const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Peripheral Vascular Disease - Case Presentation";
pres.author = "PG General Surgery";

// ─── COLOR PALETTE ───────────────────────────────────────────────
const C = {
  darkNavy:   "0A1628",   // slide background (dark)
  navy:       "102540",   // content bg (dark)
  midBlue:    "1B3E6F",   // header bars
  accent:     "E8503A",   // accent / highlight
  gold:       "F0A500",   // subheader accent
  light:      "D4E3F5",   // body text on dark
  white:      "FFFFFF",
  lightGray:  "B8CCDF",
  red:        "C0392B",
  green:      "27AE60",
  teal:       "1A8B8B",
};

// ─── HELPER: SLIDE WITH DARK BACKGROUND ─────────────────────────
function darkSlide() {
  const s = pres.addSlide();
  s.background = { color: C.darkNavy };
  return s;
}

// ─── HELPER: HEADER BAR ─────────────────────────────────────────
function header(slide, title, sub) {
  slide.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: 10, h: 0.72,
    fill: { color: C.midBlue },
    line: { color: C.accent, width: 3, dashType: "solid" },
  });
  slide.addText(title, {
    x: 0.18, y: 0.04, w: 9.5, h: 0.62,
    fontSize: 22, bold: true, color: C.white,
    fontFace: "Calibri", valign: "middle",
  });
  if (sub) {
    slide.addShape(pres.ShapeType.rect, {
      x: 0, y: 0.72, w: 10, h: 0.28,
      fill: { color: C.accent }, line: { color: C.accent, width: 0 },
    });
    slide.addText(sub, {
      x: 0.18, y: 0.72, w: 9.5, h: 0.28,
      fontSize: 11, bold: false, color: C.white, fontFace: "Calibri", valign: "middle",
    });
  }
}

// ─── HELPER: BULLET LIST ────────────────────────────────────────
function bullets(slide, items, opts = {}) {
  const {
    x = 0.3, y = 1.1, w = 9.4, h = 4.3,
    fontSize = 14, color = C.light,
    indent = 0,
  } = opts;
  slide.addText(
    items.map((item, i) => ({
      text: typeof item === "string" ? item : item.text,
      options: {
        bullet: typeof item === "object" && item.sub
          ? { indent: 30 }
          : true,
        breakLine: i < items.length - 1,
        fontSize: typeof item === "object" && item.sub ? fontSize - 1 : fontSize,
        color: typeof item === "object" && item.highlight ? C.gold : color,
        bold: typeof item === "object" && item.bold ? true : false,
        fontFace: "Calibri",
        indentLevel: typeof item === "object" && item.sub ? 1 : 0,
      },
    })),
    { x, y, w, h, valign: "top" }
  );
}

// ─── HELPER: TWO-COLUMN TABLE ───────────────────────────────────
function twoCol(slide, rows, opts = {}) {
  const {
    x = 0.3, y = 1.05, w = 9.4,
    colW = [4.5, 4.9],
    headerRow = true,
    fontSize = 12,
  } = opts;
  const tableRows = rows.map((row, ri) =>
    row.map((cell, ci) => ({
      text: cell,
      options: {
        bold: ri === 0 && headerRow,
        color: ri === 0 && headerRow ? C.white : C.light,
        fontSize,
        fontFace: "Calibri",
        fill: ri === 0 && headerRow ? { color: C.midBlue } : ci === 0 ? { color: "112038" } : { color: "0D1C30" },
        valign: "middle",
        align: "left",
      },
    }))
  );
  slide.addTable(tableRows, {
    x, y, w,
    colW,
    border: { color: C.midBlue, pt: 1 },
    rowH: 0.34,
  });
}

// ─── HELPER: SECTION DIVIDER ────────────────────────────────────
function dividerSlide(title, subtitle) {
  const s = pres.addSlide();
  s.background = { color: C.accent };
  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 2.2, w: 10, h: 0.06, fill: { color: C.white }, line: { color: C.white, width: 0 },
  });
  s.addText(title, {
    x: 0.5, y: 1.4, w: 9, h: 1.0,
    fontSize: 36, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
  });
  if (subtitle) {
    s.addText(subtitle, {
      x: 0.5, y: 2.6, w: 9, h: 0.8,
      fontSize: 18, color: C.white, fontFace: "Calibri", align: "center",
    });
  }
  return s;
}

// ─── HELPER: NUMBERED BOX LIST ──────────────────────────────────
function numberedBoxes(slide, items, cols = 2, opts = {}) {
  const {
    startY = 1.05,
    boxH = 0.55,
    gap = 0.06,
    colors = [C.midBlue, "0F3254", "163A60", "1C4570"],
  } = opts;
  const n = items.length;
  const perCol = Math.ceil(n / cols);
  const colW = 9.4 / cols;
  items.forEach((item, i) => {
    const col = Math.floor(i / perCol);
    const row = i % perCol;
    const x = 0.3 + col * (colW + 0.06);
    const y = startY + row * (boxH + gap);
    slide.addShape(pres.ShapeType.rect, {
      x, y, w: colW, h: boxH,
      fill: { color: colors[i % colors.length] },
      line: { color: C.accent, width: 1.5 },
    });
    slide.addText(`${i + 1}. ${item}`, {
      x: x + 0.12, y, w: colW - 0.12, h: boxH,
      fontSize: 12.5, color: C.white, fontFace: "Calibri", valign: "middle",
    });
  });
}

// ═══════════════════════════════════════════════════════════════
// SLIDE 1: TITLE
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: C.darkNavy };

  // Top accent bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.12, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  // Bottom accent bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: 10, h: 0.125, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });

  s.addText("PERIPHERAL VASCULAR DISEASE", {
    x: 0.4, y: 0.55, w: 9.2, h: 1.2,
    fontSize: 36, bold: true, color: C.white, fontFace: "Calibri", align: "center", charSpacing: 2,
  });
  s.addShape(pres.ShapeType.rect, { x: 2.5, y: 1.75, w: 5, h: 0.05, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  s.addText("Case Presentation", {
    x: 0.4, y: 1.85, w: 9.2, h: 0.6,
    fontSize: 24, color: C.gold, fontFace: "Calibri", align: "center", italic: true,
  });
  s.addText("PG General Surgery Grand Rounds", {
    x: 0.4, y: 2.55, w: 9.2, h: 0.5,
    fontSize: 16, color: C.lightGray, fontFace: "Calibri", align: "center",
  });
  s.addText([
    { text: "Sources: ", options: { bold: true, color: C.gold } },
    { text: "Schwartz's Principles of Surgery 11e  |  Bailey & Love's Short Practice of Surgery 28e  |  Sabiston Textbook of Surgery  |  Current Surgical Therapy 14e  |  Mulholland & Greenfield's Surgery 7e", options: { color: C.lightGray } },
  ], {
    x: 0.4, y: 3.3, w: 9.2, h: 0.6,
    fontSize: 10.5, fontFace: "Calibri", align: "center",
  });

  // Outline boxes
  const outlineItems = ["Case Presentation", "Anatomy & Pathophysiology", "Classification", "Clinical Features & Exam", "Investigations", "Management", "Buerger's Disease", "Varicose Veins", "Viva Q&A"];
  outlineItems.forEach((t, i) => {
    const x = 0.3 + (i % 3) * 3.15;
    const y = 4.2 + Math.floor(i / 3) * 0.55;
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 3.0, h: 0.42,
      fill: { color: i % 2 === 0 ? C.midBlue : "0D1C30" },
      line: { color: C.accent, width: 1 },
    });
    s.addText(t, {
      x: x + 0.1, y, w: 2.8, h: 0.42,
      fontSize: 11, color: C.white, fontFace: "Calibri", valign: "middle", align: "center",
    });
  });
}

// ═══════════════════════════════════════════════════════════════
// SECTION A: CASE PRESENTATION
// ═══════════════════════════════════════════════════════════════
dividerSlide("SECTION A", "Case Presentation");

// SLIDE: Clinical Case - Presenting Complaint
{
  const s = darkSlide();
  header(s, "CASE PRESENTATION — Presenting Complaint", "A 58-year-old male, chronic smoker, presents to surgical OPD");

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.05, w: 4.5, h: 4.35, fill: { color: C.navy }, line: { color: C.midBlue, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.05, w: 4.7, h: 4.35, fill: { color: C.navy }, line: { color: C.gold, width: 1.5 } });

  s.addText("CHIEF COMPLAINTS", { x: 0.35, y: 1.08, w: 4.4, h: 0.38, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  s.addText([
    { text: "1. Pain in bilateral calves on walking", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "   - 500 m → 200 m → 50 m (progressive worsening over 3 years)", options: { bullet: false, breakLine: true, fontSize: 11.5, color: C.lightGray } },
    { text: "2. Rest pain in both feet (night pain, relieved on hanging legs down)", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "3. Non-healing ulcer on right great toe — 3 weeks", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "4. Coldness & numbness of both feet", options: { bullet: true, breakLine: false, fontSize: 13 } },
  ], { x: 0.4, y: 1.55, w: 4.35, h: 3.7, valign: "top", color: C.light });

  s.addText("RELEVANT HISTORY", { x: 5.05, y: 1.08, w: 4.55, h: 0.38, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  s.addText([
    { text: "Smoking: 30 pack-years, current smoker", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "Type 2 DM: 10 years, on metformin", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "Hypertension: 8 years, on amlodipine", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "No prior vascular surgery or angioplasty", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "Family history: Father had CAD", options: { bullet: true, breakLine: true, fontSize: 13 } },
    { text: "Diet: High fat, sedentary lifestyle", options: { bullet: true, breakLine: false, fontSize: 13 } },
  ], { x: 5.1, y: 1.55, w: 4.55, h: 3.7, valign: "top", color: C.light });
}

// SLIDE: Clinical Case - Physical Examination
{
  const s = darkSlide();
  header(s, "CASE PRESENTATION — Physical Examination", "Systematic vascular examination findings");

  twoCol(s, [
    ["GENERAL EXAMINATION", "VASCULAR SPECIFIC EXAMINATION"],
    ["Thin, pale male, anxious, smells of tobacco", "Buerger's test: Positive (pallor at 20° elevation, rubor on dependency)"],
    ["Pallor of bilateral feet and toes", "Capillary refill time: >3 seconds bilateral feet"],
    ["Bilateral trophic changes: hair loss dorsum of feet, thickened nails", "Pulses: Femoral pulse present bilaterally (diminished R); Popliteal absent bilaterally; Dorsalis pedis absent bilaterally; Posterior tibial absent bilaterally"],
    ["Non-healing ulcer: 2×2 cm, right great toe, well-defined punched-out edges, slough at base, no granulation", "Bruit: Systolic bruit over right femoral artery"],
    ["Wasting of calf muscles bilaterally", "ABI (Ankle Brachial Index): Right 0.42, Left 0.55"],
    ["BP: 148/90 mmHg; Pulse: 88/min; Temp: 37.1°C", "Venous guttering on elevation: Present"],
  ], { colW: [4.6, 4.8], fontSize: 11.5 });
}

// SLIDE: Provisional Diagnosis & Rationale
{
  const s = darkSlide();
  header(s, "PROVISIONAL DIAGNOSIS & RATIONALE", "Synthesizing clinical findings");

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.05, w: 9.4, h: 1.0, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  s.addText("Chronic Limb-Threatening Ischemia (CLTI) — Bilateral Lower Extremities  (Fontaine Stage IV, Right; Stage III, Left)", {
    x: 0.4, y: 1.05, w: 9.2, h: 1.0,
    fontSize: 16, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
  });

  bullets(s, [
    { text: "REASONING FOR DIAGNOSIS:", bold: true, highlight: true },
    { text: "1. Intermittent claudication progressing to rest pain — hallmark of PAD progression (Schwartz's 11e)", sub: false },
    { text: "2. ABI 0.42 Right, 0.55 Left — confirms severe arterial insufficiency (ABI <0.4 = critical ischemia)", sub: false },
    { text: "3. Absent popliteal, DP, PT pulses + positive Buerger's test = infrapopliteal occlusive disease", sub: false },
    { text: "4. Non-healing punched-out ulcer on toe = ischemic ulcer (vs. neuropathic: painless, callus; vs. venous: gaiter area, irregular)", sub: false },
    { text: "5. Risk factor cluster: Smoking (30 pack-years) + DM + HTN + dyslipidemia = atherosclerotic PAD", sub: false },
    { text: "DIFFERENTIAL DIAGNOSES: Buerger's disease (TAO) | Diabetic peripheral neuropathy | DVT | Spinal stenosis (neurogenic claudication)", bold: true, highlight: true },
  ], { y: 2.12, h: 3.3, fontSize: 13 });
}

// ═══════════════════════════════════════════════════════════════
// SECTION B: TOPIC REVIEW
// ═══════════════════════════════════════════════════════════════
dividerSlide("SECTION B", "Topic Review — Peripheral Vascular Disease");

// SLIDE: Definition & Classification of PVD
{
  const s = darkSlide();
  header(s, "PERIPHERAL VASCULAR DISEASE — Overview & Classification", "Schwartz's 11e | Bailey & Love 28e");

  s.addText("DEFINITION", { x: 0.35, y: 1.08, w: 9.4, h: 0.35, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  s.addText("PVD encompasses diseases of the arterial, venous, and lymphatic systems outside the heart and great intrathoracic vessels. In common surgical parlance, it primarily refers to occlusive arterial disease of the limbs.", {
    x: 0.35, y: 1.45, w: 9.3, h: 0.7, fontSize: 13, color: C.light, fontFace: "Calibri",
  });

  twoCol(s, [
    ["ARTERIAL DISEASES", "VENOUS / LYMPHATIC DISEASES"],
    ["Peripheral Arterial Disease (PAD) — atherosclerotic", "Varicose Veins — superficial venous insufficiency"],
    ["Acute Limb Ischemia (ALI) — embolism / thrombosis", "Chronic Venous Insufficiency (CVI)"],
    ["Buerger's Disease (TAO) — nonatherosclerotic, inflammatory", "Deep Vein Thrombosis (DVT)"],
    ["Raynaud's Disease/Phenomenon — vasospastic", "Venous Leg Ulcer"],
    ["Aortoiliac Occlusive Disease (Leriche syndrome)", "Lymphedema"],
    ["Aneurysmal disease (AAA, popliteal)", "Post-thrombotic syndrome"],
  ], { y: 2.2, colW: [4.6, 4.8], fontSize: 12 });
}

// SLIDE: Anatomy of Peripheral Arterial System
{
  const s = darkSlide();
  header(s, "RELEVANT ARTERIAL ANATOMY", "Lower limb blood supply — surgical landmarks");

  s.addText("AORTOILIAC SEGMENT (Inflow)", { x: 0.35, y: 1.05, w: 9.4, h: 0.35, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  bullets(s, [
    "Abdominal aorta (L4) → Common iliac arteries → External & Internal iliac arteries",
    "Leriche syndrome: Aortoiliac occlusion → bilateral calf/thigh claudication + impotence + absent femoral pulses",
  ], { y: 1.42, h: 0.95, fontSize: 13 });

  s.addText("FEMOROPOPLITEAL SEGMENT", { x: 0.35, y: 2.45, w: 9.4, h: 0.32, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  bullets(s, [
    "Common femoral artery (CFA) → Profunda femoris (PFA) + Superficial femoral artery (SFA)",
    "SFA passes through adductor (Hunter's) canal → Popliteal artery",
    "SFA occlusion (most common site of PAD) = calf claudication",
  ], { y: 2.8, h: 1.0, fontSize: 13 });

  s.addText("INFRAPOPLITEAL (Tibial) SEGMENT — Trifurcation", { x: 0.35, y: 3.87, w: 9.4, h: 0.32, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  bullets(s, [
    "Popliteal → Anterior tibial + Tibioperoneal trunk → Posterior tibial + Peroneal arteries",
    "Dorsalis pedis (from ATA) & Posterior tibial form pedal arch",
    "Infrapopliteal disease = foot/toe ischemia — commonest in DM & Buerger's",
  ], { y: 4.22, h: 1.0, fontSize: 13 });
}

// SLIDE: Pathophysiology of PAD
{
  const s = darkSlide();
  header(s, "PATHOPHYSIOLOGY OF PAD", "Atherosclerosis → ischemia cascade");

  twoCol(s, [
    ["STAGE", "MECHANISM / KEY POINTS"],
    ["Endothelial injury", "Smoking, DM, HTN, dyslipidemia → endothelial dysfunction → LDL oxidation & macrophage infiltration"],
    ["Fatty streak formation", "Foam cells accumulate in intima → fatty streaks (reversible stage)"],
    ["Fibrous plaque", "Smooth muscle cell migration + collagen deposition → intimal thickening → lumen narrowing"],
    ["Advanced lesion / stenosis", ">70% stenosis → reduced pressure gradient → ischemia on exercise (claudication)"],
    ["Critical stenosis / occlusion", "Plaque rupture + thrombosis → sudden occlusion → rest pain / tissue loss"],
    ["Collateral circulation", "Profunda femoris key collateral for SFA occlusion; geniculate arteries for popliteal"],
    ["Microvascular disease (DM)", "Basement membrane thickening → impaired autoregulation → worsens ischemia even without large vessel occlusion"],
  ], { colW: [3.2, 6.2], fontSize: 12 });
}

// SLIDE: Risk Factors
{
  const s = darkSlide();
  header(s, "RISK FACTORS FOR PAD", "Modifiable and non-modifiable — key viva topic");

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.05, w: 4.5, h: 4.3, fill: { color: C.navy }, line: { color: C.accent, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.05, w: 4.7, h: 4.3, fill: { color: C.navy }, line: { color: C.gold, width: 1.5 } });

  s.addText("MODIFIABLE RISK FACTORS", { x: 0.35, y: 1.1, w: 4.4, h: 0.38, fontSize: 12.5, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText([
    { text: "Cigarette smoking — SINGLE STRONGEST RF (RR 2-4x; risk dose-dependent)", options: { bullet: true, breakLine: true, fontSize: 12.5, bold: true, color: C.gold } },
    { text: "Diabetes mellitus — 2-4x risk; promotes microvascular disease", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Hypertension — promotes endothelial injury", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Dyslipidemia (high LDL, low HDL)", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Obesity (BMI >30)", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Hyperhomocysteinemia", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Chronic kidney disease (CKD)", options: { bullet: true, breakLine: false, fontSize: 12.5, color: C.light } },
  ], { x: 0.4, y: 1.55, w: 4.35, h: 3.65, valign: "top" });

  s.addText("NON-MODIFIABLE RISK FACTORS", { x: 5.05, y: 1.1, w: 4.55, h: 0.38, fontSize: 12.5, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText([
    { text: "Age >50 years (prevalence 15-20% in >70 yrs — Schwartz's 11e)", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Male sex (M:F = 2:1, though gap closing)", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Family history of CAD/PVD", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "Race: Higher prevalence in African Americans", options: { bullet: true, breakLine: true, fontSize: 12.5, color: C.light } },
    { text: "EPIDEMIOLOGY: Prevalence 3-10% general population; 50% of diabetic foot ulcers have PAD (Mulholland & Greenfield's 7e)", options: { bullet: false, breakLine: false, fontSize: 11.5, color: C.gold, bold: true } },
  ], { x: 5.1, y: 1.55, w: 4.55, h: 3.65, valign: "top" });
}

// SLIDE: Classification — Fontaine & Rutherford
{
  const s = darkSlide();
  header(s, "CLASSIFICATION OF PAD", "Fontaine & Rutherford Classifications — Schwartz's 11e (Table 23-19)");

  twoCol(s, [
    ["FONTAINE STAGE", "CLINICAL DESCRIPTION"],
    ["Stage I", "Asymptomatic (disease present on testing, no symptoms)"],
    ["Stage IIa", "Mild intermittent claudication (>200 m walking distance)"],
    ["Stage IIb", "Moderate-severe claudication (<200 m walking distance)"],
    ["Stage III", "Ischemic rest pain (typically at night, in forefoot/toes)"],
    ["Stage IV", "Tissue loss: ischemic ulceration or gangrene"],
  ], { y: 1.05, colW: [2.2, 7.2], fontSize: 13 });

  s.addText("RUTHERFORD CLASSIFICATION", { x: 0.35, y: 3.45, w: 9.4, h: 0.35, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });

  twoCol(s, [
    ["GRADE / CATEGORY", "DESCRIPTION"],
    ["Grade 0, Cat 0", "Asymptomatic"],
    ["Grade I, Cat 1/2/3", "Mild/moderate/severe claudication"],
    ["Grade II, Cat 4", "Ischemic rest pain"],
    ["Grade III, Cat 5", "Minor tissue loss (non-healing ulcer, focal gangrene with diffuse pedal ischemia)"],
    ["Grade III, Cat 6", "Major tissue loss (above TM level, functional foot no longer salvageable)"],
  ], { y: 3.82, colW: [2.6, 6.8], fontSize: 12 });
}

// SLIDE: Clinical Features — Symptoms
{
  const s = darkSlide();
  header(s, "CLINICAL FEATURES OF PAD", "Symptoms — from history taking");

  twoCol(s, [
    ["SYMPTOM", "CLINICAL DETAILS"],
    ["Intermittent Claudication", "Reproducible cramping pain in calf/thigh/buttock on walking, relieved by rest (2-5 min). NEVER at rest. Site = level below occlusion"],
    ["Rest Pain", "Burning/gnawing pain in forefoot & toes at night. Relieved by dependency (hanging foot off bed). Requires analgesics. = Stage III"],
    ["Ulceration", "Punched-out, well-defined edges, painful, no slough rim, at pressure points (toes, heel, malleoli). = Stage IV"],
    ["Gangrene", "Dry (mumification) or wet (infected). Starts at toes (most distal part). = Stage IV"],
    ["Coldness & Numbness", "Due to reduced perfusion; numbness from nerve ischemia"],
    ["Impotence", "In Leriche syndrome (aortoiliac occlusion) — bilateral absent femoral pulses"],
    ["Raynaud's phenomenon", "Episodic vasospasm: white → blue → red on cold/emotional stress"],
  ], { colW: [3.0, 7.0], fontSize: 12 });
}

