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Okay. Hello. Hello. I think I'm live. I think, I hope um hopefully even all only but yeah, welcome all back. Um Thank you for coming along. This is our final session in the teaching series tonight. Um So we're going to be going through vascular surgery. Um So there's just 16 questions tonight. Um mainly on triple A's peripheral arterial disease, but a couple of questions on ulcers and varicose pains. Um So yeah, so hopefully it should be useful for your exams. I know for those at Manchester you'll have it on Thursday and maybe Friday as well. Um It's a good luck with us and I'm sure over Younis they'll be coming up soon as well. Um So yeah, let's, let's make a start. There's a few of us here so we'll make a start. Um And if anyone comes later, I'm sure they'll just pick it up. But yeah, the same as always 20 questions or 16 questions this time cover the major themes. We're gonna go for 60 seconds, we're gonna push it for the time. See, see how you do. But just remember for your real exams for those at Manchester. Anyway, you've got 80 seconds, which I think is sort of normal for most exams. Um, and yet it will be done on poles if it's your first time. So you won't get asked to pick, asked to explain anything in front of everyone or anything like that. So it should be fine. Um, so, yeah. Right. Um, I'll get started on the first question. If you have any questions at all throughout, please just pop them in the chart. Any questions about anything, just pop them in the chat. I'm happy to go over anything or re explain things. That's no problem at all. Right. First question. So I'll give you 60 seconds. So 20 seconds left, few people are getting it final couple of seconds if anyone wants to have a, a star by, if you're not sure. Right. There we go. Right. So let's go through this. So the correct answer here. Hold on to those that got it. So it's a single abdominal ultrasound, those aged 65 years old. And that is the screening for a triple A. Ok. And now there's lots of different options here. It's not to say that you can't have repeated screening, but everyone is, every male is guaranteed at least one single abdominal ultrasound at age 65. And then depending on the size of the aneurysm, then they might be entitled to further scans after that. Okay. The big thing to remember for triple A screening is it's an abdominal ultrasound it's six, it's when they're 65 years old and it's for men only. Okay. Um, so for the ultrasound, just remember it's abdominal ultrasound. It's not a CT, it's not an MRI, it's nothing like that. It's 65 years old. They'll get a letter through when they're 65. If they've not had a scan, but they present when they're 70 years old and they want it then that's fine. But generally it's when they're 65 it's only actually done for men. Um So it's only done for people of this age group, for men because those are the people that are more likely to have a triple A. So if you're a female, you're much less likely to have a triple A. So that's why they don't offer the screening also. I understand. Um So hopefully those are the main takeaways that you need to just remember for triple A screening um in terms of who it's offered for. So I go on to the next question. So this is um bit more about what to do. So, 20 seconds, a lot of you seem to be getting this one so well done, right? I think that's everyone's boat. So we'll go on from here and so welcome to, as I got it, it's a surveillance all shown in ocean scanning freedoms time. Okay. Um So if for those who have got something different, don't worry, there is an easy table to sort of remember as to what to do about it. So this is the table that you need to remember about when to scan for triple A's and how frequently. Okay. So they'd come, they normally come when they're 65 years old for their ultrasounds screening. Um, but it could be like in this case, like a CT that's done when they're 59 it's just an incidental finding. So anything below three centimeters that's deemed as normal, no further action, you just leave it like, uh anything more 5.5 centimeters or more, that's definitely abnormal. So you refer within two weeks to vascular surgery for an operation. So I always try to think of it in my head. It's less than three. Just forget it. It's fine. If it's for 5.5 or more, then it needs to go to vascular surgery for an operation and then you have this sort of middle ground in the, in the middle, obviously as to what to do. So then just remember, you have four and 4.44 point five and that's the cut off. If it's below that, then it's rescanned every 12 months. And if it's greater than that, then it's risk and every three months. So if we go back to this question, so we'll go back to the question again. So you can see, um, 59. So it's not there, uh screening appointment. This is just an incidental finding, but it's 4.6 centimeters. So 4.6 centimeters puts us into this bracket and its re scan every three months. Okay. Now, alternatively, you could have eliminated these first three just by the knowledge of, you know, it's less than 5.5 centimeters. So, you know, at that stage, it's just gonna be about monitoring. It's not going to be about doing anything about it. So you could eliminate those free because those are also surgical options. And then you just left with these bottom too. And you know that the way to investigate a triple A is an ultrasound and it's not a CT. So you could have, you could have got the correct answer just by knowing that those are basics and you don't actually have to worry about the cutoffs for each values. So there's different ways of going about it. Um Yeah, next question. So 15 seconds. All right, we've got there. So most of you got a few of you, if you, if you fell for the trick with this one is a bit more complicated than it seems at first. So the correct answer is referred to vascular surgery within two weeks. So your first might be thinking, well, it's not great than five, it's not 5.5 