Peripheral Vascular Imaging — MCQs
Deep vein thrombosis post-operatively is diagnosed by:
Claudication due to femoropopliteal incompetence is primarily seen in
Surgery in varicose veins is NOT attempted in the presence of which of the following?
May-Thurner or Cockett syndrome involves:
A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
Which of the following is a risk factor for deep vein thrombosis (DVT)?
The procedure of choice for the evaluation of an aneurysm is:
Which of the following drug causes postural hypotension commonly?
Time of Flight technique is employed in —
The largest component of the total peripheral resistance is due to:
Peripheral Vascular Imaging Indian Medical PG Practice Questions and MCQs
Question 1: Deep vein thrombosis post-operatively is diagnosed by:
- A. Clinically
- B. Ascending venography
- C. USG (Correct Answer)
- D. X-ray
Explanation: ***USG*** - **Duplex ultrasonography** is the preferred and most common imaging modality for diagnosing deep vein thrombosis (DVT) due to its non-invasive nature, accessibility, and high accuracy. - It visualizes the **vein lumen** and assesses **compressibility**, a key diagnostic feature for DVT. *Clinically* - Clinical diagnosis of DVT is unreliable, as symptoms like **leg swelling, pain, and tenderness** are non-specific and can be caused by other conditions. - While clinical suspicion can warrant further investigation, it is **insufficient for definitive diagnosis**. *Ascending venography* - **Ascending venography** was once considered the gold standard but is now rarely used due to its invasive nature, use of ionizing radiation, and potential complications. - It involves injecting **radiocontrast dye** into a foot vein and taking X-rays, making it less practical for routine use compared to ultrasound. *X-ray* - **X-rays do not directly visualize veins** or blood clots and are therefore not useful for diagnosing DVT. - They may be used to rule out other causes of leg pain or swelling, such as **bone fractures** or **arthritis**, but offer no diagnostic value for DVT itself.
Question 2: Claudication due to femoropopliteal incompetence is primarily seen in
- A. Thigh
- B. Calf (Correct Answer)
- C. Buttocks
- D. Feet
Explanation: ***Calf*** - **Femoropopliteal incompetence** refers to insufficiency in the superficial femoral and popliteal arteries. Blockage in these arteries typically results in **claudication** symptoms downstream from the obstruction. - The **calf muscles** receive their blood supply via these arteries and are therefore the primary site of pain due to inadequate blood flow during exertion, manifesting as claudication. *Thigh* - Claudication in the **thigh** is usually associated with more proximal arterial obstructions in the **aortoiliac system** or common femoral artery. - While thigh muscles are located upstream from the calf, pain would indicate a blockage higher up than the femoropopliteal segment. *Buttocks* - **Buttock claudication** points to very proximal arterial disease, specifically involving the **internal iliac arteries** or the distal aorta (**Leriche syndrome**). - This is even further upstream than the femoropopliteal arteries and would involve more significant and widespread circulatory compromise. *Feet* - While the **feet** can experience pain due to arterial insufficiency, particularly with severe disease or at rest, isolated foot claudication is less common. - **Claudication** specifically points to muscle ischemia during activity, and the robust musculature of the calf makes it the primary site when femoropopliteal arteries are involved.
Question 3: Surgery in varicose veins is NOT attempted in the presence of which of the following?
- A. Deep vein thrombosis (Correct Answer)
- B. Multiple incompetent perforators
- C. Varicose veins with leg ulcer
- D. None of the above
Explanation: ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery
Question 4: May-Thurner or Cockett syndrome involves:
- A. Left iliac vein compression (Correct Answer)
- B. Internal iliac artery obstruction
- C. Common iliac artery obstruction
- D. Internal iliac vein obstruction
Explanation: ***Correct: Left iliac vein compression*** - May-Thurner syndrome, also known as Cockett syndrome, specifically describes the **compression of the left common iliac vein** by the overlying right common iliac artery. - This anatomical compression can lead to **venous outflow obstruction**, increasing the risk of deep vein thrombosis (DVT) in the left leg. *Incorrect: Internal iliac artery obstruction* - This condition involves an artery and is unrelated to May-Thurner syndrome, which is a **venous compression disorder**. - Obstruction of the internal iliac artery would typically cause symptoms of **pelvic ischemia** or erectile dysfunction, not venous DVT. *Incorrect: Common iliac artery obstruction* - Obstruction of the common iliac artery is an **arterial occlusion** that would cause peripheral artery disease symptoms in the leg, such as claudication or rest pain. - It does not involve the compression of a vein by an artery, which is characteristic of May-Thurner syndrome. *Incorrect: Internal iliac vein obstruction* - While this is a venous issue, May-Thurner syndrome specifically involves the **common iliac vein**, not the internal iliac vein. - Obstruction of the internal iliac vein would typically present with symptoms related to pelvic venous congestion, distinct from the left lower extremity DVT associated with May-Thurner syndrome.
