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So, hi guys. Um This is Mr Lamb. He's one of the vascular surgeons in Morriston Hospital in Swansea, um who's kindly volunteers to do a MRC S revision session on vascular conditions. So he'll go through um some of the common pathologies, anatomy and hopefully help prepare for the um exam that you might be taking soon. Um So I'll hand it over to um Mr Laman. Oh, thank you very much. Um I first I apologize for being late. I had a, I had an emergency down in mtoner that required my attention and then obviously I had to drive back to Cardiff er, and then some technical issues. So um this will be a whistle stop tour um about vascular. It doesn't cover all the conditions that you need for MRC S, but it does cover a lot of vital information that you need. Uh and some key themes that come across quite often, especially in part A but uh some scenarios in part B as well. Um It's a little bit about me, I'm one of the STC S and vascular, er, I'm currently in the South Wales ju and I've also done junior fellow, er, jobs in vascular across the corridor as well. Um So uh next slide, so, objectives for you guys will be to identify common conditions, er, and also, er, understand the role for er, what sort of interventions er we suggest. Er, and you know, when you come across a question, the MRC S have some sort of idea um what, what, er, thought process come, uh we have and come to mind and so you should be able to answer those questions and also just consolidate your anatomy cos that's one of the most important parts. And uh one of the most of the questions in the MRC S is anatomy based. Um next slide. Um So, um I don't know, is, is it interactive jasmine at all? Um Yeah, so they should be, they should be able to um pop any answers on the group chat uh on the chat, which I'll monitor and I'll interrupt and let you know if they answer. Lovely. So, um if people give, give yourself two minutes just to give yourself a read and then, um and then uh if some people can come up with some answers, um and if not, then I'll just to tell you the answer, but it'll be useful for you guys to engage and just have an idea. OK. So scenario is you're doing an angiogram. So that's a picture direc directly of the artery where you put dye in and access the gain through the right groin consulting then passes some wires down the leg, ok, through a vessel with two posterior ans before it passes along the thigh immediately. Ok. The vessel then migrates behind the knee. On angiogram, it divides into two vessels. The first er, of which passes through the to us membrane towards the dorsum of the foot, foot. The second shorter branch divides into a posterior branch and into the foot and the natural b branch that ends at the ankle. Er, so the key question here is, what is the artery that's been punctured during the angioplasty? Er, I'm just gonna check if one's answered. Er, so no one's been brave. Er, I think it's on the next slide. The answer as I, yeah, I think I've switched on to the next slide. Lovely. So, so, yeah, it should be common femo archery. Ok. So that's the, that's the vessel that we tend to use for any groin punctures. Ok. Er, and if you go to the next slide, um, show a picture of the femoral triangle. Ok. Er, so the common femoral artery comes off the external iliac and it goes down in, er, and then as it goes down, the leg becomes superficial femoral archery. Ok. The reason that we use common femoral archery is actually behind it is the, uh, the head of the humerus. Um, and so if you puncture anything, ok, you need to be able to compress the archery. Er, and that's so that you don't er, get what we call a pseudoaneurysm or you don't get a bleed afterwards, ok? And by compressing it, you obviously stopped that. So the, the, the common femoral archer is the most common bit and it's also a larger caliber. Ok. This leads on to the most, one of the most common themes in M MRC S which is the Femoral triangle. OK? And you get asked countless times about this question in part A and also part B and you need to know your boundaries. OK. So uh looking at it, your roof is a fascial ladder. The floor is the muscles. So the um the hip flexors, er and the abductors, er and then the superior border is the inguinal ligament. OK? And then the lateral border is sartorius and the medial border subduct the longus, you need to know this inside out, OK? And you also need to know the contents of uh of, of the femoral triangle, which is nerve artery vein, uh femoral canal and lymphatics um related to all this but not so related. So much related to vascular. You need to know about obviously inguinal hernias and femoral hernias. OK? And understanding the femoral triangle is where you're gonna pick up loads and loads of points. OK. So make sure you revise that er coming up to uh the MRC S next. Um So as I mentioned, you've got the common femoral archery, OK? And it leads all the way down, OK. Down the leg. And as I mentioned there, you've got it in the femoral triangle and as it goes downwards, it tracks medially, OK. In, in the medial compartment, insi inside what we call the, er Hunter's canal. OK. So that what other people call it, the subsartorial canal because it lies in between sartorius. OK. Um Most this again pops up in the MRC S er, and it's a anatomy question. They quite often like to bring up and sometimes you get cross sectional images er, in your part B or even in your part A. OK. They ask, they ask you to describe it. Er, so in terms of borders, anti media sartorius, OK. Then you got vas medialis as the latch of water and in the posterior border is again the abductors. So in this case is Longus and Magnus and the main thing is he's got femor ar and vein and you've got the uh the smaller nerves. So, er, vass medialis and you've got the saf nerve as well in there, OK. Next slide. Um and that's just a, again, another picture for you guys to understand where we're coming from. So, above the inguinal ligament, you've got the common femoral artery. OK. So, so below the inguinal ligament is common femoral archery and it goes dives downwards. OK? And you get the um and it goes into the abductor, er, so the abductor canal or um hunter canal and then where it exits the abductor hiatus, which is a, you know, a gap in the abductors, um, that then becomes a popliteal artery and that's where it dives up um posteriorly behind the, er, behind the knee, behind the femur, next side. Er, and then if you guys revise your anatomy, er, further down, ok. So you've got popliteal fossa, ok? And it comes popliteal arteries and you get lots and lots of branches coming off into the knee. Er, and then from there it divides. Er, so you've got the ante uh tibial artery, which is the one that goes forwards and anterior. Ok. So it kind of looks like a uh like a hook, er and it goes through the interosseous membrane that supplies the anterior compartment, what we call the tibial peritoneal tranquil T PT is basically a continuation of popliteal and that divides into perineal and posterior tibial perineal cuts off at the ankle and that supplies the lateral compartment and posterior tibial er goes down to the foot and you can feel that as the PT pulse down at the ankle. Ok. Er and then um the, the anterotibial archy continues down to the foot and you can feel it and it ends as dorsal as pedis and that's where you can ex and when you examine the foot, that's the archer, you should be feeling like, please. Uh and again, another schematic um I don't expect you to know for MRC S but it's just for those of you that are interested, you do get the plantar