// SLIDE: Clinical Examination
{
  const s = darkSlide();
  header(s, "CLINICAL EXAMINATION OF PVD", "Inspection, Palpation, Auscultation & Special Tests");

  twoCol(s, [
    ["EXAMINATION", "FINDINGS & SIGNIFICANCE"],
    ["Inspection — trophic changes", "Hair loss (dorsum foot), thickened/brittle nails, shiny atrophic skin, muscle wasting, pallor/cyanosis/gangrene"],
    ["Capillary refill time", "Normal <2 sec; >3 sec = arterial insufficiency"],
    ["Buerger's Test (Elevation Test)", "Elevate leg to 45°: pallor within 1-2 min = positive. Dependent rubor (reactive hyperemia) on lowering = confirms ischemia. Angle at which pallor occurs = Buerger's angle (<20° = severe ischemia)"],
    ["Pulse Examination", "Radial, femoral (Scarpa's triangle), popliteal (popliteal fossa — requires deep palpation), DP (lateral to EHL tendon), PT (behind medial malleolus). Grade 0-4. Note radio-femoral delay"],
    ["Auscultation for bruits", "Systolic bruit over stenotic vessel (>50% stenosis). Sites: renal, mesenteric, iliac, femoral arteries"],
    ["ABPI / ABI", "<0.9 = abnormal PAD; 0.4-0.9 = claudication; <0.4 = critical ischemia; >1.3 = calcified vessels (non-compressible)"],
    ["Allen's Test", "For upper limb arterial occlusion — assess radial/ulnar patency"],
  ], { colW: [3.0, 7.0], fontSize: 11.5 });
}

// SLIDE: Investigations
{
  const s = darkSlide();
  header(s, "INVESTIGATIONS IN PAD", "From bedside to advanced imaging");

  twoCol(s, [
    ["INVESTIGATION", "DETAILS & NORMAL / ABNORMAL VALUES"],
    ["Ankle-Brachial Index (ABI)", "ABI = Ankle systolic BP / Brachial systolic BP. Normal ≥0.9. Claudication: 0.5-0.9. Rest pain: 0.3-0.5. Tissue loss: <0.3. Non-compressible (DM/CKD): >1.3 — use toe-brachial index (TBI) instead"],
    ["Duplex Ultrasonography", "First-line imaging. Combines B-mode anatomy + Doppler flow. Shows stenosis, PSV ratio >2 = >50% stenosis. Non-invasive, no radiation. Operator dependent"],
    ["CT Angiography (CTA)", "Investigation of choice for planning revascularization. High spatial resolution, 3D reconstruction. Contrast nephropathy risk. Shows calcification accurately. Schwartz's 11e — Fig 23-60"],
    ["MR Angiography (MRA)", "No radiation, no iodinated contrast. Preferred in CKD. Overestimates stenosis. Gadolinium risk in severe CKD (NSF)"],
    ["Digital Subtraction Angiography (DSA)", "Gold standard. Allows simultaneous endovascular intervention. Used when CTA/MRA inconclusive. Invasive (arterial access, contrast, radiation)"],
    ["Blood tests", "FBC, RFT, LFT, lipid profile, HbA1c, coagulation, homocysteine. Hypercoagulability panel if <50 yrs or no obvious RF"],
    ["ECG + Echo", "Rule out cardiac source of emboli for ALI; assess cardiac fitness pre-op"],
  ], { colW: [3.2, 6.8], fontSize: 11.5 });
}

// SLIDE: Management Overview
{
  const s = darkSlide();
  header(s, "MANAGEMENT OF PAD — Overview", "Medical | Endovascular | Surgical (Bailey & Love 28e, Schwartz's 11e)");

  s.addText("CONSERVATIVE / MEDICAL MANAGEMENT", { x: 0.35, y: 1.08, w: 9.4, h: 0.32, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  twoCol(s, [
    ["INTERVENTION", "DETAILS"],
    ["Smoking cessation", "Single most important intervention. Halts disease progression. Reduces amputation risk by >50%"],
    ["Exercise rehabilitation", "Supervised walking program — first-line for claudication. Increases claudication distance by >150%"],
    ["Antiplatelet therapy", "Aspirin 75-100 mg/day OR Clopidogrel 75 mg/day. Reduces MACE (MI, stroke, death)"],
    ["Statin therapy", "Target LDL <1.8 mmol/L. Atorvastatin 40-80 mg/day. Plaque stabilization"],
    ["BP control", "Target <140/90 (or <130/80 in DM). ACEi/ARB preferred (also renal protection)"],
    ["Diabetes control", "HbA1c <7%. Tight control reduces microvascular complications"],
    ["Cilostazol", "PDE3 inhibitor. Increases claudication distance. Contraindicated in heart failure"],
  ], { y: 1.45, colW: [3.0, 7.0], fontSize: 11.5 });
}

// SLIDE: Endovascular & Surgical Management
{
  const s = darkSlide();
  header(s, "INTERVENTIONAL MANAGEMENT OF PAD", "Endovascular vs. Open Surgery — Indications & Procedures");

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.05, w: 4.5, h: 4.35, fill: { color: C.navy }, line: { color: C.teal, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.05, w: 4.7, h: 4.35, fill: { color: C.navy }, line: { color: C.accent, width: 1.5 } });

  s.addText("ENDOVASCULAR (First line for TASC A/B)", { x: 0.35, y: 1.1, w: 4.4, h: 0.38, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });
  s.addText([
    { text: "Percutaneous Transluminal Angioplasty (PTA): Balloon dilation of stenosis", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Stenting: Bare metal or drug-eluting stents; for iliac disease (excellent patency) & focal SFA lesions", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Atherectomy: Directional, rotational, laser — for calcified lesions", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Catheter-directed thrombolysis: For ALI (Class I/IIa Rutherford) — rTPA / urokinase", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Drug-coated balloon (DCB): Reduces restenosis in infrapopliteal disease", options: { bullet: true, breakLine: false, fontSize: 12, color: C.light } },
  ], { x: 0.4, y: 1.55, w: 4.35, h: 3.6, valign: "top" });

  s.addText("OPEN SURGERY (TASC C/D, bypass failure)", { x: 5.05, y: 1.1, w: 4.55, h: 0.38, fontSize: 12, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText([
    { text: "Aortobifemoral bypass: For aortoiliac (Leriche) — Dacron graft, 5-yr patency ~90%", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Femoropopliteal bypass: Ipsilateral GSV (gold standard conduit); PTFE if vein unavailable; above/below knee popliteal", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Femorodistal (tibial) bypass: For CLTI with infrapopliteal disease; GSV mandatory", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Endarterectomy: CFA endarterectomy (common femoral); eversion carotid endarterectomy", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Embolectomy: Fogarty balloon catheter — for ALI from embolism; under LA/GA; femoral arteriotomy", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Amputation: Last resort. Below-knee (BKA) preferred over AKA (better rehabilitation). Ray amputation for toe gangrene", options: { bullet: true, breakLine: false, fontSize: 12, color: C.light } },
  ], { x: 5.1, y: 1.55, w: 4.55, h: 3.6, valign: "top" });
}

// SLIDE: TASC Classification
{
  const s = darkSlide();
  header(s, "TASC II CLASSIFICATION", "Trans-Atlantic Inter-Society Consensus — guides treatment choice");

  twoCol(s, [
    ["TASC TYPE", "FEMOROPOPLITEAL LESION DESCRIPTION", "TREATMENT"],
    ["Type A", "Single stenosis ≤10 cm OR single occlusion ≤5 cm", "Endovascular PREFERRED"],
    ["Type B", "Multiple lesions each ≤5 cm; single stenosis/occlusion ≤15 cm (not involving infragenicular popliteal); heavily calcified occlusion ≤5 cm", "Endovascular PREFERRED"],
    ["Type C", "Multiple stenoses/occlusions totalling >15 cm; recurrent stenoses after 2 endovascular procedures", "Surgery PREFERRED"],
    ["Type D", "Chronic total occlusion CFA/SFA (>20 cm involving popliteal); chronic total occlusion popliteal + trifurcation", "Surgery PREFERRED"],
  ], { colW: [1.5, 5.5, 2.4], fontSize: 12 });

  bullets(s, [
    { text: "Key principle: Endovascular for inflow disease (aortoiliac) has excellent results regardless of TASC type (iliac stenting 5-yr patency ~85%).", highlight: true },
    { text: "Infrapopliteal TASC: Also A-D but based on tibial vessel lesion length and trifurcation involvement." },
  ], { y: 4.3, h: 1.1, fontSize: 12.5 });
}

// SLIDE: Acute Limb Ischemia — 6 Ps
{
  const s = darkSlide();
  header(s, "ACUTE LIMB ISCHEMIA (ALI)", "Definition, Etiology & The 6 Ps — Sabiston Textbook of Surgery");

  s.addText('DEFINITION: Sudden loss of limb perfusion with symptoms present <2 weeks — a surgical emergency', {
    x: 0.3, y: 1.05, w: 9.4, h: 0.45,
    fontSize: 13, color: C.gold, fontFace: "Calibri", bold: true,
  });

  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.55, w: 4.5, h: 3.9, fill: { color: C.navy }, line: { color: C.accent, width: 1.5 } });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.55, w: 4.7, h: 3.9, fill: { color: C.navy }, line: { color: C.gold, width: 1.5 } });

  s.addText("THE 6 Ps (Classic Presentation)", { x: 0.35, y: 1.58, w: 4.4, h: 0.35, fontSize: 12.5, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText([
    { text: "Pain — sudden, severe (absent in late/neuropathic)", options: { bullet: true, breakLine: true, fontSize: 13, bold: true, color: C.gold } },
    { text: "Pallor — waxy white discoloration", options: { bullet: true, breakLine: true, fontSize: 13, color: C.light } },
    { text: "Pulselessness — absent distal pulses", options: { bullet: true, breakLine: true, fontSize: 13, color: C.light } },
    { text: "Paresthesia — sensory loss (early nerve ischemia)", options: { bullet: true, breakLine: true, fontSize: 13, color: C.light } },
    { text: "Paralysis — motor loss (late; indicates irreversibility risk)", options: { bullet: true, breakLine: true, fontSize: 13, bold: true, color: C.gold } },
    { text: "Perishing cold — profound coldness of limb", options: { bullet: true, breakLine: false, fontSize: 13, color: C.light } },
  ], { x: 0.4, y: 1.98, w: 4.35, h: 3.3, valign: "top" });

  s.addText("ETIOLOGY", { x: 5.05, y: 1.58, w: 4.55, h: 0.35, fontSize: 12.5, bold: true, color: C.accent, fontFace: "Calibri" });
  s.addText([
    { text: "Embolism (40%): AF (most common source), MI mural thrombus, valvular disease, proximal aneurysm. Saddle embolus at aortic bifurcation", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Thrombosis (50%): Plaque rupture on pre-existing PAD; bypass graft thrombosis. History of claudication — key differentiator from embolism", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Trauma: Arterial transection, intimal tear, compartment syndrome", options: { bullet: true, breakLine: true, fontSize: 12, color: C.light } },
    { text: "Dissection, popliteal entrapment, Buerger's flare", options: { bullet: true, breakLine: false, fontSize: 12, color: C.light } },
  ], { x: 5.1, y: 1.98, w: 4.55, h: 3.3, valign: "top" });
}

// SLIDE: ALI — Rutherford Classification & Management
{
  const s = darkSlide();
  header(s, "ALI — RUTHERFORD CLASSIFICATION & MANAGEMENT", "Sabiston Textbook of Surgery — Table 104.1");

  twoCol(s, [
    ["CATEGORY", "DESCRIPTION", "SENSORY LOSS", "MUSCLE WEAKNESS", "DOPPLER: ART/VEN", "MANAGEMENT"],
    ["I — Viable", "Not immediately threatened", "None", "None", "Audible / Audible", "Anticoagulate + imaging; elective revascularization"],
    ["IIa — Marginally threatened", "Salvageable if treated promptly", "Minimal (toes only)", "None", "Often absent / Audible", "Urgent revascularization within hours"],
    ["IIb — Immediately threatened", "Salvageable with immediate intervention", "More than toes; rest pain", "Mild-moderate", "Usually absent / Audible", "Emergency revascularization"],
    ["III — Irreversible", "Major tissue loss / permanent nerve damage", "Profound, anesthetic", "Profound, paralysis", "Absent / Absent", "Primary amputation; revascularization risks reperfusion injury"],
  ], { colW: [1.5, 1.6, 1.3, 1.3, 1.5, 2.2], fontSize: 10.5 });

  bullets(s, [
    { text: "Immediate management: IV heparin (80 U/kg bolus + 18 U/kg/hr infusion) — prevents thrombus propagation", highlight: true, bold: true },
    { text: "Compartment syndrome: Fasciotomy of all 4 compartments if ischemia >6 hours after revascularization", bold: true },
    { text: "Embolism → Fogarty embolectomy (LA, femoral arteriotomy). Thrombosis → CDT (thrombolysis) or bypass" },
  ], { y: 4.45, h: 1.05, fontSize: 12 });
}

// ═══════════════════════════════════════════════════════════════
// SECTION C: BUERGER'S DISEASE
// ═══════════════════════════════════════════════════════════════
dividerSlide("SECTION C", "Buerger's Disease (Thromboangiitis Obliterans)");

// SLIDE: Buerger's Disease
{
  const s = darkSlide();
  header(s, "BUERGER'S DISEASE (TAO)", "Thromboangiitis Obliterans — Schwartz's 11e, Bailey & Love 28e");

  twoCol(s, [
    ["FEATURE", "DETAILS"],
    ["Definition", "Progressive NON-atherosclerotic segmental inflammatory disease of small & medium arteries, veins, and nerves of extremities"],
    ["Age & Sex", "Young males, 20-50 years. Strong male predominance (M:F = 9:1)"],
    ["Essential association", "TOBACCO USE — essential for diagnosis AND progression. All forms: cigarette, bidi, chewing tobacco, passive smoking"],
    ["Pathology", "Acute phase: Thrombosis with dense PMN infiltrate + microabscesses + giant cells (pathognomonic). Chronic: organized thrombus, fibrosis, recanalization → corkscrew collaterals"],
    ["Upper limb", "Involved in up to 40% of cases. Raynaud's phenomenon in early disease"],
    ["Migratory superficial phlebitis", "Present in ~16% — indicates systemic inflammatory response"],
    ["Angiographic findings", "Disease confined to distal circulation (infrapopliteal, digital arteries). Segmental occlusions with 'skip' lesions. Corkscrew (helical) collaterals — PATHOGNOMONIC"],
    ["Treatment", "STRICT SMOKING CESSATION — the only effective treatment. No disease progression after cessation (Oregon HSC data). Prostacyclin infusion (iloprost) for digital ischemia. Surgical bypass rarely feasible (no target vessel + phlebitis limits vein use). Amputation in 31% over 15 years if they continue smoking"],
  ], { colW: [2.8, 7.2], fontSize: 11.5 });
}

// ═══════════════════════════════════════════════════════════════
// SECTION D: VARICOSE VEINS
// ═══════════════════════════════════════════════════════════════
dividerSlide("SECTION D", "Varicose Veins & Venous Disease");

// SLIDE: Varicose Veins
{
  const s = darkSlide();
  header(s, "VARICOSE VEINS", "Schwartz's 11e | Bailey & Love 28e");

  twoCol(s, [
    ["FEATURE", "DETAILS"],
    ["Definition", "Dilated, tortuous, elongated superficial veins (>3 mm diameter). Present in >10% of general population"],
    ["Types", "PRIMARY: Intrinsic valvular/wall incompetence (most common). SECONDARY: DVT/post-thrombotic (deep venous insufficiency), pregnancy, pelvic tumors, AV fistula"],
    ["Pathophysiology", "Valve incompetence → venous reflux → venous hypertension → vein wall weakening → varicosity. GSV (great saphenous vein) most commonly affected — SFJ incompetence"],
    ["Risk factors", "Female sex, pregnancy, obesity, prolonged standing, family history, age"],
    ["Clinical features", "Unsightly veins, aching, heaviness, pruritus, fatigue. Worse with standing, relieved by elevation. Edema. Complications: thrombophlebitis, hyperpigmentation, lipodermatosclerosis, venous ulcer (gaiter area), bleeding"],
    ["Special tests", "Trendelenburg test (SFJ incompetence), Tourniquet test, Cough impulse test, Doppler (hand-held) — now replaced by duplex USS"],
    ["Investigations", "Duplex ultrasound (gold standard): identifies reflux sites (SFJ, SPJ, perforators). CEAP classification for documentation"],
    ["Treatment: Conservative", "Compression stockings (20-40 mmHg); leg elevation; weight reduction — symptom relief"],
    ["Treatment: Interventional", "Endovenous thermal ablation (EVLA/RFA) — first line. Foam sclerotherapy. Open surgery (Trendelenburg + stripping of GSV) for failures or recurrence. Avulsions/phlebectomy for varicose tributaries"],
  ], { colW: [2.8, 7.2], fontSize: 11 });
}

// SLIDE: CEAP & Ulcer Comparison
{
  const s = darkSlide();
  header(s, "CEAP CLASSIFICATION & ULCER DIFFERENTIATION", "Bailey & Love 28e — Venous Leg Ulcer");

  twoCol(s, [
    ["CEAP CLASS", "CLINICAL FEATURES"],
    ["C0", "No visible or palpable venous disease"],
    ["C1", "Telangiectasia, reticular veins"],
    ["C2", "Varicose veins >3mm"],
    ["C3", "Edema (no skin changes)"],
    ["C4a", "Pigmentation / eczema"],
    ["C4b", "Lipodermatosclerosis / white atrophy"],
    ["C5", "Healed venous ulcer"],
    ["C6", "Active venous ulcer"],
  ], { y: 1.05, colW: [1.5, 4.0], fontSize: 12 });

  s.addText("ULCER DIFFERENTIATION", { x: 5.65, y: 1.05, w: 4.0, h: 0.35, fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri" });
  twoCol(s, [
    ["FEATURE", "ARTERIAL", "VENOUS", "NEUROPATHIC"],
    ["Site", "Toes, heel, pressure points", "Gaiter area (medial malleolus)", "Pressure points, sole"],
    ["Pain", "Severe — worse at night", "Mild-moderate", "Painless"],
    ["Edge", "Punched out, well-defined", "Sloping, irregular", "Punched out, callus rim"],
    ["Base", "Necrotic, pale, fibrous", "Granulating, shallow", "Deep, may expose tendon"],
    ["Surrounding skin", "Pale, shiny, cold", "Pigmented, lipodermatosclerosis", "Warm, dry, neuropathic"],
    ["ABI", "<0.9 (often <0.5)", ">0.9 (unless mixed)", "Variable (DM calcification)"],
  ], { x: 5.6, y: 1.45, w: 4.1, colW: [0.9, 1.1, 1.1, 1.0], fontSize: 10 });
}

// ═══════════════════════════════════════════════════════════════
// SECTION E: VIVA Q&A
// ═══════════════════════════════════════════════════════════════
dividerSlide("SECTION E", "Viva Voce — Commonly Asked Questions in PG Surgery");

// SLIDE: Viva Q&A Set 1
{
  const s = darkSlide();
  header(s, "VIVA Q&A — SET 1", "Peripheral Arterial Disease");

  const qas = [
    ["Q: What is ABI and how do you perform it?", "A: ABI = Ankle systolic BP / Brachial systolic BP. Measure systolic BP at brachial, DP, PT using sphygmomanometer + Doppler probe. Use HIGHER of the two ankle pressures. Normal ≥0.9. Claudication 0.5-0.9. Rest pain 0.3-0.5. Critical <0.3. Non-compressible (calcification) >1.3 → use toe-brachial index instead."],
    ["Q: What is Buerger's angle?", "A: The angle of elevation of the leg at which pallor occurs during Buerger's test. <20° = critical/severe ischemia. Normally, pallor should not occur even at 90°. Normal: no pallor at any elevation."],
    ["Q: Differentiate embolism from thrombosis in ALI", "A: EMBOLISM: Sudden onset, no prior claudication, AF history, cold/white limb, clear demarcation, other limb normal, Echo/ECG may show source. THROMBOSIS: Prior claudication, atherosclerosis risk factors, gradual onset, less severe initially, collaterals may partially maintain flow."],
    ["Q: What is Leriche syndrome?", "A: Aortoiliac occlusive disease (at aortic bifurcation or bilateral iliac arteries). Classic TRIAD: (1) Bilateral claudication (calf, thigh, buttocks), (2) Bilateral absent/diminished femoral pulses, (3) Impotence (from internal iliac occlusion). Treatment: Aortobifemoral bypass."],
  ];

  qas.forEach((qa, i) => {
    const y = 1.07 + i * 1.13;
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.33, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });
    s.addText(qa[0], { x: 0.4, y: y + 0.02, w: 9.2, h: 0.3, fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(qa[1], { x: 0.4, y: y + 0.34, w: 9.2, h: 0.72, fontSize: 11.5, color: C.light, fontFace: "Calibri", valign: "top" });
  });
}

