Vascular Access Techniques — MCQs
Which one of the following is not a wound closure technique?
Which of the following is not true regarding the surgical treatment of varicose veins?
Shirodkar cerclage may be associated with all complications except:
The best material for below-inguinal arterial graft is:
Allen's test is for the patency of:
Deep vein thrombosis most commonly occurs at which site?
According to the Spetzler-Martin grading system for arteriovenous malformations, which of the following scores corresponds to an arteriovenous malformation of size 3-6 cm with deep venous drainage and location near the internal capsule?
In which of the following locations should the incision be made for the saphenous cutdown procedure in an obese patient with no visible or palpable superficial veins, requiring intravenous fluids in shock?
In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)
What is the most common complication of TIPS (Transjugular Intrahepatic Portosystemic Shunt) procedure?
Vascular Access Techniques Indian Medical PG Practice Questions and MCQs
Question 1: Which one of the following is not a wound closure technique?
- A. Composite graft
- B. Vascular graft (Correct Answer)
- C. Partial thickness skin graft
- D. Musculocutaneous flap
Explanation: ***Vascular graft*** - A **vascular graft** is a tube-like structure used to bypass or replace a diseased or damaged blood vessel. - Its primary purpose is to **restore blood flow**, not to close a wound on the body surface or replace missing tissue. *Partial thickness skin graft* - A **partial thickness skin graft** involves transplanting the epidermis and a portion of the dermis to cover a wound. - This is a common and effective technique for **wound closure**, particularly for large surface area wounds or burns. *Composite graft* - A **composite graft** is a graft consisting of multiple tissue types, such as skin, cartilage, and fat, often used for reconstruction. - This is a direct method of **wound closure** and tissue replacement, particularly in areas requiring structural support and soft tissue coverage. *Musculocutaneous flap* - A **musculocutaneous flap** involves the transfer of skin, subcutaneous tissue, and an underlying muscle to cover a wound. - This is a versatile **wound closure technique** that provides robust soft tissue coverage and blood supply to complex defects.
Question 2: Which of the following is not true regarding the surgical treatment of varicose veins?
- A. High ligation is commonly performed
- B. Compression stockings are recommended after surgery
- C. Phlebectomy is used
- D. Sclerotherapy is curative (Correct Answer)
Explanation: ***Sclerotherapy is curative*** - **Sclerotherapy** is a procedure where a solution is injected into varicose veins to cause them to scar and collapse, but it is typically not considered **curative** on its own, especially for larger or recurrent veins. - While effective for smaller veins and spider veins, its role is often **palliative** or adjunctive, and it may require multiple sessions or be combined with other treatments to achieve long-term success. - Modern guidelines prefer endovenous ablation techniques (radiofrequency or laser) for definitive treatment of great saphenous vein incompetence. *High ligation is commonly performed* - **High ligation**, involving the surgical tie-off of the sapheno-femoral junction (SFJ), is a common component of surgical treatment for **varicose veins** to prevent reflux from the deep venous system into the superficial system. - It aims to eliminate a primary source of **venous hypertension** in the superficial veins and is often combined with stripping of the great saphenous vein. *Compression stockings are recommended after surgery* - **Compression stockings** are routinely recommended after surgical treatment of varicose veins to minimize **postoperative swelling**, reduce pain, and improve venous return. - They also play a role in preventing complications such as **thrombosis** and promoting better long-term outcomes by maintaining vein compression during healing. *Phlebectomy is used* - **Ambulatory phlebectomy** is a surgical technique used to remove varicose veins through small incisions, particularly for superficial, tortuous veins that are not easily treated by other methods. - It is often performed in conjunction with **high ligation** and stripping or as a standalone procedure for localized varicose segments.
