Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 21: Popliteal artery pulsations are difficult to feel because?

A. It is not superficial
B. It does not cross a prominent bone
C. It is not superficial and does not cross a prominent bone (Correct Answer)
D. Its pulsations are weak

Explanation: **Explanation:** The popliteal artery is the deepest structure in the popliteal fossa. To palpate any arterial pulse effectively, the artery must ideally be **superficial** and lie against a **hard, prominent bone** (which acts as a "backboard" for compression). **Why Option C is Correct:** The popliteal artery fails on both counts: 1. **Depth:** It lies deep within the popliteal fossa, covered by skin, dense popliteal fascia, and a thick layer of fat. 2. **Lack of Bony Prominence:** Unlike the radial artery (against the radius) or the femoral artery (against the head of the femur), the popliteal artery lies against the flat popliteal surface of the femur and the posterior capsule of the knee joint. It does not cross a superficial bony prominence, making it difficult to compress. **Analysis of Incorrect Options:** * **Option A & B:** These are partially correct but incomplete. The difficulty is a combined result of both its deep location and the absence of an underlying bony ridge. * **Option D:** This is incorrect. The popliteal artery is a large-caliber vessel with strong pulsations; the difficulty in palpation is purely anatomical, not hemodynamic. **Clinical Pearls for NEET-PG:** * **Palpation Technique:** To feel the pulse, the knee should be slightly flexed (to relax the popliteal fascia) and the clinician must use deep bimanual palpation in the midline of the fossa. * **Aneurysm:** The popliteal artery is the most common site for peripheral arterial aneurysms. A "prominent" or easily felt popliteal pulse should raise suspicion of an aneurysm. * **Entrapment:** Popliteal Artery Entrapment Syndrome (PAES) occurs due to an abnormal relationship with the medial head of the gastrocnemius.

Question 22: Lower leg perforators are named after which of the following?

A. Cockett (Correct Answer)
B. Boyd
C. Dodd
D. May or Kuster

Explanation: **Explanation:** Perforating veins are crucial vessels that connect the superficial venous system to the deep venous system by piercing the deep fascia. In the lower limb, these are categorized based on their anatomical location. **1. Why Cockett is Correct:** **Cockett’s perforators** are specifically located in the **lower leg** (posterior arch vein). They connect the Great Saphenous vein (GSV) territory to the deep posterior tibial veins. They are clinically significant as they are frequently involved in the development of venous ulcers (Gaiter zone). They are divided into Upper, Middle, and Lower Cockett perforators, located approximately 13.5 cm, 8.5 cm, and 5 cm above the medial malleolus, respectively. **2. Analysis of Incorrect Options:** * **Boyd’s Perforators:** These are located in the **upper medial calf** (just below the knee), connecting the GSV to the posterior tibial veins. * **Dodd’s Perforators:** These are located in the **lower thigh** (distal third), connecting the GSV to the femoral vein within the adductor (Hunterian) canal. * **May or Kuster Perforators:** These are located in the **ankle** region, specifically connecting the GSV to the deep veins at the level of the medial malleolus. **Clinical Pearls for NEET-PG:** * **Direction of Flow:** In healthy individuals, blood flows from the superficial to the deep system. Valvular incompetence in perforators leads to "outward" flow, causing superficial varicosities and skin changes. * **Hunterian Perforator:** Located in the mid-thigh. * **Gaiter Zone:** The area of the lower leg (medial aspect) most prone to venous stasis and ulceration, primarily due to Cockett’s perforator incompetence. * **Trendelenburg Test:** Used clinically to differentiate between saphenofemoral incompetence and perforator incompetence.

Question 23: What is the term for fan-shaped patterns of small intradermal veins on the medial or lateral aspect of the ankle?

