Vascular Surgery — MCQs
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A 52-year-old, nonsmoking man complains of pain and paresthesias in his right hand, particularly at night. Examination reveals a diminished radial pulse when he abducts his arm with his head turned to either side. A bruit is audible over the upper right anterior chest. His neurologic examination is unremarkable. What is the suspected diagnosis?
Which vein is preferable for coronary bypass grafting?
Intestinal angina is a symptom complex of which of the following?
What is the best surgical approach for repairing an injury to the abdominal aorta above the level of the renal arteries, involving the superior mesenteric artery, celiac trunk, and the suprarenal branch?
'SEPS' is a surgical procedure used in the treatment of which of the following conditions?
Which of the following is NOT a consequence of chronic edema of the legs?
Which of the following is a true statement regarding Buerger's disease?
Critical limb ischemia results from which of the following?
Sympathectomy is indicated in which of the following conditions?
Thrombophlebitis extending from the thigh to involve the iliofemoral vein causes which of the following conditions?
Vascular Surgery Indian Medical PG Practice Questions and MCQs
Question 11: A 52-year-old, nonsmoking man complains of pain and paresthesias in his right hand, particularly at night. Examination reveals a diminished radial pulse when he abducts his arm with his head turned to either side. A bruit is audible over the upper right anterior chest. His neurologic examination is unremarkable. What is the suspected diagnosis?
- A. A Pancoast tumor
- B. A cervical rib (Correct Answer)
- C. Cervical disc disease
- D. Subclavian steal syndrome
Explanation: The clinical presentation describes **Thoracic Outlet Syndrome (TOS)**, specifically the **Arterial** subtype caused by a **cervical rib**. ### **Explanation of the Correct Answer** A cervical rib is a supernumerary rib arising from the C7 vertebra. It narrows the space in the scalene triangle, leading to compression of the **subclavian artery** and/or the **brachial plexus**. * **Adson’s Test:** The disappearance of the radial pulse upon abduction of the arm and rotation of the head to the same side (as described) is a classic sign of arterial compression at the thoracic outlet. * **Bruit:** The audible bruit over the chest indicates turbulent flow due to extrinsic compression or post-stenotic dilatation of the subclavian artery. * **Symptoms:** Pain and paresthesia occur due to ischemia or nerve irritation, often worsening with specific limb positions. ### **Why Other Options are Incorrect** * **A. Pancoast Tumor:** While it can cause Horner’s syndrome and brachial plexus pain (C8-T2), it typically presents with a history of smoking, weight loss, and apical lung opacities, not positional pulse changes. * **C. Cervical Disc Disease:** This causes radiculopathy (pain/numbness) but does not account for a diminished radial pulse or a chest bruit. * **D. Subclavian Steal Syndrome:** This involves retrograde flow in the vertebral artery due to proximal subclavian stenosis. It presents with vertebrobasilar insufficiency (dizziness, syncope) during arm exercise, not positional compression signs. ### **NEET-PG High-Yield Pearls** * **Most common cause of TOS:** Anomalous fibromuscular bands (Cervical rib is the most common *bony* cause). * **Most common type of TOS:** Neurogenic (95%), involving the lower trunk of the brachial plexus (C8-T1). * **Paget-Schroetter Syndrome:** Venous TOS resulting in axillary-subclavian vein thrombosis ("effort thrombosis"). * **Investigation of choice:** Duplex ultrasonography (initial) and CT/MRI for anatomical visualization.
Question 12: Which vein is preferable for coronary bypass grafting?
