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Common Upper and lower limb vascular (arterial) examination  questions for medical finals, OSCEs and MRCP PACES

Click on the the example questions below to reveal the answers


Question 1: 

What is Buerger’s angle and Buerger’s test?

  • Buerger’s angle:
    • Patient lies flat on couch
    • Check for hip pain
    • Slowly flex the hip, keeping the leg straight
    • Note if the leg turns white and if so, at what angle? This is Buerger’s angle
    • People with a healthy peripheral vasculature don’t have a Buerger’s angle
    • The lower Buerger’s angle, the more severe the peripheral arterial disease; a Buerger’s angle of 20 degrees or less indicates severe peripheral arterial disease
  • Buerger’s test:
    • After finding Buerger’s angle, ask the patient to sit up and swing their legs over the side of the bed
    • Buerger’s test is positive if the leg turns purple, red and painful (reactive hyperaemia – also known as the Tequila sunset sign)


Question 2: 

How do you measure the Ankle-Brachial Pressure Index (ABPI)?

  • Using a Doppler probe
  • Measure systolic BP in both arms (inflate cuff until pulse disappears and note cuff pressure)
  • Measure systolic BP in dorsalis pedis and posterior tibial arteries of one leg (same technique as above)
  • The highest ankle pressure divided by the highest brachial pressure equals the ABPI
  • nmnm


Question 3:

How do you interpret an Ankle-Brachial Pressure Index (ABPI) result?

  • > 1.3 = calcified vessels e.g. diabetes
  • 9-1.2 = normal
  • 8-0.9 = mild peripheral arterial disease
  • 5-0.8 = moderate peripheral arterial disease. Compression bandages for venous disease are contraindicated.
  • <0.5 = critical limb ischaemia


Question 4:

What are the risk factors for peripheral arterial disease?

  • Diabetes mellitus
  • Hypertension
  • Hyperlipidaemia
  • Family history
  • Tobacco Smoking


Question 5:

How can peripheral arterial disease present?

  • Acutely
    • Acute limb ischaemia
    • Acute-on-chronic limb ischaemia
  • Chronic
    • Asymptomatic
    • Intermittent claudication
    • Critical limb ischaemia
  • Incidentally
    • With associated coronary artery disease
    • With associated cerebral vascular disease


Question 6:

What are the features of an acutely ischaemic limb (the 6 ‘P’s) in chronological order?

  • Pain
  • Pallor
  • Pulseless
  • Perishingly cold
  • Paraesthesia
  • Paralysis


Question 7:

What are the causes of acute limb ischaemia?

  • Thrombosis (70%)
  • Emboli (25%)
    • AF
    • Post-MI
    • Prosthetic metallic valves, bypass grafts
    • Aneurysmal
    • Paradoxical embolus (DVT through ASD)
  • Other causes:
    • Trauma
    • Aortic dissection
    • Iatrogenic injury
    • Compartment syndrome
    • Extreme cold
    • Raynaud’s


Question 8:

What is the timeframe for salvaging an acutely ischaemic limb?

  • Six hours or less. After this window limb viability drops off rapidly.


Question 9:

What are the management options for acute limb ischaemia?

  • Thrombotic cause:
    • Urgent CT angiography plus balloon angioplasty/ open surgery
  • Embolic causes
    • Catheter directed thrombolysis plus post- interventional anticoagulation with LMWH
    • Surgical arterial embolectomy plus post-op anticoagulation with LMWH
  • Unsalvageable limb: primary amputation


Question 10:

What are the possible reperfusion injuries that can occur as a result of revascularising an acutely ischaemic limb?

  • Compartment syndrome
    • May perform prophylactic fasciotomy at time of revascularisation to prevent this
  • Rhabdomyolysis
    • Myoglobinuria
    • Acute kidney injury
    • Hyperkalaemia, metabolic acidosis
  • Cardiac stunning
  • Non-cardiogenic pulmonary oedema, ARDS


Question 11:

What is intermittent claudication?

  • Cramping calf/thigh/ buttock pain felt after walking for a given distance (the claudication distance) and relieved by rest
  • Calf claudication suggests femoral disease
  • Buttock pain suggests iliac disease.


Question 12:

What are the management options for intermittent claudication?


  • Education
  • Supervised exercise programme
  • Secondary prevention
    • Healthy diet
    • Regular exercise
    • Weight loss
    • Smoking cessation
    • Aspirin 75mg OD
    • Statin (e.g. atorvastatin 40-80mg ON)
    • HTN treatment
  • Medical
    • Vasodilators (e.g. naftidrofuryl oxalate and cilostazol)
  • Interventional radiology
    • Balloon angioplasty
  • Surgical
    • Bypass grafting
    • Amputation


Question 13:

What is the definition of critical limb ischaemia?

  • Pain at rest associated with the requirement for strong analgesia for at least 2 weeks/ tissue necrosis or gangrene
  • and ABPI <0.5
  • The above indicate end-stage chronic peripheral arterial disease


Question 14:

What are the symptoms of critical limb ischaemia?

  • Burning pain at rest
  • Nocturnal pain that wakes patient from sleep
  • Pain may be relieved by hanging limb over side of bed/ walking on cold floor


Question 15:

How is the patient with critical limb ischaemia managed?

    • ABC approach
    • Analgesia
      • WHO pain ladder, PRN antiemetic and laxative
      • TCA or gabapentin may be used early
      • Consider referral to pain management team
    • Refer to MDT
    • Urgent CT angiography for treatment planning:
      • Conservative (as for intermittent claudication)
      • Interventional radiology
        • Urgent balloon angioplasty
      • Surgery
        • Urgent bypass surgery
        • Amputation