Vascular Surgery

Vascular Surgery US Medical PG Question 1: A 72-year-old woman comes to the physician for follow-up care. One year ago, she was diagnosed with a 3.8-cm infrarenal aortic aneurysm found incidentally on abdominal ultrasound. She has no complaints. She has hypertension, type 2 diabetes mellitus, and COPD. Current medications include hydrochlorothiazide, lisinopril, glyburide, and an albuterol inhaler. She has smoked a pack of cigarettes daily for 45 years. Her temperature is 37°C (98.6°F), pulse is 90/min, respirations are 12/min, and blood pressure is 145/85 mm Hg. Examination shows a faint abdominal bruit on auscultation. Ultrasonography of the abdomen shows a 4.9-cm saccular dilation of the infrarenal aorta. Which of the following is the most appropriate next step in management?

• A. Elective endovascular aneurysm repair (Correct Answer)
• B. Adjustment of cardiovascular risk factors and follow-up ultrasound in 12 months
• C. Adjustment of cardiovascular risk factors and follow-up ultrasound in 6 months
• D. Elective open aneurysm repair
• E. Adjustment of cardiovascular risk factors and follow-up CT in 6 months

Vascular Surgery Explanation: ***Elective endovascular aneurysm repair*** - The patient's **infrarenal aortic aneurysm** has grown from 3.8 cm to 4.9 cm in one year, approaching the **5.0 cm threshold for intervention in women** (compared to 5.5 cm for men). The **rapid growth rate of 1.1 cm/year** (normal is <0.5 cm/year) significantly increases rupture risk and is an indication for intervention even before reaching the absolute size threshold. - Given her multiple comorbidities (hypertension, diabetes, COPD, 45 pack-year smoking history), **endovascular aneurysm repair (EVAR)** is preferred over open repair due to lower perioperative morbidity and mortality in high-risk surgical candidates. - The combination of near-threshold size and rapid growth makes elective repair appropriate now rather than continued surveillance. *Adjustment of cardiovascular risk factors and follow-up ultrasound in 12 months* - While **risk factor modification** (smoking cessation, blood pressure control) is essential, it is insufficient as the primary management given the aneurysm's significant growth and imminent rupture risk. - A 12-month follow-up interval is too long for a rapidly growing aneurysm (grew 1.1 cm in the past year), as this increases the risk of rupture without intervention. *Adjustment of cardiovascular risk factors and follow-up ultrasound in 6 months* - **Risk factor management** is important but does not address the immediate need for intervention due to the aneurysm's size approaching the threshold and concerning growth rate. - While 6-month surveillance might be considered for smaller aneurysms with slower growth, this aneurysm's rapid expansion rate suggests it will exceed 5.0 cm well before the next surveillance interval, increasing rupture risk unnecessarily. *Elective open aneurysm repair* - **Open aneurysm repair** is an effective treatment but carries significantly higher perioperative risks (30-day mortality 3-5% vs 1-2% for EVAR) compared to endovascular repair, especially in patients with multiple comorbidities. - Given this patient's COPD, smoking history, and cardiovascular risk factors, EVAR is the preferred approach to minimize surgical stress and improve perioperative outcomes. *Adjustment of cardiovascular risk factors and follow-up CT in 6 months* - **Risk factor modification** alone is insufficient given the aneurysm's proximity to intervention threshold and rapid growth rate. - While CT provides more detailed anatomic imaging for surgical planning, continued surveillance is inappropriate when the patient already meets criteria for intervention. Additionally, CT involves radiation exposure and is typically reserved for pre-operative planning rather than routine surveillance.

Vascular Surgery US Medical PG Question 2: A 62-year-old woman with no significant past medical history presents with progressive dyspnea on exertion over the past 6 months. Echocardiogram reveals elevated pulmonary artery pressure (PAP) of 55 mmHg with normal left ventricular ejection fraction and no evidence of left-sided valvular disease. Right heart catheterization confirms mean PAP of 50 mmHg with pulmonary capillary wedge pressure of 10 mmHg. Intraoperative administration of intravenous adenosine causes the PAP to decrease to 35 mmHg. What pharmacological therapy is most likely to provide long-term benefit for this patient?

