Vascular Surgery — MCQs
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Intermittent claudication is defined as?
Spring water cyst is another name for which of the following?
A 65-year-old female presents for a routine examination and is found to have a pulsatile abdominal mass. She has a history of hypertension but is otherwise healthy. Her father died from a ruptured abdominal aortic aneurysm. What are the acceptable reasons to operate on a 5-cm infrarenal abdominal aortic aneurysm in this patient?
What is true about mesenteric vein thrombosis?
Which of the following is a cause of peripheral arterial occlusive disease?
Which of the following is NOT used in the treatment of superficial venous thrombosis?
Migratory thrombophlebitis is most commonly seen with which of the following malignancies?
Thromboangiitis obliterans (Buerger's disease) primarily involves which of the following vessels?
Ischaemia is characterized by all except?
White leg (phlegmasia alba dolens) is due to?
Vascular Surgery Indian Medical PG Practice Questions and MCQs
Question 141: Intermittent claudication is defined as?
- A. Pain in muscle at rest.
- B. Pain in muscle on the first step.
- C. Pain in muscle on exercise. (Correct Answer)
- D. Pain in muscle on the last step.
Explanation: **Explanation:** **Intermittent Claudication** is the hallmark symptom of Peripheral Arterial Disease (PAD). It is defined as a reproducible discomfort, ache, or pain in a muscle group that is **induced by exercise and relieved by rest** (usually within 2–5 minutes). **1. Why Option C is correct:** The underlying pathophysiology is a **supply-demand mismatch**. At rest, the stenosed arteries provide sufficient blood flow to meet the metabolic needs of the muscles. However, during exercise, the metabolic demand for oxygen increases significantly. Due to the proximal arterial obstruction, the blood flow cannot increase sufficiently, leading to anaerobic metabolism and the accumulation of lactate and other metabolites, which stimulate sensory nerve endings, causing pain. **2. Why other options are incorrect:** * **Option A (Pain at rest):** This represents **Rest Pain**, which signifies a more advanced stage of PAD (Fontaine Stage III). It indicates that blood flow is insufficient even for basic metabolic requirements. * **Option B & D:** These are not clinical definitions. Claudication is characterized by a "claudication distance"—the specific distance a patient can walk before pain forces them to stop—rather than occurring on the very first or last step specifically. **Clinical Pearls for NEET-PG:** * **Fontaine Classification:** Stage I (Asymptomatic), Stage II (Claudication), Stage III (Rest pain), Stage IV (Ulceration/Gangrene). * **Site of Pain:** The pain occurs one level distal to the site of obstruction (e.g., Calf pain = Superficial Femoral Artery; Buttock/Thigh pain = Aorto-iliac disease/Leriche Syndrome). * **Ankle-Brachial Index (ABI):** Claudicants typically have an ABI between **0.5 and 0.9**. * **Management:** The first-line treatment for stable intermittent claudication is **supervised exercise therapy** and smoking cessation.
Question 142: Spring water cyst is another name for which of the following?
- A. Hydatid cyst of lung
- B. Lung amoebic cyst
- C. Pleuropericardial cyst (Correct Answer)
- D. Enterogenous cyst
Explanation: ### Explanation **Correct Answer: C. Pleuropericardial cyst** **Why it is correct:** A **Pleuropericardial cyst** (also known as a pericardial cyst) is a benign, congenital malformation resulting from the failure of the primitive pleuropericardial lacunae to fuse. These cysts are typically filled with a clear, straw-colored, or water-like fluid, which gives them the classic descriptive name **"Spring water cyst."** On imaging, they are most commonly located at the **right cardiophrenic angle** (70% of cases), followed by the left cardiophrenic angle. **Why the other options are incorrect:** * **A. Hydatid cyst of lung:** Caused by *Echinococcus granulosus*, these are characterized by signs like the "Water lily sign" (Casoni’s test is historical). They contain "hydatid sand" rather than simple spring water fluid. * **B. Lung amoebic cyst:** These are usually complications of hepatic amoebiasis (Entamoeba histolytica) rupturing through the diaphragm. They are characterized by **"Anchovy sauce"** sputum/pus, not clear fluid. * **D. Enterogenous cyst:** These are posterior mediastinal masses derived from the primitive foregut. They are often associated with vertebral anomalies and contain mucoid material, not clear "spring water." **High-Yield Pearls for NEET-PG:** * **Most common location:** Right cardiophrenic angle. * **Clinical presentation:** Usually asymptomatic and discovered incidentally on a chest X-ray. * **Differential Diagnosis of Anterior Mediastinal Mass (The 4 Ts):** Thymoma, Teratoma, Thyroid (Retrosternal Goiter), and "Terrible" Lymphoma. Note that pericardial cysts are technically located in the **middle mediastinum** (specifically the anterior-inferior portion). * **Management:** Observation if asymptomatic; surgical excision or percutaneous aspiration if symptomatic (causing chest pain or arrhythmias).
