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In this evening for our first um MRC as part revision series session of the year. And we are going to be running several events and over the next 2 to 3 weeks before the May set. And also if there's anyone interested in sitting the winter exam, it would be a good idea to just attend the events and get a feel for the type of revision that's ahead of you. So, um I'm very happy to be joined here by Ali Reza, who's a current um academic in Leicester and he is going to take us through a vascular surgery revision event. There'll be some MC QS at the end, um which I will pop into oppose and um there will be certificates and feedback forms and everything. All at the end. All right. All right. Thank you. Thanks Sophie for the introduction. Hi, everyone. I'm uh, is in Leicester and my research project is in um vascular surgery and I'm going to start uh an ac fellowship in vascular surgery from uh August. So here I've included some slides um that would just help you with your revision with uh MRC S part A in particular, but then um these are just a, a summary of vascular surgery. Please use the resources available in terms of question by and textbooks in your library. There's no specific um resource I would recommend but the combination of resources should be a good cover for, for the whole syllabus. And I sat my part a in September 2023 and I passed in the first attempt as well. So I I'll try to include some uh exam hints and techniques as well because that's also part of um an important part of your preparation for the exam. OK, great. So in terms of learning objects for today, we are going to learn about common pathologies treated by vascular surgeons, learning about applied anatomy in the context of vascular surgery and learning about the style of questions encountered in postgraduate surgical exam such as a part A um before going to actual slides, I've included some pictures and reference them but, but those pictures, some of them might be sensitive due to the nature of um the wounds. So in case um that you would like to skip just, just giving you a pre bone. And also uh I have not been funded or I have not um had any affiliation with any of the uh in fact, higher education uh companies to prepare these slides. And also I have been invited voluntarily by FDSs London to deliver this presentation just as disclaimer. Great. OK. So in terms of M MRC S part. A focus is on anatomy based physiology, pathology, uh pathophysiology and the clinical application of the knowledge as well as awareness of the investigations and management. Uh in terms of today's session, probably we are using an applied anatomy, uh teaching as well as clinical uh aspects of vascular surgery for the uh purpose of this two hour session. Ok. And we have got some M CMC Q questions at the end. All right. Ok. In terms of the contents, um abdominal aorta, peripheral vascular disease, aneurysms, diabetic food carotid artery disease, as well as uh arteriovenous fistula, aVF fistula that commonly used for uh dialysis access in patients are amongst the topics that we are going to cover specifically today. Ok. So abdominal aorta, it runs from T 12 to L4 and it bifurcates at L4 into common like arteries, T 12. These levels are important. You need to be aware of them, you need to know them by heart in tt uh T 12, you see the inferior phrenic and celiac arteries in L1 S mesenteric artery and middle suprarenal arteries and L1 L2 level sort of, uh you see the renal arteries and L2 is specifically for gonadal artery. They all you and in terms of uh the specific position for inferior mesenteric arty, that's going to be L3. So, always remember that L1 is sma L threes. Um I, OK. So L1 to L4, you have the lumbar arteries at each level. And L4, you have the median sacral and common iliac arteries and common iliac artery is later divided into internal and external iliac arteries. So external iliac artery continues as femoral artery, after passing inferior into uh it uh inferior to the inguinal ligament in into the leg. So that's very important from a clinical point of view in vascular surgery. So that also it goes the way that you're examining patients in vascular clinics and uh the the way you're feeling pulses and usually the patients start to lose their pulses distally. And if you feel a pulse distally and you can't feel a pulse proximal to that, probably you need to assess your position for the examination because it can happen. But it's quite unusual uh for a pulse for, for, for an artery to have pulse distally but not proximally. So that that's basically las in vascular surgery and vascular examination. So, majority of pelvic organs are supplied by branches of internal iliac artery. So in terms of uh blood supply, um in terms of anatomy, it's important to have a general understanding of the blood supply to internal abdominal or organs, pelvic organs. And uh in fact, the lower limb supply in particular in this context and also the symptoms that you, you get might be associated into the, with, with the area that's affected in the pathology. If you are thinking about pathophysiology of uh conditions affecting the vascular status of the lower limbs? Ok. And by the way, have you got any questions so far? I'm happy to take questions uh during the talk. Uh Please pop them in the chat. And I'm sure Sophie, would you kindly let me know if there's any questions on the chat? And thank you. Ok. So in this figure, which is reference as well at the end of the slides, references are seen um abdominal aorta and its main branches are seen. Um So teach me anatomy was, was one of the resources I use for anatomy in particular. Then then in, in, in this picture, you can see inferior artery, celiac, celiac, sup mesenteric artery, and uh testicular artery and then um inferior mesenteric artery, branches of the abdominal aorta. Ok. All right. And also this is a, this is a nice uh illustration on an MRA so magnetic resonance angio and then basically abdominal aorta and main branches are seen. Um The these are highly sensitive examination, investigation resources that we have available when we are investigating for peral vascular disease. But often due to the cost and availability and also specific indications they're not the first line, but they certainly help in um scenarios that are quite challenging to diagnose and manage. Ok. So then in here, we have a picture of a CT scan that is showing the abdominal aorta and its branches a lot of times. Um we have to follow an order specific order in in vascular surgery, in terms of uh clinic, assessment and investigations following clinic visits. A CT angiogram can be one of the initial investigations but not necessarily one of the first few investigations. Uh For example, I was in clinic today, a patient was referred to Volz Clinic which is the vascular access. Um uh basically, it's like a sort of heart clinic that they run on a daily basis consultant, run clinics. Um The there was a patient referred by GP and um had clinical limb ischemia, uh CTI and then duplex scan was performed. And due to the narrowing seen on duplex ct angio was considered the next line. So uh from the examination was probable that the patient is going to need a CT scan CT angio. But that doesn't mean that you can skip um duplex because that's also part of an important investigation. Also remember about um the contrast nephropathy and in terms of uh the radiation risks in the long term. So all you all this have to consider those basics in vascular surgery. As as in general, you have to have a holistic approach towards patients and consider their renal function. Consider their baseline, consider their sort of comorbidities as an event you're deciding on investigations. And we have more slides on that later. Ok. So in terms of peripheral vascular disease, uh we have acute limb ischemia, chronic, uh upper limb ischemia, which is quite rare compared to chronic lower limb ischemia. And there is a misconception that many um colleagues imagine vas surgery as af feet doctors. Uh they're not feed doctors, they're not feed surgeons, they peripheral vascular disease uh experts and uh commonly uh peripheral vascular disease affect lower limbs due to a chemical factors. However, it does not mean that any dermatological conditions or rheumatology con conditions should be referred to vascular surgery and intermittent claudication. Also one of the important presentations in vascular clinics and critically Mische obviously is it is an important um uh di differential diagnosis of current in patients. Ok, great. Do you have any questions so far? All good. Yeah. Ok, great. Let's move on. All right. So acute limb ischemia, so sudden drop in perfusion of the limb. So puts the limb live for both arteries. Sometimes in vascular surgery, you need to make difficult decisions and you need to communicate with your patients and those who are close to them. And the communication aspects of the job is quite important here. You need to explain the fact that sometimes life threatening injuries can be converted to a life threatening injury. And a lot of times in particularly challenging scenarios, um the amount of I if if you're thinking about reperfusion injury and if you're thinking about saving a limb that is not salvageable, the amount of toxins produced by muscles and the electrolyte imbalances that are going to be produced because of the ischemic leg are going to cause a nonsurvivable injury to the heart and kidneys. So a lot of times the difficult decision is taken to amputate to save the life. So that is why actually the decision making is usually multidisciplinary uh approach. And also usually in contrast to many other specialties, including s surgical