Vascular Surgery Practice Questions

Q: A patient presents with occasional pain over her middle finger. The surgeon identifies a black spot. Pressing around the black spot does not elicit pain, while pain is sensed on pressing the spot itself. What is the most likely diagnosis?

Glomus tumour. **Explanation:** The clinical presentation described is classic for a **Glomus Tumour**. These are benign vascular hamartomas arising from the glomus body, a specialized neuromyovascular apparatus involved in thermoregulation. **Why it is the correct answer:** The hallmark of a glomus tumour is the **triad of severe paroxysmal pain, localized tenderness, and cold hypersensitivity**. The description of pain elicited specifically by pressing the "black spot" (the tumour itself) while surrounding areas remain painless is known as **Love’s Test**. The "black spot" or bluish discoloration represents the vascular mass seen through the skin or nail plate. These tumours are most commonly found in the subungual region of the fingers. **Why other options are incorrect:** * **Haemangioma:** While vascular, these are typically painless and present as soft, compressible masses without the exquisite point tenderness seen here. * **Arteriovenous (AV) Fistula:** These usually present with a palpable thrill, an audible bruit, and regional swelling rather than a localized, exquisitely painful spot. * **Melanoma:** Subungual melanoma presents as a dark streak (Hutchinson’s sign) or enlarging pigmented lesion. While it can be serious, it is generally not associated with the intense, localized paroxysmal pain triggered by pressure. **High-Yield Clinical Pearls for NEET-PG:** * **Love’s Test:** Positive when localized pressure with a pinhead or probe elicits excruciating pain. * **Hildreth’s Sign:** Disappearance of pain after inflating a blood pressure cuff (ischaemia) proximal to the lesion. * **Transillumination:** Glomus tumours often transilluminate due to their vascular nature. * **Treatment:** Complete surgical excision is the definitive management.

Q: What is the most common vessel affected in acute limb ischemia?

Superficial femoral artery. **Explanation:** Acute limb ischemia (ALI) is a surgical emergency characterized by a sudden decrease in limb perfusion. The most common cause of ALI is **arterial embolism**, followed by **thrombosis in situ**. **1. Why Superficial Femoral Artery (SFA) is correct:** The SFA is the most common site for both atherosclerotic occlusion and embolic lodgment. In the case of emboli (most commonly originating from the heart due to Atrial Fibrillation), the clot tends to lodge where the vessel caliber narrows or at bifurcations. The **SFA at the level of the Adductor (Hunter’s) Canal** is the most frequent site of occlusion because it is a long, relatively narrow segment where the vessel is subjected to mechanical stress. **2. Analysis of Incorrect Options:** * **B. Iliac artery:** While a common site for chronic atherosclerotic disease (Aorto-iliac disease), it is less common than the SFA for acute embolic events because of its larger diameter. * **C. Popliteal artery:** This is the second most common site for embolic lodgment. It is also the most common site for peripheral arterial aneurysms, which can lead to acute thrombosis, but statistically, it occurs less frequently than SFA involvement. * **D. Tibial artery:** These are smaller "run-off" vessels. While they can be affected by "trash foot" (microemboli) or distal propagation of a proximal clot, they are not the primary site of major acute limb-threatening ischemia compared to the SFA. **Clinical Pearls for NEET-PG:** * **The 6 P’s of ALI:** Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Initial Management:** Immediate anticoagulation with IV Unfractionated Heparin to prevent clot propagation. * **Most common source of emboli:** Left Atrium (secondary to Atrial Fibrillation). * **Fogarty Catheter:** Used for surgical embolectomy.

Q: What is the ideal material used for a femoropopliteal shunt?

