Vascular Surgery — MCQs

A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dyne * s)/cm5. Which of the following is the single best pharmacologic intervention for this patient?

Q106Easy

Coronary cabal fistula is:

Q107Medium

Risk of aneurysm rupture is >25% per year when the size is greater than what?

Q108Easy

What is the most common cause of pseudoaneurysm?

Q109Medium

In traumatic transection of the femoral artery and vein, which among the following should be done?

Q110Easy

Which are the classification systems for aortic dissection?

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 101: The Adson test is used for determining vascular sufficiency. It is useful in which of the following conditions?

A. Peripheral vascular disease
B. Varicose veins
C. Cervical rib (Correct Answer)
D. AV fistula

Explanation: **Explanation:** The **Adson test** is a clinical maneuver used to assess for **Thoracic Outlet Syndrome (TOS)**, specifically compression of the subclavian artery by a **cervical rib** or tight scalene muscles. **Why the correct answer is right:** In patients with a cervical rib, the thoracic outlet is narrowed. During the Adson test, the patient is asked to take a deep breath (which elevates the first rib), extend the neck, and rotate the head toward the affected side. This maneuver further narrows the space between the scalenus anterior and medius muscles. A **positive test** is indicated by a **marked reduction or disappearance of the radial pulse** on the ipsilateral side, suggesting vascular compression. **Why the incorrect options are wrong:** * **Peripheral Vascular Disease (PVD):** This is typically assessed using the Ankle-Brachial Index (ABI), Buerger’s test, or Doppler studies to evaluate atherosclerotic narrowing in the limbs. * **Varicose Veins:** These are evaluated using tests for venous valvular competency, such as the **Trendelenburg test**, Perthes test, or Fegan’s test. * **AV Fistula:** This is characterized by a continuous machinery murmur and a palpable thrill. It is clinically assessed using **Nicoladoni-Branham’s sign** (slowing of heart rate upon compressing the artery proximal to the fistula). **Clinical Pearls for NEET-PG:** * **Thoracic Outlet Syndrome (TOS):** Can be neurogenic (95% - brachial plexus compression) or vascular (subclavian artery/vein). * **Other TOS Tests:** **Roos test** (Elevated Arm Stress Test - "East" test) is considered the most reliable clinical screening test. * **Cervical Rib:** It is a supernumerary rib arising from the C7 vertebra. While often asymptomatic, it is the most common cause of arterial TOS.

Question 102: Fogarty's catheter is used for which of the following procedures?

A. Removal of embolus from blood vessels (Correct Answer)
B. Parenteral hyperalimentation
C. Drainage of urinary bladder
D. Ureteric catheterisation

Explanation: **Explanation:** The **Fogarty catheter** is a specialized balloon-tipped catheter designed specifically for **arterial embolectomy** (removal of an embolus) or thrombectomy. **1. Why Option A is correct:** The procedure involves inserting the catheter into the affected vessel, passing it beyond the site of the clot, and then inflating the distal balloon with saline or air. As the catheter is withdrawn, the inflated balloon "sweeps" the embolus or thrombus out through the arteriotomy. This technique is the gold standard for managing acute limb ischemia caused by arterial embolism. **2. Why the other options are incorrect:** * **Option B (Parenteral hyperalimentation):** This is typically performed using central venous catheters (e.g., PICC lines or Hickman catheters) for the administration of Total Parenteral Nutrition (TPN). * **Option C (Drainage of urinary bladder):** This is achieved using a **Foley catheter** (self-retaining) or a Robinson catheter (straight). * **Option D (Ureteric catheterisation):** This involves specialized ureteric stents (like the **Double-J stent**) or catheters used during cystoscopy to bypass obstructions. **Clinical Pearls for NEET-PG:** * **Inventor:** Developed by Dr. Thomas J. Fogarty in 1961. * **Sizing:** Catheters are sized using the **French (F) scale**. Common sizes include 3F (for smaller vessels like the brachial artery) and 4F or 5F (for the femoral artery). * **Balloon Inflation:** Always use a **tuberculin syringe** for precise volume control to prevent vessel rupture. * **High-Yield Tip:** The most common site for an embolus to lodge is the **femoral artery bifurcation**, and the Fogarty catheter is the primary tool used for its retrieval.

