Review of Critical Care Medicine

Commonest cause of A-V fistulae is – (AI 88)
a) Congenital b) Traumatic
c) Surgical creation d) Tumour erosion

Congenital A-V fistulas in the thigh will be associated with all except – (PGI 89)
a)Increased cardiac output
b)Increased skin tempreture
c)Gigantism of limb
d)Superficial venous engorgement

Continuous murmur is not found in- (AIIMS 89)
a)PDA
b)Systemic A-V fistula
c)Rupture of sinus of valsalva
d)Double outlet right ventricle

AV fistula leads to all except – (AIIMS 98)
a)Sinus tachycardia
b)Increased preload
c)Cardiac arrythm ias
d)Increased cardiac output

AV fistula causes – (PGI 98)
a) dec Diastolic b) inc Venous return
c) dec Venous congestion d) inc Systolic fillin

Nicoladoni branham sign is – (PG198)
a)Compression cause bradycardia
b)Compression cause tachycardia
c)Hypotension
d)Systolic filling

True regarding AV fistula is – (PGI 02)
a)Leads to cardiac failure
b)Causes local gigantism
c)Can cause ulcers
d)Cause excess bleeding on injury
e)Closes spontaneously

Complications arising out of A – V fistula done for renal failure include the following EXCEPT –
a)Infection (Jipmer 03)
b)Thrombosis
c)High output cardiac failure
d)Necrosis of the distal part

Ans. is ‘d’ i.e., Necrosis of the distal part [Ref Sabiston 161"/e p.1456; Love & Bailey 246/e p.950 ; 23"//e p.23]

Pulsating varicose vein in a young adult is due to-
a)Arteriovenous fistula (AIIMS 92)
b)Sapheno femoral incompetence
c)Deep vein thrombosis
d)Abdominal tumour

In Osler Weber Rendu syndrome A.V. fistulas occur.

The clinical features depend on the location and size of the fistula. Frequently, a pulsatile mass is palpable, and a thrill and bruit lasting throughout systole and diastole are present over the fistula. With longstanding fistulas, clinical manifestations of chronic venous insufficiency, including peripheral edema; large, tortuous varicose veins; and stasis pigmentation become apparent because of the high venous pressure. Evidence of ischemia may occur in the distal portion of the extremity. Skin temperature is higher over the arteriovenous fistula. Large arteriovenous fistulas may result in an increased cardiac output with consequent cardiomegaly and high-output heart failure.

The diagnosis is often evident from the physical examination. Compression of a large arteriovenous fistula may cause reflex slowing of the heart rate ( Nicoladoni -Branham sign).

Physiological effect
The combination of an uncontrolled leak from the high-pressure arterial system and an enhanced venous return and venous pressure results in an increase in pulse rate and cardiac output. The pulse pressure is high if there is a large and persistent shunt. Left ventricular enlargement and, later, cardiac failure occur. A congenital fistula in the young may cause overgrowth of a limb. In the leg, indolent ulcers may result from relative ischaemia below the short circuit.
Clinical signs
Clinically, a pulsatile swelling may be present if the lesion is relatively superficial. On palpation, a thrill is detected and auscultation reveals a buzzing continuous bruit. Dilated veins may be seen, in which there is a rapid blood flow. Pressure on the artery proximal to the fistula causes the   swelling to diminish in size, the thrill and bruit to cease, the pulse rate to fall [known variously as Nicoladoni’s (1875) or Branham’s (1890) sign] and the pulse pressure to return to normal.

AV (arteriovenous) fistulas are recognized as the preferred access method. To create a fistula, a vascular surgeon joins an artery and a vein together through anastomosis. Since this bypasses the capillaries, blood flows rapidly through the fistula. One can feel this by placing one’s finger over a mature fistula. This is called feeling for "thrill" and produces a distinct ‘buzzing’ feeling over the fistula. One can also listen through a stethoscope for the sound of the blood "whooshing" through the fistula, a sound called bruit.

Fistulas are usually created in the nondominant arm and may be situated on the hand (the ‘snuffbox‘ fistula’), the forearm (usually a radiocephalic fistula, or so-called Brescia-Cimino fistula, in which the radial artery is anastomosed to the cephalic vein), or the elbow (usually a brachiocephalic fistula, where the brachial artery is anastomosed to the cephalic vein). A fistula will take a number of weeks to mature, on average perhaps 4–6 weeks. During treatment, two needles are inserted into the fistula, one to draw blood and one to return it.

The advantages of the AV fistula use are lower infection rates, because no foreign material is involved in their formation, higher blood flow rates (which translates to more effective dialysis), and a lower incidence of thrombosis. The complications are few, but if a fistula has a very high blood flow and the vasculature that supplies the rest of the limb is poor, a steal syndrome can occur, where blood entering the limb is drawn into the fistula and returned to the general circulation without entering the limb’s capillaries.

Maximum tourniquet time for the upper limb is –
a) 1/2 hour b) 1 hr (JIPMER 87)
c) 1-1/2 hrs. d) 2 hrs
e) 2-1/2 hrs

Sabiston:-  Tourniquet Application:-       The tourniquet is used to provide a bloodless field so that clear visualization of all structures in the operative field is obtained. Penrose drains, rolled rubber glove fingers, or commercially available tourniquets can be used on digits. Great care must be taken in using any constrictive device on digits because narrow bands cause direct injury to underlying nerves and digital vessels. With the use of an arm tourniquet, the skin beneath the cuff must be protected with several wraps of cast padding. During skin preparation, this area must be kept dry to prevent blistering of the skin under an inflated cuff over moist padding. The cuff selected needs to be as wide as the diameter of the arm. Standard pressures used are 100 to 150 mm Hg greater than systolic blood pressure. The cuff is deflated every 2 hours for 15 to 20 minutes (5 minutes of reperfusion for every 30 minutes of tourniquet time) to revascularize distal tissues and to relieve pressure on nerves locally before reinflating the cuff for more extensive procedures.  Exsanguination of the extremities is performed by wrapping the extremity with a Martin’s bandage in all cases, except those involving infection or tumors. In these latter cases, because of the possibility of embolization by mechanical pressure, exsanguination by bandage wrapping needs to be avoided. Simple elevation of the extremity for a few minutes before tourniquet inflation suffices.

Bailey:-  Tourniquet:-    A bloodless field is essential for accurate surgery. A well-padded tourniquet above the elbow, inflated to 75 mmHg pressure over the systolic blood pressure, is usually satisfac­tory. The time should not exceed 2 hours. An Esmarch bandage or a rubber-tube exsanguinator are effective, but should be avoided for tumour or infection cases lest the pathology is spread systemically. In the finger, a tourniquet can be made by placing a sterile glove on the patient, snipping off the tip and then rolling the glove down to the base of the finger.

