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LOWER LIMB PERIPHERAL VASCULAR DISEASE

MS General Surgery Long Case - University Examination Standard

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SECTION 1: CLINICAL SCENARIO

The University Long Case Patient

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1. Pain in both calves on walking - 2 years
2. Pain in right foot at rest, worse at night - 3 months
3. Non-healing ulcer right great toe - 6 weeks

• Smoker: 25 pack-years (currently 1 pack/day)
• Type 2 Diabetes Mellitus: 8 years, on oral hypoglycaemics, poorly controlled (HbA1c 9.2%)
• Hypertension: 6 years, on amlodipine
• Dyslipidaemia: detected 2 years ago, on atorvastatin
• No prior vascular intervention
• Father died of "heart attack" at age 62

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Examination Findings

• Inspection: Limb pale in horizontal position; dependent rubor (Buerger's sign positive); hair loss below knee; thickened dystrophic toenails; 1.5 × 1.5 cm punched-out ulcer right great toe tip, sloughy base, no granulation, surrounding cellulitis; no oedema
• Skin temperature: Cool from mid-calf downwards; temperature gradient present
• Capillary refill: Right toes >5 seconds; left >3 seconds
• Pulses: Right femoral: present, reduced; right popliteal: absent; right posterior tibial: absent; right dorsalis pedis: absent
• Buerger's angle: 20° (normal >90°); positive Buerger's test
• Neurological: Reduced sensation right foot (stocking distribution - diabetic neuropathy)

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SECTION 2: RELEVANT SURGICAL ANATOMY

2.1 Arterial Anatomy of the Lower Limb

AORTA (Bifurcates at L4 - level of umbilicus)
         |
    COMMON ILIAC ARTERY
         |
   ┌─────┴─────┐
INTERNAL     EXTERNAL ILIAC
ILIAC        ARTERY
(pelvic)     |
             FEMORAL ARTERY
         (enters femoral triangle)
             |
    ┌─────────┴──────────┐
PROFUNDA             SUPERFICIAL
FEMORIS              FEMORAL ARTERY (SFA)
(deep femoral)       → runs in adductor canal
                     → becomes POPLITEAL
                         at adductor hiatus
                              |
              ┌───────────────┼───────────────┐
        ANTERIOR          POSTERIOR      PERONEAL
        TIBIAL            TIBIAL         ARTERY
        (→ Dorsal          (→ Plantar
         pedis)            arteries)

• Femoral artery: Midpoint of inguinal ligament (midway between ASIS and pubic symphysis) - NOT the mid-inguinal point
• Popliteal artery: Midline of popliteal fossa, deepest structure; palpated with knee semi-flexed
• Posterior tibial: Midway between medial malleolus and medial border of Achilles tendon
• Dorsalis pedis: Between 1st and 2nd extensor tendons on dorsum of foot

Examiner Alert: "What is the difference between mid-inguinal point and midpoint of inguinal ligament?" - The femoral artery lies at the midpoint of the inguinal ligament (between ASIS and pubic symphysis). The mid-inguinal point (midway between ASIS and pubic symphysis) is where the deep inguinal ring lies and where the femoral nerve is located (just lateral to the artery). These two points are essentially the same - this is a classic examiner trap.

Clinical Significance (Viva favourite): Angiosome-directed revascularization - bypass/angioplasty targeting the vessel supplying the ischemic territory achieves better wound healing than indirect revascularization. Plantar foot wounds = target posterior tibial; dorsal wounds = target anterior tibial/dorsalis pedis.

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2.2 Venous Anatomy

Superficial System

GREAT SAPHENOUS VEIN (GSV)
  Origin: Medial aspect of dorsal venous arch
  Route: Medial malleolus → medial leg → medial thigh
  Terminates: Saphenofemoral junction (SFJ) at cribriform fascia
  4 cm below & lateral to pubic tubercle
  
SHORT SAPHENOUS VEIN (SSV)
  Origin: Lateral aspect of dorsal venous arch
  Route: Behind lateral malleolus → midline of calf
  Terminates: Saphenopopliteal junction (SPJ) - variable (60-70% at popliteal fossa level)

Deep System (follows arteries)

• Common femoral → Superficial femoral (FV) → Popliteal → Tibial veins (paired)
• All veins have bicuspid valves directing flow from superficial → deep and caudal → cranial

Perforating (Hunterian/Cockett) Veins

Direct perforators: connect axial superficial trunk to deep system. Indirect: connect muscular tributaries. Incompetent perforators drive venous hypertension.

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2.3 Lymphatic Drainage

• Superficial lymphatics run with GSV → superficial inguinal nodes (horizontal group: drain perineum/gluteal region; vertical group: drain lower limb)
• Deep lymphatics run with deep vessels → deep inguinal nodes (medial to femoral vein, below cribriform fascia) → external iliac nodes
• Cloquet's (Rosenmüller's) node: Highest deep inguinal node in femoral canal - important in metastatic spread
• Stemmer's sign: Inability to pinch a fold of skin at base of second toe = positive = indicates lymphoedema

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2.4 Peripheral Nerves (Clinically Critical)

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SECTION 3: CLASSIFICATIONS

3.1 ARTERIAL DISEASE CLASSIFICATIONS

Fontaine Classification (PAD/Chronic Ischemia)

┌──────────┬──────────────────────────────────────────────────────┐
│ Stage    │ Clinical Features                                    │
├──────────┼──────────────────────────────────────────────────────┤
│ I        │ Asymptomatic PAD (ABI abnormal, no symptoms)         │
├──────────┼──────────────────────────────────────────────────────┤
│ IIa      │ Mild claudication (>200 m walking distance)          │
├──────────┼──────────────────────────────────────────────────────┤
│ IIb      │ Moderate-severe claudication (<200 m)                │
├──────────┼──────────────────────────────────────────────────────┤
│ III      │ Rest pain (ischemic rest pain)                       │
├──────────┼──────────────────────────────────────────────────────┤
│ IV       │ Tissue loss (ulceration, gangrene)                   │
└──────────┴──────────────────────────────────────────────────────┘

Rutherford Classification (PAD - More Detailed)

"CLTI" (Chronic Limb-Threatening Ischemia) = Rutherford 4, 5, 6 = Fontaine III-IV. The older term "Critical Limb Ischemia" has been replaced by CLTI in SVS/ESVS Global Vascular Guidelines 2019.

