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Hello. Hi, everybody. Welcome to um, Session Tree of our surgical teaching series. Today we have Mr Mra Hamada who has kindly agreed to come and, um, give us a one hour teaching session on vascular surgery. Um Mua worked in H ri in the vascular surgery department and I was very lucky to be able to work with him as his f one last year. Um, he's really knowledgeable, really good. So, yeah, um, we'll let him take it away. Sorry for being four minutes late guys. And if you have any questions again, like you drill, pop it in the chat, um, this would be an interactive session. So if you've got any questions or want to join in the session, please do so pop your answers in the chat and we will be creating pos as we go along as well. All right. Ok, good evening. Uh, everybody. Thanks, uh, Melanie for the nice introduction. Uh, when you send me the, uh, topic and, uh, it's very, very hard to go through all vascular surgery in one hour. So we'll try to go through the most important scenarios and case based discussion, uh, reflecting the topics which are the most important in vascular surgery, vascular surgery is a very wide specialty. Um And I don't think that we will be able to cover uh most of it today, but it will be a good introduction to the most common uh cases conditions and uh procedures uh the way. Uh So let's move to the second slide. So that's the outline. So uh there is no precision questionnaire, sorry, that's it. Uh I mean, we will have a case based discussion. So we'll start with presenting a case uh scenario uh followed by an M CQ question which will come to you as a a bone. And then uh we will look to the answers together, then go through the condition, we will go through the most common conditions in vascular surgery and then we just have a conclusion uh slide. Um So let's just start with the first case. Uh You have a picture which can give you a clue even before reading the case scenario. Uh The case scenario is about a 70 year old woman with a history of hypertension atrial fibrillation presents to the emergency uh department with a sudden onset of severe pain in her left leg. I'll be helping you guys. So this is very important uh introduction to the case uh because you see the back ground and I would like you to look carefully to the atrial fibrillation and look carefully to the presentation because it is a sudden onset then she describes the pain as exter and unlike anything she has ever experienced on examination, the left leg is notably pale and cold to the touch. The pulses in the left femoral popliteal and dorsalis pedis are absent. So no pulses, the patient is unable to move her left foot and report numbness in the left leg and there is no history of trauma and she was in her usual state of health prior to the onset of symptoms. So that's the case scenario before we move to the question. If anyone uh has any uh question, we can discuss that. Um What is the most likely diagnosis in this patient? Oh, it's coming to me to answer that now. Ok. I, OK. Ok. Ok. How long are we gi uh giving like time for answering maybe about four minutes for, for a minute. Too long. No, no, it's too long. I'll, I'll, I'll, I'll go back to the question so you can see the question and I think you have the ball in the front of the screen. Uh So we'll give uh 30 seconds because in most of the exams you have a minute. So I'll assume that 30 seconds you read the question and 30 seconds you answer the question while you are answering. Remember this patient has a history of atrial fibrillation presented with sudden onset, severe pain in the left leg and there is, there are no pulses and I think those are the key things which will help you with answering the um that question. Oops. OK. So do we have, yeah, we've gotten some responses. So everyone so far has gone for option B. So that means it's an easy question. So Rebecca downstairs will be on the slides uh just to save some time and confusion. OK. Shall do we have the results of the all or shall we continue? Oh, we could continue on. OK. So uh how, how, how many did, how many responses do we have? We've got? 16. OK. So 16 I II can uh see that 94% went for option B5 went for option A. OK. So the correct option is, is B and uh we can uh just discuss, I think option A which is the deep vein thrombosis. So usually the deep vena thrombosis, um it can present with pain but most of the time it presents with the swelling, hotness and redness to the leg rather than pain. And uh this patient uh background history of atrial fibrillation makes it more um so suggestive of an embolic event rather than a DVT. And on DVT, uh if the arterial system is fine, you will be able to feel the pulses. Uh So that's why we, the correct answer is b which most of you get a try. So um the first topic here is the acute lower limb ischemia and acute lower limb ischemia is a sudden uh decrease in limb perfusion that threatens the viability of the limb. And the the clinical presentation is again southern onset. And uh most of the time those patients have no previous symptoms at all because most of the time it is an embolic event rather than a thrombotic event. Um and it can be associated with many risk factors. Like the case we discussed, it included the atrial fibrillation, uh um recent myocardial infarction or history of of peripheral artery disease. The classical teaching for acute limb ischemia for the presentation uh includes all the six ps, which includes the pain, paler, pulselessness, paresthesia, paralysis, and uh elio hernia, which is peripherally cold, coldness. So the sex ps are not always there. That's one of the messages that you need to be aware most of the time. It's only ba and baler and sometimes uh you can uh have pulselessness especially for the foot pulses. Uh but the paralysis is very late parasthesia also is is, is very uh uh late. So if there is a sudden pain, if there is a a suspicion of acute limb ischemia, we will not be waiting to see all the six bees. Um Next slide includes the causes. So basically for uh a blood vessel to be occluded, there should be a blood clot or something occluding that vessel and that blood clot can be uh from the vessel itself. So, if you have a patient who have uh peripheral vascular disease, atherosclerosis and the vessels are already diseased. If there is an atheroma that atheroma is ruptured and the blood declot formed on that atheroma, then this is a thrombosis because the blood vessel is diseased and a blood clot formed inside that vessel and occluded it. And that's the thrombotic causes. Uh The other causes are the embolic causes where the blood, this is healthy and the blood, the clot just traveled from somewhere else. And that can, uh if you look to the first uh table to the left side, uh it is like atrial fibrillation, which can be a new onset or a chronic or the patient is not having uh the anticoagulation if the patient having this arrhythmias, uh M I um sometimes paradoxical embolus like a patient who's having a DVT and A DVT goes back to the uh right side of the heart and instead of causing a pulmonary embolism, if there is a patent for an ovary or ASD or VSD, this is called the cloth will move to the left side and cause an em ee em embolism to the arterial system, which is rare, but still we can be echoed um uh and aneurysms because most of the aneurysms, you will find some blood s inside the aneurysms, uh mural thrombus, which can travel like an abdominal aortic aneurysm. Uh rarely if patients having procedures where they use special material to occlude the blood vessels like coil which can migrate stents uh and so on fat especially in patients who's having uh PC for coronaries and the atrial my Zoma, which is very rare. Uh thrombotic causes, as we said, it is when the blood vessels, most of the time there's a primary vessel disease. This is the most common. Uh however, it can happen in patients with fetal artery disease, especially if there is an aneurysm with the thrombus, which can travel down to CLS, the crural and foot. Uh arteries like the anterior tepal and dorsalis pedis. Uh popliteal problems like petal intra syndrome, cystic adventitial disease, teal artery stent fracture, and um other causes like a trauma uh which is like in, in the knee replacement. It is iatrogenic and thrombotic cause when a patient is having a bypass graft occlusion by a thrombus, especially for the prosthetic grafts, which is more common. Patients who are um thrombophilic like malignancy and patient who's having iatrogenic closure of the devices. Many times when we do an angioplasty, we do a puncture to the blood vessel. And at the end of the procedure, we close this puncture with a closure device and that closure device, uh it should just close the puncture, but sometimes if the vessels are calcified and the small they can in occlude the whole vessel. Uh So what you need to remember when you think about acute limb ischemia, think it's either an em embolism or it is a thrombotic cause. And that's your differential diagnosis basically. So the diagnosis of the um uh acute ischemia starts from the clinical suspicion. Then imaging, then you can do some laboratory tests for a as for any admission, clinical suspicion. We know the six ps, we know the acute sudden onset of the pain. We know the background history that we spoke about. And then the most important on our physical examination and our clinical assessment to I think to follow the other for the classification for the acute lower limb ischemia. Because this classification is very important. It is a common language in the hospitals. It give us a clue how urgent we need to intervene or what intervention is needed. So class one, when the lower limb is viable and there is no loss at all in the neuromuscular finding and you can feel the pulses or the pulses are audible when you use the handheld Doppler, then you have a class two and a class three. So let's ignore class two for the moment because I want you to remember the classification easily. So remember that the class one is uh viable normal and the class three is an irreversible damage to the limb where there is paralysis, insensate no signals, sometimes fixed motor link to the lower limb. So basically, if the patient is a class one, we don't, most of the time need to do an urgent intervention because the limb is perfused. And