Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 161: A middle-aged woman presents with non-pitting edema of the right leg and foot, accompanied by dermatitis and hyperpigmentation. The diagnosis of chronic venous insufficiency is established. What is the primary treatment?

A. Vein stripping
B. Pressure-gradient stockings (Correct Answer)
C. Skin grafting
D. Perforator vein ligation

Explanation: **Explanation:** The clinical presentation of non-pitting edema, dermatitis, and hyperpigmentation (lipodermatosclerosis) in a middle-aged woman is classic for **Chronic Venous Insufficiency (CVI)**. **Why Pressure-gradient Stockings are the Correct Answer:** The primary treatment for CVI is **conservative medical management**, specifically **compression therapy**. Pressure-gradient stockings (30-40 mmHg) counteract the elevated venous hydrostatic pressure. They reduce edema, improve venous return by compressing superficial veins, and enhance the efficiency of the calf muscle pump. This remains the "Gold Standard" and first-line treatment for managing symptoms and preventing the progression to venous ulcers. **Why Other Options are Incorrect:** * **Vein Stripping (A):** This is a surgical treatment for superficial varicose veins. While it may be used in CVI if superficial reflux is the primary cause, it is not the *initial* or primary treatment, especially when skin changes are present. * **Skin Grafting (C):** This is reserved for large, refractory venous ulcers that fail to heal with compression. It does not address the underlying venous hypertension. * **Perforator Vein Ligation (D):** Procedures like SEPS (Subfascial Endoscopic Perforator Surgery) are indicated only when conservative management fails and there is documented incompetent perforator flow contributing to ulceration. **Clinical Pearls for NEET-PG:** * **CEAP Classification:** Used to grade CVI (C0-C6). This patient is likely **C4** (Skin changes). * **Gaiter Zone:** The area between the mid-calf and malleolus where CVI changes (hyperpigmentation/ulcers) are most common. * **Champagne Bottle Leg:** A high-yield sign where the lower leg is narrowed due to lipodermatosclerosis while the calf remains swollen. * **Contraindication:** Always check the **Ankle-Brachial Index (ABI)** before applying compression; stockings are contraindicated if ABI < 0.5.

Question 162: Sympathectomy is indicated in all the following conditions, except?

A. Ischemic ulcers
B. Intermittent claudication
C. Anhidrosis (Correct Answer)
D. Acrocyanosis

Explanation: **Explanation:** Lumbar sympathectomy involves the destruction of the sympathetic chain to induce peripheral vasodilation and abolish sweating. The core principle is to improve collateral skin circulation and relieve rest pain. **Why Anhidrosis is the Correct Answer:** Anhidrosis is the **absence of sweating**. Sympathectomy works by interrupting the sympathetic nerve supply to sweat glands, which actually **causes** anhidrosis (as a side effect or intended result in hyperhidrosis). Therefore, it is never an *indication* for the procedure; rather, it is a clinical outcome. **Analysis of Other Options:** * **Ischemic Ulcers:** Sympathectomy is indicated for small, superficial ischemic ulcers (Stage IV Fontaine) because it redirects blood flow to the skin by reducing vasomotor tone, promoting wound healing. * **Intermittent Claudication:** While not the primary treatment (as claudication involves deep muscle ischemia and sympathectomy mainly affects skin blood flow), it was historically used in selected cases where reconstructive surgery was not possible. However, in the context of this classic MCQ, it is considered a relative indication compared to the absolute contraindication of anhidrosis. * **Acrocyanosis:** This is a vasospastic disorder. Sympathectomy is highly effective in treating vasospastic conditions (like Raynaud’s or Acrocyanosis) by eliminating the sympathetic overactivity causing the cyanosis. **NEET-PG High-Yield Pearls:** * **Primary Indication:** Buerger’s disease (TAO) with rest pain or minor tissue loss where distal bypass is not feasible. * **Level of Surgery:** For the lower limb, the **L2, L3, and L4** ganglia are removed. L1 is preserved in males to prevent **loss of ejaculation**. * **The "Rule of Thumb":** Sympathectomy improves **skin** circulation (useful for ulcers/rest pain) but does **not** significantly improve **muscle** circulation (less effective for claudication).