Question 143: A 65-year-old female presents for a routine examination and is found to have a pulsatile abdominal mass. She has a history of hypertension but is otherwise healthy. Her father died from a ruptured abdominal aortic aneurysm. What are the acceptable reasons to operate on a 5-cm infrarenal abdominal aortic aneurysm in this patient?
- A. Presence of the aneurysm
- B. Aneurysm with intramural thrombus
- C. Asymptomatic aneurysm measuring 5.5 cm (Correct Answer)
- D. Associated 2-cm iliac aneurysm
Explanation: **Explanation:** The management of an Abdominal Aortic Aneurysm (AAA) is primarily dictated by the risk of rupture versus the risk of surgical intervention. The threshold for elective repair is based on the diameter where the annual risk of rupture exceeds the risk of perioperative mortality. **Why Option C is correct:** In asymptomatic patients, the standard threshold for elective surgical repair (Open or EVAR) is a diameter of **≥5.5 cm in men** and **≥5.0 cm to 5.5 cm in women**. Since this patient has a 5-cm aneurysm, it does not yet meet the absolute size criteria for surgery; however, reaching the 5.5 cm mark (as stated in the option) is a definitive indication for intervention. **Why the other options are incorrect:** * **Option A:** The mere presence of an aneurysm is not an indication for surgery. Small aneurysms (<5.0 cm) are managed with surveillance (ultrasound) and risk factor modification (smoking cessation, statins, and BP control). * **Option B:** Intramural thrombus is a common finding in AAA and does not independently necessitate surgery unless it causes distal embolization ("Blue Toe Syndrome"). * **Option C:** An isolated iliac artery aneurysm generally requires repair only when it reaches **≥3.5 cm**. A 2-cm iliac aneurysm is managed conservatively. **High-Yield Clinical Pearls for NEET-PG:** 1. **Indications for AAA Repair:** * Diameter ≥5.5 cm (Men) or ≥5.0 cm (Women). * Rapid expansion: >0.5 cm in 6 months or >1 cm in 1 year. * Symptomatic aneurysm (tenderness, back pain, or distal emboli). 2. **Risk Factors:** Smoking is the strongest risk factor for development/expansion; Family history is a significant predictor. 3. **Screening:** A one-time USG is recommended for men aged 65–75 who have ever smoked. 4. **Most common site:** Infrarenal (between renal arteries and aortic bifurcation).
Question 144: What is true about mesenteric vein thrombosis?
- A. Peritoneal signs are always present.
- B. It invariably involves a long length of bowel.
- C. Intravenous heparin is the treatment of choice.