• A. Amlodipine (Correct Answer)
• B. Bosentan
• C. Epoprostenol
• D. Sildenafil
• E. Adenosine

Vascular Surgery Explanation: ***Amlodipine*** - The patient has **idiopathic pulmonary arterial hypertension (PAH, Group 1 PH)** confirmed by elevated mean PAP >20 mmHg with normal pulmonary capillary wedge pressure (≤15 mmHg), excluding left heart disease. - The **positive acute vasodilator response** (PAP drop >10 mmHg to <40 mmHg) during right heart catheterization indicates **vasoreactivity**, which predicts favorable response to **calcium channel blockers (CCBs)**. - **Amlodipine** or other CCBs (nifedipine, diltiazem) are the **first-line long-term therapy** for vasoreactive idiopathic PAH, with some patients achieving near-normalization of PAP. - Only about **10% of idiopathic PAH patients** are vasoreactive, making this finding clinically significant. *Bosentan* - **Bosentan** is an **endothelin receptor antagonist** used for **PAH (Group 1)**. - While effective for PAH, it is typically reserved for patients who are **non-vasoreactive** or who fail CCB therapy. - Given this patient's positive vasodilator response, a **CCB trial is preferred first** due to better long-term outcomes in vasoreactive patients. *Epoprostenol* - **Epoprostenol** is a **prostacyclin analog** used for severe **PAH**, particularly WHO functional class III-IV. - It requires **continuous intravenous infusion** and is reserved for more advanced or refractory PAH. - Not appropriate as **first-line therapy** in a vasoreactive patient who can be treated with oral CCBs. *Sildenafil* - **Sildenafil** is a **phosphodiesterase-5 inhibitor** effective for **PAH**. - Like bosentan, it is used for patients who are **non-vasoreactive** or have failed CCB therapy. - In a vasoreactive patient, **CCBs are preferred** due to superior long-term outcomes in this subset. *Adenosine* - **Adenosine** is an **ultrashort-acting vasodilator** used as a **diagnostic agent** during right heart catheterization to assess vasoreactivity. - It has a half-life of seconds and is **not suitable for long-term therapy**. - Alternative agents for vasoreactivity testing include inhaled nitric oxide and intravenous epoprostenol.

Vascular Surgery US Medical PG Question 3: A 43-year-old man comes to the physician because of increasing shortness of breath for 1 month. He has been using two pillows at night but frequently wakes up feeling as if he is choking. Five months ago, he underwent surgery for creation of an arteriovenous fistula in his left upper arm. He has hypertension and chronic kidney disease due to reflux nephropathy. He receives hemodialysis three times a week. His current medications are enalapril, vitamin D3, erythropoietin, sevelamer, and atorvastatin. His temperature is 37.1°C (98.8°F), respirations are 22/min, pulse is 103/min and bounding, and blood pressure is 106/58 mm Hg. Examination of the lower extremities shows bilateral pitting pedal edema. There is jugular venous distention. A prominent thrill is heard over the brachiocephalic arteriovenous fistula. There are crackles heard at both lung bases. Cardiac examination shows an S3 gallop. The abdomen is soft and nontender. Which of the following is the most likely cause of this patient's symptoms?

• A. AV fistula aneurysm
• B. Pulmonary embolism
• C. Constrictive pericarditis
• D. Dialysis disequilibrium syndrome
• E. High-output heart failure (Correct Answer)