centimeters or more. So, why is that the case, um which is a valid four to have? So it's a bit more complicated than that table that I showed you before. Those are the basics, they want to overwhelm you at once, but there's two extra things here. Okay. So that's, this top part is the exact same as I showed you before. However, if the patient is symptomatic, so they've got abdominal pain is normally the big thing, then regardless of what the size is, you refer within two weeks to vascular surgery to rule out because, because if they're symptomatic, then that's an indicator that the, it's gonna rupture soon. Okay. So that's why you referring to surgery. Similarly, if they, uh, that should say aorta, not aorta, um, if it's growing rapidly and that's deemed as more than one centimeter a year, then again, you refer within two weeks to vascular surgery because it's more likely to rupture. Okay. So if we, if we go back to that question, you can see it was 3.5 centimeters last year and it's grown 1.4 centimeters in a year. So, because it's reached that threshold has grown more than a centimeter in a year, then you refer to vascular surgery. Okay. So this, this is the complete table. So if you're gonna remember anything for the screening, it's this, this table here. And so hopefully that should help, right? I think we've got one more like I said before. If you guys have any questions at all, please just pop them in the chat. I'm happy to go over anything. Yeah. So 15 seconds left and I go, I think everyone about within the last one. Let's vote now. So we'll call it that. So a few of you, most of you got this, a few of you fell for the trick there so well done to those that got it. It's referred to vascular surgery for repair. So, and that would be within two weeks, so referred to vascular surgery within two weeks. Um, now the reason is so it's so it's only grown within three months. It's gonna grown 30.1 centimeters. Okay. And he's a symptomatic, but it's now at 5.5 centimeters and it's anything that's 5.5 centimeters or above, then you refer. Okay. Um, so hopefully that makes sense from here. Um, so like I said before, if this is all new to you or if your, if your mind's full of over tables and other things that you have to remember your exam, don't worry too much. Um, the only thing if I was to tell you to remember anything about this, just remember below free normal 5.5 or more refer of in two weeks, if the symptomatic prefer of in two weeks is growing rapidly, refer within two weeks. And this here in the middle, if you can just try to remember 4.5 centimeters and then if it's above three and three weeks, three months, if it's less every 12 months. But yeah. Right. Yeah. This is the final question on triple a promise. So, 20 seconds. All right. Final couple of seconds. All right. Let's go for it. So well done. Caught one person out with this one, but most of you got it and well done. So, abdominal pain, that's the correct answer here. Okay. So we'll go through each of them. So, abdominal pain. And so, like I said before, if you've got abdominal pain with an increased, triple a, increased size of an aorta, then that class is you as a symptomatic Tripoli, okay. And if your symptomatic, then you need to be referred to vascular surgery for probable intervention. So that means you, you probably need surgery. Okay. So that's why that's the correct answer if we go through the other options. So someone put aortic diameter of 5.4. So it's close and it's, if it's 5.5 centimeters, then that indicates surgery. But if it's 5.4, then that just put, puts you into the bracket of needing, uh, scans every three months to monitor it. Okay. And then the other three things. So trace free fluid that's not used to determine whether you need surgery or not. Cardiovascular risks, factors. Exact same thing and, and then the final one, if it's gonna load, yeah, is the speed of the increase of the growth. But you can see it's only gone from 5.125 point four within six months. Um, so 0.3 centimeters in six months isn't meeting that threshold of more than a centimeter a year. Um So it wouldn't be that one. So, yeah, well done. Right. We're moving on from Triple A's okay. The 20 seconds. All right. Could find a couple of seconds. There we go. All the votes coming in now. Yes. A world into those. That got it. So, it's a venous ulcer. Okay. So it was split between Venus alta and arterial. So, so I've got a slide coming up explaining the difference between those specifically. Okay, but we'll go through this question as a whole first, right? So venous ulcers. So the reason it's venous sources is because you've got symptoms of chronic venous insufficiency. Okay. That's one condition. And then the description of the altar itself is more typical of a venous ulcer. Okay. Now, the reason that chronic venous insufficiency is important is because if you suffer from that or if a patient suffers from that, then that puts you at a greater risk of developing a venous ulcer. Okay. So you look for the features specifically of a venous ulcer that it alludes to. Um, so it's around the medial malleolus, okay, which is the inside of your ankle, a bony part inside of your ankle. Um It's slightly painful okay compared to an arterial. So where it be very painful and, and I think those are the two big features there of a venous ulcer that it mentions. Now, those of you that know quite a bit about venous ulcers. You'll know that it's a bit more complicated to that. And there's more features of what a venous ulcer is. But those are the two it alludes doing this questions then um chronic venous insufficiencies. So the features of that is an aching, heavy leg. Okay. Cramping and elevating the leg helps, which obviously makes sense if it's venous insufficiency, if you lift it up the veins, it is above the heart, it's easier for that drainage. And another classical thing of venous insufficiency is the skin discoloration. Okay. So you get hyper pigmentation and this stasis extra. So it