Vascular and Thoracic Surgery
This domain tests arterial and venous disease plus core thoracic procedures. The exam favours decision thresholds - when to operate, when to image, and when a bedside manoeuvre is the answer.
Peripheral arterial disease
- Ankle-brachial pressure index below 0.9 supports peripheral arterial disease; values above 1.3 suggest calcified, incompressible vessels in diabetes or renal failure.
- Claudication is reproducible with exercise and relieved by rest; critical limb ischaemia is rest pain, ulceration or gangrene with objectively reduced pressures.
- Best medical therapy: smoking cessation, statin, antiplatelet, exercise and blood pressure control. Revascularisation by angioplasty or bypass depending on anatomy; the BASIL trial supports bypass first in patients expected to survive more than 2 years with available vein.
- Acute limb ischaemia: the six Ps, heparin immediately, and revascularisation within about 6 hours; a tingly, weak limb is threatened and needs urgent surgery.
Aortic and carotid disease
- Abdominal aortic aneurysm repair is offered at 5.5 cm diameter or growth over 1 cm per year; endovascular repair has lower early mortality but needs anatomical suitability and lifelong surveillance.
- Ruptured aneurysm: permissive hypotension, no delay for CT in the unstable patient, straight to theatre.
- Symptomatic carotid stenosis of 70–99% (NASCET) needs endarterectomy, ideally within 2 weeks of the event.
Venous disease
- Varicose veins are classified by CEAP; endovenous ablation is first-line for truncal reflux.
- Deep vein thrombosis: Wells score, D-dimer for low probability, duplex ultrasound for high probability; anticoagulate with a direct oral anticoagulant unless cancer or pregnancy dictates otherwise.
- Pulmonary embolism: CTPA is the investigation of choice; massive PE with shock needs thrombolysis.
Thoracic basics
- Chest drain safe triangle: lateral to pectoralis, anterior to latissimus dorsi, above the fifth intercostal space.
- Primary spontaneous pneumothorax in a stable patient can be aspirated; secondary pneumothorax and any tension pneumothorax need a drain.
- Lung cancer: lobectomy with systematic node dissection is standard for fit patients; video-assisted surgery reduces morbidity.
Worked example
A 66-year-old diabetic smoker has rest pain and an ankle-brachial index of 0.5. This is critical limb ischaemia, not claudication. Urgent vascular referral for imaging and revascularisation is required, alongside best medical therapy and analgesia; delayed referral risks limb loss.
Traps that lose marks
Trusting a normal or high ABPI in a diabetic with calcified vessels; withholding heparin in acute limb ischaemia; taking an unstable ruptured aneurysm to CT; using a drain for every stable primary pneumothorax.