Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 111: What is the primary cause of varicose veins?

A. Incompetent valve perforators (Correct Answer)
B. Intrinsic abnormality of the venous wall
C. Venous hypertension
D. Decrease in collagen in the venous wall

Explanation: **Explanation:** Varicose veins are dilated, tortuous, and elongated superficial veins, most commonly occurring in the lower limbs. **Why Option A is Correct:** The physiological movement of blood in the lower limbs depends on the flow from the superficial system to the deep system via **perforating veins**. These perforators contain valves that prevent backflow. The **primary cause** (pathophysiology) of varicose veins is **valvular incompetence** at the saphenofemoral junction, saphenopopliteal junction, or within the perforators themselves. When these valves fail, high-pressure blood from the deep venous system leaks into the low-pressure superficial system (venous reflux), leading to dilation and varicosity. **Analysis of Incorrect Options:** * **Option B & D:** While intrinsic structural abnormalities and changes in the collagen/elastin ratio (Type III vs. Type I collagen) are observed in the vein walls of affected patients, these are generally considered **contributory factors** or secondary changes rather than the primary mechanical trigger for the disease. * **Option C:** **Venous hypertension** is the *result* of valvular incompetence and the *mechanism* by which skin changes (like lipodermatosclerosis) occur, but it is not the primary cause of the varicosities themselves. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Perthes Test:** Used to assess the patency of the **deep venous system** (crucial before surgery). * **Gold Standard Investigation:** Duplex Ultrasound (Color Doppler) is the investigation of choice. * **CEAP Classification:** Used for clinical grading (C0 to C6), where C2 represents varicose veins and C6 represents active venous ulcers.

Question 112: What is a characteristic of a knitted Dacron artery graft?

A. It is not porous.
B. It is eventually dissolved by tissue reaction.
C. It never gets infected.
D. It can be easily incised and the opening resutured. (Correct Answer)

Explanation: **Explanation:** Dacron (polyethylene terephthalate) is a synthetic, non-absorbable material widely used in vascular surgery for large-vessel reconstruction. **Why Option D is correct:** Knitted Dacron grafts are highly versatile because the fabric structure allows them to be easily cut (incised) to create arteriotomies or anastomoses. Crucially, the material maintains its structural integrity, allowing it to be resutured or modified without fraying excessively. This flexibility is essential for complex reconstructions, such as attaching side branches or performing "end-to-side" anastomoses. **Analysis of Incorrect Options:** * **Option A:** Knitted Dacron is **highly porous**. This porosity is intentional; it allows for "tissue ingrowth" (pseudointima formation), which helps anchor the graft. However, because they are porous, they must be "pre-clotted" with the patient's blood or impregnated with collagen/gelatin to prevent leaking during initial implantation. * **Option B:** Dacron is a **permanent, non-absorbable** synthetic polymer. It does not dissolve; it triggers a mild chronic inflammatory response that leads to fibrous encapsulation, providing long-term stability. * **Option C:** Like all foreign bodies, Dacron grafts **can become infected**. In fact, graft infection is a dreaded complication (often involving *Staphylococcus aureus* or *Staphylococcus epidermidis*), frequently requiring graft removal. **High-Yield Clinical Pearls for NEET-PG:** * **Knitted vs. Woven:** Knitted grafts are more porous and flexible (used for infra-renal aorta); Woven grafts are less porous and stronger (used for thoracic aorta to prevent hemorrhage without pre-clotting). * **Pre-clotting:** Essential for older knitted grafts to fill the interstices with fibrin. * **Gold Standard:** For peripheral bypass (below the inguinal ligament), the **Great Saphenous Vein** remains superior to Dacron due to better long-term patency and lower infection rates.

Question 113: What is the most common cause of acquired arteriovenous fistula?

