Vascular Surgery Practice Questions

Q: Buerger's disease is not associated with which of the following?

Involvement of large-sized arteries primarily. **Explanation:** **Buerger’s Disease (Thromboangiitis Obliterans - TAO)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the **small and medium-sized arteries** and veins of the upper and lower extremities. 1. **Why Option C is the Correct Answer:** Buerger’s disease characteristically spares large-sized arteries (like the aorta or iliac arteries). It is defined by its involvement of distal vessels, typically starting at the **tibial and radial arteries**. Therefore, the statement that it involves large-sized arteries primarily is incorrect. 2. **Analysis of Other Options:** * **Option A:** It classically affects **young males** (usually <40-45 years, often under 30) who are heavy smokers. * **Option B:** Unlike other vasculitides, TAO involves both arteries and veins. **Migratory superficial thrombophlebitis** is a hallmark clinical finding in about 40% of patients. * **Option C:** On angiography, while the disease is distal, proximal "corrugation" or a "standing wave" appearance can sometimes be seen in the femoral or brachial arteries due to sympathetic overactivity, though the classic finding is "corkscrew collaterals" (Martorell’s sign). **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Tobacco use (smoking or chewing) is essential for diagnosis and progression. * **Pathology:** Characterized by a **highly cellular, "inflammatory" thrombus** with relative sparing of the blood vessel wall (internal elastic lamina remains intact). * **Triad:** Distal ischemia (claudication/gangrene), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Angiographic Sign:** "Corkscrew" collaterals (vessels of Martorell). * **Treatment:** Absolute smoking cessation is the only way to prevent amputation. Sympathectomy may be used for pain relief.

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

Filariasis. **Explanation:** The correct answer is **Filariasis (Option A)**. Lymphedema is caused by the obstruction or dysfunction of the lymphatic system, leading to the accumulation of protein-rich fluid in the interstitial space. Globally and in endemic regions like India, **Filariasis** (caused primarily by *Wuchereria bancrofti*) is the most common cause of secondary lymphedema for both upper and lower limbs. The adult worms reside in the lymph nodes and vessels, causing chronic inflammation, fibrosis, and eventual obstruction of the lymphatic flow. **Analysis of Incorrect Options:** * **B. Congenital abnormalities:** These cause *primary* lymphedema (e.g., Milroy’s disease). While significant, they are statistically much rarer than secondary causes like infection. * **C. Neck surgery:** While radical neck dissections can lead to localized edema of the face or neck, they are not a leading cause of generalized upper limb lymphedema. * **D. Post-mastectomy irradiation:** This is the most common cause of upper limb lymphedema in **developed/Western countries** due to the disruption of axillary lymph nodes. However, on a global scale and specifically in the context of Indian medical exams, Filariasis remains the leading etiology overall. **High-Yield Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe/finger; a pathognomonic sign of lymphedema. * **Investigation of Choice:** Lymphoscintigraphy is the gold standard for evaluating the lymphatic system. * **Stewart-Treves Syndrome:** A rare, highly aggressive angiosarcoma that develops in a limb with long-standing chronic lymphedema (most commonly post-mastectomy). * **Treatment:** The mainstay is Complex Decongestive Therapy (CDT), which includes manual lymphatic drainage and compression bandaging.

Q: What is the treatment of choice in recurrent venous thrombosis leading to pulmonary embolism despite intensive anticoagulation?

