Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 221: Which site is most commonly affected by diabetic foot ulcers?

A. Medial malleolus
B. Lateral malleolus
C. Heel (Correct Answer)
D. Head of metatarsal

Explanation: **Explanation:** Diabetic foot ulcers are primarily a result of **peripheral neuropathy** (loss of protective sensation) and **peripheral arterial disease**. While pressure-related ulcers frequently occur at the metatarsal heads due to biomechanical changes, the **heel** is the most common site for ulcers leading to significant morbidity and hospitalization in diabetic patients. The heel is particularly vulnerable because it bears the maximum weight during the initial contact phase of the gait cycle. In a diabetic patient, the combination of **fat pad atrophy**, dry skin (due to autonomic neuropathy), and constant pressure makes the heel the primary site for deep tissue injury and ulceration. **Analysis of Options:** * **Heel (Correct):** Statistically the most frequent site for diabetic ulcers, especially those associated with prolonged pressure and high weight-bearing. * **Head of Metatarsal (Incorrect):** This is the most common site for **neuropathic (perforating) ulcers** or "Malperforans." While very common, in the context of overall diabetic foot presentations, the heel remains the leading site. * **Medial & Lateral Malleoli (Incorrect):** These are classic sites for **venous ulcers** (medial) and **hypertensive/ischemic ulcers** (lateral). They are not the primary sites for diabetic foot pathology unless associated with direct trauma or ill-fitting footwear. **Clinical Pearls for NEET-PG:** * **Wagner’s Classification:** Used to grade diabetic foot ulcers (Grade 0: Pre-ulcerative; Grade 1: Superficial; Grade 2: Deep to tendon/bone; Grade 3: Osteomyelitis/Abscess; Grade 4: Forefoot gangrene; Grade 5: Whole foot gangrene). * **Monofilament Test:** The 10g Semmes-Weinstein monofilament is the gold standard for screening loss of protective sensation. * **Charcot’s Arthropathy:** Characterized by "rocker-bottom deformity," often triggered by minor trauma in a neuropathic foot.

Question 222: Which of the following is NOT true regarding Milroy's disease?

A. It is autosomal dominant.
B. It typically involves unilateral upper and lower limbs. (Correct Answer)
C. The face may be involved.
D. It is a form of congenital lymphedema.

Explanation: **Explanation:** Milroy’s disease is a specific type of **Primary Congenital Lymphedema** caused by a mutation in the **FLT4 gene**, which encodes the **VEGFR-3** (Vascular Endothelial Growth Factor Receptor 3). This mutation leads to the failure of lymphatic vessel development. **Why Option B is the correct answer (False statement):** Milroy’s disease characteristically presents as **bilateral** swelling of the **lower limbs** only. It is present at birth or develops within the first year of life. Involvement of the upper limbs is extremely rare, and unilateral presentation is not the classic clinical picture. **Analysis of other options:** * **Option A (Autosomal Dominant):** This is true. It follows an autosomal dominant inheritance pattern with variable expressivity. * **Option C (Face involvement):** While rare, Milroy’s disease can occasionally be associated with facial edema, hydrocele, or prominent veins. * **Option D (Congenital Lymphedema):** This is true. By definition, Milroy’s is "Lymphedema Praecox" (specifically the congenital subtype), as it is present at birth. **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Age:** * **Milroy’s Disease:** Congenital (at birth). * **Meige’s Disease:** Lymphedema Praecox (at puberty/most common primary type). * **Lymphedema Tarda:** Occurs after age 35. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic sign of lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for confirming the diagnosis and assessing lymphatic flow.

Question 223: Which of the following structures is NOT involved in Berger's disease?

A. Artery
B. Veins
C. Nerve
D. Lymphatics (Correct Answer)

Explanation: **Explanation:** **Buerger’s Disease**, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that primarily affects small and medium-sized vessels of the extremities. **1. Why Lymphatics is the Correct Answer:** Buerger’s disease is characterized by a highly cellular, "soft" inflammatory thrombus that involves the **neurovascular bundle**. While it affects arteries, veins, and nerves, it characteristically **spares the lymphatics**. Therefore, lymphatic involvement is not a feature of this pathology. **2. Analysis of Incorrect Options:** * **Artery (A):** This is the primary site of involvement. It causes segmental occlusive lesions leading to distal ischemia, claudication, and gangrene. * **Veins (B):** Approximately 40-50% of patients exhibit **Migratory Superficial Thrombophlebitis**, where inflammation affects the superficial veins. * **Nerve (C):** The inflammatory process extends from the vessels to the adjacent sheath, involving the nerves within the neurovascular bundle. This often results in severe neuropathic pain and is a hallmark of the disease. **3. High-Yield Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing). Smoking cessation is the only way to halt disease progression. * **Demographics:** Classically seen in young males (<45 years). * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) due to recanalization of the vessels. * **Pathology:** Presence of **Microabscesses** (of Smith) within the thrombus, surrounded by multinucleated giant cells. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries.