Thromboembolism after pelvic surgery is usually from the veins – (A189)
a) iliac b) Calf
c) Femoral d) Pelvic

An obese patient develops acute oedematous lower limb following a Pelvic surgery. Deep vein thrombosis is suspected . The most useful investigation in this case would be – (UPSC 2002)
a) Doppler imaging b) Fibrinogen uptake
c) Venography d) Plethysmography

Which of these is not a risk factor for thromboembolism – (TN 2001)
a)Myocardial infarction
b)Hypertension
c)Estrogen therapy
d)Superficial thrmbophlebitis

Most common cause of death in patients with
Burger’s disease is – (AIIMS 87)
a) Gangrena b) Pulmonary embolism
c) Myocardial infarction d) Carcinoma lung

Which of the following best responds to sympathectomy – (JIPMER 86)
a) Burger’s disease b) Hyperhydrosis
c) Raynaud’s disease d) Acrocyanosis

Intermittent claudication at the level of the hip indicates – (PGI 87)
a)Popliteal artery occlusion
b)Bilateral iliac artery occlusion
c)Common femoral occlusion
d)superficial femoral artery occlusion

The artery commonly involved in cirsoid aneurysm is – (PGI 88)
a) Occipital b) Superficial temporal
c) Internal carotid d) External carotid

Plusating tumours include all except – (PGI 88)
a)Bone sarcoma
b)Osteoclastoma
c)Secondaries from hyper nephromas
d)Secondary from prostate

Preferred material for femoro popliteal bypass –
a) Dacron b) PTFE (PGI 89)
c) Saphenous vein d) Gortex

Prosthetic materials For bypass of the aortoiliac segment the favoured material is Dacron (Fig. 15.21a). Prostheses come in two types: woven and knitted. Woven grafts tend to leak less when first exposed to blood flow during surgery, but newer knitted prostheses may be sealed with gelatin or collagen by the manufacturer and may leak even less than their woven counterparts. In the final analysis, there is probably little to choose between any of the styles of Dacron graft; all achieve satisfactory results. For bypass in the femoropopliteal region, if autogenous long saphenous vein (or other veins such as the short saphenous or arm vein) is not available, PTFE (Fig. 15.21b) or glutaraldehyde-tanned, Dacron-supported, human umbilical vein (Fig. 15.21c) may be employed. In general, any vein used requires a diameter of at least 3.5mm. For profundaplasty, a small piece of vein may be used or, alternatively, PTFE or Dacron. Suture materials for vascular surgery are usually monofilament in nature; polypropylene has been particularly popular. In the aorta it is usual to use 2/0 or 3/0 polypropylene. In the femoral artery at the groin it is usual to use 4/0 or 5/0 polypropylene. Finer sutures, up to 7/0, may be needed further down the limb. PTFE may (alternatively) be stitched using a suture of the same material. PTFE sutures tend to cause less bleeding through stitch holes in the graft substance.

Most common cause of aneurysm of abdominal aorta is – (A196)
a) Trauma b) Atherosclerosis
c) Syphilis d) Cystic medial necrosis

The most common complication of an aortic aneurysm size 8 cm is – (Delhi, PG 96)
a) Rupture b) Intramural thrombosis
c) Embolism d) Calcification

Management of a cause of iliac artery embolism requires – (JIPMER 81, UPSC 86)
a)Embolectomy
b)Injection of vasodilators
c)Hypotensive therapy
d)Sympathectomy

Intermittent claudicatin is caused by – (TN 89)
a)Venous occlusion
b)Arteria insufficiency
c)Nerual compression
d)Muscular dystrophy

Burger’s disease is seen in – (PGI 88)
a) Only male b) Age less than 40
c) Age more than 40 d) Smoker

In the abdomen, aneurysms of the …. commonly occur next only to the aorta …. – (PGI 88)
a)Internal iliac artery
b)External iliac artery
c)Splenic artery
d)Inferior mesentric artery

In extraperitoneal approach, to left sympathectomy the following may be injured –
a) Ureter b) Gonadal vessels
c) A+B d) IVC

Lumbar sympathectomy is indicated in – (TN 90)
a)Intermittent claudication
b)TAO with skin changes
c)Burger’s disease
d)Raynaud’s disease

Commonest site of throboangitis obliterans is –
a) Femoral artery b) Popiteal artery (A190)
c) iliac artery d) Pelvic vessels

Treatment of acute femoral embolus is- (AIIMS 91)
a)Warfarin
b)Heparin
c)Immediate embolectomy
d)Embolectomy after 5 days bed rest

Ganglion which is spared in Lumbar sympathetomy is – (JIPMER 92)
a) Ll b) L2
c) L3 d) L4

Surgical lumbar sympathectomy may be indicated in arterial disease. Surgical or chemical (phenol injection) sympathectomy may be used to treat rest pain or other troublesome sensory symptoms in arterial disease or in causalgia. The segment of the chain including the second and third lumbar ganglia is removed: preservation of the first lumbar ganglion is said to lessen the risk of ejaculatory problems 

Vessels most commonly involved in thrombo angitis obliterans – (AIIMS 92)
a)ilio-femoral
b)Aorto-iliac
c)Femora popliteal
d)Arterior and Posterior tibial

Following are used in treatment of Buergers disease except – (Al 93)
a) Trental b) Anticoagulation
c) Sympathectomy d) Antiplatelets

Buerger’s disease affects all except – (PGI 01)
a) Small arteries b) Small veins
c) Medium -size arteries d) Multiparity
e) First pregnancy after 30 years

Buerger’s disease is associated with – (rGI 02)
a) smoking b) Poor nutrition
c) Alcohol d) Prolonged standing
e) Superficial thrombophlebitis

The most common cause of peripheral limb ischaemia in India is – (AIIMS NOV 05)
a) Trauma b) Altherosclerosis
c) Buerger’s disease d) Takayastu’s disease

A 45-year-old male having a long history of cigarette smoking presented with gangrene of left foot. An amputation of the left foot was done. Representative sections from the specimen revealed presence of arterial thrombus with neutrophilic infiltrate in the arterial wall. The inflammation also extended into the neighbouring veins and nerves. The most probably diagnosis is – (AIIMS 06)
a)Takayasu arteritis
b)Giant cell arteritis
c)Hypersensitivity angiitis
d)Thromboangiitis obliterans

Ans. is ‘d’ i.e., Thromboangiitis obliterans [Ref: Hariison 166/e p. 1487; Schwartz 86/e p. 792]

THROMBOANGIITIS OBLITERANS :- Thromboangiitis obliterans (Buerger’s disease) is an inflammatory occlusive vascular disorder involving small and medium-sized arteries and veins in the distal upper and lower extremities. Cerebral, visceral, and coronary vessels may be affected rarely. This disorder develops most frequently in men <40 years. The prevalence is higher in Asians and individuals of eastern European descent. While the cause of thromboangiitis obliterans is not known, there is a definite relationship to cigarette smoking in patients with this disorder. In the initial stages of thromboangiitis obliterans, polymorphonuclear leukocytes infiltrate the walls of the small and medium-sized arteries and veins. The internal elastic lamina is preserved, and a cellular, inflammatory, thrombus develops in the vascular lumen. As the disease progresses, mononuclear cells, fibroblasts, and giant cells replace the neutrophils. Later stages are characterized by perivascular fibrosis, organized thrombus, and recanalization. The clinical features of thromboangiitis obliterans often include a triad of claudication of the affected extremity, Raynaud’s phenomenon, and migratory superficial vein thrombophlebitis. Claudication is usually confined to the calves and feet or the forearms and hands because this disorder primarily affects distal vessels. In the presence of severe digital ischemia, trophic nail changes, painful ulcerations, and gangrene may develop at the tips of the fingers or toes. The physical examination shows normal brachial and popliteal pulses but reduced or absent radial, ulnar, and/or tibial pulses. Arteriography is helpful in making the diagnosis. Smooth, tapering segmental lesions in the distal vessels are characteristic, as are collateral vessels at sites of vascular occlusion. Proximal atherosclerotic disease is usually absent. The diagnosis can be confirmed by excisional biopsy and pathologic examination of an involved vessel. There is no specific treatment except abstention from tobacco. The prognosis is worse in individuals who continue to smoke, but results are discouraging even in those who do stop smoking. Arterial bypass of the larger vessels may be used in selected instances, as well as local debridement, depending on the symptoms and severity of ischemia. Antibiotics may be useful; anticoagulants and glucocorticoids are not helpful. If these measures fail, amputation may be required.

