Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 171: Thoracic outlet syndrome is primarily diagnosed by which method?

A. Clinical Evaluation (Correct Answer)
B. CT scan
C. MRI
D. Angiography

Explanation: **Explanation:** Thoracic Outlet Syndrome (TOS) is a constellation of symptoms caused by the compression of neurovascular structures (brachial plexus, subclavian artery, or subclavian vein) as they pass through the superior thoracic aperture. **Why Clinical Evaluation is the Correct Answer:** TOS is fundamentally a **clinical diagnosis**. The diagnosis is primarily based on a detailed patient history and a thorough physical examination. Since most cases (95%) are neurogenic, imaging often fails to show structural abnormalities. Clinicians rely on provocative maneuvers that narrow the thoracic outlet to reproduce symptoms. Key tests include the **Adson’s test**, **Roos test (Elevated Arm Stress Test)**, and **Wright’s test**. **Why Other Options are Incorrect:** * **CT Scan & MRI:** These are adjunct modalities used to rule out differential diagnoses (like cervical discs or tumors) or to identify anatomical predispositions (like a cervical rib or fibrous bands). They are not diagnostic of the syndrome itself. * **Angiography:** This is reserved for suspected **Vascular TOS** (arterial or venous). While it can demonstrate stenosis or occlusion, it is an invasive procedure and is not the primary method for diagnosing the more common neurogenic variety. **High-Yield Clinical Pearls for NEET-PG:** * **Most Common Type:** Neurogenic TOS (95%), involving the brachial plexus (usually lower trunk, C8-T1). * **Most Common Anatomical Cause:** Cervical rib (though many people with cervical ribs remain asymptomatic). * **Paget-Schroetter Syndrome:** Also known as "effort thrombosis," it is the spontaneous thrombosis of the subclavian vein due to venous TOS. * **Adson’s Test:** Loss of radial pulse when the patient rotates their head toward the affected side and extends the neck during deep inspiration.

Question 172: Lisker's sign is seen in which condition?

A. Deep Vein Thrombosis (DVT) (Correct Answer)
B. Berger's disease
C. Coarctation of the aorta
D. Arteriovenous fistula

Explanation: **Explanation:** **Lisker's sign** is a clinical sign used in the diagnosis of **Deep Vein Thrombosis (DVT)**. It is characterized by **tenderness elicited upon percussion of the anterior surface of the tibia**. The underlying medical concept is that the vibration or pressure from percussion irritates the inflamed deep veins (specifically the posterior tibial veins) lying in close proximity to the bone, causing localized pain. **Analysis of Options:** * **Deep Vein Thrombosis (Correct):** Along with Lisker’s sign, DVT is associated with several eponymous signs resulting from venous inflammation and calf muscle compression. * **Buerger’s Disease (Thromboangiitis Obliterans):** This is an inflammatory vasculitis of small and medium-sized arteries. It is characterized by the **Adson’s test** (for thoracic outlet) or **Allen’s test**, but not Lisker's sign. * **Coarctation of the Aorta:** This presents with radio-femoral delay and rib notching. * **Arteriovenous (AV) Fistula:** This is associated with **Nicoladoni-Branham sign** (bradycardia upon compression of the fistula), not percussion tenderness. **High-Yield Clinical Pearls for NEET-PG:** In the context of DVT, remember these other eponymous signs frequently tested: 1. **Homan’s Sign:** Pain in the calf on dorsiflexion of the foot (most famous but least specific). 2. **Moses’ Sign:** Pain on squeezing the calf muscles from side to side (anteroposteriorly). 3. **Lowenberg’s Sign:** Pain elicited when a blood pressure cuff wrapped around the calf is inflated to 80–100 mmHg. 4. **Pratt’s Sign:** Presence of prominent "sentinel" veins over the pretibial area.

Question 173: Which of the following is included in the definition of critical limb ischemia?

