Vascular Surgery — MCQs

A 55-year-old man suffers from an acute myocardial infarction after occlusion of the left anterior descending coronary artery. The patient undergoes coronary bypass surgery 3 days later. Which of the following is the most frequent cause of saphenous vein graft failure several years following coronary bypass surgery?

Q267Medium

What is the commonest site of thromboangiitis obliterans?

Q268Easy

Milroy's disease is characterized by which of the following?

Q269Easy

What is the most common site of lymphangiosarcoma?

Q270Medium

Sympathectomy is effective in all of the following conditions except one?

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 261: Which one of the following does not cause deep vein thrombosis?

A. Estrogen
B. Thrombocytosis
C. Venous stasis
D. Sickle cell Anemia (Correct Answer)

Explanation: The pathogenesis of Deep Vein Thrombosis (DVT) is governed by **Virchow’s Triad**: Venous stasis, endothelial injury, and hypercoagulability. ### **Explanation of the Correct Answer** **D. Sickle Cell Anemia:** While Sickle Cell Disease (SCD) is a prothrombotic state, it primarily causes **microvascular occlusion (Vaso-occlusive crisis)** in the arterial/capillary side due to the polymerization of HbS and sickling of RBCs. While patients with SCD have a higher baseline risk for venous thromboembolism (VTE) compared to the general population, in the context of standard surgical teaching and classical MCQ patterns, it is categorized as a cause of **arterial/microcirculatory thrombosis** rather than a primary cause of DVT, unlike the other systemic hypercoagulable states listed. ### **Why the Other Options are Wrong** * **A. Estrogen:** Estrogen (found in OCPs or HRT) increases the hepatic synthesis of clotting factors (II, VII, IX, X) and decreases anticoagulant levels (Protein S and Antithrombin III), leading to a **hypercoagulable state**. * **B. Thrombocytosis:** An abnormally high platelet count (e.g., in myeloproliferative disorders) increases blood viscosity and platelet aggregation, directly contributing to thrombus formation. * **C. Venous Stasis:** This is a core component of Virchow’s Triad. It occurs during prolonged immobilization, surgery, or obesity, allowing activated clotting factors to accumulate and form a nidus for a clot. ### **High-Yield Clinical Pearls for NEET-PG** * **Most common inherited cause of DVT:** Factor V Leiden mutation (Activated Protein C resistance). * **Most common acquired cause of DVT:** Major surgery (especially orthopedic surgery of the hip/knee). * **Trousseau’s Sign:** Migratory thrombophlebitis associated with visceral malignancy (most commonly Pancreatic Cancer). * **Gold Standard Investigation:** Contrast Venography (though Duplex Ultrasound is the initial investigation of choice).

Question 262: Bilateral pulseless disease in upper limbs is caused by which of the following conditions?

A. Takayasu arteritis (Correct Answer)
B. Coarctation of aorta
C. Fibromuscular dysplasia
D. Buerger's disease

Explanation: **Explanation:** **Takayasu Arteritis (Correct Answer):** Takayasu arteritis is a chronic, large-vessel vasculitis that primarily involves the **aorta and its main branches** (such as the subclavian, carotid, and renal arteries). It is most common in young females. The inflammation leads to segmental stenosis, occlusion, or aneurysmal dilation. When the **subclavian arteries** are bilaterally involved, it results in the characteristic clinical finding of absent or diminished pulses in the upper limbs, earning it the moniker **"Pulseless Disease."** **Analysis of Incorrect Options:** * **Coarctation of Aorta:** Typically involves narrowing distal to the origin of the left subclavian artery. This results in hypertension and strong pulses in the upper limbs, but weak/delayed pulses in the lower limbs (radio-femoral delay). * **Fibromuscular Dysplasia (FMD):** A non-inflammatory, non-atherosclerotic angiopathy that primarily affects medium-sized arteries, most commonly the **renal and internal carotid arteries**. It rarely causes bilateral upper limb pulselessness. * **Buerger’s Disease (Thromboangiitis Obliterans):** An inflammatory condition strongly associated with smoking that affects **small and medium-sized vessels** of the distal extremities (hands and feet). While it causes ischemia, it does not typically present as a proximal "pulseless disease" of the entire upper limb. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females < 40 years of age (Asian descent). * **Diagnosis:** Gold standard is **CT/MR Angiography** showing "skip lesions" or narrowing of the aorta. * **Clinical Sign:** A blood pressure difference of >10 mmHg between arms is a diagnostic criterion. * **Treatment:** Glucocorticoids are the first-line medical management; bypass surgery or angioplasty is reserved for irreversible stenosis.