// SLIDE: Viva Q&A Set 2
{
  const s = darkSlide();
  header(s, "VIVA Q&A — SET 2", "Acute Limb Ischemia & Buerger's Disease");

  const qas = [
    ["Q: Immediate management of ALI?", "A: (1) IV heparin immediately (80U/kg bolus → 18U/kg/hr infusion) to prevent clot propagation. (2) IV fluids + Foley catheter (monitor UO). (3) Baseline bloods — FBC, RFT, coagulation, group & screen. (4) ECG + echo (look for AF/source). (5) Imaging: CTA if stable, direct to OR if IIb/unstable. (6) Embolism → Fogarty embolectomy; Thrombosis → CDT (thrombolysis with rtPA) or bypass. (7) 4-compartment fasciotomy if ischemia >6 hours post revascularization."],
    ["Q: What are corkscrew collaterals and in which condition?", "A: Corkscrew (helical/spiral) collaterals are pathognomonic of Buerger's disease (TAO) on angiography. They represent extensive collateralization around segmentally occluded small/medium arteries in the distal extremity. They are NOT seen in atherosclerotic PAD (which shows diffuse disease with no such skip pattern)."],
    ["Q: Why is GSV the preferred conduit for bypass?", "A: (1) Autologous — no rejection. (2) Excellent long-term patency (5-yr > 70% for fem-pop). (3) Resistant to infection. (4) Compliance matches native artery. (5) Endothelium produces prostacyclin. Alternative: PTFE (synthetic) — used above-knee when vein unavailable but poorer below-knee patency."],
    ["Q: Indication for primary amputation in PAD?", "A: (1) Irreversible ischemia (Rutherford Class III — rigor mortis-like, anesthetic, paralysed limb). (2) Overwhelming sepsis/wet gangrene threatening life. (3) Non-ambulatory patient with extensive tissue loss where revascularization is futile. (4) Short life expectancy where risk of revascularization outweighs benefit. Prefer BKA > AKA for rehabilitation."],
  ];

  qas.forEach((qa, i) => {
    const y = 1.07 + i * 1.13;
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.33, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });
    s.addText(qa[0], { x: 0.4, y: y + 0.02, w: 9.2, h: 0.3, fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(qa[1], { x: 0.4, y: y + 0.34, w: 9.2, h: 0.72, fontSize: 11.5, color: C.light, fontFace: "Calibri", valign: "top" });
  });
}

// SLIDE: Viva Q&A Set 3
{
  const s = darkSlide();
  header(s, "VIVA Q&A — SET 3", "Varicose Veins & Investigations");

  const qas = [
    ["Q: Trendelenburg test — technique & interpretation?", "A: With patient supine, elevate leg to drain veins, compress SFJ with finger. Ask patient to stand. FAST FILL from below with finger still on = incompetent perforators. On RELEASING finger — rapid FILLING from above = SFJ incompetent (positive Trendelenburg). Duplex USS is now the gold standard."],
    ["Q: Complications of varicose veins?", "A: Mnemonic BLEEDS: Bleeding (from ruptured vein — direct pressure + leg elevation), Lipodermatosclerosis, Eczema (varicose/gravitational), Edema, DVT (superficial thrombophlebitis), Skin changes (pigmentation, atrophy blanche), Ulceration (venous leg ulcer — gaiter area). Malignant change (Marjolin's ulcer) in chronic non-healing venous ulcers."],
    ["Q: What is the WIFI classification?", "A: Wound-Ischemia-foot Infection system by SVS. Used to classify Chronic Limb-Threatening Ischemia (CLTI). Three domains: W = wound severity (0-3), I = degree of pedal ischemia/perfusion (0-3), FI = foot infection severity (0-3). Higher WIFI score = higher amputation risk. Guides treatment decisions (Sabiston 7e)."],
    ["Q: Difference between dry and wet gangrene?", "A: DRY: Gradual ischemia; mummification; clear demarcation; no infection; no smell; tx = conservative (await demarcation then amputation). WET: Venous + arterial compromise OR infection; edematous, blistering, foul smell; no clear demarcation; sepsis risk; tx = URGENT amputation above line of demarcation + IV antibiotics."],
  ];

  qas.forEach((qa, i) => {
    const y = 1.07 + i * 1.13;
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.33, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });
    s.addText(qa[0], { x: 0.4, y: y + 0.02, w: 9.2, h: 0.3, fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(qa[1], { x: 0.4, y: y + 0.34, w: 9.2, h: 0.72, fontSize: 11.5, color: C.light, fontFace: "Calibri", valign: "top" });
  });
}

// SLIDE: Viva Q&A Set 4
{
  const s = darkSlide();
  header(s, "VIVA Q&A — SET 4", "Surgical Procedures & Anatomy");

  const qas = [
    ["Q: Fogarty embolectomy — describe the steps", "A: (1) LA + sedation usually sufficient. (2) Oblique incision in femoral triangle → expose CFA. (3) Systemic heparin IV. (4) Transverse arteriotomy at CFA bifurcation. (5) Pass Fogarty balloon catheter proximally + distally. (6) Inflate balloon with saline, withdraw to extract thrombus/embolus. (7) Repeat until good back-bleed. (8) Intraoperative angiogram to confirm. (9) Close arteriotomy with 5-0 prolene (patch angioplasty if tight). (10) Fasciotomy if indicated."],
    ["Q: What is Hunter's canal (adductor canal)? Clinical significance?", "A: Fibromuscular tunnel in lower 2/3 of thigh containing SFA, femoral vein, saphenous nerve. Boundaries: anterolateral = vastus medialis, posterior = adductor longus + magnus, anteromedial = sartorius. Significance: SFA most commonly occluded here (most common site of PAD). Femoro-popliteal bypass — SFA harvested via medial incision, popliteal artery accessed at medial knee."],
    ["Q: Name the layers of the arterial wall and which is affected in atherosclerosis?", "A: INTIMA (endothelium + sub-endothelial connective tissue) — primary site of atherosclerosis. MEDIA (smooth muscle cells, elastin, collagen) — smooth muscle migrates to intima in plaque formation. ADVENTITIA (fibroblasts, vasa vasorum, lymphatics). Atherosclerosis: endothelial dysfunction → LDL deposition in intima → foam cells → fibrous plaque → calcification."],
    ["Q: What are the indications for vascular intervention in PAD?", "A: (1) Disabling claudication not responding to 3-6 months conservative therapy. (2) Ischemic rest pain (Fontaine III). (3) Tissue loss / non-healing ulcer / gangrene (Fontaine IV). (4) CLTI — all patients require revascularization if anatomically feasible. Claudication alone (without tissue threat) — conservative first (exercise, risk factor modification, cilostazol)."],
  ];

  qas.forEach((qa, i) => {
    const y = 1.07 + i * 1.13;
    s.addShape(pres.ShapeType.rect, { x: 0.3, y, w: 9.4, h: 0.33, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });
    s.addText(qa[0], { x: 0.4, y: y + 0.02, w: 9.2, h: 0.3, fontSize: 12, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(qa[1], { x: 0.4, y: y + 0.34, w: 9.2, h: 0.72, fontSize: 11.5, color: C.light, fontFace: "Calibri", valign: "top" });
  });
}

// SLIDE: Quick Reference Summary Table
{
  const s = darkSlide();
  header(s, "QUICK REFERENCE — PAD vs. ALI vs. BUERGER'S vs. VARICOSE VEINS", "Summary for viva preparation");

  twoCol(s, [
    ["FEATURE", "PAD (CHRONIC)", "ACUTE LIMB ISCHEMIA", "BUERGER'S DISEASE", "VARICOSE VEINS"],
    ["Age", "50-70 yrs", "Any age (embolic: older)", "20-45 yrs", "30-60 yrs"],
    ["Key RF", "Smoking, DM, HTN, dyslipidemia", "AF, PAD, post-bypass", "TOBACCO (essential)", "Female, pregnancy, family hx"],
    ["Onset", "Gradual (years)", "Sudden (<2 wks)", "Gradual", "Gradual"],
    ["Main symptom", "Claudication → rest pain → ulcer/gangrene", "6 Ps: pain, pallor, pulselessness, paresthesia, paralysis, perishing cold", "Foot claudication, rest pain, finger ulcers", "Aching, heaviness, cosmetic"],
    ["Vessels affected", "Large/medium (atherosclerosis)", "Varies (embolism: bifurcations)", "Small/medium, distal only", "Superficial venous (GSV, SSV)"],
    ["ABI", "<0.9", "Absent signals", "Typically low (distal)", ">0.9 (normal)"],
    ["Key investigation", "CTA / Duplex USS", "CTA / urgent DSA", "DSA (corkscrew collaterals)", "Duplex USS (reflux mapping)"],
    ["Definitive treatment", "Bypass / angioplasty", "Embolectomy / CDT / bypass", "STOP SMOKING", "EVLA / RFA / surgery"],
  ], { colW: [1.6, 2.2, 2.2, 2.2, 1.8], fontSize: 10 });
}

// SLIDE: THANK YOU
{
  const s = pres.addSlide();
  s.background = { color: C.darkNavy };
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.12, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 5.5, w: 10, h: 0.125, fill: { color: C.midBlue }, line: { color: C.midBlue, width: 0 } });
  s.addText("THANK YOU", {
    x: 0.5, y: 1.3, w: 9, h: 1.2,
    fontSize: 44, bold: true, color: C.white, fontFace: "Calibri", align: "center", charSpacing: 8,
  });
  s.addShape(pres.ShapeType.rect, { x: 3, y: 2.55, w: 4, h: 0.05, fill: { color: C.accent }, line: { color: C.accent, width: 0 } });
  s.addText("Peripheral Vascular Disease — Case Presentation\nPG General Surgery Grand Rounds", {
    x: 0.5, y: 2.7, w: 9, h: 0.9,
    fontSize: 16, color: C.gold, fontFace: "Calibri", align: "center",
  });
  s.addText([
    { text: "Key Textbooks Referenced:\n", options: { bold: true, color: C.lightGray, breakLine: true } },
    { text: "Schwartz's Principles of Surgery 11e  |  Bailey & Love's Short Practice of Surgery 28e  |  Sabiston Textbook of Surgery\nCurrent Surgical Therapy 14e  |  Mulholland & Greenfield's Surgery 7e  |  Fischer's Mastery of Surgery 8e", options: { color: C.lightGray } },
  ], {
    x: 0.5, y: 3.7, w: 9, h: 1.0,
    fontSize: 11, fontFace: "Calibri", align: "center",
  });
  s.addText('"The best preparation for tomorrow is doing your best today."', {
    x: 0.5, y: 4.75, w: 9, h: 0.55,
    fontSize: 13, italic: true, color: C.light, fontFace: "Calibri", align: "center",
  });
}

// ─── WRITE FILE ─────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/pvd-ppt/PVD_Case_Presentation_PG_Surgery.pptx" })
  .then(() => console.log("SUCCESS: PVD_Case_Presentation_PG_Surgery.pptx created"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "PG Surgery Answer Bank - Vascular Surgery";

const C = {
  bg: "0B1829", navy: "112540", mid: "1A3D6E",
  accent: "E04030", gold: "F0A000", white: "FFFFFF",
  light: "D0E4F5", gray: "9BB5CE", teal: "1A8B8B",
  green: "27AE60", purple: "7B2FBE",
};

function ds() { const s = pres.addSlide(); s.background={color:C.bg}; return s; }

function hdr(s, t, sub, clr) {
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:0.7,fill:{color:clr||C.mid},line:{color:C.accent,width:3}});
  s.addText(t,{x:0.18,y:0.04,w:9.5,h:0.62,fontSize:20,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});
  if(sub){
    s.addShape(pres.ShapeType.rect,{x:0,y:0.7,w:10,h:0.28,fill:{color:C.accent},line:{color:C.accent,width:0}});
    s.addText(sub,{x:0.18,y:0.7,w:9.5,h:0.28,fontSize:10.5,color:C.white,fontFace:"Calibri",valign:"middle"});
  }
}

function buls(s, items, opts={}) {
  const {x=0.32,y=1.05,w=9.36,h=4.4,fs=13,color=C.light}=opts;
  s.addText(items.map((it,i)=>({
    text: typeof it==="string"?it:it.t,
    options:{
      bullet: typeof it==="object"&&it.sub?{indent:30}:true,
      breakLine: i<items.length-1,
      fontSize: typeof it==="object"&&it.sub?fs-1:fs,
      color: typeof it==="object"&&it.hl?C.gold:color,
      bold: typeof it==="object"&&(it.bold||it.hl)?true:false,
      fontFace:"Calibri",
      indentLevel: typeof it==="object"&&it.sub?1:0,
    }
  })),{x,y,w,h,valign:"top"});
}

function tbl(s, rows, opts={}) {
  const {x=0.3,y=1.0,w=9.4,cw,fs=12}=opts;
  const n = rows[0].length;
  const colW = cw || Array(n).fill(9.4/n);
  s.addTable(rows.map((row,ri)=>row.map((cell,ci)=>({
    text:cell,
    options:{
      bold:ri===0,color:ri===0?C.white:C.light,
      fontSize:fs,fontFace:"Calibri",
      fill:ri===0?{color:C.mid}:ci===0?{color:"0F2035"}:{color:"0A1825"},
      valign:"middle",align:"left",
    }
  }))),{x,y,w,colW,border:{color:C.mid,pt:1},rowH:0.34});
}

function div(title,sub,clr) {
  const s=pres.addSlide(); s.background={color:clr||C.accent};
  s.addShape(pres.ShapeType.rect,{x:0,y:2.4,w:10,h:0.06,fill:{color:C.white},line:{color:C.white,width:0}});
  s.addText(title,{x:0.5,y:1.2,w:9,h:1.1,fontSize:34,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  if(sub) s.addText(sub,{x:0.5,y:2.55,w:9,h:0.8,fontSize:16,color:C.white,fontFace:"Calibri",align:"center"});
}

function box2(s,l,r,opts={}) {
  const {lclr=C.mid,rclr="0F2035",ly=1.05,lh=4.35,lt="",rt=""}=opts;
  s.addShape(pres.ShapeType.rect,{x:0.28,y:ly,w:4.55,h:lh,fill:{color:lclr},line:{color:C.accent,width:1.5}});
  s.addShape(pres.ShapeType.rect,{x:5.0,y:ly,w:4.72,h:lh,fill:{color:rclr},line:{color:C.gold,width:1.5}});
  if(lt) s.addText(lt,{x:0.38,y:ly+0.04,w:4.35,h:0.32,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri"});
  if(rt) s.addText(rt,{x:5.1,y:ly+0.04,w:4.55,h:0.32,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri"});
  s.addText(l.map((it,i)=>({text:typeof it==="string"?it:it.t,options:{bullet:true,breakLine:i<l.length-1,fontSize:12,color:typeof it==="object"&&it.hl?C.gold:C.light,bold:typeof it==="object"&&it.hl,fontFace:"Calibri"}})),{x:0.38,y:ly+(lt?0.38:0.08),w:4.4,h:lh-(lt?0.42:0.12),valign:"top"});
  s.addText(r.map((it,i)=>({text:typeof it==="string"?it:it.t,options:{bullet:true,breakLine:i<r.length-1,fontSize:12,color:typeof it==="object"&&it.hl?C.gold:C.light,bold:typeof it==="object"&&it.hl,fontFace:"Calibri"}})),{x:5.1,y:ly+(rt?0.38:0.08),w:4.55,h:lh-(rt?0.42:0.12),valign:"top"});
}

// ══════════════════════════════════════════════════════════
// TITLE SLIDE
// ══════════════════════════════════════════════════════════
{
  const s=pres.addSlide(); s.background={color:C.bg};
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:0.12,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addShape(pres.ShapeType.rect,{x:0,y:5.5,w:10,h:0.125,fill:{color:C.mid},line:{color:C.mid,width:0}});
  s.addText("PG SURGERY — VASCULAR SURGERY",{x:0.4,y:0.45,w:9.2,h:1.0,fontSize:30,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:3});
  s.addShape(pres.ShapeType.rect,{x:2,y:1.5,w:6,h:0.05,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addText("Detailed Answers — Exam Question Bank",{x:0.4,y:1.6,w:9.2,h:0.55,fontSize:22,color:C.gold,fontFace:"Calibri",align:"center",italic:true});
  s.addText("Prioritised by marks & year-wise frequency",{x:0.4,y:2.2,w:9.2,h:0.45,fontSize:15,color:C.gray,fontFace:"Calibri",align:"center"});
  const topics=[
    ["Q8.1 ★★★","Varicose Veins — Recent Modalities (20M)"],
    ["Q8.2","Recent Advances in Ix & Rx Varicose Veins"],
    ["Q8.3","Laser / Foam / RFA / Surgery for Varicose Veins"],
    ["Q8.4","Anatomical Basis of Tests for Varicose Veins"],
    ["Q8.5","Complications of Varicose Vein Surgery"],
    ["Q8.6","Pathology of DVT"],
    ["Q8.7","Prevention of Post-op DVT"],
    ["Q8.8 ★★","Classification of DVT & Pharmacology (20M)"],
    ["Q8.9","Recent Advances in PVD"],
    ["Q8.10","Recent Advances in Diabetic Foot Mx"],
    ["Q8.11","Lumbar Sympathectomy in PVD"],
    ["Q8.18","Ilizarov's Technique in Buerger's"],
    ["Q8.25 ★","Lymphedema — Pathophysiology, Classi, Mx (20M)"],
    ["Q8.22","What is PVD? Recent Mx Arterial Disease"],
    ["Q13","Trench Foot | Q14 Madura Foot | Q20 Popliteal Cyst"],
  ];
  topics.forEach((t,i)=>{
    const col=Math.floor(i/5); const row=i%5;
    const x=0.3+col*3.1; const y=2.85+row*0.52;
    s.addShape(pres.ShapeType.rect,{x,y,w:3.0,h:0.45,fill:{color:i%2===0?C.mid:"0D1E33"},line:{color:C.accent,width:1}});
    s.addText(`${t[0]}: ${t[1]}`,{x:x+0.08,y,w:2.85,h:0.45,fontSize:9.5,color:C.white,fontFace:"Calibri",valign:"middle"});
  });
  s.addText("Bailey & Love 28e | Schwartz's 11e | Current Surgical Therapy 14e | Sabiston | Fischer's Mastery 8e",{x:0.3,y:5.25,w:9.4,h:0.3,fontSize:9,color:C.gray,fontFace:"Calibri",align:"center"});
}

// ══════════════════════════════════════════════════════════
// SECTION 1: VARICOSE VEINS (★★★ MOST REPEATED)
// ══════════════════════════════════════════════════════════
div("VARICOSE VEINS","Q8.1 ★★★ — 20 Marks | Asked 2017, 2014 | Most Repeated","1A3D6E");

// 1a: Definition, Anatomy, Pathophysiology
{
  const s=ds(); hdr(s,"VARICOSE VEINS — Definition, Anatomy & Pathophysiology","Schwartz's Principles of Surgery 11e | Bailey & Love 28e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Definition","Dilated (>3 mm), tortuous, elongated superficial veins with incompetent valves. Present in ≥10% of general population"],
    ["Primary VV","Intrinsic valve/wall incompetence. Idiopathic. Most common. Risk: female sex, obesity, prolonged standing, family history, pregnancy"],
    ["Secondary VV","Deep venous obstruction (post-DVT), pelvic tumours, AV fistula, pregnancy (IVC compression)"],
    ["Anatomy","Great Saphenous Vein (GSV): medial thigh → saphenofemoral junction (SFJ) 4 cm below & lateral to pubic tubercle. Small Saphenous Vein (SSV): lateral foot → saphenopopliteal junction (SPJ) in popliteal fossa"],
    ["Pathophysiology","Valve incompetence → retrograde flow (reflux) → venous hypertension → wall dilation → more valve incompetence (vicious cycle). SFJ incompetence most common (>80%). Perforator incompetence → connects superficial to deep system"],
    ["Venous HTN consequences","Increased capillary pressure → protein leakage → fibrin cuff → impaired O2 diffusion → skin changes → ulceration"],
    ["CEAP Classification","C0=no disease; C1=telangiectasia; C2=varicose veins; C3=oedema; C4a=pigmentation/eczema; C4b=lipodermatosclerosis; C5=healed ulcer; C6=active ulcer"],
  ],{cw:[2.5,6.9],fs:12});
}

// 1b: Clinical Features & Tests
{
  const s=ds(); hdr(s,"VARICOSE VEINS — Clinical Features & Examination Tests","Anatomical basis for various tests — Bailey & Love 28e");
  tbl(s,[
    ["TEST","TECHNIQUE","ANATOMICAL BASIS","INTERPRETATION"],
    ["Trendelenburg Test","Elevate leg, compress SFJ, stand up — release","SFJ valve competence","Rapid fill on release = SFJ incompetent (positive). Fill from below with finger on = perforator incompetence"],
    ["Tourniquet / Multiple Tourniquet Test","Apply tourniquet at different levels after leg emptied","Localizes level of incompetence","Site below which VVs fill = incompetent perforators at that level"],
    ["Cough Impulse Test","Feel for impulse at SFJ on coughing","↑ pressure transmitted through incompetent SFJ valve","Impulse palpable = SFJ incompetent"],
    ["Morrissey's Test","Patient stands, SFJ palpated, flick distended vein distally","Fluid wave transmission through incompetent valves","Impulse felt at SFJ = valves incompetent in between"],
    ["Perthes' Test","Apply tourniquet mid-thigh, ask patient to walk","Deep vein patency","VVs decrease = deep veins patent. VVs worsen = deep vein occlusion (secondary VV) → CONTRAINDICATION TO SURGERY"],
    ["Duplex Ultrasound","B-mode + Doppler: probe at SFJ/SPJ, Valsalva or calf squeeze","Reflux if retrograde flow >0.5 sec","GOLD STANDARD — replaces all above clinical tests; maps reflux sites & perforators"],
  ],{cw:[2.0,2.5,2.5,2.4],fs:11});
}