Question 103: Which of the following is NOT a feature of acute limb ischemia?

A. Perishing cold
B. Cyanosis (Correct Answer)
C. Paralysis
D. Paralysis

Explanation: Acute limb ischemia (ALI) is a surgical emergency characterized by a sudden decrease in limb perfusion. The clinical diagnosis is traditionally based on the **"6 Ps"**: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Perishing Cold (Poikilothermia). **Why Cyanosis is the correct answer:** In the acute phase of limb ischemia, the hallmark skin change is **Pallor** (extreme paleness). This occurs because there is a complete cessation of arterial blood flow, leaving the capillary beds empty. **Cyanosis** (a bluish discoloration) is typically associated with *venous* congestion or *chronic* peripheral vascular disease rather than the initial presentation of acute arterial occlusion. While "mottling" can occur in late-stage ALI, it is non-blanching and signifies irreversible ischemia, but classic cyanosis is not a primary diagnostic feature of the 6 Ps. **Explanation of other options:** * **Perishing Cold (Poikilothermia):** This refers to the limb's inability to regulate temperature, becoming cold to the touch as it equilibrates with the ambient temperature due to lack of warm arterial blood. * **Paralysis:** This is a late and grave sign of ALI. It indicates significant ischemia to the motor nerves and muscles. Its presence often suggests the limb is "threatened" or "irreversible" (Rutherford Grade IIb or III). **Clinical Pearls for NEET-PG:** * **Golden Period:** Revascularization should ideally occur within **6 hours** to prevent irreversible muscle necrosis. * **Most Common Cause:** Arterial embolism (often originating from the heart due to Atrial Fibrillation). * **Rutherford Classification:** Used to grade the severity of ALI. * **Management:** Immediate anticoagulation with IV Heparin is the first step to prevent clot propagation, followed by imaging (CT Angio) or emergency embolectomy (Fogarty catheter).

Question 104: What is the characteristic angiographic finding in Buerger's disease?

A. Corkscrew arteries (Correct Answer)
B. Beaded arteries
C. Stenosed arteries
D. Arterial dissection

Explanation: **Explanation:** **Buerger’s Disease (Thromboangiitis Obliterans)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects small and medium-sized arteries and veins of the extremities. It is strongly associated with heavy tobacco use. **Why "Corkscrew Arteries" is correct:** In Buerger’s disease, chronic inflammation leads to segmental occlusions of the distal vessels. To bypass these obstructions, the body develops **tortuous, spiral-shaped collateral vessels**. On angiography, these characteristic collaterals are described as **"corkscrew" or "root-like"** appearances (Martorell’s sign). These are not the original arteries but rather the compensatory collateral circulation. **Analysis of Incorrect Options:** * **B. Beaded arteries:** This is the classic angiographic finding in **Fibromuscular Dysplasia (FMD)**, caused by alternating areas of stenosis and aneurysmal dilatation (the "string of beads" appearance). * **C. Stenosed arteries:** While stenosis occurs in Buerger’s, it is a non-specific finding seen in Atherosclerosis and various vasculitides. It is not the "characteristic" diagnostic sign. * **D. Arterial dissection:** This refers to a tear in the tunica intima (e.g., Aortic dissection) and is not a feature of the inflammatory pathology of Buerger’s disease. **NEET-PG High-Yield Pearls:** * **Patient Profile:** Young male smokers (<45 years). * **Clinical Triad:** Claudication (often involving the arch of the foot), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Pathology:** Characterized by a **highly cellular "inflammatory thrombus"** with relative sparing of the blood vessel wall. * **Management:** Absolute **smoking cessation** is the only way to halt disease progression and prevent amputation. Sympathectomy may be used for symptomatic relief.