specialties, vascular surgeons often have daily MDT S, uh lunch time, daily MDT. They discuss the cal challenging cases of the day, either in clinic or in theater or in fact on the ward. Uh at least in Leicester, that's what we do. And uh acute thrombosis usually contributes to 60% of all cases of acute limb ischemia. While emboli uh contribute to 30% of cases in terms of your MRCS questions that you might get on this scenario is usually you have a sort of chronic uh disease that has led to an acute event. And then you can think about thro thrombosis going on in the background and in terms of emboli in terms of the disease trajectory usually tells you about the patients um cardiovascular disease including af and that's been affecting them for a long time. And then they have presented with a sudden presentation without any problems affecting their legs before which we have so much slight later on this. Ok. So, predisposing factors for acute limb ischemia and we have acute thrombosis, preexisting atherosclerosis, dehydration because because of the viscosity of the blood increases, then yeah, your, your risk of uh having a thrombotic event increases. Then we have blood disorders, coagulopathies, including polycythemia and other prothrombic conditions. Hypotension, malignancy also increases the risk history of reduced pulses and intermittent claudication also may be noted. Usually these patients are vascular paths. They have had chronic conditions affecting their uh vascular uh system. So, emboli acute emboli uh for example, cause af uh after myocardial infarction or chronic uh causes such as af can cause uh an emboli. And that's also one of the reasons we need to be quite called stick in vascular surgery. When you're considering patient with uh critical limb ischemia affecting one of the legs, you also have to think about this patient might also have suffered from a myocardial infarction or might be suffering from uh another acute condition affecting the aorta or other parts of the major parts of cardiovascular system. And then that, that is going to guide your treatment in terms of ization. And also um the importance of involving a multidisciplinary team in decision making is key also the patient obviously and uh just the point that basically is going to happen in the few channels, actually happening. A lot of times you are considering palliative approach in a lot of uh not thankfully in a not in, not in a lot, but in some cases presenting with uh severe presentations like ischemia or aortic rupture. So, palliative approach is actually um getting more common in the UK and certainly in some Northern European countries. It has been in practice um more often than the UK uh absence of claudication, history and presence of acute cardiac events versus AFA sort of uh point towards consuming emboli as a cause of ischemia. So, it's about uh a bit of clever thinking and then trying to dig out like what's the main cause that has contributed to their ischemia? Ok. So rare causes of acute limb ischemia, arthrogenic injury, sometimes after um interventional radiology or interventional cardiology procedures, uh after uh needling the femoral artery, they can, they can actually um um cause athrogenic injury to the vascular system, peripheral aneurysms, popliteal aneurysms, for example, trauma and aortic dissection. Uh sometimes aortic dissection can involve the whole lymph of the aorta as well as part of the uh uh in fact, external iliac and the femoral artery all the way around. So, II in, in, in some, in some scenarios, it is actually in terms of um some of those of you applying for a course surgical training in your interview. If you get a clinical scenario or those of you prepare for a part B, these are stuff to consider when you're ordering investigations in these scenarios as well as the my and even part A. Uh it is still an important investigation if you have clinical suspicion. Ok, to get a CT aortogram to see if there has been any dissection of the aorta, either at uh lower levels or uh anywhere in the abdominal aorta. Ok. So, symptoms and signs, I'm sure, I'm sure uh you must all have come across these six PS, but it's very important. So that's why, that's why I've included them. So, p pain, pulseless leg and paralysis and cold leg. So these are um the six presentations, six symptoms that usually patients come, uh not necessarily all of them um are present when patients presenting a, ok, in terms of management. So a three assessment and resuscitation give oxygen fluid. So often these patients are critically unwell, you need to stabilize them first before ordering any investigations. Uh in terms of uh the the importance of giving oxygen because because sometimes the organ perfusion is damaged due to um the vas the poor vascular supply and hyperperfusion with oxygen actually helps to ensure that organs do not end up in anaerobic respiration and lactic production, which is going to make them uh metabolic acidosis coagulopathy and the terrible triad quite worse. So, in, in, in, in vascular surgeon, because vascular surgeons do a lot of trauma surgery and battle feed surgery and all sorts of exciting stuff. Um it is important to um apply some principles that we normally learn in ATL S as well. And um so basically, it's, it's a mixture of uh acute presentations versus um a chronic presentation to cancer. Um in terms of investigations that start from uh bedside investigations such as such as E CG chest X ray bloods F PC clotting Glucon saving case you going for F and then Trump if you are suspect uh an MRI and then lactate and glucose, uh lactate is a great marker of end organ hypoperfusion um and give IV analgesia because because these patients are often in a lot of pain. So if you're thinking about um W ladder, so probably you can use an inverted ladder. So basically, it starts from uh a strong IV pain relief and um always ask for senior health surgery short on call and assess the limb viability. So in terms of the assessment, you, you should always look for irreversible fixed modeling, tenderness on palpation and sensory ve uh P sensory motor loss and pulseless cold leg with abnormal cap refill time. So these are pointing towards an emergency and also depending on the situation that is going to guide your further management, uh in terms of amputation versus um revascularization or uh conservative approach. OK. So in terms of management, uh IV Heparin, you need to aim for a PT of 2 to 2.5 times the normal range and in terms of definitive management. So, nonsalvageable limb requires an urgent amputation. OK. So it's not usually an immediate amputation. You don't have to amputate the leg middle of the night, but obviously, you need to do that on the next surgical list. In other cases, uh immediate treatment or investigation such as CT angio and duplex can be considered based on the degree of ischemia. So, uh if certainly there are uh loss of sensation and then it's an emergency, then you can come to them out of hours and uh that's going to guide your surgical management, right? Any questions so far? Nothing in the chart at the moment? Brilliant. Thank you. OK. All right. So, chronic lower limb ischemia, aortoiliac femoral popliteal disease. So, as I said, initially, you should always think about that uh like a continuous uh flow of blood to the legs. So, aortoiliac disease, femoral popliteal disease can be continuous or the patient might have disease uh aorta at multiple level. So in terms of combinations, uh you can get intermittent claudication and critical limb ischemia affecting certain areas uh based on the blood supply to the muscles. Uh We have Fountain's classification three and four are usually known as Misia. So it's, it's classified from basically asymptomatic uh leg to intermittent claudication that is usually coming on only after a certain amount. And usually the patients can quantify exactly like 200 yours, 300 yours, they can give you the exact number uh and just just a point uh from a clinical point of view to consider. In this scenario, usually these patients are not the fittest patients in terms of the cardio respiratory function. A lot of patients with uh vascular issues, affecting their legs also have vascular issue, affecting the heart as well as pulmonary conditions that have been a smoker, for example, affecting their uh lungs. So always think about those contributing to the scenario as well. You can ask them is the shortness of breath, the fact that that is stopping you from going further or is it the pain in the leg or which one comes first or which one is going to make the other one worse? So it just ii in terms of clinical practice, it shows you have a holistic approach in this scenario. Um uh rest pain and ulcers, gangrene are usually um uh three and four in terms of calcification of content. But then you should always ask about uh how it's affecting them at home particularly at night. Do they have to hang the leg off the edge of the bed to help the symptoms? And is it happening during the night or is it particularly worsening time of the day? So all those basics? So in terms of clinical uh clinical limb ischemia is that there is a high risk of progression to limb loss and rest pain over two weeks, not relieved by simple ans. So that that's the definition, but obviously, we need to consider the patient as scenario. So Doppler an ankle pressure less than 50 millimeter he g um and also toe pressure, less than 30 millimeter, he G and a lot of times actually, toe pressure is more helpful, particularly if the patient is diabetic, toe pressure is more helpful. And I think it's a preference that I have seen many uh up from, from an evidence point of view. I'm afraid I have not had a chance to go through the evidence in enough details