- A. Saphenous vein (Correct Answer)
- B. Short saphenous vein
- C. Epigastric vessels
- D. Radial artery
Explanation: The **Great Saphenous Vein (GSV)** remains the most commonly used conduit for Coronary Artery Bypass Grafting (CABG) due to its length, ease of harvest, and diameter, which matches coronary arteries well. ### Why the Saphenous Vein is Correct: The GSV is the "gold standard" venous conduit because it is superficial, easily accessible, and provides sufficient length for multiple grafts. It has a thick muscular wall compared to other veins, allowing it to withstand arterial pressures better (arterialization). While the **Internal Thoracic Artery (ITA)** is the overall best conduit for long-term patency, the GSV is the preferred *venous* choice. ### Why Other Options are Incorrect: * **Short Saphenous Vein:** It is shorter, thinner, and its anatomical position (posterior leg) makes harvesting difficult during simultaneous cardiac surgery. * **Epigastric Vessels:** The Inferior Epigastric Artery is sometimes used as an arterial graft, but it is technically challenging to harvest and lacks the length and reliability of the GSV. * **Radial Artery:** This is an **arterial** conduit, not a vein. While it has better patency rates than veins, it is prone to vasospasm and requires a preoperative Allen’s test to ensure adequate ulnar collateral flow. ### High-Yield Clinical Pearls for NEET-PG: * **Best Patency:** The **Left Internal Mammary Artery (LIMA)** to the LAD has the highest 10-year patency rate (>90%). * **Reversal:** When using the GSV, it must be **reversed** (or valves must be lysed) to prevent valves from obstructing blood flow. * **Harvesting:** Endoscopic Vein Harvesting (EVH) is now preferred over open harvesting to reduce wound complications. * **Site:** The GSV is located **anterior** to the medial malleolus at the ankle.
Question 13: Intestinal angina is a symptom complex of which of the following?
- A. Postprandial abdominal pain, weight loss, acute mesenteric vessel occlusion
- B. Postprandial abdominal pain, weight loss, chronic mesenteric vessel occlusion (Correct Answer)
- C. Preprandial abdominal pain, weight loss, chronic mesenteric vessel occlusion
- D. Postprandial abdominal pain, weight gain, acute mesenteric vessel occlusion
Explanation: **Explanation:** **Intestinal Angina** (Chronic Mesenteric Ischemia) is a clinical syndrome resulting from inadequate blood supply to the bowel to meet the metabolic demands of digestion. It is analogous to stable angina of the heart. **1. Why Option B is Correct:** * **Postprandial Abdominal Pain:** This is the hallmark symptom. After eating, the bowel requires increased blood flow for digestion. In the presence of atherosclerotic narrowing of mesenteric vessels (usually the Celiac axis and Superior Mesenteric Artery), the blood supply cannot meet this demand, leading to ischemic pain (often called "fear of food") [1]. * **Weight Loss:** Patients develop "sitophobia" (fear of eating) to avoid the pain, leading to significant involuntary weight loss. * **Chronic Mesenteric Occlusion:** This is a chronic, progressive atherosclerotic process, not an acute event [2]. **2. Why Other Options are Incorrect:** * **Option A & D:** **Acute** mesenteric vessel occlusion presents as a surgical emergency with sudden, severe pain "out of proportion to physical findings," leading to bowel infarction rather than the recurrent, stable pattern of intestinal angina [3]. * **Option C:** The pain is **postprandial** (after meals), not preprandial, because the metabolic demand of the gut is lowest during fasting. * **Option D:** Weight **gain** is incorrect; weight loss is a cardinal feature due to decreased caloric intake. **NEET-PG High-Yield Pearls:** * **Classic Triad:** Postprandial pain, weight loss, and an abdominal bruit (though the bruit is only present in ~50% of cases) [1]. * **Diagnosis:** **CT Angiography** is the initial investigation of choice [1]. Lateral view aortography is traditionally used to visualize the origins of the celiac and mesenteric arteries. * **Vessels involved:** Usually requires significant stenosis of at least **two out of the three** major vessels (Celiac, SMA, IMA) due to extensive collateral circulation. * **Treatment:** Revascularization (Endovascular stenting or surgical bypass) [2].
Question 14: What is the best surgical approach for repairing an injury to the abdominal aorta above the level of the renal arteries, involving the superior mesenteric artery, celiac trunk, and the suprarenal branch?