arteries as well. Um which is the um is the war is basically where the er anti, so the um dorsalis pedis and post the tibial er arteries anastomosed and create the archer. Next slide, please. Um And then, so the other thing you need to understand is obviously the external iliacs. OK. So this is where the c so this is coming off the aorta and you get the bifurcation of the aorta. Um and then it, it bifurcates into exter er, common iliacs left and right. Ok. And then from there you bifurcate again, er, into the external iliac, which continues to the common femoral and you've got the internal iliacs, er, which uh will stay within the pelvis and supply the pelvic uh pelvic organs and the, and the gluteal. Um I'd be less concerned about the ex er, the er internal iliac arteries and actually the, the external arteries are more uh more relevant for you guys looking at the MRC S and looking at interventions and looking uh and understanding pathology. Um The reason we've got a cyclist in here is that you guys need to just appreciate that the external iliac comes under a lot of shear stress, er, especially in cyclists and they can get uh a certain condition called endofibrosis, which is just thickening of the artery wall. Er, not necessarily for atherosclerosis but does more of a muscular, er, muscular thickening er and fibrosis and that courses claudication in cyclists and athletes, er neck sides. Ok. Um This came up in my M RT S er is the property of fossa. So, um you know, I literally had a picture on Muck's anatomy. Um and for those of you that are sitting part, I would invest in that book because they pull loads and loads of photos, pretty much all of them from that book. OK. So that is an essential revision guide. Er and I look at pop fossa is what I had and they literally said gi er label this boundary here. What is the super boundary? What is this boundary? You just need to know it off by heart? OK. It's relatively easy. You've got your semimembranosus on one side, you've got your bicep fes er on the other, on the contralateral side. OK. And then the uh the in interior borders are the heads of gastro. OK. And then you've got the the floor which is the posterior capsule of the joint and popliteus. Er and you need to know the inside out of er what's inside er the er popliteal fossa. So, popliteal artery vein, OK. And then you get the tibial nerve and common fibular nerve. OK, which is the most lateral one. Um And I remember in my exam they said uh can you identify um some space occupying lesions uh associated with structures within this, this uh this anatomical er failure er and so you got to think of, you know, popliteal artery aneurysm, popliteal vein, er, that can also have an aneurysm. Er, and then you got to think of weird and wonderful things like neuromas. Er, and, er, you can also think of things like Baker cyst as well. Ok. Uh next slide, please. Um I wouldn't worry about the abbreviation so we can skip that. So that's fine. Uh So another one, this is slightly more tricky. I don't expect anyone to go to know this properly. But uh if you, there are certain conditions which need stenting in, in the er thoracic aorta. And in this case, the surgeon has done what we call thoracic endovascular repair of the AORTA. OK. And uh for various reasons, this patient's got uh at a high risk of having a spinal stroke and that's because certain areas of the aorta supply the spinal cord. Ok. Uh And so he performs a right supply bypass. Ok. So taking blood from the carotid down to the Subclavian bypass. And what segment? Ok. Does the subclan archy supply the spinal cord? Ok. So you gotta think what is the major artery from, from Subclavian that's, that feeds into the spinal cord? Um Just give you 10 seconds for you guys to think about it. You know, it's feel, feel free to answer as well. Does the third part go to the scapular? But I'm not too sure about the other, the 1st and 2nd part. So if you go to the next slide, I can tell you. Mhm. So it should come up there. Hang on. Sorry, my screen has gone blank. So it's uh yeah. So it's the first part. OK. So it's the vertebra art. Uh So essentially what happens is you get your vertebral arteries, don't you? And they form the Antero spinal artery uh going down retrograde. So you go next. So you just need to appreciate the um the subclavian artery. It doesn't, it does come up but it does not, it's not as often. Ok? But the main thing is is that the anterior spinal artery comes off the vertebrals, which is the first part. Er, you also feed in the spinal cord, you get the posterior spinal arteries, ok? Er which is also from the vertebral and posterior er cerebellar cerebellar arteries. Um and below the c spine, you get your intercostal and number of particular arteries, ok. Um The reason why this sort of procedure is really high risk for spinal stroke. Ok? And it is a complication that you probably might want to be aware of. Ok. For MRC S is because um when you occlude the fic aorta, um you're occluding a whole massive amount of intercostal arteries that feed the spinal cord. Ok? And you also, if you have more metal work down in the, in the abdominal aorta, you also um are uh occluding these lumbar arteries that feed the spinal cord So the main one is the angios spinal. Um but you, you also get all these feeding arteries, which is why the theory is that we do a carotid subclavian bypass to ensure that we've got blood supply going to the subclan archery on the left side. Um What you guys might not appreciate is that sometimes we cover the left subclavian archery, uh doing a uh a thoracic er endovascular repair and your, your body deals with that really well. But sometimes you just need a, a bit of a boost by stealing blood from the carotid artery. Ok. Um There is a, there is a, a named artery called the artery of DM Skow, er, which supplies to about two thirds of the spinal cord artery right by the anterior spinal. Er, and that's one that has popped up in my question. So, what is the major artery in the, er, the fascicle? OK, which is accumulation of all these posterior intercostals. Uh Next, I just to let you know that someone did put in the chat. First part. Excellent, well done. Um So yeah, uh just, just have an appreciation of the first part of the sub archery is uh it does come up often enough. Er, so you need to know er where and what relation is it? OK. So first part is always media bo body, uh media border of uh skin, anterior, OK. And from that, the major branches you need to know about are vertebral archery, internephron and foot, um, and thigh or cervical chunk. Ok. Er, and that also supplies the fire gun, doesn't it? Er, the second part is behind Scalia's anterior. Ok. And that's the cost of survival chunk. Ok. Not so many major bones to start to worry about. And as you're right, you're right there. Jasmine that, um, the third part is, er, supplies, um, is, is supplies the dorsal scapular arch. Ok. Er, so next slide. Um so um try to be quick doing an angiogram. A consultant stents to the abdominal wrist or artery rising from L1 attracts anterior in it and inferior but maintains a straight course giving off some adjacent side branches. Ok. What is this artery? This was a question I had in my own R CS party. Any answers? Give you five more seconds. Yep. Next side. Yeah, it's S MA. So, um for your MLC S this applies for um pretty much general surgery, vascular surgery. Any other, anything that deals with the abdomen, you really need to know what comes off L1. Ok. So any on that plane, the transpyloric plane is a really important area. Er, and er, so from a vascular point of view, L1, the