Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 121: Which of the following is NOT a criterion for mitral valvotomy?

A. Significant symptoms
B. Isolated mitral stenosis
C. Mobile non-calcified valve
D. Left atrial thrombus (Correct Answer)

Explanation: **Explanation:** Mitral Valvotomy (specifically Percutaneous Transvenous Mitral Commissurotomy - PTMC) is the procedure of choice for symptomatic Mitral Stenosis (MS). The goal is to mechanically separate the fused commissures to increase the valve area. **Why "Left Atrial Thrombus" is the correct answer:** The presence of a **Left Atrial (LA) thrombus** is a **strict contraindication** for mitral valvotomy. During the procedure, the manipulation of catheters and the inflation of the balloon within the left atrium can dislodge the clot, leading to catastrophic systemic embolization (e.g., an embolic stroke). A Transesophageal Echocardiogram (TEE) is mandatory before the procedure to rule out an LA appendage thrombus. **Analysis of other options:** * **Significant symptoms:** Patients with NYHA Class II, III, or IV symptoms and a mitral valve area ≤1.5 cm² are the primary candidates for the procedure. * **Isolated mitral stenosis:** Valvotomy is ideal when MS is the solitary lesion. If significant mitral regurgitation (MR > Grade 2) is present, valvotomy is contraindicated as it may worsen the regurgitation. * **Mobile non-calcified valve:** This is a key component of a "favorable" valve morphology. The **Wilkins Score** (based on mobility, thickening, calcification, and subvalvular involvement) is used to assess suitability; a score <8 predicts a high success rate. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for PTMC:** Symptomatic MS, Valve area ≤1.5 cm², Wilkins score <8, and absence of LA thrombus/significant MR. * **Contraindications:** LA thrombus, Grade >2 Mitral Regurgitation, severe calcification, or concomitant coronary artery disease requiring CABG. * **Most common complication:** Development of iatrogenic Mitral Regurgitation. * **Pregnancy:** PTMC is the preferred intervention for pregnant women with severe symptomatic MS that is refractory to medical therapy.

Question 122: What is the most common complication of an aortic aneurysm of size 8 cm?

A. Rupture (Correct Answer)
B. Intramural thrombosis
C. Embolism
D. Calcification

Explanation: **Explanation:** The primary concern with an abdominal aortic aneurysm (AAA) is its risk of **rupture**, which increases exponentially with the diameter of the vessel. According to **LaPlace’s Law** ($T = P \times r$), the wall tension ($T$) is directly proportional to the radius ($r$) of the aneurysm. As the diameter reaches 8 cm, the wall tension exceeds the tensile strength of the aortic wall, making spontaneous rupture the most common and life-threatening complication. For an aneurysm >7 cm, the annual risk of rupture is estimated at 20-40%. **Analysis of Options:** * **B. Intramural thrombosis:** While very common (almost all large aneurysms contain laminated mural thrombus due to turbulent flow), it is usually an expected finding rather than a clinical "complication" that dictates management in the same way rupture does. * **C. Embolism:** Distal embolization of the mural thrombus (causing "Blue Toe Syndrome") can occur, but it is statistically less frequent than rupture in aneurysms of this massive size. * **D. Calcification:** This is a feature of the underlying atherosclerotic process within the aneurysmal wall, not a complication of the aneurysm itself. **Clinical Pearls for NEET-PG:** * **Indications for Surgery:** Repair is generally indicated if the AAA is **>5.5 cm in men**, **>5.0 cm in women**, or if it grows **>0.5 cm in 6 months**. * **Triad of Rupture:** Hypotension, pulsatile abdominal mass, and back/abdominal pain. * **Most common site:** Infrarenal (between the renal arteries and the aortic bifurcation). * **Screening:** USG is the investigation of choice for screening; CT Angiography is the gold standard for surgical planning.

Question 123: The Fontaine and Rutherford classification of peripheral arterial disease is based on which of the following?

A. Clinical presentation (Correct Answer)
B. Severity of arterial stenosis on imaging
C. Both clinical presentation and severity of arterial stenosis on imaging
D. All of the above

