MCQ bank · 36 questions · free
Vascular surgery MCQs with answers
36 single-best-answer questions on aortic aneurysm, limb ischaemia, carotid disease, DVT and the diabetic foot. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 72-year-old woman in atrial fibrillation has a cold, pale right leg for 5 hours. She has numbness of the toes but normal power. No pulses are palpable below the femoral. What do you do?
- Antiplatelet and walking exercise
- Duplex scan next week
- Immediate intravenous heparin and urgent revascularisation (embolectomy or endovascular)
- Analgesia and review in 24 hours
- Primary amputation
Show the answer and explanation
Answer: C. Immediate intravenous heparin and urgent revascularisation (embolectomy or endovascular). Sensory loss limited to the toes without motor loss is a marginally threatened limb (Rutherford IIa) that needs urgent revascularisation, usually within hours, after immediate systemic heparin. Motor loss indicates an immediately threatened limb (IIb).
Why not the others? Delay leads to irreversible ischaemia. Amputation is for an irreversibly ischaemic limb (category III).
References
A 70-year-old man has an asymptomatic infrarenal abdominal aortic aneurysm of 5.7 cm. He is fit. What do you advise?
- Beta-blockers to stop growth
- Elective repair (open or endovascular)
- Annual CT for 5 years
- Repair only if it becomes painful
- Ultrasound surveillance every 3 months
Show the answer and explanation
Answer: B. Elective repair (open or endovascular). In men, the threshold for elective repair of an asymptomatic AAA is 5.5 cm, or growth of more than 1 cm in a year. Below this, surveillance is safer than repair.
Why not the others? Medication does not stop aneurysm growth. Waiting for symptoms risks rupture.
References
A 66-year-old woman has a 4-cm ulcer above the medial malleolus with surrounding haemosiderin staining and varicose veins. Her ankle–brachial pressure index is 0.95. What is the key treatment?
- Antibiotics for 6 weeks
- Arterial bypass
- Skin graft without compression
- Leg elevation alone
- Multilayer compression therapy, and referral for endovenous treatment of superficial venous reflux
Show the answer and explanation
Answer: E. Multilayer compression therapy, and referral for endovenous treatment of superficial venous reflux. This is a venous ulcer with no significant arterial disease (ABPI at least 0.8), so strong compression is safe and is the core of treatment. Early ablation of superficial reflux speeds healing and reduces recurrence (EVRA trial).
Why not the others? Antibiotics are only for clinical infection.
References
A 68-year-old man had a right hemispheric TIA 3 days ago. Duplex shows a 75% stenosis of the right internal carotid artery. What is the best management?
- Endarterectomy after 6 months
- Best medical therapy and carotid endarterectomy as soon as possible, ideally within 14 days
- Warfarin only
- Best medical therapy alone
- Repeat duplex in 1 year
Show the answer and explanation
Answer: B. Best medical therapy and carotid endarterectomy as soon as possible, ideally within 14 days. Symptomatic carotid stenosis of 50–99% benefits from endarterectomy, and the benefit is greatest when surgery is done early, because the risk of stroke is highest in the first days after a TIA.
Why not the others? Delaying surgery for months loses most of its benefit.
References
A 66-year-old smoker gets calf pain after walking 200 metres, relieved by rest. His ankle–brachial pressure index is 0.65. There is no rest pain or tissue loss. What is the first-line management?
- Femoral–popliteal bypass
- Urgent angioplasty
- Stop smoking, statin and antiplatelet therapy, and a supervised exercise programme
- Warfarin
- Amputation
Show the answer and explanation
Answer: C. Stop smoking, statin and antiplatelet therapy, and a supervised exercise programme. Intermittent claudication carries a low risk of limb loss but a high cardiovascular risk. Best medical therapy treats the risk, and supervised exercise improves walking distance. Revascularisation is considered only if symptoms remain disabling after exercise therapy.
Why not the others? Early intervention for claudication does not improve long-term outcome and carries risk.
References
A 74-year-old man collapses with back pain. He is conscious with a systolic pressure of 85 mmHg. Bedside ultrasound shows a 7-cm abdominal aortic aneurysm. What is the best approach?