- A. Right medial visceral rotation
- B. Left medial visceral rotation (Correct Answer)
- C. Right lateral visceral rotation
- D. Left lateral visceral rotation
Explanation: **Explanation:** The surgical management of retroperitoneal vascular injuries depends on the specific zone and vessels involved. **1. Why Left Medial Visceral Rotation (Mattox Maneuver) is correct:** The **Mattox maneuver** is the gold standard for exposing the entire length of the **descending thoracic and abdominal aorta**, including the **celiac trunk, superior mesenteric artery (SMA), and left renal artery**. It involves incising the lateral peritoneal reflection (White line of Toldt) on the left and rotating the colon, spleen, tail of the pancreas, and stomach medially. This provides the necessary exposure for suprarenal aortic injuries and their major branches. **2. Why the other options are incorrect:** * **Right Medial Visceral Rotation (Cattell-Braasch Maneuver):** This involves mobilizing the right colon, hepatic flexure, and the entire small bowel mesentery. It is used to expose the **infrarenal aorta, inferior vena cava (IVC)**, and the right iliac vessels. It does not provide access to the suprarenal aorta or the celiac/SMA origins. * **Right/Left Lateral Visceral Rotation:** These are not standard surgical terms for these maneuvers. The rotation is always described as "medial" because the viscera are moved toward the midline to expose the retroperitoneal structures located laterally or posteriorly. **Clinical Pearls for NEET-PG:** * **Mattox Maneuver:** Left-sided rotation; exposes the **entire abdominal aorta**. * **Cattell-Braasch Maneuver:** Right-sided rotation; exposes the **entire IVC**. * **Kocher Maneuver:** Specifically used to mobilize the duodenum and head of the pancreas to expose the **retropancreatic IVC** and the **renal hila**. * **Zone I Retroperitoneal Hematoma:** Central/Midline (contains aorta/IVC). These always require surgical exploration in blunt and penetrating trauma.
Question 15: 'SEPS' is a surgical procedure used in the treatment of which of the following conditions?
- A. Venous incompetence (Correct Answer)
- B. Aerial obstruction
- C. Lymphatic obstruction
- D. AV fistula
Explanation: **SEPS** stands for **Subfascial Endoscopic Perforator Surgery**. It is a minimally invasive surgical technique used primarily in the management of **chronic venous insufficiency (CVI)**, specifically to address **venous incompetence** of the perforating veins. ### 1. Why the Correct Answer is Right In patients with advanced venous disease (CEAP classes C4–C6), the valves in the **perforating veins** (which connect the superficial to the deep venous system) become incompetent. This causes high-pressure deep venous blood to reflux into the superficial system, leading to skin changes and venous ulcers. * **The Procedure:** SEPS involves using an endoscope passed into the subfascial space of the leg to visualize and ligate these incompetent perforators. By interrupting this reflux, SEPS promotes the healing of venous ulcers and prevents recurrence. ### 2. Why Other Options are Wrong * **Arterial obstruction:** Conditions like Buerger’s disease or Atherosclerosis are treated with bypass grafting, angioplasty, or sympathectomy, not by ligating perforating veins. * **Lymphatic obstruction:** Lymphedema is managed conservatively (compression) or via lymphovenous anastomosis; SEPS has no role in lymphatic drainage. * **AV fistula:** Arteriovenous fistulas require direct repair, ligation, or endovascular coiling to close the abnormal communication between an artery and a vein. ### 3. Clinical Pearls for NEET-PG * **Indications:** SEPS is most commonly indicated for **recurrent venous ulcers** (CEAP Class C5-C6) where conservative management fails. * **Advantage over Linton’s Procedure:** Traditional open subfascial ligation (Linton’s) had high rates of wound complications. SEPS offers faster healing and fewer wound infections because incisions are made away from the diseased skin/ulcer site. * **Cockett Perforators:** These are the most common perforators involved in the "gaiter area" of the lower leg, often targeted during SEPS.
Question 16: Which of the following is NOT a consequence of chronic edema of the legs?
- A. Marjolin's ulcer
- B. Thickening of the skin
- C. Soft tissue infections
- D. Varicose veins (Correct Answer)
Explanation: **Explanation:** The core concept to understand here is the **direction of causality**. Chronic edema is a *result* of underlying pathology, not the cause of varicose veins. **1. Why Varicose Veins is the Correct Answer:** Varicose veins are a **cause** of chronic edema, not a consequence. In chronic venous insufficiency (CVI), valvular incompetence leads to venous hypertension. This increased hydrostatic pressure forces fluid into the interstitial space, resulting in edema. Therefore, while edema is a hallmark sign of varicose veins, the reverse is not true; chronic swelling from other causes (like lymphedema or heart failure) does not cause veins to become dilated and tortuous. **2. Analysis of Incorrect Options (Consequences of Edema):** * **Thickening of the skin:** Chronic edema leads to **lipodermatosclerosis**. Persistent fluid accumulation triggers fibroblast proliferation and collagen deposition, causing the skin to become thick, fibrotic, and "woody." * **Soft tissue infections:** Edema compromises local lymphatic drainage and skin integrity. This creates a protein-rich environment ideal for bacterial growth, making patients highly susceptible to recurrent **cellulitis** and lymphangitis. * **Marjolin’s ulcer:** This refers to a squamous cell carcinoma arising in areas of chronic inflammation or chronic wounds. Chronic venous edema leads to venous ulcers; if these ulcers remain unhealed for decades, they can undergo malignant transformation into a Marjolin’s ulcer. **Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the second toe; a pathognomonic sign of chronic lymphedema. * **Gaiter Zone:** The lower third of the leg (medial malleolus) where chronic edema most commonly leads to venous ulceration. * **Inverted Champagne Bottle Appearance:** A classic description of the leg in advanced lipodermatosclerosis due to chronic edema and fibrosis.
