Case-based MCQ

A 60 -year- old man presents with leg pain for the past 6 months. The pain becomes worse with walking and is relieved when he rests. There is no pain at rest. He has smoked 20 cigarettes per day for the past 30 years. On examination, he is obese with a BMI of 31 and has a blood pressure of 160/110 mmHg on two readings 20 minutes apart. Distal pulses of the left lower limb, including dorsal pedis, are barely perceptible. The skin of the legs is shiny and hairless. Mild muscular atrophy of the leg is noted. Ankle-brachial index (ABI) is 0.7. Which one of the following would be the most appropriate management and advice? A. Smoking cessation, exercise and follow-up in three months B. Smoking cessation, statins and ACE inhibitors C. Duplex Doppler venous ultrasonography D. Aspirin, metoprolol and statins E. Referral for vascular surgery

Correct Answer Is E Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis. It affects 10–15% of the general population, and approximately 50% of PAD patients are asymptomatic; leading to under-diagnosis and under-treatment of the disease. The most common symptom of PAD is intermittent claudication (IC) affecting the calf muscles, which may be present in as few as 10% of patients. Symptomatic PAD patients have a worse prognosis than patients presenting with coronary artery disease or cerebrovascular disease, but their atherosclerosis risk factors are less intensively treated. Both asymptomatic and symptomatic PAD patients have a high risk of death from cardiovascular disease (CVD), therefore early treatment reduces mortality. Careful history and clinical examination remain the initial means of diagnosing PAD. Ankle-brachial index measurement should be the initial diagnostic tool used in general practice. From the context above, the findings are sufficient in supporting the diagnosis of PAD and hence the best management is to advice for smoking cessation. Smoking cessation is an important modifiable behaviour. The degree of damage caused by smoking is directly related to the amount of tobacco consumed. Smoking cessation improves walking distance, doubles the 5 year survival rate, and reduces the incidence of post-operative complications. Detailed anatomic imaging (as such US doppler or CTA) is not necessary if endovascular or open surgical intervention is not planned, and aneurysmal disease can be confidently excluded on physical examination. A more detailed anatomical information about PAD may be required to if aneurysm is suspected and to plan endovascular or open surgical intervention. Abdominal aortic aneurysm can occur in up to 10% of patients with PAD, or popliteal aneurysm might be suggested by prominent popliteal pulses. While catheter Digital Subtraction Angiography (DSA) remains the gold standard for imaging peripheral arteries, it is rarely used for diagnosis because of its invasive nature and the availability of non-invasive imaging modalities (ie. DUS, CTA, MRA). Duplex ultrasound is used to guide most endovascular interventions, and some surgeons still prefer DSA for planning open revascularisation procedures, particularly for tibial and pedal bypass procedures.

A 75-year-old man comes with left calf claudication. He has a 40 pack-year history of smoking. On examination, all peripheral pulses are palpable on the right side. On the left side, all pulses palpable except dorsalis pedis. ABI (Ankle-brachial index) on the right side is 1 and on the left side is 0.70. What is the most appropriate next step management? A. CT Angiogram B. MR Angiogram C. Digital Subtraction Angiography (DSA) D. Doppler Ultrasound (DUS) E. Advice for smoking cessation

Correct Answer Is E Treatment of DVT starts with either unfractionated or low molecular weight heparin. Warfarin could be started at the same day(or within 48 hours). Heparin therapy should be continued for 5 days and stopped once INR is above 2 in two consecutive days. Warfarin should be continued for at least 3 months or more depending on the patient’s risk of recurrent venous thromboembolism. The objectives of anticoagulation therapy are treating the current DVT and prevention of pulmonary embolism. Studies have shown that as many as 33% of patients may develop PE while receiving adequate anticoagulation therapy. Cava filters are an alternative to systemic anticoagulation with warfarin (or heparin) in the following situation. DVT or PE in patients with contraindications to anticoagulation therapy; these patients include those with: - Hemorrhagic stroke - Recent neurosurgical procedure or other major surgery Major or multiple trauma - Active internal bleeding (e.g. upper or lower gastrointestinal bleeding, hematuria, hemophilia) - lntracranial neoplasm (either primary or metastatic) - Bleeding diathesis (e.g. secondary thrombocytopenia,idiopathic thrombocytopenic purpura, hemophilia) - Pregnancy - Unsteady gate or tendency to fall (as seen in patients with previous stroke, Parkinson disease) - Poor patient compliance with medications   As this patient is known be noncompliance with his medications he should have a inferior vena cava filter for prevention of PE.