to see which one is superior. But I've seen uh quite a few registrars and seniors who prefer um to pressure in clinic and uh usually above 30 to A G is normal gangrene or ulcer presence and also pain typically worse at night and relieved by hanging. The. So that is typical history that the patient is coming here. So diagnosis is usually clinical duplex ct angio Mr angio and interventional angiography use. As I said, it's also multidisciplinary decision making. Usually uh unless there we have an interventional radiologist consultant attending our MDT S at least one of them on a daily basis. So these are some cases that we can discuss um with radiologist treatment focus can be uh can be on treating the current presentation and modifying long term risk factors. So always, when you see a patient, the vascular path, always um in terms of your approach, think about the cardiovascular risks, they think about the stroke risk MRI risk as well as um how to basically reduce it. Obviously stopping the smoking is is is one of the most effective interventions and even a brief smoking cessa cessation advice by a doctor can, can be very effective and also think about the lifestyle factors, the physical activities as well as general. Um uh based lifestyle advice and also make sure they're on antiplatelets and statins. And the preferred antiplatelet for peripheral vascular disease is called and CPI grow was a game changer over the many years ago. And then, um compared to 19 seventies that we only had aspirin uh grow has has had a massive impact in terms of improving the outcome of patients with peripheral vascular disease in terms of uh clinically mimic treatment. So medical care with analgesia tissue viability, optimizing long term conditions like hypertension, diabetes, statins, antiplatelet therapy, physical activity and a smoking sensation are key and in terms of surgical management. So that is when you get vascular surgeons uh to support you. So in terms of endovascular, um we have aortoiliac conditions, commonly femoral common femoral and superficial femoral angioplasty and a stent insertion. So at the moment, there's a trial running in the UK called OX trial and Lester uh imperial and uh whole your the, the, the, the, the the lead centers, there are multiple centers in the UK is funded by the Nr Hr that you're looking at the evidence uh surrounding aorto disease and open versus endovascular management for that. So it is an important um area of invest uh area of research at the moment for a lot of peripheral vascular disease. Over the last 10 to 15 years, we have realized that we did not have evidence based approach and um inter international and national trials. And I talk on the trials in these scenarios have certainly contributed to um getting a lot of evidence based uh uh basically knowledge in terms of management of chronic peripheral vascular conditions. So that's also a growing area. And if any of you are interested in vascular surgery in the future, and you're going into course surgical training or later on to treat vascular surgeries, there's, there's always um uh uh an uh a national and international trial you're running and I'm sure your centers will be a active in it because usually vascular surgery, research departments are quite active in the UK. Um feel free to join those. And uh II II, it is usually an important part of our role as doctors to uh to ensure that, that the management plans that we are using are up to date and we are applying evidence in terms of choosing the right type of management for the right patient. So it's always um uh an important opportunity to get involved with those trials if you can. Ok. So in terms of endovascular approach, success rate is usually lower in more distal disease. And um that is also an area that is, that may not be correct in, in, in, in a few years time uh with changes in basically endovascular approaches and um uh becoming more efficient, I think in terms of surgery. So, aorta bypass surgery that essentially um uh you bypass the obstruction, axillofemoral and femorofemoral bypass, femoral distal uh popliteal uh So basically femoral popliteal, femoral tibial, depending on the scenario. And depending on it is not only the diseased area that you're looking at, it's also the area that you're going to anasthe most to, to, to, to the next area and make it basically bypass you. You need to make sure the vascular structures at both ends are healthy. And then basically, they can at least uh create a better supply. And this is usually a very challenging thought because vascular pa patients usually have poor arterial supply regardless. And sometimes it makes it a bit of a difficult scenario in terms of decision making. And that's why a lot of vascular surgery patients in the uh in, in the like bypass surgery, patients require revision surgery or even during the operation. Sometimes um the one set uh particular bypass technique fails and another needs to be considered. And I think that's one of the interesting points about vascular surgery. Uh because because a lot of times you see your complication of your operation intraoperatively in theater and you can manage that. And part of the management could be changing the approach to your bypass surgery. So we can certainly change a femorofemoral bypass to an axillofemoral uh bypass if required if, if the situation allows. Um But then the important situation in this scenario is before the operation, you need to appropriately counsel and consent the patient. Uh because obviously you can't make them on the operation when the, the whole leg is open and then reconsent them, that's not going to be feasible. So a lot of times we need to go through that with patients in clinic, go through the details, make sure the consent that they, they, they, they have given the informed consent. And if things fail intraoperatively, other approaches may be considered and a lot of scenarios and it would be difficult to predict what is going to happen. But at least on the plus side, the big advantages of uh advantage of vascular surgery complications are because blood is under high pressure flow, you can easily see your uh complication rather than a lot of other surgical specialties that the patient ends up on the ward. And after a few days you discover an abdominal leak or um antic leak basically. And then uh could be a man uh uh basic challenging but well, I'm biased on that. Um So I'm sure I'm sure other specialties have good stuff to tell about their own specialty. Ok, great. So in terms of surgery, so we have aortoiliac bypass and but then also the bypasses, but then in some scenarios, it might be inevitable to um go ahead with amputation. And also amputation is an important area that needs to be discussed with patients in very in advance. And um because amputations, although technically, they may be um in terms of surgical approach, it might be um quicker to perform. But usually the patients end up with uh long term consequences and uh it has to be a very uh basically informed decision. Uh However, in certain scenarios, there is no potential, particularly if you are thinking about distal um vascular supply in terms of toes or midfoot. Uh usually amputations um are quite helpful as well. Ok. We have some slides on position later as well. Any questions so far, the child is still clear and one month like not to us with their mic, I hope I haven't send everyone to sleep. Ok. So, amputations in smoking related atherosclerosis, usually above and uh above or below knee, amputations are considered and in diabetic related disease, distal amputations are more commonly performed and that that could be toes, forefoot and ankle. However, this data might change in a couple of years. It II, I've, I've used a mixture of textbooks to and basically uh knowledge from uh basically uh previous backgrounds and my own medical knowledge and the knowledge I've gained from clinic. So I've, I've used a mixture of um resources to create these and uh my own understanding of VCO surgery. But uh the, as I said, as I explained, the trials that are running at the moment might change our approach. One of the senior officers in Leicester who is very keen on endovascular repairs. And a couple of years ago when he was a senior registrar, he performed more endovascular surgeries in Leicester than the whole interventional radiology department at hospital in one year. And at the same time, he was uh an N hr clinical lecturer and he was doing research and all sort of us on top. He, he, he's a fan of endovascular repair. One of the actual os uh for, for, for, for one particular condition showed that open surgery could be superior to uh endovascular repair. So uh that is actually the power of new knowledge. So things can change. But just for, I think for the moment, it's, it's some of the interesting points that OK, so Lowry syndrome is actually um sometimes encounter symptoms in terms of clinical uh questions that you might encounter in MC part A. So it's, it's a disease. Uh It is distal aorta or proximal common I uh are involved in low. So patients can present with claudication, affecting buttocks and thighs and then femoral courses are usually weakened or absent. And then I think the in terms of an exam technique, if you are approaching the question, the most important thing to consider is a combination of erectile dysfunction or impotence in males. It, it, it usually affects males by the way, II haven't seen really any questions that would um give, give a lady in the in the scenario. So it's usually a man presenting in his fifties or sixties presenting with some intermittent claudication sort of picture in addition to erectile dysfunction. So that is usually low syndrome. Uh So it's uh probably is one