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SU27.1-8 | Vascular and Lymphatic Surgery — PBL Case

CLINICAL SETTING

You are the surgical team in a district hospital outpatient department serving a population with a high burden of smoking, diabetes and, in some coastal villages, lymphatic filariasis. In one clinic three patients present with limb problems that span the arterial, venous and lymphatic systems. Your task is to reason from the bedside examination — the cornerstone of vascular diagnosis — to the principle of management for each, applying the rule that pitting versus non-pitting, arterial versus venous, and dry versus wet are the discriminations that change management. Work through the triggers in order; do not jump ahead.

Trigger 1: The painful, pulseless leg

A 60-year-old male smoker with diabetes describes cramping right-calf pain after walking 100 metres, now waking him at night in the forefoot and relieved by hanging the foot out of bed. The right foot is cool and pale on elevation, with absent foot pulses. A nurse measures the ABPI at 1.3 and reports the arteries are 'fine'.

DISCUSSION POINTS

Where does this man sit on the occlusive arterial spectrum, and what does the change from walking pain to nocturnal forefoot pain signify?
Why is the ABPI of 1.3 falsely reassuring in this diabetic, and what is the underlying vessel-wall mechanism?
What is the set-piece arterial examination, and what further investigations would you request?
What is the principle of management at this stage, beginning with the systemic disease?

Click to reveal Trigger 2: The black toe and the swollen, foul foot (discuss previous trigger first!)

Trigger 2: The black toe and the swollen, foul foot

The same patient now has a black, dry, painless, well-demarcated patch on the tip of one toe. Two weeks later he returns with a different foot that is swollen, foul-smelling, with spreading redness, crepitus, and a fever.

DISCUSSION POINTS

Classify the first lesion (dry gangrene) and explain its surgical basis and usual stability.
Why is the second presentation (wet gangrene) a surgical emergency, and how does the triage differ?
Outline the principles of amputation: treating the cause, optimising the patient, and choosing a viable level.
How do the arterial findings from Trigger 1 influence decisions about revascularisation versus amputation?

Click to reveal Trigger 3: The aching leg with visible veins and the swollen non-pitting limb (discuss previous trigger first!)

Trigger 3: The aching leg with visible veins and the swollen non-pitting limb

Two more patients are reviewed: a 45-year-old shopkeeper who stands all day with ropy medial-calf varicose veins, evening aching, ankle pigmentation and a shallow medial-malleolar ulcer; and a 50-year-old woman from a coastal village with chronic, ascending, non-pitting swelling of one leg, warty skin and a positive Stemmer's sign.

DISCUSSION POINTS

Explain the applied venous anatomy and the sapheno-femoral mechanism behind the shopkeeper's varicose veins and skin changes.
Why must arterial supply be confirmed before applying compression to the venous ulcer?
Why is the second patient's swelling lymphoedema rather than venous oedema, and what infective cause is likely in an endemic area?
Contrast the bedside discrimination of pitting versus non-pitting oedema and the principle of lifelong lymphoedema care.

Group Task Assignments

Group A: Produce a one-page comparison of dry, wet and gas gangrene (cause, appearance, infection, urgency, principle of management) and the general principles of amputation.
Group B: Draw the applied venous anatomy of the lower limb (deep, superficial, perforators, valves, calf pump, sapheno-femoral and sapheno-popliteal junctions) and annotate where varicose veins, DVT and venous ulcers arise.
Group C: Build a bedside algorithm for the swollen limb that separates pitting (cardiac/renal/hepatic/hypoalbuminaemic/venous) from non-pitting (lymphoedema, Stemmer's sign) and lists the investigations and lifelong management for filarial lymphoedema.

Learning Issues

Research these questions and bring your findings to the discussion.

[SU27.1] How does occlusive arterial disease progress along its spectrum, and what are the etiopathogenesis, investigations and stage-based principles of treatment?
[SU27.2] What is the correct set-piece examination of the vascular system, and how is ABPI interpreted — including the falsely high value from medial calcification?
[SU27.4] What are the types of gangrene (dry, wet, gas), how do they differ in urgency, and what are the principles of amputation?
[SU27.6] What is the applied venous anatomy behind varicose veins, how does sapheno-femoral incompetence cause them, and why must arterial supply be checked before compression?
[SU27.7] What distinguishes lymphoedema from venous/systemic oedema, what is the role of filariasis (Wuchereria bancrofti), and what are the principles of lifelong management?