Vascular Surgery Practice Questions

Q: Lumbar sympathectomy is not indicated in which of the following conditions?

Claudication. **Explanation:** Lumbar sympathectomy involves the excision of the 2nd, 3rd, and 4th lumbar sympathetic ganglia. The primary physiological effect is the removal of sympathetic vasoconstrictor tone, leading to **vasodilation of the cutaneous (skin) vasculature**. **Why Claudication is the Correct Answer:** Intermittent claudication is caused by ischemia in the **skeletal muscles** during exercise. Lumbar sympathectomy primarily increases blood flow to the skin, not the deep muscle beds. In fact, it may worsen claudication by causing a "steal phenomenon," where blood is diverted from the relatively ischemic muscles to the dilated cutaneous vessels. Therefore, it is not indicated for claudication. **Analysis of Other Options:** * **Healing of ulcer (Option A):** By increasing cutaneous blood flow, sympathectomy improves the microcirculation required for the healing of small, superficial ischemic ulcers. * **Rest pain (Option B):** It is indicated for the relief of rest pain in patients with non-reconstructable arterial disease, as it helps improve skin perfusion and provides a degree of sympathetic denervation (pain relief). * **Buerger’s disease (Option D):** Also known as Thromboangiitis Obliterans (TAO), this condition primarily affects distal small and medium-sized vessels. Lumbar sympathectomy is a classic palliative treatment for TAO to improve distal skin circulation and manage pain. **High-Yield Pearls for NEET-PG:** * **Primary Indication:** Distal ischemia (skin) where bypass surgery is not feasible. * **Level of Ganglionectomy:** L2-L4 is standard. L1 is preserved in males to prevent **loss of ejaculation**. * **Predictive Test:** A successful chemical sympathetic block (using phenol or alcohol) before surgery indicates a likely positive surgical outcome. * **Rule of Thumb:** Sympathectomy helps the **skin**, not the **muscle**.

Q: Milroy's disease is an example of:

Primary lymphedema. **Explanation:** **Milroy’s disease** is a classic example of **Primary Lymphedema**. It is a congenital condition, typically inherited in an autosomal dominant fashion, characterized by the malformation or hypoplasia of lymphatic vessels. 1. **Why Option A is correct:** Primary lymphedema occurs due to intrinsic genetic or developmental defects in the lymphatic system. Milroy’s disease is specifically categorized as **Congenital Lymphedema (Type I)** because it is present at birth or manifests within the first year of life. It is frequently associated with mutations in the **VEGFR-3** gene, leading to lymphatic hypoplasia. 2. **Why Option B is incorrect:** Secondary lymphedema is caused by extrinsic factors that damage an otherwise normal lymphatic system. The most common cause worldwide is **Filariasis** (*Wuchereria bancrofti*), while in developed nations, it is most commonly due to malignancy or post-surgical lymph node dissection (e.g., post-mastectomy). 3. **Why Options C & D are incorrect:** Milroy’s disease has a specific genetic etiology, placing it strictly within the primary category. **High-Yield Clinical Pearls for NEET-PG:** * **Classification of Primary Lymphedema:** * **Milroy’s Disease:** Congenital (at birth); VEGFR-3 mutation. * **Meige’s Disease (Lymphedema Praecox):** Most common primary type; manifests at puberty; FOXC2 mutation. * **Lymphedema Tarda:** Manifests after age 35. * **Clinical Sign:** **Stemmer’s Sign** (inability to pinch the skin on the dorsal surface of the base of the second toe) is a diagnostic clinical finding for lymphedema. * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for evaluating the lymphatic system.

Q: A 72-year-old woman presents with a fall after an episode of dizziness, accompanied by 3 days of low-back pain. She is hypotensive and has cold, clammy extremities. A pulsating mass is palpable on abdominal examination. Following resuscitation, what is the next most appropriate step in management?