Question 17: Which of the following is a true statement regarding Buerger's disease?
- A. Involves small and medium-sized vessels (Correct Answer)
- B. More commonly involves the upper limbs than the lower limbs
- C. Common in males
- D. Common in females
Explanation: **Explanation:** **Buerger’s Disease**, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the **small and medium-sized arteries and veins** of the distal extremities (hands and feet). 1. **Why Option A is correct:** The hallmark of TAO is a highly cellular, "soft" inflammatory thrombus that occludes the lumen of small and medium-sized vessels (e.g., radial, ulnar, tibial, and peroneal arteries). Unlike atherosclerosis, the internal elastic lamina remains intact. 2. **Why Options B, C, and D are incorrect:** * **Distribution (B):** While the upper limbs are frequently involved (a key diagnostic differentiator from atherosclerosis), the **lower limbs** are still more commonly affected first. * **Gender (C & D):** Historically, Buerger’s disease is overwhelmingly **more common in males** (typically <45 years old) who are heavy smokers. While the incidence in females is rising due to increased smoking habits, it remains a predominantly male-centric disease. **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing) is essential for diagnosis and progression. * **Triad of TAO:** Distal ischemia (claudication/ulcers), Raynaud’s phenomenon, and **Migratory Superficial Thrombophlebitis**. * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) due to recanalization of the occluded segments. * **Allen’s Test:** Often positive, indicating distal ulnar or radial artery occlusion. * **Treatment:** The only definitive treatment is **absolute smoking cessation**. Sympathectomy may be used for symptomatic relief in vasospastic cases.
Question 18: Critical limb ischemia results from which of the following?
- A. Mild arterial occlusive disease
- B. Moderate arterial occlusive disease
- C. Severe arterial occlusive disease (Correct Answer)
- D. All of the above
Explanation: **Explanation:** **Critical Limb Ischemia (CLI)** represents the most advanced and severe stage of Peripheral Arterial Disease (PAD). It occurs when **severe arterial occlusive disease** reduces blood flow to such an extent that the resting metabolic demands of the distal tissues can no longer be met. Unlike intermittent claudication, which occurs during exercise, CLI signifies that the perfusion pressure has fallen below the threshold required to maintain tissue viability at rest. * **Why Option C is correct:** CLI is clinically defined by the presence of **ischemic rest pain** (typically requiring narcotics for >2 weeks) or **tissue loss** (ulceration or gangrene). This state only occurs when there is multilevel or high-grade arterial obstruction, leading to an Ankle-Brachial Index (ABI) typically below 0.4 and a toe pressure below 30 mmHg. * **Why Options A and B are incorrect:** Mild to moderate arterial disease usually presents as either asymptomatic disease or **intermittent claudication**. In these stages, the collateral circulation is sufficient to maintain tissue integrity at rest, but cannot meet the increased oxygen demand during exertion. **Clinical Pearls for NEET-PG:** 1. **Fontaine Classification:** CLI corresponds to Stage III (Rest pain) and Stage IV (Ulceration/Gangrene). 2. **Rutherford Classification:** CLI corresponds to Categories 4, 5, and 6. 3. **The "6 Ps":** While CLI is a chronic process, the "6 Ps" (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) are used to identify *Acute* Limb Ischemia, which is a surgical emergency. 4. **Management:** The primary goal in CLI is urgent revascularization (endovascular or bypass) to prevent major limb amputation.
Question 19: Sympathectomy is indicated in which of the following conditions?