Vascular Surgery Explanation: ***High-output heart failure*** - The patient's symptoms of **dyspnea, orthopnea, pitting edema, jugular venous distention, crackles**, and **S3 gallop** strongly indicate **heart failure**. The **bounding pulse** and **wide pulse pressure** (systolic 106, diastolic 58) in the presence of an **arteriovenous fistula** suggest a **high-output state**. - An **arteriovenous fistula** used for hemodialysis can significantly increase **cardiac preload** and reduce **afterload**, leading to a persistent increase in **cardiac output**. Over time, this chronic increase in demand can overwhelm the heart, resulting in **high-output heart failure**. *AV fistula aneurysm* - An **AV fistula aneurysm** is a localized dilatation of the fistula and would typically present as a painful or compressible mass. - While it's a complication of AV fistulas, it does not directly explain the systemic signs of **heart failure** observed in this patient. *Pulmonary embolism* - **Pulmonary embolism** typically presents with sudden onset **dyspnea, pleuritic chest pain**, and sometimes **tachycardia** and **hypoxia**. - This patient's symptoms are of gradual onset, accompanied by clear signs of **fluid overload** and **cardiac dysfunction** like an S3 gallop, which are not typical for a PE. *Constrictive pericarditis* - **Constrictive pericarditis** causes symptoms of **right-sided heart failure** due to impaired diastolic filling, often with a **pericardial knock** and **Kussmaul's sign**. - While it can manifest with pedal edema and JVD, the **S3 gallop** and especially the **bounding pulse** and **wide pulse pressure** are inconsistent with constrictive pericarditis, which would typically cause a low-output state. *Dialysis disequilibrium syndrome* - **Dialysis disequilibrium syndrome** occurs shortly after hemodialysis, usually during or immediately after the first few sessions. It is characterized by neurological symptoms such as **headache, nausea, vomiting, confusion**, and **seizures**. - The patient's symptoms have been evolving over a month and describe a state of **fluid overload** and **cardiac dysfunction**, not acute neurological symptoms related to dialysis.

Vascular Surgery US Medical PG Question 4: A 69-year-old woman is admitted to the hospital with substernal, crushing chest pain. She is emergently moved to the cardiac catheterization lab where she undergoes cardiac angiography. Angiography reveals that the diameter of her left anterior descending artery (LAD) is 50% of normal. If her blood pressure, LAD length, and blood viscosity have not changed, which of the following represents the most likely change in LAD flow from baseline?

• A. Decreased by 93.75% (Correct Answer)
• B. Increased by 6.25%
• C. Decreased by 25%
• D. Decreased by 87.5%
• E. Increased by 25%

Vascular Surgery Explanation: ***Decreased by 93.75%*** - This option is correct based on Poiseuille's Law, which states that flow is proportional to the **fourth power of the radius (r^4)**. A 50% decrease in diameter means a 50% decrease in radius (0.5r). - The new flow would be (0.5)^4 = 0.0625 times the original flow. Therefore, the decrease in flow is 1 - 0.0625 = 0.9375, or **93.75%**. *Increased by 6.25%* - This answer incorrectly suggests an **increase** in flow, which is contrary to the effect of a narrowed artery. - While 6.25% represents the new flow as a percentage of baseline (since 0.0625 = 6.25%), the vessel stenosis causes a **decrease**, not an increase in flow. *Decreased by 25%* - This calculation might arise from considering a linear relationship (e.g., radius decreases by 50%, so flow decreases by 50% of 50%, which is incorrect). - It does not account for the **fourth power relationship** between radius and flow according to Poiseuille's Law. *Decreased by 87.5%* - This percentage represents a calculation error, likely from misapplying the fourth power relationship or confusing the calculation steps. - It does not accurately reflect the dramatic reduction in flow caused by a 50% reduction in vessel diameter. *Increased by 25%* - This option implies a significant increase in blood flow, which would not happen with a **stenosed artery**. - It completely contradicts the physiological response to a **narrowed vessel**.

Vascular Surgery US Medical PG Question 5: A 78-year-old left-handed woman with hypertension and hyperlipidemia is brought to the emergency room because of sudden-onset right leg weakness and urinary incontinence. Neurologic examination shows decreased sensation over the right thigh. Muscle strength is 2/5 in the right lower extremity and 4/5 in the right upper extremity. Strength and sensation in the face are normal but she has difficulty initiating sentences and she is unable to write her name. The most likely cause of this patient’s condition is an occlusion of which of the following vessels?