when it is a class of three, there is no signal then and the the, it's an irreversible ischemia. Then most of the time we cannot revascularize and those patients tend to end with an amputation. Now, class two is the important one because it is divided to two subclasses. Class two A and B. So class two A is a threatened marginal where the patient is having sensory loss only, but there is no motor loss. And mo sometimes you can uh find some signals on the uh vessels if you cannot find the signals and the patient is having motor loss, then this is uh threatened. And you can see that two A says threatened marginal. And that means this patient, especially if the patient comes, for example, overnight can be managed with analgesia with anticoagulation with uh uh more planning. And we can sometimes delay the revascularization if needed. But if the patient presents with a class two B, this is an immediate threatened limb and we need to act immediately. So we need to provide a revascularization option as soon as we can to save the limb. Uh Now management. So immediately most of the patient needs to be started on anticoagulation. Most of the time we go with unfractionated heparin, not the low molecular weight heparin. And with unfractionated heparin, uh we have charts in the wards, there will be a loading dose most of the time for average weight it's 5000 unit. But you can calculate that uh according to the weight, then we measure the aptt to make sure that the issue is within the anticoagulation and the benefit of unfractionated heparin that we can, it is short acting. So if we stop it, we can operate and it is reversible if the patient is bleeding from somewhere else. Uh Most important thing for the patients who present with ischemia is analgesia and pain killers, especially that they will be complaining of very severe pain. Many of them will need BC. Many of them or more, all of them would require a strong opioid to manage the pain and optimization, including optimization, the uh blood sugar, BP. Uh If we can if patients uh needs uh optimization to their CO PD or uh ischemic heart disease medications, if we have time, we need to do that like medical optimization in general. Now, the revascularization option. So as we said rather, for class two B, those patients will need an immediate um revascularization. Revascularization could be surgical like open surgery or by a keyhole endovascular surgery. Now, by uh open surgical, it can be an Embolectomy or a thrombectomy. And the difference is just no technical difference because we use the same uh balloon catheters for the catheters to embolectomy, catheters to take the clot out. Sometimes if the vessels are very diseased and they will keep forming the thrombus. So we need to offer a bypass surgery. Uh Endovascular option includes suction, thrombectomy, which is like the surgical thrombectomy, but they use a device which can suck all the blood clot. There, there are different devices in the market for that. And sometimes if the vessels are too small and you cannot take the thrombus out, sometimes we can leave a catheter there and they provide some thrombolysis to dissolve that clot. And sometimes if there is a disease like rupture, the black or short occlusion of the vessels, they can angioplasty that either by balloon angioplasty or by inserting a stent. So just think for revascularization is this patient going to have a surgical or endovascular operation and how to prepare the patient for these procedures. Most procedures you need to monitor the patient for some complications that can happen like compartment syndrome, reperfusion injury. And sometimes if the intervention was delayed, the pa patients, the foot will recover but there will be a permanent or transient neurological damage and deficit. On long term. When the patient is going home, you need to make sure that we are uh offering all the risk modification uh help that we can do um anticoagulation if needed. Always check for the plan is the patient. For example, if he's on atrial fibrillation, what anticoagulation if the patient was on Pixy? Most of the time, we will change the anticoagulation to something stronger because the patient is why on Apixaban, we check the comprehensive of the patient to make sure that the patient is having the anticoagulation and check with antiplatelets. Most of the time our patients will be discharged on at least single antiplatelets, sometimes for do with antiplatelets for a period of time. Uh So check for antiplatelets. Uh statin is very important for uh patients who with peripheral vascular disease in general. And we tend to give a high dose of statin regardless of the cholesterol level in the blood. And when you discharge the patient also check what is the follow up for this patient? Is he having a clinic appointment? Is there uh more investigation needed? For example, Holter monitoring, echocardiogram, cardio gated ct scan uh or any investigation that the consultant or the senior registrar uh asks you during the war rounds. Uh We will move to the case two and I'm not sure. Do you want to see if there is any question for the first to topic before we move the case two or shall we continue and leave the questions to the end? It, it's up to you. We have one question now so far. Um Just how to clinically differentiate between class two B and three. Um Sorry. Uh OK. So clinically to differentiate between them. Uh The most important thing is the motor deficit. If the patient has any motor uh uh symptoms uh can't move the toes, the foot. Uh and you cannot find any signals down if the curve is tense and tender, you know that the muscles are now being affected. So that's basically a threatened uh immediate limb needs to go to theater. If the patient can move, the toes has minimal sensory loss and the calf is not tense and uh they can wiggle the toes and uh the foot. Uh the capillary refill is not too delayed as as well. This is a marginal threaten limb. So most of those patients can be managed initially with anticoagulation. And after that, we manage them with um um mo most of them might not need an acute intervention surgical one because they will be manageable with anticoagulation. But after a few weeks, depending on the case, we can offer them ano like other revascularization uh options. We have a very specific question for how um how fast can we mobilize the vascular team for surgery if we have a patient coming to a who cannot move on ischemic? But we think there is a post on Doppler has to be I sorry, I can't see the question. So the question basically is about a patient who presented with acute ischemia to A&E and how fast can we transfer the patient to the vascular wall? That's what I understand all the questions. That is. Ok. So uh most of the time if patient presents to A&E with acute limb ischemia and it is an immediately threatened. Uh We don't care about what's happening in the world. We don't care about the bits we will be making a plan to take this patient to theaters to operate or to the uh IR suit to pro provide some revascularization and procedure. And after that, they will find a bit for the patient. So we don't, we will not be waiting to transfer this patient to the ward because it is a limb saving uh procedure that we need to do. And this is the same thing applied for a patient who for example, presented to us with a ruptured at AAA. And if, if the patient presented with uh rather for two A, uh we will speak with the matrons and make sure that they are um having bits as soon as we can and we will be starting the anticoagulation at A&E like we will be giving the loading dose of heparin and negotiating with them to start the heparin infusion as well. OK. R are we OK. Uh Do we have any further questions? Um We have one more if you're happy to go through a bit before we move on. So um someone was asking about um the difference between critical limb ischemia and acute limb ischemia. But if you want to save it for later, when you talk about, no, we, we won't save it for later. Uh I can now see the comments. It is FDA. So uh FDA, I'd like you to move to the case too. So let's look to this scenario together and then answer the M CQ question for it. So this scenario is about a 65 year old male with a history of smoking and hypertension presents to the outpatient clinic uh with complaints of intermittent claudication. So the patient describes a cramping vein in the left calf that occurs after walking about 100 m and was relieved by wrist. The vein has been progressively worsening over the past few months now. Ok. At wrist and his big toe is black on examination, there is no belt pulses below the groin and the question here is what will be the next best? Uh Let me just try to get the slide. Sorry, what is the most appropriate initial investigation you have on the choices? Duplex, ultrasound, CT angiogram, Mr angiogram and A PPI remember I'll go back to the slide just once to discuss the case. So remember that this patient is uh patient with a chronic history. It's not acid sudden onset. Remember that the symptoms started as intermittent claudication and it worsened over time um with wrist pain and then with tissue loss as the patient is having now a gangrene and uh there is no pulses uh below the groin. So you can feel the femoral but nothing below the femoral. So this is more chronic compared to the first case that we have. And then what would be the most appropriate initial investigation that we want to do? Shall we do a duplex ultra ultrasound and or CT Mr or to measure the ankle previ index? So let's give um 30 seconds from now. Then we look to the uh results we can see if we have total 18 responses. Now. So 16% they now saying duplex ultrasound 22 saying ct none is saying Mr uh 61 the majority is going with ankle brachial pressure index. I'm not sure how many audience do we have because we have 18 response. If we have most of of of the audience responded, we can carry on. We have 26 people in total with us 26. OK. So we have eight people. Let's wait for them 15 seconds to make their minds come on. Eight be. Mhm OK. One has responded. Good seven to go. This is an interactive session. So please try to answer. OK. Because of time we will be moving. We have 20 responses. Most of the responses for uh ankle prac pressure index, which is the right answer. Yes, we should start with ankle prac pressure index