Question 163: For performing Coronary Artery Bypass Grafting (CABG), the Allen test is performed to assess the patency of which vessel?

A. Ulnar artery
B. Radial artery (Correct Answer)
C. Saphenous vein
D. Internal mammary artery

Explanation: **Explanation:** The **Allen test** is a clinical bedside maneuver used to assess the **collateral circulation** of the hand. In the context of CABG, the radial artery is frequently harvested as a high-quality arterial conduit. Before harvesting, it is mandatory to ensure that the **ulnar artery** can provide sufficient blood flow to the entire hand via the palmar arches to prevent ischemic complications. * **Why Radial Artery is correct:** The test specifically evaluates the patency of the ulnar artery and the adequacy of the palmar arch *before* sacrificing the **radial artery**. If the hand does not "flush" (reperfuse) within 5–10 seconds of releasing the ulnar artery while the radial remains compressed, the test is "positive" (abnormal), indicating poor collateral flow, and the radial artery cannot be harvested. * **Why other options are wrong:** * **Ulnar artery:** While the test *checks* the ulnar artery's function, it is performed specifically to determine if the **radial artery** can be safely removed. * **Saphenous vein:** This is a venous conduit harvested from the leg; its patency is assessed via ultrasound (Doppler), not the Allen test. * **Internal mammary artery (IMA):** Also known as the Internal Thoracic Artery, this is the "gold standard" conduit for CABG (especially for the LAD). It is harvested from the chest wall and does not require an Allen test. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen Test:** The version used today where the patient clenches their fist to blanch the hand before pressure is applied. * **Gold Standard:** While the Allen test is standard, **Pulse Oximetry** or **Doppler Ultrasound** are more objective methods to confirm collateral flow. * **CABG Conduits:** The Left Internal Mammary Artery (LIMA) has the highest long-term patency rate (>90% at 10 years).

Question 164: Which of the following is true regarding subclavian steal syndrome?

A. The flow of blood in the vertebral arteries is normal.
B. The blood pressure is decreased on the ipsilateral side. (Correct Answer)
C. The patients commonly present with claudication features.
D. The patients commonly present with neurological features.

Explanation: **Subclavian Steal Syndrome (SSS)** occurs due to a high-grade stenosis or occlusion of the **subclavian artery proximal to the origin of the vertebral artery**. ### **Explanation of the Correct Option** * **Option B (Correct):** Because the obstruction is proximal to the vertebral artery, the distal subclavian artery is "starved" of blood. To compensate, blood flows in a **retrograde** fashion down the ipsilateral vertebral artery to supply the arm. Due to the proximal stenosis, the perfusion pressure in the affected arm is significantly lower than the contralateral side. A **blood pressure difference of >20 mmHg** between the two arms is a hallmark clinical finding. ### **Analysis of Incorrect Options** * **Option A:** The flow in the vertebral artery is **reversed (retrograde)**, not normal (antegrade). This "stealing" of blood from the basilar circulation is the pathophysiology of the condition. * **Option C & D:** While both can occur, they are **not the "common" presentation**. Most patients are **asymptomatic** and are diagnosed incidentally during physical exams (finding unequal pulses). If symptoms occur, arm claudication (Option C) is actually more common than neurological symptoms (Option D). Neurological features (vertigo, ataxia) typically only trigger when the affected arm is exercised (Exercise-induced vertebrobasilar insufficiency). ### **High-Yield Clinical Pearls for NEET-PG** * **Most common side:** Left subclavian artery (due to its direct origin from the aorta). * **Diagnosis:** **Color Doppler** is the initial investigation of choice (shows flow reversal). **CT Angiography** is the gold standard for anatomical mapping. * **Coronary-Subclavian Steal:** Occurs in patients with a CABG using the Internal Mammary Artery (IMA). Subclavian stenosis causes blood to be diverted from the coronary arteries to the arm, leading to angina. * **Treatment:** Indicated only for symptomatic patients. **Endovascular stenting** is currently the preferred first-line intervention.

