Examiner: 

• "Mr. Doe, a 32-year-old male with no significant past medical history, was involved in a motorcycle accident where he sustained a penetrating injury to his right thigh from a piece of debris. He was brought to the emergency department by EMS, who noted significant bleeding from the wound site and applied a tourniquet 15 minutes ago. Vitals are as follows: HR is 120 BPM, blood pressure 110/70 mmHg, respiratory rate 20 breaths per minute, oxygen saturation 98% on room air. On exam, he is in distress due to pain but is protecting his airway and has bilateral breath sounds. There is a 5 cm laceration on the medial aspect of the mid right thigh with active arterial bleeding from the wound and no distal pulses when the tourniquet is briefly taken down. What is your next step in managing this patient?"

Examinee: 

• "My first priority is to control the bleeding and begin resusciation. I would ensure the tourniquet is securely reapplied to control hemorrhage. I would ensure 2 units of whole blood are started and that the patient has at least two large bore IVs for access. Since he was in an MVC, I would evaluate for other areas of injury with a chest x-ray, FAST, and pelvis x-ray and a careful secondary exam. Given the absence of distal pulses and large amount of bleeding from the wound, I would be concerned about hard signs of vascular injury to the superficial femoral artery and prepare the operating room for at least a vascular repair. I would also get an x-ray of the thigh to look for retained foreign bodies as well as to assess for associated fractures as well. Additionally, I would initiate broad-spectrum antibiotics and tetanus prophylaxis."

Examiner: 

• "The patient gets two 16-gauge IVs in bilateral arms and blood resuscitation improves the blood pressure to 120/80 and the heart rate to 90 beats per minute. The chest x-ray, FAST, and pelvis x-ray are normal. Secondary exam demonstrates no other areas of injury. An x-ray shows no fractures and no retained foreign bodies. The patient is prepped and draped in the operating room, what is your surgical plan?"

Examinee: 

• "As I currently have control with the tourniquet, I would focus on getting local proximal and distal control. I would make an incision along the anterior border of the Sartorius muscle around the area of the wound. I would identify the superficial femoral artery, the site of the injury, and gain proximal and distal control with non-crushing vascular clamps. I would then take down the tourniquet. I would mobilize the vessel to assess if it could be primarily repaired in a tension free manner or if it would need a greater saphenous vein graft. 

Examiner: 

• "There is a 1 cm gap between the two ends of the artery despite mobilization."

Examinee: 

• "I would then use intraoperative ultrasound to identify the better of the ipsilateral and contralateral greater saphenous veins, looking for a vein with a 3mm or greater diameter, with a preference for a contralateral harvest if possible. I would prepare the harvest site. I would then use a 3 Fr Fogarty balloon to ensure any thrombus was cleared from the artery proximally and distally and then instill local heparinized saline. I would debride any damaged ends of the artery, harvest the vein, and perform a reversed interposition vein graft with two end-to-end anastomoses using interrupted 6-0 Prolene sutures, ensuring a tension-free and hemostatic repair. I would confirm adequate blood flow and distal pulses after removing the clamps."

Examiner: 

• "Post-repair, you note good distal pulses and hemostasis. What are your postoperative considerations?"

Examinee: 

• "I would closely monitor the patient for signs of reperfusion injury and compartment syndrome. I would ensure adequate pain management, monitor his hemodynamics, and schedule follow-up vascular imaging to confirm patency of the repair."

Examiner: 

• "During the postoperative period, the patient develops increasing pain and swelling in the right lower leg. On examination, the leg is tense, and the patient has pain on passive stretch of the toes."

Examinee: 

• "The patient is exhibiting signs of compartment syndrome, a surgical emergency. I would emergently take the patient to the operating room. I would make two long incisions in the lower leg: one on the lateral aspect and one on the medial aspect. The lateral incision, made just anterior to the fibula, would release the anterior and lateral compartments with care to protect the superficial peroneal nerve. The medial incision, made posterior to the tibia, would release the superficial and deep posterior compartments, and I would ensure the deep compartment is open by taking the soleus off of the posterior tibia and identifying the neurovascular bundle. I would ensure hemostasis and leave the skin and subcutaneous tissue would be left open to accommodate swelling. I would monitor the patient for any further complications and plan for delayed primary closure or skin grafting once the swelling has subsided."

Examiner: 

• "Ms. Smith, a 68-year-old right-handed female with ESRD stage 4, has been managed conservatively but is now being referred for dialysis access. She reports increased fatigue, decreased urine output, and swelling in her legs. She has a history of multiple abdominal surgeries after a motor vehicle collision and has had previous partial adhesive small bowel obstructions."