and that's for different reason, ankle plat pressure index which will go through. It is a noninvasive. It can give us a very um it is very informative because it can reflect the degree of ischemia. This patient is not presenting with um acute uh episode. So it is more a chronic. So it's worth having an ankle brachial pressure index, then decide what will be the next imaging um uh modality. If you look to the nice guidelines, the next imaging modality will for a chronic ischemia would be the duplex ultrasound because duplex ultrasound is noninvasive, it is cheap. Um And it can give us a lot of information. The problem with duplex ultrasound is the availability. You don't have uh a trained sonographer or scientist to do the duplex ultrasound for you all the time. It needs booking needs to make arrangement for it to happen. Now, CT scan is a very good modality and sometimes we do, we go for the CT scan even before DX because we can get the CT scan easier than getting the DX or the Mr. But if you look to the nice guidelines, again, it comes to the third order. So nice guidelines recommend duplex as the first initial uh study, then Mr then CT scan, but the advantage of the CT scan, it it is the availability and the the accessibility to to the CT scan. And that's why when you see vascular patient, many times you will see that we are doing many CT S compared to the recommended guidelines. The Mr angiography is a very good modality and it gives a lot of information especially for the radiologist who will love it to plan the angioplasty and the stenting the problem with the Mr angiography that at the time and the accessibility to the Mr, it will take too long to get an Mr scan. Most of the surgeons are more familiar with the CT scan. So they would prefer to do CT scans. Most of the radiologist would prefer to do an Mr angiogram, uh the CT scan advantage over the Mr that the CT scan, you can see the calcification of the vessels which help us on operation to determine where we are going to put the gland where we are going to do the anastomosis for the bypasses, for example. But the MRI is a good modality to look to the lumen and uh for the vessels and to plan the endovascular um um procedures And the good thing for the MRI, it is like it has no radiation risk as the CT scan. Uh and less contrast nephropathy, there is still contrast nephropathy, but it is less than the CT scan. So to answer the question, we are now speaking about the chronic limb ischemia, the definition of the chronic limb ischemia is it is a severe band of peripheral vascular disease. It is characterized by a chronic, insufficient blood flow to the limbs usually due to atherosclerosis. The most important thing that you need to understand about the chronic limb ischemia. It is a progressive condition. Most of the patient will have intermittent claudication and the intermittent claudication is uh not a symptom that will uh make us to intervene on those patients. All the patients with intermittent claudication, we will be managing them conservatively by optimizing the risk factors which I'll I I'll come it, I'll come to it now. So risk factor wise, you have the nonmodifiable which are uh are the age gender and ee ethnicity and the modifiable risk factors which we will be working at are the smoking, diabetes, mellitus, hypertension dyslipidemia and uh hyperhomocysteinemia. So, smoking cessation very important if you find a patient, uh, who is a smoker in the wars having problems, always offer them a referral to the, uh T DT smoking cessation team. They can offer, uh, an RT nicotine replacement treatment to help them to quit smoking. Always offer to, to them if they want to be enrolled, ask the nurses or refer them yourselves. Diabetes mellitus is a modifiable. If the patient is having a controlled blood sugar, the outcome will be much better. Um On long run, hypertension is the same dyslipidemia. So those patients with intermittent claudication, we need to help them to improve their quality of life, to increase the walking distance. This can be achieved by uh and optimizing them with the risk factors, giving them good painkillers and sometimes enroll them on the observed exercise program, which comes the first thing to do with the intermittent claudication on the guidelines and in vascular unit and how we have the observed uh exercise program. We enroll patient and we see that most of the patients will have an improved walking distance after a few months of um exercise, even if they are not involved on observed uh exercise program, advise them to exercise, advise them to walk through the vein as much as they can. This on long run will build more collaterals, the walking distance will be better and they will improve. Most of the patients will not require any intervention at this stage. Now, if we move to the second stage, which I put it intentionally on red color patients who are having wrist pain, so those patients will have pain at risk uh or um before before moving to the wrist vein. Sorry, I'll, I'll come back to the intermittent claudication. Always uh uh ask the patient good question. Have a good history because pain in the lower limb in the leg can be of vascular origin but can be from other causes. For example, like neurological origin or spinal radicular pain. So, the the claudication pain, the only thing that I forgot to say and I would like to uh say it and, and ensure that uh you know about it is this pain will improve with rest and it is a reproducible pain. It will occur again if the patient walk the same distance. So that's the claudication. Now, the wrist pain is a patient having pain at wrist even uh and at night cannot sleep. So this is a progression. The intermittent claudication now became wrist pain. And when a patient is having wrist pain more than two weeks, now, we are within the definition of uh C LTI, which is uh critically limb threating ischemia. So, if you were asked, what is C LTI C LTI is a critically limb threatening ischemia for patients who's having wrist pain or tissue loss for at least two weeks. That is the definition, tissue loss will include nonhealing, ulcers and gangrene, uh nonhealing ulcers. Most of the time if they are of arterial origin, they will be on the tips of the toes because they are the furthest point for the blood supply and they will be the most affected uh tissue. One of the important classification that I'll just go through it quickly. There is the Fontaine classification and there is the Rutherford Baker classification. And both of them describe the, the, the, the same continuum of the symptoms. They will start with asymptomatic patients, then they will go to the claudication and they will define the claudication depending on the, on the distance to mild, moderate and severe. Most of the patients, if they cannot walk more than 50 yards, uh this will be a severe claudication, then you will have the wrist band, which we now it's a critically limb threatening ischemia and then you will have the tissue loss uh which are the uh last uh like stage on the critical limb ischemia. So just be aware of Rutherford Baker and Fontan classification. Now, the diagnostic tools, the que the answer to our question was A PP and one of the things that we will be expecting you to do in vascular ward or even if you seeing patients and we will be happy when we having a referral from someone of you telling us. Oh I did the A PPI and that is the A PP that will be the best referral that we will have that day. So the ABP you need to measure you like, like we do for measuring the BP. So it is an ankle brachial pressure index. So we need to measure the pressure on the ankle, which we can do on the dorsalis pedis or on the, this is the dorsalis pus or on the posterior tibial uh artery. So basically, you apply the BP cuff, you inflate the cuff while you are listening to the signal. When the signal disappear, uh you just relieve the cuff slowly till you find when the signal come back. And that will be the pressure that we at the ankle. We tend to measure it for the PT and DD. If, if, if you can detect the signal at both of them, then you repeat the same on the brachial artery on most of the time on the right arm. And then you divide the pressure on the ankle uh over the pressure on the brachial. And then you will have that issue if the ratio is more 1.2 that means that this is are incompressible. There is a lot of calcification and uh you need then to consider something else because the readings will not be accurate. Many times this happens on patients who have diabetes and patients who have endstage renal disease. And then we will be moving to do a toe brachial pressure index, which has the same principle where we apply the cuff around the big toe. And we have a very small sensor at the tip of the toe. And we have the toe pressure then divided by the pressure on the brachial artery. We uh we will not be expecting you to do to do top pressure index, but we do that. Uh in vascular lab, we have our nurses and scientists who do that. And if someone wants to see or do it can join the vascular lab. And it is good especially for the patients with diabetes and interstate adrenal disease who are having a high A PP, incompressible calcified vessels. If the A PP is between 0.9 and 1.2 it is normal. If it is less than 0.9 it is abnormal. The patient will have peripheral uh arterial disease. If it is between 0.7 to 0.9 it is mild 0.5 to 0.7. It is moderate less than 0.5 or 0.4 it will be severe peripheral vascular disease. So that is the ABP, which is a very useful tool and you can do it anytime, noninvasive, not expensive and all of us can do it. Now, some patients, especially the patients who presented with intermittent claudication, if you do the ABP, at least it will be normal. But if you provide them a treadmill test and exercise test, you ask them to walk, then the pain will be reproducible when they have the pain. If you repeat the A PP pressure, the A PP will be reduced uh after exercise. So many times we do treadmill distinct. And we measured the ABP after exercise, which is very helpful in patients with intermittent claudication, duplex, ultrasound. We discussed that CT angiogram and Mr, we discussed that and I put them in this order because this is how it happens on the clinical practice most of the time. But according to the nice guidelines, Mr comes before