Vascular Surgery Practice Questions

Q: Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?

Young age (< 25 years). The risk of developing Deep Vein Thrombosis (DVT) is governed by **Virchow’s Triad**: endothelial injury, stasis of blood flow, and hypercoagulability. ### Why "Young age (< 25 years)" is the correct answer: Age is a significant independent risk factor for DVT. The incidence of venous thromboembolism (VTE) is extremely low in children and young adults (approximately 1 in 10,000) and increases exponentially with age. This is due to age-related changes such as decreased vessel wall elasticity, increased plasma levels of clotting factors, and higher rates of comorbidities or immobility. Therefore, being under 25 is considered a **protective factor** rather than a risk factor. ### Explanation of Incorrect Options: * **Hip fracture and prolonged immobilization:** These represent two arms of Virchow’s Triad. Surgery/trauma causes endothelial injury, while immobilization leads to venous stasis. Orthopedic surgeries (hip/knee) carry the highest risk of DVT among all surgical procedures. * **Deficiency of Protein C and Protein S:** These are natural anticoagulants that inhibit Factors Va and VIIIa. Their deficiency leads to a state of **hereditary thrombophilia**, significantly increasing the risk of clot formation. * **Factor V Leiden mutation:** This is the **most common inherited cause** of hypercoagulability. It involves a mutation that makes Factor V resistant to inactivation by activated Protein C (APC resistance). ### NEET-PG High-Yield Pearls: * **Most common inherited risk factor for DVT:** Factor V Leiden mutation. * **Most common acquired risk factor for DVT:** Recent surgery or trauma. * **Gold Standard Investigation for DVT:** Contrast Venography (though Duplex Ultrasound is the initial investigation of choice). * **Trousseau’s Sign:** Migratory thrombophlebitis associated with visceral malignancy (most commonly pancreatic cancer).

Q: Allen's test is used to diagnose which condition?

Palmar arch insufficiency. **Explanation:** **Allen’s Test** is a clinical bedside assessment used to evaluate the **patency of the radial and ulnar arteries** and the adequacy of the **dual blood supply to the hand via the palmar arches**. 1. **Why Option B is Correct:** The test is performed by asking the patient to clench their fist while the clinician compresses both the radial and ulnar arteries at the wrist. When the patient opens their hand (which appears blanched), the clinician releases pressure from one artery (usually the ulnar). If the palm flushes (reperfuses) within 5–15 seconds, the arch is patent. If the hand remains pale, it indicates **palmar arch insufficiency** or ulnar artery occlusion. This is mandatory before procedures like **Radial Artery Harvesting** (for CABG) or **Arterial Blood Gas (ABG)** sampling to ensure the hand remains viable if the radial artery is compromised. 2. **Why Other Options are Incorrect:** * **Thoracic Outlet Syndrome (TOS):** Diagnosed using **Adson’s test**, Roos test, or Wright’s maneuver, which assess compression of the neurovascular bundle at the neck/shoulder. * **Superior Vena Cava (SVC) Syndrome:** Characterized by facial puffiness and dilated neck veins; diagnosed via clinical signs (Pemberton’s sign) and CT imaging. * **Coarctation of the Aorta:** Identified by radio-femoral delay and rib notching on X-ray. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen’s Test:** The standard version used today where only one artery is released at a time. * **Normal Refill Time:** Less than 7 seconds is considered normal; 7–15 seconds is equivocal; **>15 seconds is abnormal**. * **Alternative:** If Allen’s test is inconclusive, **Pulse Oximetry** or **Doppler Ultrasound** can be used for more objective assessment.

Q: Superficial thrombophlebitis is seen in which of the following conditions?