Rutherford Classification of ACUTE Limb Ischemia (Sabiston, Table 103.4)

(Modified from Rutherford et al., J Vasc Surg. 1997)

Viva Point: Category III ALI = PRIMARY AMPUTATION. Do NOT attempt revascularization - reperfusion of an irreversibly ischemic limb causes lethal reperfusion injury, myoglobinuria, acute renal failure, and multiorgan failure.

WIfI Classification (SVS 2014 - for CLTI wound staging)

W = Wound (0-3: none → gangrene/major tissue loss)
I = Ischemia (0-3: ABI >0.8 → ABI <0.4 or TBI <0.25)
fI = Foot Infection (0-3: none → severe/limb-threatening)

Embolism vs Thrombosis in Acute Limb Ischemia

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3.2 VENOUS DISEASE CLASSIFICATIONS

CEAP Classification (Bailey & Love 28th Edition)

C - CLINICAL CLASS
   C0 = No signs
   C1 = Telangiectasia/reticular veins
   C2 = Varicose veins
   C3 = Oedema
   C4a = Pigmentation or eczema
   C4b = Lipodermatosclerosis or atrophie blanche
   C4c = Corona phlebectatica
   C5 = Healed venous ulcer
   C6 = Active venous ulcer
   (suffix 's' = symptomatic, 'a' = asymptomatic, 'r' = recurrent)

E - AETIOLOGICAL
   Ec = Congenital
   Ep = Primary (no known cause)
   Es = Secondary (post-thrombotic)
   En = No venous cause identified

A - ANATOMICAL
   As = Superficial
   Ap = Perforator
   Ad = Deep
   An = No venous location identified

P - PATHOPHYSIOLOGICAL
   Pr = Reflux
   Po = Obstruction
   Pr,o = Reflux + obstruction
   Pn = No pathophysiology identifiable

Example: A patient with active venous ulcer due to post-thrombotic SFJ incompetence with great saphenous reflux:

Villalta Scale (Post-Thrombotic Syndrome)

• Score 0-4: No PTS
• Score 5-9: Mild PTS
• Score 10-14: Moderate PTS
• Score ≥15 or ulcer: Severe PTS

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3.3 LYMPHATIC DISEASE CLASSIFICATION

Primary Lymphoedema

Secondary Lymphoedema

• Filariasis (Wuchereria bancrofti) - most common worldwide cause
• Malignancy/node dissection (breast, pelvic)
• Radiation fibrosis
• Infection/recurrent cellulitis
• Trauma

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SECTION 4: COMPLETE HISTORY TAKING

Systematic History for Vascular Long Case

4.1 Claudication History

• Where is the pain? (Site = level of occlusion)
• What brings it on? (Walking, stairs?)
• How far can you walk before pain starts? (Claudication distance in metres)
• Does it stop you? (Absolute claudication distance)
• What do you do? (Must STOP and rest)
• How long to recover? (Complete relief = arterial; incomplete = venous/neurogenic)
• Does it worsen uphill or carrying loads? (Arterial claudication does)
• Has the distance changed? (Progressive = worsening disease)

Buttock + thigh claudication = Aortoiliac (Leriche syndrome)
Thigh + calf = CFA/SFA disease
Calf only = SFA/popliteal disease  ← MOST COMMON
Foot claudication = Tibial/pedal disease

• Q: What is the difference between arterial claudication and neurogenic (spinal stenosis) claudication?

4.2 Rest Pain History

• Constant, severe burning/aching pain in foot and toes (not calf)
• Worse at night - recumbency removes gravity-assisted flow
• Relieved by dependency - hanging leg out of bed (gravity increases perfusion pressure)
• May sleep in chair with leg dependent
• Patients walk at night to get relief

4.3 Tissue Loss / Ulcer / Gangrene History

• Duration, onset (spontaneous vs traumatic)
• Progressive or static?
• Depth (superficial vs deep)
• Surrounding skin changes
• Discharge (serous/purulent/foul-smelling)
• Previous similar ulcers?
• Treated previously?

4.4 Venous History

• Visible veins on legs (standing)
• Aching, heaviness, throbbing worse at end of day (improves with elevation)
• Ankle swelling (pitting)
• Skin changes: itching, eczema, pigmentation
• Previous DVT or pulmonary embolism
• Family history of varicose veins
• Pregnancy history (women)
• Occupational history (prolonged standing)

4.5 Risk Factor Interrogation

1. Bilateral buttock and thigh claudication
2. Impotence (due to internal iliac artery occlusion)
3. Absent/reduced femoral pulses bilaterally Named after René Leriche, described in 1940.