A. Bacterial infection
B. Fungal infection
C. Blunt trauma
D. Penetrating trauma (Correct Answer)

Explanation: ### Explanation **Correct Answer: D. Penetrating Trauma** An **arteriovenous fistula (AVF)** is an abnormal communication between an artery and a vein, bypassing the capillary bed. In the acquired category, **penetrating trauma** (such as stab wounds, gunshot wounds, or accidental punctures) is the most common cause. When an artery and its adjacent vein are simultaneously injured within a confined tissue space, the high-pressure arterial blood creates a tract into the low-pressure venous system as the hematoma organizes. **Analysis of Incorrect Options:** * **A & B (Bacterial/Fungal Infections):** While infections can cause "mycotic aneurysms" that may erode into adjacent vessels, this is a rare mechanism for AVF formation compared to direct mechanical trauma. * **C (Blunt Trauma):** Blunt trauma more commonly results in vessel contusion, thrombosis, or intimal flaps. While it can theoretically cause an AVF (e.g., via a bone fracture fragment), it is significantly less frequent than penetrating injuries where the sharp mechanism directly tracks through both vessels. **Clinical Pearls for NEET-PG:** * **Iatrogenic Causes:** A major subset of penetrating trauma is iatrogenic (e.g., femoral artery catheterization for angiography or internal jugular vein cannulation). * **Clinical Triad:** Look for a **pulsatile mass**, a **palpable thrill**, and a **continuous "machinery" murmur** on auscultation. * **Nicoladoni-Branham Sign:** Bradycardia occurs upon manual compression of the feeding artery (due to a sudden increase in peripheral resistance and vagal reflex). * **Systemic Effects:** Large, long-standing AVFs can lead to **high-output heart failure** due to increased venous return and decreased systemic vascular resistance. * **Investigation of Choice:** Duplex Ultrasonography is the initial screening tool; **Digital Subtraction Angiography (DSA)** remains the gold standard for anatomical mapping.

Question 114: Bisgaard regimen is used in the treatment of which condition?

A. Trophic ulcer
B. Malignant ulcer
C. Ischaemic ulcer
D. Varicose ulcer (Correct Answer)

Explanation: **Explanation:** The **Bisgaard regimen** (also known as the "Method of Bisgaard") is a specialized conservative treatment protocol specifically designed for the management of **Varicose ulcers** (venous ulcers) and the chronic venous insufficiency that precedes them. **Why the correct answer is right:** The regimen is based on the principle of reducing venous hypertension and improving calf muscle pump function. It consists of four main components: 1. **Massage:** To reduce edema and soften indurated tissue. 2. **Exercises:** Specifically active movements of the ankle joint to activate the "peripheral heart" (calf muscles). 3. **Compression:** Using inelastic bandages or stockings to support venous return. 4. **Elevation:** Elevating the limb to facilitate gravity-assisted venous drainage. **Why the incorrect options are wrong:** * **Trophic ulcer:** These are typically neurotrophic (e.g., in Diabetes or Leprosy) caused by repetitive trauma to insensitive skin. Treatment focuses on offloading and debridement, not venous drainage exercises. * **Malignant ulcer:** These (e.g., Marjolin’s ulcer) require surgical excision with wide margins or radiotherapy. Massage is contraindicated as it may promote metastasis. * **Ischaemic ulcer:** Caused by arterial insufficiency (PAD). Compression (a key part of Bisgaard) is strictly contraindicated in severe arterial disease as it further compromises blood flow. **High-Yield Clinical Pearls for NEET-PG:** * **Cockett and Elving’s operation:** A surgical procedure for venous ulcers involving subfascial ligation of incompetent perforators. * **Marjolin’s Ulcer:** A squamous cell carcinoma arising in a chronic venous ulcer or burn scar. * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Gold Standard for Diagnosis:** Venous Duplex Ultrasound is the investigation of choice for varicose veins/ulcers.

Question 115: Buerger’s Disease is:

A. Also known as Thromboangitis Obliterans
B. A segmental inflammatory disease
C. Affects small and medium arteries in upper and lower extremities
D. All of the above (Correct Answer)

Explanation: **Explanation:** Buerger’s Disease, medically termed **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental inflammatory disease that predominantly affects the small and medium-sized arteries and veins of the extremities. * **Option A is correct:** TAO is the formal medical name for Buerger’s disease. It is characterized by highly cellular, "organized" thrombi with relative sparing of the blood vessel wall. * **Option B is correct:** The disease is **segmental**, meaning diseased sections of the vessel are separated by healthy "skip areas." It is an inflammatory process, though unlike systemic vasculitis, it does not typically show a positive ANA or ANCA. * **Option C is correct:** It primarily involves the distal vessels (e.g., radial, ulnar, tibial, and peroneal arteries). While it most commonly starts in the lower limbs, upper extremity involvement is a classic hallmark that helps distinguish it from peripheral arterial disease (PAD). Since all individual statements are accurate descriptions of the pathology, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing). Smoking cessation is the only treatment that prevents disease progression. * **Classic Triad:** Claudication (often of the arch of the foot), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) around areas of occlusion. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries. * **Demographics:** Typically affects young males (<45 years) who are heavy smokers.

Question 116: In Mondor's disease, there is swelling and hardening of which structures?