Reverse saphenous vein. The **Great Saphenous Vein (GSV)** is considered the "gold standard" conduit for infrainguinal arterial bypasses, including femoropopliteal shunts. ### **Why Reverse Saphenous Vein is Correct** The GSV is the ideal material because it is an **autologous** graft, meaning it is harvested from the patient’s own body. * **Endothelial Lining:** Unlike synthetic materials, it has a viable endothelial layer that produces nitric oxide and prostacyclin, providing superior **thromboresistance**. * **Compliance:** Its mechanical properties closely match those of native arteries, reducing intimal hyperplasia at the anastomosis. * **Infection Resistance:** Autologous veins are significantly more resistant to infection compared to prosthetic grafts. * **Patency Rates:** It offers the highest long-term patency rates (approx. 70-80% at 5 years). It is "reversed" during surgery so that the internal valves do not obstruct arterial blood flow. ### **Why Other Options are Incorrect** * **PTFE (Polytetrafluoroethylene) & Dacron:** These are synthetic (prosthetic) materials. While used when the GSV is unavailable or of poor quality, they have higher rates of thrombosis and infection, especially when the bypass extends below the knee. * **Polypropylene:** This is a non-absorbable suture material (e.g., Prolene) used to perform the anastomosis, but it is never used as a conduit material itself. ### **High-Yield Clinical Pearls for NEET-PG** * **In-situ Bypass:** An alternative to the reversed technique where the vein is left in its bed, and a **valvulotome** is used to strip the valves. * **Best Synthetic Choice:** If a vein is unavailable, **PTFE** is generally preferred over Dacron for femoropopliteal bypasses. * **Size Requirement:** For a successful bypass, the GSV should ideally have a diameter of **>3 mm**.

Q: Which of the following is a clinical finding in an arteriovenous fistula?

Sinus tachycardia. ### Explanation In an **Arteriovenous (AV) fistula**, there is a direct communication between a high-pressure artery and a low-pressure vein, bypassing the high-resistance capillary bed. This leads to significant hemodynamic changes: 1. **Why Sinus Tachycardia is Correct:** The shunt causes a decrease in **Total Peripheral Resistance (TPR)**, leading to a drop in mean arterial pressure. To maintain cardiac output and compensate for the decreased afterload, the body activates the sympathetic nervous system, resulting in a compensatory **sinus tachycardia** and increased stroke volume. Over time, this high-output state can lead to high-output cardiac failure. 2. **Analysis of Incorrect Options:** * **Pericarditis:** This is an inflammatory condition of the heart's outer lining, typically caused by infections, uremia, or MI; it is not a direct hemodynamic consequence of an AV fistula. * **Cardiac Arrhythmia:** While chronic heart failure from a large fistula can eventually lead to atrial fibrillation due to chamber enlargement, **sinus tachycardia** is the primary and most characteristic clinical finding. * **Hypothermia:** AV fistulas typically cause **increased local temperature** (hyperthermia) at the site of the shunt due to the rapid flow of warm arterial blood into superficial veins. ### High-Yield Clinical Pearls for NEET-PG: * **Nicoladoni-Branham Sign:** A pathognomonic sign where manual compression of the fistula leads to a sudden **bradycardia** and a rise in blood pressure. * **Machinery Murmur:** A continuous "bruit" or thrill is often palpable/audible over the site of the fistula. * **Proximal vs. Distal:** Proximal to the fistula, the artery dilates; distal to the fistula, there may be signs of chronic venous insufficiency or "steal syndrome" (ischemia). * **Widened Pulse Pressure:** Due to decreased diastolic pressure (rapid runoff into the vein) and increased systolic stroke volume.

Q: A 36-year-old lady presents with a 20-year duration, fluctuant, and translucent swelling on the right side of her neck. No other history or significant findings on examination are available. What is the most probable diagnosis?

Lymph cyst. ### Explanation The clinical presentation of a long-standing, **fluctuant**, and **translucent** swelling in the neck of a young adult is classic for a **Cystic Hygroma (Cystic Lymphangioma)**, often referred to in exams as a **Lymph cyst**. **Why the correct answer is right:** * **Translucency:** This is the hallmark of a lymph cyst. Because it contains clear, straw-colored lymph and has a thin epithelial lining, it allows light to pass through brilliantly (positive transillumination). * **Fluctuance:** Indicates a fluid-filled cavity. * **Duration:** These are congenital malformations of the lymphatic system (sequestration of jugular lymph sacs). While often detected at birth or by age 2, they can remain asymptomatic and present or enlarge later in life. **Why the incorrect options are wrong:** * **Lymph node:** These are typically solid, firm, and **opaque**. They do not transilluminate. * **Colloid nodule:** These are located within the thyroid gland (anterior neck/midline). While they can undergo cystic degeneration, they are generally not translucent and move with deglutition. * **Cold abscess:** Usually secondary to tuberculosis. While fluctuant, the overlying skin is thickened and the contents (caseous pus) are **opaque**, making them negative for transillumination. **Clinical Pearls for NEET-PG:** 1. **Brilliant Transillumination:** The most important diagnostic sign for Cystic Hygroma. 2. **Anatomical Site:** Most commonly found in the **posterior triangle** of the neck (Left > Right). 3. **Complications:** Sudden increase in size usually suggests hemorrhage into the cyst or secondary infection. 4. **Treatment of Choice:** Surgical excision is preferred. If surgery is risky, sclerotherapy (e.g., OK-432 or Bleomycin) is an alternative.