- D. Surgery can lead to short-bowel syndrome. (Correct Answer)
Explanation: **Explanation:** Mesenteric Vein Thrombosis (MVT) accounts for approximately 5–15% of all mesenteric ischemic events. Understanding its pathophysiology and clinical course is crucial for NEET-PG. **Why Option D is Correct:** MVT often presents with segmental ischemia, but in severe cases, it can involve extensive segments of the small intestine. If the thrombus propagates or diagnosis is delayed, massive bowel gangrene occurs. Surgical resection of these long necrotic segments is the only life-saving measure, which subsequently results in **Short Bowel Syndrome (SBS)**, leading to permanent malabsorption and dependence on total parenteral nutrition. **Analysis of Incorrect Options:** * **Option A:** Peritoneal signs (guarding, rigidity) are **late findings**. MVT typically presents with "pain out of proportion to physical examination." Peritonitis only develops once transmural infarction and gangrene have occurred. * **Option B:** While it can be extensive, it does **not invariably** involve a long length. It can be localized to a single venous tributary, leading to segmental ischemia, which carries a better prognosis than arterial occlusion. * **Option C:** While anticoagulation (Heparin) is the mainstay of medical management to prevent thrombus propagation, it is **not the "treatment of choice" if there are signs of bowel infarction**. In the presence of gangrene, **emergency surgery (resection)** is the definitive treatment. **High-Yield Clinical Pearls for NEET-PG:** * **Etiology:** Most commonly associated with **hypercoagulable states** (Protein C/S deficiency, Factor V Leiden) or portal hypertension. * **Diagnosis:** **Contrast-enhanced CT (CECT)** is the gold standard (shows the "rim sign" or "target sign" and filling defects in the vein). * **Management:** If no peritonitis, start immediate systemic anticoagulation. If peritonitis is present, proceed to laparotomy. * **Prognosis:** MVT has a lower mortality rate (approx. 20-30%) compared to mesenteric arterial embolism.
Question 145: Which of the following is a cause of peripheral arterial occlusive disease?
- A. Buerger’s disease
- B. SLE
- C. Takayasu arteritis
- D. All of the above (Correct Answer)
Explanation: **Explanation:** Peripheral Arterial Occlusive Disease (PAOD) refers to the narrowing or occlusion of arteries supplying the limbs, leading to reduced blood flow. While atherosclerosis is the most common cause, various inflammatory and autoimmune conditions can lead to arterial occlusion. * **Buerger’s Disease (Thromboangiitis Obliterans):** This is a non-atherosclerotic, segmental inflammatory disease strongly associated with tobacco use. It primarily affects small and medium-sized arteries and veins of the distal extremities, leading to ischemia, gangrene, and eventual occlusion. * **Systemic Lupus Erythematosus (SLE):** SLE can cause PAOD through multiple mechanisms, including premature atherosclerosis, vasculitis (inflammation of the vessel wall), and a prothrombotic state (often associated with Anti-Phospholipid Antibody Syndrome), all of which can result in arterial blockage. * **Takayasu Arteritis:** Known as "pulseless disease," this is a large-vessel vasculitis that primarily affects the aorta and its main branches. The resulting granulomatous inflammation leads to stenosis, occlusion, or aneurysms, frequently presenting as absent peripheral pulses. **Conclusion:** Since all three conditions involve mechanisms that lead to the narrowing or blockage of peripheral arteries, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Buerger’s Disease:** Characterized by the "corkscrew collaterals" on angiography and the classic triad of claudication, Raynaud’s phenomenon, and migratory superficial thrombophlebitis. * **Takayasu Arteritis:** Most common in young females; involves the subclavian artery most frequently, leading to blood pressure discrepancy between arms. * **Leriche Syndrome:** A specific form of PAOD involving aortoiliac occlusion, presenting with the triad of claudication (buttock/thigh), impotence, and absent femoral pulses.
Question 146: Which of the following is NOT used in the treatment of superficial venous thrombosis?
- A. Immediate anticoagulation
- B. Rest and elevation (Correct Answer)
- C. Analgesics
- D. Treat associated malignancy
Explanation: **Explanation:** Superficial Venous Thrombosis (SVT) is often considered a benign condition, but modern management focuses on preventing its progression to Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE). **Why "Rest and Elevation" is the correct answer (as the NOT used treatment):** Historically, SVT was treated with rest and elevation. However, current surgical guidelines (including ESVS and CHEST) emphasize **early mobilization** rather than rest. Prolonged immobilization (rest) is a major risk factor for Virchow’s triad, increasing the likelihood of thrombus propagation into the deep venous system via the saphenofemoral or saphenopopliteal junctions. Therefore, bed rest is now contraindicated. **Analysis of Incorrect Options:** * **Immediate Anticoagulation:** This is now a standard of care for SVT, especially if the thrombus is >5 cm in length or within 3 cm of the deep venous junction. Low Molecular Weight Heparin (LMWH) or Fondaparinux (the drug of choice based on the SURPRISE trial) are used to prevent thromboembolic complications. * **Analgesics:** NSAIDs are a cornerstone of symptomatic management to reduce pain and local inflammation associated with the thrombophlebitis. * **Treat associated malignancy:** Migratory superficial thrombophlebitis (**Trousseau sign**) is a classic paraneoplastic manifestation often associated with visceral cancers (e.g., pancreatic cancer). Identifying and treating the underlying malignancy is essential for definitive management. **NEET-PG High-Yield Pearls:** * **Drug of Choice:** Fondaparinux (2.5 mg subcutaneous daily for 45 days) is the preferred anticoagulant for SVT. * **Trousseau Sign:** Recurrent, migratory SVT at unusual sites; strongly suggests occult malignancy. * **Gold Standard Investigation:** Venous Duplex Ultrasound (to rule out concomitant DVT).