of the conditions that is more commonly encountered in exams rather than clinical practice, but an important one to be aware of for yours. Ok. All right. So leg ulcers, we have three types of leg ulcers, arterial venous and neuropathy. I'm sure we have come across that before, but I'm just going to go through uh some key uh basic phrases that would differentiate them between if you are in the body of uh question. And we have some pictures which I'm afraid to say are not quite pleasant. So just the warning. OK. So RT ulcers, they're deep ulcers with well defined borders. So that's very important to note that. So they're deep and they have well defined borders, they're punched out and then they're seen on peripheral areas and toes and they're usually painful. So that painful, um, a feature of arterioles is key to differentiate them from venous ulcers. So I want you to be aware of that. OK. So next slide here, you can see um clearly uh marked arterial ulcer and OK, so let's talk about venous ulcers. So venous ulcers are larger and more superficial than arterial ulcers. And they usually have a gentle sloping and uh irregular borders and they can affect the meal to ankle area, which is known as Gator area. It's very important, it's get gator area. Uh I haven't really come across any questions in postgraduate exams that um it's given you a venous ulcer scenario and it is not located in gator area. So it's git area. One of them, both words you need to be aware of when, when you're thinking about uh diagnosing venous ulcers and other signs of venous insufficiency such as the skin changes can be present to. So, in fact, uh because of the hemo in the position and um basically long term nature of leg ulcers, uh in fact, uh venous leg ulcers, then you might get some of those skin changes and then it, it helps you to differentiate uh the cause as well. Here, you can see a venous also um affecting the gate area. I'm afraid uh the picture is not quite clear, but I can reassure you, it's probably gate area and the references include at the end. So basically, um uh I, I'm, I'm sure Sophia and her colleagues can share these as slide with you and then uh more than happy to uh basically, if you can, if you guys get the time you can go to reference. So all include that. Yeah, at the way. OK. All right. So, neuropathic ulcers associated with peripheral neuropathy, poorly controlled diabetes, like is a common cause. So, always think about again, in this scenario, you need to demonstrate some um holistic approach. If you're walking as vascular surgeon, I'm sure in other areas you also demonstrate. But in this scenario, it's quite key because if somebody has peripheral neuropathy, they also might have retinopathy and nephropathy as well. So the end organ damage features of uh diabetes, um and sometimes they have a sky high HBA1C levels. And then you also need to think about involving other members of the team, including specialist nurses in diabetes too. Uh manage your diabetes sometimes acutely. Sometimes you need to think about uh so a sliding scale if you're going to operate on these patients because in every single operation, uh also the, the, the uh these questions are tested in other areas in MC as part a such as um anesthesia and preoperative care. So, hyperglycemia is associated with uh negative outcomes in, in terms of um uh surgery in general, particularly if you're operating, uh if you're doing a major operation like vascular surgery and then uh neuropathic ulcers commonly affect pressure areas. So it's also one of the differentiating factors and also one of the both words that's going to help you to choose the right option in I in a singular answer or m question. So, and they're often painful. So a lot of times um options like amitriptyline, pregabalin uh can be considered for the management and just, just, just a point for you to be aware of. Um we usually don't do combination treatment in these scenarios. If, if somebody is, let's say is on pregabalin and pregabalin is not helping them. We usually stop pregabalin and start gabapentin. We don't normally mix two together. So it's usually um you stop one and then you start the other one. OK. All right. So, uh these are some general knowledge about a neuropathic also. But I've, I've, I've tried to include some key phrases that's going to help you when you're choosing the right answer in the, in the written exam. So here you can see um demonstration of um neath sis. OK. So Berger's Disease. So, Bergers is also known as uh thromb uh obliterans. Uh It's basically a disease of a small and medium vessels, inflammatory conditions. Basically, uh it results in thrombosis formation and usually affects hand and feet. So uh it's usually again, um sort of typical age range is 25 to 55 in a man who is a smoking. So if they give a question in the exam and the patient is non smoker, so probably think about all the causes. So for beggars disease, typically the patient is a smoker and is a fairly young smoker as well and is a man. And so with that demographic information, probably you have, you can choose the right answer basically in a, in an exam if you come and give it episodes of cyanosis affecting fingers and toes. And then in terms of the management or basically one of the main managements, it is the smoking cessation or the management. It's a smoking cessation and it is not about reduction in the smoking. It's about complete cessation of the smoking. It's one of the very few areas that we, we should be adamant that the patient has to stop the smoking otherwise you will not get better. Uh Well, you know, a lot of other scenarios, then we can agree a plan with the patient to reduce gradually and then basically take it from there, obviously, in, in bears disease, they must completely stop smoking. Ok. So, and, and that involves a lot of communication skills and you need to liaise with the patient. Ok. Good. All right. So varicose veins. Um so veins that contain uh basic veins, all all veins contain uh valves that basically in the legs. And then they allow unidirectional blood flow, incompetent valves that could be caused due to many reasons, wear and tear, uh age degeneration, obesity increase like intraabdominal pressure, all sorts of reasons and in incompetent valves results in blood to be drawn downwards. So basically, it results in pooling of blood and then deep and superficial veins are connected by perforating veins. So essentially they're connecting deep circulation to the superficial circulation. So, in, in, in, in vascular surgery, it's always impo important to be aware of if you're dealing with the deepest structure and the superficial structure. And then in terms of the planes that the structures are located in incompetent valves. In perforator veins are basically perforating veins and perforator is essentially the same thing. So if, if there, if there's some incompetence in the valves, it results in formation of varicose veins which are great UNC can be painful, can affect many patients. And also you need to, again, uh I keep saying this holistic approach, uh because that was actually I'm a bit again bias. But I think that was one of the main reasons that I chose vascular surgery because you, you can clearly demonstrate that you're considering the patient as a whole that can affect patients massively. And um in terms of the pain and the uh the change in the, basically the cosmetic appearance of the legs also, that could be the main problem, affecting them, causing them, uh los of psychological problems. OK. So, uh in uh varicose vein, you can see a couple of pictures and uh differences include at the end. So, uh, II, I'm sure uh you all have come across patients who have had uh varicose veins, uh or uh clinical practice or some sometimes in your uh families and relatives. So they're great anxiety and they can be painful. And uh in terms of management, there are multiple management options available and also evidence is rapidly uh growing in this particular area in terms of uh the management available. And as far as I can remember, uh, basically, I've been to conferences and I think, um the there are differences in terms of available management in different areas in the NHS. But, um, uh I'm not an expert in this particular area of vein surgery. It's, it's, it's a subic of vascular surgery and a lot of that is done privately as well. Ok. So chronic venous insufficiency. So, pooling of blood distally results in veins to leak uh blood into tissues, hemosiderin, which is produced uh by breakdown of hemoglobin. Results in brown discoloration of the lower leg inflammation results in a skin changes such as uh known as venous eczema and then chronic changes and fibrosis. Basically, the fibrosis affecting the skin and the tightening of the tissues and the narrowing and the chronic changes is known as lytos sclerosis or inverted champagne. Uh Basically champagne ba ba uh bottle sign and stuff like that from medical school and stuff like that. I remember. So, so I in terms of um uh that is generally um the sort of disease trajectory that starts from incompetency in valves and that can progress all the way to chronic conditions, affecting the whole connective tissues uh surrounding the lower leg. Ok. All right. And chronic venous uh insufficiency. There are some pictures on here. Then you can see lipodermatosclerosis of the picture narrowing in terms of distal area of the lower leg is seen as well. OK. And hemosiderin deposition and chronic skin changes associated as well. Ok. Great. So, aneurysms, very interesting area. Um some of my research uh are are surrounding AAA um screening and basic aneurysms in the AORTA as well as um of basically reaching towards a target of the screening approach for uh