Question 105: A 59-year-old man with a history of myocardial infarction 2 years ago undergoes an uneventful aortobifemoral bypass graft for aortoiliac occlusive disease. Six hours later he develops ST segment depression, and a 12-lead electrocardiogram (ECG) shows anterolateral ischemia. His hemodynamic parameters are as follows: systemic BP 70/40 mm Hg, pulse 100 beats per minute, CVP 18 mm Hg, PCWP 25 mm Hg, cardiac output 1.5 L/min, and systemic vascular resistance 1000 (dyne * s)/cm5. Which of the following is the single best pharmacologic intervention for this patient?

A. Sublingual nitroglycerin
B. Intravenous nitroglycerin
C. A short-acting beta-blocker
D. Dobutamine (Correct Answer)

Explanation: ### Explanation The patient is presenting with **Cardiogenic Shock** following major vascular surgery. The diagnosis is confirmed by the hemodynamic profile: low Cardiac Output (1.5 L/min), hypotension (70/40 mmHg), and elevated filling pressures (CVP 18 mmHg, PCWP 25 mmHg). The ECG changes (ST depression) and history of MI suggest that the primary cause is myocardial dysfunction/ischemia. **Why Dobutamine is the Correct Choice:** Dobutamine is a potent **$\beta_1$-agonist** with mild $\beta_2$ effects. It is the drug of choice here because it increases myocardial contractility (**inotropy**) and heart rate (**chronotropy**), thereby increasing cardiac output. In cardiogenic shock with high PCWP (pulmonary congestion), dobutamine helps "forward" the blood, reducing the back-pressure on the lungs and improving systemic perfusion. **Why Other Options are Incorrect:** * **Sublingual/IV Nitroglycerin:** While nitrates reduce preload and are used in ischemia, they are **contraindicated** in patients with a systolic BP < 90 mmHg. Nitroglycerin would further drop the blood pressure, worsening coronary perfusion and exacerbating the shock. * **Short-acting Beta-blockers (e.g., Esmolol):** These are contraindicated in acute heart failure/cardiogenic shock as they decrease contractility (negative inotropy) and heart rate, which would lead to a further decline in cardiac output and potential cardiac arrest. **Clinical Pearls for NEET-PG:** 1. **Hemodynamic Profile of Cardiogenic Shock:** ↓ CO, ↑ PCWP, ↑ SVR (compensatory), and ↑ CVP. 2. **Goal of Therapy:** The primary goal is to improve CO and tissue perfusion. If BP is severely low, an alpha-agonist (Norepinephrine) might be added to maintain MAP, but an inotrope (Dobutamine) is essential for the failing pump. 3. **Aortobifemoral Bypass Risks:** Patients undergoing major vascular surgery often have underlying CAD; postoperative MI is a leading cause of morbidity and mortality. 4. **PCWP:** A PCWP > 18-20 mmHg usually indicates left ventricular failure or fluid overload.

Question 106: Coronary cabal fistula is:

A. Inokuchi (Correct Answer)
B. Warren's
C. Eck's fistula
D. Shamik

Explanation: **Explanation:** The question refers to various types of **Portosystemic Shunts** used in the surgical management of portal hypertension. **1. Why Inokuchi is Correct:** The **Inokuchi shunt** is a selective portosystemic shunt known as the **coronary-caval shunt**. In this procedure, the left gastric vein (coronary vein) is disconnected from the portal vein and anastomosed to the inferior vena cava (IVC), often using a vein graft. Like the Warren shunt, it aims to decompress gastric and esophageal varices while maintaining portal blood flow to the liver (prograde flow), thereby reducing the risk of hepatic encephalopathy. **2. Analysis of Incorrect Options:** * **B. Warren’s Shunt:** This is a **distal splenorenal shunt**. It involves anastomosing the splenic vein to the left renal vein. It is the most commonly performed selective shunt. * **C. Eck’s Fistula:** This is a **side-to-side portacaval shunt**. It is a non-selective shunt where the portal vein is connected directly to the IVC, completely diverting portal flow away from the liver. * **D. Shamik:** This is likely a distractor or a misspelling of "Sugiura," which refers to a non-shunt devascularization procedure (Sugiura procedure). **High-Yield Clinical Pearls for NEET-PG:** * **Selective Shunts:** (Warren, Inokuchi) Decompress varices but preserve portal flow to the liver. Lower risk of encephalopathy. * **Non-selective Shunts:** (Portacaval, Mesocaval) Completely divert portal flow. Higher risk of encephalopathy. * **H-graft:** A portacaval shunt using a synthetic (PTFE) or autologous vein graft. * **TIPS (Transjugular Intrahepatic Portosystemic Shunt):** The current gold standard for refractory variceal bleeding; it acts as a non-selective side-to-side shunt.