Question 224: Which of the following are features of Klippel-Trenaunay syndrome?

A. Varicose veins, cutaneous hemangioma, limb hypertrophy, and anomalous deep veins are true, while saphenous vein stripping is hazardous is false.
B. Varicose veins, cutaneous hemangioma, limb hypertrophy, and saphenous vein stripping being hazardous are true, while anomalous deep veins is false.
C. Varicose veins and limb hypertrophy and saphenous vein stripping being hazardous are true, while cutaneous hemangioma and anomalous deep veins are false.
D. All features are true. (Correct Answer)

Explanation: **Explanation:** **Klippel-Trenaunay Syndrome (KTS)** is a rare congenital vascular disorder characterized by a classic triad of clinical features. Understanding the pathophysiology is crucial for NEET-PG, as management differs significantly from standard venous disease. 1. **Why Option D is Correct:** All listed features are characteristic of KTS: * **Cutaneous Hemangioma:** Specifically, a "Port-wine stain" (capillary malformation) is usually the first sign. * **Varicose Veins:** Often presenting as a large lateral venous channel (Servelle-Martorell vein). * **Limb Hypertrophy:** Soft tissue and bony overgrowth of the affected extremity. * **Anomalous Deep Veins:** Patients frequently have hypoplastic or absent deep venous systems. * **Hazardous Saphenous Stripping:** Because the deep venous system is often absent or incompetent, the superficial varicose veins act as the **primary drainage** for the limb. Stripping these veins can lead to severe venous congestion and limb-threatening ischemia. 2. **Why Other Options are Incorrect:** Options A, B, and C are incorrect because they categorize one or more of these essential diagnostic or management features as "false." In KTS, the presence of deep vein anomalies and the contraindication to traditional vein stripping are defining clinical principles. **High-Yield Clinical Pearls for NEET-PG:** * **Parkes-Weber Syndrome:** Often confused with KTS; it includes the KTS triad plus **clinically significant Arteriovenous (AV) fistulas**. * **Diagnosis:** Duplex ultrasonography is the initial investigation, but **MR Venography** is the gold standard to assess the deep venous system. * **Management:** Primarily conservative (compression stockings). Surgery is reserved for complications and only after confirming a patent deep venous system.

Question 225: True about coarctation of aorta?

A. Most common site is distal to the origin of the left subclavian artery (Correct Answer)
B. Most common age of presentation is at 15–20 years
C. Upper rib notching is due to erosion by dilated collateral vessels
D. Right ventricular hypertrophy

Explanation: **Explanation:** **Coarctation of the Aorta (CoA)** is a congenital narrowing of the aortic lumen. 1. **Why Option A is Correct:** The most common site for coarctation is the **juxtaductal** region, specifically just **distal to the origin of the left subclavian artery** at the insertion of the ligamentum arteriosum. This is the "post-ductal" type typically seen in adults. 2. **Why Other Options are Incorrect:** * **Option B:** While it can be diagnosed later, the most common age of presentation is **infancy** (severe cases) or **childhood**. By age 15–20, many patients are already symptomatic with systemic hypertension. * **Option C:** Rib notching is a classic sign, but it occurs on the **lower borders** of the ribs (3rd to 8th). This is due to pressure erosion from dilated, tortuous **intercostal arteries** acting as collateral pathways. The upper borders remain unaffected. * **Option D:** Because the obstruction is in the aorta (systemic circulation), the left ventricle must pump against high afterload, leading to **Left Ventricular Hypertrophy (LVH)**, not right. **High-Yield Clinical Pearls for NEET-PG:** * **Radio-femoral delay:** The hallmark physical finding (weak/delayed pulses in lower limbs compared to upper limbs). * **Figure-of-3 Sign:** Seen on Chest X-ray due to pre-stenotic dilation, the coarctation itself, and post-stenotic dilation. * **Associations:** Strongly associated with **Bicuspid Aortic Valve** (up to 85%) and **Turner Syndrome** (15-20%). * **Blood Pressure:** Hypertension in the upper extremities with hypotension in the lower extremities.

Question 226: Which of the following describes the Nicoladoni-Branham sign?

