Specialist & Consultant Vascular Surgery oral assessment prep

Knowledge: This is a contained retroperitoneal rupture of an infrarenal aneurysm, and he is alive because the retroperitoneum is tamponading the bleed. Aggressive fluid raises pressure and dilutes clotting factors, so permissive hypotension is used while he remains alert. The ESVS 2024 guideline recommends endovascular repair as the first option when anatomy is suitable. IMPROVE showed similar early mortality with an endovascular-first strategy but faster discharge, better quality of life and a survival advantage by three years. A long neck makes him a good candidate. Threats after repair include abdominal compartment syndrome, colonic ischaemia, renal failure and limb ischaemia.

Management: I activate the ruptured aneurysm pathway: vascular consultant, anaesthetist, hybrid theatre team and the major haemorrhage protocol. While moving to theatre I accept a low systolic pressure as long as he is conscious, give blood products in balanced ratios and avoid crystalloid boluses. I place a femoral sheath under local anaesthesia, ready for an aortic occlusion balloon if he collapses, and avoid early general anaesthesia, which can precipitate cardiovascular collapse. I perform EVAR under local anaesthesia where possible. Afterwards in ICU I measure bladder pressure regularly and decompress by laparotomy if abdominal compartment syndrome develops. I watch lactate, urine output, limb perfusion and bloody diarrhoea that suggests colonic ischaemia, and correct coagulopathy and hypothermia. I would not transfer him unstable to another hospital. Follow-up includes CT surveillance for endoleak, statin and antiplatelet therapy, smoking cessation and screening advice for first-degree relatives.

Ethics and communication: If he has capacity, consent is brief but real: survival is not guaranteed and he may decline. If the family ask that he not be told how serious it is, I explain gently that he must understand to decide. I do not blame him for postponing surgery and record the facts neutrally. If repair is judged futile, I discuss palliation openly with him and his family.

Reference: ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

Knowledge: This is acute limb ischaemia, most likely embolic given atrial fibrillation, interrupted anticoagulation, sudden onset and a normal contralateral limb, with a palpable femoral pulse suggesting a femoropopliteal embolus. Sensory loss beyond the toes with mild motor weakness and audible venous but absent arterial signals places her in Rutherford class IIb, immediately threatened and needing revascularisation within hours. Class IIa allows time for imaging and thrombolysis, while class III with paralysis and absent venous signals is irreversible. Differentials include thrombosis on atherosclerotic disease, popliteal aneurysm thrombosis and aortic dissection. The ESVS 2020 guideline supports immediate anticoagulation and urgent open or endovascular revascularisation.

Management: Immediately I give intravenous unfractionated heparin, typically a 5000 unit bolus then an infusion, with analgesia and fluids. I send full blood count, renal function, creatine kinase, coagulation and an ECG. Because she is class IIb, I take her straight to a hybrid theatre for femoral embolectomy with a Fogarty catheter, with on-table angiography and endovascular or bypass adjuncts if the outflow is not cleared. Catheter-directed thrombolysis is too slow for a limb with motor deficit. After reperfusion I assess the compartments repeatedly and perform four-compartment fasciotomy if compartment syndrome develops. I monitor potassium, acidosis, myoglobinuria and urine output. Over the next days she continues anticoagulation and has echocardiography for a cardiac source. Follow-up covers limb function and long-term anticoagulation adherence.

Ethics and communication: She has capacity, so I explain the risks of embolectomy, fasciotomy and amputation in plain language. I explore why she stopped anticoagulation without judgement, looking for cost, side effects or misunderstanding, and address it with her cardiologist. If a delay in referral caused harm, I disclose it honestly. Consent, timings and examination findings are documented clearly.

Reference: ESVS 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia; Sidawy and Perler, Rutherford's Vascular Surgery and Endovascular Therapy, 10th ed, 2022

Knowledge: This is chronic limb-threatening ischaemia with diabetic foot infection and probable osteomyelitis of the hallux. The ankle brachial index is falsely raised by medial calcification, so toe pressure and waveforms are the reliable measures, and 22 mmHg indicates severe ischaemia. The Global Vascular Guidelines recommend staging with WIfI, here roughly wound 2, ischaemia 3 and foot infection 2, indicating high amputation risk and high benefit from revascularisation. Anatomy is graded with GLASS to guide endovascular versus bypass choice. Dialysis and tibial disease predict poorer outcomes. Infection must be controlled first or alongside revascularisation, because sepsis can destroy the foot within days.

Management: I admit him today, take deep tissue or bone samples and start empirical antibiotics covering Gram-positive and Gram-negative organisms, dosed for dialysis and guided by IWGDF/IDSA advice. I request plain films and MRI for osteomyelitis and examine for abscess. If there is an abscess or wet gangrene, urgent drainage or toe amputation comes first, within 24 to 48 hours. Within days, after angiography mapping tibial and pedal targets, I plan revascularisation: tibial angioplasty if the disease is focal or he lacks usable vein, or vein bypass if a good conduit and target exist and life expectancy is reasonable, informed by BEST-CLI. Wound care runs through a multidisciplinary foot team with offloading. I optimise glucose, statin and antiplatelet therapy. I would not perform a definitive minor amputation without first restoring flow. Follow-up includes surveillance, podiatry and footwear.

