequence she is describing?
Correct. The classic Raynaud's attack runs white (vasospasm/pallor) → blue (deoxygenation/cyanosis) → red (reactive hyperaemia on rewarming). Symmetrical attacks with normal hands between episodes and a negative work-up suggest primary Raynaud's.
Raynaud's phenomenon = episodic, cold/stress-triggered digital colour change, white → blue → red; the key decision is primary versus secondary.
Raynaud's phenomenon classically shows the triphasic white → blue → red colour change. Black implies tissue death (gangrene), not vasospasm.
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An elderly man with peripheral arterial disease has two toes that are black, shrivelled, dry and painless, with a clear line of demarcation from healthy tissue and no surrounding spreading infection or systemic upset. Which type of gangrene is this?
Correct. Dry gangrene results from gradual arterial occlusion without infection: the part is black, shrivelled, mummified, painless and well demarcated. It is usually stable — treat the underlying ischaemia (consider revascularisation).
Dry gangrene = gradual ischaemia, no infection, mummified and demarcated. The critical triage is dry versus wet (infected, spreading, urgent).
Black, dry, mummified, painless, well-demarcated tissue without spreading infection is DRY gangrene. Wet gangrene is infected, swollen, foul and spreading.
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A diabetic patient has a foot that is swollen, foul-smelling and discoloured, with spreading cellulitis, crepitus and systemic features of sepsis. Compared with dry gangrene, what makes this WET gangrene a surgical emergency?
Correct. Wet gangrene is infected and spreading; it threatens life from sepsis and demands urgent debridement, antibiotics, glycaemic control and often early amputation — unlike the usually stable dry gangrene.
Wet gangrene = infection + spread + sepsis risk → urgent debridement/antibiotics. Dry gangrene of a toe is usually stable; treat the ischaemia.
Wet gangrene is the infected, spreading, septic form — a surgical emergency, in contrast to the usually stable dry gangrene.
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A 45-year-old shopkeeper who stands all day has dilated, tortuous superficial veins on the medial calf, evening aching, and ankle skin pigmentation. Incompetence at which junction most commonly underlies great saphenous varicose veins?
Correct. The great (long) saphenous vein joins the femoral vein at the sapheno-femoral junction in the groin; incompetence there is the commonest cause of GSV varicose veins. The small saphenous drains at the sapheno-popliteal junction.
GSV → sapheno-femoral junction (groin); SSV → sapheno-popliteal junction (knee). Reflux at the junction drives the varicosities; CEAP grades severity.
Great saphenous varicosities arise from sapheno-femoral junction incompetence (groin); the small saphenous drains at the sapheno-popliteal junction (behind the knee).
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A 55-year-old woman develops a painful, swollen, warm left calf five days after a long-haul flight. Which combination is most appropriate to assess her pre-test probability of deep vein thrombosis and to confirm it?
Correct. DVT (driven by Virchow's triad of stasis, hypercoagulability and endothelial injury) is assessed with the Wells score for pre-test probability and confirmed with compression/Doppler ultrasound of the deep veins.
DVT: Virchow's triad → Wells score → compression Doppler ultrasound. Contrast with the Trendelenburg test used for saphenous incompetence in varicose veins.
DVT work-up uses the Wells score for probability and compression Doppler ultrasound to confirm. ABPI/angiography assess arterial disease; Trendelenburg assesses venous reflux in varicose veins.
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A man from a coastal endemic region has chronic, progressive, ascending non-pitting swelling of one leg with thickened, warty skin and a positive Stemmer's sign. Which infective cause of secondary lymphoedema is most likely?
Correct. In endemic regions, Wuchereria bancrofti (lymphatic filariasis) is the classic infective cause of secondary lymphoedema, producing chronic non-pitting swelling, warty skin changes and a positive Stemmer's sign.
Lymphoedema is protein-rich, non-pitting (positive Stemmer's sign); in endemic areas filariasis (Wuchereria bancrofti) is the leading secondary cause.
Chronic non-pitting limb swelling with a positive Stemmer's sign in an endemic area points to lymphatic filariasis (Wuchereria bancrofti), the classic infective lymphoedema.
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