Endovascular Techniques — MCQs
Complications of sling procedures (TVT) for USI are all except:
The procedure of choice for the evaluation of aortic aneurysms is -
Which one of the following is the most preferred route to perform cerebral angiography?
A patient is on follow-up for recurrent abdominal pain. USG reveals an aortic aneurysm of 40 mm. What should be the next immediate step?
A patient develops recurrent hyperparathyroidism 2 years after initial parathyroidectomy and has experienced cardiovascular complications due to persistent hypercalcemia. What is the most appropriate management?
Most common complication of cardiac catheterization is:
If posterior epistaxis cannot be controlled, which artery is ligated?
Which of the following conditions does NOT increase the risk of deep vein thrombosis (DVT)?
Allen's test is used to diagnose which condition?
What is the preferred material for femoro-popliteal bypass?
Endovascular Techniques Indian Medical PG Practice Questions and MCQs
Question 1: Complications of sling procedures (TVT) for USI are all except:
- A. Obturator nerve injury is about 10% (Correct Answer)
- B. Overactive bladder in about 7% cases
- C. Injury to bladder and wound haematoma
- D. Sling erosion particularly with polytetrafluoroethylene (Goretex)
Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.
Question 2: The procedure of choice for the evaluation of aortic aneurysms is -
- A. Computed tomography (Correct Answer)
- B. Magnetic resonance imaging
- C. Arteriography
- D. Ultrasonography
Explanation: ***Computed tomography*** - **Computed tomography (CT)** offers excellent spatial resolution and is the gold standard for diagnosing, staging, and pre-operative planning for aortic aneurysms. - It precisely measures aneurysm size, detects mural thrombus, assesses rupture risk, and evaluates the extent of involvement with surrounding structures. *Ultrasonography* - While useful for initial screening and serial monitoring of known abdominal aortic aneurysms due to its non-invasiveness and cost-effectiveness, its accuracy can be limited by **patient body habitus** and **bowel gas**. - It may not reliably visualize the entire aorta or accurately assess complex anatomy and rupture. *Magnetic resonance imaging* - **Magnetic resonance imaging (MRI)** provides detailed anatomical information and avoids radiation exposure, but it is typically more expensive and time-consuming than CT. - It is often reserved for patients with **renal insufficiency** where iodinated contrast is a concern or when evaluating specific tissue characteristics not well seen on CT. *Arteriography* - **Arteriography** (angiography) is an invasive procedure involving direct contrast injection, carrying risks such as arterial injury and nephrotoxicity. - While it can visualize the aortic lumen, it primarily shows the patent lumen and may **underestimate the true aneurysm size** due to mural thrombus. It is typically used for intervention planning or specific contexts rather than initial diagnosis.
Question 3: Which one of the following is the most preferred route to perform cerebral angiography?
- A. Direct carotid puncture
- B. Transaxillary route
- C. Transfemoral route (Correct Answer)
- D. Transbrachial route
Explanation: **Transfemoral route (Correct Answer)** - The **transfemoral** route is the **most preferred** and widely used method for cerebral angiography due to its **safety**, ease of access, and lower complication rates. - It allows for the safe cannulation of **cerebral vessels** using a catheter inserted into the **femoral artery** and advanced up to the aortic arch. - This is the **gold standard approach** (Seldinger technique) for diagnostic and interventional cerebral angiography. *Direct carotid puncture (Incorrect)* - This method is more invasive and carries a higher risk of complications, such as **hematoma**, **stroke**, or **carotid artery dissection**. - It is typically reserved for cases where other routes are inaccessible or when very specific and localized imaging is required. - Largely of **historical significance** now that safer endovascular techniques are available. *Transaxillary route (Incorrect)* - The **transaxillary** route is an alternative but carries a higher risk of complications like **brachial plexus injury** and **bleeding** compared to the transfemoral approach. - It may be considered when the femoral access is not feasible, for example, in patients with severe peripheral vascular disease affecting the femoral arteries. *Transbrachial route (Incorrect)* - The **transbrachial** (or **transradial**) route is also an alternative but is generally less preferred due to the risk of **radial or brachial artery spasm** or damage, and it can be technically more challenging. - This route is typically avoided if possible, especially when the transfemoral route is readily available and safe. - May be considered in patients with severe aortoiliac disease or morbid obesity.