looks like this. So you might have seen this on the ward or you might seen it out and about, but you see this sort of hyperpigmentation in people's lower sort of disparturient the lower limb and that's what it looks like. And that's what's described in here. So if you have this chronic venous insufficiency, then you're more likely to develop a venous also, which I think you can kind of see one there um on the ankle up. So if we go through the other options, so arterial, so, so I'll discuss that on the next slide. Um Neuropathic ulcer. Okay. So that is a few. Yeah. So there's a few things with neuropathic ulcer. Um So it appears when, when I show you an image, it looks very similar to an arterial also. Okay. So it appears as a deep punched out ulcer and it's got sort of hard and thick and skin around it and the patient will say it's tingling and it's numb over the area. And that's just because the nerves have been involved there because of that. It's normally associated with poorly controlled diabetic patients'. So, this patient is diabetic, but it doesn't really mention anything about poor control. She's only on Metformin, you know, she's not on multiple drugs for it. Um And there's no mention of this tingling and numbness. Um And that's what the neuropathic ulcer would look like. So you can see that's all punched out appearance and the thickened skin around the edges there. Um And the pyoderma gangrenosum to no one put this, so no one fall into the trap pair, but just to go through quickly. And so that's another type of skin lesion and it's when you get a minor trauma to the skin and it causes this painful postular lesion. And I'm sure those of you all know you've been revising going through a gastro, um it's associated with BD among other conditions, but mainly I D and it looks looks like that okay. Um So if we go through venous and arterial says, so if we start with venous on the right hand side, it's like I said, it occurs around the medial malleolus. So the inside of the ankle typically associated with chronic venous insufficiency and like the condition that we just talked about and the description of the ulcer themselves. So they're quite large, superficial and they've got irregular borders, okay. The less painful now an arterial. So as you can see on the image here, it's a smaller also, it's deeper and it's got well defined what they call punched out borders. So it looks like that, it looks like someone just punched out a section of tissue there. And that's more painful than arterial also. And it occurs typically on the toes on the door, some of the foot and that's associated with peripheral arterial disease, which will go through shortly. So hopefully that makes sense to you. Um Yeah, next question. Then if you've got any questions, please just put them in the chat. There's no, there's no stupid questions. So I don't want or mixed conditions, mixed presentation. I'm not sure off the top of my head. Which condition let me look it up for you. I'll give you a minute time for this one and I'll look up the need one. Uh huh 10 seconds remaining. Yeah. Right. So I have to look for like for for your the answer for that question, I can't think can't come up with a specific condition, but it's just if you're suffering from both conditions, it really says. So if you've got peripheral arterial disease and chronic peanuts insufficiency, then that obviously just puts you at risk of both types of ulcers. Um I'll try and look up more about it if anyone else knows in the chat. Uh Please say I had my exam a couple of months ago now. So that knowledge is uh has left my brain. Uh But a good question, hopefully that's somewhat goes to answer that. Um Right. So questions ever um world into those that got it most. Have you got it on this one? So well done? Um So the description here is a classical description of varicose veins, okay. And this is what varicose veins looks like. I'm sure some of you will have seen it and some of you might not. But this is hopefully you can appreciate an image. You can see these veins very visible, very prominent sticking out and there's no clear direction to the religious, very what they call tortuous um swirly around the skin. Okay. So from the description here and it's a very mild picture of varicose vein. So you can see how it says uh no pain, no swelling, no skin changes, you know, bleeding, no from both the bias, anything like that. So that puts it as a very mild religion, a mild, mild variant of it. So compression stockings is what you do is the first line from mild uh varicose veins alongside weight loss exercise and leg elevation, okay. Um So the end of thermal ablation and foam sclerotherapy and I wouldn't worry about this is really not going to come up in your exams, but you can use that, but that's the discretion of the vascular surgeon. And both of these can be used in more severe cases. Okay. So if there is bleeding and if there is pain and etcetera, etcetera, then you can start to think about these two um options for the management. But if you're gonna remember anything for your exam, hoping you now know what varicose veins looks like. You can, you can recognize it from text so visible, tortuous pains, superficial dilate that is varicose veins. And if you can remember anything about it, just remember how is it, how is it described? Compression stockings is the first line management. Okay. And the other two. Um so avoidance physical therapy. So light to moderate exercise actually reduces the symptoms. Um and ropinirole is a dopamine agonist. So it's used for a number of conditions, but you might have heard of it for Restless Leg syndrome and that's what it's used for right next question. Yeah. So 25 seconds, everyone seems to be getting this one. Um Oh wow. Right. What is it that so well done to those that got it a few votes right at the end there. Um Compression bandaging um is what you're going on is what we're going here. So hopefully you will have got from from the history here that it's