Lumbar sympathectomy:- Operative method. Using a transverse loin incision, an extraperitoneal approach is used in which the colon and peritoneum, to which the ureter clings, are stripped medially so as to expose the inner border of the psoas muscle .The sympathetic trunk lies on the sides of the bodies of the lumbar vertebrae; on the right side it is overlapped by the vena cava. Lumbar veins are apt to cross the trunk superficially. The sympathetic trunk is divided on the side of the body of the fourth lumbar vertebra. It is then traced upwards to be divided above the large second lumbar ganglion, which is easily recognised by the number of white rami which join it. Care should be taken not to mistake small lymph nodes, lymphatics, the genitofemoral nerve or the occasional tendinous strip of the psoas minor for the sympathetic chain. It is possible to perform the operation via an endoscope after the creation of a suitably expanded retroperitoneal tissue plane. Along with a decline in the recognised indications for sympathectomy there has been a move away from the operative approach in favour of the less hazardous chemical (phenol) sympathectomy.
Chemical method. This is contraindicated in patients taking anticoagulants. Under radiographic fluoroscopic control, with the   patient in the lateral position, local anaesthetic is injected. A long spinal needle is then inserted  to seek the side of the vertebral body and to pass alongside it to reach the lumbar sympathetic chain. After confirming the needle position by injection of contrast agent, approximately 5 ml of phenol in water is injected. This is usually done at two sites: beside the bodies of the second and fourth lumbar vertebrae. Great care is needed to avoid penetrating the aorta, cava or ureter; the plunger of the syringe must always be drawn back before injection to exclude the presence of blood.

In a lumbar sympathectomy the sympathetic chain in its usual position is likely to confused with the – (pal 81, AIIMS 80, 82)

a) Ureter b) Psoas minor
c) Genitofemoral nerve d) Ilioinguinal nerve e) Lymphatics

The commonest cause of aneurysm formation
is – (JIPMER 80, Delhi 89)
a) Gun shot injury b) Syphilis
c) Congenital factors d) Atherosclerosis

Bullet wounds near major blood vessels should
be explored only if- (PGI 81, AMC 85)
a)The extremity is cold
b)The fingers or toes are paralysed
c)The pulse is weakened
d)There in no pulse
e)In all cases regardiess of physical findings

A knitted Dacron artery graft (PGI 99, AIIMS 84)
a)Is not porous
b)Is eventually dissolived by tissue reaction
c)Never gets infected
d)Can be easily incised and the opening resutured

The sequence of symptoms in pulmonary embolism is – (JIPMER 89, DNB 90)
a)Fever, pain, dyspnoea
b)Fever, dyspnoea
c)Dysponea, pain, haemoptysis
d)Dysponea, cough, purulent sputum

A useful through temporary improvement in a patient’s ischaemic foot can be attained by giving intravenously – (PGI 79, Delhi 84)
a) 10% Mannitol b) 10% Dextrose
c) Dextran 40 d) Dextran 100

Diabetic gangrene is due to – (Kerala 94)
a)’schema
b)Increased blood glucose
c)Altered defence by host and neuropathy
d)All of the above

All are true about Embolic Arterial occlusion except-
a)No previous history (JIPMER 95)
b)Muscles are unaffected
c)Pulse is absent
d)Anaesthesia is present

All are true about Raynauds phenomena except-
a)Exposure to cold aggravate (Kerala 95)
b)Spasm of vessels
c)More common is females
d)Atherosclerosis of vessels

The commonest site of iodgement of a pulmonary embolus is in the territory at – (UPSC 95)
a) Rt. lower lobe b) Rt. upper lobe
c) Lt. lower lobe d) Lt. upper lobe

Kaposi sarcoma is commonly seen in – (AMU 95)
a) Upper limbs b) Lower limbs
c) Head and Neck d) Trunk

Which of the following causes meximum bleeding-
a)Partial arterial severing (PGI 95)
b)Complete arterial severing
c)Artery caught between fractured ends of bones
d)Intimal tear

In a 40 years old male thrombus in the common femoral artery is because of – (AIIMS 97)
a)Atheroma
b)Thrombangits obliterans
c)Reynauds disease
d)Abdominal mass

One of the following is not indicated for arterial
leg ulcer – (PGI 96)
a) Debridement b) Elevation of limb
c) Head end of bed is raised d) Low dose aspirin

Not used as graft material in peripheral vascular disease – (PGI 97)
a) Dacron graft b) Vein
c) PTFE d) PVC

The commonest cause of arterio-venous fistula is-
a)Penetrating injury (MP 97)
b)Congenital
c)Neoplasmic invasion of an artery and adjacent vein
d)Aneurysm of the artery eroding a vein

AV fistula leads to all except – (AIIMS 98)
a)Sinus tachycardia
b)Increased preload
c)Cardiac arrythm ias
d)Increased cardiac output

Commonest peripheral aneurysm is – (SCTIMS 98) a) Popliteal b) Femoral
c) Carotid d) iliac

Popliteal aneurysm-All are true except-
a)Presents as a swelling (SCTIMS 98) behind the knee
b)Presents with symptoms due to complication
c)Surgery is indicated in case of complication
d)Uncommon among peripheral aneurysm

Graft used in infra inguinal by pass is 4Jipmer 2K)
a) PTFE b) Dacron
c) Autologous vein d) Autologous artery

True about Erythrocyanosis except — (A.P 96)
a)Affects young girls
b)Cold peripheries
c)Palpable pulses
d)Ulceration & gangrene of fingers

Diabetic gangrene is due to AfE (TN 86)
a)Vasospasm
b)Atherosclerosis
c)Peripheral neuritis
d)Increased sugar in blood

Pseudo aneurysms are most commonly due- (Jipmer a) Atherosclerosis b) Trauma 93)
c) Congenital deficiency d) Infections

Bilateral pulseless disease in upper limbs in caused
by- (PGI 97)
a) Aortoarteritis b) Coarctation of aorta
c) Fibromuscular dysplsia d) Buerger’s disease

Abdominal Aneurysm is characterized by all except – (PGI 2000)
a)Elective surgery complication should be < 5%
b)Emergency surgery complication < 10%
c)Rarely asymptomatic before rupture
d)Bigger the size it is more prone to rupture

Dissection of which artery is seen in pregnancy –
a) Carotid artery b) Aorta (PGI 2000)
c) Coronary A d) Femoral artery

Peripheral arterial occlusion (Sudden onset) is characterized all except – (PGI 2000)
a) Paresthesia b) Rubor
c) Pallor d) Pain

In which one of the following conditions Dactylitis CANNOT be seen- (UPSC 02)
a) Sickle – cell anemia b) Beta thalassemia
c) Congenital syphilis d) Tuberculosis
e) Sarcoidosis

Not seen in sudden onset peripheral arterial occlusion – (Kerala 04)
a) Pain b) Rubor
c) Pallor d) Anesthesia