A. Rest pain (Correct Answer)
B. Ankle blood pressure >50 mm Hg
C. Intermittent claudication
D. Well preserved tissues

Explanation: **Explanation:** Critical Limb Ischemia (CLI) represents the end-stage of peripheral arterial disease (PAD), where the blood supply is insufficient to meet the metabolic demands of the tissue at rest. **Why the correct answer is right:** According to the **Fontaine Classification (Stage III and IV)** and the **Rutherford Classification (Categories 4, 5, and 6)**, CLI is defined by the presence of chronic ischemic **rest pain** (typically requiring opiate analgesia for >2 weeks) or tissue loss (ulceration or gangrene). It is objectively confirmed by hemodynamic parameters showing severely reduced perfusion, specifically an **ankle pressure <50 mm Hg** or a **toe pressure <30 mm Hg**. **Why the incorrect options are wrong:** * **B. Ankle blood pressure >50 mm Hg:** This is incorrect because the diagnostic threshold for CLI is an ankle pressure **less than** 50 mm Hg. Pressures above this level generally suggest compensated ischemia. * **C. Intermittent claudication:** This represents Fontaine Stage II. While it indicates PAD, it is not "critical" because the blood supply is adequate at rest and only becomes insufficient during exercise. * **D. Well preserved tissues:** CLI is characterized by the breakdown of tissue (Fontaine Stage IV), leading to non-healing ischemic ulcers or gangrene. **High-Yield Clinical Pearls for NEET-PG:** * **The "6 Ps"** (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) refer to **Acute** Limb Ischemia, which is a surgical emergency, whereas CLI is a **chronic** condition. * **Buerger’s Test:** A positive test (elevation pallor and dependent rubor) is a classic clinical sign of CLI. * **Management:** The primary goal in CLI is urgent revascularization (endovascular or bypass) to prevent limb loss (amputation).

Question 174: What is the first treatment for rupture of varicose veins at the ankle?

A. Rest in a prone position
B. Application of a tourniquet proximally
C. Application of a tourniquet distally
D. Direct pressure and elevation (Correct Answer)

Explanation: **Explanation:** The primary mechanism of bleeding from a ruptured varicose vein is high **hydrostatic pressure** within the superficial venous system, exacerbated by gravity when the patient is standing. **1. Why Direct Pressure and Elevation is Correct:** * **Direct Pressure:** Applying firm, manual pressure directly over the bleeding site provides immediate mechanical tamponade, stopping the hemorrhage. * **Elevation:** Raising the limb above the level of the heart utilizes gravity to reduce venous pressure and facilitate venous return. This "empties" the engorged veins, making it the most effective first-aid measure to control bleeding. **2. Why the Other Options are Incorrect:** * **Rest in a prone position (A):** While lying down helps, the prone position is impractical for managing an anterior or medial ankle bleed and does not provide the necessary elevation or compression required to stop high-pressure venous bleeding. * **Application of a tourniquet (B & C):** Tourniquets are generally **contraindicated** for venous bleeding. A proximal tourniquet (B) obstructs venous outflow while arterial inflow continues, which actually *increases* venous pressure and worsens the bleeding (the "Bier's block" effect). A distal tourniquet (C) is physiologically irrelevant to the proximal source of pressure. **3. Clinical Pearls for NEET-PG:** * **Bleeding Varices:** Often occur at the "Gaiter zone" (medial malleolus) where the skin is thin due to lipodermatosclerosis. * **Emergency Management:** Always remember the sequence: **Pressure → Elevation → Pressure Bandage.** * **Definitive Treatment:** Once the acute bleeding is controlled, the patient requires surgical intervention (e.g., ligation or endovenous ablation) to prevent recurrence. * **High-Yield Fact:** Bleeding from a varicose vein is one of the few true surgical emergencies in venous disease; never use a tourniquet as it can lead to exsanguination by preventing venous collapse.

Question 175: What is the most common cause of acute arterial occlusion?