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SECTION 5: COMPLETE CLINICAL EXAMINATION

5.1 General Examination

5.2 Local Examination of the Lower Limb

INSPECTION (Always from feet to groin, both sides, standing AND lying)

• Varicose veins (only visible standing - collapse on lying)
• Distribution: GSV territory (medial leg) vs SSV territory (posterior calf)
• Saphena varix (expansile cough impulse at SFJ)

ULCER COMPARISON TABLE (Examiner Favourite)

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REAL CLINICAL IMAGES FROM BAILEY & LOVE 28TH EDITION:

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5.3 PALPATION

• Use dorsum of hand (more sensitive than palmar surface)
• Start distally and move proximally
• Identify the level of temperature change (level of occlusion is typically one level above the thermal gradient)
• Compare both limbs

• Homan's sign (calf pain on dorsiflexion) - DVT screening (sensitivity 50%, specificity 40% - unreliable, do not rely on it alone)
• Calf tenderness on palpation (DVT)
• Perimalleolar tenderness (venous/lymphatic)

• 0: Absent
• 1+: Diminished/barely palpable
• 2+: Normal
• 3+: Increased/bounding (aneurysm?)
• 4+: Markedly bounding

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SECTION 6: PULSE EXAMINATION IN DETAIL

6.1 Femoral Pulse

1. Patient supine, hip slightly externally rotated
2. Press firmly with 2-3 fingers at the midpoint of inguinal ligament
3. Feel for rhythmic pulsation; assess strength and character
4. Auscultate over femoral artery for bruits (indicate stenosis)

• Absent: Aortoiliac occlusion or common femoral artery occlusion
• Bruit: Significant stenosis (60-80%)
• Reduced: Proximal disease
• Aneurysmal: Pulsatile, expansile mass → Femoral artery aneurysm

• Q: What is a femoral aneurysm? How do you diagnose it? - Abnormal dilatation >1.5x normal; diagnosed on duplex; >2 cm = treat; bilateral in 50%; associated with AAA in 85%
• Q: What does an absent femoral pulse indicate? - Aortoiliac occlusive disease (tailor treatment accordingly: aortobifemoral bypass or aortofemoral bypass/iliac stenting)

6.2 Popliteal Pulse

1. Prone method: Patient prone, knee flexed 30°; palpate with both thumbs on either side while fingers cup the fossa; press deeply in the midline
2. Supine method: Knee flexed 30°; both hands cup the popliteal fossa; fingertips meet in the midline and press deeply

• Easiest pulse to miss - presses deeply in the fossa
• Prominent popliteal pulse in an elderly patient = Popliteal Artery Aneurysm until proven otherwise (bilateral in 50%; associated with AAA; thromboembolism is the presenting complication)
• Absent: SFA/popliteal disease
• Hyperextension test (for popliteal entrapment in young athlete)

• Q: What is the most common peripheral arterial aneurysm? - Popliteal artery aneurysm (>50% of all peripheral aneurysms). Note: femoral is second most common.
• Q: What are the complications of popliteal aneurysm? - Distal thromboembolism (most common complication, can cause acute limb ischemia), local compression (DVT, nerve compression), rupture (rare)

6.3 Posterior Tibial Pulse

• Patient supine, foot relaxed
• Place 3 fingers in the groove behind medial malleolus
• Press against the posterior surface of the tibia

• Most reliable below-knee pulse
• Absent in posterior tibial artery occlusion (tibial disease, often in diabetics)
• Always present in normal individuals (not absent in 10% like DP)

6.4 Dorsalis Pedis Pulse

• Foot relaxed, not plantarflexed
• Palpate with 2-3 fingers, light pressure

• Absent in 10% of normal population (anatomical variant - replaced by peroneal perforator)
• If absent, DP is absent but PT may be present - check both
• Absent both DP and PT = significant tibial disease

Pearl: Before labelling dorsalis pedis as absent, confirm by auscultation with hand-held Doppler. Doppler signal present = vessel patent despite non-palpable pulse.

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SECTION 7: SPECIAL CLINICAL TESTS

7.1 BUERGER'S TEST (Most Important Arterial Test at Bedside)

1. Elevation test: Patient supine; elevate both lower limbs to 45° for 1-2 minutes; observe foot colour
2. Dependency test: Ask patient to sit up quickly and hang legs dependently; observe colour changes

• Normal: Foot remains pink throughout; dependency causes no change
• Positive Buerger's test: Elevation causes pallor (Buerger's angle <20° = severe); dependency causes reactive hyperaemia (dusky red/purple "sunset foot")
• Buerger's angle: The angle of elevation at which pallor first appears

  • 45°: Normal

  • 20-45°: Moderate ischemia
  • <20°: Severe ischemia (CLTI)
• Venous filling time: >15 seconds on going from elevation to dependency = significant ischemia (normal <10 sec)

• Q: What is the pathophysiology of dependent rubor in Buerger's test? - In severe ischemia, the arterioles are maximally vasodilated to maintain perfusion. On dependency, gravity increases the hydrostatic head but the stagnant, deoxygenated blood in maximally dilated capillaries produces the characteristic dusky red colour (dependent rubor = Buerger's sign = vasodilatory response exhausted).

7.2 ANKLE-BRACHIAL INDEX (ABI)

1. Patient supine, rested 10 minutes
2. Place BP cuff on calf above ankle
3. Locate dorsalis pedis or posterior tibial pulse with hand-held Doppler probe (8 MHz)
4. Inflate cuff until signal disappears; deflate slowly; record pressure when signal returns
5. Measure brachial systolic pressure (both arms; use higher)
6. ABI = Ankle systolic pressure / Highest brachial systolic pressure

• Falsely elevated in diabetics and CKD (medial calcification = non-compressible vessels)
• Cannot differentiate level of disease
• Poorly correlated with symptoms in diabetics (due to neuropathy)
• Solution: Use TBI, segmental pressures, or pulse volume recordings

7.3 VENOUS SPECIAL TESTS

Trendelenburg Test (Brodie-Trendelenburg Test)

1. Patient supine; elevate leg to drain varicosities
2. Apply tourniquet at groin (upper thigh) to compress SFJ
3. Ask patient to stand
4. Observe filling pattern:
   • Negative test (normal): Veins fill slowly from below over 30 seconds (competent SFJ; perforators normal)
   • Tourniquet controls filling: SFJ incompetence (release tourniquet → rapid filling = SFJ incompetent)
   • Filling occurs despite tourniquet: Incompetent perforators below tourniquet
   • Both above: SFJ + perforator incompetence

Multiple Tourniquet Test

Perthes' Test

• Normal deep system: Varicosities empty (deep veins competent; tourniquet compresses SV)
• Positive Perthes' test: Varicosities become MORE engorged and painful on walking → DO NOT OPERATE (deep system obstructed; GSV is the collateral; stripping would cause severe chronic venous insufficiency)