Drug used for Burger’s disease – (MAHE 05)
a) Xanthinol micotinate b) Propranolol
c) GTN d) All the above

Pseudoarterial aneurysm in drug abuser’s seen in -a) Radial b) Brachial (PGI June 05)
c) Femoral d) Carotid
e) Pedal

Syndrome of internal iliac artery occlusion manifested by – (PGI June 05)
a)Pain in calf
b)Absent pulse at the dorsalis pedis artery
c)Intermittent claudication
d)Gangrene

The most common cause of peripheral limb ischaemia in India is – (AIIMS NOV 05)
a) Trauma b) Altherosclerosis
c) Buerger’s disease d) Takayastu’s disease

Lumbar sympathectomy is of value in the management of- (AI 05)
a)Intermittent claudication
b)Distal ischaemia affecting the skin of the toes
c)Arteriovenous Fistula
d)Back pain

The most common cause of acquired arteriovenous fistuala is – (Al 06)
a) Bacterial infection b) Fungal infection
c) Blunt trauma d) Penetrating trauma

Etiopathogenesis of diabetic foot include the following except- (UPSC 07)
a)Myelopathy
b)Osteoarthropathy
c)Microangiopathy
d)Infection

Fogarty’s catheter is used for – (UPSC 07)
a)Drainage of urinary bladder
b)Parenteral hyperalimentation
c)Removal of embolus from blood vessels
d)Ureteric catheterisation

Pseudoaneurysms in IV drug abusesrs seen commonly in – (PGI June 07)
a)Brachial artery
b)Radial artery
c)Femoral artery

Treatment of femoral artery naeurysm –
a)Ultrasound guided compression of the neck of aneurysm (PGI June 07)
b)Thrombin injection
c)Bypass graft repair

Venous Disorders:-

Bailey & Love,Gray, Sabiston

Perforators are not present at – (AIIMS Nov 07)
a) Ankle b) Medial calf
c) Distal to calf d) Below inguinal ligament

The superficial veins are in the subcutaneous connective tissue and are interconnected with and ultimately drain into the deep veins. The superficial veins form two major channels-the great saphenous vein and the small saphenous vein. Both veins originate from a dorsal venous arch in the foot:

• the great saphenous vein originates from the medial side of the dorsal venous arch, and then ascends up the medial side of the leg, knee, and thigh to connect with the femoral vein just inferior to the inguinal ligament;
• the small saphenous vein originates from the lateral side of the dorsal venous arch, ascends up the posterior surface of the leg, and then penetrates deep fascia to join the popliteal vein posterior to the knee; proximal to the knee, the popliteal vein becomes the femoral vein.

The superficial and deep veins join at a number of points. The short saphenous vein terminates at the saphenopopliteal junction (SPJ) and the long saphenous vein at the saphenofemoral junction (SFJ) in the groin. Here the flow in the superficial veins joins that in the deep veins. There is, in addition, a number of places in the calf and thigh where flow in the superficial veins may also join that in the deep veins. These is the ankle, calf and thigh communicating or perforating veins (Fig. 16.3). The names of these veins come from their course from the superficial to the deep venous system in which they perforate the deep fascia of the leg. Near the ankle are the Cockett perforating veins, near the knee the Boyd perforators and in the thigh the Hunterian perforating vein. All veins in the upper and lower limbs contain valves every few centimetres which ensure that blood flows towards the heart.

Multiple perforator veins traverse the deep fascia to connect the superficial and deep venous systems. Clinically important perforator veins are the Cockett and Boyd perforators. The Cockett perforator veins drain the medial lower leg and are relatively constant. They connect the posterior arch vein (a tributary to the GSV) and the posterior tibial vein. They may become varicose or incompetent in venous insufficiency states. The Boyd perforator veins connect the GSV to the deep veins approximately 10 cm below the knee and 1 to 2 cm medial to the tibia.

Earliest sign of deep vein thrombosis is(AIIMS 87) a) Calf tenderness b) Rise in temperature c) Swelling of calf muscle d) Homan’s sign

 Injection sclerotherapy for varicose veins is by using – (PGI 88)
a) Phenol b) Absolute alcohol
c) 70% alcohol d) Ethanolamine oleate

Sclerotherapy acts by destroying the venous endothelium. Sclerosing agents include hypertonic saline, sodium tetradecyl sulfate, and polidocanol. Concentrations of 11.7 to 23.4% hypertonic saline, 0.125 to 0.250% sodium tetradecyl sulfate, and 0.5% polidocanol are used for telangiectasias. Larger varicose veins require higher concentrations: 23.4% hypertonic saline, 0.50 to 1% sodium tetradecyl sulfate, and 0.75 to 1.0% polidocanol.⁸³ Elastic bandages are wrapped around the leg after injection and worn continuously for 3 to 5 days to produce apposition of the inflamed vein walls and prevent thrombus formation. After the bandages are removed, elastic compression stockings should be worn for a minimum of 2 weeks. Complications from sclerotherapy include allergic reaction, pigmentation, thrombophlebitis, DVT, and possible skin necrosis.

White leg is due to – (TN 90)
a)Femoral vein thrombosis and lymphatic obstruction
b)Deep femoral vein thrombosis
c)Lymphatic obstruction only
d)None of the above

All of the following are seen in deep vein thrombosis except – (Al 90)
a) Pain b) Discolouration
c) Swelling d) Claudication

The following is the commonest site for venous ulcer- (A IIMS 91)
a)Instep of foot
b)Lower 1/3 leg and ankle
c)Lower 2/3 of leg
d)middle 1/3 of leg

The most important perforator of the Lower limb is between – (ALL INDIA 92 )
a)Long saphenous and posterior tibial vein
b)Short saphenous and posterior tibial vein
c)Short saphenous and popliteal vein
d)Long saphenous and femoral vein

Best method for diagnosis of Deep vein thromvosis is – (JIPMER 92)
a)Doppler examination
b)Plethysmography
c)Contrast phlebography
d)1131 Fibrinogen studies

Commonest complication varicose vein stripping is-
a) Thrombo embolism b) Hemorrhage
c) Ecchymosis d) Infection

Investigation of choice for diagnosis of deep vein thrombosis – (AIIMS 92)
a) Venogram b) Doppler
c) Isotope scan d) Homans sign

Pulsating varicose vein in ayoung adult is due to-
a)Arteriovenous fistula (AIIMS 92)
b)Sapheno femoral incompetence
c)Deep vein thrombosis
d)Abdominal tumour

Which is not used in treatment of Superficial venous thrombosis – (AIIMS 92)
a)Immediate anticoagulation
b)Rest and elevation
c)Analgesics
d)Treat assosiated malignancy

Most common complication of varicose vein stripping is – (JIPMER 78, AIMS 79,92)
a) Infection b) Haemorrhage
c) Ecchymosis d) Thrombo embolism

An operated case of varicose veins has a recurrence rate of – (AIIMS 80, AP 89)
a) About 10% b) About 25%
c) About 50% d) Over 60%

What is acceptable in the management of femoral vein thrombosis – (AIIMS81, PGI 86)
a)Bed rest and spiral elastic bandages
b)A venogram
c)Thrombectomy
d)Embolectomy
e)A mobin udin umbrella inserted into the vein

