Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 191: Ankle brachial pressure index is more than 1.3 in all except?

A. Diabetes mellitus
B. Mural calcification
C. Renal insufficiency
D. Critical limb ischaemia (Correct Answer)

Explanation: **Explanation:** The **Ankle-Brachial Pressure Index (ABPI)** is the ratio of the systolic blood pressure at the ankle to the systolic blood pressure in the arm. It is a primary screening tool for Peripheral Arterial Disease (PAD). **Why Critical Limb Ischaemia (CLI) is the correct answer:** In **Critical Limb Ischaemia**, there is significant arterial stenosis or occlusion, leading to severely reduced blood flow to the distal limb. This results in a **low ABPI**, typically **less than 0.4**. A low ABPI correlates with the severity of the disease and the risk of non-healing ulcers or gangrene. **Why the other options are incorrect:** An ABPI **>1.3** indicates **falsely elevated pressures** due to **Mönckeberg’s medial sclerosis** (mural calcification). In this condition, the tunica media of the arteries becomes calcified and non-compressible, requiring excessively high cuff pressures to occlude the vessel. This is commonly seen in: * **Diabetes Mellitus:** Chronic hyperglycemia leads to accelerated medial wall calcification. * **Renal Insufficiency:** Secondary hyperparathyroidism and altered calcium-phosphate metabolism promote vascular calcification. * **Mural Calcification:** This is the underlying pathological process (medial sclerosis) that causes vessel stiffness. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ABPI:** 0.9 – 1.2. * **Mild to Moderate Claudication:** 0.5 – 0.9. * **Critical Ischaemia:** <0.4. * **Incompressible Arteries (ABPI >1.3):** If ABPI is abnormally high in a symptomatic patient, the next best step is to perform a **Toe-Brachial Index (TBI)**, as digital arteries are rarely affected by medial calcification. * **Rest Pain:** Usually occurs when the absolute ankle systolic pressure is **<50 mmHg**.

Question 192: Valvoplasty is performed in which of the following conditions, except?

A. Coarctation of the aorta (Correct Answer)
B. Pulmonary stenosis
C. Mitral stenosis
D. Aortic stenosis

Explanation: ### Explanation The term **Valvoplasty** (or Balloon Valvuloplasty) refers to a procedure used to repair or widen a stenotic (narrowed) cardiac valve. **1. Why "Coarctation of the Aorta" is the Correct Answer:** Coarctation of the aorta is **not a valvular pathology**; it is a congenital narrowing of the aortic lumen, typically occurring near the ductus arteriosus. The definitive treatment for coarctation is **Angioplasty** (balloon dilation with or without stenting) or surgical resection with end-to-end anastomosis. Since the pathology involves the vessel wall and not a valve, "valvoplasty" is technically the incorrect terminology for this procedure. **2. Analysis of Incorrect Options:** * **Pulmonary Stenosis:** Balloon Pulmonary Valvuloplasty (BPV) is the **treatment of choice** for symptomatic congenital pulmonary stenosis. * **Mitral Stenosis:** Percutaneous Transvenous Mitral Commissurotomy (PTMC), a form of valvoplasty, is the gold standard for managing severe mitral stenosis with favorable valve morphology (Wilkins score). * **Aortic Stenosis:** Balloon Aortic Valvoplasty (BAV) is used as a palliative measure in elderly patients or as a bridge to TAVI/Surgical replacement, and is a primary treatment in congenital pediatric aortic stenosis. **3. NEET-PG High-Yield Pearls:** * **Gold Standard for Mitral Stenosis:** PTMC (Inoue Balloon technique). * **Coarctation of Aorta:** Associated with Turner Syndrome and Bicuspid Aortic Valve. Look for "rib notching" on X-ray and "radio-femoral delay" on examination. * **Terminology Tip:** Always distinguish between **Valvoplasty** (Valve), **Angioplasty** (Vessel), and **Septostomy** (Septum, e.g., Rashkind procedure for TGA).

Question 193: What is the initial therapy for documented deep venous thrombosis in a post-operative patient?