a venous alter, okay. And, and the key features point us towards venous ulcer. So medial aspect of the left, left around the medial malleolus, they've got chronic venous insufficiency and that comes from the fact that this chronic legs well in and, and the hyperpigmentation of the skin. Um You've also got fact the description of the ulcer itself so large and shallow. Um That's a normal thing that's pointing us towards a venous ulcer. And the final thing that Pulitzers towards venous ulcer is that we have a normal and called break your pressure index. Okay. So that as I just already all know that is the tool that's used to determine severity of peripheral arterial disease. And like I said before, an arterial also is associated with peripheral arterial. Uh yeah, an arterial also is associated with peripheral arterial disease. So because that's normal, we're not really thinking that peripheral arterial disease is going on. So I've been talking a lot there and so let's get through to why is it compression bandaging? Okay. So the strongest evidence based for using compression bandaging as opposed to anything else. Um Typically you use four layers deep and the reason you use the compression bandage in is obviously you've got to build up of like venous fluid here. So by using that compression, you're squeezing the fluid out and you're stopping it gathering there. Okay. So that's why you use it for venus alters, but you wouldn't use it for a material. So because in an arterial, so because they're not getting enough blood flow because of the peripheral arterial disease. So you don't want to add to that by further compressing, um, any arteries there. Okay. We'll go through the other options. So, compression stockings. So you can give that to a patient, but it's normally after the ulcers healed and to stop it, prevent it, to prevent it occurring again. Hydro colloid dressings, I'm sure some of you will have seen this. Um, so there's not that much evidence for how effective they are. The other thing is obviously, it says here, it doesn't look infected, which is good as I'm sure as you know, if there's any fluid around, around the wound, then it's going to increase the chance that there's an infection. And because this Hydrocoral addressing is, is a bit wet and it increases, thought that it could increase the chance of an infection because of that moisture. So generally, you don't really use hydrocod dressings for that reason as well and oral pen pox of Flynn. Um So it's a peripheral vasal dilator. You can use it and as an adjunct to compression, managing for venous ulcers. Um But you generally, it's not first line thing that you give is just something that you could do. Um But you really don't need to know this. For example, I only came across this when I was making the slides. So don't worry about that one. Um And then silver dressing. So silver dressing is something that you can use because it's got antimicrobial properties. But like it says in the questions, then it's not infected the wound. So you don't need to worry about that. And generally it's not used for venous ulcers. So, if you're gonna remember anything venous ulcers is compression bandaging. Okay. Mhm. All right. Next question. Uh, if I went too quick, if I'm speaking to quick, just tell me. Um, and I can slow down so 20 seconds. Right. Okay. So well done to those that got it. Um, let's see how many, I only got it. This actually welled into the person, that guy. I think it through a lot of you off this one and it's actually exercise, draining. Okay. Um, so Aspirin used to be the, the treatment, it used to be part of the treatment for peripheral arterial disease, but it's no longer part the treatment and it's actually exercise training. So the two drugs that you do give and this is, this is a question coming up. So don't worry about it. Now we'll go over in a second but you do give drugs for intimate and claudications, but you give the drugs specifically for secondary prevention of cardiovascular disease. Um, and that would be clopidogrel and atorvastatin. Okay. So Lipitor girl, atorvastatin, you give that 21 with um, intermittent qualification and you give that as a prevention for secondary cardiovascular disease. Then in terms of the actual management itself of internet and claudications, the first line management is exercise training. Okay. Then there's a few drugs that you can give afterwards but the quite complex drugs, they're not the basics. You don't really need to worry about that. So if you don't remember anything intimate and claudications, first line management is exercise training, okay. Um These final free ones here, the cried end up in direct to me the Johnson and Warfarin, they're not part of the treatment for peripheral arterial disease. Aspirin used to be, but no longer is okay, but we'll come to that in a second. Um So we're going to start now going through the questions on peripheral arterial disease. So just a brief summary of the different types and for those that might be a bit confused. I was confused about it for a long time until I actually sat down and, and look through it all. Um But it's, it's basically a sliding scale of the severity of it. So intimate and qualification is the mildest form of peripheral arterial disease and then it goes up and up and acute lymph threatening. The scheme is the most severe. Okay. So, intermittent qualification is essentially angina of the legs. Um So you've got signs symptoms of the ski mia in a limp. So crampy, achy pain in a car fire, it's brought on by exercise and relieved by rest. So it's literally the angina symptoms, but in the lake and it's the same puffer physiology. Um critical limb ischemia is the next step up. And similarly, if this, if, if intermittent claudications is stable angina, critical limb ischemia is unstable angina, okay, because it's constant ischemic pain. Um In addition to that, though, you've also maybe got non healing ulcers and you may also have gangrene. Okay. Now, this constant