Operative Venous Thrombectomy

In patients with acute iliofemoral DVT, surgical therapy is generally reserved for patients who worsen with anticoagulation therapy and those with phlegmasia cerulea dolens and impending venous gangrene. If the patient has phlegmasia cerulea dolens, a fasciotomy of the calf compartments is first performed. In iliofemoral DVT, a longitudinal venotomy is made in the common femoral vein and a venous balloon embolectomy catheter is passed through the thrombus into the IVC and pulled back several times until no further thrombus can be extracted. The distal thrombus in the leg is removed by manual pressure beginning in the foot

Operations for varicose veins are best accomplished by – (PGI 81, AIIMS 84, 86)
a)Stripping
b)Multiple subcutaneos ligatures
c)Subfascial ligatures
d)Division and ligation at the superficial venous system

A 60-years old male has been operated for carcinoma of caecum and right hemicolectomyhas been done. On the fourth post – oprative day, the patient develops fever and pain in the legs. The most important clinical entity one should lookfor is – (UPSC 96)
a)Urinary tract infection
b)Intravenous line infection
c)Chest infection
d)Deep vein thrombosis

All of following may be predisposing factors for deep vein thrombosis except – (AIIMS 95)
a) Oral contrceptives b) Nephrotic syndrome
c) Sickle cell anemia d) Thrombocytosis

The duration of heparin therapy in deep vein thrombosis is – (CUPGEE 96)
a) 7 – 10 days b) 15-20 days
c) 3-4 days d) 1 month

Cocket & Dodd’s operation is for (AP 96)
a)Saphenofemoral flush ligation
b)Subfascial ligation
c)Deep vein thrombosis
d)Diabetic foot

In obstruction of inferior vena cava there is -(A197)
a)Prominent thoraco epigastric vein
b)Caput medusa
c)Hemorrhoids
d)Esophageal varices

Most accurate & non invasive method for diagnosing deep vein thrombosis – (JIPMER 98)
a)Doppler duplex
b)Plethesmography
c)Radioactive labelled fibrinogen
d)Angiography

Most common site for venous thrombosis -(JIPMER a) Popliteal vein b) Soleal vein 98)
c) Femoral vein d) Internal iliac vein

Deep vein thrombosis is caused by all except –
a)Lower limb trauma (AIIMS 98)
b)Hip and pelvic surgery
c)Subungual melanoma
d)Cushing’s syndrome

Which of the following test is used to detect perforator incompetence in varicose- (JIPMER 2K)
a) Trendelenberg test b) Fegan’s test- (localise)
c) Morissey’s test d) Homan’s test

The deficiency of all of the following factors increases the incidence of thrombus formation except – (UPSC 2K)
a) Lipoprotein A b) Protein – C
c) Anti – thrombin III d) Protein – S

The most common vein to get thrombosed is the – (AIIMS 99)
a) Long saphenous b) Short saphenous
c) Both d) Posterior tibial

Brodie -Trendlenburg test demonstrates-
a)Mid – thigh perforation (ORRISA 98)
b)Deep vein thrombosis
c)Sapheno — femoral incompetence
d)Calf perforators

An intern was doing saphenous cannulation for a burns patient. Then the patient developed sudden onset of pain along the medial border of the correponding foot. Which nerve must have been accidentally ligated – (AIIMS 2K)
a) Sural nerve b) Deep peroneal nerve
c) Saphenous nerve d) Genicular nerve

In DVT all are seen except (CMC 2001)
a)High fever
b)Increased temperature at site
c)Pain
d)Tenderness

Low Grade Pyrexia is seen not High.

An obese patient develops acute oedematous lower limb following a Pelvic surgery. Deep vein thrombosis is suspected . The most useful investigation in this case would be – (UPSC 2002)
a) Doppler imaging b) Fibrinogen uptake
c) Venography d) Plethysmography

In a patient on anticoagulant therapy, the INR is maintained at – (UPSC 2002)
a)1.5 to 2.5 times the normal
b)2.5 to 3.5 times the normal
c)3.5 to 4.5 times the normal
d)4.5 to 5.5 times the normal

DVT, investigation of choice is – (PGI 97)
a) Doppler b) Plethysmography
c) Venography d) X-ray

In diabetic ulcer, following site is involved-(PGI 97)
a) Heel b) Head of metatarsal
c) Webs d) Tips of toes

For prophylaxis of deep vein thrombosis used is –
a)Warfarin (PGI 97)
b)Heparin
c)Pneumatic shock garment
d)Graded stocking

Effective methods of VTE prophylaxis involve the use of one or more pharmacologic or mechanical modalities. Currently available pharmacologic agents include low-dose UFH, LMWH, synthetic pentasaccharides, and vitamin K antagonists. Mechanical methods include intermittent pneumatic compression (IPC) and graduated compression stockings. Aspirin therapy alone is notadequate for DVT prophylaxis. These prophylaxis methods vary with regard to their efficacy, and the 2008 ACCP Clinical Practice Guidelines stratify their uses according to the patient’s level of risk.

Harrison:-

Schwartz:-

Deep vein thrombosis is best diagnosed by-(PGI 97)
a) Plethysmography b) Duplex ultrasound
c) Radionuclide scan d) CT scan

Which is true regarding Trendelenburg operation – (PGI 01)
a)Sripping of the superficial varicose vein
b)Flush ligation of the superficial varicose vein
c)Ligation of the perforators
d)Ligation of small tributaries at the distal end of superficial varicose vein
e)Ligation of short saphenous vein

Surgical treatment of varicose veins
Surgical treatment of varicose veins is widely used and is effective in removing varicose veins of the main saphenous trunks, as well as their tributaries, down to a size of about 3 mm. Veins smaller than this are best treated by sclero­therapy. Surgical removal of varices is inappropriate where these form a major part of the venous drainage of the limb, for example where a deep vein thrombosis has destroyed the main axial limb veins and the patient relies on the superficial veins. This possibility may be suggested by the patient’s medical history and can be confirmed by duplex ultrasonography or venography.
The main principles of surgical treatment are to ligate the source of the venous reflux (usually the SFJ or the SPJ) and to remove the incompetent saphenous trunks and the associated varices. Sapheno-femoral ligation alone, sometimes referred to as a ‘Trendelenburg procedure’, is associated with a high rate of recurrence of varices. Recent research has shown that it is necessary to remove the long saphenous vein to ensure that as much venous reflux as possible is eliminated. Similarly, communications between the many deep veins in the popliteal fossa and the short saphenous vein mean that some patients develop recurrences in the short saphenous vein due to the re-establishment of reflux from these veins. This problem may be eliminated by removing the short saphenous vein. Removal of the saphenous veins has the disadvantage that both veins are accompanied by a nerve that may be damaged in the vein stripping operation. To avoid nerve injury the long saphenous vein should not be removed below mid-calf level and great care should be exercised in removing the short saphenous vein.

Sensory nerve injury is seen occasionally after removal of varicose veins. The saphenous nerve and its branches accompany the long saphenous vein in the calf, the sural nerve accompanies the short saphenous vein. Damage to the main part of these nerves occurs in about 1 per cent of operations, but small areas of anaesthesia may occur more frequently (in up to 10 per cent of patients). The adoption of inverting stripping techniques and avoidance of stripping the long saphenous vein below mid-calf level have reduced the risk of damage to these nerves. All patients should be warned before surgery that they may experience small areas of numbness and tingling after the operation. These changes are usually reversible but can be quite persistent.