Question 5: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
- A. Grade I (Mild claudication)
- B. Grade II (Moderate claudication) (Correct Answer)
- C. Grade III (Severe claudication)
- D. Grade IV (Ischemic rest pain)
Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).
Question 6: Which of the following is a risk factor for deep vein thrombosis (DVT)?
- A. Hypertension
- B. Chronic kidney disease
- C. Hyperthyroidism
- D. Prolonged immobility (Correct Answer)
Explanation: Detailed understanding of deep vein thrombosis (DVT) and its risk factors is essential for clinical practice. **Prolonged immobility**, such as during long flights, bed rest, or surgery, significantly increases the risk of DVT due to **venous stasis** [1]. **Reduced blood flow** allows clotting factors to accumulate, promoting the formation of a thrombus. *Hypertension*, while a risk factor for **atherosclerosis** and cardiovascular disease, is **not directly a primary risk factor for DVT**. Its effects on blood vessels are generally distinct from the venous stasis and hypercoagulability mechanisms primarily involved in DVT. *Chronic kidney disease* (CKD) can lead to a **prothrombotic state** due to various factors like endothelial dysfunction and inflammation; specific conditions like Nephrotic syndrome are noted risk factors [1]. However, CKD is not as direct or strong a risk factor for DVT as immobility, and many deaths are related to coexisting medical conditions [1]. *Hyperthyroidism* can cause a **hypercoagulable state**, increasing the risk of both arterial and venous thrombosis, but it is less commonly emphasized as a primary DVT risk factor compared to prolonged immobility.
Question 7: The procedure of choice for the evaluation of an aneurysm is:
- A. Computed tomography (Correct Answer)
- B. Ultrasonography
- C. Magnetic resonance imaging
- D. Angiography
Explanation: ***Computed tomography*** **Computed tomography (CT)**, particularly **CT angiography (CTA)**, is widely considered the procedure of choice for evaluating aneurysms due to its **rapid acquisition**, **high spatial resolution**, and ability to visualize the vessel lumen and surrounding structures. **Key advantages:** - Particularly useful for assessing aneurysm size, morphology, thrombus formation, and rupture - Excellent for both emergent and elective settings - Widely available and fast imaging acquisition - Provides comprehensive anatomical detail *Ultrasonography* **Ultrasonography** is an excellent and cost-effective **screening tool for abdominal aortic aneurysms (AAA)** because it is non-invasive and does not involve radiation. However, its utility is limited for: - Complex aneurysms requiring detailed anatomical information - Less accessible locations (e.g., thoracic, cerebral aneurysms) - **Operator dependence** and **limited field of view** restrict its use as a definitive diagnostic tool *Magnetic resonance imaging* **Magnetic resonance imaging (MRI)** and **magnetic resonance angiography (MRA)** provide excellent soft tissue contrast without ionizing radiation and can accurately evaluate aneurysm morphology and flow characteristics. However, MRI is: - More time-consuming and expensive - May be contraindicated in patients with metallic implants or claustrophobia - Less suitable for initial acute evaluation compared to CT *Angiography* **Angiography**, traditionally a catheter-based invasive procedure, provides detailed images of the vessel lumen and is excellent for evaluating precise anatomy and planning endovascular repair. While it offers highly detailed images, its: - Invasiveness - Exposure to radiation and contrast agents - Potential for complications These factors typically reserve it for **interventional planning** or when non-invasive methods are inconclusive, rather than as the primary diagnostic tool.