the CT scan. Latest symptom men is the conventional angiography which means taking the patient to the angio suit puncture, the vessel give contrast and look to the vessels which can be diagnostic, but at the same time can be therapeutic because we can provide intervention. Ok. So that is the diagnostic tools. Now, last slide here is the management, we said lifestyle modification and what we need to do. Now, pharmacology therapy, we discussed that at the A L but it is the same for C LTI. Most patients will be on antiplatelet, the preferred one will be clopidogrel and the dose for that will be 75 mg once daily, most of our patients with C LTI will be discharged on clopidogrel at least a statin. And as we said, we give the patient a high dose of statin. The first agent to give is atorvastatin. We would like to give the patient a dose of 80 mg once a day. But because of the intolerance to the statin, because of the musculoskeletal symptoms and because of the side effect to the liver, most of the time we start the statin uh at a 20 mg one a day. And we ask the GB to increase it gradually in the community and under monitoring. And by monitoring, we repeat the liver function test, we make sure that the patient Medicare problems are optimized, especially the diabetes and BP. And there are two medication, nice guidelines. Has only the Aro il which is a medication helps sometimes on the cloudy. So we only prescribe it for the cloudy. The dose is about 100 mg. Uh three times a day, we give the patients a trial for three months. If they are improving, we continue it lifelong. If the patient is not improving with it, we just stop it. Uh Closo is a good medication which relaxes the smooth muscles in the arteries and it provide more blood supply. Uh but it is not on the guideline. There is no evidence suggestive that it is useful, but many patients have some symptomatic relief and better walking distance with it. So it's prescribed for many patients now, revascularization, especially for the patients, not the cloudy, the cloudy. Can we stop here with the pharmacotherapy and lifestyle modification? But if the patient got C LTI, then they will need revascularization, especially if they have AOS and the recommendation is uh we see them within five days and we offer uh revascularization within two weeks. That's the recommendation. So the endovascular option is one of the very good options. Currently, if you look to the M VR data, you will find that more than 60% of the revascularization or the vascular intervention currently are endovascular rather than an open surgery. Uh They can provide a balloon angioplasty and there are different kinds of balloon. Uh and they can extent some lesions if needed surgery. Most of the time it's endarterectomy. And that means to clean the calcium from the arterial wall or doing a bypass surgery to bypass and occluded l vessel. Uh l last thing on the management, remember always the pain management for those patients, many of them will uh need a strong opioid. And to be honest, paracetamol will not be sufficient nonsteroidal. They have many side effects to the kidneys. Many of them have CKD and gastric problems. So we go to the opioid. Most of the patients will uh give them either oxyCODONE or morphine for you to know if the patients are old. Uh more than 65 we go some more with oxyCODONE or if the patients have impairment, we go more with oxyCODONE and when we prescribe it, we usually prescribe the modified release tablets. So most of the time we prescribe like 5 to 10 mg, either morphine or codeine as uh MST or modified release. And we also give a breakthrough, immediate release if needed as Apr N. And if the patient presented with ulcers or presented with uh wounds, they uh will need um wound care which uh and the dressing can be deprivement can after revascularization to amputation. After revascularization, frequent dressing, vacuum assisted dressing, uh different kinds of dressing can be used in the community and wound review by podiatrist and uh treatment rooms to look to the wounds. And it most of the time it will take if the if the vascularity is improved after revascularization, uh treatment, they will have a good wound care. Um Any question before we move to case three, I think uh yeah, we covered the chronic and the acute lower limb ischemia, which are one of the most common things you will face for vascular patients. So I can't see any questions. Shall we move to? Case three? I think we should just carry on if anything pops up. Let you know if any, if any questions, write it down. Case three is a short one. So we will uh answer the question after case three. Case three is about a 55 year old male underwent an embolectomy for acute limb ischemia in his right leg, six hours was up, he begins to complain of severe pain in his calf that is not relieved by standard analgesia. On the examination, the calf is tense, swollen with pain on passive stretching on the toe. This is very important. When you see this passive stitching of the toes, it gives a clue. The patient reports increasing numbness in the foot and the pulses are weak but there is pulse, it is weak but there is pulse. Um Now the question is, what is the most appropriate next system in the management? So, if you can't see the slide, the next step will be either give more pain relief, increase, analgesia, observe and reassess the patient do a fasciotomy or do a CT scan for the patient. Ok, let's give um 30 seconds. So one of the clues is the picture which I put to the right side. It is a compartment syndrome and compartment syndrome occurs when the pressure builds up within the muscles. It can be pain, paresthesia, paler but pulselessness. And as we have 14 responses, all of them are right. The next step will be to do a fasciotomy. So for any compartment syndrome, the answer is fasciotomy and to go through the compartment syndrome quickly, uh it is a closed space, the fascia uh around the muscles and nerves and the blood vessels. The pathophysiology, the pressure will be increasing from internal factors like bleeding or edema inside the muscles or external factors. If you, if you are putting some tight casts or dressing, this will cause a critical ischemia because the pressure will increase. There will be a venous out flow obstruction. This will increase the pressure inside the compartment and this will reduce the arterial inflow and it, it, it will cause the uh ischemia to the muscle and to the nerves and the nerves are the uh uh earliest like uh tissue to be uh c like affected by the ischemia. Uh And if the nerves are damaged and they were ischemic more than six hours, many times, it is an irreversible damage and that at least will cause food to drop or nonfunctional limb many times. But if it was longer than that, it will be necrosis and um unsalvageable limb, which can end with an amputation. So that is compartment. Uh So I'm just looking to the questions. So when uh has it observed Andreas actually for the compartment, it is very vital and very important that we diagnose it with high index of suspicion and we intervene as soon as we diagnose it. And always, if you suspect a compartment syndrome, ask uh escalate at least for orthopedics or for vascular, we always can measure the um compartment pressure. And if the compartment pressure is raised because sometimes it clinically, it is difficult to have this assessment. But if you uh measure the compartment pressure and the compartment pressure is raised, then um we need to intervene because delay in intervention in compartment syndrome has a very um um severe and unfavorable consequences and uh and outcomes. Um Now we will move to the uh case four, if there is no questions and now, I think we covered most of the lower limbs. So now we will be moving to something else. Ok. I'll go with case four. As there is no questions. If there is any question, you can type it and we can always come back to it. A 75 year old male with a history of hypertension and smoking presented to A&E with sudden onset of severe abdominal and back pain. Describe uh he describes the pain as a tearing sensation uh that releases to the to his lower back on examination. He is bale uh diaphoretic hypotensive BP. 85/60. He ario uh his abdomen distended and tender and there is a palpable versatile ma mass. The patient reports, feeling dizzy and nearly fainted before arrival. I gave all the clues that you can imagine on this scenario to make it easy. So the question will be, what is the most appropriate initial imaging to confirm the diagnosis? Will you be requesting at A&E an abdomen x-ray option A option B uh CT angiography or an ultrasound or an MRI abdomen? Let's wait for the responses while waiting. Uh I'll give you a minute uh through this minute. There is a question from Erica Lo for asking, how is the compartment measure? Basically at ICU we always have like uh a kit which is connected to the catheters, for example, like central lines, arterial lines and they will be connected to a monitor and this can measure the uh pressure inside any catheter like the like we got the arterial line BP or the central line venous eis. Um For example, if you mi if you connect that kit to the fullest catheter or to the urine catheter, you can measure the intraabdominal uh pressure, which can uh give you an uh a diagnosis of um compartment uh syndrome, intraabdominal compartment syndrome. For example. And it is the same principle, we connect that catheter to a needle. And that needle uh we uh put that needle, we introduce that needle to the compartment that we need to look at. And uh when we um connect that uh pressure kit to that needle, while the needle is in the compartment first system, we do a zero pressure, then we do the measurement and it will give us the uh measurement uh of the compartment. And if the compartment pressure is high, uh then we will uh consider fasciotomy many times. Uh For example, for the legs, for example, the medial compartment is the most effective uh muscle compartment uh that we will start measuring the pressure there, which is more common for patients to have a medial compartment uh syndrome compared to the lateral compartment, for example. And while waiting for the others to answer. When we do a fasciectomy, you need to make sure that you release all the compartment. If you go back to the anatomy for the leg, for