• A. Right vertebrobasilar artery
• B. Right middle cerebral artery
• C. Left posterior cerebral artery
• D. Left anterior cerebral artery (Correct Answer)
• E. Right anterior cerebral artery

Vascular Surgery Explanation: ***Left anterior cerebral artery*** - Stroke in the **left anterior cerebral artery (ACA)** territory typically causes **contralateral leg weakness** (right leg in this case) and **urinary incontinence** due to involvement of the paracentral lobule. - The patient's difficulty writing her name (agraphia) and initiating sentences (transcortical motor aphasia, which can manifest as difficulty initiating speech) is consistent with damage to the supplemental motor area in the dominant (left) hemisphere, provided by the ACA. *Right vertebrobasilar artery* - Occlusion of the vertebrobasilar artery typically presents with a wide range of symptoms including **vertigo**, **ataxia**, **dysarthria**, and bilateral or alternating sensory/motor deficits. - It would not selectively cause isolated right leg weakness, urinary incontinence, and dominant hemisphere language difficulties without other brainstem or cerebellar signs. *Right middle cerebral artery* - A stroke in the **right middle cerebral artery (MCA)** would cause **left-sided deficit**, not right-sided. - Although it can cause motor and sensory deficits, it typically affects the arm and face more than the leg, and would not cause the specific language deficits of the dominant hemisphere seen here. *Left posterior cerebral artery* - Occlusion of the **left posterior cerebral artery (PCA)** typically leads to issues like **contralateral homonymous hemianopia**, visual field defects, and potentially memory impairment or alexia without agraphia if the splenium of the corpus callosum is involved. - It directly affects posterior brain regions, so it would not cause the anterior cerebral artery specific symptoms such as prominent contralateral leg weakness, urinary incontinence, or the described language difficulties. *Right anterior cerebral artery* - Occlusion of the **right anterior cerebral artery (ACA)** would cause **left leg weakness** and **left-sided sensory deficits**, not the right-sided deficits observed in this patient. - While it could cause urinary incontinence, the combination of right-sided weakness and dominant hemisphere language deficits points against a right ACA occlusion.

Vascular Surgery US Medical PG Question 6: A 54-year-old man comes to the emergency department because of severe pain in his right leg that began suddenly 3 hours ago. He has had repeated cramping in his right calf while walking for the past 4 months, but it has never been this severe. He has type 2 diabetes mellitus, hypercholesterolemia, and hypertension. Current medications include insulin, enalapril, aspirin, and simvastatin. He has smoked one pack of cigarettes daily for 33 years. He does not drink alcohol. His pulse is 103/min and blood pressure is 136/84 mm Hg. Femoral pulses are palpable bilaterally. The popliteal and pedal pulses are absent on the right. Laboratory studies show: Hemoglobin 16.1 g/dL Serum Urea nitrogen 14 mg/dL Glucose 166 mg/dL Creatinine 1.5 mg/dL A CT angiogram of the right lower extremity is ordered. Which of the following is the most appropriate next step in management?

• A. Administer sodium bicarbonate
• B. Administer mannitol
• C. Administer normal saline (Correct Answer)
• D. Remote ischemic preconditioning
• E. Administer heparin anticoagulation

