Vascular Surgery
Core Concepts
Understand the evaluation and management of peripheral arterial disease (PAD), carotid stenosis, aortic aneurysms, and venous disease. Key concepts: ankle-brachial index (ABI) for PAD, indications for carotid endarterectomy (symptomatic stenosis ≥70%), and surveillance of abdominal aortic aneurysms (AAA). Know the criteria for repair of AAA (size ≥5.5 cm in men, ≥5.0 cm in women, rapid growth, symptomatic). Also, understand deep vein thrombosis (DVT) prophylaxis and treatment, and the management of varicose veins.
Traps in Questions
A common trap is the use of ABI in patients with non-compressible vessels (diabetics, elderly) – falsely elevated. Another trap is the timing of carotid endarterectomy: best within 2 weeks of a transient ischemic attack (TIA) or stroke. For AAA, beware of the “ruptured AAA” triad: hypotension, pulsatile abdominal mass, and back pain – immediate surgery. Also, know that asymptomatic carotid stenosis is generally managed medically unless stenosis ≥80% in high-risk patients.
Worked Example
A 70-year-old man with a 6.0 cm infrarenal AAA and no symptoms. What is the best management? Answer: Elective endovascular aneurysm repair (EVAR) or open repair based on anatomy and comorbidities.
Rule of Thumb
In PAD, critical limb ischemia (rest pain, gangrene) requires urgent revascularization; claudication can be managed with exercise and medication first.