abdominal aorta. The prevalence of aneurysms affecting the aorta is actually declining. And that is probably probably uh due to the fact that people are aware of the smoking risks and people are smoking less than they used to do uh four decades ago. So the prevalence is coming down from 5% towards 1%. And then uh to the point, it might drop below no 0.8% and it it may not be cost efficient anymore to a screen whole population. So you're trying to develop a a new targeted screening approach to include um I in the national screening for lung cancer as the chest physicians are now going to screen patients who are smokers um above certain age and within certain limits. Um that are quite shared in terms of risk factors are quite shared between vascular. Um uh in fact, pathologies and lung cancer, they're going to screen the patients with a low dose CT scan of the chest to look for evidence of um lung cancer. Then we are proposing this idea of uh extending the CT scan further in one set to include the abdominal aorta screen for AAA in selected number of patients in selected group of patients. In fact, with certain characteristics, smoking and age, in particular, uh which are the main risk factors for uh as well. So in terms of um approach that is going to be targeted the screening rather than screen the whole population with an ultrasound. But then it's going to be a bit high sensitivity. But then in terms of the uh this advantage would be the incidental findings that you get in an abdominal ct scan and then uh potential ways to uh overcome that are basically still under investigation. But that's one of the areas that is still an a active area of research at the moment. So, aneurysms definition abnormal dilatation of a blood vessel and it is usually more common in males and associated with modifiable and non modifiable risk factors in terms of modifiable risk factors. Importantly, we have uh smoking and poorly controlled hypertension. Again. Uh the medical intervention and the lifestyle change intervention is, is uh basically amongst the amongst the uh approaches you need to undertake and then non modify the risk factors, family history, collagen disorders and age. So can't do much about them. But then at least we can focus on modified risk factors. But then you can still use that in your argument uh that when you're talking to patients and uh usually patients are sensible and then we can discuss the nonmodifiable versus modifiable risk factors and you can make them afraid that there are certain risk factors they can't do much about. But there is stuff that they can still do and uh just a simple activity like walking a few 100s of steps a day. Plus what they normally do can be a massive intervention to prevent their risk of uh peripheral vascular disease as well as cetera, uh as well as cardiovascular risk in general. So, these are still important to be aware of. And then pathology of aneurysms. We have two aneurysms and false aneurysms. Basically. So two aneurysms contain all three lay layers of the vessel wall. And then there's usually symmetrical dilatation is 10 fusiform dilatation and clog dilatation is called saccular aneurysm. So if I if you hear those terms, that is what they mean and then underlying cause usually atherosclerosis, but can also be infective mycotic aneurysms. You uh that can be tested also in mcs as well. Uh mycotic aneurysms. So there are really uh infective causes. Uh OK. So false aneurysms do not involve all three layers and they're usually covered by the adventitia of the vessel or surrounding connective tissue. So, it's also important to be aware of the definitions because it can, can be tested as well. So, false aneurysms often cau uh caused by IV drug use. So I II, in the scenario, you might, there might be hints about demographics of the patient that is an IV drug use. And, and uh basically has come in with this presentation of the lump and then that's one of the differentials and then interventional medical procedures as well. Uh when we are needling the uh the peripheral vessels to gain access to heart or any other organs in the body. Ok. All right. So we have a sites of aneurysm that can affect the thoracic aorta abdominal aorta, cerebral bar aneurysm and then peripheral aneurysms. We have aneurysms, femoral or popliteal. Essentially every part of the cardiovascular e every part of the vascular system can, can be affected by aneurysms. Ok. All right. So, thoracic aneurysms, we have presentations with Mr like symptoms. Uh and then it can also be present with swallowing difficulty or shortness of breath if it's large enough to cause a mass effect on uh basically adjusting the structures in, in, in the chest. And it's usually diagnosed by chest X ray echo CT angio Mr angio and then angiograph. So these are important investigations all in terms of management monitoring. Uh sometimes um basically depending on the criteria and usually they're national and uh local guidelines in terms of monitoring and then the size and then a referral for vas for surgery and then risk factor modification and medical management is also important. Um because because often these patients have uh other risk factors for cardiovascular disease and might, might also present with uh other types of aneurysms or other types of peripheral vascular disease and open repair versus tr which is the uh endovascular repair of that, that stent usually. And we will talk about that in a few slides actually. Ok. So thoracic aneurysms here is basically a picture of the descending aorta aneurysms. And basically, as I'm sure you can appreciate on this clearly um marked picture and uh often uh the patient comes in with similar sort of picture to N I and then usually, uh, by clinical suspicion of nonvascular surgeons. Uh, so, or nonvascular doctors, uh, in emergency department. Um, so it's usually the ed or the, er, or, uh, some, some people probably in our stages, sort of, um, suspicion is going to save somebody's life. Uh, I think about that and then getting, uh, uh, appropriate investigations in this scenario, it would be certainly life saving for many patients. Ok. So in terms of AAA. Ok. So AAA usually affects males over 55 and 65 is the range is the age for national AAA screening program and they get like a one off screening for uh for, for, for AAA cardiovascular risk factors, predispose patients. Risk of rupture is related to the size of the aneurysm and that is going to guide your um follow up and management plans later dilatation over three centimeter. Uh basically diagnostic and 32.3 to 4.4 centimeter. Usually requires um assessment and uh annual assessment. Usually every year we can do an ultrasound scan to monitor the change in inside when the aneurysm is between 4.5. Um uh So actually the, the um, yeah, it's a, it, it's actually it should be 5.5 sorry, it is actually five point there slides, I've just realized 4.5 to 5.5 centimeter every three months and then it should be a screen every two months and then when it is over 5.5 centimeter, it requires your pap. So, and in terms of repair, you have to decide between, er, versus open repair, considering the patients risk factors as well as uh, the general comorbidities and the general health as well. Ok. And also sometimes the national guidelines and local guidelines is different for males and females depending on their ages as well. I can't remember all the, on the top of my head and beyond the scope of MC as well. But for your own interest, if you want to read on that, there's, they're quite uh interesting evidence. Basically, that's going to uh guide our management. In in this scenario, AAA rupture presents with sudden severe epigastric back pain and patients uh often present with collapse and hypertension II. It's also interesting today, I was in clinic uh with a very senior consultant, uh investor and one of the uh registrars who is at the moment in training. And then uh we were discussing the in in terms of the changes in incidence of AAA. And then this consultant when he was a new consultant almost 20 years ago, uh or actually over 20 years ago, they used to see 3 to 4 AAA ruptures per week. But at the moment, it's usually a once every couple of weeks. So that is showing that that certainly the prevalence is coming down due to lifestyle factors and urine awareness and also increased number of cross sectional studies in uh in the current age of the N HSA. Lot of patients who present with uh acute conditions affecting abdomen or any other areas in the body, get sort of radiological investigation in emergency departments. And then in a lot of scenarios that in a radiological investigation is a cross sectional study, uh usually a CT scan or an MR and then a lot of times uh incidental findings of AAA are quite a life saving for the patient as well. So they, they just get picked up and they're dealt in an elective sort of setting uh when things are common rather than an emergency setting, that can be quite challenging. Ok. Uh So mortality is 80% emergency surgery needed in unstable patients and stable patients can undergo CT angio ac A CTA A orto basically aortogram, angio. OK, great. So National AAA Screening Program, uh in fact, some of the senior Lester consultants and professors have contributed to the development of this um national uh screening program uh back in uh early two thousands and 2 2010. So it's, it's an important uh screening program at the moment in UK. And it meets all the criteria actually for a good screening program. It is noninvasive, it is fairly cheap and uh patients often uh attend as well. The attendance rate is quite good and also uh whole population assessment back in 19 nineties. Uh some centers had their own sort of local regional screening program, some of