Question 3: Shirodkar cerclage may be associated with all complications except:
- A. Enterocele
- B. Ureteral injury
- C. Subacute intestinal obstructions
- D. Paresthesia over inner aspect (Correct Answer)
Explanation: ***Paresthesia over inner aspect*** - Paresthesia over the inner thigh is typically associated with injury to the **femoral nerve** or its branches, or the **obturator nerve**. - While surgery in the pelvic region always carries some nerve injury risk, a Shirodkar sling operation, which is a cervical cerclage, is **unlikely to directly cause paresthesia** in this specific distribution. *Enterocele* - An **enterocele** is a type of pelvic organ prolapse where the small bowel descends into the lower pelvic cavity, creating a bulge in the vagina. - The Shirodkar sling procedure involves placing a suture around the cervix, which can alter pelvic anatomy and potentially contribute to the development or worsening of an enterocele, by **changing pressure dynamics** or creating adhesion. *Ureteral injury* - The **ureters** pass close to the cervix as they course into the bladder, especially where the uterosacral ligaments attach. - During the placement of the Shirodkar cervical cerclage, there is a risk of **ligating or damaging the ureters** due to their proximity to the surgical field. *Subacute intestinal obstructions* - Any pelvic surgery, including a Shirodkar sling operation, carries a risk of **adhesion formation**. - These **post-surgical adhesions** can involve segments of the bowel, potentially leading to kinking or narrowing of the intestinal lumen, which can cause symptoms of subacute intestinal obstruction.
Question 4: The best material for below-inguinal arterial graft is:
- A. Saphenous vein graft (upside-down) (Correct Answer)
- B. Cryopreserved vein
- C. Dacron
- D. PTFE
Explanation: ***Saphenous vein graft (upside-down)*** - The **autologous saphenous vein** is the material of choice for below-inguinal arterial bypasses due to its superior patency rates compared to synthetic grafts. - It is often harvested and implanted **'upside-down' (reversed)** to ensure the valves do not obstruct blood flow, or can be used *in situ* after rendering the valves incompetent. - Five-year patency rates for autologous vein grafts exceed 70-80% for femoropopliteal bypasses. *Cryopreserved vein* - **Cryopreserved saphenous vein allografts** are an alternative when autologous vein is unavailable or inadequate. - However, they have **significantly lower patency rates** compared to autologous vein grafts due to immunological responses and structural degradation. - They are generally reserved for salvage situations or as a bridge in limb-threatening ischemia. *Dacron* - **Dacron (polyethylene terephthalate)** grafts are primarily used for large-diameter arterial replacements, such as in **aortic bypasses**, and are less suitable for smaller, high-resistance vessels below the inguinal ligament. - They tend to have higher rates of **thrombosis** and infection when used in infra-inguinal positions compared to vein grafts. *PTFE* - **Polytetrafluoroethylene (PTFE)** grafts have lower patency rates than autologous vein grafts, particularly in smaller diameter vessels and below-knee positions, due to issues like **intimal hyperplasia** at the anastomoses. - While suitable when autologous vein is unavailable, it is generally considered inferior for below-inguinal peripheral arterial disease, with 3-year patency rates around 50-60% for above-knee and 30-40% for below-knee positions.
Question 5: Allen's test is for the patency of:
- A. Vertebral artery
- B. Subclavian artery
- C. Radial and ulnar artery (Correct Answer)
- D. Internal carotid artery
Explanation: ***Radial and ulnar artery*** - **Allen's test** assesses the patency of the **radial** and **ulnar arteries** and the adequacy of collateral circulation to the hand. - It involves occluding both arteries and then releasing one to see if the hand reperfuses, indicating good blood flow. *Vertebral artery* - The **vertebral arteries** supply blood to the posterior part of the brain and are typically assessed through dynamic neurological exams or imaging studies. - Their patency is not evaluated by **Allen's test**. *Subclavian artery* - The **subclavian arteries** supply blood to the head, neck, and upper limbs; their patency is assessed by palpation of pulses and imaging. - **Allen's test** does not directly evaluate the subclavian artery. *Internal carotid artery* - The **internal carotid arteries** supply blood to the anterior and middle parts of the brain. - Their patency is assessed by listening for bruits or through imaging techniques, not **Allen's test**.
