Vascular Surgery Practice Questions

Q: An adult patient presents with leg pain and gangrene of the toe. What would be their Ankle-Brachial Pressure Index (ABPI)?

Less than 0.9. **Explanation:** The **Ankle-Brachial Pressure Index (ABPI)** is a non-invasive tool used to screen for Peripheral Arterial Disease (PAD). It is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure in the arm. **Why Option B is Correct:** A normal ABPI ranges from **0.9 to 1.3**. A value **less than 0.9** indicates PAD. The patient presents with **gangrene**, which signifies **Critical Limb Ischemia (CLI)**—the most severe stage of PAD. In CLI (Fontaine Stage IV or Rutherford Category 5/6), the ABPI is typically significantly reduced, often **below 0.5** (and frequently below 0.3 in cases of gangrene). Therefore, "Less than 0.9" is the only option that reflects an arterial deficit. **Analysis of Incorrect Options:** * **Option A & C:** Values between 0.9 and 1.3 are considered **normal**. A patient with gangrene has severe ischemia, which is incompatible with a normal pressure index. * **Option D:** An ABPI **greater than 1.3** suggests **non-compressible, calcified vessels** (Mönckeberg’s arteriosclerosis), commonly seen in long-standing diabetics and patients with end-stage renal disease. In these cases, the ABPI is falsely elevated and unreliable for diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ABPI:** 0.9 – 1.3 * **Mild to Moderate Claudication:** 0.5 – 0.9 * **Rest Pain:** 1.3 (calcified vessels), as digital arteries are rarely calcified. A TBI < 0.7 is diagnostic of PAD. * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA) is the gold standard, but Duplex Ultrasound is the initial investigation of choice.

Q: Fogarty's catheter is used for what purpose?

Removal of blood clots from arteries. The **Fogarty catheter** is a specialized balloon-tipped catheter designed specifically for **embolectomy or thrombectomy**. ### Why Option B is Correct The catheter is used to remove acute arterial emboli or thrombi. The procedure involves inserting the catheter past the clot, inflating the small balloon at the tip with saline, and gently withdrawing it. As the inflated balloon is pulled back, it drags the obstructing clot out through the arteriotomy, restoring distal blood flow. This is a life-saving procedure in cases of **Acute Limb Ischemia**. ### Why Other Options are Incorrect * **A & C (Urethral catheterization/Bladder drainage):** These functions are performed by **Foley catheters** or **Malecot catheters**. While a Foley also has a balloon, it is designed for retention within the bladder, not for traction or clot removal. * **D (Total Parenteral Nutrition):** TPN requires central venous access via catheters like the **Hickman, Broviac, or PICC lines**, which are designed for long-term infusion into large-bore veins. ### High-Yield Clinical Pearls for NEET-PG * **Inventor:** Thomas J. Fogarty (1963). * **Sizing:** Fogarty catheters are sized using the **French scale** (e.g., 2F to 7F). A common rule of thumb is "3F for the arm, 4F for the leg." * **Balloon Inflation:** The balloon should always be inflated with **saline**, never air (to prevent air embolism if the balloon ruptures). * **Complications:** The most common complications include **intimal injury (dissection)**, arterial perforation, or distal fragmentation of the clot. * **Key Indication:** It is the gold standard for **Acute Arterial Embolism** (often secondary to Atrial Fibrillation).

Q: What is the minimum diameter of varicose veins?

≥ 3mm. **Explanation:** The classification of chronic venous disorders is standardized using the **CEAP classification**. According to the international consensus (reiterated in the American Venous Forum and the Society for Vascular Surgery guidelines), the definition of a varicose vein is based on its diameter when measured in the upright position. * **Correct Answer: D (≥ 3mm):** By definition, **varicose veins** are subcutaneous, dilated, and tortuous veins that measure **3 mm or greater** in diameter. They typically involve the tributaries of the great or small saphenous veins but can also be non-saphenous. **Analysis of Incorrect Options:** * **Option A (≥ 1mm):** This refers to **Telangiectasias** (spider veins), which are confluent venules measuring **less than 1 mm** in diameter. They are located in the intradermal layer (CEAP Class C1). * **Option B (≥ 2mm):** This falls into the range of **Reticular veins**, which are defined as dilated bluish subdermal veins, usually **1 mm to < 3 mm** in size. They are also categorized under CEAP Class C1. * **Option C (≥ 4mm):** While varicose veins can certainly be 4 mm or larger, this is not the *minimum* threshold for the clinical definition. **High-Yield Clinical Pearls for NEET-PG:** * **CEAP Classification (Clinical Section):** * **C0:** No visible/palpable signs. * **C1:** Telangiectasia or reticular veins (< 3mm). * **C2:** Varicose veins (≥ 3mm). * **C3:** Edema. * **C4:** Skin changes (C4a: Pigmentation/Eczema; C4b: Lipodermatosclerosis). * **C5:** Healed venous ulcer. * **C6:** Active venous ulcer. * **Gold Standard Investigation:** Duplex Ultrasound (to assess for reflux at the saphenofemoral or saphenopopliteal junctions). * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence.