Inferior vena caval filters. ### **Explanation** The management of venous thromboembolism (VTE) primarily relies on anticoagulation. However, in specific scenarios where medical therapy fails or cannot be used, mechanical intervention is required. **Why Option D is Correct:** The primary indication for the insertion of an **Inferior Vena Cava (IVC) Filter** is to prevent life-threatening pulmonary embolism (PE) in patients where: 1. **Anticoagulation is contraindicated** (e.g., active major bleeding). 2. **Anticoagulation has failed** (recurrent PE despite therapeutic levels of anticoagulation, as seen in this question). 3. **Complications of anticoagulation** occur, necessitating its cessation. The filter acts as a mechanical sieve, trapping large emboli from the lower extremities before they reach the pulmonary circulation. **Why Other Options are Incorrect:** * **A. Fibrinolysis (tPA):** Indicated for "Massive PE" (hemodynamically unstable patients with hypotension). It dissolves existing clots but does not prevent recurrence in the setting of failed anticoagulation. * **B. Pulmonary Embolectomy:** A surgical or catheter-based intervention reserved for patients with massive PE who have contraindications to thrombolysis or where thrombolysis has failed. * **C. Pulmonary Thromboendarterectomy:** The definitive treatment for **Chronic Thromboembolic Pulmonary Hypertension (CTEPH)**, not acute recurrent PE. ### **Clinical Pearls for NEET-PG:** * **Most common site for IVC filter placement:** Just infra-renal (to prevent renal vein thrombosis). * **Most common complication:** Access site thrombosis; however, the most significant long-term risk is an increased incidence of **Deep Vein Thrombosis (DVT)**. * **Greenfield Filter:** A classic stainless steel, cone-shaped filter known for maintaining patency even when filled to 70% of its capacity. * **Absolute Contraindication for IVC Filter:** Total occlusion of the IVC.

Q: An arteriovenous fistula can be safely ligated if which of the following tests is positive?

Allen's Test. **Explanation:** The correct answer is **Allen’s Test**. In the context of vascular surgery, an arteriovenous (AV) fistula (often created for hemodialysis) typically involves the radial or brachial artery. Before ligating or surgically intervening on such a fistula, it is mandatory to ensure that the distal limb has adequate collateral circulation. **Allen’s Test** assesses the patency of the radial and ulnar arteries and the adequacy of the palmar arch. A "positive" (normal) Allen’s test indicates that the ulnar artery can independently maintain perfusion to the hand if the radial artery is compromised or ligated, making the procedure safe. **Analysis of Incorrect Options:** * **Henle-Coenen Sign:** This is used to assess collateral circulation *during* surgery for an aneurysm or AV fistula. After clamping the artery proximal to the lesion, if there is distal pulsation or back-bleeding, the sign is positive, suggesting ligation is safe. However, Allen's test is the standard non-invasive clinical test used for this purpose in the upper limb. * **Trendelenburg Test:** Used in the evaluation of varicose veins to assess the competency of the saphenofemoral valve and perforator veins. * **Schwartz Test (Tap Test):** Used to detect valvular incompetence in the great saphenous vein by tapping the vein and feeling for a transmitted impulse distally. **Clinical Pearls for NEET-PG:** * **Modified Allen’s Test:** Performed by compressing both radial and ulnar arteries, having the patient clench their fist until the palm blanches, then releasing the ulnar artery. Return of color within 5–15 seconds is normal. * **Nicoladoni-Branham Sign:** A diagnostic sign for AV fistula where bradycardia occurs upon manual compression of the fistula (due to sudden increase in peripheral resistance and baroreceptor reflex). * **Machinery Murmur:** The classic continuous murmur heard over an AV fistula.

Q: Which of the following is not a sclerosing agent?