S MA typically comes off. Ok. And the reason the what gives it away is that it comes off the it, so it's a, it's a single vessel. Ok. So it's unpaired. Um, and there's only a few unpaired vessels in the abdominal aorta of which is to see that S ma in and the infant mesenteric, the ones you worry about. Um, and it's the second, er, major a abdominal branch. Ok. Um, so it comes off L1, it goes anterior. Ok. And goes pretty much down downwards. Ok. And it's a fairly, it can have a fairly straight trajectory and it gets some, uh, some various branches along the way. Ok. That's the one you worry about most sea that AIS looks like a seagull. So it pretty much looks like a uh ad. Do you, do you guys know the Hollister um logo on the CT scan? It looks pretty much like that. Uh, and an I MA is this uh weedy little thing that tends to go to the left hand side and you barely see it on the CT scan. Um, right next, next one, please. Er, and so these are the branches of the ab abdominal aorta. I highlight the ones in red because those are the ones that you really want to know. Ok. Er, and no one, they're not really gonna pick up on um, the intrathenar arteries, the, the middle suprarenal arteries, they're gonna adults. Um, and the Lumb arches. So you need to know the big major branches roughly what spinal level they come off at. Um, and which ones are paired and unpaired? Ok. Er, obviously I've, I've also highlighted here the common ila, as we mentioned, earlier, they come off at L4. Ok. So that's pretty much where the abdominal rail halter ends, isn't it? And they come straight off from D 12 next side. Um So your venous ct angiogram in patients undergoing the left cross endarectomy. And uh you notice a radial dense lesion at the cross bifurcation at the level of secure thyroid cartilage. Uh So what spinal level does this correspond to? Give yourself a few, a few seconds? Any ideas? Anyone? Right next IJ. So it's C four. this again is a really common question. Uh And you'll see it come up time and time again and they love um knowing what corresponds to what spinal level er at the neck. Um So the fibro cartilage where the carotid bifurcation is, is corresponds to C four and that's classically where it is. I just did a I was just cys in, in a cot aortectomy today and it was a high bifurcation. Er So this is way up on the er way above the fire. Actually, it's pretty much at the angle mandible which corresponds to C two. and you have to think you're ba basically a base of skull at that point. Um but that, but just just keep it in your head, you know, for um the bifurca er the bifurcation of the external and internal carotid is at C four. OK. Er And at the superior border of the fibroid cartilage as long as you remember that you should be OK. Next like uh and that's just a, just a nice picture um of for you guys to appreciate that uh the, the carotid artery. So you've got the common carotid artery which on the right side comes off the b of cephalic trunk. On the left side, it comes off, off the aorta and you've got a nice um straight run up the neck, ok? Behind Sterno, the master and behind the jugular vein, right? And it divides into internal, which you can spot because it has no branches. OK? And then you've got the external carotid. Um, and uh that divides at C four next. Uh and then for you guys to remember, uh you know, you've got your uh internal coid and how it feeds into the, er, circle with us and what, what BS it supply. So, um you need to have a rough idea of that. Um It's pretty important for you guys to understand the um uh the branches of the external carotid. Uh I don't know if anyone else has uh some, some uh good ways of remembering it but um, II I've just learned off by heart now and, uh, but there are some pretty, uh pretty rude acronyms that you can use. Uh, some people are taught in various med schools. Um, and it's just finding what works for you. Now, if you ever get asked a question in, in um uh in the exam, what's the first branch um that you'll see uh doing aqua endarectomy. It is a, it's a superior thyroid artery. OK. So that's your landmark. And that's the one that you need to identify. Um the superficial temporal artery is the one that um we biopsy during uh temporal arteritis. OK. And again, that's one that pops up in the uh in the MRC S as well. Uh Next question. Uh So um we just talking about quickly about class artery stenosis, stenosis. Um So we, the nice guidelines say that we should be treating patients with uh 50 to 99% blockage, uh who are symptomatic. Ok. So, they have had symptoms of a stroke or a tia A, ok. You can have stenosis around here and not be symptomatic. Ok. The, the problem is is that, um, the operation itself carries a 2 to 3% risk of a stroke, um which is not insignificant. And, you know, if you're asymptomatic, well, essentially you're unlikely to, um likely to have an embolic event from the carotid artery stenosis. It's only when it becomes unstable. Ok. So, you know, you've got very soft plaques, um or it's uh extremely critical, not, you know, uh that you're having flow problems, that it becomes a problem. Ok. And that's when the indications for surgery. Ok. So again, remember if you have an asymptomatic. Ok. Patient, then um the answer is just best medical therapy do not operate on them if they are they, if they are symptomatic and had ati a or stroke and they've got spotted osteo stenosis needs a referral for vascular surgeons to uh, to consider an urgent um endarectomy. Ok. Next. Uh so, and, and for you, you guys just need to know that actually the best, er, the, er European Society Vascular Surgery recommend two modalities of er, imaging for carotid artery stenosis. Er, so the first line is used car, the artery duplex. Ok. So that's the, using the Doppler ultrasound on top of B mode er, ultrasound. Uh, and that can be done by two independent practitioners done at different times. Um And the, the other options are we can do CT scans and MRI scans. Ok. Um, just to, you know, just to characterize the anatomy, but AAA duplex is more than enough, some places will do a duplex on the day of surgery and that's to double check. You haven't got a complete occlusion of the clotted archery because actually, if you completely occluded the archery, you're not gonna throw off any clots to the brain because there's no flow going there. So you've completely, er, you, the patient has treated themselves and they're not gonna get a stroke next. Uh So as I said, m main things you need to know about is that we should only be operating on um, properly, um, symptomatic patients. Ok. Because there is a stroke is, is significant. Uh, and for you guys, so just to remember. Um They will ask you in the MRC S, what sort of nerves are at risk? Ok. So you need to remember that the nerves at risk here are the marginal mandibular nerve. So they might get a bit of joking of the corner of the lip, um the vagus nerve. Ok. So they get issues of BP and they also get issues with recurrent laryngeal, ok. So they might get a hoarse voice. Uh the hypoglossal nerves. So you got to remember that they get um deviation in their tongue. So those are the major cranial nerves involved. OK. Next. Uh so number seven, so this is gonna be a trick question. So just have, I think 67 year old was 60 pack year male uh comes to the hot clinic and he's got right pain. Yeah. So right calf pain and he's cramping after about 15 m, goes away after he stops and you know, he doesn't get any problem at night. He, he's he's able to sleep at night without any pain. Uh and you don't notice any, any issues with his legs in terms of ci er and