Immediate abdominal exploration. **Explanation:** The clinical presentation of a **pulsatile abdominal mass, hypotension (shock), and back pain** in an elderly patient is the classic triad of a **Ruptured Abdominal Aortic Aneurysm (AAA)**. This is a surgical emergency with extremely high mortality. **1. Why Immediate Abdominal Exploration is Correct:** In a patient with a suspected ruptured AAA who is **hemodynamically unstable** (hypotension, cold/clammy extremities), time is the most critical factor. Resuscitation should occur simultaneously with immediate transfer to the operating room for a laparotomy to control the aorta. Delaying surgery for imaging increases the risk of exsanguination and death. **2. Why Other Options are Incorrect:** * **CT scan of the abdomen:** While CT is the gold standard for diagnosing an intact AAA or a stable leak, it is **contraindicated** in an unstable patient. Moving an unstable patient to the radiology suite can be fatal. * **Abdominal aortogram:** This is an invasive procedure used for planning endovascular repair (EVAR) in stable patients. It has no role in the emergency management of a ruptured AAA in an unstable patient. * **Peritoneal lavage (DPL):** This is used to detect hemoperitoneum in blunt abdominal trauma. In this case, the diagnosis is clinically evident, and DPL would waste time and potentially miss a retroperitoneal bleed. **Clinical Pearls for NEET-PG:** * **Classic Triad of Ruptured AAA:** Hypotension, back/flank pain, and a pulsatile mass (present in <50% of cases). * **Management Rule:** Stable patient → CT Scan; Unstable patient → Immediate Surgery. * **Most common site:** Infrarenal (90% of AAAs). * **Screening:** USG is the investigation of choice for screening; CT is best for preoperative planning.

Q: A 30-year-old chronic smoker male presents with a concerning condition. What is the most likely diagnosis?

Buerger's disease. ***Buerger's disease*** - **Thromboangiitis obliterans** predominantly affects young male **heavy smokers** (20-40 years), causing **distal limb ischemia** and gangrene. - Classic presentation includes **digital gangrene**, **claudication**, and **Raynaud's phenomenon** with strong **tobacco use association**. *Diabetic gangrene* - Typically occurs in **diabetic patients** with **peripheral neuropathy** and **poor glycemic control**, not specifically linked to smoking. - Usually affects **pressure points** like heels and toes due to **diabetic foot ulcers** and **microangiopathy**. *Atherosclerotic plaque* - More common in **older patients** (>50 years) with **cardiovascular risk factors** like hypertension and hyperlipidemia. - Affects **large and medium-sized arteries**, causing **intermittent claudication** rather than distal gangrene in young adults. *Septic foot* - Results from **bacterial infection** with signs of **systemic toxicity** like fever, elevated WBC count, and purulent discharge. - **Local inflammatory signs** (redness, warmth, swelling) are prominent, unlike the **ischemic presentation** in vascular diseases.

Q: A 30-year-old construction worker presented with exertional pain in his bilateral forearms and hands. There is a history of chronic cigarette smoking. On examination, faint radial and ulnar pulses were noted, with easily palpable brachial pulses. Angiography of the hand was performed. Which of the following is the best treatment for this condition?

Smoking cessation. ***Smoking cessation*** - This is **Buerger's disease** (thromboangiitis obliterans), a condition almost exclusively seen in **young male smokers** with distal limb ischemia. - **Smoking cessation** is the only definitive treatment that can halt disease progression and prevent further vascular occlusion, as continued smoking leads to irreversible vessel damage. *Enoxaparin* - **Low molecular weight heparin** is not effective in Buerger's disease as this is primarily an **inflammatory vasculitis** rather than a thrombotic condition. - The pathophysiology involves **segmental inflammation** of small and medium arteries, not typical thromboembolic disease requiring anticoagulation. *Prednisolone* - **Corticosteroids** have limited efficacy in Buerger's disease and are not considered first-line treatment. - While inflammation is present, the primary driver is **tobacco use**, and immunosuppression does not address the underlying cause or significantly improve outcomes. *Warfarin* - **Oral anticoagulation** is ineffective in treating the underlying **thromboangiitis obliterans** pathology. - The characteristic **corkscrew collaterals** and **segmental vessel occlusion** seen on angiography are due to inflammatory vessel wall changes, not embolic phenomena requiring anticoagulation.