Question 6: Deep vein thrombosis most commonly occurs at which site?
- A. Femoral vein (Correct Answer)
- B. Subclavian vein
- C. External jugular vein
- D. Internal jugular vein
Explanation: ***Femoral vein*** - The **femoral vein**, along with the **popliteal** and **iliac veins**, are the most common sites for **deep vein thrombosis (DVT)** in the lower extremities [1]. - Due to their size and the dynamics of blood flow in these regions, they are prone to clot formation, especially in the presence of **Virchow's triad**. *Subclavian vein* - While DVT can occur in the subclavian vein (an **upper extremity DVT**), it is less common than in the lower extremities [1]. - Upper extremity DVTs are often associated with **central venous catheters** or **thoracic outlet syndrome**. *External jugular vein* - **External jugular vein thrombosis** is rare and usually associated with local trauma, infection, or central line placement, not typically primary DVT [1]. - It is a superficial vein and not considered a common site for typical deep vein thrombosis. *Internal jugular vein* - **Internal jugular vein thrombosis** is also uncommon as a primary DVT and often secondary to neck infections, malignancies, or indwelling catheters [1]. - Like the subclavian vein, it's considered an upper extremity DVT site, but less frequent than lower extremity sites.
Question 7: According to the Spetzler-Martin grading system for arteriovenous malformations, which of the following scores corresponds to an arteriovenous malformation of size 3-6 cm with deep venous drainage and location near the internal capsule?
- A. 3
- B. 5
- C. 4 (Correct Answer)
- D. 2
Explanation: ***4*** - This score aligns with the sum of the points assigned for each feature: 2 points for a **size of 3-6 cm**, 1 point for **deep venous drainage**, and 1 point for **location near the internal capsule**. - The Spetzler-Martin grade is calculated by summing points for size (small <3 cm = 1 pt, medium 3-6 cm = 2 pts, large >6 cm = 3 pts), venous drainage (superficial = 0 pts, deep = 1 pt), and eloquence of adjacent brain (non-eloquent = 0 pts, eloquent = 1 pt). *2* - A score of 2 would correspond to, for example, a medium-sized AVM (2 points) with superficial venous drainage (0 points) in a non-eloquent area (0 points), or a small AVM (1 point) with deep venous drainage (1 point) in another non-eloquent area. - This score does not account for all three high-risk factors described in the question (medium size, deep drainage, eloquent location). *3* - A score of 3 could be generated, for instance, by a large AVM (>6 cm = 3 points) with superficial drainage (0 points) in a non-eloquent area (0 points). - It could also be a medium AVM (2 points) with deep venous drainage (1 point) but in a non-eloquent brain region. *5* - A score of 5 would represent an extremely high-risk AVM, such as a large AVM (>6 cm = 3 points) with deep venous drainage (1 point) and an eloquent location (1 point). - This score would exceed the sum calculated from the specific characteristics given in the question (2 + 1 + 1 = 4).
Question 8: In which of the following locations should the incision be made for the saphenous cutdown procedure in an obese patient with no visible or palpable superficial veins, requiring intravenous fluids in shock?
- A. Anterior to the medial malleolus (Correct Answer)
- B. Posterior to the lateral malleolus
- C. Anterior to the lateral malleolus
- D. On the dorsum of the foot
Explanation: ***Anterior to the medial malleolus*** - The **greater saphenous vein** consistently runs anterior, one finger breadth to the medial malleolus, making this a reliable site for incision even when veins are not visible or palpable, particularly in **obese patients** or those in shock. - This location allows for direct access to a relatively large vein, crucial for rapid **intravenous fluid administration** in an emergency. *Posterior to the lateral malleolus* - This location is typically associated with the **small saphenous vein**, which is generally smaller and more variable in its superficial course, making it less dependable for cutdown in an emergent situation. - Incision here carries a higher risk of damaging the **sural nerve**, leading to sensory deficits. *Anterior to the lateral malleolus* - The veins in this region are usually smaller and less surgically significant for a **saphenous cutdown** required for rapid fluid infusion. - Accessing a suitable vein here is often more challenging and time-consuming, especially in an obese patient. *On the dorsum of the foot* - While veins on the **dorsum of the foot** are commonly used for routine IV access, they are smaller and more prone to collapse during shock, making them inadequate for rapid, high-volume fluid resuscitation. - The superficial location also makes them more susceptible to accidental dislodgement during patient movement.