he's, you know, but when you see him, you do think actually his right legs a bit cooler and there are some abs and bul um so based off this, what do you think we should do? Right? Any answers? Is it medical optimization? Because it's um not sort of acute critical limb ischemia or anything. Yeah. So you've got, if you go to the next exercise, perfect. It's best medical therapy, isn't it? Um, and actually physiotherapy is probably so we, we call it structured exercise program is the, is the, the post and foot. But basically these guys, he's able to walk. Ok. And much like you guys, you do when you're training or doing like, cardiovascular fitness and running or, you know, swimming, um, the more you push yourself, the better you get, don't you at, at doing the same activity? Um, and so the theory is ok is that he's got, now it's, it's kind of like the M four, when it's, when it's busy in, in traffic and they decide to close a lane or two, everything funnels down there and everything slows down, doesn't it? And if you go into a single lane, er, but actually if you open up some b roads or some alternative lanes elsewhere, suddenly flow gets a lot better. Er, and so that's the whole point of exercise is that you're creating stress in a way that forces your body to physiologically repair itself. And jasmine's absolutely right. We should be putting every patient on a statin and an antiplatelet because that is best medical therapy and actually that reduces their overall cardiovascular risk and their shit and the damage to their archer. Ok. And there's good evidence to say, uh, and, uh, to say that anyone that's got claudication, which means pain on walking that goes away with rest. Ok. Um is actually gonna have more damage by having any form of intervention. So they're more likely to lose their leg if we do anything like uh interventional radiology or do any bypasses. So we reserve that only for patients that really need it. Ok? And that's when they become critical lymph ischemia. Uh next slide. Uh So another one, you're in sho at the local T GH. And it was, um, a for a 67 year old with, er, af smoking C ob E classic vascular patient. And they have an hour history of sun onset pain, pins and needles, er, in their toes, the foot is cold but, um, she's able to wiggle toes, er, but, you know, in, in this classic ses which is vascular, you can't feel appreciate AAA Doppler signal. So, um, so the urgency today. So it was a six centimeter blockage and the SFA which is likely a bolic in nature. Oh, dear. Ok. So what do you guys do for this one? Give yourself that second. Ok. Penny guesses. No, nothing on the chart at the moment, right. So you have to read the question carefully. Cos MRC S is designed to, you know, it's a two stage thing. A, you've got to recognize what the disease is. B you have to think what is, is, um, what is the most appropriate therapy here? So that's, that's a two stage part of the question, isn't it? Um And here you, they are really sneaky and they can have a lot of double negatives. Um But actually it says is what is the most appropriate initial intervention? OK. So if we go to the next slide where the answer is it? IV Heparin, OK. You suspect you got ischemia? Um I changed, I remember EDS of things as 12 centimeter blockage. OK? The, the, the whole point of this, OK? Is what is the most uh appropriate initial investigation you've got act which confirms you've got a blockage. What do you do then? Well, actually if you look at the guidelines, OK. The, the initial, the initial management of anything is conservative. OK. So you give them fluids, you give them option, you give them Heparin. OK. Heparin stops any clot P and it helps your body just naturally break down the clot. OK? Uh And it buys it time. Now if that's not working or if it, it, the leg is profoundly ischemic, then we have options, don't we? We have options of angioplasty or, or embolectomies, we have options of fop bypass and if it's in dire straits and it's killing the patient, then you need to do an amputation. But actually looking at all this pretty much, you know, he called me at 2 a.m. two AM in the morning and I was asked the on and you told me the story, I'd be like just stick on the he and I see me in the morning. Ok. And you can get away with that. It buy some time, you know, because your body will actually try to deal with it. Uh Next question, next slide. Uh So what is peripheral artery disease? It's any narrowing or a stenosis of peripheral arteries, toric and blood flow to target or? Yeah, classically seen by in uh caused by atherosclerosis. But there are other reasons for that, isn't it? In the chronic setting? It's caused by, you know, damage to the arterial wall and the subsequent atherosclerosis. Main thing you guys need to think about is smoking, hypertension, elderly patients just because of the age and the shear stress of the artery. Ok. And they get, they get, uh, uh wear and tear and in diabetes, diabetes is probably now the number one cause and I say it's worse than smoking personally. And high cholesterol. Ok. If you're looking at uh manes patients conservative. So the ones I've mentioned earlier, which are the claudicant. Ok. So they're the ones that can walk. Um, you manage conservatively with exercise, smoking sensation. That's probably the biggest thing. Antiplatelet, statin hypertension control. Ok. So all the cardiovascular risk factors. Ok? And diabetes, uh diabetic control and then we can talk about endovascular and open repair. Um, you don't need to know the ins and outs for that for MRC S. You just need to need a decent appreciation. Ok. Next. Um, so on to chronic lymph ischemia. Um, for those of you who are queasy, I do apologize about the narcotic toes. But, um, that's vascular for you. Ok. Um, is, is, uh, people are slowly dying from their toes up. Um, so this is the definition um, of, you know, this is what we deal with most of the time. Ok. So, uh, it's most commonly, er, lower limbs chaer characterized by patients, um, who have got, uh, ischemic rest pain. Ok. That's when you get uh chronic lymph ischemia. Ok. So severe ischemia is rest pain for more than two weeks. You get tissue loss or gangrene and your A BPI is less than naught 0.5. Ok. So that's, uh, that's when you intervene, that's where you get the most benefit of any intervention. Stage four is when you get a, uh, ulceration and gangrene. And this is the, uh, this is the old school Fontaine classification of chronic leg is ok. So, three stage three and four are the ones you worry about. Er, next. Uh, that's just, again, just ideas of cla cla er, classifications for you guys just recognize. Ok, that bad is bad. Chronic limb ischemia is usually related, uh, is usually associated with rest pain. So, so as soon as they say, oh, doc, I'm lying in bed and, um, you know, I'm getting pain at night and I have to hang up my legs over the bed. You're like, ah, ok, that's when it's bad or saying I literally cannot walk because, you know, I can't take, uh, less than 5 m, but it's when literally you're lying flat. And that's because that's what that you need gravity there to, to actually help, um, get flow, uh, blood down to the foot. You know, cos when you're sleeping, your legs raise to dilate, you don't get as much blood there, uh, down into the foot. Uh, and so suddenly they wake up in screaming agony and then they need gravity to help um, blood get down into the heart. Ok. Next. Um, so investigations for you guys, um, just remember first line is uh A UK is actually part of your examination. It's not technically an investigation. Ok? Arterial duplex will give you a