them, the ultrasound, some of them, the other uh methods. But then in the best scenario was like 40% or 50% sort of success. But at the moment, uh um AAA screening program is quite successful in picking up many um dilated aortas in earlier stages of dilatation and then preventing a catastrophic rupture. So it has, it has saved certainly many lives, but we might get to a point that it may not be cost efficient anymore. And there have been previously studies that have looked at, at the moment, it's only screening in males and there have been previously um studies that have investigated the feasibility of extending AAA screening program to women as well. But then uh the evidence has showed that it is not cost efficient and it's not going to um basically feasible, however, in, in, in, in the future, uh basically, if you're thinking about targeted the screening of smokers for AAA, that's also going to include women as well. And a smoker lady has a higher risk of having a AAA compared to non smoker gentleman, according to some, some papers. So that, that's going to be interesting, that's going to include those women. So there's some ethical uh basic principles as well that we can, we can. So just, but we'll see in the next few years uh in terms of uh how we do that, like practically we send an invitation to over 6 to 65 males around their birthday. I think it's just before some point uh in and we do an ultrasound in community and normal results is when the aorta is less than three centimeter and we discharge them and there's no, and there's going to be no further follow up. And then when the aneurysm is 3.4 at 3 to 44.4 centimeter, then they require annual review and it, if it is 4.5 to 5.4 centimeter, they require assessment every three months with ultrasound. And then if I if it's a large aneurysm, certainly more than 5.5 centimeter and larger requires referral to vas surgeons quite urgently. And uh they need to consider an elective repair. Uh That's also an important area wherever you're working in medicine, always to be aware of patients um comorbidities. And also uh think of them as, as a human uh that basically might be different. Disease pathologist might be presenting with similar uh situation. In my first clinic job in F two, I was uh doing a urology job and I was an out of fiber uh urology. And then one scenario was referred to patient who had flank pain but no stones on CT scan, which is quite unusual because even ra loo and stones should still be picked up on CT scan uh on a CT. And then um this patient didn't have much else to explain the flank pain. And then when I was discussing the patient and in less every uh walk across three sites, and um it the side that is covering urology is different to damages to the problem. So then, well, one of the points I was going through that was uh was the patient's elective. Uh in fact, in terms of clinic letters and then I not to this vascular surgery clinic. And then I highlighted that to my colleagues in Ed. And then uh the patients could have been presenting with a AAA rupture with flank pain. So it's just a learning point. Um And then uh I think the uh and then eventually they got in touch with vasco surgeon, the, the, the, the patient was dealt with quite appropriately. But then uh in terms of uh in terms of your general understanding, um I think it's important to be aware of uh risks that affecting patients and uh basically the general health and comorbidities and if a patient is under regular surveillance and they become symptomatic, as I said in the scenario just yet, they should be investigated and treated as an emergency. That's, that's very important to be aware of. OK. EVR, I have included a picture of um I'm sure you, you guys have come across evar before in the vascular repair and then you can see there are different types of R as well uh like FD EV or if it's affecting the aorta at the level of, you know, arteries. And here you can see a nice picture and, uh, basically just a, uh, demonstration of the, the, the, the actual graft is there, there's some uh advantage on this, on your, er, and open surgery. For example, in open surgery you don't have to follow the patient long term, but in, er, you certainly have to follow them in certain time periods after the operation. I think initially every couple of months and then uh we can extend the timeline, but then in open surgery, you don't have to follow them all. But in a, you certainly do need to follow them all. And there are specific complications affecting each drug as well. Uh for example, R, the D and D can become infected and uh the patient can come to ca can, can become quite unwell. So these are just important stuff to be aware. Ok. So types of fever and uh fenestrated stent growth, uh as you can see. And so these fenestrated ones as the name suggests, basically, they're not going to occlude the renal arteries. And then if the dilatation affecting the level of renal arteries, which is not frequent, thankfully, then you can use fenestrated, er, which, as far as I can remember, it's not available in all centers, it's usually available in major vascular, improving uh lesser and then I'm sure. So you could as well. So I uh the there are different types and depending on if, if the aneurysm is going to affect the all art tree or any other parts uh adjacent to AORTA, then you can specifically use those. Ok. So diabetic foot is also an important area that is covered by vascular surgeons. And uh probably everyone knows them for uh their important role in management of multidisciplinary management of diabetic foot. So, sensory neuropathy, ulceration infection or amongst the complication of poorly controlled diabetes and diabetic foot ulcers are often neuropathic but can also be ischemic and makes neuroischemic. So it's also important to be aware of that. So usually a neuropathic up to just less than a heart but then uh quite a quite a quite a lot are neuroischemic and ischemic. So ii it it can be a mixture. So duplex angiography and ct angiography are amongst useful investigations that you all need to be aware of ankle brachial pressure index can be misleading in this scenario because of the calcification of vessels, it can be abnormally high. It can be even above 1.1 and 1.2 actually. So that could be uh falsely reassuring in a lot of scenarios. And as I said, it's not recommended to pressure is probably more useful but still the whole clinical context. The presentation and the investigations and being able to feel pulses or uh general sensation assessment of the legs are more helpful. So, secondary infection, cellulite Osteomyelitis can also be present in these scenarios. In terms of the management of diabetic foot, foot wear and food care and uh basically preventing harm to um, the feet. Um I've, I've been to clinics and then patients, some patients have presented after uh a holiday abroad and they, they were like, um walking in beaches and stuff like that and then barefoot and then they presented with this massive uh the foot ulcers, which is quite horrendous. And obviously, it's one of the important stuff we need to consider when we are counseling patients, when we are just giving them uh general information and advice. Uh So, debridement can be one of the management um options. Uh di digital amputations um also uh can be considered in certain scenarios and there's usually criteria in terms of um the assessment and decision making, which is also again, quite beyond MRC S part A syllabus revascularization with angioplasty and femoral distal bypass growth can be considered as well depending on the area of atherosclerosis, affecting the lower leg vessels, infections often require prolonged courses of usually IV antibiotics and uh the outcomes can be dependent on also the patient compliance. And usually they require long term hospitalizations as well. Transmetatarsal amputations and more proximal amputations can be considered as well. OK. So basically, we have distal amputations like to amputation or even part of the toe and then we have transmit toss and then we have more proximal amputations extending all the way. Oh OK. And then uh obviously, you need to think about uh physiotherapy and occupational therapy and how, how the patient is going to go and then um orthosis as well. So, again, multi sim approach involving many other individuals, which is I think one of the big advantages of working as a vascular surgeon as you can come across uh people from various backgrounds in terms of your uh regular uh practice. OK. So car artery disease. Um so this is also another area of my active research. And in fact, in fact, the approach to manage car arter disease is quite different in, in the UK, compared to many other European countries, I'm not going to go deep to that. But then the general understanding that we should all have is atherosclerosis uh can cause plaque formation, including vulnerable, common and internal carotid arteries. So if, if a patient presents with a stroke, usually we need to do a carotid Doppler and uh or duplex, in fact, and then we need to find out if they have narrowing of the or, and then we refer them uh to vascular surgery as an urgent two week appointment. And then usually they need to get their operation quite quickly as well. And usually the NHS works brilliantly in this to the area. And then uh I, I've come across many patients who have been referred within a day of symptoms, presenting and then being dealt with appropriately uh in a fairly short amount of time as well. So, uh and it's just uh is is doing a brilliant job in terms of management of art, it can be asymptomatic, however, it is um a known cause of about 10% of ischemic strokes. And we are looking currently Lester, we are looking at the