Question 263: Buerger's disease usually affects all of the following except:

A. Medium sized arteries
B. Large arteries (Correct Answer)
C. Deep veins
D. Small sized arteries

Explanation: **Explanation:** **Buerger’s Disease**, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the distal vasculature of the extremities. **Why "Large Arteries" is the correct answer:** Buerger’s disease is characteristically a disease of the **small and medium-sized** vessels. It typically starts in the distal arteries of the hands and feet (e.g., digital, tibial, and radial arteries) and progresses proximally. It **spares large-sized arteries** (like the aorta or iliac arteries), which is a key diagnostic differentiator from atherosclerosis. **Analysis of other options:** * **Small and Medium-sized arteries (Options A & D):** These are the primary targets of the disease. The pathology involves a highly cellular "soft" thrombus that occludes these vessels, leading to ischemia, claudication, and gangrene. * **Deep veins (Option C):** While primarily an arterial disease, Buerger’s is unique because it also involves veins and nerves. Approximately 40% of patients experience **migratory superficial thrombophlebitis**, and involvement of deep veins is a recognized component of the pan-vasculitis seen in this condition. **NEET-PG High-Yield Pearls:** * **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) around areas of occlusion. * **Pathology:** Characterized by **microabscesses** within the thrombus, surrounded by multinucleated giant cells. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries.

Question 264: Which of the following does NOT cause lymphoedema?

A. Syphilis
B. Tuberculosis
C. Lymphogranuloma venereum (Correct Answer)
D. Filariasis

Explanation: **Explanation:** Lymphedema results from the obstruction or destruction of lymphatic channels, leading to the accumulation of protein-rich fluid in the interstitial space. **Why Lymphogranuloma Venereum (LGV) is the correct answer:** While LGV (caused by *Chlamydia trachomatis* serotypes L1-L3) primarily affects the lymphatics, it typically causes **lymphadenitis** (buboes) and localized scarring. In the context of NEET-PG questions based on standard surgical textbooks (like Bailey & Love), LGV is classically associated with **Esthiomene** (chronic hypertrophic ulceration of the vulva) rather than generalized limb lymphedema. However, it is important to note that in many clinical classifications, LGV *can* cause localized genital lymphedema. In the context of this specific four-option MCQ, it is often singled out as the "least likely" or "incorrect" cause compared to the systemic or chronic obstructive nature of the other three. **Analysis of Incorrect Options:** * **Filariasis (Wuchereria bancrofti):** The **most common cause** of secondary lymphedema worldwide. Adult worms reside in lymph nodes, causing fibrosis and permanent lymphatic blockade. * **Tuberculosis:** TB lymphadenitis (Scrofula) can lead to extensive scarring and destruction of regional lymph nodes (especially inguinal or axillary), resulting in obstructive lymphedema of the distal limb. * **Syphilis:** Chronic tertiary syphilis can lead to lymphadenopathy and subsequent lymphatic obstruction, though it is a rarer cause in modern practice. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause worldwide:** Filariasis. * **Most common cause in developed countries:** Malignancy or its treatment (Post-mastectomy/Radiotherapy). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic sign of lymphedema. * **Milroy’s Disease:** Congenital lymphedema (present at birth) due to VEGFR3 mutation. * **Stewart-Treves Syndrome:** Lymphangiosarcoma arising in a limb with long-standing chronic lymphedema.