example, you have the medial, the lateral, the posterior and the deep posterior compartments. And you want to make sure that you open the facia for the four compartments uh and relieve the pressure on all of the muscles. Uh Now, coming back to our case, I have seen that we have 19 response and uh it is between option B and C. Option B is CT angiography. Option C is abdominal ultrasound. Um So uh the correct answer here will be a CT angiogram. And that's for a different reason. Uh I know that the argument against the CT angiogram will be uh that the CT scan uh for unstable patient is not really safe because the patient is hypotensive. So how can I take a patient to the CT scan? So, and F for this uh for AAA sometimes or most of the time the patients will be unstable, they will be hypotensive because the aneurysm has ruptured and the patient is bleeding and the only solution to stop that bleeding is a clamp on the artery or for something to seal that hole in the artery. Now, why should we go for CT scan? Not for an ultrasound? So, CT scan, uh it will give uh the anatomy of the aneurysm. It will uh exclude many other causes like sepsis, for example, and it will confirm the diagnosis of ruptured AAA for 100 patient. And it will help us to determine what will be the next because when we know the anatomy of the aneurysm. Then we will be able to decide is this patient going to have a stent, er endovascular or does this patient uh need an open surgery because the anatomy of the aneurysm is not favorable for having a stent. Uh and most of those patients will be at, at A&E, they will have a lot of uh uh support by A&E doctors. Uh me, sometimes uh IC or Medicare Registrar, surgical Registrar whole team will be going with them to the CT scan to make it as safe as we can. Uh if the patient is uh unresponsive or unrecordable BP and you are suspecting uh ruptured AAA. Then one of the things that we look at is we look, is this patient known to us? Is there any previous imaging? Is there any previous discussion with the patient? And is the patient is for repair or is he not for repair? Is the patient? Because many of them, they will not make it the mortality for rupture AAA outside the hospital reached about 80 patient. So it's very high mortality. Most of those patients are frail old with many comorbidities and they will not make it. But if you can, the best initial test to do at A&E will be the CT scan to go through the aneurysms, equ not only the abdominal aneurysm, aneurysms in general, which can affect any blood vessel. Anyway, aneurysm, by definition is a localized dilatation of an artery as a percentage, it's greater than 1.5 times of the normal diameter. And the reason for that is weakening of the arterial wall and the weakening of the arterial wall can be caused by atherosclerosis by genetic factors like connective tissue disease. Marfan syndrome, A of DS D syndrome, infectious causes mycotic aneurysms which can happen and sometimes a trauma and dissection to the blood vessels. Aneurysms can happen to the aorta starting from ascending thoracic and aortic root out of the aorta, descending thoracic abdominal, which we classify to suprarenal, juxtarenal infrarenal can affect the iliac blood vessels then to the peripheral vessels like femoral popliteal uh as well. One of the common things that is being built by the neurosurgeon is the cerebral aneurysms many times they do clipping for those aneurysms. Uh If you look to the uh this picture, it will tell you uh some information about the type of the aneurysm. This is a healthy vessel, then you have the two shapes of the aneurysm, which can be a saccular or fusiform saccular more risky of rupture. And then you have something called uh um dissection, aneurysm and false aneurysm. That's because you know the blood vessel wall has three layers. You have the intima, the media and the adventitia. The media is the thickened if there is a tear through one of the layer and the blood is tracking through those layer. This is a dissection. If the swelling is not involving the three layers. This would be a false aneurysm. If the swelling involving all the layers, they will, this will be a true aneurysm. Ok. You will see first aneurysms many times with patients IVD, patients who are injecting themselves or with patients who are having an endovascular um uh interventions with punctures uh and um true aneurysm. You see it more with atherosclerosis and the causes that we discussed earlier. Now going to the abdominal aortic aneurysm, which is the most common uh aneurysm. You will face uh it is uh aneurysm dilatation to the abdominal aorta. The normal diameter of abdominal aorta is uh 2 to 2.5. So if it is more than three, it's aneurysmal uh small aneurysms, 324 or 4.5 threshold to intervene when the aneurysm is more than 5.5. The epidemiology, most of the aneurysms happens in the elderly more than 65 years. It is more common in males, male to female is 4 to 1 and the risk of rupture. We said more than 5.5 in your study saying that for females, the risk of rupture is at lower threshold. So many will consider to intervene in aneurysms at five centimeter for women uh presentation, most of the aneurysms are asymptomatic if they have symptoms. Most of the time it would be either pain or versatile mass and sometimes, unfortunately, they can present with rupture and rupture has a high mortality. As we discussed, rupture outside the hospital, it is about 80% inside the hospital. It depends like 20 to 40 patients. But many patients. If they are symptomatic, we will admit them and then we will arrange the repair. While our inpatient asymptomatic patient, they will be worked up as an outpatient under surveillance program until they reach the fo 5.5 they reach the threshold, then we will offer them the bare, very bare could uh be either endovascular stenting if the anatomy is favorable, which can be as simple, er, or sometimes frate to the graft fever or a branch graft BVA. I'm not going through the different kinds of them. It's more advanced, but I just want to mention them if someone is interested and uh wants to look at them uh and uh open repair, of course. So if you look to the pictures, this is an aneurysm intraoperatively. Many times we just open the aneurysm, you can see the aneurysm is opened and then we sutured a tube graft to the top end just below the renal arteries and to the uh bottom end just on the bifurcation of the iliac arteries. This is the shape of the tube uh of the stent grafts for the er different sizes, different companies, different devices, tub grafts, bifurcated grafts, a lot of uh knowledge and skills and efforts on this uh kind of devices. And it's very nice and interesting of like a procedure and this is an X ray which shows the bifurcated scintigraph for the er la. Latest thing I want to I missed here is the diagnosis. If the patient is in a screening, the screening we do is an ultrasound screening. Uh If we need to look to the anatomy, most of the time we'll go for a CT angiogram. But MRI is an option. Abdominal is x-ray is not a diagnostic option for the AAA. But if you look to some x-rays, you can see the aneurysm because the wall of the artery will be calcified and many aneurysms detected on the x-ray. But for the, it's like an incidental finding on the X ray. Then after doing the x-ray noticing the aneurysm, you can then go for the ultrasound if you are screening or for the CT scan to have more information about the aneurysm. Uh So that's the AAA any questions about the aneurysms, feel free to uh write it down while we are going to the next case. So I have, I think uh two more cases. So I think we will need about 20 minutes from now. I know the incision is for an hour. I try to be as fast as I can. Um And uh it's up to you guys if you want to continue or do you want to schedule another time to continue? It's uh OK for me, otherwise you can put Apple to them lie. Uh Actually, uh because uh it's about five past eight. Uh, there is a question. Is there any way to get a recording, I think? Yeah, we are recording. That's, that's what I know. Yes, we are recording and as long as you're ok, we'll just put it on as a catch up. So you should be able to access it when you go on the links. Ok. I, I'm, I'm happy to continue. Just want to make sure that, uh the others are happy to continue or we can continue later on on another session if that's uh better for all people. I've popped the feedback form in the chat. So, um if anyone wants to head off, thanks so much for giving us your evening, just fill in the feedback form and then head off. I think there's some interest there. So I think we'll continue on then with Moran. OK. I'll try to be as fast as I can. So uh II don't want for you to have uh I'll, I'll vote for continue. I'll see the others. Uh But I II want you to have a good evening as well after a long working day. Um OK. So we have 12 to continue. That's good. So we'll continue. Uh That's very encouraging guys. Thank you. I think uh you are enjoying it. Uh Case five. Um We have a 68 year old male with a history of hypertension hyperlipidemia and smoking presents to the emergency department with sudden onset of right-sided weakness and difficulty speaking on examination. He has a right facial droop weakness is in his right arm and leg and slurred speech. An un contrast ct scan of the brain shows no hemorrhage. And uh we don't know if there's any ischemic changes because it's too early to have an ischemic changes. And next day, we did a carotid Doppler ultrasound reviews as 75 patient of stenosis in the left internal carotid artery. So let me say that this adding to this case, that all of those symptoms resolved after uh two hours patient, two hours after those symptoms started, he was completely normal. So these symptoms were resolved and we have a CT scan with no hemorrhage and a carotid Doppler or DX showed 75 in the left internal carotid artery. So now we have the question, which is what is the most appropriate next step in the management of this patient. So for this patient, ct scan is normal. He's having a carotid artery, uh stenosis symptoms resolved within two hours. What you would like to do initiate intravenous thrombolysis start him on dual antiplatelet aspirin and the clopidogrel. Option B option C, proceed with carotid and arterectomy. Option D, proceed with carotid stenting. We have six