good uh idea of the flow going down the leg. Ok? And, and what uh any sort of stenosis, uh and what, what percentage stenosis is there and, and away from characteristics. Um I don't expect you guys to know other pressures. That's something that ii see a lot more often. But, um, for those of you that are a bit more interested or want a bit more dear. Um, diabetics, which often will have chronic lymph ischemia, ok? Their, um, their re vessels and their calf vessels are massively calcified and the ABP readings are unreliable, um, because they can't compress the arteries. And so for some reason, the, the, the arteries in the toes are preventively spared from um, the diabetes uh from diabetes. And so they give a more accurate reading, ok. But it, it's a bit more fiddly and more special equipment. Um, CT angiograms are great. They, you know, they give you a good, quick, easy, reliable snapshot and you can see how much calcium there is. But for diabetics, they're not as useful. Cos the calf vessels are like two millimeters in diameter and it, it, it's, they do struggle to, to, to find those um those small vessels. So an Mr is great. Um The gold standard is direct angiogram. Ok. So knees on in the groin, direct some dye and, and uh shoot some x rays to get a picture. Unfortunately, it's highly invasive and it doesn't come without complications. Uh And so sometimes we reserve that. Um we, we reserve that if we were thinking of treating this patient with um endovascular treatment as well because you, you can just do it at the same time, you can take a picture of the artery and then you can decide uh how you're gonna treat that artery. Ok. Next. Er so treatment um so here we've got a picture of endovascular er ballooning and stenting, ok. Er So that's endovascular, that's one option. OK. Er and er the other options are bypass. OK. That's the surgical management, conservative management, er as we mentioned, ex exercise therapy, medical optimization. OK. You, you literally just have to get used to saying this for your exams for your interviews. Ok. Whenever you sit down, uh, and it's like I will you have to split your treatment options into best medical therapy or conservative management. Ok. Or non operative management and operative management, which include uh endovascular and vascular. Ok. Just remember, just keep, keep those options in your head, endovascular open. Uh, and you can't go far too far, er, wrong. Um, as we mentioned, uh I haven't mentioned it but short segment disease is probably more suitable for angioplasty. But again, you know, if you have a tiny lesion, which is like four centimeters in length, ok. Um, then that's probably a good one if you got, you know, for an angioplasty, if you've got one that's about 12 to 15 centimeters. Ok. And it covers most of the superficial panel archer down to pop the deal. That's not good for an angioplasty at all. That's good for bypass. Ok. So I have an appreciation of that because that sometimes does, uh, does pop up. Ok. Next. Uh, and so bypass surgery is easy. Ok. Well, it's not easy. Technically, it's quite difficult, but in terms of understanding what a bypass surgery is, is relatively easy, you take blood from a more proximal vessel, ok. Er, which has good blood flow and then you bypass it onto a distal vessel, ok, which has really clapped blood flow and then you're trying to get, you know, uh, some sort of conduit. So it's either plastic or vein in vein is the gold standard and it's the best has less like likely to infection. Ok. And it's likely that complications has a better patency rate after five years, but then you plow it on to that target vessel. Ok. Er And the name and convention is easy, you take where the proximal vessel is. So femoral artery down to, let's say the popliteal artery and that's a fem pop bypass. Ok. Uh And the other thing that you need to, to mention is that bit. Uh I've seen it come up in one of my, my first set in November. Yes. Er, and that was um that you can get bacteria from a bile film onto the plastic of any er, anything that's prosthetic. So, in this case, a plastic graft and so therefore, antibiotics will never, er, will never penetrate to it. Ok. Er, and, and it forms a protective layer and develops antibiotic resistance. Um The concept, the biofilm is something that pops up er, in your pathology station in your MRC S part B. Uh So next, er, so er, onto the thing that you guys will probably more associated with vascular. OK. Is acute limb ischemia. So sudden decrease in perfusion to, to your limb causing reduced oxygen delivery and end organ dysfunction, you can just stop it there basically. Ok. Um And then that, that's the sort of definition you wanna give in partly. Ok. Er, now causes are many but most often we see it in uh in embolization, thrombus in situ. So you've got a narrowing the arteries and then you let's say, convey hypotensive and you just clot off because there's very low flow and then trauma. OK? And this includes uh compartment syndrome, mixed. So um you're familiar with the six PS OK. Being paralysis partially called pa pa, you all wanna be surgeons if you're coming to this talk and you all want pass the Mr CSI kind of want you to forget this, ok. Keep it in your back of your mind. But this isn't how you assess the painful limb. It's not very helpful. By the time you get to the six ps, the leg is dead. Ok? And it's not viable. If you get paralysis, you're at the end stage. Ok. So if you go to the next slide, this is what you need to know. It's the Rufo classification, OK? Of acute limb ischemia. If you take anything away from today, I want you to remember this. Ok. Er, and so this is simple. It's 123, OK? With two straight into A and B. Um A is viable. OK? You just stick on the heparin. They haven't got, you know, they've got pain mainly, ok? And then T two A is sensation changes, ok? Er, and er, it's confined to the toes, they can still wiggle their foot. Ok? Again, sit on the heparin. You call me with a two way margin of F foot. I'll be, like, stick on the heparin. I'll see you in the morning. Ok. Two B is immediately fet. And so that means you're telling me. Oh, right. Ok. They're struggling to move their toes a little bit or they can't move their toes and I'm like, ah, ok, that's when the motor nerve are dying and that's actually in terms of, and, and function, er, and what's, and prognostics and, you know, what matters to the patient that's really important, isn't it? Cos at the end of the day, a motor, er, someone that can't use their leg, I, it's a useless leg then, so you need to intervene quickly. So if you told me that, that story in the 2 a.m. morning, I'd be like, I'll be down here the next hour. Can you, can you book a theater slot for them as a cat? One? Ok. Then three is uh not irreversible non salable. Um, there, there are some people that will try to bypass on, on, on, on we for free. Ok. So if you came to me and said on, on the, on call basis and said, you know, I've got two b I'd be like, right, just stop right there. I'm coming in, you know, you don't just, instead of telling me this long winded history and telling me individually what components they are, if you can classify this, that's brilliant. Er, and again, as I mentioned, if you know what stage two difference between two A 2 D3. Ok. You can come up with um, treatment options. Ok. Er, to answer your exam, you, you need to know, you know, essentially 22 A, you stick on the heparin and then you can maybe think of an answer two. B you'd be like, well book them for a bypass or book them for an angioplasty. Ok. Or, er, if it's an acute event that's, you