Vascular Surgery Explanation: ***Administer normal saline*** - The patient has an acute limb ischemia and needs a **CT angiogram** with contrast to locate the thrombus for intervention. Administering **normal saline** prior to contrast administration is crucial to prevent contrast-induced nephropathy, especially in a patient with **diabetes** and mildly elevated **creatinine**. - **Aggressive hydration** with intravenous fluids helps maintain renal perfusion and dilute the contrast agent, thereby reducing its nephrotoxic effects. *Administer sodium bicarbonate* - While sometimes used for renal protection, **sodium bicarbonate** is generally reserved for patients with more severe metabolic acidosis or for specific situations where its alkalizing properties are beneficial. - In this context, **normal saline** is the primary choice for generalized hydration and prevention of contrast-induced nephropathy before contrast administration. *Administer mannitol* - **Mannitol** is an osmotic diuretic used to induce diuresis and reduce intracranial pressure or treat cerebral edema. - It is **not the primary fluid** for preventing contrast-induced nephropathy and could potentially worsen dehydration if used inappropriately. *Remote ischemic preconditioning* - **Remote ischemic preconditioning** involves inducing brief, controlled periods of ischemia and reperfusion in one organ to protect another organ from a subsequent, more prolonged ischemic insult. - While an interesting concept, it is **not a standard or immediate treatment** for preventing contrast-induced nephropathy in this acute setting and has not shown consistent, strong evidence for this specific indication. *Administer heparin anticoagulation* - **Heparin anticoagulation** is critical for treating acute limb ischemia to prevent thrombus propagation. However, the question specifically asks for the most appropriate next step **in management regarding the CT angiogram**. - While heparin should be given, **renal protection** prior to contrast administration is a more immediate and specific concern related to the ordered diagnostic test. The question asks for the step **before** the CT angiogram.

Vascular Surgery US Medical PG Question 7: A 68-year-old man presents to the emergency department with leg pain. He states that the pain started suddenly while he was walking outside. The patient has a past medical history of diabetes, hypertension, obesity, and atrial fibrillation. His temperature is 99.3°F (37.4°C), blood pressure is 152/98 mmHg, pulse is 97/min, respirations are 15/min, and oxygen saturation is 99% on room air. Physical exam is notable for a cold and pale left leg. The patient’s sensation is markedly diminished in the left leg when compared to the right, and his muscle strength is 1/5 in his left leg. Which of the following is the best next step in management?

• A. Graded exercise and aspirin
• B. Surgical thrombectomy
• C. CT angiogram
• D. Heparin drip (Correct Answer)
• E. Tissue plasminogen activator

Vascular Surgery Explanation: ***Heparin drip*** - This patient presents with signs and symptoms of **acute limb ischemia** (sudden onset leg pain, cold and pale limb, diminished sensation, and motor weakness) in the setting of **atrial fibrillation**. - Immediate initiation of an **anticoagulant**, such as a heparin drip, is crucial to prevent further clot propagation while definitive treatment is being arranged. *Graded exercise and aspirin* - This management strategy is typically reserved for **chronic peripheral artery disease** (PAD) with intermittent claudication, not acute limb ischemia. - In acute limb ischemia, immediate reperfusion is critical to preserve limb viability, which cannot be achieved with exercise or aspirin alone. *Surgical thrombectomy* - While **surgical thrombectomy** may be the definitive treatment for acute limb ischemia, it is not the *immediate* next step in management. - Anticoagulation should be initiated *before* surgical intervention to stabilize the patient and prevent further thrombosis. *CT angiogram* - A **CT angiogram** is a valuable diagnostic tool to pinpoint the location and extent of the occlusion. - However, in a patient with clear signs of acute limb ischemia, **anticoagulation should not be delayed** for imaging alone. Heparin should be started immediately, and imaging can be performed concurrently if feasible or shortly thereafter. *Tissue plasminogen activator* - **Tissue plasminogen activator (tPA)** is a thrombolytic agent that can be used in some cases of acute limb ischemia, particularly for smaller, more distal thrombi or when surgical options are difficult. - However, its use carries a higher risk of bleeding complications and is generally considered after initial anticoagulation and a thorough assessment, sometimes guided by angiography. It's not typically the *first* step in an emergency presentation like this.

Vascular Surgery US Medical PG Question 8: A 54-year-old man comes to the physician because of a painful mass in his left thigh for 3 days. He underwent a left lower limb angiography for femoral artery stenosis and had a stent placed 2 weeks ago. He has peripheral artery disease, coronary artery disease, hypercholesterolemia and type 2 diabetes mellitus. He has smoked one pack of cigarettes daily for 34 years. Current medications include enalapril, aspirin, simvastatin, metformin, and sitagliptin. His temperature is 36.7°C (98°F), pulse is 88/min, and blood pressure is 116/72 mm Hg. Examination shows a 3-cm (1.2-in) tender, pulsatile mass in the left groin. The skin over the area of the mass shows no erythema and is cool to the touch. A loud bruit is heard on auscultation over this area. The remainder of the examination shows no abnormalities. Results of a complete blood count and serum electrolyte concentrations show no abnormalities. Duplex ultrasonography shows an echolucent sac connected to the common femoral artery, with pulsatile and turbulent blood flow between the artery and the sac. Which of the following is the most appropriate next best step in management?

