Vascular Surgery Practice Questions

Q: 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?

Pressure-gradient stockings. **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.

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

Anhidrosis. **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).

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

Radial artery. **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).

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

Poland Syndrome. **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.

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

Painless enlargement of lymph node. **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.

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

Lipoprotein A. **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.

Q: What is the most common visceral artery aneurysm?

Splenic artery. **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.

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

Vasospasm. **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).

Question 1

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?

Accepted Answer

Pressure-gradient stockings

Answer

Vein stripping

Answer

Skin grafting

Answer

Perforator vein ligation

Question 2

Sympathectomy is indicated in all the following conditions, except?

Accepted Answer

Anhidrosis

Answer

Ischemic ulcers

Answer

Intermittent claudication

Answer

Acrocyanosis

Question 3

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

Accepted Answer

Radial artery

Answer

Ulnar artery

Answer

Saphenous vein

Answer

Internal mammary artery

Question 4

Which of the following is true regarding subclavian steal syndrome?

Accepted Answer

The blood pressure is decreased on the ipsilateral side.

Answer

The flow of blood in the vertebral arteries is normal.

Answer

The patients commonly present with claudication features.

Answer

The patients commonly present with neurological features.

Question 5

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

Accepted Answer

Poland Syndrome

Answer

Asthma

Answer

Acute Bronchiolitis

Answer

Pleural effusion

Question 6

What is the commonest presentation of Hodgkin's lymphoma?

Accepted Answer

Painless enlargement of lymph node

Answer

Pruritus

Answer

Fever

Answer

Leukocytosis

Question 7

Deficiency of which of the following factors increases the incidence of thrombus formation?

Accepted Answer

Lipoprotein A

Answer

Protein C

Answer

Antithrombin III

Answer

Protein S

Question 8

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

Accepted Answer

All the above

Answer

Suture with polypropylene

Answer

6-0 suture is used

Answer

Needle pass from within outwards

Question 9

What is the most common visceral artery aneurysm?

Accepted Answer

Splenic artery

Answer

Hepatic artery

Answer

Gastric artery

Answer

None of the above

Question 10

Diabetic gangrene is due to which of the following mechanisms?

Accepted Answer

Vasospasm

Answer

Atherosclerosis

Answer

Peripheral neuritis

Answer

Increased sugar in blood

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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