Q: A 27-year-old female with no past medical history presented with chronic postprandial pain for 10 months, accompanied by a 10 kg weight loss. Her whole abdomen sonogram was within normal limits. However, a CT scan of the abdomen revealed severe compression of the celiac axis. Based on her clinical symptoms and imaging findings, what is the most likely diagnosis?

Median arcuate ligament syndrome. ### Explanation **Median Arcuate Ligament Syndrome (MALS)**, also known as Dunbar Syndrome, occurs due to the extrinsic compression of the **celiac axis** by the median arcuate ligament (a fibrous band connecting the diaphragmatic crura). #### Why the Correct Answer is Right: * **Clinical Presentation:** MALS typically affects young females (20–40 years). The classic triad includes **chronic postprandial abdominal pain**, **weight loss** (due to "food fear"), and sometimes an epigastric bruit. * **Imaging:** While ultrasound is often normal or shows non-specific findings, the **CT Angiography** is the gold standard, showing a characteristic **"hook-shaped" narrowing** of the celiac artery. The compression is often worse during expiration when the diaphragm moves superiorly. #### Why Other Options are Incorrect: * **A. Vasculitis:** While Takayasu arteritis can affect the celiac artery, it usually presents with systemic inflammatory markers (elevated ESR/CRP) and involvement of other major branches of the aorta. * **B. Peptic Ulcer Disease:** Though it causes postprandial pain, it does not explain the CT finding of celiac axis compression. * **C. Atherosclerosis:** This is the most common cause of mesenteric ischemia in **elderly** patients with cardiovascular risk factors (smoking, HTN, DM). It is highly unlikely in a 27-year-old with no medical history. #### NEET-PG High-Yield Pearls: * **Pathophysiology:** Compression is caused by an abnormally low insertion of the median arcuate ligament. * **Diagnosis:** CT Angiography is the preferred imaging modality. * **Treatment:** The definitive management is **Surgical Decompression** (division of the median arcuate ligament), which can be performed laparoscopically. * **Key Differentiator:** If the question mentions pain worsening with **expiration**, think MALS.

Q: Bisgard treatment is indicated for which of the following conditions?

Venous ulcer. **Explanation:** **Bisgard’s Method** is a conservative management strategy specifically designed for **Venous Ulcers** (stasis ulcers). The treatment is based on the principle of reducing venous hypertension and improving calf muscle pump efficiency. It involves a combination of: 1. **Elevation:** Keeping the limb elevated above the level of the heart to facilitate venous drainage. 2. **Compression:** Using elastic bandages or Unna boots to reduce edema. 3. **Exercise:** Active ankle movements to activate the "peripheral heart" (calf muscles). **Analysis of Options:** * **Option A (Arterial Ulcer):** These are caused by ischemia. Elevation (a key part of Bisgard's) is contraindicated here as it further reduces arterial perfusion, worsening the pain. * **Option C (TAO/Buerger’s Disease):** This is an inflammatory occlusive disease of small/medium arteries. Management focuses on smoking cessation and lumbar sympathectomy, not venous decompression. * **Option D (Raynaud’s Phenomenon):** This is a vasospastic disorder. Treatment involves avoiding cold triggers and using calcium channel blockers, not mechanical venous drainage. **High-Yield Clinical Pearls for NEET-PG:** * **Venous Ulcers:** Typically located at the **"Gaiter Zone"** (medial malleolus). They are usually painless (unless infected) and shallow with irregular borders. * **Standard of Care:** While Bisgard’s is a classic description, the modern "Gold Standard" for venous ulcer healing is **Four-layer compression bandaging**. * **Marjolin’s Ulcer:** Always remember that a long-standing non-healing venous ulcer can undergo malignant transformation into Squamous Cell Carcinoma.

Q: Which of the following is NOT used as graft material in peripheral vascular disease?