Schwartz Test

• Positive: Fluid impulse transmitted upwards = incompetent valves in GSV (no valves between tap point and SFJ)

Fegan's Test

Stemmer's Sign (Lymphoedema)

• Positive (Stemmer's sign): Cannot pinch a fold = lymphoedema (fibrosis of dermis)
• Negative: Normal or venous oedema

• Pitting: Venous/cardiac/hepatic/renal (fluid easily displaced)
• Non-pitting: Lymphoedema (protein-rich fluid + fibrosis); myxoedema
• Positive Stemmer = lymphoedema confirmed

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SECTION 8: DIFFERENTIAL DIAGNOSIS

8.1 Arterial vs Venous vs Neuropathic vs Lymphatic Disease

8.2 DVT vs Cellulitis vs Lymphoedema

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SECTION 9: UNIVERSITY LONG CASE PRESENTATION (5 minutes)

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SECTION 10: INVESTIGATIONS

10.1 Basic Blood Investigations

10.2 Thrombophilia/Hypercoagulable Workup

10.3 Non-Invasive Vascular Studies

Duplex Doppler Ultrasound

• B-mode: visualises plaque, stenosis, aneurysm
• Colour Doppler: flow direction and turbulence
• Spectral Doppler: waveform analysis

TRIPHASIC (normal lower limb artery):
    ___
   /   \
  /     \___   (reverse flow component)
               ___  (forward diastolic component)

BIPHASIC (moderate disease):
    ___
   /   \
  /     \_____  (forward flow only, no reverse)

MONOPHASIC (severe disease/stenosis):
  ____
 /    \________  (blunted, slow, forward flow only)

• Non-compressibility of vein (most sensitive criterion)
• Absent spontaneous flow
• Absent augmentation
• Absent phasic flow with respiration

CT Angiography (CTA)

• Images aorta to foot in one scan
• Identifies: occlusion level, calcification, run-off vessels, aneurysms
• Contrast nephropathy risk: Hydrate pre-contrast; stop metformin 24-48h before; monitor creatinine
• Calcium blooms obscure vessel lumen in heavily calcified tibial arteries (limitation)

MR Angiography (MRA)

• No ionising radiation, no iodinated contrast (use gadolinium)
• Better soft-tissue contrast
• Tends to overestimate stenosis
• Contraindicated with metallic implants, claustrophobia
• Preferred in CKD (no nephrotoxic iodinated contrast) - but gadolinium can cause nephrogenic systemic fibrosis in eGFR <30

Digital Subtraction Angiography (DSA)

• Gold standard for intervention - allows simultaneous diagnosis and treatment
• Subtraction removes bony background, showing pure vascular anatomy
• Risk: Contrast nephrotoxicity, arterial access site complications, embolisation
• Used when CTA/MRA inconclusive or immediately before/during endovascular intervention

10.4 Investigation Algorithm

SUSPECTED LOWER LIMB ISCHEMIA
           │
    ┌──────┴──────┐
ACUTE (<2wks)    CHRONIC (>2wks)
    │                  │
    ▼                  ▼
Immediate CTA     ABI Measurement
or urgent DSA          │
    │             ┌────┴────┐
    ▼          ABI ≤0.9   ABI >1.3
Emergency     (PAD)      (Calcified)
management        │           │
              Duplex      Toe-Brachial
              Doppler      Index (TBI)
                  │
              Asymptomatic  Symptomatic
              │              │
          Treat risk    Duplex for anatomy
          factors       +
                    CTA/MRA if revascular-
                    ization planned

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SECTION 11: EVIDENCE-BASED MANAGEMENT

11.1 Medical Management (All Stages)

Smoking Cessation

• Increases claudication distance more than any drug
• Reduces progression to CLTI
• Reduces amputation rate
• Reduces cardiovascular mortality
• NRT, varenicline, bupropion; referral to cessation services

Antiplatelet Therapy

• Aspirin 75-100 mg daily OR Clopidogrel 75 mg daily (slightly superior in CAPRIE trial)
• Dual antiplatelet (DAPT) for 1-3 months post-endovascular stenting
• SVS 2016 Guidelines: Clopidogrel monotherapy preferred for symptomatic PAD

Statins

• Target LDL <70 mg/dL (or 50% reduction) - AHA/ACC 2018
• Atorvastatin 40-80 mg; Rosuvastatin 20-40 mg
• Anti-inflammatory + lipid-lowering + pleiotropic effects
• Reduces cardiovascular events AND limb events

Blood Pressure Control

• Target <130/80 mmHg (AHA/ACC 2017)
• ACE inhibitor/ARB preferred in diabetics
• Avoid beta-blockers in severe PAD (peripheral vasoconstriction worsens claudication) - though in practice cardioselective beta-blockers are used if indicated for cardiac reasons

Glycaemic Control

• HbA1c target <7% (diabetics)
• Strict control reduces microvascular complications
• SGLT2 inhibitors (empagliflozin) have cardioprotective benefit

Exercise Therapy

• Supervised exercise programme = first-line for claudication (Class IA evidence, AHA/ACC, NICE)
• 30-45 minutes walking, 3 times/week, for at least 12 weeks
• Promotes collateral development, increases claudication distance by 100-150%
• More effective than angioplasty for claudication in most trials (CLEVER trial)

Cilostazol

• Phosphodiesterase III inhibitor; vasodilatory + antiplatelet
• Increases pain-free and maximum walking distance by 40-50%
• Contraindicated in heart failure
• 100 mg BD; drug of choice for claudication pharmacotherapy

Anticoagulation

• Not routinely used in chronic PAD
• Indicated for: AF (DOACs), acute DVT, post-bypass graft thrombosis, antiphospholipid syndrome
• Low-dose rivaroxaban 2.5 mg BD + aspirin 100 mg (COMPASS trial) - reduces MACE and MALE in PAD