- MRI angiography
- Elective repair next week
- Fluids to restore a systolic pressure of 140
- Permissive hypotension, alert the vascular team, CT angiography if he remains stable, and endovascular repair if the anatomy is suitable
- Admit to the ward for observation
Show the answer and explanation
Answer: D. Permissive hypotension, alert the vascular team, CT angiography if he remains stable, and endovascular repair if the anatomy is suitable. Over-aggressive fluid worsens bleeding, so a lower blood pressure is accepted while the patient remains conscious. A rapid CT in a stable patient allows endovascular repair, which most guidelines now prefer when the anatomy is suitable. Unstable patients go straight to theatre.
Why not the others? MRI is too slow. Restoring normal pressure before control of the aorta increases blood loss.
References
Two weeks after a laparoscopic colectomy, a 55-year-old woman has a proximal deep vein thrombosis. She has no cancer and no other risk factors. How long should she be anticoagulated?
- 2 weeks
- No anticoagulation; compression stockings only
- About 3 months
- Lifelong
- 10 years
Show the answer and explanation
Answer: C. About 3 months. A DVT provoked by a major transient risk factor such as surgery has a low recurrence risk once the factor has gone, so 3 months of anticoagulation (usually a DOAC) is recommended. Unprovoked clots and cancer-related clots are treated for longer.
Why not the others? Stockings do not treat DVT.
References
A man with type 2 diabetes has a hot, swollen forefoot, fever and fluctuance in the plantar space. X-ray shows gas in the soft tissues. What is required?
- Oral antibiotics and review in 2 weeks
- Offloading boot only
- MRI and then decide in a week
- Urgent surgical drainage and debridement with intravenous antibiotics, then vascular assessment
- Below-knee amputation as the first step
Show the answer and explanation
Answer: D. Urgent surgical drainage and debridement with intravenous antibiotics, then vascular assessment. A deep abscess, gas or necrotising infection in the diabetic foot needs urgent surgery to drain pus and remove dead tissue, together with intravenous antibiotics. Perfusion must then be assessed, because revascularisation may be needed for healing.
Why not the others? Delay leads to rapid spread along the tendon sheaths and to major amputation.
References
A 52-year-old woman has aching, heavy legs and ankle swelling from varicose veins. Duplex shows great saphenous vein reflux. What is the first-line treatment?
- No treatment is available
- Open high tie and stripping as first choice
- Foam sclerotherapy for every patient first
- Endothermal ablation (radiofrequency or laser)
- Compression stockings as definitive treatment
Show the answer and explanation
Answer: D. Endothermal ablation (radiofrequency or laser). Endothermal ablation is recommended first for symptomatic varicose veins with truncal reflux. If it is unsuitable, ultrasound-guided foam sclerotherapy is offered, then open surgery. Compression is used only if interventional treatment is not possible.
Why not the others? Open stripping has more pain and a slower recovery.
References
A 67-year-old man who smoked for 30 years asks whether he should be screened for abdominal aortic aneurysm. What is the recommendation?
- No screening, because the yield is too low
- Screening only if he has back pain
- Annual CT
- MRI every 5 years
- A one-time abdominal ultrasound
Show the answer and explanation
Answer: E. A one-time abdominal ultrasound. One-time ultrasound screening for men aged 65–75 who have ever smoked reduces aneurysm-related deaths. The UK programme invites all men in the year they turn 65. Ultrasound is safe, cheap and accurate.
Why not the others? CT exposes the patient to radiation and is not used for screening.
References
A 65-year-old man has sudden tearing back pain. CT angiography shows an aortic dissection beginning beyond the left subclavian artery (type B), with no malperfusion, rupture or uncontrolled pain. What is the initial treatment?
- Discharge on oral analgesia
- Thrombolysis
- Emergency open surgery
- Intravenous beta-blocker and other antihypertensives to a systolic pressure below about 120 mmHg and heart rate below 60, in a monitored setting
- Aggressive fluid loading
Show the answer and explanation
Answer: D. Intravenous beta-blocker and other antihypertensives to a systolic pressure below about 120 mmHg and heart rate below 60, in a monitored setting. Uncomplicated type B dissection is treated medically by reducing blood pressure and the force of contraction to limit extension. Complicated cases (rupture, malperfusion, refractory pain or hypertension) need endovascular repair (TEVAR). Type A dissection, involving the ascending aorta, needs emergency surgery.