Question 8: Which of the following drug causes postural hypotension commonly?
- A. Alpha blocker (Correct Answer)
- B. Angiotensin receptor blockers
- C. Beta blocker
- D. ACE inhibitor
Explanation: ***Alpha blocker*** - **Alpha-1 adrenergic blockers** cause common postural hypotension by blocking **alpha-1 receptors** on vascular smooth muscle, leading to vasodilation and reduced peripheral vascular resistance. - This vasodilation, especially in the upright position, can cause blood to pool in the lower extremities, decreasing venous return to the heart and thus lowering blood pressure. *Angiotensin receptor blockers* - These drugs block the effects of **angiotensin II**, leading to vasodilation and decreased aldosterone secretion, typically causing a more gradual and less pronounced drop in blood pressure. - While they can cause hypotension, **postural hypotension** is less common and usually less severe compared to alpha blockers due to their different mechanism of action and less abrupt vasodilation. *Beta blocker* - **Beta-blockers** primarily reduce heart rate and myocardial contractility, thereby decreasing cardiac output, which can contribute to generalized hypotension. - They do not directly cause significant **vasodilation** in the same manner as alpha-blockers, making postural hypotension less common unless there are other contributing factors. *ACE inhibitor* - **ACE inhibitors** prevent the conversion of angiotensin I to **angiotensin II**, leading to vasodilation and reduced aldosterone. - They can cause hypotension, especially with the first dose or in volume-depleted patients, but **postural hypotension** is typically less frequent and severe than with alpha-blockers.
Question 9: Time of Flight technique is employed in —
- A. Spiral CT
- B. MR imaging (Correct Answer)
- C. Digital radiography
- D. CT angiography
Explanation: ***MR imaging*** - The **Time of Flight (TOF)** technique is a type of **magnetic resonance angiography (MRA)** that exploits the phenomenon of **flow-related enhancement** of fresh, unsaturated blood entering an imaging slice. - It is used to visualize blood flow without the need for an external contrast agent, making it particularly useful for assessing vessels in the brain and neck. *Spiral CT* - **Spiral CT** (helical CT) involves continuous data acquisition as the patient moves through the gantry, creating a spiral path of X-ray projection data. - While it has revolutionised CT angiography, it does not employ the Time of Flight principle, which is specific to MR imaging. *Digital radiography* - **Digital radiography** uses X-rays to create images, which are captured by digital sensors rather than photographic film. - This technique primarily focuses on structural imaging and does not involve the physical principles (like spin physics of protons in a magnetic field) necessary for Time of Flight applications. *CT angiography* - **CT angiography** uses **iodinated contrast material** injected intravenously to visualize blood vessels with high resolution using X-rays. - Unlike Time of Flight MRA, it relies on the contrast enhancement of flowing blood with an exogenous agent, not on the intrinsic properties of blood flow within a magnetic field.
Question 10: The largest component of the total peripheral resistance is due to:
- A. Venules
- B. Arterioles (Correct Answer)
- C. Capillaries
- D. Precapillary sphincters
Explanation: ***Arterioles*** - **Arterioles** are the primary site of **resistance** in the cardiovascular system due to their relatively small diameter and the significant ability of their **smooth muscle** walls to constrict or dilate. - This resistance plays a crucial role in regulating **blood flow** to various organs and contributes to **mean arterial pressure**. *Venules* - **Venules** are primarily involved in collecting blood from capillaries and have relatively low resistance compared to arteries and arterioles. - While they contribute to capacitance, their impact on **total peripheral resistance** is minimal. *Capillaries* - Although **capillaries** have very small diameters, their sheer number in parallel reduces the overall resistance of the capillary bed. - The primary function of capillaries is **exchange** of nutrients and waste, not primarily resistance. *Precapillary sphincters* - **Precapillary sphincters** control blood flow *into* capillaries from arterioles, acting as gates. - While they regulate flow to specific capillary beds, they are not the largest *component* of total systemic resistance; the **arterioles themselves** are.
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