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11.2 Endovascular Management

Principles

Balloon Angioplasty (PTA)

• Wire crosses lesion; balloon inflated to dilate stenosis/occlusion
• Best results: Iliac > SFA > tibial vessels
• Primary patency: Iliac ~70-85% at 5 years; SFA ~50% at 1 year

Drug-Coated Balloons (DCB)

• Paclitaxel-coated balloon inhibits neointimal hyperplasia
• Superior to plain balloon angioplasty in SFA disease (IN.PACT Admiral trial)
• Reduces re-stenosis rates
• Currently used for femoropopliteal segment

Stenting

• Self-expanding nitinol stents for SFA/iliac
• Bare metal stents → Drug-eluting stents (DES) for tibial vessels
• Stenting reserved for: failed/recoil after PTA, residual stenosis >30%, flow-limiting dissection

Atherectomy

• Directional, rotational, orbital, or laser atherectomy
• Removes plaque rather than dilating it
• Useful in heavily calcified lesions
• High re-stenosis rates - usually combined with DCB

Catheter-Directed Thrombolysis (CDT)

• For acute/subacute limb ischemia (ALI - Rutherford IIa/IIb)
• Infuse tPA into thrombus via catheter over 12-24 hours
• Advantages: Opens occluded grafts/bypasses; reveals underlying stenosis treatable by PTA; lower morbidity than open surgery
• Contraindications: Stroke within 3 months, active bleeding, major surgery within 10 days, Category III ALI
• Complication: Haemorrhage (intracranial haemorrhage 1%)

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11.3 Open Surgical Management

Embolectomy (Fogarty Catheter Technique)

1. Groin incision; expose common, superficial, and profunda femoral arteries
2. Systemic heparin 5000 IU IV
3. Arteriotomy (transverse preferred to avoid narrowing)
4. Pass Fogarty catheter distally (2F-4F) through tibial vessels to remove distal clot
5. Pass Fogarty catheter proximally to remove proximal clot
6. Irrigate with heparinised saline
7. Check back-bleeding (venous) and forward-bleeding (arterial pulsation)
8. Confirm flow with intraoperative Doppler or angiogram
9. Close arteriotomy with patch if needed; 6-0 prolene continuous suture
10. Four-compartment fasciotomy if ischemia >4-6 hours

• 2F: Tibial vessels
• 3F: Popliteal, tibial
• 4F: SFA, popliteal
• 5-6F: Common femoral, iliac
• 7F: Aorta

Femoropopliteal Bypass

• First choice: Autologous great saphenous vein (GSV) - Reversed or in-situ
  • Superior long-term patency (5-year patency 70-80%)
  • Resistant to infection
  • Ideal for below-knee anastomosis
• Alternative: PTFE (polytetrafluoroethylene) prosthetic graft
  • Above-knee popliteal bypass: PTFE acceptable (5-year patency 50-60%)
  • Below-knee: inferior results with PTFE; vein strongly preferred

• GSV left in situ; valves destroyed with valvulotome
• GSV tributaries ligated
• Proximal and distal anastomoses
• Advantage: Better size match between vein and artery at each end

• GSV harvested, reversed (so valves don't obstruct flow), anastomosed
• Traditional technique

1. Supine; padding under knee; thigh externally rotated
2. Groin incision: expose CFA, SFA origin, PFA
3. Medial thigh incision: expose above-knee popliteal artery at adductor hiatus
4. Harvest GSV from same or opposite leg
5. Systemic heparin 5000 IU IV
6. Clamp SFA; proximal anastomosis: end-to-side with 5-0 prolene
7. Tunnel graft through subsartorial plane
8. Distal anastomosis: end-to-side to above-knee popliteal with 6-0 prolene
9. Release clamps; check graft pulsation and Doppler signal
10. Achieve haemostasis; close wounds in layers

• Always end-to-side anastomoses (preserves native circulation)
• Prolene suture (monofilament, non-absorbable)
• Parachute technique for posterior wall of anastomosis
• Suture bites: 1-2 mm from edge, 1-2 mm apart
• No tension; adequate mobilisation of vessels

Aortobifemoral Bypass

1. Supine; transperitoneal or retroperitoneal approach
2. Expose infrarenal aorta (between renal arteries and IMA)
3. Expose both common femoral arteries through groin incisions
4. Systemic heparin 5000 IU IV
5. Proximal clamp below renal arteries; distal clamp on aorta
6. Proximal anastomosis: end-to-end (aortic occlusion) or end-to-side (aortic stenosis)
7. Tunnel each limb of graft retro-peritoneally to respective groin
8. Distal anastomoses: end-to-side to CFAs
9. Close retroperitoneum to cover graft (prevents aortoenteric fistula)

Fasciotomy

• Compartment syndrome following revascularization
• Ischemia time >4-6 hours before reperfusion
• Prophylactic after embolectomy in severely ischemic limb

TWO-INCISION TECHNIQUE:
Lateral incision (fibula):
  - Opens anterior compartment (between fibula and tibia anteriorly)
  - Opens lateral compartment (between fibula and lateral skin)
  
Medial incision (medial calf):
  - Opens superficial posterior compartment
  - Opens deep posterior compartment

Amputation Decision-Making

AMPUTATION DECISION ALGORITHM
           │
  IRREVERSIBLE ISCHEMIA
  (Rutherford III)
  OR
  Failed all revascularization
  OR
  No suitable conduit/runoff
  OR
  Life expectancy poor / non-ambulatory
           │
    ┌──────┴──────┐
   Viable         Not viable
   below-knee     below-knee
   tissues        tissues
    │              │
Below-knee      Above-knee
amputation      amputation
(BKA)           (AKA)
    │
  Goal: Preserve knee joint
  (functional prosthetic)
  Stump length: 12-15 cm
  below tibial tuberosity

• Toe/ray amputation: Single digit; for localised gangrene
• Transmetatarsal: Forefoot gangrene
• Syme's amputation: Through ankle joint
• Below-knee (BKA): Ideal if knee can be preserved; best functional outcome
• Knee disarticulation: Rarely used
• Above-knee (AKA): When BKA not viable; higher mortality, poorer prosthetic outcome
• Hip disarticulation: Extreme tissue loss/sepsis

Key Pearl: A healed BKA is far superior to an AKA. Preserve the knee if possible - a BKA with a good prosthesis allows near-normal walking; AKA requires 60-80% more energy expenditure.