Examinee: 

• "Now that she is stage 4, it is appropriate to consider durable and permanent dialysis access. I would want to know how long her nephrologist thinks she has before needing dialysis, as that would determine what type of access she needs. As these patients tend to have several comorbid conditions, I would perform a thorough history and physical, with attention to her cardiovascular and peripheral vascular history, previous central line history, and extremity neurovascular exam. Though I would want to discuss peritoneal dialysis with her, her complex abdominal surgical history and adhesive small bowel obstruction history precludes such." 

Examiner: 

1. "Her nephrologist told her she has 6-12 months before she'll likely need dialysis. She has medically controlled diabetes, hypertension, and hyperlipidemia. She was a previous 10 pack-year smoker but has not smoked for 38 years. She denies any previous heart disease or claudication. She has had previous central lines, all on the right side. On exam, she is well-nourished and in no acute distress. Vitals are as follows: blood pressure 140/85 mmHg, heart rate 75 bpm, respiratory rate 16 breaths per minute, oxygen saturation 98% on room air. The right and left arms have no signs of infection or previous surgical scars, and bilateral radial and ulnar pulses are palpable. Bilateral Allen's tests are normal."

Examinee: 

2. "Based on the timing before dialysis and her history and exam, it seems like she would be a candidate for an AV fistula. Since she is right-handed and has had right sided central lines that could lead to some central venous stenosis, I would recommend a left upper extremity AV fistula. I would want to further assess the inflow and outflow of the left arm prior to surgery, so I would order a duplex evaluation."

Examiner: 

3. "Duplex ultrasound of the left arm evaluation shows a cephalic vein with a diameter of 3.5 mm and a brachial artery with a diameter of 3.2 mm."

Examinee: 

• "As the artery is greater than 2mm and the vein is greater than 3 mm, she has adequate vessel diameters for a brachiocephalic fistula."

Examiner: 

• "Describe the preoperative steps you would take before proceeding with the surgery."

Examinee: 

• "I would ensure the patient is medically optimized for surgery with her primary care provider and nephrologist, including managing her blood pressure and electrolyte levels. Preoperative labs would include a complete blood count, basic metabolic panel, and coagulation profile. Informed consent would be obtained after discussing the procedure, risks, benefits, and alternatives with the patient. Additionally, I would coordinate with anesthesia for regional or local anesthesia planning."

Examiner: 

• "The patient is medically optimized, and anesthesia is ready. Tell me your operative approach."

Examinee: 

• "I would position the patient supine with the left arm extended on an arm board. After administering local anesthesia, I would prep and drape the left arm in a sterile fashion. I would make an incision along the anterior aspect of the left arm overlying the cephalic vein. I would carefully dissect and mobilize the cephalic vein, ensuring adequate length and diameter. Next, I would expose the brachial artery by freeing the bicipital aponeurosis and gently dissecting around it. After achieving proximal and distal control of the brachial artery with vascular clamps, I would create an end-to-side anastomosis between the cephalic vein and the brachial artery using 6-0 Prolene sutures. Throughout the procedure, I would ensure a tension-free and hemostatic connection. Once the anastomosis is complete, I would release the clamps and check for a palpable thrill and audible bruit to confirm patency and check the hand for any signs of arterial insufficiency. Finally, I would close the incisions in layers and apply a sterile dressing."

Examiner: 

• "Assuming the cephalic vein is suitable, and the fistula is successfully created, what are your immediate postoperative considerations?"

Examinee: 

• "Immediate postoperative considerations include monitoring the patient for signs of bleeding, infection, and thrombosis at the surgical site. I would ensure that the patient has adequate pain control and that the arm is elevated to reduce swelling. The patient should be observed for any signs of distal ischemia, such as pain, pallor, or decreased pulses in the hand. Additionally, I would educate the patient on the importance of keeping the arm clean and dry, and to avoid any heavy lifting or trauma to the arm. I would schedule a follow-up visit within 1-2 weeks to assess the fistula for maturation and to monitor for any complications."

Examiner: 

• "Two weeks postoperatively, the patient returns for follow-up. On examination, there is a strong thrill and bruit, but the patient reports pain and coolness in her hand that is provoked with movement."

Examinee: 

• "I am concerned about steal syndrome. This occurs when the fistula diverts too much blood from the hand, leading to ischemic symptoms. My management plan would involve confirming the diagnosis with duplex ultrasound with additional fistula compression to assess blood flow. If confirmed, I would perform a distal revascularization with interval ligation (DRIL) procedure."

Examiner: 

• "Describe the DRIL procedure."

Examinee: 

• "The procedure involves creating a bypass graft from a point on the artery above the fistula to a point below the fistula, ensuring adequate blood flow to the distal limb. The artery just distal to the fistula is then ligated to prevent the high flow from the fistula from stealing blood away from the hand."

Examiner: 

• "Assuming the hand ischemia is managed and the fistula remains functional, what are the criteria you would use to determine if the fistula is mature and ready for use?"