ischemic pain has to be present for two weeks for it to be classed as critical limb ischemia as opposed to internet and claudications. Okay. And then the final stage is acute limb threatening ischemia. And the classical features for this is I'm sure you've probably gone through the six Pedes. So pale, pulseless, painful, paralyzed parasthesia and it's like numbness and tingling and then perishing the cold. So if you read in a question, stem and you start seeing a few of these words, this diagnosis should be popping up in your head straight away. Okay. And it's the same goes for Russkies. And right. So next question. So they'll all be on peripheral arterial disease. I hope they will build up your knowledge. Um Question 10. Here we go. Okay. Yeah. So 30 seconds left, someone's got it, someone's got it well done. It's a bit of a tricky question this one. Um okay. It looks like you all know the drug name. It's just the doses right. There we go. So well done to those that got it. So most of you go up there, the fact that it's clopidogrel and it's 75 mg for this one. So, like I said before, anyone with this chemical education or intermittent qualification, I should say um is given drugs to prevent the secondary prevention of cardiovascular disease. And that's because peripheral arterial disease is a former cardiovascular disease. You've already got it. So there's no point trying to trying to do primary prevention. So now we're focusing on secondary prevention. So the two drugs that you give clopidogrel and a tour of the statin, okay. Those are the two drugs you give it then just comes down to the dosage. So we'll go through it. So a goal of 75 mg, see if that plus 80 mg, atorvastatin for the secondary prevention of cardiovascular is and if we go through the other ones, so aspirin, so some, some imposter prin and it seems like an obvious one for this. However, if you remember like what I said before, aspirin is no longer part of the management for peripheral arterial disease. Okay. Um In addition to that 300 mg, aspirin, that's a loading dose. So you would be wanting to give that as a daily dose anyway, and clopidogrel 300 mg. Likewise, that's a loading dose. See, you won't want to give that daily. Um If you put that though, don't worry. As long as you've got the pitta gral, that's the main thing. I think it'd be very harsh for a very an exam to be testing you on this um for the dosage. Anyway, a tool start of 4 mg. So primary prevention, you give 20 mg of the tour starting and secondary prevention, you give 80 mg. So because 40 mg is neither of these, then it's the incorrect option is incorrect answer. What you do give atorvastatin, 80 mg plus club grill 75 mg. That is the manager, that is what you give. Um It's just this option wasn't available. Um So, so yeah, the final one simvastatin. So it's the guidance that 8 mg at all. The statin is the drug that you should use for Secretary prevention. Um And it's so you just stick with that. So because it's not atorvastatin, you don't give it. Um So hopefully that makes sense. So secondary prevention is clopidogrel, 75 mg plus atorvastatin, 80 mg and, and that's a secondary prevention. And then like we talked about the question before. So that's your secondary prevention and then you've got your management options and that would be things like the exercise therapy. Um So yeah, next question. So this again, it's just once a challenger. Um Don't worry if you don't know, just have a, have an educated guess. Thank you. Yeah, a couple of people seem to be getting it so well done. This is a tricky question that someone don't worry. All right, final couple of seconds right. There we go. So let's go for, it's a world into those that got it is actually iliac stenosis that's going on here. Okay. So it'll help if I've got a photo here at the blood vessels. So the main thing that we've got here is Buttock pain and then it just comes out of what vessels. So hopefully you all got the fact that Popliteal s stenosis that's down in the knee. So unlikely to cause symptoms further up more proximal. Same thing goes for posterior tibial and same fingers with your stylist peers, they're all lower limb. So, you know that if there's something going wrong, they're unlikely to cause an issue presenting in the buttock. So then you're left with femoral stenosis and iliac stenosis. Now, it's a bit cheeky here because when it says iliac stenosis, it's not specifying which one and, and to cause buttock pain, it would likely be the internal iliac artery. That's the nose. So I don't know if you can see here, which is at the very top here on this anterior view. That is where the internal iliac arteries coming off because you can imagine if there's claudications or obstruction, um going on in that internal iliac artery, you're going to get symptoms around that area, but you're not going to disrupt any of the blood flow further down in the femoral artery and below. So you're going to get no symptoms, you know, in the calf or in the thigh. Whereas if you had an obstruction in the femoral artery that and that would block everything else down below. Okay. And that is where you start seeing calf symptoms because if you're going to reduce the blood flow in the femoral artery and there's gonna be less blood in the popliteal artery, less blood in the less arterial blood, I should say in the anterior tibial, less than the dorsal of Peter's. Okay. So, it's a bit, it's a bit cheesy here. But iliac stenosis is specifically internal iliac stenosis, um, unlikely to come up in your exams. But just to get you thinking about, about the anatomy, um, as there's normally like one or two questions on, on blood vessels. Um But hopefully that helps. Um Right next question, it's about 25 seconds. All right, time's up with a view a couple of seconds for those last people to vote. All right, let's go for it. So this one caught a few people I've got. And so it's, it's actually spinal stenosis. So it's not truly a vascular condition, but I've put