PVC. **Explanation:** In peripheral vascular surgery, graft materials must be biocompatible, non-thrombogenic, durable, and resistant to infection. **PVC (Polyvinyl Chloride)** is a rigid plastic commonly used for medical tubing (like IV sets) and construction, but it is **not** used as a vascular graft because it is thrombogenic, lacks the necessary compliance, and can leach toxic plasticizers into the bloodstream. **Analysis of Options:** * **Dacron (Polyester):** A synthetic material used primarily for **large-diameter, high-flow vessels** (e.g., Aorto-iliac bypass). It requires "pre-clotting" unless coated with collagen or albumin to prevent leakage through the fabric pores. * **Vein (Autologous):** The **Gold Standard** for peripheral bypass, especially below the knee. The **Great Saphenous Vein (GSV)** is most commonly used due to its superior patency rates and resistance to infection. * **PTFE (Polytetrafluoroethylene/Gore-Tex):** A synthetic material preferred for **medium-sized vessels** or when a suitable autologous vein is unavailable. It is non-porous and does not require pre-clotting. **High-Yield Clinical Pearls for NEET-PG:** * **Best Graft Material:** Autologous vein (Great Saphenous Vein) is always superior to synthetic grafts for distal bypasses. * **Dacron vs. PTFE:** Dacron is preferred for **aortic** surgery; PTFE is often preferred for **axillo-femoral** or **femoropopliteal** bypasses when the vein is unavailable. * **Infection Risk:** Synthetic grafts (Dacron/PTFE) have a much higher risk of infection compared to autologous veins. If a graft becomes infected, it usually requires complete removal. * **Anastomosis:** The most common site of failure for synthetic grafts is **intimal hyperplasia** at the distal anastomosis.

Question 1

Lumbar sympathectomy is not indicated in which of the following conditions?

Accepted Answer

Claudication

Answer

Healing of ulcer over great toe

Answer

Rest pain

Answer

Buerger's disease

Question 2

Milroy's disease is an example of:

Accepted Answer

Primary lymphedema

Answer

Secondary lymphedema

Answer

Both

Answer

None

Question 3

A 72-year-old woman presents with a fall after an episode of dizziness, accompanied by 3 days of low-back pain. She is hypotensive and has cold, clammy extremities. A pulsating mass is palpable on abdominal examination. Following resuscitation, what is the next most appropriate step in management?

Accepted Answer

Immediate abdominal exploration

Answer

Peritoneal lavage

Answer

CT scan of the abdomen

Answer

Abdominal aortogram

Question 4

A 30-year-old chronic smoker male presents with a concerning condition. What is the most likely diagnosis?

Accepted Answer

Buerger's disease

Answer

Diabetic gangrene

Answer

Atherosclerotic plaque

Answer

Septic foot

Question 5

A 30-year-old construction worker presented with exertional pain in his bilateral forearms and hands. There is a history of chronic cigarette smoking. On examination, faint radial and ulnar pulses were noted, with easily palpable brachial pulses. Angiography of the hand was performed. Which of the following is the best treatment for this condition?

Accepted Answer

Smoking cessation

Answer

Enoxaparin

Answer

Prednisolone

Answer

Warfarin

Question 6

A 27-year-old female with no past medical history presented with chronic postprandial pain for 10 months, accompanied by a 10 kg weight loss. Her whole abdomen sonogram was within normal limits. However, a CT scan of the abdomen revealed severe compression of the celiac axis. Based on her clinical symptoms and imaging findings, what is the most likely diagnosis?

Accepted Answer

Median arcuate ligament syndrome

Answer

Vasculitis

Answer

Peptic ulcer disease

Answer

Atherosclerosis of the celiac artery

Question 7

Bisgard treatment is indicated for which of the following conditions?

Accepted Answer

Venous ulcer

Answer

Aerial ulcer

Answer

Thromboangiitis obliterans (TAO)

Answer

Raynaud's phenomenon

Question 8

An IVC filter is indicated in all of the following conditions except?

Accepted Answer

Negligible size of emboli

Answer

Massive emboli

Answer

Repeated emboli

Answer

None of the above

Question 9

What is the most common cause of lymphedema of the upper limb?

Accepted Answer

Post mastectomy

Answer

Filariasis

Answer

Bacterial infection

Answer

Congenital anomaly

Question 10

Which of the following is NOT used as graft material in peripheral vascular disease?

Accepted Answer

PVC

Answer

Dacron graft

Answer

Vein

Answer

PTFE

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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