Question 147: Migratory thrombophlebitis is most commonly seen with which of the following malignancies?
- A. Testicular cancer
- B. Breast cancer
- C. Pancreatic cancer (Correct Answer)
- D. Liver cancer
Explanation: **Explanation:** **Migratory thrombophlebitis**, also known as **Trousseau sign of malignancy**, is a paraneoplastic syndrome characterized by recurrent episodes of superficial venous thrombosis that appear at different sites (migrating) over time. **Why Pancreatic Cancer is correct:** The association is strongest with **adenocarcinomas**, particularly **pancreatic cancer** (most commonly involving the body and tail). The underlying pathophysiology involves the release of procoagulants, such as **mucin** and tissue factor-like substances, from the tumor cells. these substances activate the coagulation cascade (specifically Factor X), leading to a hypercoagulable state and spontaneous clot formation in superficial veins. **Why other options are incorrect:** * **Testicular cancer:** While it can increase the risk of deep vein thrombosis (DVT) due to bulky lymphadenopathy causing venous stasis, it is not classically associated with migratory thrombophlebitis. * **Breast cancer:** Although breast cancer is a common malignancy that increases general VTE risk, it does not typically present with the specific "migratory" pattern seen in Trousseau syndrome. * **Liver cancer:** Hepatocellular carcinoma is more frequently associated with portal vein thrombosis or Budd-Chiari syndrome rather than systemic migratory superficial phlebitis. **High-Yield Clinical Pearls for NEET-PG:** * **Trousseau Sign:** Do not confuse this with the Trousseau sign of latent tetany (carpopedal spasm induced by BP cuff inflation). * **Location:** Pancreatic **body and tail** tumors are more likely to present with Trousseau syndrome than head tumors, as head tumors present earlier with obstructive jaundice. * **Other associated cancers:** Lung, gastric, and colon adenocarcinomas. * **Management:** The treatment of choice for cancer-associated thrombosis is generally **Low Molecular Weight Heparin (LMWH)**, as these patients often show resistance to warfarin.
Question 148: Thromboangiitis obliterans (Buerger's disease) primarily involves which of the following vessels?
- A. Anterior and posterior tibial arteries (Correct Answer)
- B. Femoral arteries
- C. Aortoiliac arteries
- D. Popliteal arteries
Explanation: **Explanation:** **Thromboangiitis obliterans (Buerger’s disease)** is a non-atherosclerotic, segmental, inflammatory vasculitis that predominantly affects **small and medium-sized arteries and veins** of the distal upper and lower extremities. 1. **Why Option A is Correct:** Buerger’s disease characteristically involves distal vessels. The **anterior and posterior tibial arteries** (along with the radial and ulnar arteries) are the classic medium-sized vessels targeted. The disease typically starts distally and progresses proximally, leading to digital ischemia, rest pain, and gangrene. Pathologically, it features a highly cellular "tobacco-associated" thrombus with relative sparing of the vessel wall. 2. **Why Other Options are Incorrect:** * **Options B, C, and D:** The femoral, aortoiliac, and popliteal arteries are **large-sized elastic/muscular arteries**. These vessels are the primary sites for **Atherosclerosis Obliterans (ASO)**. Buerger’s disease is distinguished from ASO by its predilection for distal vessels and the absence of traditional atherosclerotic risk factors (except smoking). **High-Yield Clinical Pearls for NEET-PG:** * **Patient Profile:** Young male smokers (usually <45 years). * **Triad:** Distal arterial ischemia, Raynaud’s phenomenon, and **Migratory Superficial Thrombophlebitis**. * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign) due to recanalization of the thrombus. * **Diagnosis:** Allen’s test is often positive (indicating distal ulnar/radial involvement). * **Management:** Absolute **smoking cessation** is the only definitive treatment to prevent amputation. Sympathectomy may be used for symptomatic relief in vasospastic cases.