responses. This is a difficult question because I'm asking about the management. Um and we have um variable responses till now. We have an eight responses. We will wait uh more. Let's give more 30 seconds to have most of the people answers. And so for the question uh because B and C, most of the people, uh I'm not sure if you can change the ques your answer, but I'll give you a hint. Uh Is what is the most uh appropriate? Next step is different from what is the best initial. So uh maybe it's a bit confusing. But if I am saying what is the initial step, I will go with the option B because it will be a dual antiplatelet therapy as the first initial step that I will do for such a patient. Uh If I am going about intervention and definitely treating this, I will go with uh option C which is carotid and arterectomy, which is the correct answer here. Um Option A uh intravenous thrombolysis. So that's uh um this answer is very good because it will bring us now to discuss what is the difference between the stroke and the ti A and intentionally not to confuse you. I uh said that this patient's symptoms resolved within two hours. So that meant that this patient had a tia A. So a tia a, there is no blood clot to dissolve and there is no rule for thrombolysis. So thrombolysis is not the best option to do here. Dual antiplatelet, the people who answer that this is the best initial step to do. Uh and this is uh very good thinking. Uh But the most appropriate next step will be in management in general is to offer the patient a carotid and arterectomy. Uh carotid tenting is not the right uh answer here because uh it is a lot of discussion in the evidence based here. But most of the carotid distin thing will be more beneficial in patients who are either having asymptomatic severe stenosis. This patient is symptomatic or patients who are not fit enough to have the surgery and having sedate that many times. We do carotid endarterectomy under local anesthesia. Uh So we can do it even in patients who are not uh relief it. Um So the correct option will be here, carotid endarterectomy. You don't need to worry about this question. It's a bit uh There is a lot of uh things to speak around it. Uh But I brought this question to have a look to the one of the common procedures that we do in vascular surgery and to discuss the uh CVA or cerebral vascular accident. Um ok. Uh ignore this division uh definition. It is wrong definition. Uh The definition for the CVA for the stroke is when there is uh either ati a or the stroke. And tia A or uh a stroke will be the difference between them is a transient ischemic attack when you have a neurological deficit, which is resolving within uh 24 hours. If you are having a ergic deficit, which is lasting more than 24 hour, it will be a stroke and a stroke could be either as you know, ischemic or hemorrhagic. Most of the time when it comes to the carotid artery disease, it is an ischemic stroke rather than a hemorrhagic stroke. Uh the pathophysiology of it, that as any other blood vessel in our parties, the carotid can uh the uh carotid arteries can build uh atheromas through the atherosclerosis. And this atheroma can either cause to the uh critical stenosis. And that stenosis can decrease the blood flow to the brain. And that will cause the tia A and then the brain compensated and then the resolve many times. This atheroma can rupture. And if it ruptured the particles of atheroma can embolize and can travel to the circle of wills and include either a big blood vessels like middle cerebral artery or uh branches uh to those arteries with uh a stroke of less intensive stroke. Um So it's either the tit stenosis or the embolization from the ruptured plaque. Uh always look for the presentation. It's very important as you know, the blood supply to the brain through circuit of FS have four blood vessels. Anteriorly, you have both carotids and posteriorly. You have both vertebral arteries, vertebral arteries uh will supply the posterior circulation. Carotid will supply the anterior circulation and the booster circulation is stroke symptoms and presentation is different from the anterior circulation. So, if patient presented with symptoms, suggestive of posterior circulation, dizziness disturbance, which is affecting basically the cereal limb um or the occipital lobe. We don't offer them any intervention because we don't intervene on the vertebral arteries. And uh they will not be a candidate for any stenting or any arterectomy. If it's the symptoms are on the anterior circulation, then it is carotid arteries. The most important thing here is to check for the laterality of the symptoms as you know, the weakness, facial droop is more of contralateral. So if the right IC is uh stenos tight or uh right hemisphere, in fact, stroke, then the symptoms will be on the left side. And the two things I would like to highlight here. The first thing is about the slurred speech and this art because most of the patients, the language center will be on the left side, especially if they are righthanded. So it is likely uh for those patients who presented with left hemispheric or left ICA uh uh a stroke or tia A to have a slurred speech, uh if they are right-handed, especially if they are righthanded. Uh The other thing is the eye symptoms and having uh aurosus ff jus the eye symptoms is unilateral and that uh plaque out that will happen to the right eye. If it's right eye, it will be the right carotid. So if you think about laterality, always think that eye symptoms is unilateral, but the weakness, facial dru uh is uh contralateral and slurred speech look, always ask is, is the, is this patient is right handed or is he left-handed and which hemisphere most likely to be affected? Uh imaging wise, the carotid dux is very good modality, noninvasive uh accessible. Um It will give us a lot of information, it will give us the big systolic velocity. Uh It will help us measuring the uh percentage of um narrowing and um uh it uh it it can be also a dynamic scan if needed. Uh CT scan uh is good, especially that it can give us a clue or more information about distal uh arteries to the I I ICA. See if there is any distal obstruction, see if the circle of wills is patent. Is it complete? Which will help, which is the same uh advantages of the Mr scan. Now, um um the risk factors is the same modifiable and not, not, not modify modi modifiable. We, we discussed that before and uh the management, the management of those patients, as you said, dual antiplatelets, then uh counsel them for endarterectomy. And here the counseling is very, very important because if this patient is having a stroke, they will uh and they are having a neurological deficit. The procedure that we are offering, it will not improve their symptoms. The only reason that we are of offering a carotid endarterectomy that we just want to prevent a major stroke in the future. And uh if we manage those patients only with conservative Medicaid treatment like dual antiplatelet statin control BP, uh optimization of their medical comorbidities. The risk of major stroke, it will be in, in the next three months. It will be 3 to 6 months. It will be around uh 25%. So 20 to 25%. But what we tend to tell them if you are having a carotid endarterectomy, the uh the surgery itself, it is not going to improve the symptoms that you are having if they are uh stroke symptoms. Uh not Ti A because the Ti A will improve because Ti A is not a permanent neurological deficit, as we said, and uh the surgery itself will decrease the risk of major stroke. It will not prevent the risk of major stroke 100 person and it will decrease it from around the 20 to 25% to about 5% or 3 to 5%. And they will need to know that the surgery itself carries a risk of the stroke. The surgery itself can cause a stroke maybe 1 to 3 person. So it is the patient decision because it is more that you tell the patient all the facts, all the percentage, they do their own calculation and they accept whatever risk they want to do. So that's for the surgery counseling. Um Now the complications of the carotid and arterectomy, anything can happen for any surgery including death. We discussed the stroke which is can can happen in preoperative or postoperative uh cerebral hyperperfusion and very, we don't like the high BP uh o of uh after the surgery because hyperperfusion can cause cerebral hemorrhage and can cause neurological damage. So most of the time post operatively, we will keep our eyes on the BP and ask not to uh uh for the BP, not to be higher than 160 try to keep it between 121 140. Um cardiovascular complication is common with those patients because they tend to have atherosclerosis everywhere. Arrhythmias M I uh respiratory complications. A cranial and peripheral nerve injury. Very important the operation. It is near uh the cranial nerves, hypoglycin nerve can be injured if it is injured. This hypoglycin nerve uh give the blood, uh give the nerve supply to the motor function of the tongue. And if it is injured, it will be uh unilateral tongue deviation. So if the right hypoglycin injured, right lung, uh right tongue, uh deviation of the tongue to the right side, sorry, um vagus nerve is in the area. Hypoglycin nerve is uh uh sorry, glysal nerve is in the area. So, hoarseness of the voice is common. Uh swallowing a problem is, is, is common and we need to counsel patients about those risks as well. A bleeding uh is very uh important most of complication, especially that it's uh bleeding into the neck which can compress the airway. So if a patient in the ward having hematoma. After neck surgery, like carotid endarterectomy, or even if you are doing general surgeon or ent uh thyroidectomy, then uh those patients need uh uh a rapid attention. And most of the time if the bleeding is increasing or the hematoma is expanding, uh immediate intervention to open the wound, raise the pressure, then take the patient back to theater and control the uh bleeding. Uh infection rate in the neck is very, very low neck wounds are wonderful. They heal, they rarely uh get infected. The batch that we use with the carotid endarterectomy. Many times we can use the patient on vein like the common facial ne uh vein or the external jugular vein which decreases the risk of infection a bit. Uh But if even if you use the bovine or the dacron patches, the risk of infection is uh