A. Subcutaneous heparin therapy
B. Intravenous heparin therapy (Correct Answer)
C. Thrombolytic therapy with urokinase
D. Aspirin therapy

Explanation: **Explanation:** The management of documented Deep Venous Thrombosis (DVT) in the post-operative period focuses on preventing pulmonary embolism (PE) and limiting thrombus propagation. **1. Why Intravenous (IV) Heparin is Correct:** Unfractionated Heparin (UFH) administered intravenously is the traditional gold standard for initial therapy in a hospital setting. Its primary advantage is its **rapid onset of action** and **short half-life**. In post-operative patients, who carry a higher risk of bleeding complications, IV heparin is preferred because its effect can be terminated quickly (within hours) or rapidly reversed with Protamine Sulfate if emergency re-operation or intervention is required. It achieves immediate therapeutic anticoagulation, measured by the activated partial thromboplastin time (aPTT). **2. Why Other Options are Incorrect:** * **Subcutaneous Heparin:** While Low Molecular Weight Heparin (LMWH) is given subcutaneously and is now common, standard subcutaneous UFH is primarily used for *prophylaxis*, not the initial *treatment* of documented acute DVT, due to unpredictable bioavailability in the acute phase. * **Thrombolytic Therapy (Urokinase):** This is reserved for "massive" DVT (e.g., Phlegmasia cerulea dolens) or massive PE with hemodynamic instability. In a post-operative patient, thrombolytics are generally **contraindicated** due to the high risk of life-threatening hemorrhage from the surgical site. * **Aspirin Therapy:** Aspirin is an antiplatelet agent. It is insufficient for treating an established venous thrombus, which requires anticoagulants to inhibit the coagulation cascade. **Clinical Pearls for NEET-PG:** * **Target aPTT:** For therapeutic heparinization, the goal is 1.5 to 2.5 times the control value. * **Warfarin Bridge:** Anticoagulation is usually started with Heparin and bridged to Warfarin (overlapping for at least 5 days) until the INR reaches the therapeutic range (2.0–3.0). * **LMWH vs. UFH:** LMWH is often preferred today due to a lower risk of Heparin-Induced Thrombocytopenia (HIT), but UFH remains the answer of choice in exams when rapid reversibility is prioritized post-surgery.

Question 194: All of the following are seen in deep vein thrombosis except?

A. Pain
B. Discoloration
C. Swelling
D. Claudication (Correct Answer)

Explanation: **Explanation:** Deep Vein Thrombosis (DVT) is a condition characterized by the formation of a blood clot within the deep venous system, most commonly in the lower limbs. The fundamental pathophysiology involves **venous obstruction** and inflammation. **Why Claudication is the Correct Answer:** Claudication is a hallmark symptom of **Peripheral Arterial Disease (PAD)**, not venous disease. It refers to cramp-like muscle pain that occurs predictably during exercise and is relieved by rest. This occurs because narrowed arteries cannot meet the increased oxygen demand of exercising muscles. In DVT, the pathology is venous congestion, not arterial insufficiency; therefore, classic claudication is absent. **Analysis of Incorrect Options:** * **Pain:** This is a common symptom of DVT, typically described as a dull ache or heaviness in the calf or thigh, exacerbated by weight-bearing. * **Discoloration:** Venous stasis leads to skin changes. In acute DVT, the limb may appear slightly cyanotic (blue) or erythematous (red) due to congestion. In severe cases, it can progress to *Phlegmasia cerulea dolens*. * **Swelling:** Unilateral leg edema is the most sensitive clinical sign of DVT, resulting from increased hydrostatic pressure behind the venous obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, Endothelial injury, and Hypercoagulability are the three factors predisposing to DVT. * **Homan’s Sign:** Calf pain on dorsiflexion of the foot (low sensitivity and specificity). * **Moses Sign:** Pain on squeezing the calf muscles from side to side. * **Gold Standard Investigation:** Contrast Venography (rarely used now). * **Investigation of Choice:** Duplex Ultrasound (Compression Ultrasonography). * **Phlegmasia Alba Dolens:** "Milk leg" – massive iliofemoral DVT causing a pale, white limb (associated with pregnancy).