Question 4: A patient is on follow-up for recurrent abdominal pain. USG reveals an aortic aneurysm of 40 mm. What should be the next immediate step?
- A. Establish surveillance protocol with repeat imaging in 6-12 months. (Correct Answer)
- B. Initiate medical management with beta-blockers.
- C. Perform surgical intervention immediately.
- D. Start antihypertensive therapy immediately.
Explanation: ***Establish surveillance protocol with repeat imaging in 6-12 months.*** - A **40mm abdominal aortic aneurysm (AAA)** is below the threshold for elective surgical repair (typically **55mm for men, 50mm for women**). - The **immediate next step** is to establish a **surveillance protocol** with repeat imaging at appropriate intervals (every **6-12 months** for 40-44mm AAAs). - Surveillance allows monitoring of aneurysm growth rate and timely intervention if it expands to surgical threshold or becomes symptomatic. - **Risk factor modification** (smoking cessation, BP control, statin therapy) should accompany surveillance but is secondary to establishing the monitoring plan. *Initiate medical management with beta-blockers.* - **Beta-blockers are NOT recommended** for AAA management and may actually be harmful by reducing aortic wall stress detection. - Current guidelines do not support routine pharmacological therapy specifically to prevent AAA expansion, though **statins** may have some benefit. *Perform surgical intervention immediately.* - A **40mm AAA is well below surgical threshold** and does not require immediate intervention. - Surgery is considered when AAA reaches **≥55mm (men) or ≥50mm (women)**, growth rate **>10mm/year**, or when **symptomatic/ruptured**. *Start antihypertensive therapy immediately.* - While **blood pressure control is important** in AAA management, it is not the immediate next step without first establishing a surveillance protocol. - Antihypertensive therapy should be part of overall cardiovascular risk management but assumes the patient is hypertensive (not specified in the question).
Question 5: A patient develops recurrent hyperparathyroidism 2 years after initial parathyroidectomy and has experienced cardiovascular complications due to persistent hypercalcemia. What is the most appropriate management?
- A. Repeat neck surgery
- B. Observation and repeat serum Ca2+ in two months
- C. Repeat parathyroidectomy after medical optimization (Correct Answer)
- D. Medical management with calcimimetics (cinacalcet)
Explanation: ***Repeat parathyroidectomy after medical optimization*** - Recurrent **hyperparathyroidism** often requires repeat surgery, particularly in patients who have experienced cardiovascular events, as persistent hypercalcemia can exacerbate cardiac risk. - **Medical optimization** of cardiovascular conditions and metabolic status before reoperation is crucial to minimize surgical risks and improve outcomes. *Repeat neck surgery* - While repeat neck surgery is often necessary, this option is incomplete as it does not sufficiently emphasize the importance of **medical optimization** in patients with a history of cardiovascular events. - Performing surgery without adequate pre-operative evaluation and optimization can lead to increased **perioperative complications** in this high-risk group. *Observation and repeat serum Ca2+ in two months* - **Observation** is generally not appropriate for recurrent hyperparathyroidism, especially when it has already led to cardiovascular events, as continued hypercalcemia poses significant long-term health risks. - Delaying definitive treatment allows for ongoing end-organ damage, including worsening **cardiovascular disease** and bone complications. *Medical management with calcimimetics (cinacalcet)* - **Calcimimetics** like **cinacalcet** can reduce parathyroid hormone (PTH) and calcium levels, but they are typically used as an adjunct or for patients who are not surgical candidates. - In cases of recurrent hyperparathyroidism, especially with clinical sequelae like cardiovascular events, **surgical removal of the adenoma** remains the definitive treatment to achieve a cure.