know, embolic in nature, book him for an umbilectomy. OK. So you need to really get this into your head and it, it helps you think of um management like next uh so investigations, just the basic things that I expect from you guys make sure you do act angiogram. That's the one I recommend. OK. It's quick, it's easy accessible if they say what sort of axial imaging do you want? Ok, then say CT angiogram cos you, you know, you can get it done within 15 minutes and you can see the images. I don't need to look at the report for Act Angiogram. Um, it, it, it, you can just see the pictures, it's useful. OK. Next, er, management, er, time this issue and as I mentioned earlier, OK, stick on one heparin first. Give them oxygen. OK? Cos they might be saturating fine but they're not getting oxygen down to that leg. So you need to give them as much as you can and they give them fluids there is a role for conservative management. The Ruford ones are two way that get better on the heparin, you just stick them on long term anticoagulation. Uh, and there's, you know, you can revascularize them, you know, you can either do an embolectomy if there's an acute embolus. Ok. You've got a history of af it's an onset, you can also do thrombolysis, although that's, that's very limited. Um, you can do thrombectomy. Ok. Uh, and then you've got the options of bypassing. Ok. Uh and er, recognize that these patients are really at risk of reperfusion injury. Ok. So their potassiums will go off off the chart sometimes. Er, and they, they get ac Kr don't, they cos they might have some dead tissue and they get rhabdomyolysis. These are complications you wanna think of um that they might ask you in the MRC sra er, and then you also get compartment syndrome. Um So again, please recognize that sort of thing and uh that could be a scenario in your stations next, er, will skip chronic mesenteric ischemia. Ok. So you just need to know that they get postprandial pain. Er, and you can work them out. Acute acute mesenteric ischemia is um key things for you guys to take away is that um they examine not typical for an acute abdomen, so they're in severe amount of pain, but their abdomen is actually quite soft. Um So when you, you know, they haven't got ap in their abdomen, they're just in a lot of pain whenever you do it. Ok. And the definition is acute, abrupt interruption of the blood supply to the bowel, resulting in bowel ischemia, necrosis and death. Ok. Er, and they associate it with nausea, vomiting, they get up the pain. Uh, so sometimes they get, um, bloody stools as well. Er, next. Um, and then you just need to know the causes. So, um, thrombosis, embolism, non occlusive. So, non occlusive being that they're in septic shock or something, uh, or they drop their BP and then you get venous thrombosis, which you can see, but II don't see it too often. Ok. Next. Er, and then, er, just a good revision point. Uh, we mentioned the sma a artery earlier and these are just some of the b branches you want to know about. Um, so I colic is the main one and you use that for the right hemi, er, and, and the white colic as well and the extended right hemes take out the, um, middle colic artery. Ok. And then you need to just know about the judging on and ileal cascades as well. Um, but just have a general gist here next. Um, probably won't go through that so we can skip it. Just get a CT scan guys. Ok. That's mostly general surgery for you. Uh, I viv antibiotics, fluids. Ok. Er, and, and the main thing is is that as a vascular surgeon, there's no point in me revascularizing in this patient if they've still got dead gut in there, because all I'm doing is is feeding all this sepsis in into the system. You need to do a bad resection first and then we can think about whether not we revascularize. OK. Next. Uh so uh patient comes in, this is an important one. OK. So um patient comes in with diabetic um uh who's diabetic smokes and in septic shock. So, they're really well and you notice a large ulcer on the plantar a in the foot x-ray shows no evidence of gas in the foot. Uh And you start the mon tazocin. However, before dividing the foot, what further imaging would you require to ensure adequate pound healing? Um I'm gonna change the scenario for you. Cos I think it was meant to show uh shows evidence of gas in the foot. Um So, uh actually, you need to think carefully on this one. So give you five seconds just to think about it and your dear in anything. No. Um No, I don't think there's um there's nothing on the chat at the moment. That's fine. So it's a trick question because this is something I'm gonna hammer home to you. OK? Is this patient's septic? OK. Do not delay imaging. OK. Do not delay for imaging. This patient's septic. They're gonna, they're in septic shock, they're unwell, just take them to theater. You know, I did say in, I did say actually the change scenario is basically get them. Uh, there is gas in the foot. So ideally if they're really unwell, you should just take them straight up. Ok. You can get act angiogram on the way, way up. That's fine if you know. Um, but most onsets will say during sepsis first, think about revascularisation. Ok. Er, and I've done it plenty of times but there have been times when the CT has already been booked and they've gone straight and they've gone to theaters via the CT scan and, you know, like, well, I'm not going to intervene on, on the vasculature in the meantime, I'm just gonna drain that sepsis. Uh And you know, you in this scenario, it doesn't matter. Uh I've had patients that have referred to me as uh as um gang winners foot. It's all micro, um it's all small vessel. Um Thrombosis small vessels, um infarcts. Uh and he had pulses in the leg and the foot. Er, and TN O refused to take it and this guy was in DK A uh and he was septic hypotensive tachycardic 100 and 50. And again, TN O just wouldn't do it. They just said, oh no, it's vascular. He's got, he's got necrosis on the foot. Uh So just, just, just meant that fine, he's got pulses. I'm not gonna do act on this guy. I'm just going to take him to the theater and goes j sepsis. Ok. I had to call in consultant cos it was a, it was a clear tier no issue. Er, and then, um, and then we thought about Revasc T. Um, so it's a bit of a trick question. I just wanted you to appreciate mainly that this one uses immediate debridement. So if they ask you, what is the initial management after antibiotics and uh resuscitation, you'd be like debridement. Ok. Er, and if you think about imaging, well, uh you open a can of WMS but uh I would go for CT angiogram as, as my initial one, plus a minus an MRI afterwards. But, um, I wouldn't take that as possible. Ok. Uh, and those are diabetic conditions that you uh ulcers and see. So you've got a venous ulcer on uh the foot, well, on the left of the screen? Ok. Er, and then you got a, er, uh arterial suddenly you got a diabetic diabetic foot, uh, infection with what seems like a big collection, er, an Osteomyelitis of the second toe. Next. Ok. So me saying that the ulcers um, comes up quite commonly in the M RT S. Um II, just answer it quickly. It's shallow, typically in the gated areas, irregular borders and there's a granulating base. Ok. And they're usually quite painful, er, next. So, just, just some more pictures next. Er, so, um, just remember get venous duplex check that they haven't got RT O in insufficiency and show to treat any infections. Those are the main ones. Ok. Um, I think you can, er, and you know, if they, if they haven't got an RT O component, you put them in Stockings. Next. Uh, as I mentioned. Yes. Yeah. Contraindicative