Question 107: Risk of aneurysm rupture is >25% per year when the size is greater than what?

A. 4 cm
B. 6 cm
C. 7 cm (Correct Answer)
D. 8 cm

Explanation: **Explanation:** The risk of Abdominal Aortic Aneurysm (AAA) rupture is directly proportional to the diameter of the aneurysm, governed by **Laplace’s Law** ($T = P \times r$). As the radius ($r$) increases, the wall tension ($T$) increases, significantly elevating the risk of spontaneous rupture. * **Why 7 cm is correct:** Clinical data and surgical guidelines (such as SVS and ESVS) indicate a steep exponential increase in rupture risk once the diameter exceeds 6 cm. For an aneurysm **>7 cm**, the annual risk of rupture is estimated at **20–25% or higher**. At this size, the risk of death from rupture far outweighs the risks associated with elective surgical or endovascular repair. * **Why other options are incorrect:** * **4 cm:** The risk is near 0%. These are managed with ultrasound surveillance every 6–12 months. * **6 cm:** The annual rupture risk is approximately 10–15%. While significant, it does not reach the >25% threshold. * **8 cm:** While the risk is even higher (>30–50%), the "threshold" where the risk first exceeds 25% is clinically recognized at the 7 cm mark. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Surgery:** 1. Diameter **>5.5 cm in men** or **>5.0 cm in women**. 2. Rapid expansion: **>0.5 cm in 6 months** or **>1 cm in 1 year**. 3. Any symptomatic aneurysm (pain/tenderness) regardless of size. * **Most common site:** Infra-renal aorta. * **Investigation of choice:** Ultrasound (Screening/Monitoring); Contrast-Enhanced CT (Pre-operative planning). * **Triad of Rupture:** Hypotension, pulsatile abdominal mass, and back/abdominal pain.

Question 108: What is the most common cause of pseudoaneurysm?

A. Intravenous drug abuse
B. Trauma (Correct Answer)
C. Congenital anomaly
D. None of the above

Explanation: ### Explanation A **pseudoaneurysm** (false aneurysm) occurs when there is a breach in the arterial wall, leading to blood leaking out and being contained by the surrounding fibrous tissue or adventitia, rather than all three layers of the arterial wall (intima, media, and adventitia). **Why Trauma is the Correct Answer:** Trauma is the most common cause of pseudoaneurysms. This includes both **accidental trauma** (penetrating injuries like stabbings or gunshots) and, increasingly, **iatrogenic trauma**. In modern clinical practice, iatrogenic injury during percutaneous arterial procedures (e.g., femoral artery catheterization for coronary angiography) is the single most frequent specific cause of pseudoaneurysms. **Analysis of Incorrect Options:** * **Intravenous drug abuse (IVDA):** While a significant cause of "infected" or mycotic pseudoaneurysms (due to repeated needle trauma and local infection), it is less common than general traumatic or iatrogenic causes in the overall population. * **Congenital anomaly:** These typically lead to "true" aneurysms (involving all three layers), such as Berry aneurysms in the Circle of Willis, rather than pseudoaneurysms. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Characterized by a **pulsatile mass** with a **systolic bruit**. * **Diagnosis:** The investigation of choice is **Duplex Ultrasonography**, which shows the classic **"Yin-Yang sign"** (turbulent blood flow within the sac). * **Management:** Small iatrogenic pseudoaneurysms may resolve spontaneously. Active management includes **Ultrasound-guided Thrombin Injection (UGTI)**—the current gold standard—or surgical repair if the patient is unstable or the neck is wide. * **Distinction:** Unlike true aneurysms, pseudoaneurysms have a high risk of rupture because they lack a true structural wall.