is low. So that's the CVA um any questions you can write it down. Uh We have only two more cases, quick ones. Uh This case scenario is about a 62 year old ma male with 15 year history of type two diabetes. Mellitus presented to the clinic with nonhealing ulcer on the o on the sole of his right foot. Um ulcer has been present for two weeks. Reports increasing redness, swelling and foul swelling, discharge. Those are signs of infection. He has been poorly controlled on his diabetes medication. So diabetes is uncontrolled BP is high. 20 mg. I used to milligram but per dec. But let's say above like 30 millimoles per liter. Um On the examination, the ulcer is, is a three centimeter in diameter with surrounding erythema warmth and mild swelling. He has palpable foot pulses. So the pulses are good. There is a pent discharge and the patient has low grade fever. The question, you can see the picture of the foot. What is the most appropriate uh initial management? Will you start a option? A start oral antibiotics and will follow up in one week. Discharge the patient, bring him back to the clinic. B perform a wound culture and start empiric IV antibiotic. C refer to pa uh to vascular surgery for possible revascularization and last option, immediate deprivement and admission to the hospital. So uh for this patient, as you see most of the posters in the hospitals as uh as we say, always think CSIS uh patient presented with, with, with, with CSIS, we need uh remember the six days to do think sex of sepsis. So uh we are having five responses. So most of the response is still now is going around. Option B which is perform a wound culture and start empiric IV antibiotics. And we have a few responses to option B, immediate deprivement and admission to the hospital. And uh both are the options that you need to think about. Option C you don't need to think about because revascularization is not needed. You can feel the and option A, I don't think it is safe for this patient who is diabetic immunocompromised, having fever to be discharged on, on just oral antibiotic. Uh We have nine responses. This is less than it was before. So I'm not sure if we still have all the people with us, but the correct option here will be option B and then this patient might need. Uh So the trick in this question again, uh The question was what is the most appropriate initial management? So what's the first thing that you will do? You won't take the patient to deprive the foot in the, the first thing. The first thing that you will do, you will uh give antibiotics, take cultures and man and stabilize this. This, this patient uh later on if the patient has bone infection or he's not improving, definitely he will need deprive. So, o option D is right, but it is not the initial step. Diabetic foot infection is very common with uh and uh start with ulcers. Many patients have uh neuropathy, they don't feel their feet, they get them injured, they didn't pay attention to it. It get more severe, it get more infected, it involves the bone and many times it, it ends with needing some deprivement or even major amputation. Uh Many patients will present with a life threatening sepsis. So the pathophysiology, neuropathy, peripheral vascular disease, immunosuppression, which we discussed diagnosis, clinical assessment. See the patient, you need to assess two things as assist for infection and assist for the vascularity. And here meet the Wi Fi. The Wi Fi classification is very good and is very uh handy tool to uh to use you. It can describe three things w for the wound and zero, no ulcer or gangrene, no wound at all. One small ulcer, two deep ulcer or gangrene, three extensive ulcer or so, if you tell me W three, I'll be OK thinking there is a big wound there. I is for ischemia. And uh uh it depends on the pressure there, but it depends also on the A PPI you can use A PPI and uh if I is uh the presence of the foot infection, which is, is there an infection or not? So zero, no infection, mild, moderate severe infection or if there is uh sepsis. So this is a good tool to be used for the clinical assessment. Imaging studies is very important for all of those uh patients with um wounds. You need to do an X ray to start with. Uh if there is gas on the X ray, you will be thinking this is severe, this need urgent deprivement. Uh If there is osteomyelitis, then we need to discuss with the patient option with antibiotics and then um go with um uh like deprivement. If there, if there is no response for long term antibiotic, sometimes x-ray is not uh very like um informative. We need to do Mr to rule out uh osteomyelitis rarely we do CT scan. But if you are thinking of necrotizing fasciitis, maybe the CT scan is that is that you will do at A&E we send mic micro microbiological specimen, uh blood cultures, wound culture and specimen. When we do the deprivement laboratory test, you do what inflammatory marker is most important kidney function. If you are having AKI from the infection and uh assessment of the vascular status, feel the pulses and try to get a PPI or T PPI. If the this is are incompressible uh management, medical glycemic control surgical, we said deprivement. If there is ischemia, they will need revascularization. If the patient is septic, we will not wait for, for revascularization, we will do the deprivement, then we will do the revascularization. But if the patient is not septic and we are controlling that with antibiotic, we will do the revascularization first, then we will offer the deprivement wound care, which includes dressing and offloading. There is offloading uh shoes with the physiotherapist. They can offload the heel or the uh toes, prevention and long term they will need uh foot care, education, uh regular follow up smoking cessation. Most common pathogens for diabetic foot infection will be gram positives most of the time. If there's an ischemia and uh aero uh an aerobic uh pathogens will be there. Uh always. Um if patients are septic spiking fever, we tend to cover almost everything, but specifically the gram positive and uh an aerobic. If the patient is ischemic, our guidelines for severe infection will be tazocin and uh L le Lanzol. And uh for moderate infection, it can be only cotrim and for severe you or for sorry for mild cotrim for moderate cotrim and meth and for severe, as we said, Taz and Linzo, uh I think this might be the last case with us today. A 70 year old male with a history of peripheral vascular disease and poorly controlled diabetes. Mellitus presented to the emergency department with a severely infected foot ulcer that has not responded to previous medical management. So, same scenario but is not responding. Patient has non healing ulcer on the dorsum of his foot, uh right foot extending to the toes with signs of gangrene. He reports severe pain at risk and there is a foul odor coming from the wound. Examination reveals extensive necrosis of the forefoot and absent needle pulses, no pulses. A B uh 0.1 very low on the right side. He was discussed at vascular MDT. There is no revascularization option. Doppler ultrasound shows minimal blood flow to the foot and X ray reveals osteomyelitis. The question will be. What is the most appropriate next step in the management of this patient? Will you continue the wound care and oral antibiotic attempt, revascularization with angioplasty, administer intravenous antibiotic and the plan for surgical deprivement, perform Aloni amputation. Again, this is not the best in issue before you answer this thing that is asking what is the most appropriate, how you will manage that? Because I think most of you would be thinking between C and D because for such a patient option B is completely wrong. This patient was discussed at the MDT no revascularization option. So option B is wrong. Now, option A continue with wound care and oral antibiotics. So from the scenario, we know that the um the wound is worsening, the patient started to be septic. So it's not a good idea to continue wound care and oral antibiotic and discharge the patient. So we remain with option C and D initially. Uh Option C will be right because this patient will need IV antibiotic will need to be planned for surgical deprivement. But uh surgical deprivement is not the right phrase here again, because this patient has no revascularization option and there is excessive damage to the foot and this patient will end with having a major amputation. So I think that makes option D is the correct answer here which I think we have 44 responses saying option D. So option C, most of you said option C again, if the question asked you not appropriate but ask what is the initial I will go with the antibiotics. It is right. Surgical deprivement is not right because if we go back to the scenario, it says that most of the forefoot somewhere is right foot. So extending to the toes. Um I thought I put 4 ft infection here. OK. So it is not salvageable. There is no revascularization option. And if you do deprivement just to the foot, this wound will stay infected because there is no good blood supply. So D is the right that brings me to the lastest uh topic here. And the last, the last thing that we need to do as vascular surgeon, which we don't like to do is to do an amputation. Major amputation refers to the surgical removal of a limb or part of the limb typically above or below the knee, to manage severe condition that can't be treated conservatively sorry indications. It can be a critical limb ischemia can be severe infection. Uh So critical limb ischemia with no option to revascularize just ischemia, severe infection, trauma, malignancy, and nonfunctional limb for patients who have trauma or uh joint surgery before and they can't walk anymore. The goals of an amputation is to eliminate the infection, especially in the diabetic and in a diabetic. I will say that especially when the infection affecting the heel, affecting the calcaneum. It is very difficult to, to manage most of the insulin and mutation and patients with ischemia, they are in much pain. They will ask you to do the amputation because of the pain. Many times the pain killers are not really enough for that and to improve the quality of life. Many times we would like to do if you look to this, you can see the this picture, the level of the amputation. If we are doing a major amputation, we will try to do a belo amputation. 