A. Lymphatics
B. Veins (Correct Answer)
C. Arteries
D. Nerves

Explanation: **Explanation:** **Mondor’s disease** is a clinical condition characterized by **superficial thrombophlebitis** (inflammation and clotting) of the subcutaneous veins. It most commonly affects the chest wall, specifically involving the **lateral thoracic, thoracoepigastric, or superior epigastric veins**. 1. **Why Veins are correct:** The underlying pathology is the formation of a blood clot within a superficial vein, followed by inflammation and subsequent fibrosis. This leads to the classic clinical presentation of a **palpable, tender, "cord-like" structure** under the skin, which becomes more prominent when the arm is abducted or the breast is elevated. 2. **Why other options are incorrect:** * **Lymphatics:** While lymphangitis can cause red streaks, it does not typically present as a persistent, hard, thrombosed cord. * **Arteries:** Arterial thrombosis leads to ischemia (pallor, pulselessness, pain), not superficial subcutaneous cords. * **Nerves:** Nerve pathologies (like neuromas) present with sensory or motor deficits rather than visible, superficial vascular hardening. **High-Yield Clinical Pearls for NEET-PG:** * **Presentation:** A "string-like" or "iron-wire" cord on the breast or chest wall. * **Etiology:** Usually idiopathic, but can be triggered by trauma, vigorous exercise, or breast surgery. * **Association:** While usually benign and self-limiting, it can rarely be a marker of underlying **breast malignancy**; therefore, a mammogram is often recommended to rule out occult cancer. * **Management:** Reassurance and NSAIDs for pain relief. It typically resolves spontaneously within 4–8 weeks.

Question 117: Which of the following does NOT describe critical limb ischemia?

A. Ankle-Brachial Pulse Index (ABPI) = 0.3
B. Ankle Systolic Blood Pressure (SBP) < 50 mmHg
C. Toe Systolic Blood Pressure (SBP) < 30 mmHg
D. Ankle Systolic Blood Pressure (SBP) > 30 mmHg (Correct Answer)

Explanation: **Explanation:** Critical Limb Ischemia (CLI) is the most severe stage of Peripheral Arterial Disease (PAD), characterized by chronic ischemic rest pain, ulcers, or gangrene. It represents a state where blood flow is insufficient to maintain tissue viability. **Why Option D is the Correct Answer:** The diagnostic criteria for CLI are strictly defined by objective hemodynamic measurements. For a diagnosis of CLI, the **Ankle Systolic Blood Pressure (SBP) must be < 50 mmHg**. Therefore, an Ankle SBP > 30 mmHg (which could be 40 or 45 mmHg) still falls within the range of CLI. The option is technically incorrect as a "description" because the threshold for CLI is specifically **less than 50 mmHg**, not just greater than 30 mmHg. In the context of this question, it is the only value that does not align with the standard diagnostic cutoff. **Analysis of Incorrect Options:** * **Option A (ABPI = 0.3):** An ABPI of **≤ 0.4** is a classic diagnostic criterion for CLI. A value of 0.3 indicates severe ischemia. * **Option B (Ankle SBP < 50 mmHg):** This is the standard threshold for CLI in patients with rest pain or tissue loss. * **Option C (Toe SBP < 30 mmHg):** Toe pressure is often more reliable in diabetics (due to calcified, non-compressible ankle arteries). A Toe SBP **< 30 mmHg** is a definitive criterion for CLI. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine Classification:** CLI corresponds to Stage III (Rest pain) and Stage IV (Ulceration/Gangrene). * **Rutherford Classification:** CLI corresponds to Categories 4, 5, and 6. * **The "6 Ps"** (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) refer to **Acute** Limb Ischemia, which is a surgical emergency, unlike the chronic nature of CLI. * **Management:** The primary goal in CLI is urgent revascularization (Endovascular or Bypass) to prevent amputation.

Question 118: Nicoladoni sign is also known as what?

A. Branham sign (Correct Answer)
B. Murray sign
C. Frei's sign
D. Darrier's sign

Explanation: **Explanation:** **Nicoladoni sign**, also known as the **Branham sign**, is a classic clinical finding associated with large, long-standing **Arteriovenous Fistulas (AVFs)**. When digital pressure is applied to the artery proximal to the AV fistula, the shunt is temporarily abolished. This leads to a sudden increase in peripheral resistance and an increase in effective circulating blood volume. The body compensates via the baroreceptor reflex, resulting in **reflex bradycardia** and a rise in systolic blood pressure. This sign is a strong clinical indicator of a high-flow fistula that may be placing a significant burden on the heart (potentially leading to high-output cardiac failure). **Analysis of Incorrect Options:** * **Murray sign:** This is not a standard vascular sign. (Note: Not to be confused with Murphy’s sign for cholecystitis). * **Frei's sign:** This is not a recognized vascular eponym. (Note: Frey’s syndrome refers to gustatory sweating). * **Darrier's sign:** A dermatological sign where rubbing a lesion (usually in mastocytosis) leads to localized urticaria and erythema due to histamine release from mast cells. **High-Yield Clinical Pearls for NEET-PG:** * **Machinery Murmur:** AV fistulas are characterized by a continuous "bruit" or "thrill" that persists throughout systole and diastole. * **Proximal Dilatation:** The artery proximal to a chronic AVF often becomes dilated and tortuous (cirsoid aneurysm). * **Management:** Large symptomatic AVFs are typically managed via surgical excision or endovascular embolization/stenting.