A. Pulmonary emboli
B. Atherosclerosis plaque
C. Emboli from atrial fibrillation (Correct Answer)
D. Thrombosis of an aneurysm

Explanation: ### Explanation Acute arterial occlusion is a surgical emergency characterized by the sudden cessation of blood flow to an extremity. The most common cause is **embolism**, and the most frequent source of these emboli is the **heart (80-90%)**. **1. Why Option C is Correct:** In patients with **Atrial Fibrillation (AF)**, the lack of coordinated atrial contraction leads to blood stasis, particularly in the left atrial appendage. This promotes the formation of thrombi. When these thrombi dislodge, they enter the systemic circulation and lodge in smaller distal vessels (most commonly the femoral artery bifurcation), causing acute ischemia. AF remains the single most common predisposing factor for peripheral arterial embolization. **2. Analysis of Incorrect Options:** * **Option A (Pulmonary emboli):** These originate in the venous system (usually DVT) and lodge in the pulmonary arteries. They do not cause systemic arterial occlusion unless a "paradoxical embolism" occurs via a right-to-left shunt (e.g., Patent Foramen Ovale). * **Option B (Atherosclerosis plaque):** While atherosclerosis is the leading cause of *chronic* limb-threatening ischemia, it typically causes acute occlusion only if a plaque ruptures leading to "thrombosis in situ." This is less common than embolic events. * **Option D (Thrombosis of an aneurysm):** This is a recognized cause (especially in popliteal aneurysms), but it is statistically much less frequent than cardioembolism. **3. NEET-PG High-Yield Pearls:** * **The 6 P’s of Acute Ischemia:** Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). * **Most common site of embolus lodgment:** Femoral artery bifurcation (followed by the iliac arteries). * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Immediate Management:** Intravenous Heparin to prevent clot propagation. * **Definitive Treatment:** Surgical embolectomy using a **Fogarty catheter**.

Question 176: Which of the following types of dissecting aneurysm does NOT involve the ascending aorta?

A. Stanford type B (Correct Answer)
B. Stanford type A
C. DeBakey type I
D. DeBakey type II

Explanation: Aortic dissection is classified based on the anatomical location of the intimal tear and the extent of the dissection. The two primary systems used are the **Stanford** and **DeBakey** classifications. ### **Explanation of the Correct Answer** **A. Stanford type B:** This classification is based solely on whether the **ascending aorta** is involved. * **Stanford Type A:** Involves the ascending aorta (regardless of the site of the primary tear). * **Stanford Type B:** Involves only the descending aorta (distal to the left subclavian artery) and **spares the ascending aorta**. Therefore, Type B is the correct answer. ### **Explanation of Incorrect Options** * **B. Stanford type A:** By definition, this involves the ascending aorta. It is a surgical emergency due to the risk of coronary artery occlusion, aortic regurgitation, and cardiac tamponade. * **C. DeBakey type I:** This involves the **ascending aorta**, the arch, and extends into the descending aorta. * **D. DeBakey type II:** This is confined strictly to the **ascending aorta**. ### **High-Yield NEET-PG Pearls** * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice for diagnosis. * **Management Rule:** * **Stanford Type A (DeBakey I & II):** Requires urgent **Surgical** repair. * **Stanford Type B (DeBakey III):** Primarily managed **Medically** (blood pressure control using Beta-blockers like Labetalol) unless complications like ischemia or rupture occur. * **Risk Factors:** Hypertension (most common), Marfan Syndrome, and Bicuspid aortic valve. * **Clinical Sign:** "Tearing" chest pain radiating to the back with a blood pressure discrepancy between arms.

Question 177: What is the treatment of choice for acute lymphadenitis?

