Vascular Surgery: Aortic Emergencies, Ischaemia and Venous Disease
Vascular Surgery tests aortic emergencies, peripheral arterial disease, carotid disease, venous thromboembolism and vascular trauma. The MCQ often asks for immediate management before definitive imaging.
Core rules
- Ruptured abdominal aortic aneurysm: sudden abdominal or back pain, pulsatile expansile mass and hypotension. Use permissive hypotension with a systolic pressure around 80 to 90 mmHg. An unstable patient goes straight to theatre; a stable patient has CT angiography.
- Peripheral arterial disease: ankle-brachial pressure index below 0.9 is abnormal. Claudication is managed with best medical therapy and exercise; critical limb ischaemia with rest pain, ulceration or gangrene requires urgent revascularisation.
- Acute limb ischaemia: the six Ps are pain, pallor, pulselessness, paraesthesia, paralysis and perishing cold. Give heparin and arrange urgent imaging and revascularisation; irreversible ischaemia may require amputation.
- Carotid disease: symptomatic stenosis of 70% to 99% warrants carotid endarterectomy within 2 weeks, plus best medical therapy.
- Deep vein thrombosis: use the Wells score, D-dimer and ultrasound. Anticoagulation duration depends on whether the event is provoked or unprovoked.
- Varicose veins: duplex ultrasound maps reflux; compression and endovenous ablation are options.
- Vascular trauma: hard signs such as pulsatile bleeding, expanding haematoma or absent distal pulses require immediate exploration; soft signs require CT angiography.
Worked example
A 72-year-old man has sudden severe abdominal pain, syncope, BP 85/50 mmHg and a pulsatile expansile abdominal mass.
Reasoning: this is a ruptured abdominal aortic aneurysm. Avoid large fluid boluses that raise pressure and worsen bleeding; aim for permissive hypotension. Because he is unstable, transfer directly to theatre for open or endovascular repair rather than CT.
Traps
- A normal ankle-brachial index does not exclude peripheral arterial disease in diabetes, because calcified vessels are falsely stiff.
- A carotid bruit does not indicate stenosis severity.
- D-dimer is not useful when clinical probability of deep vein thrombosis is high.
- Abdominal aortic aneurysm screening is by ultrasound, not CT.