Why not the others? Thrombolysis is contraindicated; ask about dissection before treating “chest pain” with thrombolytics.
References
A 74-year-old diabetic has rest pain in the right foot at night and a non-healing ulcer on the toe. The ankle pressure is 40 mmHg. What is the appropriate plan?
- Supervised exercise programme
- Urgent vascular referral for imaging and revascularisation, with wound care, infection control and best medical therapy
- Primary below-knee amputation
- Antibiotics and review in 3 months
- Compression bandaging
Show the answer and explanation
Answer: B. Urgent vascular referral for imaging and revascularisation, with wound care, infection control and best medical therapy. Rest pain and tissue loss define chronic limb-threatening ischaemia, which carries a high risk of amputation without revascularisation. Patients need urgent assessment of anatomy and fitness for bypass or endovascular treatment.
Why not the others? Compression can cause necrosis in an ischaemic limb. Exercise therapy is for claudication only.
References
A woman has a tender, red cord along the great saphenous vein in her thigh. Duplex shows superficial vein thrombosis 8 cm long, ending 6 cm below the saphenofemoral junction, with no DVT. What is the treatment?
- No treatment and no follow-up
- Topical gel only
- Emergency surgical ligation
- Fondaparinux 2.5 mg daily (or prophylactic-dose anticoagulation) for 45 days
- Full therapeutic anticoagulation for 6 months
Show the answer and explanation
Answer: D. Fondaparinux 2.5 mg daily (or prophylactic-dose anticoagulation) for 45 days. Superficial vein thrombosis of 5 cm or more and more than 3 cm from the saphenofemoral junction carries a risk of extension to DVT. Prophylactic-dose fondaparinux for 45 days reduces this. Thrombosis within 3 cm of the junction is treated as a DVT.
Why not the others? Short segments (under 5 cm) can be managed with analgesia and compression.
References
A 71-year-old man has an asymptomatic 4.8-cm abdominal aortic aneurysm on ultrasound. What is the management?
- Ultrasound surveillance every 3 months, cardiovascular risk reduction, and referral to a vascular service
- Repair only if he develops back pain
- Immediate repair
- Discharge
- Ultrasound every 5 years
Show the answer and explanation
Answer: A. Ultrasound surveillance every 3 months, cardiovascular risk reduction, and referral to a vascular service. Aneurysms of 4.5–5.4 cm are monitored every 3 months, and those of 3.0–4.4 cm every year. Repair is considered at 5.5 cm, rapid growth (over 1 cm a year) or symptoms. Smoking cessation, statin, antiplatelet therapy and blood pressure control reduce cardiovascular risk.
Why not the others? Early repair of small aneurysms does not improve survival.
References
A 70-year-old man with no symptoms has a 70% stenosis of the left internal carotid artery on duplex. He has never had a stroke or TIA. What is the management?
- Best medical therapy for all (antiplatelet, statin, blood pressure control, stopping smoking); endarterectomy is considered only in selected patients with features of higher stroke risk
- Urgent endarterectomy within 14 days
- Warfarin
- Carotid stenting for every patient
- No treatment
Show the answer and explanation
Answer: A. Best medical therapy for all (antiplatelet, statin, blood pressure control, stopping smoking); endarterectomy is considered only in selected patients with features of higher stroke risk. With modern medical therapy, the annual stroke risk in asymptomatic stenosis is low, so the benefit of intervention is small. Intervention may be considered when life expectancy is good and imaging or clinical features suggest higher risk. Symptomatic stenosis is a different situation and needs urgent surgery.
Why not the others? The 14-day rule applies to symptomatic stenosis.
References
A 78-year-old presents 3 days after the onset of a cold leg. The leg is mottled with fixed staining, there is no capillary refill, the calf is hard and he cannot move his foot. What is the management?