Question 165: Which of the following is a cause of unilateral hyperluscent lung on chest radiography?

A. Poland Syndrome (Correct Answer)
B. Asthma
C. Acute Bronchiolitis
D. Pleural effusion

Explanation: **Explanation:** A **unilateral hyperlucent lung** on a chest X-ray (CXR) occurs when one side of the chest appears darker (more radiolucent) than the other. This can be due to increased air in the lung (hyperinflation), decreased pulmonary blood flow (oligemia), or a **deficiency in the chest wall soft tissues**. **Why Poland Syndrome is correct:** Poland Syndrome is a rare congenital anomaly characterized by the **unilateral absence of the pectoralis major muscle** (and sometimes the pectoralis minor). Because there is less soft tissue to attenuate the X-ray beams on the affected side, the underlying lung appears hyperlucent compared to the normal side. Importantly, the lung parenchyma itself is normal. **Analysis of Incorrect Options:** * **Asthma & Acute Bronchiolitis:** These conditions typically cause **bilateral** hyperlucency due to generalized air trapping and hyperinflation. While focal air trapping can occur, they are not classic causes of a persistent unilateral hyperlucent hemithorax. * **Pleural Effusion:** This causes **increased opacity** (whiteness) on the affected side, not hyperlucency. **High-Yield Clinical Pearls for NEET-PG:** * **Differential Diagnosis for Unilateral Hyperlucent Lung:** 1. **Technical:** Patient rotation. 2. **Chest Wall:** Poland Syndrome, Mastectomy. 3. **Airway/Lung:** Swyer-James-MacLeod Syndrome (post-infectious obliterative bronchiolitis), Tension Pneumothorax, Foreign body aspiration (obstructive emphysema). 4. **Vascular:** Pulmonary Embolism (Westermark sign). * **Poland Syndrome Triad:** Unilateral absence of pectoralis major, chest wall depression, and ipsilateral **syndactyly** (webbed fingers) or brachydactyly.

Question 166: What is the commonest presentation of Hodgkin's lymphoma?

A. Pruritus
B. Fever
C. Painless enlargement of lymph node (Correct Answer)
D. Leukocytosis

Explanation: **Explanation:** **Correct Answer: C. Painless enlargement of lymph node** The hallmark clinical presentation of Hodgkin’s Lymphoma (HL) is **painless, rubbery, non-tender lymphadenopathy**. In approximately 60-80% of cases, the cervical lymph nodes are the first to be involved. The nodes are typically discrete but can become matted over time. A unique, though rare, diagnostic clue is pain in the lymph nodes specifically after alcohol consumption. **Analysis of Incorrect Options:** * **A & B (Pruritus and Fever):** These are categorized as **"B-symptoms"** (which also include night sweats and weight loss). While clinically significant for staging and prognosis, they are not the *most common* initial presentation. Fever (Pel-Ebstein type) and generalized pruritus occur in only about 25-30% of patients. * **D (Leukocytosis):** While a mild to moderate polymorphonuclear leukocytosis or eosinophilia may be seen on a complete blood count, it is a non-specific laboratory finding and not a primary presenting symptom. **High-Yield Clinical Pearls for NEET-PG:** * **Bimodal Age Distribution:** HL shows two peaks, one in the 20s and another after age 50. * **Spread:** Unlike Non-Hodgkin Lymphoma, HL typically spreads in a **contiguous (predictable)** fashion along lymph node chains. * **Diagnosis:** The gold standard is an **Excisional Lymph Node Biopsy** (FNAC is generally insufficient). * **Pathognomonic Feature:** Presence of **Reed-Sternberg (RS) cells** (described as "Owl’s eye appearance") on a background of reactive inflammatory cells. * **Most Common Subtype:** Nodular Sclerosis (especially in young females). * **Best Prognosis:** Lymphocyte Predominant subtype.