A. Antibiotics and rest (Correct Answer)
B. Lymphangiography
C. Excision
D. No treatment needed

Explanation: **Explanation:** **Acute lymphadenitis** is the inflammation and infection of one or more lymph nodes, most commonly occurring secondary to a primary pyogenic infection (usually *Staphylococcus aureus* or *Streptococcus pyogenes*) in the drainage area of the node. **Why Option A is Correct:** The mainstay of management for acute lymphadenitis is **medical therapy**. Since the underlying cause is typically a bacterial infection, **systemic antibiotics** are essential to eradicate the pathogen. **Rest** and elevation of the affected part help reduce lymphatic flow and decrease regional congestion, thereby alleviating pain and preventing the further spread of infection. **Why Other Options are Incorrect:** * **B. Lymphangiography:** This is a diagnostic imaging modality used to visualize lymphatic vessels. It has no therapeutic role in acute infection and is contraindicated in the acute phase as it can worsen the spread of bacteria. * **C. Excision:** Surgical excision is generally avoided in the acute inflammatory phase. Surgery is only indicated if the lymphadenitis progresses to an **abscess**, in which case **Incision and Drainage (I&D)** is performed, not excision. * **D. No treatment needed:** Untreated acute lymphadenitis can progress to suppuration (abscess formation), cellulitis, or systemic sepsis. **NEET-PG Clinical Pearls:** * **Most common cause:** Skin or soft tissue infection in the distal drainage area. * **Clinical Sign:** Nodes are enlarged, tender, warm, and the overlying skin may be erythematous. * **Key Distinction:** If the node becomes fluctuant, it indicates **suppuration**, and the treatment shifts from antibiotics alone to **Incision and Drainage**. * **Chronic Lymphadenitis:** If nodes are painless and persistent, consider Tuberculosis (Cold Abscess) or Malignancy.

Question 178: What is the best graft material for aortic dissection?

A. Dacron (Correct Answer)
B. Autologous vein
C. Autologous artery
D. PTFE

Explanation: **Explanation:** In the surgical management of aortic dissection (especially Type A or complicated Type B), the primary goal is to replace the diseased segment of the aorta with a durable, synthetic conduit. **Why Dacron is the Correct Answer:** **Dacron (Polyethylene terephthalate)** is a braided, synthetic polyester material that is the gold standard for large-vessel reconstruction. It is preferred for the aorta because: 1. **Strength and Durability:** It can withstand the high-pressure, high-flow environment of the aorta without forming aneurysms over time. 2. **Tissue Incorporation:** Its porous nature allows for "pseudointima" formation (fibrous ingrowth), which secures the graft in place. 3. **Handling:** Modern Dacron grafts are often "collagen-coated" or "gelatin-sealed," making them impervious to blood (reducing intraoperative bleeding) while maintaining excellent handling characteristics for suturing. **Why Other Options are Incorrect:** * **Autologous Vein (e.g., Great Saphenous Vein):** While excellent for small-caliber vessels (coronary or peripheral bypass), a vein cannot withstand aortic pressures and would undergo aneurysmal dilation or rupture. * **Autologous Artery:** There is no autologous artery large enough to replace the aorta. * **PTFE (Polytetrafluoroethylene):** While used in peripheral vascular surgery and AV shunts, PTFE is less compliant than Dacron and more prone to kinking in the large, curved segments of the aorta (like the arch). **High-Yield Clinical Pearls for NEET-PG:** * **Aortic Dissection:** The most common site of origin is just distal to the left subclavian artery (Type B) or the ascending aorta (Type A). * **Graft Choice:** Dacron is the material of choice for **Aorta**; PTFE is often preferred for **below-knee** bypasses or when a smaller diameter is needed. * **Complication:** The most dreaded late complication of a synthetic aortic graft is an **Aorto-enteric fistula** (usually presenting as a "herald bleed"). * **Surgical Emergency:** Stanford Type A dissections require immediate surgery; Type B is typically managed medically unless complications (malperfusion, rupture) occur.

Question 179: A 67-year-old man with a history of hypertension, hyperlipidemia, and tobacco use has been diagnosed with an infra-renal aortic aneurysm of size 3 x 3.5 cm. Which management strategy is best suited for this patient?