Explanation: **Explanation:** The **Fontaine** and **Rutherford** classifications are the two primary clinical grading systems used to assess the severity of **Peripheral Arterial Disease (PAD)**. Both systems are based entirely on **clinical presentation** (symptoms and physical findings) rather than anatomical imaging. 1. **Why Option A is correct:** These classifications categorize PAD based on the progression of symptoms—ranging from asymptomatic disease to intermittent claudication, rest pain, and finally, tissue loss (ulceration or gangrene). They allow clinicians to standardize the patient's functional status and guide management decisions (e.g., conservative vs. surgical) without needing an angiogram. 2. **Why Options B, C, and D are wrong:** While imaging (Duplex Ultrasound, CT Angiography, or DSA) is used to determine the *anatomical* site and severity of stenosis (e.g., TASC II classification), it is not a component of the Fontaine or Rutherford scales. A patient can have significant stenosis on imaging but remain in a low Fontaine stage if they are asymptomatic. **High-Yield Clinical Pearls for NEET-PG:** * **Fontaine Classification:** * Stage I: Asymptomatic * Stage II: Intermittent Claudication (IIa >200m; IIb <200m) * Stage III: Rest Pain * Stage IV: Ulceration/Gangrene * **Rutherford Classification:** Uses 7 categories (0–6) and 4 grades. It is more detailed than Fontaine and includes objective findings like treadmill exercise tests. * **Critical Limb Ischemia (CLI):** Defined as Fontaine Stage III/IV or Rutherford Category 4/5/6. * **TASC II Classification:** Unlike the clinical Fontaine/Rutherford scales, TASC II is based on **anatomical distribution** and length of the lesion to decide between endovascular vs. open surgery.

Question 124: True about aortic transection?

A. Most commonly due to deceleration injury
B. High mortality
C. Surgery is the definitive treatment
D. All of the above (Correct Answer)

Explanation: **Explanation:** Aortic transection (Traumatic Aortic Disruption) is a life-threatening emergency typically resulting from high-energy blunt trauma. 1. **Mechanism (Option A):** The most common cause is a **sudden deceleration injury** (e.g., high-speed motor vehicle accidents or falls from heights). The heart and great vessels move forward while the descending aorta is fixed to the posterior chest wall. This creates a shear force, most commonly at the **aortic isthmus** (just distal to the left subclavian artery), where the mobile arch meets the fixed descending aorta. 2. **Mortality (Option B):** It carries a **very high mortality rate**. Approximately 80-85% of patients die at the scene due to complete rupture. Of those who reach the hospital alive, mortality remains high if not diagnosed and stabilized immediately. 3. **Treatment (Option C):** While initial management involves strict blood pressure and heart rate control (Beta-blockers), **surgery is the definitive treatment**. Modern management has shifted towards **TEVAR (Thoracic Endovascular Aortic Repair)** as the preferred definitive modality over open surgery due to lower morbidity. **Why "All of the above" is correct:** All three statements accurately describe the pathophysiology, prognosis, and management of aortic transection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site:** Aortic Isthmus (distal to the origin of the left subclavian artery). * **Chest X-ray findings:** Widened mediastinum (>8 cm), obliteration of the aortic knob, apical cap sign, and deviation of the nasogastric tube to the right. * **Gold Standard Investigation:** CT Angiography (CTA) is the diagnostic study of choice in hemodynamically stable patients. * **Associated Injury:** Often associated with first and second rib fractures.

Question 125: In the abdomen, aneurysms of which vessel commonly occur next only to the aorta?

A. Internal iliac artery
B. External iliac artery
C. Splenic artery (Correct Answer)
D. Inferior mesenteric artery

Explanation: **Explanation:** The **Splenic artery** is the most common site for visceral artery aneurysms (VAAs) and the second most common site for intra-abdominal aneurysms overall, following the abdominal aorta. **Why Splenic Artery is Correct:** Splenic artery aneurysms (SAAs) account for approximately **60% of all visceral artery aneurysms**. They are more common in females (4:1 ratio) and are strongly associated with conditions that increase splenic blood flow or weaken the arterial wall, such as multiple pregnancies (due to hormonal changes and portal congestion), portal hypertension, and medial dysplasia. **Analysis of Incorrect Options:** * **Internal and External Iliac Arteries:** While iliac artery aneurysms are common, they are usually associated with the extension of an Abdominal Aortic Aneurysm (AAA). Isolated iliac aneurysms are relatively rare compared to the high incidence of splenic artery involvement. * **Inferior Mesenteric Artery (IMA):** Aneurysms of the IMA are extremely rare, accounting for less than 1% of all visceral aneurysms. **High-Yield Clinical Pearls for NEET-PG:** * **The "Double Rupture" Phenomenon:** An SAA may first rupture into the lesser sac (tamponade effect) and later into the general peritoneal cavity through the Foramen of Winslow, leading to sudden cardiovascular collapse. * **Indications for Surgery:** Treatment is generally indicated if the aneurysm is **>2 cm**, in **pregnant women**, or in women of childbearing age (due to the high risk of rupture during pregnancy, which carries a maternal mortality rate of ~70%). * **Radiological Sign:** On a plain X-ray, an SAA may appear as a "eggshell" calcification in the left upper quadrant.

Question 126: Varicose veins of size less than what measurement can be best treated by sclerotherapy?