For which of the following venous abnormality is surgery indicated – (PGI 01)
a)Deep vein incompetence with DVT
b)Deep vein incompetence without DVT
c)Varicosity > 3 cm
b) Varicosity < 3 cm
e) Saphenofemoral incompetence

Imp:- Surgical treatment of varicose veins is widely used and is effective in removing varicose veins of the main saphenous trunks, as well as their tributaries, down to a size of about 3 mm. Veins smaller than this are best treated by sclero­therapy. Surgical removal of varices is inappropriate where these form a major part of the venous drainage of the limb, for example where a deep vein thrombosis has destroyed the main axial limb veins and the patient relies on the superficial veins. This possibility may be suggested by the patient’s medical history and can be confirmed by duplex ultrasonography or venography
Saphenous vein ligation and stripping is still the more commonly performed procedure worldwide, and it may be the preferred therapy for patients with GSVs of very large diameter (>2 cm).

Migratory thrombophlebitis is seen most commonly with- (PGI 02)
a) Pancreatic ca b) Testicular ca
c) Gastric ca d) Breast ca
e) Liver ca

Brodie-Tredenlenburg test is positive in – (PGI 02)
a)Sapheno-Femoral incompetence
b)Perforator competence above knee
c)Deep vein incompetence
d)Perforator competence below knee
e)SVT

Varicose veins are seen in – (PGI 02)
a) DVT
b) Superficial venous thrombosis

c)AV fistula
d)Prolonged standing
e)Obesity

Gold standard diagnostic test in varicose veins is
a)Photoplethysmography (Jipmer 03)
b)Duplex imaging
c)Ultrasonography
d)Radio – labeled fibrinogen study

The initial therapy of documented deep venous thrombosis in a post operative case is –
a)Subcutaneous heparin therapy (Karnataka 03)
b)Intravenous heparin therapy
c)Thropmbolytic therapy with urokinase
d)Aspirin therapy

Which one of the following reagents is not used as sclerosant in the treatment of bleeding varices –
a) Ethyl alcohol .b) Ethanolamine oleate (ICS 05)
c) Phenol d) Sodium morrhuate

Site of diabetic for ulcer – (PGI June 05)
a) Medial malleolus b) Lateral malleolus
c) Heel d) Head of metatarsal
e) Head of toes

Harrison:-Approximately 15% of individuals with DM develop a foot ulcer (great toe or MTP areas are most common), and a significant subset will ultimately undergo amputation (14–24% risk with that ulcer or subsequent ulceration). Risk factors for foot ulcers or amputation include: male sex, diabetes >10 years’ duration, peripheral neuropathy, abnormal structure of foot (bony abnormalities, callus, thickened nails), peripheral arterial disease, smoking, history of previous ulcer or amputation, and poor glycemic control. Large callouses are often precursors to or overlie ulcerations.

Which of the following statements is true regarding fat embolism – (AJIMS NOV 05)
a)Most patients with major trauma involving long bones have urinary fat globules
b)All patients with urinary fat globules develop fat embolism
c)Peak incidence of respiratory insufficiency for pulmonary fat embolism is around day 7 after injury
d)Heparin as an anticoagulant decreases mortality and morbidity in fat embolism syndrome

Fat Embolism::- A certain degree of lung dysfunction occurs in all patients after long bone fractures, but clinically significant fat embolism syndrome as such develops in only 10 to 15 percent of these patients. Signs include hypoxia, tachycardia, mental status changes, and petechiae on the conjunctiva, axilla, or upper thorax. Fat globules in the urine are nondiagnostic, but lung infiltrates seen on chest radiograph confirm the presence of lung injury.
The pathophysiology of fat embolism represents capillary endothelial breakdown causing pericapillary hemorrhagic exudates most apparent in the lungs and brain. Pulmonary edema and hypoxemia occur as a result of pulmonary exudates. Hypoxia and areas of cerebral edema may account for the variable neurologic abnormalities seen.
The more severe cases of fat embolism involve fractures of the femur and tibia. Delays in fixation of bones and extensive reaming of the medullary canals contribute to perioperative morbidity and to the severity of fat embolism syndrome. Efforts to surgically correct fractures early and minimize trauma to the bone marrow lessen the degree of fat/bone marrow embolism. Patients with coexisting lung injury are at additional risk of fat embolism. Evidence suggests that fat may pass to the systemic circulation through a patent foramen ovale  or by transpulmonary passage.The chemical composition of the fat may even contribute to this process.  For this reason, it is preferable to minimize pulmonary artery hypertension to reduce transpulmonary passage of fat and limit pulmonary endothelial transudation of fluid.
Treatment includes early recognition, oxygen administration, and judicious fluid management. Corticosteroids in large doses shortly after major trauma have been found to minimize the clinical presentation of fat embolism but are probably not necessary in most cases if oxygen therapy is administered. With appropriate fluid management, adequate ventilation, and the prevention of hypoxemia, outcome is usually excellent.

Which of the following is true about varicocele except ? (Manipal 06)
a)Incompetent valves of testicular vein are responsible for varicocele
b)90% are on the left side
c)Asymptomatic cases require surgery
d)Femoral catheterization with spermatic vien ablation is done in recurrence

Which one of the following is the investigation of choice for suspected deep vein thrombosis of the lower extremity ? (UPSC 07)
a)Radioactive labelled fibrinogen uptake
b)Ascending contrast phlebography
c)D-dimer estimation
d)Duplex ultrasonography

With reference to varicocele, which one of the following is not true of it ? (UPSC 07)
a)Varicosity of cremastric veins
b)Left side is affected usually
c)Feels like a bag of worms
d)May lead to infertility

All are done for a case of deep vein thrombosis except – (MAHE 07)
a) Thrombolytic therapy b) Bandage
c) Heparin d) Bed rest

The practice of having a patient “out of bed into a chair” is one of the most thrombogenic positions that one could order a patient into. Sitting in a chair with the legs in a dependent position causes venous pooling, which in the postoperative milieu could easily be a predisposing factor in the development of thromboembolism

Treatment regimens may include antithrombotic therapy, vena caval interruption, catheter-directed or systemic thrombolytic therapy, and operative thrombectomy

studies, as well as the current ACCP guidelines, suggest that catheter-directed thrombolysis (with adjunctive angioplasty, venous stenting, and pharmacomechanical fragmentation and extraction) may be useful in selected patients with extensive iliofemoral DVT. Patients should have a recent onset of symptoms (<14 days), good functional status, decent life expectancy, and low bleeding risk.

Early in the course of DVT development, venous thrombosis is thought to begin in an area of relative stasis, such as a soleal sinus vein or immediately downstream of the cusps of a venous valve in the axial calf veins. Isolated proximal DVT without tibial vein thrombosis is unusual. Early in the course of a DVT, there may be no or few clinical findings such as pain or swelling. Even extensive DVT may sometimes be present without signs or symptoms. History and physical examination are therefore unreliable in the diagnosis of DVT. In addition, symptoms and signs generally associated with DVT, such as extremity pain and/or swelling, are nonspecific. In large studies, DVT has been found by venography or DUS in ≤50% of patients in whom it was clinically suspected.Objective studies are therefore required to confirm a diagnosis of DVT or to exclude the presence of DVT.

Investigation of Choice-Duplex USG

With major advances in technology of imaging, magnetic resonance venography has come to the forefront of imaging for proximal venous disease. The cost and the issue of patient tolerance due to claustrophobia limit the widespread application, but this is changing. It is a useful test for imaging the iliac veins and the IVC, an area where duplex ultrasound is limited in its usefulness.