Q: Peripheral arterial occlusion (sudden onset) is characterized by all of the following except:

Rubor. **Explanation:** Acute Peripheral Arterial Occlusion is a surgical emergency typically caused by an embolism or thrombosis. It is clinically diagnosed using the classic **"6 Ps"** mnemonic: **P**ain, **P**allor, **P**ulselessness, **P**aresthesia, **P**aralysis, and **P**oikilothermia (coldness). **Why Rubor is the Correct Answer (The "Except"):** **Rubor** (specifically "Dependent Rubor") is a feature of **Chronic Limb-Threatening Ischemia (CLTI)**, not acute occlusion. In chronic disease, arterioles remain chronically dilated to compensate for poor flow; when the limb is dangled, gravity fills these dilated vessels, causing a dusky red appearance. In **acute** occlusion, there is a sudden, total cessation of blood flow, leading to immediate **Pallor** (Option C) because the capillary bed is empty. **Analysis of Other Options:** * **Pain (Option D):** Usually the first symptom. It is sudden, severe, and located distal to the site of occlusion. * **Paresthesia (Option A):** Indicates ischemic injury to sensitive nerve fibers. Along with paralysis, it is a late sign suggesting a threatened limb that requires urgent intervention. * **Pallor (Option C):** The limb appears "waxy white" due to the lack of erythrocyte perfusion. **NEET-PG High-Yield Pearls:** * **Most common source of emboli:** Left Atrium (Atrial Fibrillation). * **Most common site of embolism:** Bifurcation of the Common Femoral Artery. * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Management:** Immediate anticoagulation with IV Heparin, followed by surgical embolectomy (Fogarty catheter) or catheter-directed thrombolysis.

Q: Which of the following is true about primary lymphedema?

It is associated with Milroy's disease. **Explanation:** Primary lymphedema results from congenital developmental abnormalities of the lymphatic system (aplasia, hypoplasia, or hyperplasia of lymphatics). It is classified based on the age of onset, and its association with specific genetic syndromes is a high-yield topic for NEET-PG. **Why Option D is Correct:** Primary lymphedema is associated with several hereditary syndromes. **Milroy’s disease** (Lymphedema Congenita) is a familial form of primary lymphedema that is present at birth or within the first year of life. It is typically inherited in an autosomal dominant pattern and is linked to mutations in the **VEGFR-3** gene. **Why Other Options are Incorrect:** * **Option A:** The prevalence of primary lymphedema is much lower than 2%, affecting approximately **1 in 6,000 to 10,000** individuals. Secondary lymphedema (e.g., post-filariasis or post-mastectomy) is far more common globally. * **Option B & C:** These options swap the clinical definitions. * **Lymphedema Praecox:** Onset between **1 and 35 years** (most common type, often occurring at puberty). * **Lymphedema Tarda:** Onset **after 35 years** of age. **High-Yield Clinical Pearls for NEET-PG:** 1. **Kinmonth Classification:** * *Congenital:* Birth to 1 year (e.g., Milroy’s Disease). * *Praecox:* 1 to 35 years (e.g., Meige’s Disease - familial type). * *Tarda:* After 35 years. 2. **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; it is a pathognomonic physical finding for lymphedema. 3. **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for confirming the diagnosis and assessing lymphatic flow. 4. **Complication:** Long-standing lymphedema can lead to **Stewart-Treves Syndrome** (lymphangiosarcoma).