A. 2 mm
B. 3 mm (Correct Answer)
C. 4 mm
D. 6 mm

Explanation: **Explanation:** The management of varicose veins is determined primarily by the diameter of the vessel and the presence of axial reflux. **Sclerotherapy** is the treatment of choice for small-caliber veins, specifically those **less than 3 mm** in diameter. * **Why 3 mm is correct:** According to the classification of chronic venous disorders, veins are categorized by size. **Reticular veins** (1–3 mm) and **telangiectasias** (spider veins, <1 mm) respond best to sclerotherapy. When the vein diameter exceeds 3 mm, they are classified as "true" varicose veins, which often involve truncal reflux (Great or Short Saphenous Veins). In these larger vessels, sclerotherapy has a higher failure rate and a significant risk of recurrence compared to endovenous thermal ablation or surgery. * **Why other options are incorrect:** * **2 mm:** While sclerotherapy works well for 2 mm veins, the clinical threshold for transitioning from sclerotherapy to more invasive procedures is generally accepted as 3 mm. * **4 mm and 6 mm:** Veins of this size are typically truncal varicosities. Treating these with liquid or foam sclerotherapy alone (without addressing the saphenofemoral junction) leads to high rates of thrombophlebitis and recanalization. **High-Yield Clinical Pearls for NEET-PG:** 1. **Sclerosants used:** Sodium Tetradecyl Sulfate (STS) is the most common. Others include Polidocanol and Hypertonic saline. 2. **Mechanism:** Sclerosants cause endothelial damage, leading to fibrosis and permanent occlusion of the vessel (obliterative sclerosis). 3. **Gold Standard for Diagnosis:** Duplex Ultrasound is the investigation of choice for all varicose veins. 4. **Treatment Hierarchy:** * <3 mm: Sclerotherapy. * >3 mm/Truncal Reflux: Endovenous Laser Ablation (EVLA) or Radiofrequency Ablation (RFA) is now preferred over traditional stripping.

Question 127: What is the procedure of choice for the evaluation of an aortic aneurysm?

A. Ultrasound (USG)
B. Computed Tomography (CT) (Correct Answer)
C. Magnetic Resonance Imaging (MRI)
D. Angiography

Explanation: **Explanation:** The gold standard and procedure of choice for the evaluation of an aortic aneurysm (specifically Abdominal Aortic Aneurysm - AAA) is **Contrast-Enhanced Computed Tomography (CECT)**. **Why CT is the Correct Choice:** CT provides precise anatomical detail, including the maximum diameter of the aneurysm, its longitudinal extent, and its relationship to the renal and iliac arteries. It is essential for **pre-operative planning** (determining suitability for EVAR vs. open repair) and can detect signs of impending rupture (e.g., "draped aorta" sign) or retroperitoneal hemorrhage. **Analysis of Incorrect Options:** * **Ultrasound (USG):** While USG is the investigation of choice for **screening** and longitudinal **monitoring** of small asymptomatic aneurysms due to its low cost and lack of radiation, it is operator-dependent and less accurate for surgical planning. * **MRI:** Offers excellent detail without ionizing radiation, but it is time-consuming, expensive, and often impractical in emergency settings or for patients with metallic implants. * **Angiography:** Historically the gold standard, it is now rarely used for diagnosis. It is an invasive procedure that only visualizes the **lumen**; if a large mural thrombus is present, angiography may underestimate the true size of the aneurysm. **High-Yield Clinical Pearls for NEET-PG:** * **Screening/Initial Investigation:** Ultrasound. * **Pre-operative Planning/Evaluation:** CT Scan. * **Indication for Surgery:** Diameter >5.5 cm in men, >5.0 cm in women, or rapid expansion (>0.5 cm in 6 months). * **Most common site:** Infra-renal (between the renal arteries and the aortic bifurcation). * **Triad of Ruptured AAA:** Hypotension, pulsatile abdominal mass, and back/abdominal pain.

Question 128: What is the most common cause of abdominal aortic aneurysm?