// 1c: Recent Modalities - Investigations
{
  const s=ds(); hdr(s,"VARICOSE VEINS — Recent Advances in Investigation","Q8.2: Describe recent advances in Ix of LL varicose veins");
  tbl(s,[
    ["INVESTIGATION","DETAILS & CURRENT STATUS"],
    ["Duplex Ultrasound (Gold Standard)","Colour Doppler + B-mode. Maps: SFJ, SPJ, perforators, deep venous reflux. Detects reflux (>0.5s retrograde) & obstruction. Guides ablation catheter placement. Replaces clinical tests. Mandatory pre-operatively"],
    ["Air Plethysmography (APG)","Quantifies venous reflux, calf pump function, outflow obstruction. Venous Filling Index (VFI), Ejection Fraction (EF), Residual Volume Fraction (RVF). Used in research & complex cases"],
    ["CT/MR Venography","For secondary VVs — identifies pelvic causes (May-Thurner, nutcracker, pelvic venous congestion). MRV preferred (no radiation). CTV if MRV unavailable"],
    ["Intravascular Ultrasound (IVUS)","Used during endovascular treatment of iliac vein obstruction. Superior to venography for iliac stenosis assessment. Gold standard for stent sizing"],
    ["Ambulatory Venous Pressure (AVP)","Direct measurement via foot vein cannula. Definitive test of venous function. Rarely used now (replaced by duplex + APG)"],
    ["Photoplethysmography (PPG)","Infrared light measures skin blood flow changes. Assesses venous refilling time. Simple, non-invasive, but less accurate than duplex"],
    ["D-dimer (if DVT suspected)","High sensitivity, low specificity. Used as screening. If negative + low Wells score → DVT excluded"],
  ],{cw:[3.0,6.4],fs:12});
}

// 1d: Recent Modalities - Treatment ★★★
{
  const s=ds(); hdr(s,"VARICOSE VEINS — Recent Modalities of Treatment","Q8.1 ★★★: Discuss recent modality for Mx of varicose veins (20M) — Schwartz's 11e");
  tbl(s,[
    ["MODALITY","MECHANISM","TECHNIQUE","OUTCOMES / NOTES"],
    ["ENDOVENOUS LASER ABLATION (EVLA/EVLT) ★","Laser energy (810-1470nm) absorbed by blood/vein wall → heat → endothelial damage → fibrosis → occlusion","Duplex-guided puncture of GSV at knee; laser fibre advanced to SFJ; tumescent anaesthesia injected; laser activated on pullback at 3-5 cm/min; BRUISED stocking","1st LINE treatment. 5-yr occlusion 85-95%. Less bruising with longer wavelengths (1470nm). NICE recommends as first choice"],
    ["RADIOFREQUENCY ABLATION (RFA/VNUS Closure) ★","7MHz RF energy → resistive heating → collagen shrinkage → vein wall destruction → fibrosis","ClosureFAST catheter: 7cm heating segments heated to 120°C for 20s each; tumescent LA; post-procedure compression","Equal efficacy to EVLA; less post-op pain & bruising than EVLA; faster return to activity; 5-yr occlusion ~90%"],
    ["FOAM SCLEROTHERAPY","Liquid sclerosant + air/CO2 mixed to foam (Tessari technique) → displaces blood → prolonged endothelial contact → destruction → thrombosis → fibrosis","Ultrasound-guided injection; agents: Polidocanol 1-3%, Sodium tetradecyl sulfate 1-3%; Foam = 1:4 liquid:gas ratio","For recurrent VVs, perforators, SSV, patients unfit for surgery. Less effective for large GSV (62-84% at 5yr). Risk: DVT, visual disturbance, stroke (via PFO)"],
    ["CYANOACRYLATE GLUE (VenaSeal) ★ Recent","N-butyl cyanoacrylate adhesive → mechanically occludes vein + inflammatory reaction","No tumescent anaesthesia needed; no compression stockings required; catheter-based delivery every 3 cm","Excellent 3-yr occlusion (94%). Advantage: No thermal injury, no tumescent, comfortable. Disadvantage: Cost, allergy risk"],
    ["MECHANOCHEMICAL ABLATION (MOCA/ClariVein) ★ Recent","Rotating wire causes mechanical endothelial damage + concurrent sclerosant infusion (polidocanol) → synergistic effect","Rotating catheter at 3500 rpm + liquid sclerosant simultaneously; no tumescent needed","No thermal injury, preserves saphenous nerve. 3-yr occlusion ~85%. Good for tortuous veins"],
    ["OPEN SURGERY (Trendelenburg + Stripping)","Ligation + avulsion","High tie at SFJ; stripping GSV to knee (not calf - saphenous nerve risk); stab avulsions for tributaries","Now reserved for: recurrent disease, failure of endovenous, complex anatomy. 5-yr recurrence 20-30%"],
  ],{cw:[2.5,2.0,2.5,2.4],fs:10.5});
}

// 1e: Complications of surgery
{
  const s=ds(); hdr(s,"VARICOSE VEINS — Complications of Surgery & Management","Q8.5: Complications of varicose vein surgery — Bailey & Love 28e");
  box2(s,
    [
      {t:"INTRAOPERATIVE",hl:true},
      "Haemorrhage — SFJ tributaries, femoral vein injury",
      "Lymphatic injury → lymphocoele / lymph fistula",
      "Femoral artery / nerve injury (deep dissection)",
      "DVT (uncommon, LMWH prophylaxis given)",
      {t:"EARLY POST-OP",hl:true},
      "Haematoma — along stripping track",
      "Wound infection (groin most common)",
      "Saphenous nerve injury → numbness medial calf/leg (if stripped below knee)",
      "Sural nerve injury → numbness lateral foot (SSV surgery)",
    ],
    [
      {t:"LATE COMPLICATIONS",hl:true},
      "Recurrence (20-30% at 5 yrs) — neovascularization at SFJ (CHIVA, redo surgery)",
      "Deep vein thrombosis → PE (rare, 0.3-0.5%)",
      "Lymphoedema — if lymphatics disrupted at groin",
      "Thrombophlebitis — of residual tributaries",
      "Skin necrosis — if stripping subcutaneous",
      {t:"SPECIFIC TO ENDOVENOUS",hl:true},
      "Thermal injury to skin / nerves (EVLA/RFA)",
      "Endovenous heat-induced thrombosis (EHIT) — thrombus at SFJ → anticoagulate",
      "Skin burns, pigmentation (foam sclerotherapy)",
      "Visual disturbance / TIA with foam (right-to-left shunt via PFO)",
    ],
    {lt:"INTRA/EARLY",rt:"LATE / SPECIFIC",lclr:"1A3D5E",rclr:"1E1A3E",ly:1.05,lh:4.35}
  );
}

// ══════════════════════════════════════════════════════════
// SECTION 2: DVT
// ══════════════════════════════════════════════════════════
div("DEEP VEIN THROMBOSIS","Q8.6-8.8 ★★ — 20 Marks | Pathology, Prevention, Classification, Pharmacology","1A3D6E");

// 2a: Pathology of DVT
{
  const s=ds(); hdr(s,"PATHOLOGY OF DVT","Q8.6: Pathology of DVT — Bailey & Love 28e | Schwartz's 11e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Virchow's Triad (pathogenesis)","(1) STASIS — immobility, cardiac failure, post-op, pregnancy, long flights. (2) HYPERCOAGULABILITY — malignancy, OCP, thrombophilia (Factor V Leiden, Protein C/S deficiency, Antiphospholipid syndrome). (3) ENDOTHELIAL INJURY — surgery, trauma, catheter, chemotherapy. All three not required — any combination sufficient"],
    ["Sites of origin","Deep calf veins (tibial, peroneal) → 90% origin. Propagates proximally → popliteal → femoral → iliac → IVC. Iliofemoral DVT → highest PE risk"],
    ["Macroscopic pathology","Red thrombus (fibrin + RBCs + platelets) attached to vessel wall at origin (white head) with propagating tail (red)"],
    ["Microscopic pathology","Lines of Zahn in organized thrombus (alternating pale platelet/fibrin & dark RBC layers). PMN infiltration initially → organization → fibrosis → recanalization"],
    ["Natural history","1. Complete lysis (rare). 2. Recanalization — partial restoration of lumen (leads to post-thrombotic syndrome). 3. Propagation → PE. 4. Organization & fibrosis → permanent valve destruction → chronic venous insufficiency"],
    ["Post-thrombotic syndrome (PTS)","Valve destruction → chronic venous hypertension → edema, pain, hyperpigmentation, lipodermatosclerosis, venous ulceration. Villalta score grades severity"],
    ["PE risk","Proximal DVT (iliofemoral) → 50% risk of PE if untreated. Calf DVT → 20% propagate proximally. Massive PE → RV failure → haemodynamic collapse → death"],
  ],{cw:[2.8,6.6],fs:12});
}

// 2b: Classification of DVT
{
  const s=ds(); hdr(s,"CLASSIFICATION OF DVT","Q8.8 ★★: Classify DVT — by site, extent, severity — Bailey & Love 28e");
  tbl(s,[
    ["CLASSIFICATION","TYPES & DETAILS"],
    ["BY SITE","Calf (distal) DVT: Below popliteal; lower PE risk; treat with anticoagulation 3 months. Proximal DVT: Popliteal or above; high PE risk — full anticoagulation mandatory. Iliofemoral DVT: Highest risk; may need thrombolysis/CDT + stenting"],
    ["BY EXTENT / PRESENTATION","Isolated calf. Femoropopliteal. Iliofemoral. Caval thrombosis (IVC). Bilateral DVT — consider malignancy"],
    ["SPECIAL FORMS","Phlegmasia Alba Dolens ('white leg'): Massive femoral vein thrombosis → severe oedema, white pale limb, painful. Phlegmasia Cerulea Dolens ('blue leg'): Near-total venous occlusion → cyanosis, extreme pain, impending venous gangrene → emergency thrombectomy/thrombolysis. URGENCY: Venous gangrene can occur if untreated"],
    ["BY AETIOLOGY","Provoked: Surgery, trauma, immobilisation, OCP, pregnancy — lower recurrence risk. Unprovoked (idiopathic): No clear cause — higher recurrence risk, screen for malignancy, thrombophilia. Cancer-associated: Treat with LMWH long-term or DOAC (rivaroxaban)"],
    ["Wells Score (2-level)","≥2 = DVT likely → Duplex USS immediately. <2 = DVT unlikely → D-dimer → if positive, duplex USS. Wells criteria: active cancer, immobility, surgery, local tenderness, whole leg swollen, calf >3cm larger, pitting oedema, collateral veins, previous DVT (each = 1 point). Alternative diagnosis as likely = -2"],
    ["Investigations","D-dimer (screening — high sensitivity), Duplex USS (gold standard — sensitivity 94-99% proximal DVT), CT venography (pelvic/IVC), MR venography. Thrombophilia screen BEFORE anticoagulation"],
  ],{cw:[2.5,6.9],fs:12});
}

// 2c: DVT Prevention
{
  const s=ds(); hdr(s,"PREVENTION OF POST-OPERATIVE DVT","Q8.7: Preventive measures — Bailey & Love 28e");
  tbl(s,[
    ["RISK LEVEL","EXAMPLES","PROPHYLAXIS"],
    ["LOW RISK","Minor surgery <30 min, age <40, no other RF","Early mobilisation + adequate hydration only"],
    ["MODERATE RISK","Major surgery, age 40-60, no other RF; Minor surgery + additional RF","LMWH (enoxaparin 20mg OD or 40mg OD) + Graduated compression stockings (TED stockings) + Early mobilisation"],
    ["HIGH RISK","Hip/knee replacement, pelvic cancer surgery, major trauma, previous DVT, thrombophilia, age >60","LMWH (enoxaparin 40mg OD) + IPC (intermittent pneumatic compression) devices + TED stockings. Extended prophylaxis 28 days for hip/knee arthroplasty"],
    ["MECHANICAL METHODS","All patients unless contraindicated","TED Stockings (18 mmHg at ankle): reduce stasis. IPC (Sequential Compression Devices): rhythmic calf compression mimics muscle pump. Foot pumps. Anti-embolism stockings NOT for PAD or neuropathy"],
    ["PHARMACOLOGICAL","As per risk","LMWH (enoxaparin, dalteparin, tinzaparin): Inhibit factor Xa, some IIa. Safe, predictable, no routine monitoring. UFH: Multiple daily injections, monitor APTT, risk HIT. Fondaparinux: Indirect Xa inhibitor, once daily. NOACs (rivaroxaban, apixaban): Oral, for hip/knee arthroplasty prophylaxis"],
    ["SPECIAL SITUATIONS","Contraindicated anticoagulation","IVC filter (retrievable): For high-risk patients who cannot be anticoagulated. NOT routine. Retrieve once anticoagulation safe to resume"],
    ["INTRAOPERATIVE","Regional vs. general anaesthesia","Spinal/epidural anaesthesia: reduces DVT risk (better perfusion, less venous stasis). Minimize tourniquet time. Careful positioning"],
  ],{cw:[2.0,2.5,5.0],fs:11.5});
}

// 2d: Pharmacological basis
{
  const s=ds(); hdr(s,"PHARMACOLOGICAL BASIS OF DRUGS USED IN DVT TREATMENT","Q8.8 ★★(20M): Pharmacological basis — Bailey & Love 28e | Schwartz's 11e");
  tbl(s,[
    ["DRUG","CLASS / MECHANISM","DOSE","NOTES"],
    ["Unfractionated Heparin (UFH)","Binds antithrombin III → ↑ 1000x inhibition of IIa (thrombin) & Xa. Also inhibits IXa, XIa","80 U/kg IV bolus → 18 U/kg/hr infusion. Target APTT 60-100s (1.5-2.5x normal)","Immediate action. Reversible with protamine. Monitor APTT. Risk: HIT (heparin-induced thrombocytopenia — type II, day 5-10, use argatroban)"],
    ["LMWH (Enoxaparin, Dalteparin)","Selectively inhibit Factor Xa (anti-Xa:anti-IIa ratio 4:1). More predictable PK","Enoxaparin: Treatment = 1mg/kg SC BD or 1.5mg/kg OD. Prophylaxis = 40mg OD","No routine monitoring (anti-Xa if renal failure, obesity, pregnancy). Partially reversible by protamine. Avoid if CrCl <15 ml/min"],
    ["Fondaparinux","Synthetic pentasaccharide → binds AT-III → selective indirect factor Xa inhibitor. NO anti-IIa activity","2.5mg SC OD (prophylaxis); 5-10mg OD (treatment, wt-based)","No HIT risk. Not reversible. Avoid in CKD. Once daily. Can use if HIT history"],
    ["Warfarin (Vitamin K antagonist)","Inhibits carboxylation of Vitamin K-dependent factors II, VII, IX, X, Protein C & S","Start day 1 with heparin bridge. Target INR 2.0-3.0 (DVT/PE). Duration: Provoked 3 months; unprovoked 6 months-lifelong","Multiple interactions (CYP450). Slow onset 3-5 days. Reverse with Vitamin K / FFP / PCC. Monitor INR"],
    ["Rivaroxaban (Xarelto)","Direct factor Xa inhibitor (binds active site of Xa). Oral bioavailability 66-100%","DVT/PE: 15mg BD x21 days → 20mg OD with food","NOAC: No monitoring, fewer interactions. VTE: 10mg OD for prophylaxis (hip/knee). Reverse with Andexanet alfa"],
    ["Apixaban (Eliquis)","Direct factor Xa inhibitor. Better renal clearance profile than rivaroxaban","10mg BD x7d → 5mg BD for DVT/PE","Less GI bleeding than rivaroxaban. Preferred in GI risk patients. Reverse with Andexanet alfa"],
    ["Dabigatran (Pradaxa)","Direct thrombin (IIa) inhibitor. Pro-drug dabigatran etexilate → dabigatran","150mg BD after 5-10 days LMWH (PE/DVT). 110mg BD in elderly/renal","Only NOAC reversed by specific antidote: Idarucizumab (Praxbind). Renal clearance 80% — avoid CrCl <30"],
    ["Alteplase / Streptokinase","Thrombolytics: Activate plasminogen → plasmin → lyses fibrin clot","CDT (catheter-directed): rtPA 0.5-1mg/hr over 12-24h for massive iliofemoral DVT or massive PE","Systemic thrombolysis for massive PE with haemodynamic compromise. Risk: Major bleeding including ICH (~2%)"],
  ],{cw:[2.0,2.8,1.8,2.8],fs:10.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 3: DIABETIC FOOT
// ══════════════════════════════════════════════════════════
div("DIABETIC FOOT","Q8.10: Recent Advances in Management — Current Surgical Therapy 14e","1A3D6E");

{
  const s=ds(); hdr(s,"DIABETIC FOOT — Pathophysiology & Classification","Current Surgical Therapy 14e | Sabiston Textbook of Surgery");
  tbl(s,[
    ["COMPONENT","DETAILS"],
    ["Triad","NEUROPATHY + ISCHEMIA + INFECTION — the three pillars of diabetic foot pathology"],
    ["Neuropathy (60-70%)","Sensorimotor: Loss of protective sensation → pressure ulcers, Charcot joints, deformity. Autonomic: Dry skin → fissures; arteriovenous shunting → warm foot but ischemic tissues. Motor: Intrinsic muscle wasting → claw/hammer toe deformity → abnormal pressure distribution"],
    ["Ischemia (PVD, 50%)","Atherosclerosis affects tibial/pedal vessels preferentially in DM (unlike non-DM PAD). 50% of diabetic foot ulcers have PAD. ABI unreliable (calcification) → use TOE BRACHIAL INDEX (TBI <0.7 = ischemia). CTA/MRA for revascularization planning"],
    ["Infection","Most dangerous component driving amputation. Polymicrobial: Staph aureus, Streptococcus, Gram-negatives, anaerobes. Probe-to-bone test: touches bone → osteomyelitis (PPV 89%). X-ray: late osteomyelitis. MRI: investigation of choice for osteomyelitis"],
    ["Wagner Classification","Grade 0: Intact skin, pre-ulcer lesion. Grade 1: Superficial ulcer. Grade 2: Deep ulcer to tendon/capsule/bone. Grade 3: Deep ulcer + abscess/osteomyelitis. Grade 4: Forefoot gangrene. Grade 5: Whole foot gangrene"],
    ["WIfI Classification (Current)","Wound (0-3) + Ischemia (0-3) + Foot Infection (0-3) → 64 permutations → predicts amputation risk & benefit of revascularization. Superior to Wagner. SVS recommended"],
    ["SINBAD Score","Site + Ischemia + Neuropathy + Bacterial infection + Area + Depth → 0-6 score. Used in resource-limited settings"],
  ],{cw:[2.5,6.9],fs:12});
}

{
  const s=ds(); hdr(s,"DIABETIC FOOT — Recent Advances in Management","Q8.10: Recent advances in Mx of diabetic foot — Current Surgical Therapy 14e");
  tbl(s,[
    ["MODALITY","DETAILS"],
    ["Multidisciplinary Team (MDT) ★","Diabetologist + Vascular surgeon + Orthopaedic surgeon + Podiatrist + Infectious disease + Plastic surgery. MDT approach reduces major amputation rate by 49-85%"],
    ["Advanced Wound Dressings","VAC therapy (NPWT/Negative Pressure Wound Therapy): -125 mmHg promotes granulation, reduces bacterial load, removes exudate. Collagen/alginate dressings. Bioengineered skin substitutes (Dermagraft, Apligraf). Growth factor-impregnated dressings (PDGF = becaplermin/Regranex — FDA approved)"],
    ["Pressure Off-loading ★","Total Contact Cast (TCC): Gold standard for neuropathic plantar ulcers. Instant TCC. Removable cast walker. Custom therapeutic footwear. Off-loading essential for healing — without it, 90% fail to heal"],
    ["Revascularization","Endovascular (PTA, drug-coated balloon, drug-eluting stent for infrapopliteal): First-line for tibial disease. Bypass (GSV to pedal artery — dorsalis pedis bypass): For CLTI with target vessel. Angiosome-directed revascularization: Revascularize artery feeding wound angiosome"],
    ["Hyperbaric Oxygen Therapy (HBOT)","2-2.5 atm O2 × 90 min × 20-40 sessions → ↑ tissue O2, ↑ angiogenesis, ↑ leucocyte function, bactericidal for anaerobes. Used for Wagner grade 3-4 with adequate perfusion. NICE: adjunct only"],
    ["Maggot Debridement Therapy (MDT/Biosurgery)","Lucilia sericata (green bottle fly) larvae: selective debridement (secrete collagenase), bactericidal (lyse MRSA), stimulate granulation. Contained in mesh pouch. Evidence: faster debridement than sharp"],
    ["Stem Cell Therapy ★ Recent","Autologous bone marrow-derived or adipose-derived MSCs injected into ischemic tissue → angiogenesis, paracrine healing. Phase II/III trials ongoing. Promising for no-option CLTI"],
    ["Gene Therapy","Vascular endothelial growth factor (VEGF) gene delivery → therapeutic angiogenesis. HIF-1α gene therapy. Still investigational. NV1FGF (fibroblast growth factor gene): failed Phase III"],
    ["Bioelectric Stimulation","Electrical stimulation of wound → promotes granulation, reduces bacteria. Used as adjunct"],
    ["Prevention","Annual foot exam, HbA1c <7%, custom footwear, patient education, podiatry — most cost-effective intervention"],
  ],{cw:[2.5,6.9],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 4: LUMBAR SYMPATHECTOMY
// ══════════════════════════════════════════════════════════
div("LUMBAR SYMPATHECTOMY IN PVD","Q8.11: Role in Treatment of PVD — Schwartz's 11e | Bailey & Love 28e","1A3D6E");