• A. Ultrasound-guided thrombin injection (Correct Answer)
• B. Covered stent implantation
• C. Ultrasound-guided compression
• D. Coil embolization
• E. Schedule surgical repair

Vascular Surgery Explanation: ***Ultrasound-guided thrombin injection*** - The patient presents with a **post-catheterization pseudoaneurysm** as indicated by the pulsatile, tender mass with a bruit after recent femoral angiography, and confirmed by duplex ultrasonography showing an echolucent sac connected to the common femoral artery with pulsatile flow. - **Ultrasound-guided thrombin injection** is the preferred treatment for pseudoaneurysms that are larger than 2-3 cm or have been present for more than 1 week, as it effectively closes the pseudoaneurysm sac with a high success rate and minimal invasiveness. *Covered stent implantation* - This is a treatment for arterial injury or aneurysm, but it is generally reserved for **larger or more complex pseudoaneurysms**, or those that have failed less invasive treatments, due to its greater invasiveness and potential complications. - It involves placing a stent graft to exclude the pseudoaneurysm from the circulation. *Ultrasound-guided compression* - This technique involves applying sustained pressure to the pseudoaneurysm neck, which can lead to thrombosis. However, it has a **lower success rate** compared to thrombin injection, especially for larger pseudoaneurysms, and is often painful and time-consuming. - It is often considered a first-line therapy for smaller pseudoaneurysms (<2-3 cm) before thrombin injection, but in this case, the pseudoaneurysm is 3 cm. *Coil embolization* - This procedure is typically used to treat **arteriovenous malformations** or high-flow bleeding rather than pseudoaneurysms. - It involves placing coils into the vessel to induce thrombosis, but carries risks of distal embolization and might be overly aggressive for a femoral pseudoaneurysm. *Schedule surgical repair* - **Surgical repair** is indicated for pseudoaneurysms that are rapidly expanding, symptomatic with critical limb ischemia, infected, or those that have failed less invasive treatments. - In this case, given the patient's stable condition and the availability of less invasive options, surgical repair is not the initial best step.

Vascular Surgery US Medical PG Question 9: A 68-year-old female presents to the emergency room with acute onset of dyspnea and hemoptysis. Her past medical history is unremarkable and she has had no prior surgeries. A ventilation-perfusion scan demonstrates a large perfusion defect that is not matched by a ventilation defect in the left lower lobe. Which of the following would you also expect to find in this patient:

• A. Bradycardia
• B. Increased inspiratory capacity
• C. Claudication
• D. Aortic dilation
• E. Pleuritic chest pain (Correct Answer)

Vascular Surgery Explanation: ***Pleuritic chest pain*** - The presented symptoms (dyspnea, hemoptysis, V/Q scan showing unmatched perfusion defect) are highly suggestive of **pulmonary embolism (PE)**. **Pleuritic chest pain** is a common symptom of PE, resulting from inflammation of the pleura often associated with a pulmonary infarct. - **Pleuritic chest pain** is classically described as sharp, localized pain that worsens with deep inspiration or coughing, which aligns with the potential for pleural irritation in PE. *Bradycardia* - **Tachycardia**, not bradycardia, is a common finding in pulmonary embolism, often due to the body's compensatory response to hypoxemia and increased cardiovascular strain. - Bradycardia would be atypical and likely unrelated to the acute presentation of PE in a previously healthy individual. *Increased inspiratory capacity* - In a patient with an acute pulmonary embolism, the inspiratory capacity is more likely to be normal or **decreased** due to discomfort from pleuritic chest pain, dyspnea, and potential V/Q mismatch affecting lung mechanics. - Increased inspiratory capacity is not a typical physiological response to an acute PE; instead, patients often experience **restrictive breathing patterns**. *Claudication* - **Claudication** refers to pain, usually in the legs, caused by too little blood flow during exercise; it typically indicates **peripheral artery disease**. - While PE is a thrombotic event, claudication is a symptom of chronic arterial insufficiency and is not directly related to acute pulmonary embolism. *Aortic dilation* - **Aortic dilation** is associated with conditions like aortic aneurysm or Marfan syndrome and is not a direct consequence or expected finding in acute pulmonary embolism. - There is no pathophysiological link between acute PE and the immediate development or presence of aortic dilation.