performance of um our vascular surgery departments, pre and post COVID in terms of management of car ulcer disease, we have to start them on best medical management, which is clopidogrel and statins and then give lifestyle award obviously. But in terms of the best medical management versus surgery, we're looking at pre and post COVID times. So during COVID, unfortunately, a lot of these operations did not happen uh due to restrictions but then not a significant number of patients end up with a stroke. So we are looking at um potentially see best medical management being as effective as surgery, which we, which we still don't know surgery might be still superior. But that's also an area that we are looking into at the moment. And we are, we are fortunate to have a large database as well in less than for any, if you might be interested in vascular surgery in the future, you might be considered uh uh basically uh a job in the UK, then less there is I is one of the best places as well. Ok. But again, I'm bi so it can also result in tia s and more extensive strokes as well. So the classification is actually very important for your exam. So, mild to severe forms exist and that is, the classification is based on the degree of stenosis. If it's less than 50% is classified as mild. If it's moderate 50 to 69 7 to 99% severe stenosis and total occlusion is 100% stenosis. Ok. So, in terms of risk factors for carotid artery disease, these risk risk factors are quite common. Uh in terms of vascular pathologist in general, in terms of peripheral vascular disease, cardiovascular disease. So, uh basically, in older people, smokers, patients who have hypertension, hypercholesteremia, obesity, diabetes, and then he cardiovascular disease and history of cardiovascular disease. Uh basically in the in, in, in the family. Basically. So as you can see, thi this can apply to a large proportion of the population. So a significant number of population are basically a actually at risk of having carried out, which is quite challenging to manage. So, in terms of carotid artery disease examination, you need to perform a cardiovascular examination, peripheral vascular disease examination and auscultation for carotid prof in terms of investigations you need to perform. Uh basically, I start always from cost efficient bedside, important investigations. Ecg that is going to tell you a lot of information about uh the general health of the patient as well as ruling out any acute lifethreatening condition. And then blood CT head CT angio and duplex, ultrasound or slightly, sometimes in a different order. Uh But then, um you're, you, you're, you're right by the scenario as well. Ok. And then in terms of management of carotid artery disease, thrombectomy and thrombolysis in confirmed acute strokes depending on uh local availability of resources. Uh Thrombectomy obviously is um a surgical operation, removing the basically the clot. But then um thrombolysis is usually from oncology. Uh But there are certain criteria that you need to ensure the patient is safe to receive thrombolysis. Uh for example, if they have had any recent surgery or any bleed in the head, then, then you need to rule out first. And then, uh there's usually a strict criteria for long term medical management with antiplatelets and statins, key and risk factor modification, your uh smoking cessation, diabetes control, hypertension management, lifestyle modifications, exercise, um basically can be very helpful and exercise doesn't have to be going to the gym five times a week. It can be just walking a few 100 yards more per day. So that would be a life-changing intervention. Uh, patients with symptomatic car disea, uh, car stenosis of 50 to 99% should have an endarterectomy within two weeks. That is the UK standard practice at the moment, but things can change in the future. But in some of the countries, obviously, the approach is different. They even in, in some of the countries they even operate on uh asymptomatic car stenosis. That's been an incidental finding. But, but usually in the UK for the purpose of your exam, symptomatic stenosis of 50 to 9th, 9th, 9%. Ok. And to me within two weeks. All right. Ok. And let's move on next slide. Ok. So, car anatomy. So I've just included um a brief slide on, on anatomy just to make it. But I'm sure you guys have come across that new preparations. So then, uh here you have the right internal car uh uh carotid artery and then you have uh the right external carotid artery and then the right common carotid artery that is going to give rise uh to, to basically internal and external carotid artery. Ok. All right. So endarectomy and this is quite a nice picture. I think it's ii it's a good illustration of the technique that we use to remove the plaque. And then um if you ever get a chance and you are on a uh a basic vasco surgery rotation or in a hospital that has access to vasco surgeons, uh please do attend theater and if you can get a chance, uh normally vasco surgeons perform this operation, at least in a, in a busy department at least five times, uh five cases per week or four or five cases per week. So there should be plenty of opportunities for you guys to attend and it's usually not an emergency operation. So it's usually done during the daytime. So, uh in sort of semielective urgent sort of scenario uh but then there should be plenty of opportunities for you guys to attend and appreciate the anatomy of the neck. And then if you can get the opportunity before your part A of mrcs, uh that would be brilliant in terms of gaining a general, good understanding of the neck anatomy and uh basically uh structures in the head and neck. OK. Brien, arteriovenous fistula AV F. So when I was a medical student and I was doing my vascular surgery rotation in office and then a DF were still done by vascular surgeons. But then currently in lesser, it's not done by vascular surgeons anymore. And it's done by transparent surgeons, which is sort of a new surgical specialty. Usually they have a background in general surgery. Uh The ones I've come across at least, but then, uh they, they usually work very closely with uh renal medicine doctors, nephrologist. At the moment. I'm actually in my clinical job, I'm doing a nephrology job. And uh we frequently have uh sort of uh joint care for dialysis patients uh who have uh basically uh a fistula. They also transplantation also do that kidney transplantation, which used to be uh by vascular surgeons. And for example, in Lesser Professor Bell, who is a phenomenal professor, he was practicing um for decades and was one of the founders of the lesser medical school in 19 seventies and eighties used to do uh transplantation transplant surgery. But nowadays, transplant surgery is done by transplant surgeons or experts. And then uh it, it it is one of the successful areas in the NHS that basically a noise uh collaboration exist with the medics and surgeons. So, artery venous fistula is a connection, basically, basically arteries and veins and commonly performed in upper limbs to create an access point for hemodialysis. So most common types are break your basilic, ra your cholic and break your cholic. So essentially connect an er with the vein and deeper fistula ba basically, I in terms of your exam, um questions, I think, I think they usually they sometimes ask about maturation of the fistula. But uh the timeline that we clinically use is quite different to the one that they test in the exam. So I think the exam is uh some of the might be a little bit old uh compared to care practice, but you, you have to leave it for a good few weeks, months basically before you can use that. Um but, but certainly in clinical practice, it is a bit different. Um Most common types um are the ones I mentioned, but some of them are quite deep and they need, they need to be superficialized later in a, in a in another operation setting. Uh That's also the transplant surgeons. So, complications associated with a fistula, uh basically ABFI are known to be quite safe approaches for dialysis. OK. And the NHS is actually advocating use of a V fistulas for, for. So a V fistula actually recommended by now is recommended by national and local uh bodies to use in dialysis patients for many reasons. Basically, it reduces the risk of infection compared to having a perf for dialysis. Um because essentially there's no foreign bodies inside the human body, that's a big advantage. So, but the complications include thrombosis, aneurysm formation and spontaneous bleeding, which can be fatal in few minutes only. And that's actually very important to stress in few minutes. I, if I in it's very rare, it's very rare that like 100s and 100s of patients who have uh a fistula. Um But then only tiny, tiny number of it gets uh spontaneous bleed and sometimes they can bleed to death within a few minutes, only 3 to 4 minutes because of the high uh velocity of blood running through the fistula. And I'm afraid, um, usually those patients are uh cannot survive at all, even uh basically cause a lot of times are in, in the bed in hospital or at home and then they slept on it and then spontaneous bleed and then they die. But uh fortunately, that's quite rare. I II it's a, it's a catastrophic uh situation. But um uh at least it is, it is, it is very rare. Very, very rare. But then, um these are the general complications we need to be aware of and uh obviously, uh use when you're getting uh gaining in cancer from patients? Ok. OK. There's a picture here, the different types of um basically uh a v fistula. It, it, it, it, it is one of the areas tested in MRC as an example but not, not to a significant degree as well. You might get just one question on it. But then um uh it is an important area to be