{
  const s=ds(); hdr(s,"LUMBAR SYMPATHECTOMY IN PVD","Q8.11: Role of lumbar sympathectomy in Rx of PVD — Schwartz's 11e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Anatomy","Lumbar sympathetic chain: L1-L4 ganglia on anterolateral surface of lumbar vertebrae. L2, L3 ganglia most important for lower limb vasomotion. Removal of L2-L4 ganglia → denervation → vasodilation of skin vessels of foot & calf"],
    ["Mechanism of action","Removes sympathetic vasoconstriction → relative vasodilation → increased skin blood flow (NOT muscle blood flow). Effect is temperature-dependent: skin warming, reduced sweating. Does NOT increase total limb blood flow significantly in atherosclerotic disease (muscle vessels already maximally dilated)"],
    ["INDICATIONS (Current — limited role)","1. INOPERABLE (Buerger's disease — no target vessel for bypass). 2. Vasospastic conditions: Raynaud's phenomenon (2nd line after CCB). 3. Causalgia / reflex sympathetic dystrophy. 4. Hyperhidrosis. 5. Rest pain in patients unfit for revascularization. 6. As ADJUNCT to revascularization for tissue perfusion"],
    ["Contraindications","Calcified/rigid arteries (sympathectomy has no vasodilatory effect). Extensive fixed atheromatous disease. Diabetic neuropathy already has autosympathectomy"],
    ["Procedures","SURGICAL (Open): Flank retroperitoneal approach; excise L2, L3, L4 ganglia. LAPAROSCOPIC (now preferred): Retroperitoneoscopic approach — faster recovery, less pain. CHEMICAL (Phenol injection): Fluoroscopy/CT-guided; phenol 6% injected at L2-L4; Used if patient unfit for GA. RADIOFREQUENCY ABLATION: CT-guided percutaneous RF ablation of ganglia"],
    ["Results / Evidence","Improvement in rest pain: 60-70% short-term. Improvement in healing of minor tissue loss: 40-50%. DOES NOT improve claudication (muscle blood flow not improved). Long-term: Sympathetic re-innervation occurs over 12-18 months → effect wanes"],
    ["Complications","Ejaculatory failure (bilateral L1 sympathectomy → damage presacral nerve/superior hypogastric plexus). Genitofemoral neuralgia (burning thigh pain — temporary). Postural hypotension. Lymphatic injury"],
  ],{cw:[2.5,6.9],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 5: RECENT ADVANCES IN PVD
// ══════════════════════════════════════════════════════════
div("RECENT ADVANCES IN PVD","Q8.9 | Q22: What is PVD? Describe recent Mx of arterial disease of limbs","1A3D6E");

{
  const s=ds(); hdr(s,"RECENT ADVANCES IN PVD — Endovascular Innovations","Q8.9 & Q22: Recent Mx of arterial disease of limbs (2016, 20M)");
  tbl(s,[
    ["ADVANCE","DETAILS"],
    ["Drug-Coated Balloon (DCB) ★","Paclitaxel-coated balloon catheter → PTA + sustained drug release → inhibits neointimal hyperplasia → reduces restenosis. Lutonix, IN.PACT balloons. RCT (IN.PACT SFA): 82% patency at 3 yrs vs. 55% plain PTA. Concerns: Mortality signal with paclitaxel (FDA investigation — now largely resolved). Also used for infrapopliteal (below-knee) disease"],
    ["Drug-Eluting Stent (DES)","Paclitaxel/zotarolimus-eluting stents for SFA. Zilver PTX: 79.9% primary patency at 2 yrs vs. 62.7% bare metal. Interwoven stents (Supera) for SFA — resist deformation. Bioresorbable scaffolds: Investigational"],
    ["Covered Stents (PTFE-covered)","For aortoiliac disease: Covered stents (iCAST, Viabahn) reduce restenosis vs. bare metal in iliac arteries. Viabahn for long SFA occlusions"],
    ["Intravascular Lithotripsy (IVL)","Shockwave IVL (Shockwave Medical): Sonic pressure waves fracture intimal & medial calcification → vessel compliance → better PTA/stent result. Game-changing for heavily calcified lesions. FDA approved 2021"],
    ["Atherectomy Devices","Directional (Silverhawk/Turbohawk): Plaque excision. Orbital (CSI): Differentially sanding calcified plaque. Rotational (Rotarex): For in-stent restenosis. Laser (CVX-300 Excimer): Ablates plaque. All used before PTA/stenting in heavily diseased segments"],
    ["CLTI/WIFI-guided Limb Salvage","Wound, Ischemia, foot Infection (WIfI) score guides: whether to amputate or revascularize, level of amputation, benefit of revascularization. Combined with angiosome theory for targeted perfusion"],
    ["Hybrid Procedures","Combined open surgery + endovascular: e.g., CFA endarterectomy + iliac stenting or SFA PTA in same sitting. Allows treatment of multilevel disease in single anaesthetic"],
    ["Prosthetic Graft Advances","Heparin-bonded PTFE (Propaten): Improved below-knee bypass patency. Silver-coated grafts for infected fields. Biologic scaffolds (Omniflow II bovine ureteric) for infection-resistant bypass"],
    ["TCAR (Transcarotid Artery Revascularization)","Recent carotid artery stenting technique with flow reversal for neuroprotection — applicable to PVD patients with carotid disease"],
    ["DSA (Digital Subtraction Angiography)","Gold standard for imaging + intervention. CO2 angiography for CKD patients (avoids iodinated contrast). 3D rotational angiography for complex anatomy"],
  ],{cw:[2.8,6.6],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 6: LYMPHEDEMA
// ══════════════════════════════════════════════════════════
div("LYMPHEDEMA","Q8.25 ★ — 20 Marks (2020): Pathophysiology, Classification & Management","1A3D6E");

{
  const s=ds(); hdr(s,"LYMPHEDEMA — Pathophysiology & Classification","Q8.25 (20M, 2020): Current Surgical Therapy 14e | Bailey & Love 28e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Definition","Chronic progressive disease: failure of lymphatic transport capacity → interstitial accumulation of protein-rich fluid → fibrosis → elephantiasis"],
    ["Pathophysiology","Lymphatic obstruction/insufficiency → lymph stasis → ↑ oncotic pressure → oedema → CD4+ cell-mediated inflammation → progressive fibrosis of lymphatics → valve incompetence → further stasis. Fibroadipose deposition in subcutaneous tissue. Recurrent cellulitis/lymphangitis exacerbates fibrosis"],
    ["PRIMARY (Developmental)","MILROY's DISEASE (congenital lymphedema): Mutation FLT4 (VEGFR3); presents at birth; bilateral leg oedema; 10-25% of primary. LYMPHEDEMA PRAECOX (Meige's disease): Most common (80%); onset puberty-35 yrs; female > male; unilateral; most common form overall. LYMPHEDEMA TARDA: Onset >35 yrs; rare; must exclude secondary cause"],
    ["SECONDARY (Acquired) — Most common worldwide","FILARIASIS (Wuchereria bancrofti): Most common cause worldwide; affects tropical regions; adult worms in lymphatics → obstruction → elephantiasis. POST-MALIGNANCY: Breast cancer (axillary clearance), pelvic cancer (groin dissection). POST-RADIOTHERAPY: Fibrosis of lymphatics. POST-INFECTION/CELLULITIS: Repeated episodes destroy lymphatics. POST-TRAUMA/SURGERY. MALIGNANT INFILTRATION"],
    ["ISL Staging","Stage 0 (Latent): Impaired transport, no oedema. Stage 1 (Reversible): Pitting oedema, subsides with elevation. Stage 2 (Irreversible): Pitting → non-pitting; does not resolve with elevation alone. Stage 3 (Elephantiasis): Non-pitting, massive, fibrosis, trophic skin changes (acanthosis, hyperkeratosis, papillomatosis)"],
    ["Investigations","Lymphoscintigraphy (Gold standard): Tc-99m nanocolloid injection → maps lymphatic channels & nodes. ICG lymphography (Indocyanine green): Near-infrared imaging; identifies lymphatic anatomy before surgery. MR lymphangiography: Non-invasive, no radiation. Duplex USS: Exclude venous cause. Bioimpedance spectroscopy: Early detection, quantifies extracellular fluid"],
    ["Complications","Recurrent cellulitis/lymphangitis. Skin changes: papillomatosis, verrucous hyperplasia. Stewart-Treves syndrome: Lymphangiosarcoma — rare but highly aggressive malignancy in chronic lymphedema (classically post-mastectomy arm). Psychosocial impact"],
  ],{cw:[2.5,6.9],fs:11.5});
}

{
  const s=ds(); hdr(s,"LYMPHEDEMA — Management","Q8.25 (20M): Complete Decongestive Therapy & Surgical Options — Current Surgical Therapy 14e");
  tbl(s,[
    ["MODALITY","DETAILS"],
    ["COMPLETE DECONGESTIVE THERAPY (CDT) — Gold Standard Conservative Rx ★","Phase 1 (Intensive): Manual Lymphatic Drainage (MLD) by trained therapist daily × 2-4 wks + Multi-layer short-stretch bandaging (24 hrs/day) + Skin care (moisturiser, antifungals) + Exercise (activates muscle pump). Phase 2 (Maintenance): Compression garments (20-40 mmHg) lifelong + Self-MLD + Exercise"],
    ["Compression Garments","Class I: 14-17 mmHg (mild). Class II: 18-24 mmHg (moderate). Class III: 25-35 mmHg (severe). Class IV: >35 mmHg (very severe). Must be worn lifelong"],
    ["Intermittent Pneumatic Compression (IPC)","Sequential pneumatic compression sleeves — augments CDT. Used at home as maintenance"],
    ["SURGICAL OPTIONS — PHYSIOLOGICAL (Lymphatic Reconstruction) ★","LYMPHATICOVENULAR ANASTOMOSIS (LVA/LVA): Supermicrosurgery (0.3-0.8mm vessels); lymphatic-to-venule end-to-end anastomosis under 40x magnification; Best results in early disease (Stage 1-2); reduction in volume 40-60%. VASCULARISED LYMPH NODE TRANSFER (VLNT): Harvest lymph node flap (inguinal, submental, lateral thoracic) with artery+vein; transfer to axilla/groin; induces lymphangiogenesis; Combined with LVA (LYMPHA procedure at mastectomy)"],
    ["SURGICAL OPTIONS — EXCISIONAL (Debulking) ★","CHARLES OPERATION: Radical excision of all subcutaneous tissue down to deep fascia; skin grafting with excised dermis or SSG; for massive/stage 3 disease. HOMANS' OPERATION (Modified Thompson): Staged excision + subfascial flaps buried to restore lymphatic drainage. SISTRUNK'S OPERATION: For localized disease; excision of skin + subcutaneous tissue in stages"],
    ["Medical — Benzopyrones","Coumarin (benzopyrone): Stimulates macrophage proteolysis of lymph proteins → reduces protein concentration → reduces fibrosis. Limited evidence. Diosmin: Widely used in Europe"],
    ["Anti-filarial therapy","DEC (Diethylcarbamazine) + Albendazole: WHO mass drug administration. Kills microfilariae; adult worms: Doxycycline (anti-Wolbachia). Does not reverse established lymphoedema but prevents progression"],
    ["PREVENTION","Sentinel lymph node biopsy instead of ALND. LYMPHA (LYmPHatic microsurgical Preventive Healing Approach): Immediate LVA at time of axillary clearance → prevents breast cancer-related lymphoedema"],
  ],{cw:[2.8,6.6],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 7: BUERGER'S DISEASE & ILIZAROV
// ══════════════════════════════════════════════════════════
div("BUERGER'S DISEASE & ILIZAROV TECHNIQUE","Q8.24 (Mx of TAO) | Q8.18: Ilizarov's Technique — Schwartz's 11e","1A3D6E");

{
  const s=ds(); hdr(s,"BUERGER'S DISEASE (TAO) — Management & Ilizarov's Technique","Q8.24 Mx of TAO | Q8.18: Ilizarov's technique in Buerger's disease — Schwartz's 11e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Diagnosis (Mills/Pope criteria)","Age <45 yrs. Current/recent tobacco use. Infrapopliteal or distal upper extremity ischemia (occlusive disease). Absence of: DM, hyperlipidaemia, HTN, thromboembolism, autoimmune disease. Consistent arteriographic findings: segmental occlusions, skip lesions, corkscrew collaterals"],
    ["Angiographic findings (Pathognomonic)","Disease confined to distal circulation (below popliteal & distal brachial). Segmental occlusions with SKIP LESIONS. CORKSCREW COLLATERALS (helical, spiral). Smooth vessel wall (no atherosclerotic calcification). All four limbs affected (angiograph all four even if asymptomatic)"],
    ["SMOKING CESSATION ★ (Most Important)","Single most effective treatment. Oregon HSC data: no disease progression after tobacco cessation. Limb loss 67% (continued smokers) vs. 35% (quit smoking) over 15 yrs. Must include ALL tobacco forms: cigarette, bidi, chewing, smokeless tobacco. Nicotine replacement/bupropion/varenicline adjuncts"],
    ["Medical Management","ILOPROST (Prostacyclin analogue) ★: IV infusion 0.5-2ng/kg/min × 6 hrs/day × 14-28 days → vasodilation + antiplatelet + angiogenesis. Best evidence for rest pain & ulcer healing in TAO. PGE1 (alprostadil): Similar mechanism. Calcium channel blockers: For Raynaud's component. Antiplatelet: Aspirin/clopidogrel. Statins: Anti-inflammatory; may have role"],
    ["Surgical Management","Bypass surgery: Rarely feasible (no target vessel, limited vein due to migratory phlebitis). When feasible: autogenous vein only. Sympathectomy: Chemical or laparoscopic lumbar sympathectomy — modest benefit for rest pain. Amputation: 31% over 15 yrs in quitters; 67% in smokers — ray/toe/BKA"],
    ["ILIZAROV TECHNIQUE in Buerger's Disease ★★ (2023 asked)","MECHANISM: Distraction osteogenesis → new bone formation + NEOVASCULARIZATION at distraction site. Tension stress principle (Ilizarov law). Creates new vessels that supply ischemic tissue distal to occlusion. PROCEDURE: Bifocal or trifocal corticotomy of tibia/fibula. Ilizarov ring external fixator applied. Distraction at 1mm/day (4×0.25mm). New bone forms in distraction gap → extensive neovascular network. OUTCOME: ↑ Skin perfusion pressure, ↑ TcPO2, ulcer healing, rest pain relief, limb salvage in no-option cases. Studies: 70-85% ulcer healing, significant limb salvage. Advantage: Works where no target vessel — bypasses need for conventional bypass"],
    ["Bone Marrow Aspirate Concentrate (BMAC)","Autologous BMC injection into ischemic muscle → angiogenesis via MSCs & growth factors. Used as adjunct or alone in no-option cases. Evidence mounting"],
    ["Spinal Cord Stimulation (SCS)","Epidural electrode at T9-T10 → inhibits sympathetic vasoconstriction via dorsal horn → skin vasodilation. Pain relief in 70-80%. Used for inoperable CLTI & Buerger's"],
  ],{cw:[2.5,6.9],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SECTION 8: MISC TOPICS
// ══════════════════════════════════════════════════════════
div("MISCELLANEOUS TOPICS","Trench Foot | Madura Foot | Popliteal Cyst | Filariasis | Post-thrombotic Claudication","1A3D6E");

{
  const s=ds(); hdr(s,"TRENCH FOOT, MADURA FOOT & POPLITEAL CYST","Q13, Q14, Q20 — Bailey & Love 28e | Schwartz's 11e");
  tbl(s,[
    ["TOPIC","DEFINITION","PATHOLOGY","FEATURES","MANAGEMENT"],
    ["TRENCH FOOT (Non-freezing cold injury)","Tissue damage from prolonged cold + wet + constriction. T > 0°C (unlike frostbite)","Peripheral vasoconstriction → endothelial damage → microvascular thrombosis → tissue necrosis. No ice crystal formation","Numbness, paresthesia, cold pale/mottled foot → on rewarming: intense pain, hyperemia, blistering, oedema, necrosis. Hyperhydrosis persists long-term","Remove wet footwear, gentle rewarming (NOT rapid), elevation, analgesia, wound care. Prevention: Dry socks, regular boot removal (WW1 prevention). Antibiotics if infected. Late: Chronic neuropathic pain — gabapentin"],
    ["MADURA FOOT (Mycetoma)","Chronic granulomatous infection of foot. 2 types: EUMYCETOMA (fungal, most common worldwide — Madurella mycetomatis) and ACTINOMYCETOMA (bacterial — Nocardia, Actinomadura)","Triad: (1) Subcutaneous swelling, (2) Discharging sinuses, (3) Grains/granules in discharge. Granules: black (Madurella), white/yellow (Actinomadura)","Painless swelling of foot/ankle → multiple sinuses → discharge of granules → bone destruction → deformity. Rural farmers/workers. India endemic (Madura, Tamil Nadu)","Actinomycetoma: Cotrimoxazole + amikacin/rifampicin (prolonged, 6-12 months). Eumycetoma: Itraconazole/voriconazole (prolonged). Surgery: Wide excision for localized. Amputation if extensive bone destruction. MRI for extent. NO steroids"],
    ["POPLITEAL CYST (Baker's Cyst)","Fluid-filled synovial cyst in popliteal fossa — communicates with knee joint via medial gastrocnemius bursa","Increased intra-articular pressure → fluid herniation through posterior capsule between medial head gastrocnemius & semimembranosus tendons","Fluctuant swelling in popliteal fossa. Asymptomatic or aching knee. Transilluminates. Foucher's sign: Harder on extension. Complication: Rupture → 'pseudo-thrombophlebitis' (sudden calf pain, swelling — DD: DVT)","Treat underlying cause (OA, RA, meniscal tear). Aspiration ± steroid injection. Arthroscopic treatment of underlying pathology (meniscectomy). Open excision for persistent/symptomatic. Ruptured cyst: NSAIDS + elevation (NOT anticoagulation unless DVT confirmed on Doppler)"],
  ],{cw:[1.6,1.8,1.8,2.0,2.2],fs:10.5});
}

{
  const s=ds(); hdr(s,"FILARIASIS IN LOWER LIMB & POST-THROMBOTIC CLAUDICATION","Q21: Filariasis in LL | Q8.6: Post-thrombotic/Intermittent Claudication (2022, 10M)");
  tbl(s,[
    ["TOPIC","DETAILS"],
    ["FILARIASIS (Wuchereria bancrofti) — LL","Transmission: Culex mosquito. Microfilariae → adult worms in lymphatics → obstruction → lymphedema → elephantiasis. Incubation 6-12 months. Stages: (1) Asymptomatic microfilaremia. (2) Acute: Fever + lymphangitis + lymphadenitis (ADLA episodes). (3) Chronic: Lymphedema → elephantiasis of leg, scrotum, vulva. Blood smear (nocturnal — 10pm-2am) for microfilariae. ICT antigen test. Tropical pulmonary eosinophilia (pulmonary form). Rx: DEC (6mg/kg/day × 12 days); Albendazole 400mg; Doxycycline 200mg OD × 4-6 wks (anti-Wolbachia kills adult worms). WHO mass drug admin: DEC+albendazole annually. Surgical: CDT for lymphedema, Charles operation for elephantiasis"],
    ["POST-THROMBOTIC SYNDROME (PTS)","After DVT: valve destruction → chronic venous HTN → edema, pain, varicosities, hyperpigmentation, ulcer. Villalta score: ≥5 = PTS; ≥15 = severe PTS. PREVENTION: LMWH → switch to NOAC; elastic stockings for 2 years. Endovascular: Venous stenting for iliofemoral obstruction (ATTRACT trial — selective benefit for iliofemoral DVT with CDT)"],
    ["POST-THROMBOTIC / VENOUS CLAUDICATION","Exertional leg pain (bursting/heaviness) on walking due to venous outflow obstruction (vs. arterial: cramping). Relieved by ELEVATION (not rest alone). ABI normal. Duplex shows deep venous obstruction. Rx: Compression + iliac vein stenting (for iliofemoral obstruction — excellent results)"],
    ["ULL AND LLL OEDEMA — Causes (Q15/16)","ULL (upper limb): Post-mastectomy lymphedema, axillary vein thrombosis (Paget-Schroetter — effort thrombosis), malignant infiltration, cellulitis. LLL (lower limb): DVT, CVI, lymphedema, hypoproteinaemia (cirrhosis, nephrotic), cardiac failure, dependency, filariasis, lipedema, drug-induced (CCB, steroids)"],
    ["ELEPHANTIASIS IN YOUNG MALE (Q15)","Filariasis most likely diagnosis. Investigate: blood smear (nocturnal), ICT antigen, lymphoscintigraphy. Rx: Anti-filarial (DEC/albendazole/doxycycline) + CDT (MLD + bandaging) + compression garments. Surgery if established elephantiasis: Charles/Homans/Sistrunk. Psychological support"],
    ["PSOAS ABSCESS (Q19 — 10M)","Primary: Haematogenous (Staphylococcus). Secondary: TB (most common in developing countries — Pott's spine), Crohn's, appendicitis, instrumentation. Features: Triad — back pain + fever + groin/thigh pain. Psoas sign positive. Hip kept flexed (psoas spasm). X-ray: Absent psoas shadow. CT: Hypoattenuating psoas collection. Rx: CT-guided percutaneous drainage (1st line) + antibiotics. Surgical drainage if fails/complex. Anti-TB therapy if tuberculous"],
  ],{cw:[2.5,6.9],fs:11.5});
}

// ══════════════════════════════════════════════════════════
// SUMMARY PRIORITY TABLE
// ══════════════════════════════════════════════════════════
{
  const s=ds(); hdr(s,"EXAM PRIORITY GUIDE — Answer Marks & Year Frequency","Study smartly — highest yield topics first");
  tbl(s,[
    ["TOPIC","MARKS","YEARS ASKED","PRIORITY"],
    ["Varicose Veins — recent modalities, laser/foam/RFA","20M","2017 ×2, 2014, 2019","★★★ MOST IMPORTANT"],
    ["DVT — classification + pharmacological basis of drugs","20M","2016, 2015, 2022","★★★ MOST IMPORTANT"],
    ["Lymphedema — pathophysiology, classification, Mx","20M","2020","★★★ Important"],
    ["PVD — What is PVD? Recent Mx of arterial disease","20M","2016, 2019","★★ Very Important"],
    ["LL varicose veins — Ix advances + Rx advances","10-20M","2017, 2014","★★ Very Important"],
    ["Diabetic foot / Recent advances in Rx","10M","Repeated","★★ Very Important"],
    ["DVT — pathology, prevention, post-op DVT","10M","2022, 2015","★★ Important"],
    ["Anatomical basis of tests for varicose veins","10M","Multiple years","★★ Important"],
    ["Buerger's disease / TAO / Ilizarov technique","10M","2024, 2023","★★ Important"],
    ["Lumbar sympathectomy in PVD","Short","2016-2019","★ Important"],
    ["Complications of varicose vein surgery","Short","Multiple","★ Important"],
    ["Post-thrombotic claudication (10M)","10M","2022","★ Important"],
    ["DSA — Digital Subtraction Angiography","10M","2016 (10M)","★ Important"],
    ["Trench foot, Madura foot","Short","Asked","Study"],
    ["Popliteal cyst, Psoas abscess, Filariasis","Short-10M","Multiple","Study"],
  ],{cw:[4.0,1.2,2.2,2.6],fs:12});
}

