VASCULAR SURGERY
Questions&Answers
Q-1
A 55 year old smoker presents to the emergency department with complaint of
severe left leg and foot pain that began earlier in the day. The pain spreads to the
level just above the inguinal ligament. His past medical history includes
hypertension. On examination, he has atrophic skin changes in his left leg and
his left limb is cold to touch. He has no palpable pulses in the left lower
extremity. Gross motor and sensory functions were intact in the symptomatic leg
and foot. What is the SINGLE most likely occluded artery?
A. Left femoro-popliteal artery
B. Left common iliac artery
C. Aortoiliac artery
D. Left femoral artery
E. Left deep femoral artery
ANSWER:
Left common iliac artery
EXPLANATION:
The answer here is left common iliac artery. Femoral artery and deep femoral artery is
less likely as the pain would start below the inguinal ligament. The external iliac artery
becomes the femoral artery after it passes under the inguinal ligament. Hence the
occlusion would be above the inguinal ligament.
If it was a femoro-popliteal artery occlusion, the pain would be described below the
knee.
The option of aortoiliac artery occlusion is not specific as it does not state if it is right or
left. It would also have symptoms of claudication and pain of the buttocks and thighs.
Symptoms of erectile dysfunction can also be seen in aortoiliac artery occlusion. The
ideal answer would actually be an external iliac artery occlusion as there are no
symptoms of gluteal pain in the stem. The common iliac bifurcates into internal and
external iliac arteries and since there is no mention of symptoms of internal iliac artery
obstruction in the stem, an external iliac artery occlusion would actually be the best
option if it was given in the exam. However, since it is not an option given, common
iliac artery occlusion falls into first place as the answer.
Remember, symptoms of occlusion has to occur distal to the level of the occlusion.
,LOWER LIMB ARTERIES
Q-2
A 76 year old man suddenly collapsed and died. At postmortem exam, a
retroperitoneal haematoma was found due to ruptured abdominal aortic
aneurysm. What is the SINGLE most likely underlying aetiology of the aortic
aneurysm?
A. Atheroma
B. Cystic medial necrosis
C. Marfan’s syndrome
D. Polyarteritis nodosa
E. Syphilis
, ANSWER:
Atheroma
EXPLANATION:
There are many causes of aortic aneurysm but the most typical cause of an aortic
aneurysm is atheroma.
Abdominal Aortic Aneurysms
Aetiology/Risk factors
• Severe atherosclerotic damage of the aortic wall
• Family history
• Male sex
• Increasing age
• Hypertension, smoking
• Syphilis
• Ehlers Danlos
• Marfan’s syndrome
Q-3
A 28 year old construction worker was admitted for pain in his right calf while at
work which has been increasing over the last 3 months. There is no history of
hypertension or diabetes, but he is a smoker. On examination, loss of posterior
tibial and dorsalis pedis pulsation was noticed along with a non-healing ulcer at
the base of the right 1st metatarsophalangeal joint. What is the SINGLE most
probable diagnosis?
A. Thromboangitis obliterans
B. Sciatica
C. Deep venous thrombosis
D. Baker’s cyst
E. Embolus
ANSWER:
Thromboangitis obliterans
EXPLANATION:
The diagnosis here is thromboangitis obliterans (Buerger’s disease). It usually presents
in young men around 40 years with strong smoking history. This particular question
might be a little confusing and some might argue that an embolus could have caused an
acute limb ischaemia causing admission. But given his young age, smoking history,
chronic pain that was increasing over a long period, and a non healing ulcer, Buerger’s
disease fits better.
Thromboangitis obliterans (Buerger’s disease)
Involves small vessels of the lower limbs and occurs in young men who smoke. It is
thought by some workers to be indistinguishable from atheromatous disease. However,
pathologically there is inflammation of the arteries and sometimes veins that may
indicate a separate disease entity. Clinically, it presents with severe claudication and
rest pain. Treatment is as for all peripheral vascular disease, but patients must stop
smoking.