a better in Gerard uh as, as a doctor because you will come across patients who have it. Ok, great. Do you have any questions at all? Are we good to move to MCQ S? Great? Ok. So let's move on to MCQ. Thank you so much Sophie for sharing that. Ok. So here we have a 58 year old lady presenting with angled veins, affecting her left leg. Her BMI is 32. She has been pregnant four times in her lifetime. On examination, the veins are painful to touch but there is no skin break. What would be the first line management for her condition? So choose your answer, please. I think you need to move on one of the other side. So we can sorry for that. Sorry. Um Let me hang on, let me just uh is that, is that all right now? Yeah, that's perfect. Brilliant. So can everyone see the a question and the options you can feel free to choose the right answer? I think that's most people have so. Ok. Brilliant. OK. So we have an actually an equal uh distribution between AC and D. So A is advised to use compression stockings. OK. Uh C is endothermal ablation procedure and then D is pain management nsaids. OK. Fine. Yeah, good. So, first of all, let, let's think about the uh the scenario. So we have uh a lady who is 58 years, middle age towards um uh basically 60 then presented with engorged veins. So we have to thinking about the venous condition and then her BMI is very the fact that as I mentioned that her BMI is very tissue, we are thinking about uh obesity in this scenario. And then she has been pregnant four times the importance of having that figure there. And that information is we are trying to um demonstrate the situation that she has experienced period of or at least uh episodes of increased abdominal pressure in her lifetime uh which has increased her risk of uh developing uh basically uh varicose veins. The the term varicose vein is not mentioned in this scenario as will be similar in mcs questions. Actually, it does not mention the term varicose veins, but it has also for the management for that. So you need to treat the stem of the question in order to get the diagnosis and think about the appropriate management yourself. So that's very important. Don't skip the stem of questions actually. Um uh a lot of people say just go to the uh or actually some people might choose that they might go to the question at the end. But then make sure you don't miss that stent that time is usually improve. But then on examination, the veins are painful to touch. So that means we need to treat her. We need to consider treatment because it is symptomatic for her. It's not just uh uh uh uh basically, it is not just the uh varicose vein that's uh is not causing her much trouble, but then it's a symptomatic one. So here we are dealing with the symptomatic varicose vein and then noise guidelines uh recommend actually endothermal ablation in this scenario. So the correct answer is C and uh endothermal ablation procedure is recommended by nur for management of symptomatic varicose vein in this scenario. So, uh do you have any questions on that one? Are we good to move on to next question? Are you happy? Yeah, I'll pop the second one in the pool now. Great. I, you too. Ok, brilliant. So we have a se 76 year old man presenting with um chronic leg ulcers that have been present for over two years and dressing of large, regular with district nurses have not made a significant difference on examination, raised irregular edges with excessive granulation tissues, not what would be the appropriate management um recommendation in the vascular surgery clinic. So we have five options that you can use compression stockings, refer for punch biopsy. Ok. I can see the answers already refer for endothermal ablation or a plastic surgeon to consider a split thickness graft and then perform debridement tissue for his uh histology. Oh, sorry. That is a type again, history of not history assessment, histology. Sorry for that. It should be his, his story. I I'll, I'll, I'll make sure that I correct these. Um the type was before sending you the slide. Sophie. Sorry about that. All right. Just waiting on two more to reply. That's all the responses by my brilliant. OK. So we have um a mixture. OK. Good. So we have two options actually now. All right. So we have um uh use of compression stockings. 33% of part have voted 50 person voted for referring, for punch biopsy and then 16 persons voted for referring for endodermal ablation procedure. Great. OK, good. So uh let's move on actually, let's read the them again. So we have a 76 year old man. He has chronic leg ulcers. So it's a chronic condition and it's been going on for actually years now and then dressing has been applied. And then the, the important buzzword here points uh sinister thing going on is uh basically the fact that there is excessive granulation and raised irregular edges and then the the dressing and the interventions done by the district nurses who are brilliant in terms of managing uh chronic leg uh leg ulcers in community have not made much difference. So in this scenario, we are thinking about something else is going on. And chronic leg ulcers can be a risk factor for a type of skin cancer. It's a type of SCC uh called margin ulcer. So in probably in this gentleman margin ulcer has been developed uh which requires uh histological assessment and um basic diagnosis. So, referring uh for a punch biopsy is in fact the correct answer in this scenario. Uh Option B because the findings, as I said, the excessive granulation tissue with irregular ages are quite concerning for emerin ulcer. And we need histological assessment of tissue to rule out uh this particular type of uh squamous cell carcinoma of the skin. Ok. All right. Are we all happy? Do you have any questions on that? Ok. We have the next question. Let me move on to the next one M CQ three. OK. So let's move on to five questions, which is a lost. Ok. So the blood supply to the adrenal glands um is from the abdominal aorta. At what level does the arterial supply originate from? So, we have L4 L2 L1 T 2 L anatomy question. You can still get that actually. Part A is well known too, uh cover basics in addition to clinical meds, basic science and all that. Ok. I'm not sure how many people have voted yet, but I can see 100% going on for one of the options or oh, we have two options. Good. Interesting. It's good. You like that? Just wait for two more. I think there's been about six months. Ok. Brilliant. Oh, yeah. It shows a total number of responses as great. Good. Oh, good. You have a mixture now? Oh, interesting. Ok. I can see that. Ok. So all have answer, right? Yeah. Brilliant. Ok, great. So, actually, uh, basic, uh, anatomy question. I'm afraid there is no clever way of, uh, figuring out the answer in the middle of the exam. It just you need to apply your knowledge that you have memorized. Uh We just try to, there are many resources, there are like um anatomy books, they're like um visual re resources grow of surgeons have access, it gives you access to Oakland anatomy. And there, there, there are many resources out there. So try to use different approaches to learning anatomy, those flashcards and uh anatomy, uh apps and videos and textbook and just use a combination of things to ensure you maximize your opportunity to learn stuff and basically memorize the stuff before going to the exam. So the correct answer in this scenario is in fact, alon, which the majority of people, in fact, 66% of um uh people voted have chosen correctly. So uh the uh the correct option is the L1 middle suprarenal arteries supplied adrenals and the origin from abdominal aorta at L1 level. So again, uh going back to, to the first few slides that I had included a couple of uh important points on um, the arteries and the origin or from the aorta abdominal. A. Ok, great. I think that's it. Yeah, the references are there for the slides, uh, for the pictures I'll just make, um, to a small, uh, they were like two types of just one digit of number missing and uh history to histology. And then I'll share the slides again with uh Sophie. I've included my email address and my linkedin account and then Twitter or like it's like the previous Twitter um account as well, feel free to give me a follow. And then I'll be more than happy to, if there's any further questions later, feel free to email me, I'll be more than happy to get back to you. If I, if I know the answer and if I don't know the answer, I'll ask somebody who knows the answer and get back to you. Thank you. I'll be happy to intake any questions though. Yeah. If there's any last-minute questions and work in the chat, and I've also put the feedback form in the chat. If everyone could just take a minute, it's only about five questions and just to get some feedback for a um for the society ourselves. Um Also for anyone who's joined us by Facebook or Instagram, we now have a new whatsapp community where we're going to post um kind of the direct lengths for our future revision events. Um over the next coming weeks, we have a few in the pipeline that we will post the next one tonight. I believe the next one is going to be on Thursday this week. Um or maybe Friday. Um So we'll get that up this evening once we're done here. Um Julie says, thanks and I don't see any other. Great, thank you, but thank you so much. Um Aza, it was great. You've somehow summed up an entire specialty into like an hour and 15 minutes. Thank you. Thanks. Thanks for, and I'll forward you a copy of the feedback as well. That would be great. All right. Yeah, no questions I don't like. And if there is any in the chat after then I can forward them on to you. Of course. Thank you. Bye. Ok. Thanks everyone again for um tuning in and thanks and enjoy the rest of your evening. Ok, bye bye.