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MyPasTest: MRCS A Online - Jan Exam 201530. Systemic Surgery- Vascular Surgery (38Qs)
01. A 78-year-old lifelong smoker presents with a punched out deep ulcer on the ball of his foot. On
examination the foot is cool and hairless and sensation is reduced. The Dorsalis Pedis and Posterior
Tibial pulse are difficult to feel. What is the likely aetiology? Select one answer only.
Arterial « YOUR ANSWER (Correct Answer)
Diabetic
Infective Page |
Malignant 1659
Venous.
This patient has peripheral arterial disease with typical deep punched out ulcers. The limb has signs
of chronic ischaemia with absent pulses. These ulcers usually occur in pressure areas such as the
ball of the foot or heel.
02. Theme: level of arterial disease and location of symptoms
A Aorto-iliac occlusion
B External iliac/common femoral occlusion
C Superficial femoral artery occlusion
D Crural vessel occlusion
E Aorto-iliac occlusion and superficial femoral artery occlusion.
For each of the patients below, choose the most likely level of arterial disease from the list above.
Each option may be selected once, more than once or not at all.
Scenario 1
Rest pain and foot ulcers
A - Aorto-iliac occlusion« YOUR ANSWER
E - Aorto-iliac occlusion and superficial femoral artery occlusion« CORRECT ANSWER.
Scenario 2
Impotence
B - External iliac/common femoral occlusion« YOUR ANSWER
A - Aorto-iliac occlusion« CORRECT ANSWER.
Scenario 3
Calf claudication
C - Superficial femoral artery occlusion« CORRECT ANSWER.
Scenario 4
Thigh claudication
D - Crural vessel occlusion« YOUR ANSWER
B - External iliac/common femoral occlusion« CORRECT ANSWER.
Scenario 5
Buttock claudication
E - Aorto-iliac occlusion and superficial femoral artery occlusion« YOUR ANSWER
A - Aorto-iliac occlusion« CORRECT ANSWER.
Claudication pain usually occurs in the muscle group just distal to the diseased artery. Tissue loss
usually only results when there is disease at more than one level.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
30. Systemic Surgery- Vascular Surgery (38Qs)
02. Theme: supra-aortic arterial surgey
A Carotid-carotid bypass
B Carotid-subclavian bypass
C Carotid endarterectomy
D Superficial temporal artery-middle cerebral artery bypass
E Thoracic-outlet decompression.
Page |
For each of the pathologies below, choose the procedure from the list above that may be required to
deal with the condition. Each option may be selected once, more than once or not at all. 1660
Scenario 1
Subclavian steal syndrome
A - Carotid-carotid bypass« YOUR ANSWER
B - Carotid-subclavian bypass« CORRECT ANSWER.
Scenario 2
Amaurosis fugax
B - Carotid-subclavian bypass« YOUR ANSWER
C - Carotid endarterectomy« CORRECT ANSWER.
Scenario 3
Unilateral 95% stenosis of the carotid bifurcation
C - Carotid endarterectomy« CORRECT ANSWER.
Scenario 4
Paget–Schroetter syndrome (axillary vein thrombosis)
D - Superficial temporal artery-middle cerebral artery bypass« YOUR ANSWER
E - Thoracic-outlet decompression« CORRECT ANSWER.
Scenario 5
Endovascular repair of a thoracic aneurysm where the landing zone involves the origin of the left carotid artery
(ie the origin of the left carotid artery is covered by the stent graft)
E - Thoracic-outlet decompression« YOUR ANSWER
A - Carotid-carotid bypass« CORRECT ANSWER.
Superficial temporal artery to middle cerebral artery bypass is now an obsolete procedure. Carotid
endarterectomy is indicated for both symptomatic and asymptomatic internal carotid artery stenosis
70%. Stenting of thoracic aneurysms is becoming preferable to ope n surgery due to its much lower
peri-/post-operative mortality. If the aneurysm is close to the origins of the left subclavian and left
carotid vessels, these may be covered by the stent as long as a carotid–carotid bypass is performed
before stenting, thereby preventing a left cerebrovascular accident. The left subclavian can usually be
covered without impunity. Paget–Schroetter syndrome (axillary vein thrombosis) is likely to recur
unless the thoracic outlet is decompressed.
04. A 72-year-old man is transferred to your vascular centre with a suspected AAA. Fast scan at the
initial hospital emergency department showed a 9cm suspected aneurysm. Vital signs are as follows;
heart rate 100, Blood pressure 117 systolic, 02sats 94% on room air. What is the next appropriate
step? Select one answer only.
CT scan« YOUR ANSWER (Correct Answer)
Elective repair
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
30. Systemic Surgery- Vascular Surgery (38Qs)
Theatre for emergency EVAR
Theatre for emergency open repair
Repeat Fast Scan.
This patient has a AAA and at present is relatively haemodynamically stable. Preferably when the Page |
surgical team is alerted to this transfer, radiology should be alerted to be on standby. Once the patient
is rapidly assessed in the emergency department and if haemodynamically stable and appears safe to 1661
do so as in the case above, an urgent CT scan should be performed. This allows confirmation of
diagnosis of the aneurysm and potential complication – leak or rupture and allows the vascular
surgeon to review the anatomy including the neck of the aneurysm as this aids planning for surgical
intervention including potential suitability for EVAR which if available can be performed in the
emergency setting if the patient is stable. Clearly if the patient is haemodynamically unstable and a
ruptured AAA is suspected, the vascular consultant should be informed and there should be no delay
to theatre.
05. THEME: LOWER-LIMB ULCERATION
A Squamous cell carcinoma
B Hypertensive ulcer (Martorell syndrome)
C Pyoderma gangrenosum
D Neuropathic ulcer
E Vasculitic ulcer
F Necrobiosis lipoidica
G Sickle cell disease
H Venous ulcer
I Basal cell carcinoma
J Erythema nodosum.
For each of the case descriptions below, select the most appropriate diagnosis from the list above.
Each option may be used once, more than once, or not at all.
Scenario 1
A 54-year-old woman with known inflammatory bowel disease presents with a large nodulopustular ulcerating
lesion over her right anterior shin. It has a blue overhanging necrotic edge. Her ankle–brachial pressure
indices are normal.
A - Squamous cell carcinoma« YOUR ANSWER
C - Pyoderma gangrenosum« CORRECT ANSWER.
Pyoderma gangrenosum (PG) are recurring nodulopustular ulcers commonly affecting the legs,
abdomen and face. They are tender and have a red or blue overhanging necrotic edge. They heal with
cribriform scars. Over 50% of patients with PG have associated underlying active or quiescent
systemic disease – such as inflammatory bowel disease, seronegative rheumatoid arthritis, a
lymphoproliferative disease, autoimmune hepatitis or Wegener’s granulomatosis. The diagnosis of PG
is primarily clinical and by exclusion of other causes of cutaneous ulcerations with a similar
appearance; skin histology may help. Treatment is usually with immunosuppressants and
corticosteroids.
Scenario 2
A 57-year-old woman with varicose veins presents with a large ulcer over her left medial malleolus. This is
associated with surrounding lipodermatosclerosis and eczema. The ankle–brachial pressure index in this leg
is 1. The patient is moderately obese.
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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