Question 265: A 30-year-old male, a labourer and chronic smoker and alcoholic, presents with acute chest pain, severe back pain radiating to the interscapular area. What is the most likely diagnosis?

A. Pericarditis
B. Tension pneumothorax
C. Myocardial infarction
D. Ruptured aortic aneurysm (Correct Answer)

Explanation: **Explanation:** The clinical presentation of sudden, "tearing" or "ripping" chest pain radiating to the **interscapular area** (back) in a patient with risk factors like smoking and heavy labor is a classic hallmark of an **Aortic Dissection or Ruptured Aortic Aneurysm**. In this case, the radiation to the back specifically points toward involvement of the descending thoracic aorta. **Why the correct answer is right:** A ruptured aortic aneurysm (or acute aortic syndrome) causes intense, maximal-at-onset pain. The interscapular radiation occurs as the hematoma or rupture tracks along the posterior mediastinum. While typically associated with hypertension in older patients, in a young laborer, the acute physical strain combined with chronic smoking (which weakens the vessel wall) can precipitate a rupture or dissection. **Why the other options are incorrect:** * **Pericarditis:** Usually presents with pleuritic chest pain that is relieved by leaning forward and worsened by lying supine. It is often associated with a pericardial friction rub and diffuse ST-elevation on ECG. * **Tension Pneumothorax:** Characterized by sudden pleuritic pain and respiratory distress, but clinical signs would include tracheal deviation, absent breath sounds on one side, and hemodynamic instability due to decreased venous return. * **Myocardial Infarction (MI):** While MI causes severe retrosternal chest pain, it typically radiates to the left arm, jaw, or neck, rather than the interscapular region. The pain is usually "crushing" rather than "tearing." **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** CT Angiography is the investigation of choice for suspected aortic rupture/dissection. * **Chest X-ray sign:** Look for **mediastinal widening** (>8cm). * **Stanford Classification:** Type A involves the ascending aorta (surgical emergency); Type B involves only the descending aorta (often managed medically with BP control). * **Risk Factors:** Hypertension (most common), Marfan Syndrome (in young patients), and smoking/atherosclerosis.

Question 266: A 55-year-old man suffers from an acute myocardial infarction after occlusion of the left anterior descending coronary artery. The patient undergoes coronary bypass surgery 3 days later. Which of the following is the most frequent cause of saphenous vein graft failure several years following coronary bypass surgery?

A. Acute inflammation
B. Atherosclerosis (Correct Answer)
C. Graft-versus-host disease
D. Metastatic calcification

Explanation: **Explanation:** The failure of a Great Saphenous Vein (GSV) graft follows a predictable chronological pattern. The correct answer is **Atherosclerosis** because the question specifically asks for the cause of failure **several years** (late phase) following the procedure. 1. **Why Atherosclerosis is Correct:** In the long term (typically >1 year post-surgery), the primary cause of graft failure is **graft atherosclerosis**. Unlike native coronary artery disease, vein graft atherosclerosis develops more rapidly, is more friable, and often lacks a well-defined fibrous cap, making it highly prone to rupture and thrombosis. This process is often preceded by **intimal hyperplasia**, which occurs in the first year as the vein adapts to the high-pressure arterial environment (arterialization). 2. **Why Incorrect Options are Wrong:** * **Acute Inflammation:** While surgery triggers a local inflammatory response, it is not the primary driver of late-stage graft failure. * **Graft-versus-host disease (GVHD):** This occurs in the context of allogeneic bone marrow or organ transplants where donor T-cells attack host tissues. Since a saphenous vein graft is an **autograft** (the patient's own tissue), GVHD is impossible. * **Metastatic Calcification:** This refers to calcium deposition in normal tissues due to hypercalcemia (e.g., hyperparathyroidism). While grafts can calcify, it is a feature of the atherosclerotic process (dystrophic calcification), not a systemic metabolic derangement. **High-Yield Clinical Pearls for NEET-PG:** * **Timeline of Graft Failure:** * **Early (<1 month):** Thrombosis (usually due to technical errors or poor runoff). * **Intermediate (1 month – 1 year):** Intimal Hyperplasia (smooth muscle cell proliferation). * **Late (>1 year):** Atherosclerosis. * **Graft Choice:** The **Internal Mammary Artery (IMA)** is the gold standard for CABG (especially to the LAD) because it has superior long-term patency rates (>90% at 10 years) compared to saphenous veins, as it is less susceptible to atherosclerosis.