Buerger's disease. **Explanation:** **Buerger’s Disease (Thromboangiitis Obliterans - TAO)** is the correct answer because it is a non-atherosclerotic, segmental, inflammatory disease that affects small and medium-sized arteries and veins of the extremities. A classic clinical triad of TAO includes intermittent claudication, Raynaud’s phenomenon, and **migratory superficial thrombophlebitis**. The latter occurs in approximately 40–50% of patients and is characterized by painful, red, nodules along the course of superficial veins. **Analysis of Incorrect Options:** * **AV Fistula:** This is an abnormal communication between an artery and a vein. While it causes venous hypertension and dilated "varicose" veins due to high pressure, it does not typically present with inflammatory thrombophlebitis. * **Raynaud’s Disease:** This is a primary vasospastic disorder triggered by cold or stress. While it causes digital ischemia (pallor, cyanosis, rubor), it involves the digital arteries and does not involve venous inflammation or thrombosis. * **Aneurysm:** An aneurysm is a localized permanent dilation of an artery. Complications include thrombosis (arterial), embolism, or rupture, but not superficial venous inflammation. **High-Yield Clinical Pearls for NEET-PG:** * **Patient Profile:** Almost exclusively seen in young male smokers (usually <45 years). * **Pathology:** Characterized by "highly cellular" thrombi with preserved vessel wall architecture (internal elastic lamina remains intact). * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) are seen due to distal small vessel occlusion. * **Management:** Absolute smoking cessation is the only way to halt disease progression. Sympathectomy may be used for symptomatic relief of vasospasm.

Q: Adson's test is used for determining vascular insufficiency. It is useful in?

Cervical rib. **Explanation:** **Adson’s Test** is a clinical maneuver used to assess for **Thoracic Outlet Syndrome (TOS)**, specifically when caused by a **Cervical rib** or scalene hypertrophy. The test aims to detect compression of the subclavian artery as it passes through the scalene triangle. **Why Cervical Rib is correct:** A cervical rib is a supernumerary rib arising from the C7 vertebra. It narrows the space in the thoracic outlet. During Adson’s test, the patient’s neck is extended and the head is rotated toward the affected side while taking a deep breath. This action further narrows the interscalene space. A **positive test** is indicated by a **marked decrease or disappearance of the radial pulse** on the ipsilateral side, suggesting vascular compression. **Why other options are incorrect:** * **Peripheral Vascular Disease (PVD):** This involves atherosclerotic narrowing of lower limb arteries. Tests like Buerger’s test or Ankle-Brachial Index (ABI) are used here. * **Varicose Veins:** This is a venous pathology of the lower limbs. Clinical tests include the Trendelenburg test, Perthes test, and Fegan’s test. * **AV Fistula:** This is an abnormal communication between an artery and a vein. It is clinically assessed via the **Nicoladoni-Branham sign** (slowing of heart rate upon compressing the artery proximal to the fistula). **High-Yield Clinical Pearls for NEET-PG:** * **Halsted’s Maneuver:** Similar to Adson’s but involves downward traction on the arm and neck extension (used for costoclavicular space compression). * **Roos Test (Elevated Arm Stress Test):** The most sensitive clinical test for TOS; the patient "pumps" their hands with arms abducted and externally rotated. * **Cervical Rib Association:** It is most commonly associated with **neurological symptoms** (wasting of T1 intrinsic hand muscles) rather than purely vascular symptoms.

Q: What is the normal pressure in the superficial venous system of the leg while walking?

30 mmHg. ### Explanation The correct answer is **30 mmHg**. **Underlying Medical Concept:** The venous system of the lower limb relies on the **calf muscle pump** (the "peripheral heart") to return blood against gravity. * **At Rest (Standing):** The venous pressure at the ankle is equivalent to the hydrostatic pressure of a column of blood from the heart to the ankle, which is approximately **80–90 mmHg**. * **During Walking:** As the calf muscles (gastrocnemius and soleus) contract, they squeeze the deep veins, forcing blood upward. The competent valves prevent backflow. This rhythmic pumping action significantly reduces the pressure in the superficial veins. In a healthy individual with competent valves, the ambulatory venous pressure (AVP) drops to approximately **20–30 mmHg**. **Analysis of Options:** * **A. 80 mmHg:** This represents the normal **resting** venous pressure at the ankle while standing still. It is the baseline before the muscle pump is activated. * **B. 60 mmHg & C. 50 mmHg:** These values are seen in patients with **venous insufficiency** or varicose veins. If valves are incompetent, the "drop" in pressure during walking is insufficient, leading to ambulatory venous hypertension. **High-Yield Clinical Pearls for NEET-PG:** 1. **Ambulatory Venous Hypertension:** This is the physiological hallmark of chronic venous insufficiency (CVI). Failure of the pressure to drop below 30 mmHg leads to skin changes and ulceration. 2. **Venous Refill Time:** After walking, the time taken for the pressure to return to resting levels is >20 seconds. A refill time of <20 seconds indicates valvular reflux. 3. **Gold Standard:** While rarely used in routine practice, **direct venous pressure measurement** (needle in a dorsal foot vein) remains the gold standard for assessing venous hemodynamics.