A. Bradycardia caused by compression (Correct Answer)
B. Tachycardia caused by compression
C. Hypotension
D. Systolic filling

Explanation: The **Nicoladoni-Branham sign** (also known as the Branham sign) is a classic clinical finding used in the diagnosis of large **Arteriovenous Fistulas (AVFs)**. ### **Explanation of the Correct Answer** When a large AV fistula is manually compressed, the abnormal shunting of blood from the high-pressure arterial system to the low-pressure venous system is suddenly halted. This leads to: 1. **Increased Peripheral Resistance:** Closing the "leak" increases systemic vascular resistance. 2. **Increased Stroke Volume:** The blood that was previously shunted is now redirected into the systemic circulation, increasing effective circulating volume. 3. **Reflex Bradycardia:** The sudden rise in mean arterial pressure is sensed by the **baroreceptors** (in the carotid sinus and aortic arch), which triggers a parasympathetic response via the vagus nerve, resulting in a **slowing of the heart rate (bradycardia)**. ### **Why Other Options are Incorrect** * **B. Tachycardia:** This is the opposite of the physiological response. Tachycardia is often seen *before* compression due to the high-output state caused by the fistula. * **C. Hypotension:** Compression of an AVF typically causes a transient **increase** in blood pressure (hypertension), not hypotension, due to the sudden increase in peripheral resistance. * **D. Systolic filling:** This is not a recognized clinical sign associated with AVF compression. ### **High-Yield Clinical Pearls for NEET-PG** * **Definition:** Nicoladoni-Branham sign = Compression of AVF → Bradycardia + Rise in Blood Pressure. * **Clinical Significance:** A positive sign indicates a large, hemodynamically significant fistula that may be causing high-output cardiac failure. * **Associated Murmur:** AV fistulas are characterized by a **continuous "machinery" murmur** and a palpable thrill. * **Proximal Changes:** Over time, the artery proximal to a chronic AVF becomes dilated and tortuous (cirsoid aneurysm).

Question 227: What is the most common bacterial infection associated with lymphedema?

A. Staphylococcus
B. Streptococcus (Correct Answer)
C. E. coli
D. Pseudomonas

Explanation: **Explanation:** Lymphedema results from impaired lymphatic drainage, leading to the accumulation of protein-rich fluid in the interstitial space. This stagnant fluid acts as an ideal culture medium for bacteria and impairs local immune surveillance (local immunodeficiency), making the affected limb highly susceptible to soft tissue infections. **Why Streptococcus is Correct:** The most common bacterial cause of infection in lymphedema (cellulitis or lymphangitis) is **Group A Beta-hemolytic Streptococcus** (e.g., *Streptococcus pyogenes*). These bacteria produce enzymes like hyaluronidase and streptokinase that facilitate rapid spread through the protein-rich interstitial fluid. Recurrent streptococcal infections further damage the remaining lymphatic channels, creating a vicious cycle that worsens the lymphedema (Elephantiasis). **Why Other Options are Incorrect:** * **Staphylococcus:** While *Staphylococcus aureus* is a common cause of skin abscesses and wound infections, it is less common than Streptococcus in the context of non-purulent cellulitis associated with lymphedema. * **E. coli & Pseudomonas:** These are Gram-negative organisms. They are typically associated with hospital-acquired infections, chronic ulcers, or infections in immunocompromised states, but they are not the primary causative agents for standard lymphedema-associated cellulitis. **High-Yield Clinical Pearls for NEET-PG:** * **Dermatolymphangioadenitis (DLA):** The clinical term for the acute inflammatory episodes (fever, chills, erythema) seen in lymphedema. * **Treatment:** Penicillin is the drug of choice for prophylaxis in patients with recurrent episodes. * **Stewart-Treves Syndrome:** A rare, highly aggressive **angiosarcoma** that develops in a limb with long-standing chronic lymphedema (most commonly post-mastectomy). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic physical finding for lymphedema.

Question 228: A 45-year-old male with a history of chronic smoking presents with pain in his lower limb due to blockage of the femoral artery. What is the most likely diagnosis?

A. Thromboangiitis obliterans
B. Atherosclerosis (Correct Answer)
C. Embolism
D. Arteritis

Explanation: **Explanation:** **Atherosclerosis** is the most common cause of chronic arterial occlusive disease in the lower limbs, especially in patients over 40 with a history of smoking. It is a systemic inflammatory process where lipid-rich plaques accumulate in the tunica intima, leading to progressive narrowing (stenosis) or complete occlusion of large and medium-sized arteries like the femoral artery. Smoking is the most potent modifiable risk factor, accelerating plaque formation and peripheral arterial disease (PAD). **Why other options are incorrect:** * **Thromboangiitis obliterans (Buerger’s Disease):** While strongly associated with smoking, it typically affects **small and medium-sized distal arteries** (radial, tibial, plantar) in younger males (<40 years). It is an inflammatory vasculitis, not a primary blockage of the proximal femoral artery. * **Embolism:** This usually presents as an **acute** event (the "6 Ps": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) rather than a chronic presentation. The source is often the heart (atrial fibrillation). * **Arteritis:** This refers to inflammatory conditions (like Takayasu’s). While they cause blockages, they are less common than atherosclerosis in a 45-year-old male smoker and usually involve the aorta or its primary branches. **NEET-PG High-Yield Pearls:** * **Most common site of atherosclerosis in the lower limb:** The **Adductor (Hunter’s) canal**, where the superficial femoral artery is most vulnerable. * **Leriche Syndrome:** A triad of claudication (buttock/thigh), impotence, and absent femoral pulses due to aortoiliac occlusion. * **Ankle-Brachial Index (ABI):** The best initial screening test for PAD. A value **<0.9** is diagnostic; **<0.4** indicates critical limb ischemia. * **Management:** Smoking cessation is the single most important step to prevent disease progression.