- A. Buerger’s disease
- B. Atherosclerosis producing ischemia of limbs
- C. Raynaud’s disease
- D. All of the above (Correct Answer)
Explanation: **Explanation:** The primary objective of a **sympathectomy** is to eliminate sympathetic vasoconstrictor tone, thereby inducing vasodilation and increasing skin blood flow. This procedure is indicated in conditions where vasospasm or chronic arterial occlusion limits peripheral perfusion, particularly in the upper and lower limbs. * **Buerger’s Disease (Thromboangiitis Obliterans):** In this non-atherosclerotic inflammatory disease, sympathectomy is used as a palliative measure. While it does not cure the underlying arterial inflammation, it helps improve collateral circulation, aids in the healing of small ischemic ulcers, and provides relief from rest pain. * **Atherosclerosis producing ischemia:** In patients with peripheral arterial disease (PAD) who are not candidates for reconstructive surgery (distal disease), lumbar sympathectomy can improve cutaneous blood flow. It is specifically beneficial for "rest pain" and superficial ischemic ulcers, though it rarely improves intermittent claudication (as muscle blood flow is regulated by metabolites rather than the sympathetic system). * **Raynaud’s Disease:** This is a vasospastic disorder. Cervicothoracic sympathectomy is indicated when medical management fails and there is a risk of digital gangrene. **Clinical Pearls for NEET-PG:** 1. **Level of Sympathectomy:** For the lower limb, the **L2-L4 ganglia** are removed (L1 is preserved in males to prevent loss of ejaculation). For the upper limb, the **T2-T3 ganglia** are targeted. 2. **Stellate Ganglion:** Removal of the T1 ganglion (Stellate) is usually avoided to prevent **Horner’s Syndrome**. 3. **Key Limitation:** Sympathectomy increases **skin** blood flow but has **no effect on muscle blood flow**; therefore, it is NOT effective for treating intermittent claudication.
Question 20: Thrombophlebitis extending from the thigh to involve the iliofemoral vein causes which of the following conditions?
- A. Red leg
- B. Blue leg
- C. Purple leg
- D. White leg (Correct Answer)
Explanation: **Explanation:** The correct answer is **White leg**, clinically known as **Phlegmasia Alba Dolens**. **1. Why "White Leg" is Correct:** Phlegmasia Alba Dolens (White leg) occurs when extensive deep vein thrombosis (DVT) involves the **iliofemoral segment**. The massive clot causes significant obstruction to venous outflow. This leads to a rapid increase in interstitial pressure, which eventually compresses the **capillary beds and small arterioles**. The resulting ischemia and lack of arterial blood flow give the limb a characteristic pale, milky-white appearance. It is classically associated with pregnancy (traditionally called "milk leg"). **2. Analysis of Incorrect Options:** * **Blue leg (Phlegmasia Cerulea Dolens):** This is a more severe progression of the condition. It involves total or near-total occlusion of all venous tributaries (including collaterals). This leads to profound venous congestion, cyanosis, and severe pain. It often progresses to venous gangrene. * **Red leg:** This is typically associated with **Cellulitis** or superficial thrombophlebitis, where localized inflammation and vasodilation cause erythema. * **Purple leg:** This is not a standard clinical term in vascular surgery but may be seen in the transition phase between Alba and Cerulea dolens as cyanosis sets in. **3. NEET-PG Clinical Pearls:** * **Phlegmasia Alba Dolens:** "Alba" = White. Key features: Pain, Edema, Pallor. Arterial pulses may be weak but are usually present. * **Phlegmasia Cerulea Dolens:** "Cerulea" = Blue. Key features: Severe pain, Cyanosis, and risk of Gangrene. This is a surgical emergency. * **Most common site for DVT:** Left iliac vein (due to compression by the right common iliac artery, known as **May-Thurner Syndrome**). * **Investigation of choice:** Duplex Ultrasonography. Gold standard is Contrast Venography.
Practice by Chapter
Atherosclerotic Disease
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Aortic Aneurysms
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Peripheral Arterial Disease
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Carotid Artery Disease
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Venous Thromboembolism
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Chronic Venous Insufficiency
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Mesenteric Vascular Disease
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Vascular Trauma
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Vascular Access for Hemodialysis
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Endovascular Techniques
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Diabetic Foot Vascular Disease
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Vasculitis
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