in here just so that you're aware of what the differential are for peripheral arterial disease and how to distinguish them. Okay. So, looking at spinal stenosis, the classical feature of spy stenosis in a Noski or in an M C Q exam is that it's easier to walk uphill compared downhill. And you can see here it says, um struggling to walk downhill after managing to walk uphill with no symptoms. Okay. Additionally, it also helps bending forward, relieve the pain. And so those are the two sort of classical features of spinal stenosis. The one that I remember is that it's easier to walk uphill first downhill. But what spinal stenosis is the fact that she's got this reduced exercise tolerance that's explained by the spinal canal is becoming more stenosis and narrowing. Um So that's what I explained in this reduction in exercise tolerance, which sounds similar to peripheral arterial disease. But the key features here is that it's easier to walk uphill and it's relieved by bending forwards. Okay. We'll go through the other options and close and spawn. The lightest normally presents earlier than 65 you'd be expecting more than stiffness and joint swelling and which is improved with exercise, not rest, okay and quarter acquire syndrome. So it's being acute onset back pain, um as opposed to over two months and for M C Q S always having the back of your mind, bowel and urinary dysfunction. Now, that's a late stage sign of quarter acquirer. So, yeah, it doesn't have to be there. Um But you can also get saddle paresthesia, osteoarthritis. Um So the pain there would be increasing throughout the day and it wouldn't be relieved by the posture changes there. Um And again, it wouldn't explain the differences walking uphill and downhill and the examination findings begetting limited movements. Um It's a peripheral arterial disease. The main one here to remember peripheral arterial disease or intimate claudications is the angina of the legs. Um So angina general and is brought on by exercise and relieved by rest and it's brought on by all exercise because any exercise involving the legs is going to increase the oxygen demands for the blood, for the muscles and the blood vessels aren't able to accommodate that increased demand. Okay. So it doesn't matter whether you're going uphill or downhill, if you're gonna have an increased demand, then it should be getting more painful. So the fact that it's not getting more painful when you're walking uphill doesn't add up something else is going on there. Okay. So spinal stenosis is a big differential for peripheral arterial disease and calf pain, leg pain. And then key feature is, is it easier to walk uphill or downhill? Um, or is it easier to walk uphill? Um That's the key thing that I think of, but also relieved by bending forwards, right? Question 13. Uh Let me start the phone and I'll answer your question. No, let me have a look. I'm just looking at the answer to your question is a great question. I've always just remembered that it's the pain. The result gets better walking uphill. But I've never actually thought about why is that you're getting the pain? I'm just having a look for you now. So there's 20 seconds. If anyone else knows a chat, feel free to answer. Um I would assume is, uh the honest answer is I actually don't know. The proper answer is probably worth having a look. I'll try have another look for the next question, but yeah, good question. So I can't answer these. Um Right. I might not be able to answer that question, but a lot of you have answered this question correctly. So well done. Um endovascular re vascularies ation is the answer here. Okay. So, from the history, hopefully you've got the fact that this isn't a classical picture of intermittent qualification and it's actually regressed to critical limb ischemia. Now, the key features for that is that it's this pain is worse with activity, but it's present at rest now, okay. And it's been going on for three weeks. So more than two weeks and another classical feature of critical them ischemia is that the pain is relieved by hanging your legs over the bed out of the bed. Okay. So constant and present at rest going on for longer than two weeks um and resolved and somewhat resolved by hanging legs over the bed is classical of critical limb ischemia. So then it comes down to the management. Okay. So that we've passed the point now of exercise therapy and now we need to do something um more severe than that. So there's two different ways in general of how to treat it. There's endovascular revascularization and surgical revascularization. So, endovascular is more of like an interventional radiology procedure where you going in through the, through the vasculature. Um So if we start with this one, so endovascular revascularization is used for short segments that clusters less than 10 centimeters long and in high risk patients' or a surgical management is used for longer segments where it's more than 10 centimeters. And if it's multifocal, so if you have eight centimeters, then a gap of a couple of centimeters, then six centimeters, then another gap and then five centimeters, it's multifocal, then you would just do a surgery to get rid of it. But here is a 35 year old, otherwise quite healthy, it sounds like, well, they've got hypertension and diabetes but generally okay. Um So you are not high risk, um not particularly high risk. The key feature here is short segments. Okay. So it's eight centimeters in length, less than 10 centimeters. So that's why we use endovascular. Okay. So intimate and claudications in um looks milder form exercise therapy. When it progresses on two critical limb ischemia, you then chase, uh then faced with this decision is the end of vascular. What kind of vascular down surgical management? And that just depends. Is it less or greater than 10 centimeters the segment? Okay. So, hopefully, that makes sense. Yeah. Thanks very much. Putting that, that video of that Lincoln the spinal stenosis, hopefully that helps. I'll