Question 195: A patient sustained traumatic injury to major abdominal vessels. It has been planned to explore the suprarenal aorta, the celiac axis, the superior mesenteric artery, and the left renal artery. Which maneuver is recommended for exposure of all these structures?

A. Cranial visceral rotation
B. Caudal visceral rotation
C. Left medial visceral rotation (Correct Answer)
D. Right medial visceral rotation

Explanation: ### Explanation **1. Why Left Medial Visceral Rotation (Mattox Maneuver) is Correct:** The **Mattox maneuver** involves mobilizing the left colon, spleen, tail of the pancreas, and the fundus of the stomach toward the midline (medially). By incising the lateral peritoneal reflection (White line of Toldt) and rotating these viscera, the surgeon gains extensive exposure to the **entire length of the abdominal aorta**, from the hiatus to the iliac bifurcation. This is the gold-standard approach for accessing the **suprarenal aorta, celiac axis, SMA, and the left renal artery**, as it provides a lateral view of these vessels without the interference of the vena cava. **2. Why the Other Options are Incorrect:** * **Right Medial Visceral Rotation (Cattell-Braasch Maneuver):** This involves mobilizing the right colon and the small bowel mesentery. It provides excellent exposure to the **Inferior Vena Cava (IVC)**, right renal vessels, and the superior mesenteric vein. It is *not* used for the suprarenal aorta or the celiac axis. * **Cranial/Caudal Visceral Rotation:** These are not standard surgical terms for the mobilization of abdominal organs to expose retroperitoneal vascular structures. Visceral rotation is primarily described in the medial-lateral axis. **3. Clinical Pearls for NEET-PG:** * **Mattox Maneuver (Left):** Think "Aorta." Best for suprarenal aortic injuries and its major branches (Celiac, SMA, Left Renal). * **Cattell-Braasch Maneuver (Right):** Think "IVC." Best for infrahepatic IVC and right-sided retroperitoneal structures. * **Kocher Maneuver:** A component of right-sided rotation used specifically to mobilize the duodenum and head of the pancreas to expose the infrahepatic IVC and the posterior aspect of the duodenum. * **High-Yield Tip:** If the question mentions "Suprarenal Aorta," the answer is almost always the Mattox Maneuver (Left Medial Visceral Rotation).

Question 196: What is the commonest complication of a prosthetic valve?

A. Embolism
B. Subacute bacterial endocarditis (Correct Answer)
C. Rejection
D. Infarction

Explanation: **Explanation:** The most common and significant complication associated with prosthetic heart valves is **Subacute Bacterial Endocarditis (SBE)**. 1. **Why SBE is the correct answer:** Prosthetic materials are highly susceptible to bacterial colonization because they lack a natural endothelial lining and immune defense mechanisms. Turbulence created by the mechanical or bioprosthetic structure can cause minor endocardial damage, facilitating the adherence of organisms (commonly *Staphylococcus epidermidis* in the early postoperative period and *Streptococcus viridans* in the late period). This leads to the formation of vegetations, making SBE the most frequent serious complication. 2. **Why other options are incorrect:** * **Embolism:** While systemic thromboembolism is a major risk (especially with mechanical valves), it is generally ranked secondary to infective endocarditis in terms of overall frequency and morbidity in classic surgical teaching. * **Rejection:** Unlike solid organ transplants (kidney, liver), prosthetic valves (mechanical or bioprosthetic) do not trigger a classic T-cell mediated "rejection" because they are either inert materials or chemically treated (glutaraldehyde-fixed) tissues that are non-immunogenic. * **Infarction:** This is a *consequence* of an embolism (e.g., myocardial or cerebral infarction) rather than a primary complication of the valve itself. **High-Yield Clinical Pearls for NEET-PG:** * **Early Prosthetic Valve Endocarditis (PVE):** Occurs within 1 year of surgery; most common organism is **Staphylococcus epidermidis**. * **Late PVE:** Occurs after 1 year; most common organism is **Streptococcus species**. * **Anticoagulation:** Mechanical valves require lifelong anticoagulation with Warfarin (INR 2.5–3.5), whereas bioprosthetic valves usually require only 3 months of therapy. * **Hemolysis:** Mechanical valves can cause microangiopathic hemolytic anemia due to high shear stress.

