Fellowship of the Royal College of Surgeons (FRCS) Vascular Surgery Syllabus

Vascular Surgery syllabus — full chapter and topic list

Expand any chapter to see its topics and sub-topics. This is the whole examinable outline for Vascular Surgery in Fellowship of the Royal College of Surgeons (FRCS), not a summary of it.

1. 1

   Arterial Occlusive Disease

   5 topics

   • Chronic limb-threatening ischaemia
     • Assessment and ABPI
     • Endovascular and open revascularisation
     • Amputation indications and levels
   • Intermittent claudication management
   • Acute limb ischaemia
     • Embolic versus thrombotic causes
     • Embolectomy and thrombolysis
   • Carotid artery disease and stroke prevention
   • Mesenteric and renal artery disease
2. 2

   Aneurysmal Disease

   4 topics

   • Abdominal aortic aneurysm
     • Screening and surveillance
     • Open versus endovascular repair (EVAR)
     • Ruptured AAA management
   • Thoracic and thoracoabdominal aneurysms
   • Peripheral and visceral aneurysms
   • Aortic dissection
3. 3

   Venous and Lymphatic Disorders

   4 topics

   • Varicose veins and chronic venous insufficiency
     • Assessment and duplex
     • Endovenous and surgical treatment
   • Venous thromboembolism and management
   • Venous ulceration
   • Lymphoedema
4. 4

   Vascular Access and Trauma

   3 topics

   • Dialysis access surgery
     • Arteriovenous fistula creation and complications
   • Vascular trauma management
   • The diabetic foot
     • Neuropathic versus ischaemic ulceration
     • Multidisciplinary foot care

Vascular Surgery flashcards for Fellowship of the Royal College of Surgeons (FRCS)

24 of 60 cards from the Vascular Surgery deck — real questions with worked answers.

1. What is the definition of chronic limb-threatening ischaemia (CLTI)?

   Peripheral arterial disease with ischaemic rest pain (>2 weeks), tissue loss (ulceration or gangrene), or both, generally with an ankle pressure $<50$ mmHg or toe pressure $<30$ mmHg. It represents the end stage of chronic lower-limb ischaemia.

2. How is the Ankle-Brachial Pressure Index (ABPI) calculated and what value defines peripheral arterial disease?

   $\text{ABPI} = \dfrac{\text{highest ankle systolic pressure}}{\text{highest brachial systolic pressure}}$. Normal $0.9\text{–}1.3$; PAD if $<0.9$; CLTI typically $<0.5$; values $>1.3$ suggest incompressible, calcified vessels (e.g. diabetes/renal disease).

3. What is the Fontaine classification of chronic lower-limb ischaemia?

   Stage I: asymptomatic. Stage II: intermittent claudication (IIa $>200$ m, IIb $<200$ m). Stage III: ischaemic rest pain. Stage IV: ulceration or gangrene (tissue loss).

4. What is the Rutherford classification used for and its broad categories?

   Classifies chronic limb ischaemia severity. Categories 0–3 are claudication (mild to severe); category 4 is ischaemic rest pain; categories 5–6 are minor and major tissue loss respectively. Categories 4–6 equate to CLTI.

5. What is the WIfI classification and what does it predict?

   Wound, Ischaemia, foot Infection — each graded 0–3. It stratifies amputation risk and the likely benefit of revascularisation in CLTI, providing a more functional alternative to anatomical staging alone.

6. What is the first-line management of intermittent claudication?

   Best medical therapy and risk-factor modification: supervised exercise programme, smoking cessation, antiplatelet (clopidogrel preferred), high-intensity statin, and control of hypertension and diabetes. Most patients improve without intervention.

7. When is revascularisation indicated for intermittent claudication, and what is the supervised exercise prescription?

   Considered if symptoms are lifestyle-limiting and refractory to a trial of supervised exercise plus risk-factor control. NICE recommends supervised exercise of 2 hours per week for 3 months, exercising to near-maximal claudication pain.

8. Which vasoactive drug may be considered for intermittent claudication when exercise/surgery are unsuitable, and which is contraindicated in heart failure?

   Naftidrofuryl oxalate (a $5\text{-}HT_2$ antagonist) may be offered. Cilostazol, a phosphodiesterase-III inhibitor, is contraindicated in heart failure of any severity.

9. What are the '6 Ps' of acute limb ischaemia?

   Pain, Pallor, Pulselessness, Perishingly cold (Poikilothermia), Paraesthesia, and Paralysis. Sensory loss (paraesthesia) and motor deficit (paralysis) are the late, limb-threatening signs.