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SECTION 12: OPERATIVE DISCUSSION

Fogarty Catheter Embolectomy - Complete Operative Description

Instruments

• Standard vascular set
• Fogarty balloon catheters (2F, 3F, 4F)
• Vessel loops (red for artery, yellow for vein)
• Bulldog clamps (DeBakey, Cooley)
• Vascular clamps (Satinsky, Potts)
• 5-0 and 6-0 Prolene sutures on BV needles
• Heparinised saline syringe
• Doppler probe (sterile)

Pitfalls

• Vigorous balloon inflation causes intimal injury/dissection - inflate gently
• Failure to check for distal clot - always pass catheter to level of foot
• Missing underlying stenosis - always do intraoperative angiogram
• Not considering compartment syndrome - prophylactic fasciotomy in prolonged ischemia

Complications

• Haemorrhage
• Vessel injury / intimal tear
• Distal embolisation
• Re-thrombosis
• Compartment syndrome / reperfusion injury
• Wound infection
• Lymphocele

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SECTION 13: COMPLICATIONS AND MANAGEMENT FLOWCHARTS

Reperfusion Injury

• Myoglobinuria → Acute renal failure
• Hyperkalaemia (from ischemic muscle)
• Metabolic acidosis
• Cardiac arrhythmias
• ARDS / SIRS / MODS

• IV hydration pre- and post-reperfusion
• Sodium bicarbonate to alkalinise urine (reduces myoglobin precipitation)
• Monitor urine output (target >1 mL/kg/hr)
• Monitor ECG for arrhythmias
• Consider prophylactic fasciotomy

Graft Occlusion

GRAFT OCCLUSION
      │
  ┌───┴───┐
Early     Late
(<30 days) (>2 years)
  │         │
Technical  Intimal
failure    hyperplasia
Thrombosis Neo-atherosclerosis
  │         │
  ▼         ▼
Re-explore  Thrombolysis
or          or
Thrombolysis Re-do bypass

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SECTION 14: COMPLETE VIVA SECTION

100+ Examiner Questions with Model Answers

ANATOMY VIVA

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EXAMINATION VIVA

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INVESTIGATION VIVA

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CLASSIFICATION VIVA

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MANAGEMENT VIVA

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EMERGENCY VASCULAR VIVA

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OPERATIVE VIVA

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IMAGE-BASED VIVA

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DOPPLER VIVA

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INSTRUMENT VIVA

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SECTION 15: IMAGE-BASED DISCUSSION

Images from Bailey & Love 28th Edition (Authentic Textbook Images)

Image Gallery with Clinical Teaching Points

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SECTION 16: FLOWCHARTS

Flowchart 1: Approach to Lower Limb Ischaemia

PATIENT WITH LOWER LIMB ISCHAEMIA
               │
    ┌──────────┴──────────┐
ACUTE (<2 wks)          CHRONIC (>2 wks)
    │                        │
6 Ps present           Claudication / Rest pain /
(Pain, Pale,           Tissue loss / Ulcer
Pulseless,                   │
Paralysis,             ABI Measurement
Paresthesia,                 │
Poikilothermia)        ┌─────┴──────┐
    │                ABI           ABI
    │               ≤0.9          >1.3
    │            (PAD)          (Calcified)
    │                │               │
    │           Risk factor      Toe-Brachial
Rutherford      modification     Index (TBI)
Classification       │
    │           Asymptomatic  Symptomatic PAD
    │               │              │
    │           Observe &     ┌────┴────┐
Cat I: CTA     treat risks  Claudication  CLTI
then plan                      │          │
Cat IIa: CDT   Exercise +   Duplex +
               Cilostazol   CTA/MRA →
Cat IIb:       ± PTA if     Revascularization
Urgent         TASC A-B     planning
revascularize
Cat III:
Primary
amputation

Flowchart 2: DVT Diagnosis and Management (Bailey & Love / NICE)

SUSPECTED DVT
      │
Calculate Two-Level Wells Score
      │
  ┌───┴───┐
 ≥2        <2
(Likely)  (Unlikely)
  │           │
Duplex    D-Dimer
Ultrasound    │
  │       ┌──┴──┐
Positive  Neg   Pos
  │       │     │
Treat  No DVT  Duplex US
  │             │
DOAC ×3m      Positive → Treat
(rivaroxaban   Negative → No DVT
/apixaban)
  │
LMWH bridge
if cancer

Flowchart 3: Varicose Vein Management (NICE CG168)

VARICOSE VEINS
      │
Clinical Assessment + CEAP
      │
  Asymptomatic C2   Symptomatic C2+   Complications
  (Cosmetic only)                     (ulcer, bleed, SVT)
       │                │                    │
  Conservative     Duplex US            PRIORITY
  (compression)    Mapping               referral
                       │
             ┌─────────┼─────────┐
        EVLA/RFA    UGFS    Surgery (3rd line)
        (1st line) (2nd)   Ligation + stripping
             │
    Perforator disease?
         │
    Ultrasound-guided
    perforator ablation

Flowchart 4: Revascularization Strategy for PAD

SYMPTOMATIC PAD - REVASCULARIZATION DECISION
               │
         Duplex/CTA Anatomy
               │
      ┌────────┴────────┐
   TASC A/B          TASC C/D
  (focal disease)  (diffuse disease)
      │                │
 Endovascular      Open Surgery
  First           Preferred
      │                │
 PTA ± stent    Aortoiliac: Aortobifemoral bypass
 ± DCB          Fem-Popliteal: Bypass with GSV
                Femoro-tibial: GSV bypass
                Profundaplasty
      │
  Failed endo
      │
 Open Surgery