Gold standard:-Injection of contrast material into the venous system is obviously and understandably the most accurate method of confirming DVT and the location.Not used usually.

Clinical symptoms may worsen as DVT propagates and involves the major proximal deep veins. Massive DVT that obliterates the major deep venous channel of the extremity with relative sparing of collateral veins causes a condition called phlegmasia alba dolens or white leg .This condition is characterized by pain, pitting edema, and blanching. There is no associated cyanosis. When the thrombosis extends to the collateral veins, massive fluid sequestration and more significant edema ensues, resulting in a condition known as phlegmasia cerulea dolens.Phlegmasia cerulea dolens is preceded by phlegmasia alba dolens in 50 to 60% of patients. The affected extremity in phlegmasia cerulea dolens is extremely painful, edematous, and cyanotic, and arterial insufficiency or compartment syndrome may be present. If the condition is left untreated, venous gangrene can ensue, leading to amputation

SVT

Superficial vein thrombophlebitis (SVT) most commonly occurs in varicose veins but can occur in normal veins. When SVT recurs at variable sites in normal superficial veins, it may signify a hidden visceral malignancy or a systemic disease such as a blood dyscrasia and/or a collagen vascular disease. This condition is known as thrombophlebitis migrans. SVT also frequently occurs as a complication of indwelling catheters, with or without associated extravasation of injected material. Upper extremity vein thrombosis has been reported to occur in 38% of patients with peripherally inserted central catheters; 57% of these developed in the cephalic vein ^. Finally, suppurative SVT may occur in veins with indwelling catheters and may be associated with generalized sepsis.

Rx of SVT by schwartz:- In patients with SVT not within 1 cm of the saphenofemoral junction, treatment consists of compression and administration of an anti-inflammatory medication such as indomethacin. In patients with suppurative SVT, removal of any existing indwelling catheters is mandatory, and excision of the vein may be necessary. If the SVT extends proximally to within 1 cm of the saphenofemoral junction, extension into the common femoral vein is more likely to occur. In these patients, anticoagulation therapy for 6 weeks and GSV ligation appear equally effective in preventing thrombus extension into the deep venous system.

Rx of SVT by Harrisons:- Treatment is primarily supportive. Initially, patients can be placed at bed rest with leg elevation and application of warm compresses. Nonsteroidal anti-inflammatory drugs may provide analgesia but may also obscure clinical evidence of thrombus propagation. If a thrombosis of the greater saphenous vein develops in the thigh and extends toward the saphenofemoral vein junction, it is reasonable to consider anticoagulant therapy to prevent extension of the thrombus into the deep system and a possible pulmonary embolism.

____________________________________________________________________________________

Elastic compression stocking with zippered side to facilitate treatment of chronic venous insufficiency

Compression therapy is most commonly achieved with graduated elastic compression stockings. Graduated elastic compression stockings, initially developed by Conrad Jobst in the 1950s, were made to simulate the gradient of hydrostatic forces exerted by water in a swimming pool. Elastic compression stockings are available in various compositions, strengths, and lengths, and can be customized for a particular patient.

To improve compliance, patients should be instructed to wear their stockings initially only as long as it is easily tolerated and then gradually to increase the amount of time the stockings are worn. Alternatively, patients can be fitted with lower-strength stockings initially followed by introduction of higher-strength stockings over a period of several weeks. Many commercially available devices, such as silk inner toe liners, stockings with zippered sides,and metal fitting aids ,are available to assist patients in applying elastic stockings.

Metal fitting aid to assist in placement of elastic compression stockings

Lymphatic Disorders

Lymphedema is extremity swelling that results from a reduction in lymphatic transport, with resultant pooling of lymph within the interstitial space. It is caused by anatomic problems such as lymphatic hypoplasia, functional insufficiency, or absence of lymphatic valves.

The original classification system, described by Allen, is based on the cause of the lymphedema.

Primary lymphedema is further subdivided into

1. Congenital lymphedema may involve a single lower extremity, multiple limbs, the genitalia, or the face. The edema typically develops before 2 years of age and may be associated with specific hereditary syndromes (Turner syndrome, Milroy syndrome, Klippel-Trénaunay-Weber syndrome).The familial version of congenital lymphedema is known as Milroy’s disease and is inherited as a dominant trait

2.Lymphedema praecox is the most common form of primary lymphedema, accounting for 94% of cases. Lymphedema praecox is far more common in women, with the gender ratio favoring women 10:1. The onset is during childhood or the teenage years, and the swelling involves the foot and calf. The familial version of lymphedema praecox is known as Meige’s disease.

3.Lymphedema tarda is uncommon, accounting for <10% of cases of primary lymphedema. The onset of edema is after 35 years of age.

Secondary lymphedema is far more common than primary lymphedema. Secondary lymphedema develops as a result of lymphatic obstruction or disruption. Axillary node dissection leading to lymphedema of the arm is the most common cause of secondary lymphedema in the United States. Other causes of secondary lymphedema include radiation therapy, trauma, infection, and malignancy. Globally, filariasis (caused by Wuchereria bancrofti, Brugia malayi, and Brugia timori) is the most common cause of secondary lymphedema.In developed countries, the most common causes of secondary lymphedema involve resection or ablation of regional lymph nodes by surgery, radiation therapy, tumor invasion, direct trauma, or less commonly, an infectious process.

Lymphoscintigraphy has emerged as the test of choice in patients with suspected lymphedema.It cannot differentiate between primary and secondary lymphedemas; however, it has a sensitivity of 70% to 90% and a specificity of nearly 100% in differentiating lymphedema from other causes of limb swelling.

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Malignant cell in Hodgkin’s lymphoma is –

a) Reed sternberg cell b) Lymphocytes 85)
c) Histiocyte d) Reticulum cells

Chronic lymphedema predisposes to all except – (PGI 89)
a) Lymphangiosarcoma b) Marjolins ulcer
c) Recurrent infections d) Thickening of skin
In the lower extremity the swelling involves the dorsum of the foot, and the toes have a squared-off appearance. In advanced cases, hyperkeratosis of the skin develops, and fluid weeps from lymph-filled vesicles

Recurrent cellulitis is a common complication of lymphedema. Repeated infection results in further lymphatic damage, worsening existing disease. The clinical presentation of cellulitis ranges from subtle erythema and worsening of edema to a rapidly progressive soft tissue infection with systemic toxicity

Commonest cause of unilareral pedal edema in india is – (A190)
a) Filariasis b) Post traumatic
c) Post irradiation d) Milroy’s disease

All are true about congenital lymphedema except-
a)It is bilateral (AI 91)
b)Involve lower limb
c)Almost always manifests before puberty
d)Acute lymphangitis may occur
All are true?

The commonest cause for lymphedema of upper limb is – (AI 91)
a) Filariasis b) Congenital
c) Neck surgery d) Post mastectomy irradiation

Commonest cause of upper limb lymphedema is –
a) Congenital b) Filariasis (AI 92)
c) Post mastectomy d) Irradiation

???

ANS given in all guides is Filariasis but it should be Post Mastectomy.