Q: Which of the following statements about primary lymphedema is NOT TRUE?

Lymphangiosarcoma never occurs. Primary lymphedema results from congenital developmental abnormalities of the lymphatic system (aplasia, hypoplasia, or hyperplasia). **Explanation of the Correct Answer:** Option **C** is the incorrect statement because **lymphangiosarcoma can occur** in patients with long-standing lymphedema. This rare, highly aggressive tumor is known as **Stewart-Treves Syndrome**. While most classically associated with post-mastectomy secondary lymphedema, it is a documented (though rare) complication of chronic primary lymphedema as well. **Analysis of Other Options:** * **Option A (Lymphedema Praecox):** This is the most common type of primary lymphedema (approx. 80%). It typically manifests during puberty or pregnancy, with an onset between ages **2 and 35**. * **Option B (Lymphedema Tarda):** This refers to primary lymphedema that manifests later in life, specifically **after age 35**. It is the least common form. * **Option D (Milroy’s Disease):** This is a specific form of **congenital lymphedema** (onset 35 years). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic clinical sign of lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for confirming the diagnosis. * **Treatment:** The mainstay is **Complex Decongestive Therapy (CDT)**; surgery (e.g., Charles procedure) is reserved for refractory cases.

Q: Classification of aortic dissection depends upon?

Level of aorta affected. **Explanation:** Aortic dissection is classified based on the **anatomical location (level) of the intimal tear and the extent of the involvement of the aorta**, rather than the etiology or the volume of the vessel wall affected. This anatomical classification is crucial because it dictates whether the management is a surgical emergency or medical stabilization. The two primary classification systems used are: 1. **Stanford Classification:** * **Type A:** Involves the **ascending aorta** (proximal to the left subclavian artery). These are surgical emergencies. * **Type B:** Involves only the **descending aorta** (distal to the left subclavian artery). These are typically managed medically unless complications arise. 2. **DeBakey Classification:** * **Type I:** Originates in the ascending aorta and extends to the arch/descending aorta. * **Type II:** Confined to the ascending aorta. * **Type III:** Confined to the descending aorta. **Why other options are incorrect:** * **Option A:** While hypertension is the most common *cause*, and connective tissue disorders (like Marfan syndrome) are significant risk factors, they do not define the classification categories. * **Option C:** Classification is binary based on the specific segment involved (ascending vs. descending), not the total percentage of the aortic surface area or length involved. **High-Yield Pearls for NEET-PG:** * **Most common risk factor:** Hypertension. * **Gold standard investigation:** CT Angiography (CTA). * **Initial Management:** "Anti-impulse therapy" using IV Beta-blockers (e.g., Labetalol) to reduce heart rate and BP. * **Chest X-ray finding:** Widened mediastinum (seen in ~80% of cases).

Q: Which of the following is the most preferred graft in Coronary Artery Bypass Grafting (CABG)?

Internal mammary artery. **Explanation:** The **Internal Mammary Artery (IMA)**, specifically the Left Internal Mammary Artery (LIMA), is the gold standard and most preferred graft for CABG, particularly for bypassing the Left Anterior Descending (LAD) artery. **Why IMA is the Correct Answer:** 1. **Superior Patency Rates:** The IMA boasts a 10-year patency rate of >90%, significantly higher than venous grafts. 2. **Biological Resistance:** It is an elastic artery that is relatively resistant to atherosclerosis. It also produces nitric oxide, which promotes vasodilation and inhibits platelet aggregation. 3. **Live Graft:** When used as a pedicled graft, it maintains its own nutrient supply (vasa vasorum) and sympathetic innervation. **Analysis of Incorrect Options:** * **Saphenous Vein (A):** While commonly used for multiple bypasses due to its length and ease of harvesting, it has poor long-term patency (approx. 50-60% at 10 years) due to intimal hyperplasia and graft atherosclerosis. * **Radial Artery (B):** A secondary arterial choice. It is prone to vasospasm and requires preoperative assessment (Allen’s test). While better than veins, it is inferior to the IMA. * **Internal Jugular Vein (D):** This is not used in CABG. Its large caliber and thin walls make it unsuitable for coronary revascularization. **High-Yield Clinical Pearls for NEET-PG:** * **LIMA to LAD** is the single most important factor for improving long-term survival in CABG patients. * **Bilateral IMA (BIMA)** use further improves survival but increases the risk of sternal wound infections, especially in diabetics. * **Reversed Saphenous Vein Graft:** Veins must be "reversed" during grafting so that the valves do not obstruct blood flow.