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SECTION 17: MIND MAPS

Mind Map 1: Acute Limb Ischemia

                ACUTE LIMB ISCHEMIA
                        │
         ┌──────────────┼──────────────┐
      CAUSES         6 Ps         CLASSIFY
         │              │         (Rutherford)
  Embolism (50%)   Pain            │
  Thrombosis (40%) Pallor       I-Viable
  Trauma (5%)      Pulseless    IIa-Marginally
  Iatrogenic (5%)  Paralysis    IIb-Immediately
         │         Paresthesia  III-Irreversible
         │         Poikilothermia
         │
    EMBOLISM vs THROMBOSIS
    (see comparison table)
         │
    MANAGEMENT
         │
    ┌────┴────┐
  Medical    Surgical
  Heparin   Fogarty / CDT /
  IV        Bypass / Amputation

Mind Map 2: Varicose Veins (SMARTER)

                VARICOSE VEINS
                      │
        ┌─────────────┼─────────────┐
    ANATOMY       CLINICAL       TREATMENT
        │              │              │
   SFJ/SPJ         CEAP         EVLA/RFA
   Perforators     C0-C6        UGFS
   Great/Small     E,A,P        Surgery
   Saphenous       Classification   Sclerotherapy
        │
    TESTS
        │
  Trendelenburg
  Perthes
  Schwartz
  Fegan
  Doppler duplex

Mind Map 3: PAD Risk Factors (HEADS)

H - Hypertension
E - Everything lipid (dyslipidaemia)
A - Atherosclerosis / Age / Arrhythmia (AF)
D - Diabetes Mellitus
S - Smoking (most important modifiable risk factor)

Additional:
C - CKD
O - Obesity
F - Family history
H - Hyperhomocysteinaemia

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SECTION 18: HIGH-YIELD MS/DNB PEARLS

Commonly Asked Long-Case Questions (MS/DNB India)

1. "Present the case." - Practise the 5-minute presentation format; include all risk factors
2. "What is your working diagnosis?" - Commit to a specific diagnosis with Fontaine/Rutherford stage
3. "How will you investigate this patient?" - Start with bedside (ABI), then duplex, then CTA
4. "What is your management plan?" - Medical first, then revascularization; MDT approach
5. "Why is vein graft preferred over PTFE?" - Patency, resistance to infection, size matching

Examiner's Favourite Cross-Questions

• "What is the ABI? How does diabetes affect it?"
• "Classify this patient's varicose veins using CEAP."
• "What is Leriche syndrome?"
• "What is the first-line treatment for claudication?" (Exercise - not surgery!)
• "Why does this patient have rest pain worse at night?"
• "What is Buerger's disease? How does it differ from atherosclerotic PAD?"
• "Name the complications of DVT."
• "What is post-thrombotic syndrome? How do you prevent it?"

Common Candidate Mistakes

Buerger's Disease (TAO) - High Yield Points

• Thromboangiitis obliterans (Buerger's disease): Inflammatory segmental occlusion of small/medium arteries and veins in young smokers
• Classic triad: Young male (<45 yrs), heavy smoker, distal limb ischemia (hands AND feet involved)
• Diagnostic criteria (Shionoya): Onset <50 yrs, tobacco use history, infrapopliteal occlusive disease, upper limb involvement or phlebitis migrans, no atherosclerotic risk factors except smoking
• Angiography: "Corkscrew" collaterals; tapering segmental occlusions of distal vessels
• Treatment: The ONLY effective treatment is COMPLETE AND PERMANENT smoking cessation. No bypass (small vessels; no good runoff). Prostaglandins (iloprost) for pain relief. Amputation if gangrene develops.
• Key difference from atherosclerosis: Young age, involves upper limbs, superficial phlebitis migrans, no diabetes/hypertension/dyslipidaemia, completely different angiographic appearance

Mnemonics

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SECTION 19: FINAL RAPID REVISION

One-Page Rapid Revision Sheet

╔══════════════════════════════════════════════════════════════════╗
║         LOWER LIMB PVD - RAPID REVISION                         ║
╠══════════════════════════════════════════════════════════════════╣
║ PULSE SITES                                                       ║
║ Femoral: Midpoint inguinal ligament                               ║
║ Popliteal: Midline fossa, knee semi-flexed                       ║
║ Post tibial: Behind medial malleolus                             ║
║ Dorsalis pedis: Between EHL and EDL tendons                       ║
╠══════════════════════════════════════════════════════════════════╣
║ ABI VALUES                                                        ║
║ >1.3=calcified, 0.9-1.3=normal, 0.7-0.9=mild, 0.5-0.7=moderate ║
║ 0.3-0.5=severe PAD, <0.3=CLTI                                    ║
╠══════════════════════════════════════════════════════════════════╣
║ RUTHERFORD ALI: I=viable, IIa=marginal, IIb=immediate, III=dead ║
║ FONTAINE: I=asymp, II=claud, III=rest pain, IV=tissue loss       ║
╠══════════════════════════════════════════════════════════════════╣
║ CEAP: C0=none, C1=telang, C2=varix, C3=oedema,                  ║
║ C4=skin, C5=healed ulcer, C6=active ulcer                        ║
╠══════════════════════════════════════════════════════════════════╣
║ EMBOLISM vs THROMBOSIS                                            ║
║ Embolism: Sudden, no PAD history, AF source, Fogarty             ║
║ Thrombosis: Gradual, prior claudication, bypass/CDT              ║
╠══════════════════════════════════════════════════════════════════╣
║ TREATMENT HIERARCHY                                               ║
║ Claudication: Exercise > Cilostazol > PTA (TASC A/B)             ║
║ CLTI: Risk factor control + Revascularization (endo or open)     ║
║ ALI: Heparin → Fogarty/CDT → Fasciotomy                         ║
║ DVT: DOAC ≥3 months (LMWH → oral)                                ║
║ VV: EVLA/RFA > UGFS > Surgery                                    ║
╠══════════════════════════════════════════════════════════════════╣
║ GRAFT CHOICE: GSV >> PTFE (especially below-knee)                ║
║ FOGARTY: 2F=tibial, 3F=popliteal, 4F=SFA, 5F=iliac              ║
╚══════════════════════════════════════════════════════════════════╝