Q: Abdominal aortic aneurysm is operated when the size is more than:

5.5 cm. **Explanation:** The management of an Abdominal Aortic Aneurysm (AAA) is based on balancing the risk of spontaneous rupture against the risks associated with surgical intervention (Open or EVAR). **Why 5.5 cm is the correct answer:** The risk of rupture increases exponentially with the diameter of the aneurysm. Clinical trials (such as the UK Small Aneurysm Study) have demonstrated that for asymptomatic patients, the risk of rupture significantly outweighs the surgical risk once the aneurysm reaches **5.5 cm in men**. In women, due to smaller vessel size and higher rupture risk at smaller diameters, intervention is often considered at **5.0 cm**. **Analysis of Incorrect Options:** * **A (3.5 cm) & B (4.5 cm):** These are considered "Small AAAs." The risk of rupture is <1% per year. These are managed conservatively with "Watchful Waiting" (ultrasound surveillance every 6–12 months) and aggressive risk factor modification (smoking cessation and statins). * **D (6.5 cm):** While surgery is definitely indicated at this size, it is considered delayed. At 6.0–6.9 cm, the annual risk of rupture jumps to 10–20%. Waiting until 6.5 cm unnecessarily exposes the patient to a high risk of fatal hemorrhage. **High-Yield Clinical Pearls for NEET-PG:** * **Indications for Surgery regardless of size:** 1. Symptomatic AAA (back/abdominal pain, tenderness). 2. Rapid expansion (>0.5 cm in 6 months or >1 cm in 1 year). * **Most common site:** Infra-renal (between renal arteries and aortic bifurcation). * **Most common cause:** Atherosclerosis (historically), though smoking is the strongest modifiable risk factor. * **Screening:** A one-time USG is recommended for all men aged 65–75 who have ever smoked.

Question 1

What is true about venous ulcers?

Accepted Answer

The deep venous system should always be examined

Answer

Stripping is always performed

Answer

A biopsy should be taken from a chronic ulcer

Answer

Associated with Klippel-Trenaunay syndrome

Question 2

An adult patient presents with leg pain and gangrene of the toe. What would be their Ankle-Brachial Pressure Index (ABPI)?

Accepted Answer

Less than 0.9

Answer

Greater than 1

Answer

Between 0.9 and 1.3

Answer

Greater than 1.3

Question 3

Fogarty's catheter is used for what purpose?

Accepted Answer

Removal of blood clots from arteries

Answer

Urethral catheterization

Answer

Bladder drainage

Answer

Total Parenteral Nutrition (TPN)

Question 4

Which of the following is true about primary lymphedema?

Accepted Answer

Onset between 2-35 years indicates lymphedema tarda

Answer

Prevalence is 2%

Answer

Onset >35 years indicates praecox type

Answer

Associated with Milroy's disease

Question 5

What is the minimum diameter of varicose veins?

Accepted Answer

≥ 3mm

Answer

≥ 1mm

Answer

≥ 2mm

Answer

≥ 4mm

Question 6

Peripheral arterial occlusion (sudden onset) is characterized by all of the following except:

Accepted Answer

Rubor

Answer

Paresthesia

Answer

Pallor

Answer

Pain

Question 7

Which of the following is NOT a predisposing factor for chronic limb ischemia?

Accepted Answer

Hyperbilirubinemia

Answer

Diabetes mellitus

Answer

Hyperlipidemia

Answer

Renal insufficiency

Question 8

Which of the following is true about primary lymphedema?

Accepted Answer

It is associated with Milroy's disease

Answer

Its prevalence is 2%

Answer

Onset between 2-35 years indicates lymphedema tarda

Answer

Onset greater than 35 years indicates the praecox type

Question 9

A 56-year-old male with a history of severe coronary artery disease presents with rest leg pain and dyspnea on exertion (unable to walk two flights of steps). Evaluation revealed complete aortoiliac occlusive disease requiring surgical intervention. Which of the following surgical options is acceptable?

Accepted Answer

Axillobifemoral bypass

Answer

Aortobililiac bypass

Answer

Aortobifemoral bypass

Answer

Aortoiliac angioplasty and stent placement

Question 10

Abdominal aortic aneurysm is operated when the size is more than:

Accepted Answer

5.5 cm

Answer

3.5 cm

Answer

4.5 cm

Answer

6.5 cm

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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