Question 197: Grade 4 clinically in varicose veins is characterised by all except?

A. Eczema
B. Lipodermatosclerosis
C. Ulceration (Correct Answer)
D. Pigmentation

Explanation: This question tests your knowledge of the **CEAP Classification**, which is the gold standard for describing the clinical severity of chronic venous disorders. ### **Explanation** The CEAP classification categorizes varicose veins from C0 to C6 based on clinical signs. **Grade 4 (C4)** is specifically characterized by **skin changes** resulting from chronic venous hypertension, but it does **not** include active or healed ulcers. * **Why Option C is the correct answer:** Ulceration is classified under Grade 5 and Grade 6. Specifically, **C5** represents a healed venous ulcer, while **C6** represents an active venous ulcer. Therefore, ulceration is "excepted" from Grade 4. ### **Analysis of Incorrect Options (Features of Grade 4)** Grade 4 is subdivided into 4a and 4b: * **Option D (Pigmentation):** Part of C4a. It occurs due to haemosiderin deposition from extravasated red blood cells. * **Option A (Eczema):** Part of C4a. Also known as stasis dermatitis, it presents as erythema, scaling, and itching. * **Option B (Lipodermatosclerosis):** Part of C4b. This refers to chronic inflammation and fibrosis of the skin and subcutaneous fat, often leading to the "inverted champagne bottle" appearance of the leg. Atrophie blanche is also included in C4b. ### **High-Yield Clinical Pearls for NEET-PG** * **C0:** No visible or palpable signs of venous disease. * **C1:** Telangiectasia (spider veins) or reticular veins (<3mm). * **C2:** Varicose veins (≥3mm). * **C3:** Edema (without skin changes). * **C4:** Skin changes (Pigmentation, Eczema, Lipodermatosclerosis). * **C5:** Healed venous ulcer. * **C6:** Active venous ulcer. * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Gold Standard Investigation:** Duplex Ultrasound (Doppler).

Question 198: A patient presented with pulsating varicose veins of the lower limb. On examination, he was having cutaneous hemangioma involving the face with enlarged toes. What is the most probable diagnosis?

A. Klippel-Trenaunay syndrome (Correct Answer)
B. Tricuspid regurgitation
C. Deep vein thrombosis (DVT)
D. Kasabach-Merritt syndrome

Explanation: ### Explanation The correct diagnosis is **Klippel-Trenaunay Syndrome (KTS)**. This is a rare congenital vascular disorder characterized by a classic triad: 1. **Port-wine stain** (Capillary malformation/Cutaneous hemangioma). 2. **Venous malformations** (typically presenting as "pulsating" or atypical varicose veins). 3. **Soft tissue and bony hypertrophy** (leading to limb overgrowth or enlarged toes/macrodactyly). In this case, the combination of cutaneous hemangiomas, varicose veins, and enlarged toes (local hypertrophy) fits the classic presentation of KTS. #### Why the other options are incorrect: * **Tricuspid Regurgitation:** While it can cause "pulsating" neck veins (systolic v-waves) and peripheral edema, it does not cause localized limb hypertrophy or cutaneous hemangiomas. * **Deep Vein Thrombosis (DVT):** DVT presents with acute limb swelling, pain, and tenderness. It does not involve congenital hemangiomas or bony overgrowth. * **Kasabach-Merritt Syndrome:** This involves a rapidly growing vascular tumor (usually a tufted angioma or kaposiform hemangioendothelioma) that leads to **consumptive coagulopathy** and severe thrombocytopenia. It is not characterized by limb hypertrophy. #### NEET-PG High-Yield Pearls: * **KTS vs. Parkes-Weber Syndrome:** If the patient also has significant **Arteriovenous Fistulas (AVFs)** leading to high-output heart failure, the diagnosis shifts to Parkes-Weber Syndrome. * **Servelle-Martorell Syndrome:** Characterized by limb **hypotrophy** (shortening) due to intraosseous vascular malformations, contrasting with the hypertrophy seen in KTS. * **Management:** Primarily conservative (compression stockings). Surgery is reserved for complications due to the high risk of recurrence and bleeding.