Examinee: 

• "The rule of 6s is used to assess fistula maturation. The fistula should be at least 6 mm in diameter, the flow rate should be at least 600 mL/min, and the fistula should be no more than 6 mm below the skin surface. Additionally, the fistula should have a continuous thrill upon palpation and should be suitable for cannulation within 6 weeks of creation."

Examiner: 

• "Mr. Brown, a 74-year-old male with a history of hypertension, hyperlipidemia, and a 40-pack year smoking history (quit 15 years ago), reports experiencing episodes of transient vision loss in his right eye over the past month. Each episode lasts a few minutes and resolves spontaneously. He was referred to the vascular surgery clinic after his primary care physician detected a right-sided carotid bruit during a routine examination."

Examinee: 

• "His vision loss sounds like amaurosis fugax. With a carotid bruit and a history of hypertension, hyperlipidemia, and smoking, this presentation is concerning for symptomatic carotid stenosis. Less likely these are atypical migraines or true orbital pathology. I would take a focused history and exam, focusing on his central and peripheral vascular disease factors, surgical history, and medications, and perform a full neurovascular exam."

Examiner: 

• "His history is as otherwise stated, and he has never had surgery before. He currently takes Losartan, 81 mg of aspirin daily, and is on a high-intensity statin. His vital signs are as follow: Blood pressure 135/80 mmHg, heart rate 70 bpm, respiratory rate 16 breaths per minute, oxygen saturation 98% on room air. He has normal heart sounds but has a carotid bruit heard over the right carotid artery. The rest of his vascular exam is unremarkable except for some decreased hair over his lower legs and biphasic DP and PT pulses."

Examinee:

• "This appears to be congruent with peripheral vascular disease and symptomatic carotid stenosis. Since the patient is symptomatic and I am considering operative intervention, I would want to evaluate the cerebrovascular system with a duplex ultrasound to quantify any stenosis as well a CTA to evaluate the stenosis and the circle of Willis. Since I am referring the patient for studies, I would also ensure the patient is working with his PCP to ensure these symptoms are not cardiac in nature and to perform preoperative risk stratification."

Examiner:

• "His EKG and ECHO show some left ventricular hypertrophy, but no other pathology such as thrombus. He is able to walk up two flights of stairs without chest pain or shortness of breath, and his PCP does not order further cardiac testing. His carotid duplex ultrasound showed severe stenosis (>70%) of the right internal carotid artery with peak systolic velocity of 300 cm/s and significant plaque burden. A CT angiogram confirms severe stenosis of the right ICA with no evidence of significant contralateral disease or intracranial pathology."

Examinee: 

• "Given Mr. Brown's symptomatic presentation with amaurosis fugax and significant stenosis of the right internal carotid artery confirmed on two testes, I would recommend carotid endarterectomy with patch angioplasty to prevent future ischemic events."

Examiner: 

• "Describe the steps involved in performing a carotid endarterectomy with patch angioplasty."

Examinee: 

• "I would position the patient supine with the head turned away from the operative side. After administering general anesthesia, I would make an incision along the anterior border of the sternocleidomastoid muscle, ligate the facial vein, and expose the common carotid artery (CCA), internal carotid artery (ICA), and external carotid artery (ECA). I would heparinize the patient and then apply vessel loops for proximal and distal control in the following order with care to protect the hypoglossal and Vagus nerves: I would start with the ICA, then the CCA, and then finally clamp the ECA. I would perform an arteriotomy along the length of the stenotic segment and place a shunt from the CCA to the ICA. I would carefully remove the atherosclerotic plaque, ensuring a smooth intimal surface and a tapering end. If there were any intimal flaps, I would secure them with 6-0 prolene tacking sutures. I would then suture a Bovine pericardium patch to the arteriotomy site using 6-0 Prolene sutures to widen the artery and reduce the risk of restenosis. Prior to my final sutures, I would remove the shunt and flush the vessels by releasing the ECA, then the CCA, and finally the ICA. After ensuring a tension-free and hemostatic anastomosis, I would confirm patency and adequate blood flow through the patch with Doppler ultrasound. Finally, I would close the incision in layers and apply a sterile dressing and perform a neurological exam prior to rolling out of the operating room."

Examiner: 

• "What are your key postoperative considerations for Mr. Brown?"

Examinee: 

• "I would closely monitor Mr. Brown for signs of complications such as bleeding, cranial nerve injury, stroke, or myocardial infarction. Ensuring adequate perfusion to the brain and monitoring for any neurological changes is crucial. I would manage his blood pressure meticulously to avoid hyperperfusion syndrome and continue his aspirin and statin therapy. Follow-up duplex ultrasound would be scheduled to assess the patency of the repair and to monitor for any signs of restenosis. Additionally, patient education on recognizing symptoms of stroke or TIA is essential, along with lifestyle modifications to reduce cardiovascular risk."