Question 149: Ischaemia is characterized by all except?
- A. Brittle nails
- B. Thickening of skin (Correct Answer)
- C. Muscle wasting
- D. Loss of subcutaneous fat
Explanation: In chronic limb-threatening ischemia (CLTI), the fundamental pathophysiology is a **reduction in blood flow and nutrient delivery** to the distal tissues. This leads to **atrophic changes**, not hypertrophic ones. ### Why "Thickening of skin" is the correct answer: Ischemia causes the skin to become **thin, shiny, and atrophic** (parchment-like) due to the loss of dermal collagen and reduced cell turnover. Thickening of the skin (hyperkeratosis or lipodermatosclerosis) is typically a feature of **chronic venous insufficiency** or chronic lymphatic obstruction, rather than arterial ischemia. ### Analysis of Incorrect Options: * **Brittle nails:** Reduced blood supply to the nail matrix leads to trophic changes, causing the nails to become brittle, ridged, and slow-growing. (In some cases, they may appear thickened/hypertrophic due to fungal infections secondary to poor tissue health, but brittleness is a classic ischemic sign). * **Muscle wasting:** Chronic oxygen deprivation leads to myocyte atrophy and replacement of muscle fibers with fibrous tissue, clinically manifesting as a reduction in calf or thigh circumference. * **Loss of subcutaneous fat:** Ischemia leads to the depletion of the subcutaneous layer, contributing to the "skeletal" appearance of a chronically ischemic limb. ### NEET-PG High-Yield Pearls: * **Trophic Changes of Ischemia:** Remember the "4 Loses": Loss of hair, Loss of fat (subcutaneous), Loss of muscle (wasting), and Loss of skin thickness (atrophy). * **Buerger’s Test:** A positive test (pallor on elevation, rubor on dependency) is a hallmark of significant arterial ischemia. * **Critical Limb Ischemia (CLI) Definition:** Characterized by rest pain for >2 weeks, ulceration, or gangrene, corresponding to Fontaine stages III/IV or Rutherford categories 4-6.
Question 150: White leg (phlegmasia alba dolens) is due to?
- A. Femoral vein thrombosis and lymphatic obstruction
- B. Deep femoral vein thrombosis (Correct Answer)
- C. Lymphatic obstruction only
- D. None of the above
Explanation: **Explanation:** **Phlegmasia Alba Dolens** (literally "painful white edema") is a clinical manifestation of massive Deep Vein Thrombosis (DVT). **1. Why the correct answer is right:** The condition occurs due to extensive **Deep Venous Thrombosis** involving the major deep venous channels of the extremity (most commonly the iliofemoral segments), but with the **preservation of collateral venous circulation**. Because the superficial system remains patent, some venous return continues. However, the deep obstruction leads to significant edema. This interstitial pressure compromises capillary perfusion (but does not stop it), leading to a pale, "milky white" appearance of the limb. **2. Why the other options are wrong:** * **Option A:** While femoral vein thrombosis is involved, the primary pathology is venous, not lymphatic. Lymphatic obstruction is a secondary effect of massive edema, not the primary cause. * **Option C:** Pure lymphatic obstruction (Lymphedema) presents with "woody" non-pitting edema and skin changes, but it does not cause the acute, painful, pale swelling characteristic of Phlegmasia. **3. Clinical Pearls for NEET-PG:** * **The Progression:** Phlegmasia Alba Dolens (White leg) → Phlegmasia Cerulea Dolens (Blue leg) → Venous Gangrene. * **Phlegmasia Cerulea Dolens:** This is more severe. It involves thrombosis of **both deep and collateral (superficial) venous systems**. This leads to total venous stasis, severe cyanosis (blue leg), and high risk of gangrene. * **Clinical Triad:** Pain, massive swelling, and blanching (Alba) or cyanosis (Cerulea). * **Management:** Requires aggressive anticoagulation (Heparin) and often catheter-directed thrombolysis or thrombectomy to prevent limb loss.
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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