- Urgent embolectomy
- Primary amputation (with palliative care if unfit), because the limb is irreversibly ischaemic
- Catheter-directed thrombolysis
- Heparin and observe for 1 week
- Compression bandaging
Show the answer and explanation
Answer: B. Primary amputation (with palliative care if unfit), because the limb is irreversibly ischaemic. Fixed mottling, paralysis and a rigid muscle compartment indicate irreversible ischaemia (category III). Revascularisation would release toxic products into the circulation (reperfusion injury) without saving the limb, so amputation or palliation is appropriate.
Why not the others? Revascularisation is for viable or threatened limbs (categories I and II).
References
One year after endovascular aneurysm repair (EVAR), CT shows a type II endoleak (filling of the sac from a lumbar artery). The sac diameter has not increased. What is the management?
- Anticoagulation
- Immediate open conversion
- Stop all surveillance
- Continued surveillance, with intervention only if the sac grows
- Emergency embolisation
Show the answer and explanation
Answer: D. Continued surveillance, with intervention only if the sac grows. Type II endoleaks are common, and many seal spontaneously. If the sac is stable, observation is appropriate; embolisation is considered if the sac grows significantly (for example over 10 mm). Type I and III endoleaks, from graft seal or junction failure, carry a rupture risk and need prompt treatment.
Why not the others? Not every endoleak needs treatment; the type and sac behaviour decide.
References
Five days after a hip replacement, a patient collapses with breathlessness. Her blood pressure is 75/40 and bedside echocardiography shows a dilated right ventricle. CT confirms a large pulmonary embolism. What is the treatment?
- IVC filter alone
- Oral apixaban and discharge
- Systemic thrombolysis (unless contraindicated), with surgical or catheter embolectomy if thrombolysis is contraindicated or fails
- Observation
- Aspirin
Show the answer and explanation
Answer: C. Systemic thrombolysis (unless contraindicated), with surgical or catheter embolectomy if thrombolysis is contraindicated or fails. High-risk PE with shock carries a high mortality. Systemic thrombolysis rapidly reduces the clot burden. Recent major surgery is a relative contraindication, so the risk of bleeding must be weighed; surgical or catheter embolectomy are alternatives when thrombolysis is contraindicated.
Why not the others? Stable patients are treated with anticoagulation alone.
References
A man with diabetic neuropathy has a non-infected ulcer under the first metatarsal head. Foot pulses are palpable and the ABPI is normal. What is the most important treatment to heal it?
- Antibiotics
- Bed rest only
- Compression stockings
- Offloading with a non-removable knee-high device (such as a total contact cast), plus debridement and wound care
- Amputation of the toe
Show the answer and explanation
Answer: D. Offloading with a non-removable knee-high device (such as a total contact cast), plus debridement and wound care. Neuropathic plantar ulcers persist because the patient keeps walking on them without feeling pain. Effective offloading, ideally a non-removable cast, is the key treatment, along with regular debridement, glucose control and education.
Why not the others? Antibiotics are only for clinically infected wounds.
References
A 70-year-old man has a pulsatile mass behind the knee. Duplex shows a 2.4-cm popliteal artery aneurysm with thrombus. He has no symptoms. What do you advise?
- Amputation
- No action
- Aspirin only and discharge
- Surveillance only until it is 5 cm
- Elective repair (open bypass with exclusion or endovascular stent graft), because of the risk of thrombosis and embolism
Show the answer and explanation
Answer: E. Elective repair (open bypass with exclusion or endovascular stent graft), because of the risk of thrombosis and embolism. Popliteal aneurysms rarely rupture but often thrombose or embolise, causing acute limb ischaemia with a high amputation rate. Repair is recommended for asymptomatic aneurysms of 2 cm or more. About half are bilateral, and many patients also have an aortic aneurysm.
Why not the others? The size threshold used for aortic aneurysms does not apply.
References
A 70-year-old woman has pain after eating, a fear of food and 12 kg of weight loss. CT angiography shows severe stenoses of the coeliac and superior mesenteric arteries. What is the treatment?