Question 9: In the condition shown below, rib notching is present in which of the following ribs? (AIIMS Nov 2015)
- A. 3rd to 9th ribs (Correct Answer)
- B. 1st to 9th ribs
- C. 11th and 12th ribs
- D. All ribs
Explanation: **3rd to 9th ribs** - The image provided depicts **coarctation of the aorta**, characterized by a narrowing of the aorta, typically distal to the origin of the left subclavian artery. - In coarctation of the aorta, collateral circulation develops through the **intercostal arteries** to bypass the constriction, leading to their enlargement and subsequent erosion of the inferior margins of the **3rd to 9th ribs**, a finding known as "rib notching." *1st to 9th ribs* - While rib notching affects upper ribs, it typically **spares the 1st and 2nd ribs** because the superior intercostal arteries (which supply these ribs) originate directly from the subclavian artery, often proximal to the coarctation, so they do not participate in collateral circulation as significantly. - The pattern of notching is usually more concentrated in the mid-thoracic region. *11th and 12th ribs* - Rib notching from coarctation of the aorta is rarely observed in the **floating ribs** (11th and 12th ribs). - These ribs have a different anatomical relationship with the pleura and typically do not bear the brunt of increased collateral flow from the intercostal arteries in the same way as the higher ribs. *All ribs* - Rib notching is a localized phenomenon reflecting increased blood flow through specific intercostal arteries involved in collateral circulation due to aortic coarctation. - Therefore, it does **not affect all ribs**, and its absence in certain ribs (like the 1st, 2nd, 11th, and 12th) helps differentiate this condition radiologically.
Question 10: What is the most common complication of TIPS (Transjugular Intrahepatic Portosystemic Shunt) procedure?
- A. Heart failure
- B. Hepatic Encephalopathy (Correct Answer)
- C. Thrombosis
- D. Recurrent Variceal bleed
Explanation: **Explanation:** **TIPS (Transjugular Intrahepatic Portosystemic Shunt)** is an artificial channel created between the high-pressure portal vein and the low-pressure hepatic vein to treat complications of portal hypertension. **Why Hepatic Encephalopathy (HE) is the correct answer:** The primary mechanism of TIPS involves bypassing the liver’s filtration system. By creating a shunt, portal blood (rich in ammonia and other neurotoxins derived from the gut) enters the systemic circulation directly without being detoxified by hepatocytes. This leads to **Hepatic Encephalopathy in approximately 25–45% of patients**, making it the most frequent complication post-procedure. **Analysis of Incorrect Options:** * **A. Heart Failure:** While the sudden increase in venous return to the right atrium (preload) can precipitate acute heart failure in patients with underlying cardiac disease, it is far less common than HE. * **C. Thrombosis:** Shunt stenosis or thrombosis was common with bare-metal stents; however, with the modern use of **PTFE-covered stents**, the incidence of thrombosis has significantly decreased. * **D. Recurrent Variceal Bleed:** TIPS is highly effective at decompressing varices. Re-bleeding usually only occurs if the shunt becomes occluded or stenosed, which is a secondary event. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** Refractory variceal bleeding (most common indication) and refractory ascites. * **Absolute Contraindications:** Severe congestive heart failure (Right-sided), polycystic liver disease, and severe active systemic infection/sepsis. * **Technical Goal:** To reduce the **Portosystemic Pressure Gradient (PSG) to <12 mmHg** to prevent re-bleeding. * **Stent Type:** PTFE-covered stents (e.g., VIATORR) are the gold standard to maintain patency.
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