10. What is the Rutherford classification of acute limb ischaemia (I, IIa, IIb, III)?

    I: viable, not immediately threatened. IIa: marginally threatened, salvageable if promptly treated (minimal sensory loss, no motor). IIb: immediately threatened, salvageable with immediate revascularisation (sensory loss + mild/moderate motor deficit). III: irreversible — profound sensory/motor loss, requires amputation.

11. How do you distinguish embolic from thrombotic acute limb ischaemia?

    Embolic: sudden onset, no prior claudication, often AF/cardiac source, contralateral pulses normal, no collaterals. Thrombotic: more gradual, prior history of claudication/PAD, diffusely abnormal pulses, established collaterals — often less severe ischaemia.

12. What is the immediate medical management of acute limb ischaemia?

    Immediate IV unfractionated heparin to prevent clot propagation, IV fluids, analgesia, oxygen, and urgent vascular referral. Definitive treatment (embolectomy, thrombolysis, or bypass) depends on Rutherford category and aetiology.

13. What metabolic complication can occur after reperfusion of an acutely ischaemic limb?

    Reperfusion injury: release of $\ce{K+}$ (hyperkalaemia), myoglobin (rhabdomyolysis → acute kidney injury), and acidosis, which can cause cardiac arrhythmia. Compartment syndrome may also develop, sometimes requiring fasciotomy.

14. What degree of internal carotid artery stenosis warrants intervention in a symptomatic patient?

    Symptomatic stenosis of $50\text{–}99\%$ (NASCET method) benefits from carotid endarterectomy; benefit is greatest at $70\text{–}99\%$. Surgery should ideally be performed within 2 weeks of the index TIA/stroke event.

15. What is the difference between NASCET and ECST methods of measuring carotid stenosis?

    NASCET measures the residual lumen against the diameter of the normal distal ICA; ECST measures it against the estimated original lumen at the stenosis. ECST gives a higher percentage than NASCET for the same lesion.

16. What is amaurosis fugax and what does it indicate?

    A transient, painless monocular visual loss often described as a 'curtain descending', caused by retinal emboli (typically from carotid atherosclerosis) occluding the central retinal/ophthalmic artery. It is a form of TIA and a marker of stroke risk.

17. What are the main complications of carotid endarterectomy?

    Perioperative stroke/death (~$2\text{–}3\%$), cranial nerve injury (hypoglossal, vagus/recurrent laryngeal, marginal mandibular), bleeding/haematoma causing airway compromise, MI, and hyperperfusion syndrome.

18. Why is carotid endarterectomy generally not offered for asymptomatic stenosis below a threshold, and how is asymptomatic disease usually managed?

    The annual stroke risk from asymptomatic stenosis is low and modern best medical therapy markedly reduces it, so the absolute benefit of surgery is small. Most asymptomatic patients are managed with antiplatelet, statin and risk-factor control; intervention is selective.

19. What is the classic clinical triad of chronic mesenteric ischaemia?

    Postprandial abdominal pain ('intestinal angina'), food fear (sitophobia), and weight loss. It results from atherosclerotic stenosis of two or more of the coeliac, SMA and IMA, with insufficient flow during the postprandial demand.

20. What investigation confirms acute mesenteric ischaemia and what is a key biochemical marker?

    CT angiography of the mesenteric vessels is the investigation of choice. A raised serum lactate with metabolic acidosis and a markedly elevated white cell count suggests bowel infarction; lactate is a late marker.

21. What are the four main causes of acute mesenteric ischaemia?

    (1) SMA embolism (most common, often cardiac/AF source), (2) SMA thrombosis (on pre-existing atheroma), (3) non-occlusive mesenteric ischaemia (low-flow states), and (4) mesenteric venous thrombosis.

22. What is the typical presentation of renal artery stenosis and its commonest cause?

    Resistant or accelerated hypertension, 'flash' pulmonary oedema, and progressive renal impairment (especially after ACE inhibitor/ARB). The commonest cause is atherosclerosis; in younger women, fibromuscular dysplasia.

23. What is the definition of an abdominal aortic aneurysm (AAA)?

    A permanent focal dilatation of the abdominal aorta to $\geq 3$ cm, or more than $1.5\times$ the expected normal diameter. Most are infrarenal and true aneurysms involving all three vessel-wall layers.

24. What are the UK threshold diameters for elective AAA repair?

    Repair is generally offered when the aneurysm is $\geq 5.5$ cm in diameter, expands by $>1$ cm per year, or becomes symptomatic. Below these thresholds the rupture risk is lower than the operative risk.

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