abi is less than 0.6. Next. Uh, Neop paic ulcers. Oh, sorry about the images. Uh, so diabetes, you've got a neuropathic component, you've got an arterial component and you have a mixed component. Um And so it was really important that you appreciate that. Er, and so you just want to do some basic investigations. Ok. So you got to do the monofilament test that's really important comes up, came up in my exam. Ok? Um and just say what is the test for neuropathic ulcers? You've gotta say monofilament. Ok? And, and not of they cos they lose their fine touch and their hoping exception and the pain responses. Um and then uh just the usual stuff. So check the blood supply, do an X ray, do an MRI defer to if you think there's Osteomyelitis. Ok. Uh and uh check the H py and C and good diabetic control, good angio IV antibotics debridement or amputation. Of course, what's necessary sometimes next. Uh RT U ulcers um as you get taught in med school, punched out ulcers very well defined um extreme. Er, and you know, they have a uh well defined board and they usually on the PES areas. Ok. Next, um, it's like So, same investigations as, as with any arterial disease. Ok. So, um, the best side of investigations will be API and you can go for an RT or Duplex cos it's non invasive, it can be done in. Now gives you good at imaging, er, and er, you can do CT or MRI as, as your, er, axial imaging depending on the urgency of it. Ok. And as we discussed options are conservative. So non uh non surgical management, endovasc er surgical management, which includes endovascular or open. Ok. And, and the worst case scenario is amputation. Next. Uh diabetic infections are really common. Uh You have to remember that uh they obviously come with um mo mo polymicrobial er and associated with soft tissue infections that can lead to osteomyelitis. Ok. Whatever you need, you need to know is remember to drain the sepsis. Ok. If they di if the diabetics, ok, they get really unwell with diabetic for the sepsis. Next. Er so investigations, all the usual stuff include H B1 C er foot x rays to check for signs of Osteomyelitis or any gas in the, in the foot. Um Osteomyelitis comes quite late. It takes up to six weeks for to show on the x rays. So um the gold standard is an MRI. All right. Next. Um please please please learn this if um you know, this is called the wi fi score. Ok. So wound er ischemia foot infection. If you have a, if you just mention this in your part B you score really well. Uh uh it's a score for classification for diabetic foot sepsis. OK. Which risk stratifies the patient's um risk for um either an intervention in terms of revasc or an amputation within one year. OK. So you can say, you know, and I had this in my part B station had diabetic foot ulcer. Er and they said to me and I said I would risk flat fight this with uh the wi I score, er, and I scored tons of points on that and they were really impressed. So just, just have an idea, have some sort of grading system um for diabetic foot ulcer operations. Ok. Really important that you have, this is an easy one. You should say wi fi wound infection. Um and er, and er, say wound infection ischemia. Yeah. Yes. Uh A man's went, already talked about that. So the next, um, so I don't know how much time we've probably got left. Jaz. Um I think we're reaching sort of an hour point now. That's fine. I don't think I have much left. Uh Well, I probably got the domino orders so we skipped this. This is neck fash. Ok. Um You guys need to know it, you know, it depends on what your local trust is, but II was based in the South Wales. You guys need to know this, this is, but this is your bond or stuff isn't it. So just come in and say bacteria, you get crepitus. Ok? And they're sick, they need to divide. Ok. So I have antibiotics is the initial line, uh, stimulate wet gangrene typically seen in diabetics. Ok. If you get something like this you're gonna end up taking most of that foot off. Ok. Next, er, dry gangrene doesn't necessarily need an amputation straight away. Your body actually demarcates it really well. Ok. Er, and, er, doesn't nec nesa an er, any intervention unless it gets infected. Yeah. Um so this one is probably one of the big things that comes up, you know, R CS, it comes up in interviews. Ok. Is a 62 year old male comes to Ed recess and has got witness abdominal pain and collapse. He's shocked. Ok. He's got a heart rate of 100 and seven. His BP is er 83 of 56. Er BBg shows a BH is 7.4 lactate two HB is 76 and he's got a fast scan of flu fluid in the abdomen. So an, an easy already um activated uh massive hemorrhage. So guys, you know, what do you think we should do here? What is the next step you've been resuscitated? What do you think you're gonna do next? Give me 10 seconds anything. No, but I guess if, if he's resuscitated and stable, would you image or? Absolutely, absolutely. Image, image it. Ok. Cos you don't know it could be it could be an aneurysm, isn't it? You know, you haven't got proof, it's an aneurysm. Uh And, and it's always useful and it, even if you image it, OK, you have anatomical considerations to do with the aneurysm, you can plot, plot what sort of intervention you do. Yeah. So always trying to get imaging. Um And nowadays, I think most of the mantra is that even if they are slightly hypertensive, you think you can squeeze them through a scan and just do it. Ok. Um, and CT s the, the one for choice, right? So, um important topic for you guys. Er AAA is technically a um, an aneurysm. It's technically an aneurysm when it comes 50% or more uh of the vessel diameter. Ok. So abdominal aorta is normally two centimeters. So therefore, it's aneurys, not free men get it. Um, and uh that is the major risk factor it seems. And, er, age fsis, smoking and hypertension, the usual vascular risk factors. Ok. Next, uh uh looks like, please. Oh, and can you see the next slide on symptoms? Yeah. Uh So, um, aneurysms are generally asymptomatic, however, they become symptomatic when they rupture. Ok. So you get back pain, uh, a dawn's distension, you might get a bit of embolization down the legs and that might have been, you know, they might have had calf pain for see all this. Ok. And fairly rarely seen for where they do ha happen. And you get he down shock and collapse. Ok. Next. Uh so um you guys need to have an idea about screening. OK. Cos it does come up. Um So men over 65 3 to 34.4 centimeters to get a yearly ultrasound and sort of come off the screening program uh and 4.5 to 5.4 again, a free monthly ultrasound after 5.5. And that's at the point where um it's beneficial to do a repair because your annual rupture rate is higher than your death from um having an intervention. Ok. So that's what we deem as the uh the cut off and that's 5.5. Uh and I did have in my exam at what uh at what cut off do you notify the T VLA and it's 6.5 centimeters next. Uh So as I mentioned, all vascular patients, best medical therapy exercise. Ok. That's the non non um operative management. Next. Uh an intervention. Um So you can consider a patient for er, ok. Um which is the endovascular stenting? Ok. So you know, you, you ch wires er, through the e in the groin, shove the wires up and then you put stents in. Ok. Er, and you treat that for anyone over the threshold or it's rapidly expanding or it's symptomatic. The other thing you can add in there is if, if it's ruptured. Ok. Um Open repair is actually, I think personally the better repair. But, um, that's because it's more definitive. You actually put stitches in there. However, it's really high risk surgery. It's 3 to 5% mortality. Er, and you get the