A. Atherosclerosis (Correct Answer)
B. Trauma
C. Syphilis
D. Vasculitis

Explanation: **Explanation:** **1. Why Atherosclerosis is the Correct Answer:** Atherosclerosis is the leading cause of Abdominal Aortic Aneurysms (AAA). The pathophysiology involves the chronic inflammation of the arterial wall, leading to the degradation of elastin and collagen by matrix metalloproteinases (MMPs). This weakens the tunica media, causing the vessel wall to lose its structural integrity and dilate under physiological pressure. Most AAAs are "true aneurysms" (involving all three layers) and are typically located **infra-renally**. **2. Why the Other Options are Incorrect:** * **Trauma:** More commonly leads to "pseudoaneurysms" or aortic transection (typically at the aortic isthmus), rather than chronic aneurysmal dilation. * **Syphilis:** Historically associated with aneurysms, but it characteristically affects the **ascending aorta** (thoracic aorta) due to endarteritis obliterans of the vasa vasorum. It is now rare due to antibiotic availability. * **Vasculitis:** Conditions like Takayasu arteritis or Giant Cell Arteritis can cause aneurysms, but these are significantly less common than atherosclerotic causes. **3. High-Yield Clinical Pearls for NEET-PG:** * **Definition:** An aneurysm is defined as a focal dilation of the artery >50% of its normal diameter (for the aorta, usually **>3 cm**). * **Risk Factors:** Smoking is the strongest modifiable risk factor. Others include male gender, age >65, and family history. * **Screening:** USG is the investigation of choice for screening; CT Angiography is the gold standard for surgical planning. * **Surgical Threshold:** Intervention (EVAR or Open Repair) is generally indicated if the diameter is **>5.5 cm in men** or **>5.0 cm in women**, or if it grows >0.5 cm in 6 months.

Question 129: What is the commonest complication of varicose vein stripping?

A. Thromboembolism
B. Hemorrhage
C. Ecchymosis (Correct Answer)
D. Infection

Explanation: **Explanation:** Varicose vein stripping (Babcock’s procedure) involves the surgical removal of the Great Saphenous Vein (GSV) using a stripper. **1. Why Ecchymosis is the Correct Answer:** Ecchymosis (bruising) is the **most common** complication following stripping. During the procedure, as the stripper is pulled through the subcutaneous tissue, small tributary veins are torn. This leads to localized extravasation of blood into the surrounding tissues along the stripping track. While it is benign and usually resolves within a few weeks, it occurs in nearly all patients to some degree. **2. Analysis of Incorrect Options:** * **Thromboembolism (DVT/PE):** While this is the most **serious** or dreaded complication, it is relatively rare (occurring in <1% of cases) due to early postoperative mobilization. * **Hemorrhage:** Significant intraoperative or postoperative bleeding is uncommon if proper pressure bandages are applied immediately after stripping. * **Infection:** Surgical site infection (SSI) occurs in approximately 2–5% of cases, making it less frequent than ecchymosis. **3. High-Yield Clinical Pearls for NEET-PG:** * **Commonest Nerve Injury:** The **Saphenous nerve** (at the ankle) is the most common nerve injured during GSV stripping, leading to numbness along the medial aspect of the leg/foot. * **Sural Nerve Injury:** Occurs during Small Saphenous Vein (SSV) surgery. * **Trendelenburg Procedure:** Refers to juxtafemoral ligation (high ligation) of the GSV at the saphenofemoral junction. * **Modern Gold Standard:** Endovenous Thermal Ablation (EVLA/RFA) has largely replaced stripping as it avoids ecchymosis and nerve injury.

Question 130: What is the most common site of acute aortic dissection?

A. Right lateral wall of the ascending aorta (Correct Answer)
B. Arch of the aorta
C. Suprarenal abdominal aorta
D. Infrarenal abdominal aorta

Explanation: **Explanation:** **1. Why Option A is Correct:** The most common site for the initiation of an acute aortic dissection is the **ascending aorta**, specifically the **right lateral wall** (within 2–3 cm of the aortic valve). This is due to the unique hemodynamics of the proximal aorta: this area experiences the highest **shear stress** ($dP/dt$) from the forceful ejection of blood from the left ventricle. The right lateral wall bears the brunt of this repetitive mechanical trauma, leading to an intimal tear that allows blood to enter the media. **2. Why the Other Options are Incorrect:** * **Option B (Arch of the aorta):** While dissections can involve the arch, it is a less frequent site for the primary intimal tear compared to the ascending aorta. * **Option C & D (Abdominal Aorta):** Dissections rarely originate in the abdominal aorta. When they do, it is usually associated with localized pathology like an aneurysm or trauma. Most abdominal aortic involvements are extensions of a Stanford Type B dissection originating in the descending thoracic aorta (just distal to the left subclavian artery). **3. NEET-PG High-Yield Pearls:** * **Classification:** * **Stanford Type A:** Involves ascending aorta (Requires urgent surgery). * **Stanford Type B:** Distal to left subclavian artery (Managed medically unless complications arise). * **Risk Factors:** Hypertension is the #1 risk factor. Genetic conditions like Marfan Syndrome and Ehlers-Danlos are high-yield associations. * **Clinical Sign:** "Tearing" chest pain radiating to the back with a **blood pressure discrepancy** between arms. * **Investigation of Choice:** **Contrast-Enhanced CT (CECT)** is the gold standard for diagnosis in stable patients; Transesophageal Echo (TEE) is preferred for unstable patients.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

Practice Questions

Venous Thromboembolism

Practice Questions

Chronic Venous Insufficiency

Practice Questions

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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