Q: What is the most common source of pulmonary embolism?

Deep leg veins. **Explanation:** The correct answer is **Deep leg veins (Option B)**. Pulmonary Embolism (PE) is a life-threatening condition where a blood clot (thrombus) dislodges and travels to the pulmonary arteries. Approximately **90-95% of all pulmonary emboli** originate from Deep Vein Thrombosis (DVT) of the lower extremities. Specifically, thrombi originating from the **proximal deep veins** (popliteal, femoral, and iliac veins) carry the highest risk of embolization compared to distal calf vein thrombi. **Analysis of Incorrect Options:** * **A. Hemorrhoids:** These involve the rectal venous plexus. While they can thrombose locally (causing pain), they rarely lead to PE because the venous drainage often goes into the portal system or involves small-caliber vessels where clots are unlikely to reach the pulmonary circulation in a significant size. * **C. Portal vein:** Thrombi in the portal vein (Portal Vein Thrombosis) lead to portal hypertension and intestinal ischemia. Because the portal system drains into the liver (capillary bed of the sinusoids), these clots are "filtered" by the liver and do not reach the systemic venous circulation or the lungs. **NEET-PG High-Yield Pearls:** * **Most common site for DVT:** The muscular veins of the calf (soleal sinuses), but the **most common source of PE** is the proximal leg veins (Femoral vein). * **Virchow’s Triad:** The three factors contributing to venous thrombosis are Stasis, Endothelial Injury, and Hypercoagulability. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **ECG Finding:** The most common finding is sinus tachycardia; the classic but rare sign is the **S1Q3T3 pattern**.

Question 1

A patient presents with occasional pain over her middle finger. The surgeon identifies a black spot. Pressing around the black spot does not elicit pain, while pain is sensed on pressing the spot itself. What is the most likely diagnosis?

Accepted Answer

Glomus tumour

Answer

Haemangioma

Answer

Arteriovenous fistula

Answer

Melanoma

Question 2

Pseudoaneurysm is most commonly seen in which of the following vessels in a drug abuser?

Accepted Answer

All of the above

Answer

Radial

Answer

Brachial

Answer

Femoral

Question 3

What is the most common vessel affected in acute limb ischemia?

Accepted Answer

Superficial femoral artery

Answer

Iliac artery

Answer

Popliteal artery

Answer

Tibial artery

Question 4

What is the ideal material used for a femoropopliteal shunt?

Accepted Answer

Reverse saphenous vein

Answer

PTFE

Answer

Polypropylene

Answer

Dacron

Question 5

Which of the following is a clinical finding in an arteriovenous fistula?

Accepted Answer

Sinus tachycardia

Answer

Pericarditis

Answer

Cardiac arrhythmia

Answer

Hypothermia

Question 6

All of the following are true about varicose veins except:

Accepted Answer

The Trendelenburg operation is the gold standard treatment for varicose veins.

Answer

The most common symptom is dull aching pain in the veins at the end of the day, after prolonged standing.

Answer

Duplex ultrasound is the investigation of choice for the diagnosis of varicose veins.

Answer

Bisgaard's regimen is used for venous ulcers.

Question 7

A 36-year-old lady presents with a 20-year duration, fluctuant, and translucent swelling on the right side of her neck. No other history or significant findings on examination are available. What is the most probable diagnosis?

Accepted Answer

Lymph cyst

Answer

Lymph node

Answer

Colloid nodule

Answer

Cold abscess

Question 8

What is the most commonly used graft for the repair of an aortic coarctation?

Accepted Answer

Dacron

Answer

Autologous vein

Answer

Autologous artery

Answer

PTFE

Question 9

What is the most common source of pulmonary embolism?

Accepted Answer

Deep leg veins

Answer

Hemorrhoids

Answer

Portal vein

Answer

None of the above

Question 10

Which of the following is NOT a clinical test used to assess perforator vein incompetence?

Accepted Answer

Morrisey's cough impulse test

Answer

Pratt's test

Answer

Trendelenburg-II test

Answer

Fegan test

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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