Question 119: Etiopathogenesis of diabetic foot includes the following except:

A. Myelopathy (Correct Answer)
B. Osteoarthropathy
C. Microangiopathy
D. Infection

Explanation: The etiopathogenesis of diabetic foot is a multifactorial process primarily driven by the "triad" of neuropathy, ischemia, and infection. **Explanation of the Correct Answer:** * **A. Myelopathy:** This refers to pathology of the spinal cord. While diabetes can cause various neurological issues, it primarily affects the peripheral nervous system (**Peripheral Neuropathy**), not the spinal cord. Therefore, myelopathy is not a standard component of diabetic foot pathogenesis. **Explanation of Incorrect Options:** * **B. Osteoarthropathy:** Specifically **Charcot’s Arthropathy**, this results from motor and sensory neuropathy. Loss of proprioception and repetitive microtrauma lead to joint destruction, bone fragmentation, and the classic "rocker-bottom" foot deformity. * **C. Microangiopathy:** Chronic hyperglycemia leads to basement membrane thickening in capillaries and arterioles. While macroangiopathy (atherosclerosis) causes large vessel ischemia, microangiopathy impairs nutrient exchange and wound healing at the cellular level. * **D. Infection:** Hyperglycemia impairs leukocyte function (chemotaxis and phagocytosis). Combined with a lack of protective sensation (sensory neuropathy) and poor blood supply (ischemia), minor injuries quickly escalate into deep-seated infections and gangrene. **High-Yield Clinical Pearls for NEET-PG:** * **The Diabetic Triad:** Neuropathy (Sensory, Motor, and Autonomic), Ischemia, and Infection. * **Sensory Neuropathy:** Leads to "painless" trauma (the most common initiating factor). * **Autonomic Neuropathy:** Causes anhidrosis (dry, cracked skin) and arteriovenous shunting, which bypasses capillary beds. * **Motor Neuropathy:** Leads to atrophy of intrinsic foot muscles, causing claw toes and abnormal pressure distribution. * **Wagner’s Classification:** Used to grade the severity of diabetic foot ulcers (Grade 0 to 5).

Question 120: Which is the most common part of the subclavian artery to be affected by stenosis?

A. First part (Correct Answer)
B. Second part
C. Third part
D. Equally affected

Explanation: **Explanation:** The subclavian artery is anatomically divided into three parts by the **scalenus anterior muscle**. The **first part** (from its origin to the medial border of the muscle) is the most common site for atherosclerotic stenosis. **1. Why the First Part is Correct:** Atherosclerosis is the primary cause of subclavian artery stenosis, and like most arterial diseases, it tends to occur at the **origin of the vessel** or near branching points due to turbulent blood flow. In the majority of cases (approx. 85-90%), the lesion is located proximal to the origin of the **vertebral artery**. This specific location is clinically significant because it can lead to **Subclavian Steal Syndrome**, where blood is "stolen" from the cerebral circulation via the vertebral artery to supply the ischemic arm. **2. Why Other Options are Incorrect:** * **Second Part:** This portion lies posterior to the scalenus anterior. It is less frequently affected by primary atherosclerosis but is a common site for compression in **Thoracic Outlet Syndrome (TOS)**. * **Third Part:** This extends from the lateral border of the scalenus anterior to the outer border of the first rib. While it can be affected by trauma or aneurysms (often secondary to cervical ribs), primary atherosclerotic stenosis is rare here compared to the origin. * **Equally Affected:** This is incorrect as the distribution of atherosclerotic plaque is highly site-specific, favoring the proximal segments. **High-Yield Clinical Pearls for NEET-PG:** * **Left vs. Right:** The **left subclavian artery** is affected 3 to 4 times more commonly than the right. * **Clinical Presentation:** Patients often present with a blood pressure difference between arms (**>15-20 mmHg**) and a weak radial pulse on the affected side. * **Subclavian Steal Syndrome:** Occurs when proximal stenosis causes retrograde flow in the ipsilateral vertebral artery, leading to neurological symptoms (vertigo, syncope) during arm exercise.

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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