Question 267: What is the commonest site of thromboangiitis obliterans?

A. Femoral artery
B. Popliteal artery
C. Iliac artery
D. None of the above (Correct Answer)

Explanation: **Explanation:** **Thromboangiitis Obliterans (TAO)**, also known as **Buerger’s Disease**, is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the **small and medium-sized arteries and veins** of the distal extremities. **Why "None of the above" is correct:** The hallmark of TAO is its predilection for **distal vessels**. The most common sites of involvement are the **infrapopliteal arteries** (specifically the **Anterior Tibial, Posterior Tibial, and Peroneal arteries**) in the lower limbs, and the **Radial and Ulnar arteries** in the upper limbs. Since the options provided (Femoral, Popliteal, and Iliac) are all large, proximal arteries, they are typically spared in the early and middle stages of the disease. **Analysis of Incorrect Options:** * **A, B, and C (Femoral, Popliteal, and Iliac):** These are large-caliber, proximal elastic/muscular arteries. These vessels are the classic sites for **Atherosclerosis Obliterans (ASO)**, not Buerger’s disease. In TAO, the proximal pulses (Femoral and Popliteal) are characteristically preserved, while distal pulses (Dorsalis Pedis and Posterior Tibial) are absent. **High-Yield Clinical Pearls for NEET-PG:** * **Strongest Risk Factor:** Heavy tobacco consumption (smoking or chewing). * **Classic Triad:** Distal ischemia (claudication/gangrene), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) due to recanalization of the thrombus. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis). * **Treatment:** Absolute smoking cessation is the only way to halt disease progression. Sympathectomy may be used for symptomatic relief.

Question 268: Milroy's disease is characterized by which of the following?

A. Edema due to filariasis
B. Post-cellulitic lymphedema
C. Congenital lymphedema (Correct Answer)
D. Lymphedema following surgery

Explanation: **Explanation:** Milroy’s disease is a specific form of **Primary Lymphedema**, classified as **Lymphedema Congenita**. It is an autosomal dominant condition typically caused by a mutation in the **FLT4 gene**, which encodes the Vascular Endothelial Growth Factor Receptor-3 (VEGFR-3). This mutation leads to the hypoplasia or failure of development of lymphatic vessels. **Why the correct answer is right:** * **Option C:** Milroy’s disease is defined by the presence of lymphedema at birth or within the first year of life. It typically presents as bilateral, non-pitting edema of the lower limbs and is the classic example of congenital primary lymphedema. **Why the other options are wrong:** * **Option A & B:** These represent **Secondary Lymphedema**. Filariasis (caused by *Wuchereria bancrofti*) is the most common cause of secondary lymphedema worldwide, while post-cellulitic edema occurs due to lymphatic destruction following recurrent infections. * **Option D:** This is also a form of secondary lymphedema, commonly seen after radical lymph node dissections (e.g., post-mastectomy lymphedema). **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Age of Onset:** * **Lymphedema Congenita:** Present at birth (e.g., Milroy’s Disease). * **Lymphedema Praecox:** Most common primary type; appears during puberty/before age 35 (e.g., **Meige’s Disease**). * **Lymphedema Tarda:** Appears after age 35. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic clinical sign for lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for evaluating the lymphatic system.