complications of xylia, uh, you know, bowel ischemia, um, renal failure and it, it does come with this package. Uh, and so these patients need to undergo risk stratification. Ok. Next, uh, just an idea about endoleaks or endoleaks is, uh, meaning that you basically haven't repaired the aorta uh the aneurysm and there's still blood going around it. Uh So type one is the one that you're most worried about. OK. So it's high pressure leaks, er, or blood and that's uh either coming in through the proximal end of the a, the stent or um or retrograde by the IX. OK. Er, and that again is something that can come up the MRC S but it doesn't happen too often. OK. Uh So we play um it's a classic child just, just, just have a low threshold for it, especially in men. OK. That come in with back pain, abdo pain and they've got expansor mass. Next, er, management, as I mentioned, this is like teaching you just like eggs if you're um doing your, your MRC S. But this is, you know, you need to do ABCD S er massive hemorrhage protocol, permissive hypertension hypotension. Um I think that came up in my exam actually. Um and then, er, CT angiogram if they're stable now. And then you can consider the options. Ok. Next, er, the reason I put Einstein on here is cos he had a rupture AAA and actually he was one of the, he had one of the first open repairs of the AORTA and they used Sellotape to wrap the aorta. So they used, er, and they thought that would uh reduce his risk of an aneurysm and he still died of a lot of ch, a ex. Uh So, uh this one is a 90 year old and she's got severe er back pain and her BP is 220. And it's to on the beta law, what I'm trying to show here is that she's got a um an aortic dissection. Er and I'll give you the answer because we run out of time. Uh So if you go to the next slide, it's intima and media, next slide. So, as you know, the vessel vessel uh layers, you do need to notice this comes up in the exam is uh intima media and tunica adventitia, the media is the muscular layer, OK. The intima is that that endothelial layer, the smooth layer that prevents blood clots. OK. And uh tunica adventitia is that really tough fibrous tissue er and a a um So an aortic dissection is a, is basically you're, you're separating out those layers, aren't you? So it's between the intima and the media. OK. So the first two layers and they're literally just creating a flap that's opening up and blocking the flow next. Uh so, dissection, um you need to know. Um Basically, the main thing is is that they're really tachycardic. It's like um they're really hypertensive, they've got back pain. Uh and they've got differences in their pulses uh typically. OK. And uh if you go to the next one, uh so you need to know, get, get an idea about type eight IB er in the Stanford Cup classification. Easy way to remember it is type B starts after the er, left Subclavian archery. OK. That's all you need to say. Type B after subclan archery type A are the ones that people typically die of. Um Next, that's Stanford classification. Er, imaging choice is CT angiogram guys. Just, just, just get it, it's easy and it's the only one that's gonna give you good imaging for the next um next uh management. Er, so um get the BP under control, especially for type BS, send them to itu. Er, and then, er, you might have to consider um some sort of intervention type A s are classically treated with um surgical intervention and that's usually cardiothoracic actually. Uh next, er Michael DeBakey is the father of vascular surgery. He actually had a uh a Stanford type a dissection and apparently when they told him he had a Stanford type A, he said no, actually I had a DeBakey type one, because he has the name of classification. Er, he actually had a type, a dissection, er, and, er, went into a coma and because he owned a hospital, um, the, er, the ethics Boards decided that, that he needed to have the operation to survive and he saw for five years and continued to work, er, up until the age of like 97. Which is crazy. Anyways, that's, er, that's just, just a bit of history next. Um, and one of the things I saw today, uh just, just appreciate pseudoaneurysm guys, typically, what happens is that you do some sort of operation around, around the radial archery, for example, in a colony angiogram and you damage the vessel wall and it creates a, what we call pseudoaneurysm. OK. So that's a false aneurysm. Uh And um typically you need to get a duplex on that, especially in the wrist, OK? Or CT in the groin uh and just have a low threshold if they have something like a, um, a, you know, a common angiogram or uh an outline. But in um, and basically come in pain, swelling. Uh and sometimes you get lots of bruising. OK. Next. And that's just a picture and that's a classic one, isn't it? It's, er, you get damage pretty much through all the vessel layers, including, er, and you get the adventitia that bulges out and um, and helps, er, keeps the blood in and sometimes it can rupture. OK. Next. Uh And so basically that comes to the end of the talk and I do apologize. There was quite a lot and I really brushed through that. Um, but there are a few things that you need to know about for MRC S uh so venous disease. Uh I haven't really covered for you guys. Um, so that's your varicose veins. Ok. And your DVTs, er, Phlegmasia, um I haven't covered, that comes up, that comes up every now and again, acute aortic system probably doesn't um utilize compartment syndrome. Ok. That comes up often enough. Er, and for us outlet um is not too common thankfully, but it does occur. Pl still, I don't think I've seen it come up. Um and uh vascular access uh does it can come up in the MRC S? And it did come up in um one of my scenarios. Ok. Uh So top steps is learn the anatomy, um practice your question banks, learn your anatomy, practice, practice, practice and find a study buddy. Ok. Um Especially for heartbeat. You've just gotta get used to grilling each other. That's it. Ok. Thank you kit. That was really helpful. I feel like I learned loads as well. Um because I didn't know that you had to use um the other classification and not usually the six PS because that's where we get put in. Uh Yeah, if you, if you learn the six P, it just gives you a basic understanding, but it does not help you at all in terms of managing the patients and, uh, and also just communicating with a vascular surgeon as well. Yeah, like it, it's going forward is what we use on a daily basis and it's really quick and easy. Uh, and if you understand it, then you'll be able to answer the questions in the MRC S as long as, you know, vaguely what sort of pathology you're dealing with. Um, it gives you an idea. Ok. Um, I think I, um, if anyone has any questions, feel free to, um, pop it in the chat, um, it doesn't necessarily need to be a vascular, we can be above the exam itself. Um, otherwise, um, I think that's the end of the session. Um, I, from what I'm hearing, the main thing with the exam is, is mostly questions about anatomy as opposed to pathologies. Um, I think for part A definitely, er, for part B, you, you, it can be quite varied. Um, and, um, I think I had two stations on macular for mine. Ok. Ok. I think if no one has any questions then I think that that'll probably bring us to the end. Um, if people want to fill in the feedback form, um, it'll be helpful to get the feedback, how the session was and any, um, suggestions you have for future ones. Um, also if you fill it in then if you're happy, um, we can send the slides out as well then, um, Yeah, thanks. Kit. Thank you. Have a good evening. Thank you. Just gonna end the session now.