Questions&Answers
Q-1
A 55 year old smoker presents to the emergency department with complaint of
severe left leg and foot pain that began earlier in the day. The pain spreads to the
level just above the inguinal ligament. His past medical history includes
hypertension. On examination, he has atrophic skin changes in his left leg and
his left limb is cold to touch. He has no palpable pulses in the left lower
extremity. Gross motor and sensory functions were intact in the symptomatic leg
and foot. What is the SINGLE most likely occluded artery?
A. Left femoro-popliteal artery
B. Left common iliac artery
C. Aortoiliac artery
D. Left femoral artery
E. Left deep femoral artery
ANSWER:
Left common iliac artery
EXPLANATION:
The answer here is left common iliac artery. Femoral artery and deep femoral artery is
less likely as the pain would start below the inguinal ligament. The external iliac artery
becomes the femoral artery after it passes under the inguinal ligament. Hence the
occlusion would be above the inguinal ligament.
If it was a femoro-popliteal artery occlusion, the pain would be described below the
knee.
The option of aortoiliac artery occlusion is not specific as it does not state if it is right or
left. It would also have symptoms of claudication and pain of the buttocks and thighs.
Symptoms of erectile dysfunction can also be seen in aortoiliac artery occlusion. The
ideal answer would actually be an external iliac artery occlusion as there are no
symptoms of gluteal pain in the stem. The common iliac bifurcates into internal and
external iliac arteries and since there is no mention of symptoms of internal iliac artery
obstruction in the stem, an external iliac artery occlusion would actually be the best
option if it was given in the exam. However, since it is not an option given, common
iliac artery occlusion falls into first place as the answer.
Remember, symptoms of occlusion has to occur distal to the level of the occlusion.
,LOWER LIMB ARTERIES
Q-2
A 76 year old man suddenly collapsed and died. At postmortem exam, a
retroperitoneal haematoma was found due to ruptured abdominal aortic
aneurysm. What is the SINGLE most likely underlying aetiology of the aortic
aneurysm?
A. Atheroma
B. Cystic medial necrosis
C. Marfan’s syndrome
D. Polyarteritis nodosa
E. Syphilis
, ANSWER:
Atheroma
EXPLANATION:
There are many causes of aortic aneurysm but the most typical cause of an aortic
aneurysm is atheroma.
Abdominal Aortic Aneurysms
Aetiology/Risk factors
• Severe atherosclerotic damage of the aortic wall
• Family history
• Male sex
• Increasing age
• Hypertension, smoking
• Syphilis
• Ehlers Danlos
• Marfan’s syndrome
Q-3
A 28 year old construction worker was admitted for pain in his right calf while at
work which has been increasing over the last 3 months. There is no history of
hypertension or diabetes, but he is a smoker. On examination, loss of posterior
tibial and dorsalis pedis pulsation was noticed along with a non-healing ulcer at
the base of the right 1st metatarsophalangeal joint. What is the SINGLE most
probable diagnosis?
A. Thromboangitis obliterans
B. Sciatica
C. Deep venous thrombosis
D. Baker’s cyst
E. Embolus
ANSWER:
Thromboangitis obliterans
EXPLANATION:
The diagnosis here is thromboangitis obliterans (Buerger’s disease). It usually presents
in young men around 40 years with strong smoking history. This particular question
might be a little confusing and some might argue that an embolus could have caused an
acute limb ischaemia causing admission. But given his young age, smoking history,
chronic pain that was increasing over a long period, and a non healing ulcer, Buerger’s
disease fits better.
Thromboangitis obliterans (Buerger’s disease)
Involves small vessels of the lower limbs and occurs in young men who smoke. It is
thought by some workers to be indistinguishable from atheromatous disease. However,
pathologically there is inflammation of the arteries and sometimes veins that may
indicate a separate disease entity. Clinically, it presents with severe claudication and
rest pain. Treatment is as for all peripheral vascular disease, but patients must stop
smoking.
