Vascular and Thoracic Surgery
Core concepts
Vascular surgery questions emphasize AAA, peripheral arterial disease, acute limb ischemia, carotid disease, venous thromboembolism, and dialysis access. Ruptured AAA is a surgical emergency with hypotension, back or abdominal pain, and a pulsatile mass; unstable patients need operative repair, often endovascular where anatomy and resources permit. Acute limb ischemia presents with the six Ps and requires heparin and urgent revascularization. ABPI below 0.9 suggests arterial disease; above 1.3 suggests noncompressible vessels. Carotid endarterectomy is considered for symptomatic high-grade stenosis. Thoracic surgery includes lung cancer staging, solitary pulmonary nodule evaluation, pneumothorax, pleural effusion, and esophageal disease.
Traps
Do not attribute hypotension and back pain in an older adult to renal colic without considering AAA. Do not delay heparin in acute limb ischemia. A normal ABPI can occur with calcified vessels. Tension pneumothorax is clinical, and chest tube placement should not wait for a chest radiograph. In lung cancer, staging precedes resection; tissue diagnosis may be omitted only in selected high-risk presentations.
Worked example
A smoker with sudden severe back pain, syncope, and a pulsatile abdominal mass should be assumed to have a ruptured AAA. Activate massive transfusion, obtain bedside ultrasound if it does not delay care, and move to definitive repair. Rule of thumb: unstable ruptured AAA goes to the OR or hybrid suite, not CT.