Sodium bicarbonate. **Explanation:** Sclerotherapy is a medical procedure used to eliminate varicose veins and spider veins by injecting a **sclerosing agent** into the vessel. These agents cause controlled endothelial damage, leading to thrombosis, fibrosis, and eventual obliteration of the vascular lumen. **Why Sodium Bicarbonate is the Correct Answer:** **Sodium bicarbonate** is not a sclerosing agent. In clinical practice, it is primarily used as an alkalizing agent to treat metabolic acidosis or to neutralize the pH of local anesthetics (like lidocaine) to reduce the stinging sensation during injection. It does not possess the chemical properties required to induce endothelial destruction and venous fibrosis. **Analysis of Incorrect Options (Common Sclerosing Agents):** * **Sodium tetradecyl sulphate (STS):** The most commonly used detergent-based sclerosant. It works by disrupting the lipid molecules in the endothelial cell surface. * **Sodium morrhuate:** A mixture of sodium salts of saturated and unsaturated fatty acids derived from cod liver oil. It is a traditional sclerosant used for varicose veins and esophageal varices. * **Sodium psylliate:** A salt of fatty acids derived from the seeds of the psyllium plant (*Plantago ovata*), used historically as a sclerosing agent. **High-Yield Clinical Pearls for NEET-PG:** * **Classification:** Sclerosants are classified into **Detergents** (STS, Polidocanol), **Osmotic agents** (Hypertonic saline), and **Chemical irritants** (Chromated glycerin). * **Polidocanol:** Currently favored due to its low risk of skin necrosis and painless injection (it has local anesthetic properties). * **Complications:** The most feared complication of sclerotherapy is accidental **intra-arterial injection**, which can lead to gangrene. Other risks include deep vein thrombosis (DVT) and skin hyperpigmentation.

Question 1

A 67-year-old man presents with a 3.0x3.5 cm abdominal aortic aneurysm detected by community ultrasound screening. Physical examination reveals a palpable, pulsatile, nontender abdominal mass just above the umbilicus. The patient has a history of hypertension, hyperlipidemia, and tobacco use. What is the best recommendation for this patient?

Accepted Answer

Serial follow-up with ultrasound, CT, or MRI, with the major determinant for surgery being aneurysmal size greater than 5.5 cm.

Answer

Watchful waiting until the first onset of abdominal pain.

Answer

Surgery is indicated now, with the patient's hypertension and tobacco use representing excess operative risk.

Answer

Serial follow-up with ultrasound, CT, or MRI, with the major determinant for surgery being involvement of a renal artery.

Question 2

Lumbar sympathectomy is of value in the management of which of the following conditions?

Accepted Answer

Distal ischemia affecting the skin of the toes

Answer

Intermittent claudication

Answer

Arteriovenous fistula

Answer

Back pain

Question 3

Buerger's disease is not associated with which of the following?

Accepted Answer

Involvement of large-sized arteries primarily

Answer

Affects males under the age of 30 years

Answer

Thrombophlebitis of deep or superficial veins

Answer

Characteristic 'corrugation' of femoral arteries on angiography

Question 4

A 83-year-old retired navy general shows improvement in claudication following aortoiliac bypass surgery. What is the factor that would cause the greatest concern over the possibility of developing cardiac complications?

Accepted Answer

Signs of left ventricular failure

Answer

History of angina and prior MI

Answer

Left ventricular ejection fraction of over 50%

Answer

Aortic stenosis

Question 5

Lipodermatosclerosis is most commonly seen at which aspect of the leg?

Accepted Answer

Medial aspect of leg

Answer

Anterior aspect of leg

Answer

Anterior aspect of thigh

Answer

Posterior aspect of thigh

Question 6

What is the most common cause of upper limb lymphedema?

Accepted Answer

Filariasis

Answer

Congenital abnormalities

Answer

Neck surgery

Answer

Post-mastectomy irradiation

Question 7

What is the treatment of choice in recurrent venous thrombosis leading to pulmonary embolism despite intensive anticoagulation?

Accepted Answer

Inferior vena caval filters

Answer

Fibrinolysis treatment with tissue plasminogen activator

Answer

Pulmonary embolectomy

Answer

Pulmonary thromboendarterectomy

Question 8

An arteriovenous fistula can be safely ligated if which of the following tests is positive?

Accepted Answer

Allen's Test

Answer

Henle-Coenen sign

Answer

Trendelenburg test

Answer

Schwartz Test

Question 9

Which of the following is not a sclerosing agent?

Accepted Answer

Sodium bicarbonate

Answer

Sodium psylliate

Answer

Sodium morrhuate

Answer

Sodium tetradecyl sulphate

Question 10

Which of the following is NOT indicated for an arterial leg ulcer?

Accepted Answer

Elevation of the limb

Answer

Debridement

Answer

Head end of the bed raised

Answer

Low-dose aspirin

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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