Question 229: Which of the following drugs is NOT used for sclerotherapy of varicose veins?

A. Ethanolamine oleate
B. Polidocanol
C. Ethanol (Correct Answer)
D. Sodium tetradecyl sulfate

Explanation: **Explanation** Sclerotherapy is a procedure where a chemical agent (sclerosant) is injected into a vein to cause endothelial damage, leading to fibrosis and permanent occlusion of the vessel. **Why Ethanol is the Correct Answer:** While **Ethanol (Absolute Alcohol)** is a potent sclerosing agent, it is **NOT** used for the treatment of varicose veins. Its action is too aggressive, often leading to full-thickness necrosis of the vessel wall, skin ulceration, and significant systemic toxicity. In vascular surgery, absolute ethanol is primarily reserved for the embolization of **Arteriovenous Malformations (AVMs)** and certain tumors, rather than superficial venous insufficiency. **Analysis of Incorrect Options:** * **Ethanolamine oleate (Option A):** A traditional detergent sclerosant used for both varicose veins and esophageal varices. * **Polidocanol (Option B):** Currently the most popular sclerosant due to its low risk of allergic reactions and painless injection (it has local anesthetic properties). It is frequently used in "foam sclerotherapy." * **Sodium tetradecyl sulfate (STS) (Option D):** A powerful detergent sclerosant commonly used for larger varicose veins. It is highly effective but carries a slightly higher risk of skin staining and tissue necrosis if extravasated compared to Polidocanol. **NEET-PG High-Yield Pearls:** * **Mechanism of Sclerosants:** They work by damaging the endothelium, exposing subendothelial collagen, and inducing a "controlled" thrombofibrosis. * **Classification:** Sclerosants are classified into **Detergents** (STS, Polidocanol), **Osmotic agents** (Hypertonic saline), and **Chemical irritants** (Chromated glycerin). * **Complications:** The most common side effects include hyperpigmentation (hemosiderin staining), superficial thrombophlebitis, and rarely, deep vein thrombosis (DVT). * **Contraindication:** Sclerotherapy is contraindicated if there is an underlying saphenofemoral junction (SFJ) incompetence that has not been addressed, or in the presence of active DVT.

Question 230: What does a Potts shunt connect?

A. Right subclavian artery to pulmonary artery
B. Descending aorta to left pulmonary artery (Correct Answer)
C. Left subclavian artery to left pulmonary artery
D. Ascending aorta to right pulmonary artery

Explanation: ### Explanation The **Potts shunt** is a palliative systemic-to-pulmonary shunt historically used to increase pulmonary blood flow in cyanotic congenital heart diseases with decreased pulmonary perfusion (e.g., Tetralogy of Fallot). **1. Why Option B is Correct:** The Potts shunt involves a side-to-side anastomosis between the **descending thoracic aorta** and the **left pulmonary artery**. It was designed to provide a reliable source of pulmonary blood flow; however, it is rarely performed today because it is technically difficult to take down during definitive repair and carries a high risk of causing pulmonary hypertension due to excessive flow. **2. Analysis of Incorrect Options:** * **Option A & C:** A shunt between the **subclavian artery** and the **pulmonary artery** is known as a **Blalock-Taussig (BT) shunt**. The "Classic" BT shunt uses the subclavian artery branch itself, while the "Modified" BT shunt uses a GORE-TEX conduit. * **Option D:** A shunt between the **ascending aorta** and the **right pulmonary artery** is known as a **Waterston-Cooley shunt**. Like the Potts shunt, it is prone to causing heart failure and pulmonary vascular disease. **3. High-Yield Clinical Pearls for NEET-PG:** * **Blalock-Taussig Shunt:** Subclavian artery to Pulmonary artery (Most commonly tested). * **Waterston Shunt:** Ascending Aorta to Right Pulmonary artery. * **Potts Shunt:** Descending Aorta to Left Pulmonary artery. * **Glenn Shunt:** Superior Vena Cava (SVC) to Right Pulmonary artery (A cavopulmonary shunt). * **Fontan Procedure:** Total cavopulmonary connection (IVC and SVC to Pulmonary artery).

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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