Question 167: Deficiency of which of the following factors increases the incidence of thrombus formation?

A. Lipoprotein A (Correct Answer)
B. Protein C
C. Antithrombin III
D. Protein S

Explanation: **Explanation** The question asks which **deficiency** increases the incidence of thrombus formation. This is a classic "except" style logic trap common in NEET-PG. **1. Why Lipoprotein (a) is the Correct Answer:** Unlike the other options, **Lipoprotein (a) [Lp(a)]** is a pro-thrombotic and pro-atherogenic factor. Therefore, its **elevation** (excess), not its deficiency, leads to thrombosis. A **deficiency** of Lp(a) would actually be cardioprotective and decrease the risk of thrombus formation. In the context of this specific question, it is the "odd one out" because the other three factors are natural anticoagulants whose deficiency causes a hypercoagulable state. **2. Analysis of Incorrect Options (Natural Anticoagulants):** * **Protein C & Protein S:** These are Vitamin K-dependent proteins. Protein C (activated by thrombomodulin) inactivates Factors Va and VIIIa, with Protein S acting as its cofactor. A **deficiency** in either leads to unchecked coagulation and venous thromboembolism (VTE). * **Antithrombin III (ATIII):** This is the most potent natural inhibitor of thrombin (IIa) and Factor Xa. **Deficiency** of ATIII leads to severe hypercoagulability and is clinically significant because it causes **heparin resistance**. **3. Clinical Pearls for NEET-PG:** * **Lp(a) Mechanism:** It is structurally similar to plasminogen; it competes for binding sites, thereby inhibiting fibrinolysis and promoting clot stability. * **Warfarin-Induced Skin Necrosis:** This occurs in patients with **Protein C deficiency** when starting Warfarin without a heparin bridge (due to the short half-life of Protein C). * **Most Common Inherited Thrombophilia:** Factor V Leiden (resistance to Activated Protein C). * **Antithrombin III Deficiency:** Suspect this if a patient’s PTT fails to prolong despite therapeutic doses of Heparin.

Question 168: Regarding vascular surgery distal to the popliteal artery, which of the following statements is true?

A. Suture with polypropylene
B. 6-0 suture is used
C. Needle pass from within outwards
D. All the above (Correct Answer)

Explanation: In vascular surgery, particularly when dealing with small-caliber vessels distal to the popliteal artery (such as the tibial or peroneal arteries), meticulous technique is paramount to ensure patency and prevent thrombosis. **Explanation of the Correct Answer:** The correct answer is **D (All the above)** because each option describes a standard principle of microvascular or small-vessel anastomosis: * **Suture with Polypropylene (Option A):** Polypropylene (e.g., Prolene) is a non-absorbable, monofilament synthetic suture. It is the gold standard for vascular surgery because it has high tensile strength, minimal tissue reactivity, and a very smooth surface that allows it to glide through the vessel wall without causing a "sawing" effect, thereby reducing the risk of intimal damage. * **6-0 Suture is used (Option B):** The size of the suture must be proportional to the vessel diameter. For large vessels like the aorta, 3-0 or 4-0 is used; for the femoral/popliteal arteries, 5-0 is common. For vessels **distal to the popliteal artery**, finer sutures like **6-0 or 7-0** are required to minimize the foreign body footprint and prevent narrowing of the small lumen. * **Needle pass from within outwards (Option C):** When suturing an anastomosis, the needle should pass from the **inside (intima) to the outside (adventitia)** on the distal vessel. This "tacks down" the intima against the media, preventing **intimal flaps** or dissection, which could otherwise lead to acute thrombosis when blood flow is restored. **Clinical Pearls for NEET-PG:** * **Monofilament vs. Braided:** Always choose monofilament (Polypropylene/PVDF) for vascular work to prevent "wicking" of bacteria and reduce friction. * **Eversion:** Vascular anastomoses are always performed **edge-to-edge with eversion** (intima-to-intima contact) to provide a smooth thromboresistant surface. * **The "Stay" Sutures:** Small vessel repairs often use the **Carrel technique** (triangulation) or stay sutures at 180 degrees to maintain orientation and prevent "back-walling" (accidentally suturing the front and back walls together).

