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SU27.1-8 | Vascular and Lymphatic Surgery — Graded Quiz
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A vascular surgeon places four patients on the continuous spectrum of chronic occlusive arterial disease. Which ordering, from mildest to most severe, is correct?
Correct. Chronic limb ischaemia is one continuum: intermittent claudication (exertional pain relieved by rest) → nocturnal rest pain relieved by dependency → tissue loss (ulceration/gangrene). The Fontaine classification formalises this.
Fontaine spectrum: claudication → rest pain → tissue loss; severity guides whether best medical therapy or revascularisation is needed.
The spectrum runs from mildest (claudication) through rest pain to most severe (tissue loss). The Fontaine stages follow this order.
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During examination of an acutely ischaemic limb, a junior doctor recalls the classic clinical features of severe arterial ischaemia. Which set best captures the 'six P's'?
Correct. The six P's of acute limb ischaemia are Pain, Pallor, Pulselessness, Paraesthesia, Paralysis and Perishing cold (poikilothermia) — paraesthesia and paralysis signal a threatened limb needing urgent action.
Six P's of arterial ischaemia: Pain, Pallor, Pulselessness, Paraesthesia, Paralysis, Perishing cold; the last two mark a limb at imminent risk.
The six P's of arterial ischaemia are Pain, Pallor, Pulselessness, Paraesthesia, Paralysis and Perishing cold. Pitting/pigmentation/pruritus are venous features.
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An ABPI is part of the set-piece vascular examination and investigation. Which interpretation is correct?
Correct. An ABPI <0.9 indicates arterial disease; a value >1.3 is unreliable because medial calcification (diabetes, renal failure) makes ankle vessels non-compressible and falsely raises the pressure.
ABPI: normal ~1.0; <0.9 = arterial disease; >1.3 = falsely high (medial calcification) and must not reassure in diabetics/renal patients.
ABPI <0.9 = disease; >1.3 = falsely high from non-compressible calcified vessels — a key trap in diabetics and renal patients.
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A patient with Raynaud's phenomenon is being assessed to decide between primary and secondary disease. Which feature should most strongly raise suspicion of SECONDARY Raynaud's and prompt an ANA and connective-tissue work-up?
Correct. Asymmetry, digital ulceration/tissue loss and abnormal nailfold capillaries suggest an underlying connective-tissue disease (secondary Raynaud's), warranting an ANA and further work-up. Symmetrical attacks in a young patient with normal hands between episodes suggest primary Raynaud's.
Primary vs secondary Raynaud's is the key decision: ulceration, asymmetry and abnormal nailfold capillaries point to an underlying connective-tissue disorder.
Secondary Raynaud's is suggested by asymmetry, ulceration and abnormal nailfold capillaries. Symmetrical young-onset attacks with normal interval hands suggest primary disease.
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Before applying graduated compression for a venous leg ulcer, the team performs one essential check. Which statement reflects correct practice?
Correct. Graduated compression is the mainstay of venous disease and venous ulcers, but you must first confirm the arterial supply is adequate — compressing an ischaemic leg can precipitate harm.
Never compress a leg before checking its arterial supply — compression is the venous mainstay but dangerous in coexisting arterial disease.
Compression treats venous disease, but never apply it before confirming adequate arterial supply (e.g. ABPI), or you risk harming an ischaemic limb.
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A clinician must distinguish pitting limb oedema from established lymphoedema at the bedside. Which finding most reliably indicates LYMPHOEDEMA rather than systemic/venous pitting oedema?
Correct. Established lymphoedema is the accumulation of protein-rich fluid: it is characteristically non-pitting with a positive Stemmer's sign (inability to pinch a skinfold at the base of the second toe). Pitting oedema with raised JVP/proteinuria/ascites suggests cardiac, renal or hepatic causes.
Pitting (cardiac/renal/hepatic/venous) vs non-pitting (lymphoedema, positive Stemmer's sign) is the bedside discrimination in the swollen limb.
Lymphoedema is protein-rich and non-pitting with a positive Stemmer's sign; pitting oedema points to cardiac, renal, hepatic, hypoalbuminaemic or venous causes.
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