Question 6: Most common complication of cardiac catheterization is:
- A. Vascular Access Site Bleeding (Correct Answer)
- B. Arrhythmia
- C. Contrast reaction
- D. Perforation of heart chamber
Explanation: ***Vascular Access Site Bleeding*** - This is the **most common complication** of cardiac catheterization, occurring in 2-6% of procedures due to the invasive nature of puncturing an artery or vein for catheter insertion. - Complications can range from a **small hematoma or bruising** to more serious issues like pseudoaneurysm formation or arteriovenous fistula. - Risk factors include larger sheath size, anticoagulation, and femoral access (compared to radial access). *Arrhythmia* - While rhythm disturbances can occur during catheterization, especially when the catheter irritates the myocardium, they are **less frequent** than access site complications. - Most arrhythmias are **transient** and resolve spontaneously without intervention. - Common types include PVCs, NSVT, and rarely sustained ventricular arrhythmias. *Contrast reaction* - Reactions to contrast media can occur, ranging from mild (e.g., rash, itching) to severe (e.g., anaphylaxis). - However, with modern non-ionic, low-osmolar contrast agents and careful patient screening, these are **not the most common complications**. - Incidence of severe reactions is less than 0.1% with modern agents. *Perforation of heart chamber* - This is a **rare but serious complication** (incidence <0.1%) that can lead to cardiac tamponade. - It is typically associated with complex procedures, stiff guidewires, or difficult anatomical features. - Its incidence is significantly lower than access site bleeding.
Question 7: If posterior epistaxis cannot be controlled, which artery is ligated?
- A. Sphenopalatine artery (Correct Answer)
- B. External carotid artery
- C. Posterior ethmoidal artery
- D. Maxillary artery
Explanation: ***Sphenopalatine artery*** - The **sphenopalatine artery** is the primary blood supply to the posterior nasal cavity, making its ligation highly effective for persistent **posterior epistaxis**. - It is a terminal branch of the **maxillary artery** and enters the nasal cavity through the sphenopalatine foramen. *Maxillary artery* - While the **maxillary artery** is the parent vessel of the sphenopalatine artery, ligating it further upstream can be more invasive and carry higher risks. - Ligation of the **sphenopalatine artery** directly addresses the most common source of posterior bleeding with less morbidity. *External carotid artery* - The **external carotid artery** is the main source of blood for the internal maxillary artery which gives origin to the sphenopalatine artery. - Ligation at this level is a more proximal and generalized intervention that might not be specific enough for intractable posterior epistaxis and can affect other vascular territories. *Posterior ethmoidal artery* - The **posterior ethmoidal artery** supplies a smaller, more superior portion of the posterior nasal cavity and is less frequently the primary source of severe posterior epistaxis. - Ligation of the ethmoidal arteries is typically reserved for cases where anterior or superior bleeding is refractory, not standard posterior epistaxis.
Question 8: 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 9: 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 10: What is the preferred material for femoro-popliteal bypass?
- A. Dacron
- B. Polytetrafluoroethylene (PTFE)
- C. Saphenous vein (Correct Answer)
- D. Gore-Tex
Explanation: **Explanation:** The **Great Saphenous Vein (GSV)** is considered the "gold standard" conduit for infrainguinal arterial bypass, including femoro-popliteal bypass. **Why Saphenous Vein is Correct:** The GSV is preferred due to its superior **long-term patency rates** compared to synthetic grafts. Being an autologous living tissue, it possesses an intact endothelial lining that produces nitric oxide and prostacyclin, which are essential for preventing thrombosis. It also has better resistance to infection and handles mechanical stress (like knee flexion) more effectively than rigid synthetic materials. **Why Other Options are Incorrect:** * **Dacron (Polyester):** While excellent for large-diameter, high-flow vessels like the aorta (e.g., AAA repair), it has poor patency in smaller peripheral vessels due to high thrombogenicity and compliance mismatch. * **PTFE (Polytetrafluoroethylene) & Gore-Tex:** PTFE (Gore-Tex is a brand name) is the second-line choice used only when the saphenous vein is unavailable or inadequate. While acceptable for bypasses ending *above* the knee, its performance is significantly inferior to the GSV for *below-knee* bypasses due to the risk of intimal hyperplasia and thrombosis. **High-Yield Clinical Pearls for NEET-PG:** * **Patency Rule:** Autologous vein > Synthetic graft. * **Reversed vs. In-situ:** The GSV can be used as a "reversed" graft (to bypass valves) or "in-situ" (where valves are lysed with a valvulotome). * **Infection:** In a contaminated field or infected site, synthetic grafts are strictly contraindicated; autologous veins must be used. * **Alternative Veins:** If the GSV is absent, the Small Saphenous Vein or cephalic/basilic veins are the next autologous options.
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