Question 199: What is the most common complication of below-knee stripping of varicose veins?

A. Hemorrhage
B. Thromboembolism
C. Neuralgia (Correct Answer)
D. Infection

Explanation: The correct answer is **Neuralgia (C)**. ### **Explanation** The primary surgical treatment for varicose veins involves high ligation and stripping of the Great Saphenous Vein (GSV). Below the knee, the GSV runs in close anatomical proximity to the **Saphenous Nerve**. During the stripping process, particularly if the vein is stripped downward to the ankle, the nerve is frequently stretched, bruised, or severed. This leads to postoperative **neuralgia** or paresthesia along the medial aspect of the leg and foot. To minimize this risk, modern surgical practice often limits stripping to the level of the knee (proximal stripping). ### **Why other options are incorrect:** * **Hemorrhage (A):** While bruising (ecchymosis) is very common, significant hemorrhage is rare if proper pressure bandages are applied postoperatively. * **Thromboembolism (B):** Deep Vein Thrombosis (DVT) and Pulmonary Embolism are serious but rare complications (occurring in <1% of cases) due to early ambulation protocols. * **Infection (D):** Wound infection occurs in approximately 2–5% of cases, making it less frequent than sensory nerve injury. ### **High-Yield Clinical Pearls for NEET-PG:** * **Most common nerve injured in GSV stripping:** Saphenous Nerve (causes medial leg numbness). * **Most common nerve injured in Short Saphenous Vein (SSV) surgery:** Sural Nerve (causes lateral foot numbness). * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Gold Standard Investigation:** Duplex Ultrasound is the investigation of choice for varicose veins. * **Complication Prevention:** Stripping the vein from **below upwards** (distal to proximal) or limiting stripping to the knee reduces the incidence of saphenous neuralgia.

Question 200: For bleeding varices of the esophagus, which operation or operations are commonly performed?

A. Portacaval shunt (Correct Answer)
B. Gastrectomy
C. Splenectomy
D. All of the above

Explanation: **Explanation:** The management of bleeding esophageal varices focuses on reducing portal hypertension, which is the underlying cause of the collateral venous dilation. **Why Portacaval Shunt is Correct:** A **Portacaval shunt** is a surgical decompression procedure that creates a communication between the high-pressure portal vein and the low-pressure inferior vena cava. By diverting portal blood flow into the systemic circulation, it effectively lowers portal venous pressure, thereby collapsing the varices and preventing further hemorrhage. While less common today due to TIPS (Transjugular Intrahepatic Portosystemic Shunt) and endoscopic therapies, it remains a definitive surgical option for refractory cases. **Why Other Options are Incorrect:** * **Gastrectomy:** This involves the removal of the stomach. While gastric varices can bleed, a gastrectomy is not a standard treatment for esophageal varices and does not address the primary issue of portal hypertension. * **Splenectomy:** While often performed as part of a "Sugiura procedure" (devascularization) or for isolated splenic vein thrombosis (sinistral hypertension), a splenectomy alone is generally insufficient to control bleeding from generalized portal hypertension caused by cirrhosis. **NEET-PG High-Yield Pearls:** * **Gold Standard for Acute Bleed:** Endoscopic Variceal Ligation (EVL) is the first-line treatment. * **Pharmacotherapy:** Octreotide or Terlipressin are used to reduce portal inflow. * **Sugiura Procedure:** An extensive devascularization operation (esophageal transection + splenectomy + gastric devascularization) used when shunts are not feasible. * **Warren Shunt:** A distal splenorenal shunt (DSRS) is a "selective" shunt that decompression varices while maintaining some portal flow to the liver, reducing the risk of hepatic encephalopathy compared to a portacaval shunt.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

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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