get this poll running, then I'll have a flick for. So I'll put the feedback from as well. But at the moment, there's only 16 questions of this and two more. And so we should, should get through it within the next 56 minutes. But if you have to leave now and no worries, please just fill out the feed on with any positives or any negatives or anything that can be improved. Um Yeah. Okay. Five seconds she interviewed. Correct. Right. A couple seconds. There we go. Right. So let's go through it. So, correct answer is a bedside and held Doppler. Okay. So looking through the question stem, hopefully it's some some word uh sticking out to you and pointing towards the diagnosis of acute limb threatening ischemia. So you've got your pain parasthesia and you have paleness perishing the cold, pulseless, okay. So also pointed towards cute limb threatening ischemia. So the reason that handheld Doppler is the first line is very cheap, very easy to do. You can do it any time of the day, any time of the night and you can get the results back very quickly, okay, because you're just doing it yourself. So that's why it's a first line investigation. And plus it tells you quite a bit. Um So what you'd expect here is you'd be you'd be expecting absent or reduced pulses or signals. And that's why it's a first line investigation. We'll go through the other ones. So A BP I um so that is used to assess peripheral arterial perfusion in lower land. You, I'm sure you might come across this when you're practicing your vascular exams um in an emergency. So, acute limb threatening ischemia as the name suggest an emergency, you're not going to do it because it's going to delay treatment further and you're not gonna get any information out of it because you know that it's likely that this peripheral arterial disease there. And so it doesn't really matter what the score is because you're going to need to do something straightaway. Plus it's not telling you where the inclusion actually is and we'll go briefly through the values and I didn't commit these all to memory, but the view ones that was worth just remembering. So if it's less than 0.5, then that indicates severe peripheral arterial disease, if it's from 0.5, up to 0.9, and it's mild peripheral arterial disease, 0.9 to 1.2, that's deemed as normal. Okay. And if it's anything more than 1.2, then there's some arterial calcification going on. So all I remembered is 0.9 to 1.2. Remember that's the normal and then anything less than 0.5 is severe. Okay. And I think you can even break it down further and anything less than point free is sort of uh imminent, uh imminently dangerous. But those, the ones that I've highlighted in bold are the main ones were remember and invasive angiography. Um So that's like an interventional radiology, radiology procedure and of managing it and you sort of can go in observe where the clot is and break it up and put a stent in place. Um However, at the moment that isn't available at all hospitals. So for that reason, it's not the first line investigation or management and CT and your grant. So you can do that as a next step as a second step after the Doppler because as I'm sure you can imagine if you do that with contrast, it helps to tell you where the inclusion is. Um an ultrasound of the lower limb veins. Um It says here, veins, obviously, we're at the moment we're looking at the arterial supply, okay. So you're not worried at the moment about the venous system. Um So yeah. All right. Next question. So this and one more. Yeah. Yeah. So very mixed responses so far, I'll just give it 10 or seven more seconds. All right, let's go for it. So a few people got it so well done. It's Heparin that you give for this one. Okay. So again, looking through some people have put Rivaroxaban and some people put fasciotomy. So maybe they were thinking along different lines for differentials hit. But looking through here, there's quite a lot of the six P S present. Okay. So again, pain, um you got pain, you've got pulseless nous and got pale legs. Um So there's a couple of couple of features going on there. Um But we'll go through it. Okay. So with those peas, you're thinking of acute lymph retin a ski mia, okay. So, IV Heparin is the management of choice for acute limb threatening ischemia. And the reason for that is it just prevents the clock building up and it prevents further ischemia from happening. Okay. The other thing that's important for acute limb threatening ischemia is pain relief is reminding, it's very painful. Similarly, for you know, acute coronary syndrome or the Angina, you have to give proper pain relief is the same thing here. So over time off is the one that you give for that. So a few people put urgent fasciotomy, thinking of acute compartment syndrome. The thing is here, obviously thinking of compartment syndrome, but this they're presenting to the uh to A and E so uh presenting to A and A. So it is quite acute, but there's been a background of uh two months over a few months of intimate and qualification. Um So compartment syndrome typically is caused by trauma to the lower limb. So you're thinking of a tibial fracture pain. It's got pain exacerbated by with passive flexion as a characteristic feature of compartment syndrome. Okay. So you just manually move the ankle that causes extreme pain. It doesn't mention that here. Another classical feature of compartment syndrome is that the pain isn't managed with analgesia. Okay. So it might say in the question stem, the patient is repeatedly asking for over a moth. Um But here it says it's been managed. So it's staying elsewhere in your way from that. Um Plus specifically for this question, they've got this background of intimate and qualification for a few months. That's um that's already been going on. So you, you've got to be thinking of something vascular with that in mind. Um, because like I said before, it's like a sliding scale. So if you have intimate and claudications, it can progress on words, what's going on