A. Endovascular stenting of the aneurysm
B. Serial follow-up with MRI; major determinant of surgery being renal artery involvement
C. Serial follow-up with MRI; initiate statins, and the major determinant of surgery being size greater than 5.5 cm (Correct Answer)
D. Serial follow-up with MRI; initiate statins and operate only in case of acute anginal pain

Explanation: **Explanation:** The management of an Abdominal Aortic Aneurysm (AAA) is primarily dictated by the **risk of rupture versus the risk of surgical intervention**. For small, asymptomatic infra-renal aneurysms, conservative management is the standard of care. 1. **Why Option C is Correct:** * **Size Threshold:** In asymptomatic males, the threshold for elective repair (Open or EVAR) is a diameter **≥ 5.5 cm**. For females, it is often ≥ 5.0 cm. This patient’s aneurysm (3.5 cm) is well below the threshold. * **Medical Optimization:** Patients with AAA have a high risk of cardiovascular events. Initiating **statins** and smoking cessation are critical to reduce overall mortality and potentially slow aneurysm expansion. * **Surveillance:** Serial imaging (Ultrasound or MRI/CT) is mandatory to monitor the growth rate. 2. **Why Other Options are Incorrect:** * **Option A:** Invasive intervention (stenting) is not indicated for a 3.5 cm asymptomatic aneurysm as the procedural risks outweigh the minimal rupture risk. * **Option B:** While renal artery involvement is important for surgical planning (clamping site), the **major determinant** for the *timing* of surgery is the maximum transverse diameter or a rapid expansion rate (>0.5 cm in 6 months). * **Option D:** "Acute anginal pain" refers to cardiac ischemia. The indication for urgent surgery in AAA is **acute abdominal or back pain**, which suggests impending or actual rupture. **Clinical Pearls for NEET-PG:** * **Gold Standard Screening:** Ultrasonography (USG) is the investigation of choice for screening and surveillance. * **Indications for Surgery:** 1. Diameter ≥ 5.5 cm (males) or ≥ 5.0 cm (females). 2. Rapid expansion (>0.5 cm in 6 months or >1 cm in 1 year). 3. Symptomatic aneurysm (pain or tenderness) regardless of size. * **Risk Factors:** Smoking is the strongest risk factor for development and expansion; however, Diabetes Mellitus is paradoxically associated with a *slower* rate of AAA growth.

Question 180: Unna boot is used for the treatment of which condition?

A. Diabetic foot ulcer
B. Varicose ulcers (Correct Answer)
C. Ankle instability
D. Calcaneum fracture

Explanation: **Explanation:** The **Unna boot** is a specialized compression dressing used primarily for the management of **venous stasis ulcers (varicose ulcers)**. It consists of a zinc oxide-impregnated gauze wrap, often containing calamine and glycerin, which provides inelastic compression. **Why it is the correct answer:** Venous ulcers occur due to chronic venous insufficiency and ambulatory venous hypertension. The Unna boot works by providing **high-pressure compression during muscle contraction** (walking) and low pressure at rest. This "semi-rigid" cast enhances the calf muscle pump function, reduces edema, and promotes venous return, creating an optimal environment for the ulcer to heal. The zinc oxide also helps soothe the skin and manage dermatitis. **Analysis of incorrect options:** * **Diabetic foot ulcer:** These are primarily neuropathic or ischemic. Compression is often contraindicated if there is associated Peripheral Arterial Disease (PAD), as it can worsen ischemia. * **Ankle instability:** This requires stabilization via ligaments repair or rigid bracing (like an Aircast), not a medicated compression wrap. * **Calcaneum fracture:** This requires immobilization (Plaster of Paris cast) or surgical fixation (ORIF), depending on the displacement. **Clinical Pearls for NEET-PG:** * **Contraindication:** Do not use an Unna boot in patients with severe **Peripheral Arterial Disease (ABI < 0.5)**, as compression can cause tissue necrosis. * **Application:** It is applied from the base of the toes to just below the knee. * **Gold Standard:** While the Unna boot is classic, **multi-layer compression bandages** (e.g., Profore) are now often considered the gold standard for venous ulcers.

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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