60% of patients will use the prosthesis and walk again with biro amputation. This is compared to 20% to at the past 30% for patients who's having a through knee or above knee, a mutation. Even sometimes we will be offering some revascularization for the SFA or thigh vessels to improve the blood supply for the patients. So we can get away with abi amputation rather than doing an above knee amputation. So even if you are losing the foot, revascularization is still an option to get away with aone and try for this. Uh give the patient the chance to walk again with the prosthesis. But even the best numbers for the bina amputation is 60 patients who can ambulate with the prosthesis. It, it, it is, it has many dependent, many uh factors that can affect that. And for patients who's having um amputation or a critical limb ischemia, the mortality in the next 3 to 5 years is higher than many, many even malignancies. It is very serious condition. We know that to patients who is having an amputation for C LTI or patients who is having C LCL Vaas. If you look to different registries, the mortality rate within uh three years, 3 to 5 years is about 25%. It is too high. So the vascular disease are very significant complication for amputation as any surgery, infection, wound defense, phantom pain. And that's the pain when the patients will feel the foot hurting. Though the foot is not there anymore contractures, especially for Benoni amputation, they can have contracture to the knee joint. So they cannot stretch or extend the knee fully. And that's why the physical therapist will be doing a lot of exercises to them and stretching their knees and prosthetic related issues, especially with the pressure with fitting with walking, physiotherapists deal more with them rather than us. Rehabilitation for amputation is very important. Uh Psychological support, prosthetic fitting and uh physical therapy. And physiotherapy is very important. Last slide for today. Sorry, it's too long. Um Because one of the curriculum asked me to speak through what is expected from uh uh you especially many of you are are are new patients. So a new doctor. Sorry. So if you are reviewing a new patient, you need to go see this patient, the clerking by clerking, you need to take a proper medical history, do physical examination as you have been trained in your medical school. I am sure while you are doing that, you need to think as a doctor, not as a secretary, you can work as a secretary. Take the medic uh like the history, the physical examination, the list of medication ask about of thi o of things, but your pain is not functional. While you are asking your pain should be functional, you should be thinking OK, what is the differential diagnosis? What is uh what does this patient might have? What would be the next step? So if you are thinking of a differential diagnosis, when you're asking that question, you will be asking questions in the history to include or exclude to uh make an order of the differential diagnosis. What is the most likely thing? Many times with good history and physical examination, more than 80 to 90 patients of cases without doing any blood without doing any imaging, you will be getting the right diagnosis and then building the right management plan. And when you have, when you finish declaring the patient, the next thing will be to do the stuff that I think now we are aware of how to do it. You need to request the bloods. So if you are thinking about the differential diagnosis, the bloods and imaging, you will be knowing what to request. You will need full blood count for almost every vascular patient, you will need um kidney function. Many of them have CKD, uh diabetes, random blood sugar or hemoglobin A1C. If they never tested for that before, uh liver function uh uh profile. If this patient having an acute ischemia or uh diabetic foot sepsis or when you were looking at this patient. And after this lecture, you think this patient might need to go to theater. So you will need them to think of a group and say have two samples, make sure that this he's ready for theater. Uh If the patient is anticoagulated or is having acute uh limb ischemia started on heparin or will be started on heparin, then it is worth sending a coagulation profile for the blocks. Now, for the for the imaging, if the patient having a foot wound, there's an ulcer to the foot. So and I look to the back, there is no foot x-ray. I'll, I'll, I'll be requesting a foot x-ray. Oh, the ulcer was to the heel then II, instead of requesting a foot X ray, I will be doing a a calcemia x-ray to look to the calcaneum because the ulcer was on the heel. Oh, the patient has cough, he got COPD. It might be just infection. So why not to do a chest X ray? Uh Well, this patient is acute ischemia will uh you have no access to the registrar notes at A&E or you don't know you can discuss that. Ok. This patient will need act scan. Uh This patient is a chronic limb ischemia or maybe the best option is to do a carotid DX. This patient referred to us because he had uh ti A. So it, it, it will be a carotid DX. Um So think of investigation. Uh I think this patient having C LTI need you, you or you need to do an A PPI for this patient and the comment that well a patient presented to us uh with chronic limb ischemia A PP 0.3 and we did for him an anal pressure index. After the procedure, you are seeing him. Oh, I will do another A PPI to see if the ABP is improved as expected. After a revascularization surgery review, the medication look to the patient's medication, some medications will need to be continued, some needs to be stopped, some needs to be changed. So if a patient on Pixy, on Rivaroxaban, he's in, in, in uh for, for like uh DVT or um atrial fibrillation. Well, this patient might have uh surgery and intervention so it's better to stop the do and start them on low molecular weight enoxaparin, for example, following the trust guidelines. Ok. This patient is in, in me, Metformin, we are doing a CT scan, maybe I should stop the Metformin uh give more uh hydration, speak with the diabetic nurses to if I if, if the di diabetes is not controlled as well, so always look around the medication. Many medication can't be stopped even if the patient is a start and he's having surgery next day or now like beta blockers, they, we will give them a statin, we will give them uh thyroxine for the thyroid. We will give, we will give that uh and some medication will lead to stopping as we said, like for example, Metformin, before angiogram, it will be stopped. So look to the, there are a lot of posters around as well which will help you to decide if you don't know. Always ask. Now the plan, always with a plan for this patient. This patient will have a plan either for revascularization, uh for IV antibiotics. Um uh pain relief. Uh always think of pain pa many patients are in pain just because we did not prescribe proper pain killers to them. Think of the wh o liver for the pain control, paracetamol is not very good. Actually, for vascular patient, most of the vascular pain needs opioid. So it's always double check with the patient. When you see him. If he is not on opioid, he is in severe pain, then give him opioid. Um three important things. Uh proper documentation is very crucial, especially that you would be doing that. Most of the time you are doing the clerking, you are writing when the consultants or the registerr are doing the word round. If you miss something, stop the word round, ask because if something missed it sometimes bring harm to the patient. So make sure proper documentation. Always write the date. The time the w was that award round? Was that a review for the patient who is doing that? Who is there? What is the plan after this review? And what is the relevant information that you need to do? Uh a recent investigation for a patient who was arrested in vascular ward last year uh there was a good documentation but they were just putting the date without the time. So we could not track the the timing. This was one of the comments about our documentation. So always we make sure that all the elements are there. And if you don't know, ask escalation, if you are not sure, ask someone, ask the nurses if you are more concerned, speak with the senior registrar, even if he's not answering, busy in theater, speak with the consultant, always ask, always escalate when you feel uncomfortable or you feel that you need help. And even if you need to discuss the cases because sometimes you don't know what is the plan. You don't know what is this case. If you discuss this case, you will improve your knowledge. You will start to think as more senior doctors, you will uh uh be better when you finish your uh rotation. I'll be honest with you. Many of the junior doctors who comes to the vascular will uh come and will be better doctors when they finish because they will deal with a lot of medical uh diseases. They will deal with diabetes with ischemic heart disease, with peripheral vascular disease, with anticoagulation, with a preoperative evaluation with postoperative care. So they will gain many skills during their rotation with vascular. But if you come just to do the job, just to the comment without thinking without uh discussing the cases and without putting the effort, uh it's a good chance that you will come and live without gaining much knowledge. So uh always be initiative and uh I think that's that, that's all what I need to say. And I am so sorry, so sorry because it took too long back, back to you, lie and uh Melanie, sorry. Thank you very much vra obviously, like we'll send you some feedback. Uh Please put any feedback that you can, will be able to see that and um just give us suggestions if you have any suggestions for any future sessions. Um As you've agreed to record this session, we'll put it as a catch up content in a couple of days. Um And thank you for all of you who actually state you at the very end um and make sure you join us in our future sessions and you follow us. Um So you can get some alerts. Um Thank you again for doing this and you can share this probably with your future colleagues. And if once, yeah, we'll, we'll be waiting for them at vascular seven. It will be nice uh to work with you all. Uh You are welcome. It was a pleasure and very nice to uh meet you all today. Thank you very much Moran.