Secondary lymphedema, more common than the primary form, usually develops following disruption or obstruction of lymphatic pathways associated with a disease process, or following surgery or radiotherapy. Worldwide, filariasis is the most common cause of secondary lymphedema usually affecting lower limbs.In the United States, the most common secondary lymphedema develops in the upper extremity following axillary lymph node dissection.The incidence varies considerably, depending on the definition of edema. Results of one series of published reports reveal a 14 percent rate of secondary lymphedema in postmastectomy patients who also had undergone irradiation therapy.

Milroys disease is – (JIPMER 92)
a)Edema due to filareasis
b)Post cellulitic lymphedema
c)Congenital lymphedema
d)Lymphedema following surgery

Investigation of choice in detecting small para-aortic lymph node is – (JIPMER 92)
a) Ultra sound scan b) CT scan
c) Lymphangiography d) Arteriography

Not Sure

Contrast lymphangiography. Although few centres now perform this technique, it remains the standard by which all other lymphatic imaging is judged and provides precise information about the anatomy of the lymphatic system. It is now generally reserved for preoperative evaluation of patients with megalymphatics who arc being considered for bypass or fistula ligation.

CT scanning may be useful in identifying pathologic intra-abdominal lymph nodes and masses and in identifying the extent and localization of fluid. Lymphangiography and lymphoscintigraphy may help localize lymph leaks and obstruction; this information is particularly useful for surgical planning.

Milroys disease is lymphedema which is-(AMU 85)
a)Familial
b)Follows filariasis
c)Follows erysipelas
d)A sequele to white leg

Lymphangiography of the leg is performed by –
a)An injection of sodium diatrizoate (Hypaque) subcutaneously between the toes
b)Injecting sodium diatrizoate retrogradely under pressure into a small vein on the dorsum of the foot
c)Dissecting lymphatics through an incision on the dorsum of the foot
d)The use of an infusion pump

Direct-contrast lymphangiography provides the finest details of the lymphatic anatomy. However, it is an invasive study that involves exposure and cannulation of lymphatics at the dorsum of the forefoot, followed by slow injection of contrast medium (ethiodized oil).

Radiologic lymphology is performed by first visualizing the lymphatics by injecting colored dye into the hand or foot. The visualized lymphatic segment is exposed through a small incision and cannulated with a 27- to 30-gauge needle. An oil-based dye is then injected slowly into the lymphatics over several hours. The lymphatic channels and nodes are then visualized with traditional radiographs . Lymphangiography is reserved for patients with lymphangiectasia or lymphatic fistulas, and patients who are being considered for microvascular reconstruction

Under local anaesthesia, a small transverse incision is made in the dorsum of the foot after I ml of isosulphan blue has been injected subcutaneously to identify the lymphatics. Lymphatics are dissected out under loupe magnification and a 30G needle used to infuse lipid-soluble contrast at a rate of I ml in 8 minutes to a maximum of 7 ml (taking about 1 hour) into each limb

Finding the cause of unilateral lympoedema of the leg includes – (JIPMER 78,79, PGI 85)
a)Taking a family history
b)Looking for chronic infection in the foot
c)Looking for early malignant disease of the testis…(Not early.It should have been late metastatic )
d)Looking for filariasis
e)Performing a casoni

Treatment of Acute lymphangitis requires –
a)Antibiotic and rest (JIPMER 81, AMC 84)
b)Immediate lymphangiography
c)Immediate multiple incisions
d)No special treatment

Acute inflammation of the Iymphatics
Acute lymphangitis occurs when a deep or superficial infec­tion, often due to Streptococcus pyogenes or Staphylococcus aureus, spreads to the draining lymphatics and lymph nodes (lymphadenitis) where an abscess may form. Eventually this may progress to bacteraemia or septicaemia. The normal signs of infection (rubor, calor, dolor) are present and a red streak is seen in the skin along the line of the inflamed lymphatic. The part should be rested to reduce lymphatic drainage, elevated to reduce swelling and the patient treated with intravenous antibiotics based upon actual or suspected sensitivities. Failure to improve within 48 hours suggests inappropriate antibiotic therapy, the presence of undrained pus either in the lymph nodes or at the site of primary infection, or the presence of an underlying systemic disorder (malignancy, immunodeficiency). The lymphatic damage caused by acute lymphangitis may lead to recurrent attacks of infection and lymphoedema.

Total dose of radiation in Hodgkins dosease is – (JIPMER 95)
a) 500 -1000 rad b) 1000 – 2000 rad
c) 3000 – 5000 rad d) 5000 – 7000 rad

The most important prognostic indicator of Hodgkin’s lymphoma is – (TN 95)
a)Lymphocytic predominance histology
b)Visceral involvement
c)Hepatic involvement
d)Involvement of spleen

Diagnosis of Hodgkin’s disease is.confirmed by –
a)CT scan (PGI 9 7)
b)Bone marrow biopsy
c)Lymph node biopsy
d)Lymphangiography

Grade I lymphedema means – (JIPMER 2K)
a)Pitting edema upto the ankle
b)Pitting edema upto the knee
c)Non-pitting edema
d)Edema disapearing after overnight rest

Lymphovenous anastomosis is done for – (PGI 97)
a)Filarial lymphoedema
b)Lymphoid cyst
c)Cystic hygroma
d)Malignant lymphoedema

Surgery

A variety of surgical procedures have been devised for the treatment of lymphedema. Surgical treatment involves either excision of extra tissue or anastomosis of a lymphatic vessel to another lymphatic or vein.¹²⁵ In excisional procedures, part or all of the edematous tissue is removed. This does not improve lymphatic drainage but debulks redundant tissue. The microsurgical procedures involve the creation of a lymphaticolymphatic or lymphaticovenous anastomosis, which theoretically improves lymphatic drainage. No long-term follow-up data are available for these interventions, and therefore operative therapy for lymphedema is not well accepted worldwide. Furthermore, operative intervention can further obliterate lymphatic channels, worsening the edema.¹²⁶

Summary

Lymphedema is a chronic condition caused by ineffective lymphatic transport, which results in edema and skin damage. Lymphedema is not curable, but the symptoms can be controlled with a combination of elastic compression stockings, limb elevation, pneumatic compression, and massage. Controlling the edema protects the skin and potentially prevents cellulitis

True about lymphangioma – (PGI 03)
a)It is a malignant tumour
b)It is a congenital sequestration of lymphatic
c)Cystic hygroma is a lymphangioma
d)Laser excision is done
e)Sclerotherapy is commonly done

The most common site of lymphangiosarcoma is
a)Liver (UPSC 04)
b)Spleen
c)Post mastectomy edema of arm
d)Retroperitoenum

Commonest cause of A/C Lymphadenitis in India –
a)Barefoot walking (MAHE 05)
b)TB
c)Staphylococcal skin infection
d)Lymphoma

All of the following soft tissue sarcomas have a propensity for lymphatic spread except –
a)Neurofibrosarcoma (AiimsNov 05)
b)Synovial sarcoma
c)Rhabdomyosarcoma
d)Epitheloid sarcoma

A 40 year old man presented with a flat 1 cm x 1 cm scaly, itchy black mole on the front of thigh. Examination did reveal any inguinal lymphadenopathy. The best course of management would be- (UPSC 07)
a)FNAC of the lesion
b)Incision biopsy
c)Excisional biopsy
d)Wide excision with inguinal lymphadenectomy

In India, what is the most common cause of unilateral lymphoedema of lower limb ? (UPSC 07)
a)Lymphoedema tarda
b)Carcinoma of penis with metastatic nodes
c)Filariasis
d)Tubercular lymphadenopathy