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John, 35 years old, presents to the emergency department with pain and swelling of his left thigh since this morning. Investigations establish the diagnosis of deep venous thrombosis for which he is started on heparin in hospital. He has diabetes and hypertension and his wife mentions that is very busy and distracted and always forgets to take the drugs he is prescribed for treatment of his hypertension and diabetes. Which one of the following options would be the most appropriate management for him after the course of heparin is completed? A. No more treatment is needed B. Warfarin for 6 months C. Aspirin for 6 months D. Surgical intervention E. Caval filter

Correct Answer Is B This patient has developed critical acute limb ischemia requiring urgent vascular surgery for revascularization and restoration of blood supply. Clinical signs of acute arterial occlusion include (6 P’s): Pain Paralysis Pulselessness Pallor Paresthesia Poikilothermia. With any of the above signs or symptoms the patient is considered to have acute limb ischemia. To confirm the diagnosis of acute arterial occlusion and the extent of obstruction, the patient should have an urgent CT angiogram as the road map to the surgery. Magnetic resonance angiography with contrast is an alternative to CT angiography with about the same sensitivity and specificity. Abdominal CT scan is not required as this patient did not present primarily with abdominal problems. Pelvic ultrasound or Doppler Duplex ultrasound of the calf veins adds nothing to the management strategy because firstly the diagnosis is already made, and secondly these modalities do not provide adequate information regarding the anatomical site of the occlusion. Furthermore , Doppler Duplex ultrasound is highly operator-dependent. Echocardiography is the investigation to consider once acute phase of arterial occlusion has been managed. Thombi from the heart is a main source of acute limb ischemia

A 40-year-old man presents to the emergency department after sudden onset of the right calf pain and paralysis. The right dorsal pedis pulse is not perceptible. The limb feels cold and is pale. The patient is given analgesics. After starting the patient on heparin , which one of the following would be the most appropriate step in management? A. Abdominal CT B. CT angiogram C. Doppler Duplex ultrasound of the calf veins D. Pelvic ultrasound E. Echocardiography

Correct Answer Is D Leg pain brought up by walking and relieved by rest and weak or absent distal pulses are characteristic of chronic limb ischemias as a result of chronic obstructive arterial disease. Atrophied muscles and shiny hairless skin supports the diagnosis. The clinical findings in chronic limb ischemia include: Weak or absent distal pulses – the hallmark finding Shiny and hyperpigmented skin Hair loss and leg ulcers Thickened nails Muscular atrophy Vascular bruits   Acute limb ischemia presents with sudden onset pain, pallor, paralysis, paresthesia, pulselessness and poikilothermia. This patient has features of chronic limb ischemia. Leg pain due to deep vein thrombosis can be brought on by walking and relieved by rest (similar to chronic limb ischemia), but other features such as sparse leg hair, pigmen tation, muscle atrophy, etc are not features of DVT. DVT presents with leg pa in and tenderness, swelling and warmth. Superficial thrombophlebitis presents with pain, erythema, induration and tenderness along the course of a superficial vein. Leg pain caused by neurogenic claudication due to spinal canal stenosis tends to get worse with erect posture and relieved by recumbency . Absence of neurological deficits makes this diagnosis less likely

A 76-year-old man comes to your office for evaluation . He mentions that he has difficulty walking because of the left leg pain. The pain is brought on after walking two blocks and gets better when he stops to rest. On examination, the leg skin is shiny and dark. The legs hair is lost and the muscles are atrophied. Distal pulses are difficult to palpate . Which one of the following is the most likely diagnosis? A. Acute limb ischemia B. Deep vein thrombosis C. Superficial vein thrombosis D. Chronic obstructive arterial disease E. Spinal canal stenosis

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Correct Answer Is B Reperfusion injury is a complication of blood restoration to a limb, which has been ischemic for a while. Characteristic features of reperfusion injury are all related to ischemia and its impacts on tissue (especially muscle cells). Features of reperfusion syndrome include: -Metabolic acidosis (lactic acidosis) -Elevated creatinine kinase -Hyperkalemia -Myoglobinemia and myoglobinuria   These findings are caused by hypoxemia resulting in metabolic acidosis, and muscle cell breakdown an d release of its cell into the blood. Hypokalemia is not a characteristic feature of reperfusion injury. The extent of the reperfusion injury depends on the following: Duration and the site of arterial blockage The extent of collateral flow to the affected area The previous health of the affected limb   Approximately one third of all deaths from arterial occlusions are due to metabolic complications after revascularisation.

A 70-year-old man presents with acute pain and paralysis of the right leg diagnosed to have been caused by acute leg ischemia. Heparin is started immediately. After emergency imaging, he is transferred to the operating room for embolectomy. Surgical intervention successfully restored blood supply to the affected limb after 3 hours. This patient is at risk of developing reperfusion injury as a result of prolonged ischemia. Which one of the following is not a characteristic feature of reperfusion injury? A. Hyperkalemia B. Hypokelemia C. Metabolic acidosis D. Myoglobinuria E. Elevate creatinine kinase

This patient presented with acute lower limb ischemia caused by femoral artery occlusion by an embolus. Signs and symptoms of acute arterial limb ischemia include pain, pallor, paraesthesia, pulselessness, paralysis and perishing cold. Paralysis or paresis and muscle compartment pain is the most ominous sign. Arterial occlusion is usually reversible if treated within 4 hours. It is often irreversible if treated after 6 hours. This patient should be given heparin 5000units intravenously and emergency embolectomy should be performed either under local or general anaesthesia. Arterial bypass is helpful if it is chronic limb ischemia. Amputation is required only if there are irreversible ischemic changes.

A 67-year-old male presented with sudden onset of left sided leg pain and paresthesias. On examination distal pulses are absent and the limb is cold. Neurological examination is normal. CT angiogram shows femoral artery embolism. What will you do next? A. Intravenous heparin infusion for 24 hours and then review B. Intravenous heparin and emergency embolectomy C. Complete bed rest until pulses are normal D. Give warfarin E. Give vitamin K

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