// THANK YOU
{
  const s=pres.addSlide(); s.background={color:C.bg};
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:0.12,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addShape(pres.ShapeType.rect,{x:0,y:5.5,w:10,h:0.125,fill:{color:C.mid},line:{color:C.mid,width:0}});
  s.addText("ALL THE BEST FOR YOUR EXAMS!",{x:0.5,y:1.4,w:9,h:1.0,fontSize:36,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:4});
  s.addShape(pres.ShapeType.rect,{x:3,y:2.45,w:4,h:0.05,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addText("PG Surgery — Vascular Surgery Answer Bank",{x:0.5,y:2.6,w:9,h:0.55,fontSize:18,color:C.gold,fontFace:"Calibri",align:"center"});
  s.addText("Bailey & Love 28e  |  Schwartz's Principles of Surgery 11e  |  Sabiston Textbook of Surgery\nCurrent Surgical Therapy 14e  |  Fischer's Mastery of Surgery 8e  |  Mulholland & Greenfield's Surgery 7e",{x:0.5,y:3.3,w:9,h:0.8,fontSize:11.5,color:C.gray,fontFace:"Calibri",align:"center"});
  s.addText('"Success is the sum of small efforts, repeated day in and day out."',{x:0.5,y:4.3,w:9,h:0.55,fontSize:13,italic:true,color:C.light,fontFace:"Calibri",align:"center"});
}

pres.writeFile({fileName:"/home/daytona/workspace/pvd-ppt/Surgery_Answers_Vascular.pptx"})
  .then(()=>console.log("SUCCESS: Surgery_Answers_Vascular.pptx created"))
  .catch(err=>{console.error("ERROR:",err);process.exit(1);});

const pptxgen = require("pptxgenjs");
const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Varicose Veins - Case Presentation - PG General Surgery";

// ─── PALETTE ────────────────────────────────────────────────────
const C = {
  bg:      "07131F",
  navy:    "0E2035",
  mid:     "163354",
  teal:    "0D6E6E",
  accent:  "2196A8",
  gold:    "F0A500",
  red:     "C0392B",
  green:   "1E8449",
  white:   "FFFFFF",
  light:   "D0E8F0",
  gray:    "8DAFC0",
};

// ─── HELPERS ─────────────────────────────────────────────────────
const ds = () => { const s = pres.addSlide(); s.background = { color: C.bg }; return s; };

const hdr = (s, title, sub, hclr) => {
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:10, h:0.72, fill:{color: hclr||C.mid}, line:{color:C.accent, width:3} });
  s.addText(title, { x:0.18, y:0.04, w:9.5, h:0.62, fontSize:20, bold:true, color:C.white, fontFace:"Calibri", valign:"middle" });
  if (sub) {
    s.addShape(pres.ShapeType.rect, { x:0, y:0.72, w:10, h:0.26, fill:{color:C.accent}, line:{color:C.accent, width:0} });
    s.addText(sub, { x:0.18, y:0.72, w:9.5, h:0.26, fontSize:10.5, color:C.white, fontFace:"Calibri", valign:"middle" });
  }
};

const buls = (s, items, o={}) => {
  const { x=0.32, y=1.05, w=9.36, h=4.4, fs=13 } = o;
  s.addText(items.map((it,i) => ({
    text: typeof it==="string" ? it : it.t,
    options: {
      bullet: typeof it==="object" && it.sub ? { indent:28 } : true,
      breakLine: i < items.length-1,
      fontSize: typeof it==="object" && it.sub ? fs-1 : fs,
      color: typeof it==="object" && it.hl ? C.gold : C.light,
      bold: typeof it==="object" && (it.bold||it.hl) ? true : false,
      fontFace:"Calibri",
      indentLevel: typeof it==="object" && it.sub ? 1 : 0,
    }
  })), { x, y, w, h, valign:"top" });
};

const tbl = (s, rows, o={}) => {
  const { x=0.3, y=1.0, w=9.4, cw, fs=12 } = o;
  const n = rows[0].length;
  const colW = cw || Array(n).fill(9.4/n);
  s.addTable(rows.map((row, ri) => row.map((cell, ci) => ({
    text: cell,
    options: {
      bold: ri===0,
      color: ri===0 ? C.white : C.light,
      fontSize: fs, fontFace:"Calibri",
      fill: ri===0 ? {color:C.mid} : ci===0 ? {color:"0C1D2E"} : {color:"071525"},
      valign:"middle", align:"left",
    }
  }))), { x, y, w, colW, border:{color:C.mid, pt:1}, rowH:0.33 });
};

const div = (title, sub, clr) => {
  const s = pres.addSlide();
  s.background = { color: clr||C.teal };
  s.addShape(pres.ShapeType.rect, { x:0, y:2.35, w:10, h:0.07, fill:{color:C.white}, line:{color:C.white,width:0} });
  s.addText(title, { x:0.5, y:1.1, w:9, h:1.1, fontSize:34, bold:true, color:C.white, fontFace:"Calibri", align:"center", valign:"middle" });
  if (sub) s.addText(sub, { x:0.5, y:2.55, w:9, h:0.8, fontSize:16, color:C.white, fontFace:"Calibri", align:"center" });
};

const box2 = (s, l, r, o={}) => {
  const { lt="", rt="", lc=C.mid, rc="0C1D2E", y=1.05, h=4.35 } = o;
  s.addShape(pres.ShapeType.rect, { x:0.28, y, w:4.52, h, fill:{color:lc}, line:{color:C.accent,width:1.5} });
  s.addShape(pres.ShapeType.rect, { x:4.98, y, w:4.74, h, fill:{color:rc}, line:{color:C.gold,width:1.5} });
  if(lt) s.addText(lt, { x:0.38, y:y+0.05, w:4.3, h:0.32, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri" });
  if(rt) s.addText(rt, { x:5.08, y:y+0.05, w:4.5, h:0.32, fontSize:12, bold:true, color:C.gold, fontFace:"Calibri" });
  const off = (t)=>t?0.4:0.08;
  s.addText(l.map((it,i)=>({text:typeof it==="string"?it:it.t,options:{bullet:true,breakLine:i<l.length-1,fontSize:12,color:typeof it==="object"&&it.hl?C.gold:C.light,bold:typeof it==="object"&&it.hl,fontFace:"Calibri"}})),{x:0.38,y:y+off(lt),w:4.38,h:h-off(lt)-0.05,valign:"top"});
  s.addText(r.map((it,i)=>({text:typeof it==="string"?it:it.t,options:{bullet:true,breakLine:i<r.length-1,fontSize:12,color:typeof it==="object"&&it.hl?C.gold:C.light,bold:typeof it==="object"&&it.hl,fontFace:"Calibri"}})),{x:5.08,y:y+off(rt),w:4.58,h:h-off(rt)-0.05,valign:"top"});
};

// ════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ════════════════════════════════════════════════════════════
{
  const s = pres.addSlide(); s.background={color:C.bg};
  s.addShape(pres.ShapeType.rect, {x:0,y:0,w:10,h:0.12,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addShape(pres.ShapeType.rect, {x:0,y:5.5,w:10,h:0.125,fill:{color:C.mid},line:{color:C.mid,width:0}});
  s.addText("VARICOSE VEINS", {x:0.4,y:0.4,w:9.2,h:1.1,fontSize:42,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:4});
  s.addShape(pres.ShapeType.rect, {x:2.2,y:1.55,w:5.6,h:0.06,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addText("Case Presentation — PG General Surgery", {x:0.4,y:1.7,w:9.2,h:0.55,fontSize:22,color:C.gold,fontFace:"Calibri",align:"center",italic:true});
  s.addText("A comprehensive clinical & surgical review covering all viva questions", {x:0.4,y:2.3,w:9.2,h:0.45,fontSize:14,color:C.gray,fontFace:"Calibri",align:"center"});
  const secs = [
    "Case Presentation","Anatomy & Embryology","Definition & Classification",
    "Pathophysiology","Risk Factors & Epidemiology","Clinical Features & Signs",
    "Clinical Examination Tests","CEAP Classification","Investigations & Duplex USS",
    "Medical Management","Endovenous Treatment (EVLA/RFA)","Foam Sclerotherapy",
    "Open Surgery — Trendelenburg + Stripping","Complications of Surgery",
    "Recurrent Varicose Veins","Venous Leg Ulcer","Viva Q&A"
  ];
  secs.forEach((t,i)=>{
    const col=Math.floor(i/6); const row=i%6;
    const x=0.28+col*3.06; const y=2.95+row*0.42;
    s.addShape(pres.ShapeType.rect,{x,y,w:3.0,h:0.37,fill:{color:i%2===0?C.mid:"0C1D2E"},line:{color:C.accent,width:1}});
    s.addText(t,{x:x+0.08,y,w:2.84,h:0.37,fontSize:9.5,color:C.white,fontFace:"Calibri",valign:"middle"});
  });
  s.addText("Bailey & Love 28e | Schwartz's 11e | Gray's Anatomy for Students | Robbins Pathology | Current Surgical Therapy 14e",{x:0.3,y:5.27,w:9.4,h:0.28,fontSize:9,color:C.gray,fontFace:"Calibri",align:"center"});
}

// ════════════════════════════════════════════════════════════
// SECTION A: CASE
// ════════════════════════════════════════════════════════════
div("SECTION A", "Case Presentation", C.teal);

// Case: Chief Complaint
{
  const s=ds(); hdr(s,"CASE PRESENTATION — Presenting Complaint","A 35-year-old female, para 2, teacher by occupation");
  s.addShape(pres.ShapeType.rect,{x:0.28,y:1.05,w:4.52,h:4.3,fill:{color:C.navy},line:{color:C.accent,width:1.5}});
  s.addShape(pres.ShapeType.rect,{x:4.98,y:1.05,w:4.74,h:4.3,fill:{color:C.navy},line:{color:C.gold,width:1.5}});
  s.addText("CHIEF COMPLAINTS",{x:0.38,y:1.08,w:4.3,h:0.34,fontSize:12.5,bold:true,color:C.gold,fontFace:"Calibri"});
  s.addText([
    {text:"1. Dilated, tortuous, prominent veins on the right leg — 5 years",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"   Gradually increasing in size and extent",options:{bullet:false,breakLine:true,fontSize:11.5,color:C.gray,fontFace:"Calibri"}},
    {text:"2. Aching pain & heaviness in the right leg",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"   Worse at end of day / prolonged standing",options:{bullet:false,breakLine:true,fontSize:11.5,color:C.gray,fontFace:"Calibri"}},
    {text:"   Relieved by leg elevation & compression",options:{bullet:false,breakLine:true,fontSize:11.5,color:C.gray,fontFace:"Calibri"}},
    {text:"3. Itching around the ankle — 2 years",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"4. Mild swelling of right ankle — 1 year",options:{bullet:true,breakLine:false,fontSize:13,color:C.light,fontFace:"Calibri"}},
  ],{x:0.38,y:1.48,w:4.4,h:3.75,valign:"top"});
  s.addText("HISTORY OF PRESENTING ILLNESS",{x:5.08,y:1.08,w:4.5,h:0.34,fontSize:12.5,bold:true,color:C.gold,fontFace:"Calibri"});
  s.addText([
    {text:"First noticed dilated veins after 2nd pregnancy",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"No prior DVT, trauma, or surgery on legs",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"Stands >6 hours/day as a teacher",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"Family history: Mother had varicose veins",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"No oral contraceptive use currently",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"No abdominal mass, no pelvic symptoms",options:{bullet:true,breakLine:true,fontSize:13,color:C.light,fontFace:"Calibri"}},
    {text:"Wore compression stockings — partial relief only",options:{bullet:true,breakLine:false,fontSize:13,color:C.light,fontFace:"Calibri"}},
  ],{x:5.08,y:1.48,w:4.6,h:3.75,valign:"top"});
}

// Case: Examination
{
  const s=ds(); hdr(s,"CASE — Physical Examination","Systematic venous examination findings");
  tbl(s,[
    ["EXAMINATION","FINDINGS & SIGNIFICANCE"],
    ["General","BMI 27. No pallor/jaundice. BP 122/78 mmHg. No signs of cardiac failure or chronic liver disease"],
    ["Inspection — standing","Dilated tortuous veins: medial thigh + medial calf (GSV distribution). Ankle flare (corona phlebectatica). Mild ankle oedema. No skin pigmentation, lipodermatosclerosis, or ulcer. C2 disease (CEAP)"],
    ["Saphena varix","No palpable lump at groin — SFJ not grossly dilated. (Note: Saphena varix = dilated SFJ, appears on standing, disappears lying, cough impulse — differentiate from groin hernia)"],
    ["Palpation","Veins soft, compressible, non-tender. No thickening, tenderness or induration over the calf. Pulses intact — DP and PT present bilaterally. ABI not required (no ischaemic features)"],
    ["Cough impulse test","Positive at SFJ region — confirms SFJ incompetence (fluid impulse transmitted through incompetent SFJ valve on coughing)"],
    ["Trendelenburg test","Veins drained by leg elevation + SFJ compression. On standing: no filling from below. On releasing: rapid filling from above = POSITIVE = SFJ incompetent"],
    ["Tourniquet test","Tourniquet at upper thigh: veins don't fill (confirms SFJ source). Placed below knee — some veins fill → incompetent below-knee perforators also present"],
    ["Perthes' test","Tourniquet mid-thigh, patient walks — veins remain / decrease = deep veins PATENT. (If they worsen → secondary VV with deep obstruction — contraindication to surgery)"],
  ],{cw:[2.8,6.6],fs:12});
}

// Case: Diagnosis
{
  const s=ds(); hdr(s,"PROVISIONAL DIAGNOSIS, CLASSIFICATION & PLAN","Synthesising clinical findings");
  s.addShape(pres.ShapeType.rect,{x:0.28,y:1.05,w:9.44,h:0.92,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addText("PRIMARY VARICOSE VEINS — Right Lower Limb\nSaphenofemoral Junction Incompetence (GSV System) | CEAP C2,S | Ep,As,Pr",{x:0.4,y:1.05,w:9.22,h:0.92,fontSize:15.5,bold:true,color:C.white,fontFace:"Calibri",align:"center",valign:"middle"});
  buls(s,[
    {t:"REASONING:",hl:true,bold:true},
    "Female, 35 yrs, para 2, teacher (prolonged standing) — multiple risk factors for primary VV",
    "Medial thigh + calf distribution = GSV system. Lateral thigh = AAGSV. Posterior calf = SSV",
    "Positive Trendelenburg at upper thigh level = SFJ incompetence (most common junction, >80%)",
    "Positive cough impulse at groin = SFJ incompetence confirmed",
    "Perthes' test negative (veins decrease) = deep veins patent → safe for surgery/ablation",
    "No skin changes (C4), no ulcer (C5/C6) → CEAP C2 (varicose veins only)",
    {t:"DIFFERENTIALS TO EXCLUDE:",hl:true,bold:true},
    "Secondary VV: No DVT history, no pelvic mass, Perthes' normal → ruled out",
    "Saphena varix: No groin lump on standing → ruled out (but must differentiate from femoral hernia)",
    "Lymphedema: Oedema is pitting, no skin changes characteristic of lymphedema → ruled out",
  ],{y:2.05,h:3.3,fs:13});
}

// ════════════════════════════════════════════════════════════
// SECTION B: TOPIC REVIEW
// ════════════════════════════════════════════════════════════
div("SECTION B","Topic Review — Varicose Veins", C.teal);

// Anatomy
{
  const s=ds(); hdr(s,"SURGICAL ANATOMY OF THE VENOUS SYSTEM OF LOWER LIMB","Gray's Anatomy for Students | Bailey & Love 28e — foundation for understanding VV");
  tbl(s,[
    ["STRUCTURE","DETAILS"],
    ["Great Saphenous Vein (GSV)","Longest vein. Begins at medial end of dorsal venous arch of foot. Passes anterior to medial malleolus → medial leg → medial knee (posteromedial to medial condyle femur) → medial thigh → drains into femoral vein at SFJ (4 cm below & lateral to pubic tubercle). Joined by 5 tributaries at SFJ: superficial epigastric, superficial circumflex iliac, superficial external pudendal, posteromedial, anterolateral thigh veins"],
    ["Saphenofemoral Junction (SFJ)","GSV passes through the saphenous opening (fossa ovalis) in fascia lata → joins femoral vein. KEY SURGICAL LANDMARK — medial to femoral artery at mid-inguinal point. 'Confluence of tributaries' = flower-head arrangement"],
    ["Small Saphenous Vein (SSV)","Begins at lateral end of dorsal venous arch. Passes posterior to lateral malleolus → posterior calf → pierces deep fascia (variable level) → joins popliteal vein at SPJ (variable: 0-5 cm above popliteal crease). ALWAYS mark with duplex pre-op — highly variable anatomy"],
    ["Perforating Veins (COCKETT'S & DODD'S)","Connect superficial to deep veins. Valves direct flow: superficial → deep (centripetal). Cockett's perforators: 5, 10, 15 cm above medial malleolus (lower leg). Dodd's perforator: Lower thigh (Hunter's canal level). Boyd's perforator: Below knee medial. Incompetent perforators: >3.5mm, bidirectional flow >0.5s on Duplex = significant"],
    ["Deep Venous System","Anterior/posterior tibial + peroneal veins → popliteal vein → femoral vein (SFA accompanies) + profunda femoris vein → common femoral vein → external iliac vein → IVC"],
    ["Venous valves","Bicuspid pocket valves. More numerous distally. Direct blood centripetally and from superficial → deep. Loss of valve competence → reflux → varicosity"],
    ["Fascial compartments","Superficial fascia compartment (GSV, SSV, perforators). Deep fascia separates from deep compartment (tibial veins, muscles). Muscle pump in deep compartment acts as 'peripheral heart'"],
  ],{cw:[2.5,6.9],fs:12});
}

// Definition & Classification
{
  const s=ds(); hdr(s,"DEFINITION & CLASSIFICATION OF VARICOSE VEINS","Bailey & Love 28e | Schwartz's Principles of Surgery 11e");
  tbl(s,[
    ["CLASS","DETAILS"],
    ["DEFINITION","Dilated (>3 mm), tortuous, elongated superficial veins, with incompetent valves. Prevalence: 30-50% adults. F>M (Edinburgh Vein Study). Increase with age: 11.5% at 18-24 yrs → 55.7% at 55-64 yrs"],
    ["PRIMARY VV","Intrinsic valve/wall abnormality. No identifiable cause. Majority of cases. Vein wall weakness → valve ring dilation → incompetence (NOT valve disease first). Genetic predisposition"],
    ["SECONDARY VV","Due to deep venous obstruction/hypertension. Causes: (1) Post-DVT (post-thrombotic syndrome), (2) Pelvic tumours (uterine, ovarian — compress iliac veins), (3) Pregnancy (IVC compression + hormonal), (4) AV fistula, (5) Klippel-Trenaunay syndrome"],
    ["BY SITE (GSV System)","Medial thigh + calf → SFJ incompetence (most common, >80%). AAGSV (Anterior Accessory GSV) → anterolateral thigh/calf. Thigh perforator (Dodd's) → medial lower thigh. Calf perforators (Cockett's) → medial lower leg"],
    ["BY SITE (SSV System)","Posterior and posterolateral calf → SPJ incompetence (~20%). Variable SPJ anatomy → always duplex map pre-op"],
    ["SYMPTOMATIC vs ASYMPTOMATIC","Symptomatic (C,S): Aching, heaviness, throbbing, itching, burning — worse with prolonged standing, relieved by elevation. Asymptomatic (C,A): Visible veins only. Treatment depends on symptoms + complications"],
    ["COMPLICATED VV","Thrombophlebitis. Haemorrhage (spontaneous rupture — treated with leg elevation + direct pressure). Chronic venous insufficiency. Venous leg ulcer (gaiter area). Lipodermatosclerosis. Pigmentation (haemosiderin). Eczema (venous/gravitational)"],
  ],{cw:[2.5,6.9],fs:12});
}

// Pathophysiology
{
  const s=ds(); hdr(s,"PATHOPHYSIOLOGY OF VARICOSE VEINS","Robbins Pathology | Bailey & Love 28e — vein wall to skin ulceration");
  tbl(s,[
    ["STEP","MECHANISM"],
    ["1. Valve incompetence","Primary: Intrinsic weakness of vein wall → dilation of valve ring → leaflets don't coapt → incompetence (valve structure normal initially). Genetic: Abnormal collagen/elastin in vein wall. Secondary: DVT destroys valve leaflets directly"],
    ["2. Venous reflux","Incompetent valve → retrograde blood flow (reflux) in superficial veins on standing/straining. Retrograde flow >0.5 sec on Doppler = significant reflux. Creates high-pressure column of blood in lower leg"],
    ["3. Venous hypertension","Standing column of blood from groin to ankle (~120 cmH2O) transmitted to superficial veins. Normal calf muscle pump reduces this → post-exercise ankle venous pressure <30 mmHg (normal). In VV: pressure remains >50 mmHg = chronic venous hypertension"],
    ["4. Microcirculation changes","Venous HTN → capillary distension → extravasation of RBCs, proteins, fibrin into dermis. Fibrin cuffs around capillaries → impaired O2 diffusion ('fibrin cuff hypothesis' — Browse & Burnand). Leucocyte trapping → inflammatory mediators → endothelial damage"],
    ["5. Skin changes (lipodermatosclerosis)","Chronic inflammation + haemosiderin deposition → skin pigmentation. Fibrosis of dermis + subcutaneous fat → lipodermatosclerosis (woody induration). 'Inverted champagne bottle' leg deformity"],
    ["6. Ulceration","Continued ischaemia of skin → breakdown → venous leg ulcer (VLU). Classically at gaiter area (medial malleolus — Cockett's perforators). Shallow, sloping edges, granulating base, fibrinous exudate. Heals with compression if venous cause corrected"],
    ["VICIOUS CYCLE","Reflux → venous HTN → wall dilation → further valve incompetence → more reflux → expansion of disease"],
  ],{cw:[2.5,6.9],fs:12});
}