- Revascularisation, usually endovascular stenting of the superior mesenteric artery as first choice
- Proton pump inhibitor
- Psychiatric referral for anorexia
- Observation
- Cholecystectomy
Show the answer and explanation
Answer: A. Revascularisation, usually endovascular stenting of the superior mesenteric artery as first choice. Chronic mesenteric ischaemia causes post-prandial pain, food fear and weight loss. Symptomatic patients are revascularised to relieve symptoms and prevent acute bowel infarction. Endovascular treatment is usually first choice; open bypass is used for unsuitable anatomy or recurrence.
Why not the others? Untreated, it may progress to acute mesenteric ischaemia.
References
A 48-year-old has completed 3 months of anticoagulation for a first unprovoked proximal DVT. He has a low bleeding risk. What is recommended?
- IVC filter
- Consider continuing anticoagulation long term, balancing the risk of recurrence against bleeding
- Stop at 3 months in every case
- Full-body CT for cancer screening in every patient
- Switch to aspirin for 1 month
Show the answer and explanation
Answer: B. Consider continuing anticoagulation long term, balancing the risk of recurrence against bleeding. Unprovoked VTE has a high recurrence risk after anticoagulation is stopped. Extended treatment is offered to those with acceptable bleeding risk, with periodic review. Extensive cancer screening has not been shown to improve outcomes; history, examination and basic tests are used.
Why not the others? IVC filters are only for patients who cannot be anticoagulated.
References
A 62-year-old receiving chemotherapy for colon cancer has a new proximal DVT. What is the treatment?
- No anticoagulation during chemotherapy
- A direct oral anticoagulant (such as apixaban or edoxaban) or low-molecular-weight heparin for at least 6 months, continued while the cancer is active
- Aspirin
- Compression stockings alone
- Warfarin for 6 weeks
Show the answer and explanation
Answer: B. A direct oral anticoagulant (such as apixaban or edoxaban) or low-molecular-weight heparin for at least 6 months, continued while the cancer is active. Cancer-associated thrombosis is treated with LMWH or a DOAC for at least 6 months. Edoxaban and rivaroxaban carry a higher risk of GI bleeding in GI cancers, so apixaban or LMWH are often preferred in those patients.
Why not the others? Interactions and bleeding risk guide the choice of drug.
References
A right-handed 58-year-old with kidney failure needs a fistula for haemodialysis. Arm vessels are suitable on vein mapping. Which access is preferred first?
- A tunnelled central venous catheter long term
- A prosthetic graft as first choice
- A radiocephalic (wrist) arteriovenous fistula in the non-dominant arm
- A brachiocephalic fistula in the dominant arm as first choice
- A femoral catheter
Show the answer and explanation
Answer: C. A radiocephalic (wrist) arteriovenous fistula in the non-dominant arm. The most distal autogenous fistula in the non-dominant arm is preferred, preserving proximal vessels for later access. Fistulas have fewer infections and longer patency than grafts or catheters. Veins in that arm should be protected from cannulation.
Why not the others? Long-term central venous catheters have high infection and central vein stenosis rates.
References
After a coronary angiogram through the right femoral artery, a patient has a pulsatile groin swelling with a bruit. Duplex shows a 3-cm pseudoaneurysm with a narrow neck. What is the first-line treatment?
- Tight compression bandage for a month
- Ultrasound-guided thrombin injection
- Open surgical repair for every case
- Ignore it
- Aspirin and discharge
Show the answer and explanation
Answer: B. Ultrasound-guided thrombin injection. Ultrasound-guided thrombin injection closes most femoral pseudoaneurysms quickly and with little discomfort. Very small ones may close spontaneously. Surgery is reserved for rapid growth, infection, skin compromise or failure of thrombin.
Why not the others? Pseudoaneurysms can rupture, so larger ones are not ignored.
References
A few hours after embolectomy for a 12-hour-old acute limb ischaemia, the patient’s calf is tense and very painful, with pain on passive movement of the foot. What is the management?
- Elevate the leg
- Urgent four-compartment fasciotomy for reperfusion compartment syndrome
- More analgesia and observe overnight
- Repeat embolectomy
- Diuretics
Show the answer and explanation
Answer: B. Urgent four-compartment fasciotomy for reperfusion compartment syndrome. Restoring flow to an ischaemic limb causes swelling within the muscle compartments. Compartment syndrome must be decompressed immediately. Prophylactic fasciotomy is often done when ischaemia has lasted long. Check for rhabdomyolysis and hyperkalaemia.
