Vascular Surgery Practice Questions

Q: Intermittent claudication is defined as?

Pain in muscle on exercise.. **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.

Q: Spring water cyst is another name for which of the following?

Pleuropericardial cyst. ### 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).

Q: 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?

Asymptomatic aneurysm measuring 5.5 cm. **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).

Q: Which of the following is a cause of peripheral arterial occlusive disease?

All of the above. **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.

Q: Which of the following is NOT used in the treatment of superficial venous thrombosis?

Rest and elevation. **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).

Q: Migratory thrombophlebitis is most commonly seen with which of the following malignancies?

Pancreatic cancer. **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.

Q: Thromboangiitis obliterans (Buerger's disease) primarily involves which of the following vessels?

Anterior and posterior tibial arteries. **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.

Q: Ischaemia is characterized by all except?

Thickening of skin. 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.

Q: White leg (phlegmasia alba dolens) is due to?

Deep femoral vein thrombosis. **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.

Question 1

Intermittent claudication is defined as?

Accepted Answer

Pain in muscle on exercise.

Answer

Pain in muscle at rest.

Answer

Pain in muscle on the first step.

Answer

Pain in muscle on the last step.

Question 2

Spring water cyst is another name for which of the following?

Accepted Answer

Pleuropericardial cyst

Answer

Hydatid cyst of lung

Answer

Lung amoebic cyst

Answer

Enterogenous cyst

Question 3

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?

Accepted Answer

Asymptomatic aneurysm measuring 5.5 cm

Answer

Presence of the aneurysm

Answer

Aneurysm with intramural thrombus

Answer

Associated 2-cm iliac aneurysm

Question 4

What is true about mesenteric vein thrombosis?

Accepted Answer

Surgery can lead to short-bowel syndrome.

Answer

Peritoneal signs are always present.

Answer

It invariably involves a long length of bowel.

Answer

Intravenous heparin is the treatment of choice.

Question 5

Which of the following is a cause of peripheral arterial occlusive disease?

Accepted Answer

All of the above

Answer

Buerger’s disease

Answer

SLE

Answer

Takayasu arteritis

Question 6

Which of the following is NOT used in the treatment of superficial venous thrombosis?

Accepted Answer

Rest and elevation

Answer

Immediate anticoagulation

Answer

Analgesics

Answer

Treat associated malignancy

Question 7

Migratory thrombophlebitis is most commonly seen with which of the following malignancies?

Accepted Answer

Pancreatic cancer

Answer

Testicular cancer

Answer

Breast cancer

Answer

Liver cancer

Question 8

Thromboangiitis obliterans (Buerger's disease) primarily involves which of the following vessels?

Accepted Answer

Anterior and posterior tibial arteries

Answer

Femoral arteries

Answer

Aortoiliac arteries

Answer

Popliteal arteries

Question 9

Ischaemia is characterized by all except?

Accepted Answer

Thickening of skin

Answer

Brittle nails

Answer

Muscle wasting

Answer

Loss of subcutaneous fat

Question 10

White leg (phlegmasia alba dolens) is due to?

Accepted Answer

Deep femoral vein thrombosis

Answer

Femoral vein thrombosis and lymphatic obstruction

Answer

Lymphatic obstruction only

Answer

None of the above

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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