Vascular surgery

As the patient in clinic describes the cramp-like pain that he gets in his calf when he walks, a pain that disappears on resting but which is exac­erbated by walking up hills and necessitates him stopping to look in shop windows when out and about, you will be thinking about questioning him for risk factors for vascular disease. Atherosclerosis is a systemic disease. Identification and early treatment of diabetes, hypercholesterolaemia, hypertension, and provision of antiplatelet agents and smoking cessation therapy will confer important cardio- and cerebroprotective benefits. Acute vascular emergencies requiring an urgent response include the patient with sudden onset, limb-threatening ischaemia; the collapsed patient with a ruptured aortic aneurysm; and the patient in whom haemorrhage or ischaemia comprises part of the picture of complex trauma. Rapid, but thorough examination, appropriate resuscitation, and judicious use of diagnostic imaging will help to underpin urgent manage­ment and interventions necessary to obtain the best outcomes for these patients. Despite increasing reliance on minimally invasive diagnostic modali­ties including duplex Doppler ultrasound, magnetic resonance angiog­raphy, and computed tomography angiography, principles of history taking and good clinical examination remain of paramount importance. Observation to detect nuances of ischaemic trophic changes and skin colour, as well as more overt signs of necrosis, gangrene, and ulceration, complements palpation of pulses, detection of subtle changes in skin temperature, delayed capillary refill, and presence of sensory neuropa­thy. A positive Buerger’s test, with pallor of the foot and venous gutter­ing on leg elevation, and rubor (redness), due to reactive hyperaemia on dependency, may help clinch the diagnosis of critical limb ischaemia when other diagnostic features are equivocal. Careful distinction between features of arterial insufficiency, venous hypertension, and diabetic neuropathy may help to determine aetiol­ogy of a recalcitrant lower limb ulcer and the consequent course of management. In the UK, vascular surgery has recently become an independent surgi­cal specialty. This chapter will test your understanding of signs and symp­toms of vascular disease and will hopefully stimulate your understanding of priorities for investigation and management of the range of conditions comprising this exciting sphere of surgery.