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Top 50 Viva Questions (Final Revision)

1. Where is the femoral pulse palpated?
2. What are the contents of the femoral triangle?
3. What is Hunter's canal?
4. What is the angiosome concept?
5. Name the branches of the popliteal artery.
6. What are the 6 Ps of ALI?
7. Classify ALI using Rutherford.
8. Differentiate embolism from thrombosis.
9. What is Leriche syndrome?
10. What is the ABI? Normal values?
11. Why is ABI falsely elevated in diabetics?
12. What is TBI? When used?
13. Describe Buerger's test.
14. What is Buerger's angle?
15. What is the CEAP classification?
16. What is Fontaine classification?
17. What is CLTI?
18. Describe Trendelenburg test.
19. What is Perthes' test? Significance?
20. What is Stemmer's sign?
21. Compare arterial vs venous vs neuropathic ulcer.
22. What is venous guttering?
23. What is dependent rubor?
24. What is lipodermatosclerosis?
25. What is atrophie blanche?
26. What is a saphena varix?
27. What are Cockett perforators?
28. First-line treatment for claudication?
29. What is cilostazol? Contraindications?
30. Graft of choice for femoropopliteal bypass?
31. In-situ vs reversed vein bypass?
32. What is fasciotomy? Indications?
33. Compartment syndrome - diagnosis?
34. Fogarty catheter - describe and sizes?
35. What is a patch angioplasty?
36. When to amputate vs revascularize?
37. BKA vs AKA - which is preferred?
38. What is DVT Wells score?
39. Treatment of acute DVT?
40. What is post-thrombotic syndrome?
41. What is the Villalta score?
42. What is Buerger's disease (TAO)?
43. How to treat Buerger's disease?
44. What is a popliteal aneurysm? Complications?
45. What is aortoenteric fistula?
46. What sutures in vascular anastomosis?
47. What is TASC classification?
48. What is CDT? Contraindications?
49. What is reperfusion injury?
50. What is DCB (drug-coated balloon)?

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Top 20 One-Liners

1. Femoral pulse: Midpoint of inguinal ligament (NOT mid-inguinal point)
2. Most common peripheral arterial aneurysm: Popliteal artery aneurysm
3. Most common cause of peripheral arterial embolism: Atrial fibrillation
4. Gold standard first-line investigation: Duplex Doppler ultrasound
5. ABI falsely elevated because: Medial calcinosis (Monckeberg sclerosis) in diabetics
6. First-line treatment for claudication: Supervised exercise programme
7. Graft of choice below knee: Autologous great saphenous vein
8. Fogarty catheter 2F: Tibial vessels; 4F: SFA; 5F: Iliac
9. Fasciotomy indication: Compartment pressure >30 mmHg or within 20-30 of diastolic
10. Category III ALI: Primary amputation (do NOT revascularize)
11. Buerger's disease treatment: Complete and permanent smoking cessation
12. CEAP C6: Active venous ulcer
13. Most important finding on duplex for DVT: Non-compressibility of vein
14. Positive Perthes' test: Do NOT strip the saphenous vein (it is the collateral)
15. Angiosome concept: Direct revascularization to vessel supplying the ischemic territory
16. Wells score ≥2: DVT likely - proceed to duplex
17. D-dimer: Highly sensitive, not specific; useful to RULE OUT in low probability
18. Leriche syndrome: Aortoiliac occlusion = buttock claudication + impotence + absent femoral pulses
19. Stemmer's sign positive: Cannot pinch skin at base of 2nd toe = lymphoedema
20. CLTI criteria (ABI): Resting ankle pressure <50 mmHg or ABI <0.4

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Top 10 Examiner Traps

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Top 10 Vascular Examination Pearls

1. Always examine standing AND lying - varicosities only visible standing
2. Always examine BOTH limbs - contralateral PAD is common
3. Temperature assessment with dorsum of hand - more sensitive than palm
4. Grade ALL pulses 0-3 - do not just say "present/absent"
5. Auscultate over femoral and popliteal arteries for bruits (indicate stenosis)
6. Always auscultate aorta for aortic bruit (aortoiliac disease)
7. Prominent popliteal pulse = aneurysm until proven otherwise
8. Buerger's test every time in arterial case - gives Buerger's angle
9. Neurological exam in all diabetic patients - neuropathy modifies presentation
10. Capillary refill time >5 sec in toes = severe ischemia

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Top 10 Operative Pearls

1. GSV is the first choice for all below-knee bypass grafting
2. Always send biopsy from amputated limb if unusual (malignancy?)
3. Heparin before clamping - prevents distal propagation of thrombus
4. Always do completion angiogram or Doppler after embolectomy
5. Prophylactic fasciotomy if ischemia >4-6 hours before reperfusion
6. Cover prosthetic graft with retroperitoneum - prevents aortoenteric fistula
7. Patch closure of arteriotomy - prevents stenosis
8. Saphenous nerve runs with GSV - gentle retraction avoids injury
9. Vertical skin incision at groin (parallel to femoral vessels); not transverse
10. BKA stump length 12-15 cm below tibial tuberosity for best prosthetic fit

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A note from your examiner: The mark of a great vascular long-case presentation is not just knowing the facts, but demonstrating clinical reasoning - WHY this patient has this condition, WHAT the examination findings tell you about the level and severity of disease, and HOW you would make a rational management decision. Always start with the bedside, work your way to imaging, and present a patient-centred management plan. Good luck.