here. And if we look then at the over options. So IV from the para nooks. So that is a Heparin like drug, but it's given, it's used for acute Coronary syndromes, but the efficacy of it hasn't been um well documented for acute limb threatening ischemia. So for that reason, it's not given, it's just Heparin that gets given a few people put oral rivaroxaban. So you might have put that thinking, it's a DVT or you might have just put that thinking just to break up a clock. So it's unlikely to be a DVT because there's no clear and obvious cause of the DVT. And it doesn't explain the background history of intermittent qualification. And in a DVT, you'd expect the leg to be hot and red whereas here it's cold and painful. Um So less likely. Um And then take a grill all again, that's used for acs, but it's not used for acute lymph, threatened ischemia. Um So IV Heparin is the management for acute limb threatening ischemia. Fine, final question. So 15 seconds, someone's got it, but five seconds left to someone's got it. But a lot of people have, have fallen into the trap there. Um, so we'll go through it. So it's actually the second one. So it's a f, is the answer here. Um, don't worry if you got it wrong, it's not a key. It's not a huge part of MCQ exams, but we'll go through it. And so hopefully you've got from the history here that it's acute limb threatening scheme. Yeah. Okay. So, like I said, the six piece, so painful, pale, perishing a cold parasthesia, um paralysis. Um Those are the key sort of things there. So what is the biggest cause of it? So there's two different types, two main causes of acute limb threatening ischemia. You've got a from bus or you've got an embolus causes it. So if we start with, from us, that is where and you've just got like a plaque that's just building up, building up, building up and then just blocks it off. Okay. And, and the key features of the history, if it's caused by a from bus is that you're gonna have pre existing claudications, which makes sense. You've, you've got a plaque that's building in size. So you can have pre existing claudications and suddenly it's just going to get worse. It's just gonna form from Mr. Um you're gonna have no obvious source of an MBA Leet. So you're not going to have a patient wouldn't have a f um because they've got pre existing claudications. Generally, they should, you should also expect to see some signs of that in the other limb as well. Um, because obviously it doesn't target just one limp and you're gonna have evidence of widespread vascular disease. So they might have had a previous stroke, you might have a T I A, they might have had an M I may be a heavy smoker, diabetic, things like that. Okay. So that's a from bus. Now, an embolus, that's the other type of the other main course is where you've got, for example, atrial fibrillation, it forms a clot, it fires that cloth and it gets lodged in, in a specific artery along the lower limb that causes causes ischemic symptoms depending on which artery it's in. Okay. So here because it's a clot and it's just gonna suddenly impact and book a vessel, it's gonna be a very sudden onset of a painful leg. There's gonna be no, no very little background history of um intimate quadication or any other peripheral arterial disease. You're going to have a clinic obvious source for where this embolize come from. And I said this can be no evidence or very little evidence of a peripheral vascular disease. So if we go through this one again, you can see 75 year old female acute onset left pain before today, she has not had any leg pain. She's got history of a F and yeah, and she's got a history of a half. So those are sort of just from those bits of information. Hopefully you can appreciate why it's more likely to be caused by an ambulance as opposed to a from bus. So for those that put cigarette smoking, it's not specifically wrong for the cause of acute lymph rent and ischemia. It would be more though, if it was from this picture, then you'd be putting cigarette smoking whereas because it's an ambulance picture, then you put in a f. So hopefully that makes sense. Um Let me know if you want me to go over anything or if you've got any questions. If not, thank you very much for sticking with me. Run over a little bit. Um I'll just put the feedback form it and again, like I said, it's our final, final session. Um So any feedback much appreciated if there's anything that you think could be done better if we were to run this series in the future, um Please just let us know in the feedback form. It's all really helpful. Um Good luck with your exams. Um If you have any questions, please feel free to email me um or email Luckman ones, obviously been doing a couple of the sessions as well. Um You can email us both. Um Yeah, so hopefully, hopefully that's all been useful and all the previous sessions should be available on catch up. So if there's anything that you want to go over last minute, it should be there um on medal. If it's not there just email us and we can sort it out. Um, yeah, I'll stick around it just for a minute or so if anyone's got any questions, but if not good luck for your exams. Okay. Yes. Um, so I think for like all the sessions should be available for catch up and we'll have been uploaded. I think you just have to register, um, for the possession. If you go back on our list and register for sessions, it should be available. Um, if it's not available though, if you just email even me or Luckman, um and we can sort that out for you. 10, it should be available as a record and the sides it should also be up there. So if you wanted to just offer it quickly, then you could, you can do it that as well. Right. Uh Yeah. On metal, on metal. Exactly. Perfect. Perfect. Right. I think everyone seems to have believed in so I will leave it there but any more questions for anyone. Um No worries. And if anyone's got any more questions, please feel free to email me or look when and we'll get back to a citizen. Can a good look.