Q: Which of the following is a clinical feature of intermittent claudication?

Pain in the leg only on exercise. **Explanation:** **Intermittent Claudication** is the hallmark clinical symptom of Peripheral Arterial Disease (PAD). It is defined as a reproducible discomfort (aching, cramping, or fatigue) in a muscle group that is **induced by exercise and relieved by rest.** 1. **Why Option C is Correct:** The underlying pathophysiology is a **demand-supply mismatch.** In patients with arterial stenosis, blood flow is sufficient at rest. However, during exercise, the metabolic demands of the muscles increase. The narrowed arteries cannot provide the necessary oxygenated blood, leading to anaerobic metabolism and the accumulation of lactate and other metabolites, which trigger pain. This pain characteristically disappears within 2–5 minutes of stopping the activity. 2. **Why Other Options are Incorrect:** * **Option A:** "Pain in the leg" is too non-specific; it could be due to venous insufficiency, sciatica, or trauma. * **Option B:** Pain at rest (Rest Pain) indicates **Critical Limb Ischemia (Fontaine Stage III).** It usually occurs at night in the forefoot and is a sign of advanced disease, not simple claudication. * **Option C:** Cyanosis (Option D) is a physical sign of severe ischemia or venous congestion, not a defining symptom of claudication itself. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine Classification:** Stage I (Asymptomatic), Stage II (Claudication), Stage III (Rest pain), Stage IV (Ulceration/Gangrene). * **Boyd’s Classification:** Used specifically to grade the severity of intermittent claudication. * **Ankle-Brachial Index (ABI):** Claudicants typically have an ABI between **0.5 and 0.9**. * **Leriche Syndrome:** A triad of claudication (buttock/thigh), impotence, and absent femoral pulses due to aortoiliac occlusion.

Question 1

Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?

Accepted Answer

Young age (< 25 years)

Answer

Hip fracture and prolonged immobilization

Answer

Deficiency of Protein C and Protein S

Answer

Factor V Leiden mutation

Question 2

Allen's test is used to diagnose which condition?

Accepted Answer

Palmar arch insufficiency

Answer

Thoracic outlet syndrome

Answer

Superior vena cava syndrome

Answer

Coarctation of the aorta

Question 3

Superficial thrombophlebitis is seen in which of the following conditions?

Accepted Answer

Buerger's disease

Answer

AV fistula

Answer

Raynaud's disease

Answer

Aneurysm

Question 4

Adson's test is used for determining vascular insufficiency. It is useful in?

Accepted Answer

Cervical rib

Answer

Peripheral vascular disease

Answer

Varicose veins

Answer

AV fistula

Question 5

What is the normal pressure in the superficial venous system of the leg while walking?

Accepted Answer

30 mmHg

Answer

80 mmHg

Answer

60 mmHg

Answer

50 mmHg

Question 6

A 66-year-old woman has a 5.5-cm infrarenal abdominal aortic aneurysm. What is the most common manifestation of such an aneurysm?

Accepted Answer

Incidental finding on abdominal examination

Answer

Abdominal or back pain

Answer

Acute leak or rupture

Answer

Atheroembolism

Question 7

Which of the following statements about primary lymphedema is NOT TRUE?

Accepted Answer

Lymphangiosarcoma never occurs

Answer

Onset between 2-35 years indicates lymphedema praecox

Answer

Onset after 35 years indicates lymphedema tarda

Answer

Associated with Milroy's disease

Question 8

Classification of aortic dissection depends upon?

Accepted Answer

Level of aorta affected

Answer

Cause of dissection

Answer

Percentage of aorta affected

Answer

None of the above

Question 9

Which of the following is the most preferred graft in Coronary Artery Bypass Grafting (CABG)?

Accepted Answer

Internal mammary artery

Answer

Saphenous vein

Answer

Radial artery

Answer

Internal jugular vein

Question 10

Which of the following is a clinical feature of intermittent claudication?

Accepted Answer

Pain in the leg only on exercise

Answer

Pain in the leg

Answer

Pain in the leg at rest

Answer

Cyanosis of the leg

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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