Question 109: In traumatic transection of the femoral artery and vein, which among the following should be done?

A. Femoral artery repair with vein ligation
B. Repair of artery and vein (Correct Answer)
C. Ligation of femoral artery
D. Below knee amputation

Explanation: In vascular trauma involving both the artery and the vein, the modern surgical principle is to **repair both vessels** whenever hemodynamically feasible. ### Why Option B is Correct Restoring arterial flow is critical to prevent limb ischemia and gangrene. However, repairing the concomitant venous injury is equally vital. If the femoral vein is ligated, the resulting venous hypertension leads to massive limb edema, which increases compartmental pressure. This can compromise the newly repaired arterial graft (venous outflow obstruction leads to arterial inflow failure) and significantly increases the risk of **Compartment Syndrome**. ### Why Other Options are Incorrect * **Option A:** Ligation of the femoral vein was common in wartime (e.g., WWII), but it leads to chronic venous insufficiency and high rates of secondary amputation due to swelling and compartment syndrome. * **Option C:** Ligation of the femoral artery is contraindicated as it leads to a very high risk of limb loss (approximately 80% amputation rate for common femoral injuries). * **Option D:** Amputation is a "last resort" procedure, reserved only for unsalvageable limbs with extensive tissue necrosis or life-threatening sepsis. ### High-Yield Clinical Pearls for NEET-PG * **Sequence of Repair:** In a mangled extremity, the sequence is typically: **Bone (Stabilization/Shunt) → Vein → Artery → Nerve**. However, if ischemia time is high, a temporary vascular shunt is placed first. * **Conduit of Choice:** The **Autologous Great Saphenous Vein (GSV)** from the contralateral limb is the gold standard for arterial repair. * **Hard Signs of Vascular Injury:** Pulsatile bleeding, expanding hematoma, thrill/bruit, and the 5 P’s (Pulselessness, Pallor, Paresthesia, Pain, Paralysis). Presence of hard signs warrants immediate surgical exploration.

Question 110: Which are the classification systems for aortic dissection?

A. Crawford
B. DeBakey
C. Stanford
D. All of the above (Correct Answer)

Explanation: Aortic dissection is a life-threatening condition characterized by a tear in the aortic intima, leading to the creation of a false lumen. To guide management, surgeons rely on specific classification systems based on anatomical location and extent. **Explanation of Classification Systems:** 1. **Stanford Classification:** This is the most clinically relevant system. * **Type A:** Involves the ascending aorta (requires urgent surgery). * **Type B:** Does not involve the ascending aorta (usually managed medically). 2. **DeBakey Classification:** Based on the site of origin and extent of the dissection. * **Type I:** Originates in the ascending aorta and extends to the arch/descending aorta. * **Type II:** Confined to the ascending aorta. * **Type III:** Originates in the descending aorta (IIIa: thoracic only; IIIb: extends below diaphragm). 3. **Crawford Classification:** While primarily used for **Thoracoabdominal Aortic Aneurysms (TAAA)**, it is also utilized to classify the extent of chronic aortic dissections that have become aneurysmal. It categorizes them into four (later five) types based on the involvement of the thoracic and abdominal segments. **Why "All of the Above" is Correct:** All three systems are standard nomenclature in vascular surgery to describe the pathology, extent, and surgical approach for aortic dissections and associated aneurysmal changes. **High-Yield NEET-PG Pearls:** * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice. * **Most Common Site of Tear:** Just distal to the origin of the left subclavian artery (for Type B) or the right lateral wall of the ascending aorta (for Type A). * **Management:** "A" (Stanford) = **A**ct (Surgery); "B" (Stanford) = **B**edside (Medical management/Beta-blockers).

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

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Peripheral Arterial Disease

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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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