// Risk Factors & Epidemiology
{
  const s=ds(); hdr(s,"RISK FACTORS & EPIDEMIOLOGY","Bailey & Love 28e — Edinburgh Vein Study data");
  box2(s,
    [
      {t:"NON-MODIFIABLE",hl:true},
      "Female sex: F>M. Studies show 1.5-2x higher prevalence in women (hormonal + obstetric factors)",
      "Age: Prevalence rises from 11.5% (18-24 yr) to 55.7% (55-64 yr) — Edinburgh Vein Study",
      "Family history: Strong genetic component (autosomal dominant with variable penetrance). Risk ×3 if first-degree relative affected",
      "Ethnicity: Lower in African populations; higher in Western/developed populations",
      "Tall stature: Long column of venous blood",
      {t:"PREGNANCY",hl:true},
      "Multiple pregnancies: Increases risk. Mechanisms: IVC + iliac vein compression → raised venous pressure. Progesterone → vein wall relaxation/dilation. Elevated blood volume",
    ],
    [
      {t:"MODIFIABLE / LIFESTYLE",hl:true},
      "Prolonged standing: Strong occupational risk. Teachers, surgeons, shopworkers, hairdressers",
      "Obesity (BMI >30): Increased intraabdominal pressure → impairs femoral/iliac venous drainage",
      "Constipation: Straining raises IAP → transmitted to iliac veins. Disputed evidence",
      "Sedentary lifestyle: Reduced calf muscle pump activity",
      {t:"PROTECTIVE FACTORS",hl:true},
      "Regular exercise: Enhances calf muscle pump",
      "Compression stockings: Reduces venous hypertension",
      {t:"PATHOLOGICAL",hl:true},
      "DVT: Destroys deep venous valves → secondary VV + CVI",
      "Pelvic masses / AV fistula",
      "Klippel-Trenaunay syndrome (port-wine stain + VV + limb hypertrophy)",
    ],
    {lt:"NON-MODIFIABLE / PREGNANCY",rt:"LIFESTYLE / PROTECTIVE",y:1.05,h:4.35}
  );
}

// Clinical Tests — anatomical basis
{
  const s=ds(); hdr(s,"CLINICAL EXAMINATION TESTS — Anatomical Basis","Q: Anatomical basis for various tests for varicose vein of lower limb — Bailey & Love 28e");
  tbl(s,[
    ["TEST","TECHNIQUE","ANATOMICAL BASIS","RESULT & INTERPRETATION"],
    ["TRENDELENBURG TEST (Brodie-Trendelenburg)","Patient supine, elevate leg 45° to empty veins. Apply tourniquet at upper thigh (just below SFJ). Patient stands. Observe filling. Then release tourniquet","Tourniquet occludes GSV just below SFJ. Controls communication at SFJ. Tests: (1) SFJ valve competence (2) Perforator competence","Filling from below with tourniquet ON = incompetent perforators below. Rapid filling from above on RELEASING tourniquet = SFJ incompetent (positive Trendelenburg). No filling on release = SFJ competent. Note: Duplex has replaced this test clinically"],
    ["MULTIPLE TOURNIQUET TEST","Same principle with tourniquet applied at different levels: upper thigh (SFJ), knee (Dodd's), upper calf (Boyd's), lower calf (Cockett's)","Localises the level of reflux entry. Each tourniquet occludes superficial veins at that level","Site below which veins fill = site of incompetent perforator. Allows mapping of all incompetent junctions"],
    ["PERTHES' TEST","Apply tourniquet mid-thigh in STANDING patient. Ask patient to walk 50 paces or do calf raises","Tourniquet mimics superficial vein occlusion. Tests deep venous patency & perforator competence","Veins DECREASE on walking = deep veins patent + muscle pump working. Veins INCREASE or pain = deep venous obstruction/incompetence = CONTRAINDICATION to superficial venous surgery"],
    ["COUGH IMPULSE TEST","Palpate at SFJ region in groin while patient coughs","Cough raises intraabdominal → intravenous pressure. Impulse transmitted retrograde through incompetent SFJ valve","Impulse felt = SFJ incompetent. Normal valve stops transmission. Saphena varix also shows impulse"],
    ["MORRISSEY'S PERCUSSION TEST","Flick one varicose vein distally while palpating the column of varices proximally","Fluid wave transmission through incompetent valve segment","Thrill felt proximally = incompetent valves between the two points. Normal valve stops transmission"],
    ["HAND-HELD DOPPLER","Place probe over SFJ/SPJ, perform calf squeeze/release or Valsalva","Detects retrograde flow (reflux) through incompetent junction","Biphasic sound: forward flow on augmentation (normal). Reversal on relaxation >0.5 sec = incompetent junction. Better than tourniquet tests but replaced by duplex"],
  ],{cw:[1.8,2.2,2.5,2.9],fs:11});
}

// CEAP Classification
{
  const s=ds(); hdr(s,"CEAP CLASSIFICATION OF VENOUS DISEASE","Clinical-Etiological-Anatomical-Pathophysiological — International Standard");
  tbl(s,[
    ["CEAP","CLINICAL CLASS","DESCRIPTION","NOTES"],
    ["C0","No visible / palpable disease","Normal leg","Subclinical symptoms possible"],
    ["C1","Telangiectasia / reticular veins","<3mm diameter, thread veins or reticular","Cosmetic only. Treat with microsclerotherapy"],
    ["C2","Varicose veins (>3mm)","Dilated tortuous subcutaneous veins","Most common surgical presentation. S=symptomatic, A=asymptomatic"],
    ["C3","Oedema (venous)","Ankle oedema due to venous disease","No skin changes. Compression +/- treat reflux"],
    ["C4a","Pigmentation & eczema","Haemosiderin deposition (brown) + venous eczema (C4a)","Lipodermatosclerosis (C4b) = more advanced fibrosis"],
    ["C4b","Lipodermatosclerosis / atrophie blanche","Woody induration, white atrophy","Indicates high-risk for ulceration"],
    ["C5","Healed venous ulcer","Scar from previous ulcer","Still requires treatment to prevent recurrence"],
    ["C6","Active venous ulcer","Open ulcer at gaiter area","Compression + treat underlying reflux"],
    ["ETIOLOGICAL","Ep=primary; Es=secondary (post-DVT); Ec=congenital","",""],
    ["ANATOMICAL","As=superficial; Ad=deep; Ap=perforator","","Multiple levels common"],
    ["PATHOPHYSIOLOGICAL","Pr=reflux; Po=obstruction; Pr,o=both","","Duplex defines this"],
    ["Our case","C2, S, Ep, As, Pr","Symptomatic primary varicose veins; superficial; reflux only","Ideal for endovenous treatment"],
  ],{cw:[1.5,2.5,3.2,2.2],fs:11.5});
}

// Investigations
{
  const s=ds(); hdr(s,"INVESTIGATIONS IN VARICOSE VEINS","Duplex ultrasound is GOLD STANDARD — Bailey & Love 28e");
  tbl(s,[
    ["INVESTIGATION","DETAILS"],
    ["DUPLEX ULTRASOUND (Gold Standard) ★","7.5-13 MHz linear transducer. Patient STANDING (most sensitive position). B-mode + colour/spectral Doppler. WHAT TO ASSESS: (1) Presence & distribution of reflux (SFJ, SPJ, perforators, deep veins). (2) Duration of reflux: >0.5 sec superficial = significant; >1 sec deep = significant. (3) Vein diameter (treat if GSV >5-6mm). (4) Suitability for endovenous ablation (tortuosity, proximity to skin). (5) Deep vein patency (exclude DVT/obstruction). (6) Pelvic source? ELICIT reflux with: calf squeeze/release, Valsalva, foot dorsiflexion"],
    ["Clinical tests (now superseded)","Trendelenburg, tourniquet tests, hand-held Doppler — used in resource-limited settings. Bailey & Love 28e: 'Tourniquet tests and hand-held Doppler have now been abandoned' in favour of duplex"],
    ["Air Plethysmography (APG)","Quantifies venous haemodynamics: Venous Filling Index (VFI), Ejection Fraction (EF), Residual Volume Fraction (RVF). VFI >2ml/s = significant reflux. Used for research and complex cases"],
    ["CT / MR Venography","For secondary VV — identifies pelvic causes (May-Thurner syndrome, nutcracker syndrome, pelvic congestion). Also for complex recurrent disease. IVUS for iliac vein stenting"],
    ["D-Dimer + Duplex","For suspected DVT/thrombophlebitis as acute complication. D-dimer: high sensitivity. Duplex: diagnostic gold standard for DVT"],
    ["Photoplethysmography (PPG)","Infrared reflectance measures dermal blood flow. Venous refilling time (VRT): <20 sec = significant reflux. Simple screening tool"],
    ["Blood tests","FBC (polycythaemia — hypercoagulable). Coagulation screen (thrombophilia if DVT suspected). Not routinely required for primary VV"],
    ["Pre-operative workup","Duplex USS (mandatory before any intervention). Consent for specific complications. ABPI if >60 yrs or diabetic (exclude PAD before compression)"],
  ],{cw:[3.0,6.4],fs:12});
}

// ════════════════════════════════════════════════════════════
// SECTION C: MANAGEMENT
// ════════════════════════════════════════════════════════════
div("SECTION C","Management of Varicose Veins", C.teal);

// Conservative
{
  const s=ds(); hdr(s,"CONSERVATIVE & MEDICAL MANAGEMENT","NICE Guidelines | Bailey & Love 28e — first-line treatment");
  tbl(s,[
    ["MODALITY","DETAILS & EVIDENCE"],
    ["Compression Stockings ★","Class I (14-17 mmHg): Mild symptoms, telangiectasia. Class II (18-24 mmHg): Varicose veins — STANDARD. Class III (25-35 mmHg): CVI, post-DVT, lipodermatosclerosis. Class IV (>35 mmHg): Lymphoedema/severe CVI. Mechanism: Reduces venous hypertension, aids calf pump, reduces oedema. Knee-high covers most VV. CHECK ABI FIRST (if <0.8, do not use compression). Evidence: Symptomatic relief only — does NOT reverse VV. Required 2 yrs post-DVT to prevent PTS"],
    ["Lifestyle modifications","Weight loss (reduces IAP). Regular walking/exercise (enhances calf muscle pump). Leg elevation when resting. Avoid prolonged standing (change position frequently). Avoid constipation"],
    ["Indications for active intervention","(1) Symptomatic VV unresponsive to compression. (2) Skin changes (C4-C6) — prevent progression to ulcer. (3) Bleeding varicose veins (acute). (4) Thrombophlebitis (after acute treatment). (5) Patient preference (cosmesis). NICE 2013: Offer endovenous treatment to all patients with truncal reflux with VV (not conservative first)"],
    ["Pharmacotherapy (limited role)","Diosmin (Daflon): Micronized purified flavonoid fraction. Reduces capillary permeability, antiinflammatory. Reduces symptoms and aids VLU healing. Class evidence for VLU healing; less clear for VV alone. Oxerutins. Horse chestnut seed extract (aescin). Not routinely recommended in UK/US guidelines"],
  ],{cw:[2.8,6.6],fs:13});
}

// Foam Sclerotherapy
{
  const s=ds(); hdr(s,"FOAM SCLEROTHERAPY","Mechanism, Technique & Evidence — Schwartz's 11e | Bailey & Love 28e");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Mechanism","Sclerosant liquid mixed with air/CO2 to form foam (Tessari technique: 1 part liquid: 4 parts gas, 3-way stopcock mixing × 20 passes). FOAM advantages over liquid: Displaces blood → prolongs endothelial contact. Visible on USS (echogenic). More effective for larger vessels. Foam destroys venous endothelium → thrombosis → inflammatory fibrosis → occlusion"],
    ["Sclerosing Agents","POLIDOCANOL (Aethoxysklerol): 0.5-1% for telangiectasia; 1-3% for VV (foam). Preferred in Europe. SODIUM TETRADECYL SULFATE (STS/Fibro-Vein): 0.125-0.25% for telangiectasia; 0.5-3% for VV (foam). Preferred in USA. Mechanism: Both are detergents — disrupt lipid bilayer of endothelial cells. HYPERTONIC SALINE: Rarely used now (painful, limited volume, no foam)"],
    ["Technique — Ultrasound-Guided (UGFS) ★","Patient supine/standing. Duplex guides needle placement. Prepare foam (Tessari method). Inject at least two sites proximally. Maximum foam volume: 12ml per session (European guidelines). Compression bandage immediately. Elevation for 30 min post. Compression stocking for 2-3 weeks. Repeat after 6-8 weeks if needed"],
    ["Indications","Recurrent VV (after failed surgery). Perforator incompetence. SSV (preferred over surgery — less nerve risk). Tributaries. Patients unfit for thermal ablation or surgery. Telangiectasia (liquid). Less effective for large straight GSV (endovenous thermal preferred)"],
    ["Results","5-yr occlusion: ~60-80% (less than EVLA/RFA). Recurrence higher. Fewer procedures initially → often needs retreatment. NICE: Ultrasound-guided foam sclerotherapy (UGFS) as 3rd line after EVLA and RFA"],
    ["Complications","Thrombophlebitis (inflammatory response — self-limiting). Local hyperpigmentation (haemosiderin). DVT (rare, ~0.5%). Allergic/anaphylactic reaction. Skin necrosis if extravasation. Visual disturbances (phosphenes, migraine — pass through PFO). TIA/stroke (rare — foam embolus via right-to-left shunt). Headache, cough, chest tightness (transient)"],
  ],{cw:[2.5,6.9],fs:12});
}

// EVLA / RFA
{
  const s=ds(); hdr(s,"ENDOVENOUS THERMAL ABLATION — EVLA & RFA","NICE First-Line | Bailey & Love 28e | Schwartz's 11e");
  tbl(s,[
    ["MODALITY","EVLA (Endovenous Laser Ablation)","RFA (Radiofrequency Ablation)"],
    ["Mechanism","Laser energy (810, 940, 1064, 1320, 1470 nm) → absorbed by water (1320/1470nm) or haemoglobin (810nm) → direct thermal injury + steam bubbles → endothelial destruction + collagen contraction → fibrosis","Resistive heating at 120°C (ClosureFAST) or 85°C (VNUS Closure PLUS) → collagen shrinkage → immediate occlusion + fibrosis"],
    ["Device","Laser fibre directly in vein (diode lasers). Tumescent anaesthesia essential. Pullback speed: 1-3mm/sec. Energy: 60-100 J/cm","ClosureFAST catheter: 7 cm heating element. Treat each 7cm segment for 20 sec, two cycles. Pull back. Simple button-press operation"],
    ["Technique — Steps","1. Duplex guidance: Mark GSV/SSV. 2. Percutaneous access at knee level (below valved segment). 3. Guidewire + sheath introduction. 4. Advance laser fibre/catheter to 2cm below SFJ. 5. Tumescent local anaesthesia (TLA): peri-venous injection of 0.1% lidocaine + saline → compress vein + protect nerves + skin. 6. Activate energy delivery during pullback. 7. Treat tributaries (phlebectomy or concurrent foam). 8. Apply compression dressing","Same steps 1-5. ClosureFAST: each 7cm heated to 120°C for 20s. Two cycles per segment. Pullback after each cycle. Tumescent LA mandatory. Post: compression stocking × 1-2 wks"],
    ["Anaesthesia","Tumescent LA (day case). No GA needed. Occasional IV sedation","Tumescent LA (day case)"],
    ["Closure rate",">95% at 1-3 years. Comparable to surgery for efficacy (NICE, 2013)","~90-95% at 3 years. Comparable to EVLA"],
    ["Advantages","Better for large veins (>15mm) — increase energy. Well-established technique","Less post-op pain/bruising vs EVLA. Simpler learning curve. No laser safety protocols needed. Automatic cycle frees operator"],
    ["Special complications","Skin burn if insufficient TLA. Nerve paresthesia (thermal). EHIT (endovenous heat-induced thrombus) at SFJ — DVT extension risk — anticoagulate if Grade 2+. Recanalization","Same as EVLA. Slightly narrower catheter (limits concurrent foam injection)"],
  ],{cw:[2.0,3.7,3.7],fs:11});
}

// Open Surgery
{
  const s=ds(); hdr(s,"OPEN SURGERY — TRENDELENBURG OPERATION + STRIPPING","Procedure, Anatomy & Steps — Bailey & Love 28e | Gray's Anatomy for Students");
  tbl(s,[
    ["PROCEDURE","DETAILS"],
    ["Indications (current)","Failure / unsuitability for endovenous ablation. Recurrent VV after endovenous. Very large saphena varix. Complex anatomy. No endovenous services available. NICE: Surgery remains an option if endovenous not suitable"],
    ["Pre-operative preparation","Duplex USS mapping (mandatory). Mark veins with patient standing. Consent: specific risks. LMWH prophylaxis (medium risk). TED stockings. GA or spinal / regional (spinal preferred — reduces DVT risk)"],
    ["STEP 1: SFJ Ligation (Trendelenburg)","Incision: 3-4 cm oblique/transverse, 2-3 cm below and lateral to pubic tubercle (SFJ at saphenous opening in fossa ovalis). Dissect: identify GSV → trace to SFJ. Ligate ALL tributaries at SFJ (superficial epigastric, circumflex iliac, external pudendal, posteromedial, anterolateral). Flush ligation of GSV at femoral vein (leave NO stump). KEY: Close fascia lata to prevent neovascularisation and lymphocele"],
    ["STEP 2: GSV Stripping","Pass stripper from SFJ distally to KNEE LEVEL only (NOT to ankle — saphenous nerve runs with GSV below knee → injury if stripped → medial calf sensory loss). Invagination stripper (PIN stripping) preferred — less trauma, haematoma, nerve injury. External (Babcock) stripper also used"],
    ["STEP 3: Phlebectomy (Avulsions)","Multiple 2-3mm stab incisions over pre-marked varicosities. Hook/mosquito forceps to avulse tributary varicosities under LA. Avulsion through small incisions → excellent cosmesis, minimal scarring"],
    ["STEP 4: SSV (if required)","Patient prone. Preoperative duplex marking of SPJ (ESSENTIAL — variable anatomy). Transverse incision over marked SPJ. Ligate SSV proximally ± strip proximal SSV. Risk: sural nerve (lateral) and common peroneal nerve injury"],
    ["Post-operative care","Compression bandage for 24-48 hrs. Compression stockings for 2-4 weeks. Ambulate day of surgery. Day-case or overnight admission. DVT prophylaxis (LMWH 5-7 days)"],
    ["Results","Short-term: >90% satisfaction. 5-yr recurrence: 20-30%. Commonest cause of recurrence: NEOVASCULARISATION at SFJ (angiogenesis → new incompetent channels). Secondary: Missed tributaries, new reflux, residual disease"],
  ],{cw:[2.8,6.6],fs:12});
}

// Complications
{
  const s=ds(); hdr(s,"COMPLICATIONS OF VARICOSE VEIN SURGERY","Bailey & Love 28e — must know for viva");
  box2(s,
    [
      {t:"INTRAOPERATIVE",hl:true},
      "Femoral vein injury (at SFJ if flush ligation not done carefully) — can cause fatal haemorrhage or DVT",
      "Femoral artery injury (deep dissection — rare but catastrophic)",
      "Femoral nerve injury → sensory loss anterior thigh",
      "Lymphatic injury at groin → lymphocele / chyle leak / lymphoedema",
      "Bleeding from tributary avulsion",
      {t:"EARLY POST-OPERATIVE (within 2 weeks)",hl:true},
      "Haematoma along stripping track (common — usually self-resolving)",
      "Wound infection (groin incision — prophylactic antibiotics reduce risk)",
      "DVT / pulmonary embolism (rare 0.3-0.5% with prophylaxis)",
      "Bruising and inflammation",
    ],
    [
      {t:"NERVE INJURIES (Important for viva)",hl:true},
      "SAPHENOUS NERVE (GSV): runs with GSV in lower leg. Stripped to ankle → medial calf/foot sensory loss. Strip to KNEE ONLY to avoid. Incidence: 7-12%",
      "SURAL NERVE (SSV): posterolateral leg. SSV stripping → lateral foot sensory loss. Present in 20-30%",
      "COMMON PERONEAL NERVE: SPJ surgery in popliteal fossa → footdrop (Gray's anatomy case). Occurs if lateral popliteal structure mistaken for SSV",
      {t:"LATE COMPLICATIONS",hl:true},
      "RECURRENCE (20-30% at 5 yrs): Neovascularisation at groin (new incompetent vessels). Missed disease. New disease progression",
      "Lymphoedema (disruption of lymphatics at groin)",
      "Wound scar hypersensitivity / keloid",
      "Superficial thrombophlebitis (residual veins)",
      "EHIT (endovenous) → anticoagulate if Grade 2+",
    ],
    {lt:"INTRA/EARLY",rt:"NERVE INJURIES / LATE",y:1.05,h:4.35}
  );
}