Why not the others? Pulses may still be present in compartment syndrome.
References
A diabetic woman with neuropathy has a hot, red, swollen foot with intact skin and no fever. It is 3 °C warmer than the other foot, and the X-ray is normal. What is the most important diagnosis to consider and treatment?
- Acute Charcot neuro-osteoarthropathy; immediate offloading and immobilisation (total contact cast) and MRI
- Gout; colchicine
- Cellulitis; oral antibiotics
- Sprain; walk normally
- DVT; anticoagulation
Show the answer and explanation
Answer: A. Acute Charcot neuro-osteoarthropathy; immediate offloading and immobilisation (total contact cast) and MRI. Active Charcot foot causes inflammation, then fractures and dislocation that deform the foot. X-rays may be normal early, so MRI helps. Strict immobilisation and offloading until the temperature difference settles prevents collapse of the foot.
Why not the others? Misdiagnosis as cellulitis or a sprain allows the foot to collapse.
References
A 32-year-old heavy smoker has rest pain and ulcers on several fingertips and toes. Angiography shows segmental occlusion of small and medium distal arteries with corkscrew collaterals. What is the most important treatment?
- Warfarin
- Complete and permanent cessation of tobacco in all forms
- Steroids
- Bypass surgery for every patient
- Smoking reduction to 5 cigarettes a day
Show the answer and explanation
Answer: B. Complete and permanent cessation of tobacco in all forms. Thromboangiitis obliterans (Buerger’s disease) affects young smokers. Stopping tobacco completely is the only treatment that halts progression and prevents amputation; even small amounts of tobacco can continue the disease.
Why not the others? Bypass options are limited by the distal disease.
References
A fit 70-year-old woman has an asymptomatic abdominal aortic aneurysm of 5.1 cm. Which statement is correct?
- Repair at 4.0 cm
- Women should wait until 6.5 cm
- Women never need repair
- The threshold is the same 5.5 cm for both sexes in all guidelines
- Repair may be considered at 5.0 cm in women, because aneurysms rupture at smaller diameters in women
Show the answer and explanation
Answer: E. Repair may be considered at 5.0 cm in women, because aneurysms rupture at smaller diameters in women. Women have smaller aortas and a higher rupture risk at any given diameter. European guidelines suggest considering repair at 5.0 cm in women. Women are also under-represented in screening and in trials.
Why not the others? Rupture carries a higher mortality in women.
References
A 22-year-old weightlifter has a swollen, blue, painful right arm after heavy training. Duplex shows subclavian–axillary vein thrombosis. What is the management?
- Aspirin only
- Amputation
- Elevation alone
- Anticoagulation, with catheter-directed thrombolysis and decompression of the thoracic outlet (for example first rib resection) considered in young active patients
- No treatment
Show the answer and explanation
Answer: D. Anticoagulation, with catheter-directed thrombolysis and decompression of the thoracic outlet (for example first rib resection) considered in young active patients. Effort thrombosis (Paget–Schroetter syndrome) is caused by compression of the subclavian vein at the thoracic outlet. All patients are anticoagulated. Early clot removal and decompression of the outlet are considered in young active patients to reduce long-term symptoms and recurrence.
Why not the others? Without treating the compression, recurrence is common.
References
A 76-year-old had a TIA 5 days ago and has an 80% symptomatic carotid stenosis. He is fit for either procedure. Which intervention is generally preferred at his age?
- Carotid stenting
- Thrombolysis
- Carotid endarterectomy, because stenting carries a higher stroke risk in patients over about 70
- Medical therapy only
- Wait 6 months, then decide
Show the answer and explanation
Answer: C. Carotid endarterectomy, because stenting carries a higher stroke risk in patients over about 70. In symptomatic patients over 70, carotid stenting has a higher periprocedural stroke risk than endarterectomy, so endarterectomy is preferred if the patient is fit. Stenting is an option for younger patients or those with surgical challenges, such as a hostile neck after radiotherapy.