Question 169: What is the most common visceral artery aneurysm?

A. Hepatic artery
B. Splenic artery (Correct Answer)
C. Gastric artery
D. None of the above

Explanation: **Explanation:** Visceral artery aneurysms (VAAs) are rare but clinically significant due to their risk of rupture. Among all VAAs, the **Splenic Artery Aneurysm (SAA)** is the most common, accounting for approximately **60%** of all cases. **1. Why Splenic Artery is Correct:** The splenic artery is the most frequent site for visceral aneurysms. They are significantly more common in **females** (4:1 ratio), often 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 fibrodysplasia. **2. Why Other Options are Incorrect:** * **Hepatic Artery:** This is the **second most common** visceral artery aneurysm, accounting for about 20% of cases. They are more common in males and are often associated with trauma, infection, or vasculitis. * **Gastric/Gastroepiploic Arteries:** These are extremely rare, accounting for less than 4% of all VAAs. They are usually intramural and often present with GI bleeding rather than intraperitoneal rupture. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Double Rupture" Phenomenon:** SAA can initially rupture into the lesser sac (tamponade effect) and then later into the general peritoneal cavity through the Foramen of Winslow. * **Pregnancy Risk:** While most SAAs are asymptomatic, the risk of rupture increases significantly during the **third trimester of pregnancy**, carrying a high maternal and fetal mortality rate. * **Indications for Surgery:** Treatment is generally indicated if the aneurysm is **>2 cm**, if the patient is **pregnant** or planning pregnancy, or if the patient is symptomatic. * **Imaging:** Digital Subtraction Angiography (DSA) remains the gold standard for diagnosis and planning intervention.

Question 170: Diabetic gangrene is due to which of the following mechanisms?

A. Vasospasm (Correct Answer)
B. Atherosclerosis
C. Peripheral neuritis
D. Increased sugar in blood

Explanation: **Explanation:** The pathogenesis of diabetic gangrene is multifactorial, involving a triad of ischemia, neuropathy, and infection. However, in the context of this specific question, **Vasospasm (Option A)** is identified as a significant functional component of the microvascular impairment. In diabetic patients, autonomic dysfunction leads to an imbalance in vasomotor tone. The loss of sympathetic control and endothelial dysfunction results in persistent vasoconstriction and vasospasm of the microcirculation, which acutely compromises tissue perfusion and precipitates gangrene. **Analysis of Incorrect Options:** * **B. Atherosclerosis:** While macrovascular disease (atherosclerosis) is a major risk factor for limb ischemia in diabetics, it is a chronic, structural process. Diabetic gangrene often occurs even in the presence of palpable pulses due to microvascular dysfunction and vasospasm. * **C. Peripheral Neuritis:** Neuropathy leads to a "painless" foot, loss of protective sensation, and structural deformities (Charcot’s joint), which predispose the foot to trauma and ulcers. While it is a precursor, it is not the direct vascular mechanism of gangrene. * **D. Increased sugar in blood:** Hyperglycemia impairs wound healing and provides a medium for bacterial growth (infection), but it is a metabolic state rather than the direct hemodynamic mechanism causing tissue necrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Diabetic Foot Triad:** Neuropathy (most common trigger), Ischemia, and Infection. * **Microangiopathy:** Characterized by basement membrane thickening; unlike macroangiopathy, it is not reversible by bypass surgery. * **Monckeberg’s Arteriosclerosis:** Medial calcific sclerosis is common in diabetics, often leading to falsely elevated Ankle-Brachial Index (ABI) readings. * **Wagner’s Classification:** Used to grade the severity of diabetic foot ulcers (Grade 0 to 5).

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

Practice Questions

Vascular Trauma

Practice Questions

Vascular Access for Hemodialysis

Practice Questions

Endovascular Techniques

Practice Questions

Diabetic Foot Vascular Disease

Practice Questions

Vasculitis

Practice Questions

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