Vascular Surgery
Arterial disease
Peripheral arterial disease is assessed with the ankle–brachial index; below 0.9 is abnormal, and above 1.3 suggests medial calcification, common in diabetes and renal failure. Claudication is reproducible with exercise and relieved by rest; critical limb ischaemia is rest pain, ulceration or gangrene with objectively reduced perfusion. Acute limb ischaemia presents with the six Ps; Rutherford classification guides immediate revascularisation, and heparin is started before imaging. Always check for compartment syndrome after revascularisation.
Aortic aneurysm: elective repair is considered at 5.5 cm in men, or if rapidly growing or symptomatic. Rupture presents with back pain, hypotension and a pulsatile mass; do not delay for CT in the unstable patient.
Carotid disease: symptomatic stenosis greater than 50% warrants endarterectomy, ideally within 2 weeks; asymptomatic disease is managed selectively.
Venous and lymphatic
Virchow's triad (stasis, endothelial injury, hypercoagulability) explains deep vein thrombosis. Proximal DVT needs anticoagulation; post-thrombotic syndrome is a late complication. Varicose veins are managed by compression, ablation or surgery depending on symptoms and duplex findings. Lymphoedema is managed with compression and skin care; cellulitis is a common complication.
Access and diabetic foot
An arteriovenous fistula needs an adequate vein, maturation for 6–8 weeks, and monitoring for stenosis and steal. Diabetic foot: neuropathy, ischaemia and infection coexist; assess pulses and ankle–brachial index, debride, offload, and treat osteomyelitis with prolonged antibiotics.
Rule of thumb
A cold, painful, pulseless leg is a vascular emergency: heparin, analgesia and vascular surgical review before any imaging that delays theatre.