Why not the others? Treatment should be done early, ideally within 14 days.
References
Months after an aortobifemoral bypass, a patient has a pus-draining sinus in the groin, and CT shows fluid and gas around the graft. What is the usual principle of treatment?
- Simple drainage of the groin
- Observation
- Amputation as the first step
- Antibiotics alone, keeping the graft
- Excision of the infected graft and debridement, with revascularisation by an in-situ replacement or extra-anatomic bypass, plus long-term antibiotics
Show the answer and explanation
Answer: E. Excision of the infected graft and debridement, with revascularisation by an in-situ replacement or extra-anatomic bypass, plus long-term antibiotics. Vascular graft infection rarely clears with antibiotics alone. Most patients need removal of the infected graft and revascularisation, using an autologous vein, a rifampicin-bonded or cryopreserved graft, or an extra-anatomic route. In unfit patients, graft-preserving strategies may be tried.
Why not the others? Untreated graft infection can cause rupture of the anastomosis.
References
A diabetic patient has an ulcer over the second toe. A sterile metal probe touches bone through the ulcer. What does this suggest, and which test helps confirm it?
- Osteomyelitis; X-ray and, if unclear, MRI, with a bone biopsy for culture where possible
- Gout; uric acid
- Normal finding
- Fracture; bone scan only
- Superficial infection only; no tests
Show the answer and explanation
Answer: A. Osteomyelitis; X-ray and, if unclear, MRI, with a bone biopsy for culture where possible. A positive probe-to-bone test, combined with X-ray changes and raised inflammatory markers, strongly suggests diabetic foot osteomyelitis. MRI is the most sensitive imaging, and bone culture guides antibiotics. Treatment may be antibiotics alone or surgical resection, depending on the case.
Why not the others? Superficial swabs do not reliably identify the bone organism.
References
A patient with intermittent claudication has completed supervised exercise and is on best medical therapy, but his walking distance is still unsatisfactory. Which drug does NICE recommend considering?
- Warfarin
- High-dose diuretics
- Naftidrofuryl oxalate, reviewed after 3–6 months
- Steroids
- Long-term opioids
Show the answer and explanation
Answer: C. Naftidrofuryl oxalate, reviewed after 3–6 months. NICE suggests naftidrofuryl oxalate for claudication when supervised exercise has not helped enough and the patient does not want revascularisation, stopping it if there is no benefit after 3–6 months. Cilostazol is used in other countries.
Why not the others? Anticoagulation alone is not a treatment for claudication.
References
After lower-limb revascularisation for symptomatic peripheral arterial disease, which antithrombotic regimen reduced major limb and cardiovascular events in the VOYAGER PAD trial?
- Heparin for life
- Full-dose warfarin alone
- No antithrombotic therapy
- NSAIDs
- Low-dose rivaroxaban (2.5 mg twice daily) plus aspirin
Show the answer and explanation
Answer: E. Low-dose rivaroxaban (2.5 mg twice daily) plus aspirin. VOYAGER PAD showed that adding low-dose rivaroxaban to aspirin after revascularisation reduced acute limb ischaemia, major amputation, myocardial infarction, stroke and cardiovascular death, with some increase in bleeding.
Why not the others? Bleeding risk must be considered for each patient.
References
A patient with an extensive iliofemoral DVT has a massively swollen, blue, painful leg with blisters and weak pulses. What is the diagnosis and treatment?
- Arterial embolism only; embolectomy
- Lymphoedema; compression
- Simple DVT; oral anticoagulation at home
- Phlegmasia cerulea dolens; anticoagulation and urgent thrombus removal (catheter-directed or surgical thrombectomy) to save the limb
- Cellulitis; antibiotics
Show the answer and explanation
Answer: D. Phlegmasia cerulea dolens; anticoagulation and urgent thrombus removal (catheter-directed or surgical thrombectomy) to save the limb. Phlegmasia cerulea dolens is massive venous thrombosis that blocks outflow and compromises arterial inflow, risking venous gangrene. It requires urgent clot removal along with anticoagulation and leg elevation. An underlying cancer should be looked for.
Why not the others? Venous gangrene carries a high risk of amputation and death.
References