Ethics and communication: He needs time and clear information on limb salvage versus primary amputation, including realistic outcomes on dialysis. Decisions are his, and family join only if he wishes. Insurance approval must not delay urgent infection surgery, and I document my advocacy with the insurer. I offer psychological support given the burden of repeated procedures.

Reference: Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia, 2019; IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections, 2023

Knowledge: This is recently symptomatic severe left carotid stenosis with a minor stroke. The risk of recurrent stroke is highest in the first days, and the benefit of endarterectomy shown in NASCET and ECST is greatest when surgery is early and falls sharply after two weeks. The ESVS 2023 guideline recommends endarterectomy for recently symptomatic 50 to 99 percent stenosis, ideally within 14 days of symptoms. Stenting is an alternative in selected patients, but procedural stroke risk is higher with stenting in the early period and in patients over 70. Best medical therapy is required whatever intervention is chosen.

Management: Today I start antiplatelet therapy according to the stroke team protocol, which may be short-term aspirin with clopidogrel after a minor stroke, together with a high-intensity statin, blood pressure control and smoking cessation support. I confirm the stenosis on a second modality and discuss him at the neurovascular meeting within 24 to 48 hours. I offer carotid endarterectomy this week, before his travel, under general or local anaesthesia with selective shunting and patch closure. After surgery I monitor neurological status, control blood pressure to prevent hyperperfusion syndrome, and watch for neck haematoma and cranial nerve injury. I would not defer surgery until after his trip without explaining the risk. Follow-up includes duplex, lipid targets and risk factor control.

Ethics and communication: He must understand that the procedural risk of stroke or death is small but real, and that delaying for travel increases his stroke risk, so the decision balances his priorities. If he still chooses to travel, I respect it, maximise medical therapy and give written stroke warning advice. Fitness to drive and fly after a stroke is addressed according to local rules and airline guidance.

Reference: ESVS 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease

Knowledge: This is a bleeding femoral access complication from a high puncture, which is associated with retroperitoneal haemorrhage because the artery above the inguinal ligament cannot be compressed against bone. Instability and a falling haemoglobin make ultrasound-guided compression or thrombin injection inappropriate; thrombin injection suits small, narrow-necked pseudoaneurysms in stable patients. The definitive option is open repair, with endovascular balloon tamponade or a covered stent reserved for selected cases because stenting the common femoral artery has drawbacks. Risk factors include antithrombotic therapy, female sex and high or low puncture. Being a recognised complication makes honest disclosure easier, not unnecessary.

Management: I resuscitate with blood products and adjust antithrombotic therapy only as far as cardiac safety allows, agreeing this with the cardiologist, then take her urgently to theatre. Through a groin incision, extended above the inguinal ligament if needed, I gain proximal control, repair the arterial defect, evacuate the haematoma and confirm distal pulses. Post-operatively I monitor haemoglobin, limb perfusion, femoral nerve function and the wound, and plan antiplatelet therapy for her coronary stent with cardiology. Within 24 hours I make sure she is told what happened, and I complete an incident report. I would not write a misleading operative note or omit the puncture site. The case goes to morbidity review to support measures such as ultrasound-guided puncture.

Ethics and communication: Honest disclosure of a complication is expected whether or not it was avoidable, and accurate records are a legal duty under Federal Decree-Law No. 4 of 2016 on Medical Liability. I decline the request respectfully, explain that disclosure protects the patient and both of us, and offer to speak to her together with the cardiologist. If he refuses, I escalate to the department head. I avoid blaming him in front of the patient.

Reference: Sidawy and Perler, Rutherford's Vascular Surgery and Endovascular Therapy, 10th ed, 2022

Knowledge: This is acute type B dissection, now complicated by mesenteric and left leg malperfusion. Uncomplicated type B dissection is treated medically, but malperfusion, rupture, rapid expansion and refractory pain or hypertension define complicated dissection, for which the 2022 ACC/AHA guideline recommends thoracic endovascular aortic repair (TEVAR) covering the primary entry tear. Mesenteric malperfusion carries high mortality and is time-critical. Mimics include myocardial infarction and pancreatitis, and extension into the ascending aorta must be excluded. The mechanism is usually dynamic true lumen collapse, which TEVAR corrects by redirecting flow into the true lumen.

Management: Immediately I admit him to a monitored bed, give opioid analgesia and intravenous beta-blockade such as esmolol or labetalol, aiming for a heart rate below 60 and systolic pressure below 120 mmHg, adding a vasodilator only after beta-blockade. Given malperfusion, I proceed to emergency TEVAR in a hybrid theatre, considering cerebrospinal fluid drainage for long coverage and left subclavian revascularisation if coverage threatens the vertebral or spinal circulation. After TEVAR I reassess visceral and limb perfusion, adding branch stenting if needed and laparotomy if lactate does not clear. Over the following days I watch for paraplegia, retrograde type A dissection and kidney injury. Long-term care includes strict blood pressure control, regular CT surveillance and genetic assessment if indicated. I would not manage complicated dissection with medical therapy alone.

Ethics and communication: Consent is obtained urgently but must include the risks of paraplegia, stroke and death, with an interpreter if needed. If he loses capacity, treatment proceeds under the emergency exception in UAE law. His occupation raises fitness to drive questions, which I address honestly in line with local rules. His family are updated promptly with his permission.

Reference: 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease