Vascular Surgery Practice Questions

Q: Diagnosis of thoracic outlet syndrome is made by which one of the following?

Clinical evaluation. **Explanation:** Thoracic Outlet Syndrome (TOS) is primarily a **clinical diagnosis**. It refers to the compression of the neurovascular bundle (brachial plexus, subclavian artery, or subclavian vein) as it passes through the thoracic outlet. 1. **Why Clinical Evaluation is Correct:** The diagnosis is established through a detailed history and provocative physical examination maneuvers. Since over 90% of TOS cases are **neurogenic** (involving the brachial plexus), they often do not show structural abnormalities on routine imaging. Clinical tests like **Adson’s test**, **Roos test (Elevated Arm Stress Test)**, and **Wright’s test** are the mainstays for identifying the site of compression. 2. **Why Other Options are Incorrect:** * **CT Scan & MRI:** These are supportive investigations used to rule out differential diagnoses (like cervical disc prolapse) or to identify anatomical predispositions (like a cervical rib or fibrous bands). However, they cannot confirm the functional compression that occurs during movement. * **Angiography:** This is only indicated in **Vascular TOS** (Arterial or Venous), which accounts for less than 5% of cases. It is not the primary diagnostic tool for the most common neurogenic variety. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Neurogenic TOS (95%). * **Most common site of compression:** Interscalene triangle. * **Adson’s Test:** Loss of radial pulse when the patient extends the neck and turns the head *toward* the affected side while taking a deep breath. * **Roos Test:** The most reliable screening test (patient opens/closes hands for 3 minutes with arms abducted). * **Cervical Rib:** The most common bony abnormality associated with TOS.

Q: What is the most common complication of below-knee stripping of varicose veins?

Neuralgia. The correct answer is **Neuralgia (C)**. ### **Explanation** The primary surgical treatment for varicose veins involves high ligation and stripping of the Great Saphenous Vein (GSV). Below the knee, the GSV runs in close anatomical proximity to the **Saphenous Nerve**. During the stripping process, particularly if the vein is stripped downward to the ankle, the nerve is frequently stretched, bruised, or severed. This leads to postoperative **neuralgia** or paresthesia along the medial aspect of the leg and foot. To minimize this risk, modern surgical practice often limits stripping to the level of the knee (proximal stripping). ### **Why other options are incorrect:** * **Hemorrhage (A):** While bruising (ecchymosis) is very common, significant hemorrhage is rare if proper pressure bandages are applied postoperatively. * **Thromboembolism (B):** Deep Vein Thrombosis (DVT) and Pulmonary Embolism are serious but rare complications (occurring in <1% of cases) due to early ambulation protocols. * **Infection (D):** Wound infection occurs in approximately 2–5% of cases, making it less frequent than sensory nerve injury. ### **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured in GSV stripping:** Saphenous Nerve (causes medial leg numbness). * **Most common nerve injured in Short Saphenous Vein (SSV) surgery:** Sural Nerve (causes lateral foot numbness). * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Gold Standard Investigation:** Duplex Ultrasound is the investigation of choice for varicose veins. * **Complication Prevention:** Stripping the vein from **below upwards** (distal to proximal) or limiting stripping to the knee reduces the incidence of saphenous neuralgia.

Q: An arteriogram of a 75-year-old man with an asymptomatic carotid bruit, mild hypertension, and mild COPD is shown. What is the current recommended management for this patient?

Carotid endarterectomy. ***Carotid endarterectomy*** - **ACAS trial** evidence shows **CEA** reduces stroke risk by **53%** in asymptomatic patients with **≥60% stenosis** who have life expectancy >5 years. - **Mild COPD** and **mild hypertension** are not contraindications to CEA in a 75-year-old with good functional status. *Medical therapy with aspirin 325 mg/day and medical risk factor management* - While **antiplatelet therapy** is important, aspirin alone is **insufficient** for significant asymptomatic carotid stenosis (≥60-70%). - Medical management alone has **higher stroke risk** compared to CEA plus medical therapy in appropriate surgical candidates. *Medical therapy with warfarin* - **Warfarin** is not indicated for **carotid artery stenosis** and does not reduce stroke risk in this condition. - **Anticoagulation** carries **bleeding risks** without proven benefit for atherosclerotic carotid disease. *Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful* - **Carotid angioplasty** is typically reserved for **high-risk surgical candidates** or hostile neck anatomy. - **CEA remains gold standard** for asymptomatic stenosis in good surgical candidates based on **superior long-term outcomes**.

Q: A 40-year-old male, a chronic smoker, presents with claudication and a medial leg ulcer. For the past one month, he is experiencing rest pain. Which of the following procedures would not relieve his rest pain?

Femoropopliteal bypass. **Explanation:** The clinical presentation (young male, chronic smoker, claudication, rest pain, and medial leg ulcer) is highly suggestive of **Buerger’s Disease (Thromboangiitis Obliterans - TAO)**. **1. Why Femoropopliteal Bypass is the Correct Answer:** Buerger’s disease is characterized by **segmental, inflammatory involvement of small and medium-sized arteries** (distal to the knee or elbow). Because the disease typically involves the distal infrapopliteal vessels (tibial and peroneal arteries), there is usually no "run-off" vessel available to receive a graft. Therefore, a proximal bypass like a **Femoropopliteal bypass is not feasible or effective** because the distal target vessels are occluded. **2. Analysis of Other Options:** * **Lumbar Sympathectomy:** This is a classic palliative treatment for TAO. It reduces vasomotor tone, increases skin blood flow, and helps in relieving rest pain and promoting the healing of small ulcers. * **Omentopexy:** This involves mobilizing the omentum and bringing it down to the limb. The omentum produces angiogenic factors (VEGF) that promote collateral circulation, which can relieve rest pain in patients with no distal bypass options. * **Conservative Amputation:** In cases of gangrene or intractable rest pain where revascularization is impossible, a conservative (minor) amputation of a toe or part of the foot can remove the source of pain and infection. **Clinical Pearls for NEET-PG:** * **Buerger’s Disease Triad:** Claudication (often arch of foot), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Gold Standard Diagnosis:** Angiography showing a **"Corkscrew" appearance** of collateral vessels. * **Most Important Management:** Absolute smoking cessation (the only way to stop disease progression). * **Medial Leg Ulcer:** While classically associated with venous stasis, in TAO, it represents ischemic ulceration due to distal small vessel occlusion.

Q: Which of the following is NOT a risk factor for the development of critical limb ischemia?

Moderate alcohol intake. **Explanation:** Critical Limb Ischemia (CLI) is the most advanced stage of Peripheral Arterial Disease (PAD), characterized by chronic ischemic rest pain, ulcers, or gangrene. The pathophysiology involves systemic atherosclerosis, and its risk factors are identical to those of coronary artery disease. **Why Moderate Alcohol Intake is the Correct Answer:** Moderate alcohol consumption (typically defined as 1–2 drinks per day) has not been proven to be a risk factor for CLI. In fact, several epidemiological studies suggest a "U-shaped" relationship, where moderate intake may have a mild protective effect on the vascular endothelium and lipid profiles, unlike heavy consumption which increases cardiovascular risk. **Analysis of Incorrect Options:** * **Diabetes Mellitus:** This is the most potent risk factor for CLI. It promotes "Mönckeberg’s medial calcification" and leads to multisegmental, infrapopliteal (below-the-knee) arterial involvement, significantly increasing the risk of amputation. * **Hyperlipidemia:** Elevated LDL and low HDL levels promote the formation of atherosclerotic plaques within the arterial walls, narrowing the lumen and reducing distal perfusion. * **Hyperhomocysteinemia:** High levels of homocysteine cause endothelial damage and promote a pro-thrombotic state, acting as an independent risk factor for premature atherosclerosis and CLI. **Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Smoking is the most significant modifiable risk factor for PAD/CLI. * **Fontaine Classification:** Stage III (Rest pain) and Stage IV (Ulceration/Gangrene) constitute CLI. * **Ankle-Brachial Index (ABI):** An ABI < 0.4 is typically associated with Critical Limb Ischemia. * **TASC II Criteria:** Used for the management of aorto-iliac and femoropopliteal lesions.

Q: Intermittent claudication at the hip level indicates which of the following?

Bilateral iliac artery occlusion. **Explanation:** The level of intermittent claudication (pain induced by exercise and relieved by rest) is a reliable clinical indicator of the anatomical site of arterial obstruction. The pain always occurs **distal** to the level of the occlusion. **1. Why Bilateral Iliac Artery Occlusion is Correct:** The internal iliac arteries supply the gluteal muscles (hip region). Therefore, an occlusion at or above the level of the **iliac arteries** (Aorto-iliac segment) results in claudication felt in the hips, buttocks, and thighs. When this occurs bilaterally, it is often associated with Leriche Syndrome (aortoiliac occlusive disease), characterized by the triad of hip/buttock claudication, erectile dysfunction, and absent femoral pulses. **2. Why the Other Options are Incorrect:** * **Popliteal artery occlusion:** This would typically cause claudication in the **lower calf** and foot. * **Common femoral artery occlusion:** This results in claudication of the **thigh** and calf muscles, but usually spares the hip/gluteal region as the internal iliac artery (which supplies the hip) remains patent. * **Superficial femoral artery (SFA) occlusion:** This is the most common site of occlusion in peripheral arterial disease (PAD). It characteristically causes **mid-calf claudication**. **Clinical Pearls for NEET-PG:** * **Rule of Thumb:** The site of obstruction is usually one joint proximal to the site of symptoms. * **Leriche Syndrome Triad:** 1. Buttock/Hip claudication, 2. Impotence, 3. Absent/diminished femoral pulses. * **Most common site of PAD:** Superficial Femoral Artery (within the Adductor/Hunter’s canal). * **Investigation of choice:** Duplex Ultrasound is the initial screen; CT Angiography is the gold standard for anatomical mapping before intervention.

Question 1

Diagnosis of thoracic outlet syndrome is made by which one of the following?

Accepted Answer

Clinical evaluation

Answer

CT scan

Answer

MRI

Answer

Angiography

Question 2

What is the most common complication of below-knee stripping of varicose veins?

Accepted Answer

Neuralgia

Answer

Hemorrhage

Answer

Thromboembolism

Answer

Infection

Question 3

An arteriogram of a 75-year-old man with an asymptomatic carotid bruit, mild hypertension, and mild COPD is shown. What is the current recommended management for this patient?

Accepted Answer

Carotid endarterectomy

Answer

Medical therapy with aspirin 325 mg/day and medical risk factor management

Answer

Medical therapy with warfarin

Answer

Angioplasty of the carotid lesion followed by carotid endarterectomy if the angioplasty is unsuccessful

Question 4

A 40-year-old male, a chronic smoker, presents with claudication and a medial leg ulcer. For the past one month, he is experiencing rest pain. Which of the following procedures would not relieve his rest pain?

Accepted Answer

Femoropopliteal bypass

Answer

Lumbar sympathectomy

Answer

Omentopexy

Answer

Conservative amputation

Question 5

Which of the following is NOT a risk factor for the development of critical limb ischemia?

Accepted Answer

Moderate alcohol intake

Answer

Diabetes

Answer

Hyperlipidemia

Answer

Hyperhomocysteinemia

Question 6

Intermittent claudication at the hip level indicates which of the following?

Accepted Answer

Bilateral iliac artery occlusion

Answer

Popliteal artery occlusion

Answer

Common femoral artery occlusion

Answer

Superficial femoral artery occlusion

Question 7

What are the causes of unilateral lymphedema of the leg that should be investigated?

Accepted Answer

Taking a family history, Looking for chronic infection in the foot, Performing a Casoni test

Answer

Taking a family history, Looking for chronic infection in the foot, Looking for filariasis

Answer

Taking a family history, Looking for chronic infection in the foot, Looking for early malignant disease of the testis

Answer

Taking a family history, Looking for chronic infection in the foot, Looking for early malignant disease of the testis, Looking for filariasis, Performing a Casoni test

Question 8

Regarding varicose veins, which one of the following statements is true?

Accepted Answer

5% oily phenol is used as a sclerosant in venous sclerotherapy.

Answer

Over 20% of varicose veins are recurrent varicosities.

Answer

The sural nerve is in danger during stripping of the long saphenous vein.

Answer

The superficial venous system is closely associated with the short saphenous vein.

Question 9

Which of the following statements about carotid stenosis is true?

Accepted Answer

Aspirin therapy can reduce the risk of Transient Ischemic Attack (TIA).

Answer

Ipsilateral hemiplegia is caused by embolism of the Middle Cerebral Artery (MCA).

Answer

A bruit reliably indicates the severity of stenosis.

Answer

Carotid stenosis is common in the External carotid artery.

Question 10

Which of the following is NOT a bypass procedure used in the surgical management of lymphedema?

Accepted Answer

Homan's operation

Answer

Handley's operation

Answer

Kinmonth operation

Answer

Gillies operation

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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