Vascular Surgery US Medical PG Question 10: A 31-year-old man presents to the Emergency Department with severe left leg pain and paresthesias 4 hours after his leg got trapped by the closing door of a bus. Initially, he had a mild pain which gradually increased to unbearable levels. Past medical history is noncontributory. In the Emergency Department, his blood pressure is 130/80 mm Hg, heart rate is 87/min, respiratory rate is 14/min, and temperature is 36.8℃ (98.2℉). On physical exam, his left calf is firm and severely tender on palpation. The patient cannot actively dorsiflex his left foot, and passive dorsiflexion is limited. Posterior tibial and dorsalis pedis pulses are 2+ in the right leg and 1+ in the left leg. Axial load does not increase the pain. Which of the following is the best next step in the management of this patient?

• A. Lower limb CT scan
• B. Lower limb ultrasound
• C. Splinting and limb rest
• D. Fasciotomy (Correct Answer)
• E. Lower limb X-ray in two projections

Vascular Surgery Explanation: ***Fasciotomy*** - The patient presents with classic signs and symptoms of **acute compartment syndrome**, including unrelieved pain by analgesics, paresthesias, pain with passive stretching, and a tense compartment due to the bus door trauma. - **Fasciotomy** is the definitive and urgent treatment to relieve pressure within the muscle compartments, prevent muscle ischemia, and avoid permanent nerve damage or limb loss. *Lower limb CT scan* - A **CT scan** is primarily used to evaluate bony structures and soft tissue injuries but is not the most immediate or definitive diagnostic tool for acute compartment syndrome. - Delaying **fasciotomy** for imaging in a clear case of compartment syndrome can lead to irreversible damage. *Lower limb ultrasound* - **Ultrasound** can assess vascular flow and some soft tissue aspects but is not accurate or rapid enough for diagnosing compartment syndrome. - It would not provide the necessary information to guide urgent surgical intervention. *Splinting and limb rest* - This approach is appropriate for fractures or soft tissue injuries without compartment syndrome; however, in acute compartment syndrome, **splinting or limb rest** will worsen the condition. - **Immobilization** and elevation are contraindicated as they can further decrease blood flow and increase compartment pressure. *Lower limb X-ray in two projections* - An **X-ray** is useful for ruling out fractures but will not provide information about compartment pressure or muscle viability. - While a fracture can sometimes cause compartment syndrome, the immediate concern here is the compartment syndrome itself, for which **X-rays** are not diagnostic.

Vascular Surgery Flashcard 1 of 5

Question: EF < _____% and MI within _____ months are absolute contraindications to non-cardiac surgery

Answer: 35

Extra Information:  https://onlinemeded.org/spa/surgery?ref=anki 

Vascular Surgery Flashcard 2 of 5

Question: Peripheral Arterial Disease is most commonly caused by occlusion of the _____

Answer: popliteal artery

Vascular Surgery Flashcard 3 of 5

Question: Ischemia priapism may lead to permanent erectile dysfunction and _____

Answer: penile necrosis

Vascular Surgery Flashcard 4 of 5

Question: Gas emboli may be iatrogenic, secondary to _____ procedures as air is pumped into the abdomen

Answer: laparoscopic

Vascular Surgery Flashcard 5 of 5

Question: What is the treatment for Stanford type A aortic dissection? _____

Answer: Surgery