// Recurrent Varicose Veins
{
  const s=ds(); hdr(s,"RECURRENT VARICOSE VEINS","Bailey & Love 28e — causes, assessment & management");
  tbl(s,[
    ["ASPECT","DETAILS"],
    ["Definition","Return of varicose veins after previous treatment. Clinically significant recurrence: 20-30% at 5 yrs after surgery; 10-20% at 3 yrs after endovenous. Impact on quality of life similar to primary VV"],
    ["Causes (mnemonic TARDN)","1. TACTICAL ERROR (inadequate surgery/ablation): Missed tributaries, incomplete SFJ flush ligation, residual SSV. 2. ANGIOGENESIS / NEOVASCULARISATION: Most common (40-60% of recurrence). New vessels grow into groin fibrosis → bypass previous ligation. 3. REFLUX at another site: New disease in AAGSV, SSV, or perforators not treated originally. 4. DEEP VENOUS DISEASE: Post-thrombotic recanalisation drives new superficial reflux. 5. NEOVASCULOGENESIS: Stem cell-derived new vascular channels"],
    ["REVAS classification","RE=recurrent; V=varices; A=after; S=surgery. Identifies: SFJ stump residual, groin neovascularisation, pelvic reflux, perforator source, new GSV/SSV reflux"],
    ["Assessment","DUPLEX USS (essential): maps all sources. Patient must stand. Assess: SFJ stump length, neovascularisation pattern, new reflux sites, deep veins. MR/CT venography if pelvic source suspected (pelvic congestion, May-Thurner)"],
    ["Management","Endovenous (preferred): UGFS for neovascular tissue (best option — thermal ablation difficult in fibrotic groin). EVLA/RFA for new GSV/SSV reflux. Phlebectomy for isolated tributaries. Surgery: Re-do Trendelenburg if large stump (high risk — scarring, lymphatic/nerve injury). Pelvic: Gonadal vein embolisation for ovarian reflux source (pelvic congestion syndrome)"],
    ["Prevention","Use endovenous ablation (less neovascularisation than surgery — no groin incision). Avoid groin incision when possible. Phlebectomy of junctional tributaries at same time reduces neovascularisation stimulus"],
  ],{cw:[2.5,6.9],fs:12});
}

// VLU
{
  const s=ds(); hdr(s,"VENOUS LEG ULCER","Bailey & Love 28e — complication of advanced CVI | Ulcer differentiation viva");
  tbl(s,[
    ["FEATURE","VENOUS ULCER","ARTERIAL ULCER","NEUROPATHIC ULCER"],
    ["Site","Gaiter area — medial > lateral malleolus. Cockett's perforators territory","Toes, heel, pressure points","Pressure points, ball of foot, sole"],
    ["Pain","Mild-moderate aching. Worse on standing, better with elevation","Severe, especially at night. Worse on elevation","PAINLESS (loss of protective sensation)"],
    ["Edge","Sloping, irregular, shallow","Punched-out, well-defined","Punched-out with callus rim"],
    ["Base","Granulating, shallow. Fibrinous slough. Pink/red","Necrotic, pale, fibrous, deep","Deep. May involve tendon/bone"],
    ["Surrounding skin","Pigmentation (haemosiderin). Lipodermatosclerosis. Venous eczema. Atrophie blanche","Pale, shiny, atrophic, cold. Absent pulses. Trophic changes","Warm, dry, cracked. Charcot joints. Callus. Neuropathy signs"],
    ["ABI",">0.9 (normal) — unless mixed. 15-30% VLU have concomitant PAD (mixed ulcer)","<0.5 (severe). Measure before ANY compression","Variable. DM may have calcified vessels (falsely high ABI)"],
    ["Management","4-layer compression bandaging (Charing Cross). Or 2-layer inelastic. Target: >40 mmHg at ankle. Treat underlying reflux. Pentoxifylline adjunct. Skin grafting for resistant ulcers","Treat PAD first (revascularise). NO compression. Wound care","Offloading (total contact cast). Glycaemic control. Wound debridement"],
  ],{cw:[1.9,2.5,2.5,2.5],fs:11});
}

// New modalities
{
  const s=ds(); hdr(s,"RECENT ADVANCES IN TREATMENT","VenaSeal | MOCA/ClariVein | Cryostripping — Bailey & Love 28e | Schwartz's 11e");
  tbl(s,[
    ["MODALITY","MECHANISM","DETAILS & OUTCOMES"],
    ["CYANOACRYLATE GLUE (VenaSeal) ★","N-butyl cyanoacrylate adhesive delivered into vein lumen → mechanical occlusion + inflammatory reaction → permanent fibrosis","No tumescent anaesthesia required (no perivenous injection). No compression stocking required post-procedure. Catheter-based delivery every 3 cm along vein. 3-yr occlusion ~94%. ADVANTAGE: No thermal injury, no nerve risk, no LA injections. DISADVANTAGE: Cost. Potential allergic reaction (foreign body). Not suitable for very tortuous veins"],
    ["MECHANOCHEMICAL ABLATION (MOCA/ClariVein) ★","Rotating wire tip (3500 rpm) → mechanical endothelial damage + simultaneous liquid sclerosant (polidocanol) infusion → synergistic destruction","No tumescent anaesthesia. No thermal energy → no skin/nerve thermal risk. 3-yr occlusion ~82-87%. Suitable for tortuous veins. Preferred for SSV (no thermal nerve risk). DISADVANTAGE: Lower long-term occlusion vs EVLA/RFA. Sclerosant systemic absorption"],
    ["SCLEROTHERAPY — Varithena (Polidocanol endovenous microfoam)","Proprietary blend of CO2/O2 polidocanol foam — FDA approved. Fine uniform bubble size → consistent endothelial contact","Treats GSV + tributaries simultaneously. Good for tortuous, large veins. 3-yr data: 62% symptomatic improvement. Particularly useful for post-surgical recurrence"],
    ["STEAM VEIN SCLEROSIS (SVS)","Pulses of steam at 120°C delivered via catheter → thermal injury → fibrosis","Less data than EVLA/RFA. May be useful for tributaries. SVS catheter can navigate tortuous veins better"],
    ["AMBULATORY CONSERVATIVE + HEMODYNAMIC TREATMENT (CHIVA)","Identifies and selectively interrupts specific reflux points based on haemodynamic mapping by duplex → minimal intervention under LA","Lower morbidity. Day case. Higher recurrence short-term. Selected centres only. Not mainstream in UK/US"],
    ["SUBFASCIAL ENDOSCOPIC PERFORATOR SURGERY (SEPS)","Endoscopic interruption of incompetent perforating veins (Cockett's) via subfascial approach","Replaced by UGFS and ultrasound-guided thermal ablation of perforators. Rarely performed now. Indicated in refractory VLU with isolated perforator incompetence"],
  ],{cw:[2.0,2.8,4.6],fs:11.5});
}

// ════════════════════════════════════════════════════════════
// SECTION D: VIVA Q&A
// ════════════════════════════════════════════════════════════
div("SECTION D","Viva Voce — All Commonly Asked Questions", C.teal);

// Viva 1
{
  const s=ds(); hdr(s,"VIVA Q&A — SET 1","Anatomy, definitions & pathophysiology");
  const qas=[
    ["Q: Define varicose veins. What is the difference between primary and secondary?","A: Dilated (>3mm), tortuous, elongated superficial veins with incompetent valves. PRIMARY: Intrinsic vein wall/valve weakness — no identifiable deep venous cause. Secondary: Due to deep venous hypertension (DVT, pelvic tumour, AV fistula, pregnancy). Perthes' test differentiates: positive = secondary (deep obstruction)."],
    ["Q: What are the tributaries of the GSV at the SFJ?","A: 5 tributaries at the 'flower head': (1) Superficial epigastric, (2) Superficial circumflex iliac, (3) Superficial external pudendal, (4) Posteromedial thigh vein (PMTV), (5) Anterolateral thigh vein (ALTV). All must be ligated at flush SFJ ligation to prevent recurrence."],
    ["Q: Why strip only to the knee and not to the ankle?","A: The saphenous nerve runs in close proximity to the GSV below the knee, in the subsartorial canal and then in the leg. Stripping below the knee risks sensory denervation of the medial calf and foot. The varicose tributaries in the lower leg are dealt with by phlebectomy (stab avulsions), not stripping."],
    ["Q: What is a saphena varix? How do you differentiate it from a femoral hernia?","A: Saphena varix: Dilation of GSV at SFJ, forming a soft lump in upper medial thigh. EMERGES ON STANDING, DISAPPEARS ON LYING DOWN. Cough impulse present. No bowel sounds. Reducible and vanishes on lying. VS Femoral hernia: Below and lateral to pubic tubercle, may not disappear on lying, no venous skin changes. Duplex confirms saphena varix."],
  ];
  qas.forEach((qa,i)=>{
    const y=1.07+i*1.13;
    s.addShape(pres.ShapeType.rect,{x:0.28,y,w:9.44,h:0.33,fill:{color:C.mid},line:{color:C.mid,width:0}});
    s.addText(qa[0],{x:0.38,y:y+0.02,w:9.22,h:0.3,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle"});
    s.addText(qa[1],{x:0.38,y:y+0.34,w:9.22,h:0.72,fontSize:12,color:C.light,fontFace:"Calibri",valign:"top"});
  });
}

// Viva 2
{
  const s=ds(); hdr(s,"VIVA Q&A — SET 2","Clinical tests, duplex, and CEAP");
  const qas=[
    ["Q: Describe the Trendelenburg test — technique and anatomical basis.","A: TECHNIQUE: Patient supine, leg elevated to drain veins. Compress SFJ with thumb or tourniquet. Ask patient to stand. Observe filling pattern. THEN release compression. RESULT: Filling from below with compression ON = incompetent perforators below tourniquet level. Rapid filling from ABOVE on RELEASING = SFJ incompetent (positive Trendelenburg). ANATOMICAL BASIS: Tourniquet occludes the GSV at its junction, testing whether SFJ valve is maintaining competence against the column of blood above."],
    ["Q: What information does duplex ultrasound provide in varicose veins?","A: (1) Presence and distribution of reflux (SFJ, SPJ, perforators). (2) Duration of reflux (>0.5 sec superficial; >1 sec deep = significant). (3) Vein diameter and suitability for ablation. (4) Deep vein patency (exclude DVT/obstruction). (5) Tortuosity of vein. (6) Pelvic sources. Patient must stand. Elicit with: calf squeeze/Valsalva. GOLD STANDARD — replaces all clinical tests clinically (Bailey & Love 28e)."],
    ["Q: What is the CEAP classification? Classify our patient.","A: Clinical-Etiological-Anatomical-Pathophysiological. C0-C6 (clinical severity). E: Ep=primary, Es=secondary, Ec=congenital. A: As=superficial, Ad=deep, Ap=perforator. P: Pr=reflux, Po=obstruction. OUR PATIENT: C2,S (symptomatic varicose veins) — Ep (primary) — As (superficial only) — Pr (reflux). Full classification: C2,S,Ep,As,Pr."],
    ["Q: What is the difference between venous, arterial and neuropathic ulcers?","A: VENOUS: Gaiter area, mild pain, sloping edges, granulating base, pigmentation, lipodermatosclerosis, ABI>0.9, worse on standing. ARTERIAL: Toes/pressure points, severe nocturnal pain, punched-out edges, necrotic base, cold pale leg, absent pulses, ABI<0.5. NEUROPATHIC: Pressure points/sole, PAINLESS, punched-out with callus rim, warm foot, DM/leprosy, Charcot joints. Treatment differs fundamentally."],
  ];
  qas.forEach((qa,i)=>{
    const y=1.07+i*1.13;
    s.addShape(pres.ShapeType.rect,{x:0.28,y,w:9.44,h:0.33,fill:{color:C.mid},line:{color:C.mid,width:0}});
    s.addText(qa[0],{x:0.38,y:y+0.02,w:9.22,h:0.3,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle"});
    s.addText(qa[1],{x:0.38,y:y+0.34,w:9.22,h:0.72,fontSize:12,color:C.light,fontFace:"Calibri",valign:"top"});
  });
}

// Viva 3
{
  const s=ds(); hdr(s,"VIVA Q&A — SET 3","Surgery, endovenous treatment & complications");
  const qas=[
    ["Q: Describe the steps of Trendelenburg operation for SFJ ligation + stripping.","A: (1) GA/spinal anaesthesia. Patient supine. (2) Oblique groin incision 3-4cm below and lateral to pubic tubercle. (3) Expose SFJ through saphenous opening (fossa ovalis). (4) Identify and ligate ALL 5 tributaries of GSV at SFJ. (5) FLUSH ligation of GSV at femoral vein (NO stump). Close cribriform fascia. (6) Pass PIN stripper distally to KNEE LEVEL only. (7) Strip GSV from groin to knee. (8) Phlebectomy via multiple 2-3mm stab incisions over pre-marked tributaries. (9) Compression bandage. CAUTION: Avoid femoral artery/vein (medial to femoral artery at SFJ). Close fascia lata."],
    ["Q: What is endovenous laser ablation (EVLA)? What are its advantages over surgery?","A: EVLA: Laser energy delivered intraluminally via fibre → thermal injury → endothelial destruction → fibrosis. Technique: Percutaneous access + tumescent LA + activated during pullback. ADVANTAGES over surgery: Day-case/LA. No groin incision → less neovascularisation risk → less recurrence. No GA risk. Faster return to work. Less haematoma, bruising, scarring. Equivalent efficacy (>95% closure). NICE 2013 recommends as FIRST LINE over surgery."],
    ["Q: What are the complications of varicose vein surgery?","A: INTRAOPERATIVE: Femoral vein injury, femoral artery injury, lymphatic injury (lymphocele). EARLY: Haematoma (stripping track), wound infection (groin), DVT (<0.5%), bruising. NERVE INJURIES: Saphenous nerve → medial calf sensory loss (strip only to knee). Sural nerve → SSV surgery → lateral foot. Common peroneal nerve → SPJ surgery → foot drop. LATE: Recurrence (20-30% at 5yr — neovascularisation). Lymphoedema. Thrombophlebitis."],
    ["Q: What is EHIT and how do you manage it?","A: EHIT = Endovenous Heat-Induced Thrombus. Thrombus extension from ablated GSV into the femoral vein through the SFJ. Classified Grade 1-4: Grade 1 = thrombus at SFJ but NOT into femoral (monitor). Grade 2 = <50% femoral vein occlusion. Grade 3 = >50% occlusion. Grade 4 = complete occlusion. MANAGEMENT: Grade 1: Monitor with USS. Grade 2+: Anticoagulate with LMWH then DOAC until thrombus resolved (typically 4-6 weeks). Risk reduced by: stopping ablation 2cm below SFJ, adequate tumescent anaesthesia."],
  ];
  qas.forEach((qa,i)=>{
    const y=1.07+i*1.13;
    s.addShape(pres.ShapeType.rect,{x:0.28,y,w:9.44,h:0.33,fill:{color:C.mid},line:{color:C.mid,width:0}});
    s.addText(qa[0],{x:0.38,y:y+0.02,w:9.22,h:0.3,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle"});
    s.addText(qa[1],{x:0.38,y:y+0.34,w:9.22,h:0.72,fontSize:12,color:C.light,fontFace:"Calibri",valign:"top"});
  });
}

// Viva 4
{
  const s=ds(); hdr(s,"VIVA Q&A — SET 4","Advanced & miscellaneous viva questions");
  const qas=[
    ["Q: What are the causes of recurrent varicose veins?","A: Mnemonic TARDN: (1) TACTICAL ERROR — missed tributaries, incomplete SFJ ligation, residual stump, untreated SSV. (2) ANGIOGENESIS/NEOVASCULARISATION — most common cause (40-60%). New vessels develop in groin scar tissue → bypass previous ligation. Less with endovenous (no groin incision). (3) REFLUX from new site — AAGSV, SSV, new perforator not identified. (4) DEEP VENOUS disease progression. (5) NEOVASCULOGENESIS. Assessment: Duplex USS mapping. Management: UGFS for neovascular tissue (1st choice), re-do surgery (high risk, scarring)."],
    ["Q: What is the mechanism of venous leg ulcer formation in varicose veins?","A: Venous hypertension (incompetent valves → high-pressure reflux) → capillary hypertension → RBC extravasation → haemosiderin deposition → fibrin cuffs around capillaries (Browse & Burnand fibrin cuff hypothesis) → leucocyte trapping → inflammatory cytokines → endothelial damage → skin ischaemia → ulceration. Site: Gaiter area (medial malleolus) — Cockett's perforators area. Management: 4-layer compression bandaging (reduce venous HTN) + treat underlying reflux. Pentoxifylline adjunct."],
    ["Q: What is foam sclerotherapy? Describe the Tessari technique.","A: Sclerosant liquid (polidocanol 1-3% or STS) converted to foam by mixing with air/CO2 (Tessari method: 1 part liquid: 4 parts gas, two 10ml syringes connected by 3-way stopcock, passed 20 times). Foam displaces blood → prolongs endothelial contact → destroys endothelium → thrombosis → fibrosis. UGFS: USS-guided needle placement, inject proximally, compress immediately. Max 12ml per session. Complication: Visual disturbance/TIA if PFO present (gas emboli pass to arterial circulation). Use CO2/O2 instead of room air to reduce this risk."],
    ["Q: What is Perthes' test and when is surgery contraindicated in VV?","A: PERTHES' TEST: Tourniquet mid-thigh in standing patient. Ask to walk 50 paces or do calf raises. Veins decrease = deep veins patent, muscle pump functioning (SAFE for surgery). Veins increase or pain develops = deep venous obstruction present (secondary VV or post-DVT). CONTRAINDICATIONS to superficial venous surgery/ablation: (1) Deep venous obstruction (positive Perthes') — removing superficial veins = only drainage route → limb threatened. (2) PAD with ABI <0.8 (no compression). (3) Pregnancy (wait 3 months post-delivery). (4) Active infection/cellulitis over vein."],
  ];
  qas.forEach((qa,i)=>{
    const y=1.07+i*1.13;
    s.addShape(pres.ShapeType.rect,{x:0.28,y,w:9.44,h:0.33,fill:{color:C.mid},line:{color:C.mid,width:0}});
    s.addText(qa[0],{x:0.38,y:y+0.02,w:9.22,h:0.3,fontSize:12,bold:true,color:C.gold,fontFace:"Calibri",valign:"middle"});
    s.addText(qa[1],{x:0.38,y:y+0.34,w:9.22,h:0.72,fontSize:12,color:C.light,fontFace:"Calibri",valign:"top"});
  });
}

// Quick reference summary
{
  const s=ds(); hdr(s,"QUICK REFERENCE — VV AT A GLANCE","Master summary for viva");
  tbl(s,[
    ["TOPIC","KEY POINTS"],
    ["Definition","Dilated >3mm, tortuous superficial veins with incompetent valves"],
    ["Most common site","SFJ incompetence >80%. SSV ~20%"],
    ["Most common cause of recurrence","Neovascularisation at groin (40-60%)"],
    ["Gold standard investigation","Duplex ultrasound — reflux >0.5s superficial / >1s deep"],
    ["NICE first-line treatment","EVLA or RFA (endovenous thermal ablation)"],
    ["Contraindication to surgery","Deep venous obstruction (Perthes' +ve), ABI <0.8, active pregnancy"],
    ["Most common nerve injury (GSV stripping)","Saphenous nerve → strip to KNEE only (NOT ankle)"],
    ["Most common nerve injury (SSV surgery)","Sural nerve (lateral foot). Also: common peroneal → footdrop"],
    ["VLU site","Gaiter area — medial malleolus. Cockett's perforators (5, 10, 15 cm above MM)"],
    ["VLU management","4-layer compression + treat reflux. Pentoxifylline adjunct"],
    ["Foam complications","Visual disturbance, TIA/stroke (PFO), DVT, thrombophlebitis, pigmentation"],
    ["EHIT management","Grade 1: monitor. Grade 2+: anticoagulate (LMWH → DOAC)"],
    ["Saphena varix vs hernia","Varix: appears standing, disappears lying, cough impulse, venous; Hernia: persistent, may have bowel content"],
    ["Perthes' test","NEGATIVE (veins decrease) = safe to operate. POSITIVE (veins worsen) = contraindication"],
    ["CEAP our case","C2,S,Ep,As,Pr — symptomatic primary VV, superficial reflux only"],
  ],{cw:[3.5,5.9],fs:12});
}

// THANK YOU
{
  const s=pres.addSlide(); s.background={color:C.bg};
  s.addShape(pres.ShapeType.rect,{x:0,y:0,w:10,h:0.12,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addShape(pres.ShapeType.rect,{x:0,y:5.5,w:10,h:0.125,fill:{color:C.mid},line:{color:C.mid,width:0}});
  s.addText("THANK YOU",{x:0.5,y:1.3,w:9,h:1.2,fontSize:44,bold:true,color:C.white,fontFace:"Calibri",align:"center",charSpacing:8});
  s.addShape(pres.ShapeType.rect,{x:3,y:2.6,w:4,h:0.05,fill:{color:C.accent},line:{color:C.accent,width:0}});
  s.addText("Varicose Veins — Case Presentation & Complete Review\nPG General Surgery",{x:0.5,y:2.75,w:9,h:0.8,fontSize:16,color:C.gold,fontFace:"Calibri",align:"center"});
  s.addText("Bailey & Love's Short Practice of Surgery 28e  |  Schwartz's Principles of Surgery 11e\nGray's Anatomy for Students  |  Robbins Pathology  |  Current Surgical Therapy 14e",{x:0.5,y:3.7,w:9,h:0.8,fontSize:11.5,color:C.gray,fontFace:"Calibri",align:"center"});
  s.addText('"The best surgeon knows when NOT to operate."  — Lord Moynihan',{x:0.5,y:4.65,w:9,h:0.55,fontSize:13,italic:true,color:C.light,fontFace:"Calibri",align:"center"});
}

pres.writeFile({fileName:"/home/daytona/workspace/vv-ppt/VV_Case_Presentation_PG_Surgery.pptx"})
  .then(()=>console.log("SUCCESS: VV_Case_Presentation_PG_Surgery.pptx created"))
  .catch(err=>{console.error("ERROR:",err);process.exit(1);});