SU27.1-8 | Vascular and Lymphatic Surgery — Assignment

CLINICAL SCENARIO

A 64-year-old man, a long-standing smoker with type 2 diabetes, attends the vascular clinic. For a year he has had cramping right-calf pain on walking 150 metres, relieved by rest; over the last month the pain wakes him at night in the forefoot and is eased by hanging the leg out of bed. On examination the right foot is cool with absent foot pulses, there is a small black, dry, painless, well-demarcated patch on the tip of the second toe, and an ABPI is recorded as 1.3 on the right. He also has dilated tortuous veins on the medial aspect of the same calf with ankle pigmentation, and mentions that his wife has chronic non-pitting swelling of one leg after living in a filariasis-endemic region. Work through this man's intertwined arterial, venous, gangrenous and lymphatic problems using vascular reasoning.

1. Placing the patient on the occlusive arterial spectrum (SU27.1)

Explain, with reasoning, where this man sits on the spectrum of chronic occlusive arterial disease and how his symptoms have progressed. Describe the principle of management at each stage (best medical therapy/risk-factor modification through to revascularisation).

Guidance: Claudication → nocturnal rest pain relieved by dependency → early tissue loss; smoking cessation and risk-factor control are the foundation.

2. The falsely reassuring ABPI (SU27.1, SU27.2)

His ABPI is 1.3 yet his leg is clearly ischaemic. Explain this paradox, why it is especially relevant in a diabetic, and how it changes your interpretation and further investigation.

Guidance: Medial arterial calcification → non-compressible vessels → falsely normal/high ABPI; consider toe pressures/duplex/imaging.

3. Dry gangrene of the toe and amputation principles (SU27.4)

Classify the lesion on his toe and contrast dry versus wet gangrene. State the principle of management of dry gangrene of a toe in a patient with peripheral arterial disease, and the general principles of amputation (treat the cause, optimise the patient, level selection).

Guidance: Dry = gradual ischaemia, no infection, mummified/demarcated, usually stable → treat ischaemia/consider revascularisation; wet = infected, spreading, emergency.

4. The varicose veins and venous anatomy (SU27.5, SU27.6)

Explain the applied venous anatomy of the lower limb (deep, superficial, perforators, valves, calf pump) and how sapheno-femoral junction incompetence produces great saphenous varicose veins with skin changes. State why arterial supply MUST be checked before compression therapy.

Guidance: GSV → sapheno-femoral junction; SSV → sapheno-popliteal junction; never compress an ischaemic leg — directly relevant given his arterial disease.

5. The wife's lymphoedema and the swollen-limb discrimination (SU27.7, SU27.8)

Explain why the wife's swelling is lymphoedema rather than venous/systemic oedema, the likely infective cause in an endemic area, and the bedside discrimination between pitting and non-pitting oedema. Outline the principle of lifelong conservative management.

Guidance: Non-pitting, positive Stemmer's sign, filariasis (Wuchereria bancrofti); skin hygiene, compression, limb care are lifelong.