Question 269: What is the most common site of lymphangiosarcoma?

A. Liver
B. Spleen
C. Post-mastectomy edema of arm (Correct Answer)
D. Retroperitoneum

Explanation: **Explanation:** **Lymphangiosarcoma** is a rare, highly aggressive malignant tumor arising from the endothelial lining of lymphatic vessels. **Why Option C is correct:** The most common clinical setting for lymphangiosarcoma is chronic, long-standing lymphedema. Specifically, it is most frequently associated with **Stewart-Treves Syndrome**. This syndrome refers to the development of lymphangiosarcoma in an arm affected by chronic lymphedema following a radical mastectomy with axillary lymph node dissection (usually for breast cancer). The tumor typically appears 10–20 years after the initial surgery as persistent cutaneous nodules or purple-red patches. **Why other options are incorrect:** * **A & B (Liver and Spleen):** While primary angiosarcomas can occur in the liver (often associated with vinyl chloride or thorotrast exposure) and the spleen, these are blood vessel malignancies (hemangiosarcomas), not primary lymphangiosarcomas. * **D (Retroperitoneum):** This is a common site for other sarcomas (like liposarcoma or leiomyosarcoma), but it is an extremely rare site for primary lymphangiosarcoma. **High-Yield Clinical Pearls for NEET-PG:** * **Stewart-Treves Syndrome:** Classic triad = Post-mastectomy + Chronic Lymphedema + Lymphangiosarcoma. * **Latent Period:** Usually occurs **10 years** or more after surgery. * **Clinical Presentation:** Look for "bruise-like" lesions or purple subcutaneous nodules on a lymphedematous limb that do not resolve. * **Prognosis:** Extremely poor due to early hematogenous metastasis (most commonly to the lungs). * **Treatment:** Radical amputation of the limb is often required, but survival rates remain low.

Question 270: Sympathectomy is effective in all of the following conditions except one?

A. Intermittent claudication (Correct Answer)
B. Hyperhydrosis
C. Raynaud's disease
D. Causalgia

Explanation: **Explanation:** Sympathectomy involves the surgical interruption of sympathetic nerve pathways to induce vasodilation and abolish sweating in a specific distribution. **Why Intermittent Claudication is the Correct Answer:** Intermittent claudication is caused by **macrovascular** atherosclerotic obstruction in the large arteries. During exercise, the metabolic demand of the muscles increases significantly. Sympathectomy primarily affects the **cutaneous (skin) circulation** rather than the deep intramuscular vessels. Furthermore, in patients with fixed arterial stenosis, the distal vessels are already maximally dilated due to local metabolites. Therefore, sympathectomy fails to increase blood flow to the exercising muscles and does not improve walking distance. **Analysis of Other Options:** * **Hyperhidrosis:** This is a primary indication for sympathectomy (e.g., Thoracic T2-T3). It eliminates the cholinergic sympathetic supply to eccrine sweat glands, providing a permanent cure. * **Raynaud’s Disease:** Sympathectomy is used in severe, refractory cases to reduce vasospasm and improve digital skin blood flow by removing sympathetic vasoconstrictor tone. * **Causalgia (Complex Regional Pain Syndrome Type II):** Sympathectomy is highly effective for "sympathetically maintained pain." It interrupts the pain-spasm-pain cycle and provides significant symptomatic relief. **High-Yield Clinical Pearls for NEET-PG:** * **Lumbar Sympathectomy:** The chain is usually removed from **L2 to L4**. L1 is preserved in males to prevent **loss of ejaculation**. * **Best Indication in PVD:** Sympathectomy is most effective for **rest pain** and **distal ischemic ulcers** (skin involvement) rather than claudication (muscle involvement). * **Buerger’s Disease:** It is often used as a palliative measure to improve skin vascularity and promote ulcer healing.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

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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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