Vascular Surgery — MCQs
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Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?
Allen's test is used to diagnose which condition?
Superficial thrombophlebitis is seen in which of the following conditions?
Adson's test is used for determining vascular insufficiency. It is useful in?
What is the normal pressure in the superficial venous system of the leg while walking?
A 66-year-old woman has a 5.5-cm infrarenal abdominal aortic aneurysm. What is the most common manifestation of such an aneurysm?
Which of the following statements about primary lymphedema is NOT TRUE?
Classification of aortic dissection depends upon?
Which of the following is the most preferred graft in Coronary Artery Bypass Grafting (CABG)?
Which of the following is a clinical feature of intermittent claudication?
Vascular Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?
- A. Hip fracture and prolonged immobilization
- B. Young age (< 25 years) (Correct Answer)
- C. Deficiency of Protein C and Protein S
- D. Factor V Leiden mutation
Explanation: 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).
Question 2: Allen's test is used to diagnose which condition?
- A. Thoracic outlet syndrome
- B. Palmar arch insufficiency (Correct Answer)
- C. Superior vena cava syndrome
- D. Coarctation of the aorta
Explanation: **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.
Question 3: Superficial thrombophlebitis is seen in which of the following conditions?
- A. AV fistula
- B. Raynaud's disease
- C. Buerger's disease (Correct Answer)
- D. Aneurysm
Explanation: **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.
Question 4: Adson's test is used for determining vascular insufficiency. It is useful in?
- A. Peripheral vascular disease
- B. Varicose veins
- C. Cervical rib (Correct Answer)
- D. AV fistula
Explanation: **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.
Question 5: What is the normal pressure in the superficial venous system of the leg while walking?
- A. 80 mmHg
- B. 60 mmHg
- C. 50 mmHg
- D. 30 mmHg (Correct Answer)
Explanation: ### 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.
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?
- A. Abdominal or back pain
- B. Acute leak or rupture
- C. Incidental finding on abdominal examination (Correct Answer)
- D. Atheroembolism
Explanation: **Explanation:** The correct answer is **C. Incidental finding on abdominal examination.** **1. Why Option C is Correct:** The vast majority of abdominal aortic aneurysms (AAAs) are **asymptomatic**. They are most frequently discovered incidentally during a routine physical examination as a palpable, pulsatile abdominal mass, or during imaging (Ultrasound or CT) performed for unrelated complaints. In clinical practice, the "silent" nature of AAAs is why screening programs (like USG in elderly male smokers) are emphasized. **2. Why Other Options are Incorrect:** * **A. Abdominal or back pain:** While these are classic symptoms, they usually indicate that the aneurysm is rapidly expanding or "leaking" (impending rupture). Most stable aneurysms do not cause pain. * **B. Acute leak or rupture:** This is the most dreaded complication, but it is not the most common presentation. Rupture typically presents with the triad of pain, hypotension, and a pulsatile mass, but many patients do not survive to reach the hospital. * **C. Atheroembolism:** Also known as "Blue Toe Syndrome," this occurs when mural thrombus within the aneurysm breaks off and occludes distal digital arteries. While a known complication, it is far less common than incidental detection. **3. High-Yield Clinical Pearls for NEET-PG:** * **Definition:** An AAA is defined as a permanent focal dilation of the aorta >1.5 times its normal diameter (usually **>3 cm**). * **Location:** Most AAAs are **infrarenal** (90%). * **Risk Factors:** Smoking is the strongest risk factor; male gender and age >65 are also significant. * **Surgical Threshold:** Elective repair is generally indicated when the diameter reaches **≥5.5 cm in men** or **≥5.0 cm in women**, or if the expansion rate is **>0.5 cm in 6 months**. * **Investigation of Choice:** **Ultrasound** is the best for screening/monitoring; **Contrast-Enhanced CT (CECT)** is the gold standard for preoperative planning.
Question 7: Which of the following statements about primary lymphedema is NOT TRUE?
- A. Onset between 2-35 years indicates lymphedema praecox
- B. Onset after 35 years indicates lymphedema tarda
- C. Lymphangiosarcoma never occurs (Correct Answer)
- D. Associated with Milroy's disease
Explanation: 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 <2 years) that is hereditary (autosomal dominant) and linked to mutations in the **VEGFR-3** gene. **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Onset:** Congenital (<2 years), Praecox (2–35 years), Tarda (>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.
Question 8: Classification of aortic dissection depends upon?
- A. Cause of dissection
- B. Level of aorta affected (Correct Answer)
- C. Percentage of aorta affected
- D. None of the above
Explanation: **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).
Question 9: Which of the following is the most preferred graft in Coronary Artery Bypass Grafting (CABG)?
- A. Saphenous vein
- B. Radial artery
- C. Internal mammary artery (Correct Answer)
- D. Internal jugular vein
Explanation: **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.
Question 10: Which of the following is a clinical feature of intermittent claudication?
- A. Pain in the leg
- B. Pain in the leg at rest
- C. Pain in the leg only on exercise (Correct Answer)
- D. Cyanosis of the leg
Explanation: **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.
Practice by Chapter
Atherosclerotic Disease
Practice Questions
Aortic Aneurysms
Practice Questions
Peripheral Arterial Disease
Practice Questions
Carotid Artery Disease
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Venous Thromboembolism
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Chronic Venous Insufficiency
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Mesenteric Vascular Disease
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Vascular Trauma
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Vascular Access for Hemodialysis
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Endovascular Techniques
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Diabetic Foot Vascular Disease
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Vasculitis
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