A. Saphena varix
B. Hyphen webs
C. Corona phlebectasia (Correct Answer)
D. Dermal flare

Explanation: **Explanation:** **Corona phlebectasia** (also known as *Corona phlebectatica paraplantaris*) is the correct term for the fan-shaped pattern of small, dilated intradermal veins found on the medial or lateral aspects of the ankle and foot. It is a clinical sign of chronic venous insufficiency (CVI) and is classified as **C1** in the CEAP classification. It typically results from the incompetence of the perforating veins and the saphenous system, leading to high pressure in the dermal venous plexus. **Analysis of Incorrect Options:** * **Saphena varix:** This is a saccular aneurysm or localized dilation of the Great Saphenous Vein at its junction with the femoral vein (Saphenofemoral junction). It presents as a soft swelling in the groin that disappears on lying down and exhibits a cough impulse. * **Hyphen webs:** This is an older, less specific term sometimes used to describe telangiectasias or spider veins, but it does not specifically refer to the fan-shaped ankle distribution characteristic of Corona phlebectasia. * **Dermal flare:** While "flare" is often used colloquially to describe redness or telangiectasias, it is not the formal anatomical term for this specific ankle venous pattern. **High-Yield Clinical Pearls for NEET-PG:** * **CEAP Classification:** Remember that Corona phlebectasia is a strong clinical predictor of advanced venous disease (often progressing to C4-C6, i.e., skin changes and ulcers). * **Location:** It is most commonly seen on the **medial** aspect of the ankle. * **Significance:** Its presence indicates significant underlying venous hypertension, even if large varicose veins are not visible.

Question 24: What is the most common type of primary lymphedema?

A. Lymphedema congenital
B. Lymphedema precox (Correct Answer)
C. Lymphedema tarda
D. None of the above

Explanation: **Explanation:** Primary lymphedema is a developmental abnormality of the lymphatic system, classified based on the age of onset. **Lymphedema Precox (Option B)** is the most common type of primary lymphedema, accounting for approximately **65–80% of cases**. It is defined by an onset between the ages of 1 and 35 years. It typically manifests during puberty or pregnancy, suggesting a hormonal influence on lymphatic demand. It is more common in females and usually presents as unilateral swelling of the lower limbs. **Why other options are incorrect:** * **Lymphedema Congenita (Option A):** This accounts for about 10–15% of cases. It is present at birth or manifests within the first year of life. When it is familial (autosomal dominant), it is known as **Milroy’s disease**. * **Lymphedema Tarda (Option C):** This is the rarest form (approx. 10%), occurring after the age of 35. It is often associated with a defect in the lymphatic valves. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause of lymphedema worldwide:** Filariasis (*Wuchereria bancrofti*). * **Most common cause of lymphedema in developed countries:** Secondary to malignancy or its treatment (e.g., Axillary lymph node dissection for Breast Cancer). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic clinical sign of lymphedema. * **Stewart-Treves Syndrome:** A rare, highly aggressive angiosarcoma arising in a limb with chronic long-standing lymphedema.

Question 25: What is the preferred shunt procedure in a patient with portal hypertension who has acceptable operative risk and adequate liver function?

A. End to side portocaval shunt
B. End to end portocaval shunt
C. Mesocaval shunt
D. Distal splenorenal shunt (Correct Answer)

Explanation: **Explanation:** The management of portal hypertension focuses on reducing portal pressure while maintaining hepatic perfusion. In patients with **preserved liver function (Child-Pugh Class A)** and acceptable operative risk, the goal is to prevent variceal bleeding without inducing hepatic encephalopathy. **Why Distal Splenorenal Shunt (DSRS) is correct:** The DSRS (Warren shunt) is a **selective shunt**. It compartmentalizes the venous system: it decompresses the gastroesophageal varices via the short gastric and splenic veins into the left renal vein, while simultaneously **preserving portal flow** to the liver from the superior mesenteric vein. By maintaining prograde portal flow, it significantly reduces the risk of post-operative hepatic encephalopathy compared to non-selective shunts. **Analysis of Incorrect Options:** * **A & B (Portocaval Shunts):** These are **total (non-selective) shunts**. They divert all portal blood flow away from the liver into the systemic circulation (IVC). While highly effective at preventing re-bleeding, they carry a very high risk of hepatic encephalopathy and accelerated liver failure due to the loss of hepatotrophic factors. * **C (Mesocaval Shunt):** This is also a non-selective shunt (usually involving a prosthetic H-graft). It is typically reserved for emergency decompression or when the splenic vein is unavailable (e.g., prior splenectomy), but it does not offer the selective benefits of DSRS. **High-Yield Pearls for NEET-PG:** * **Gold Standard for Refractory Variceal Bleed:** TIPS (Transjugular Intrahepatic Portosystemic Shunt) is the preferred non-surgical intervention. * **DSRS Contraindication:** Presence of intractable ascites (DSRS does not decompress the mesenteric bed, potentially worsening ascites). * **Budd-Chiari Syndrome:** Side-to-side portocaval shunt is the classic surgical choice if the IVC is patent. * **Most common cause of Portal HTN in India:** Non-cirrhotic portal fibrosis (NCPF) and Extrahepatic portal venous obstruction (EHPVO).

Question 26: What is the primary surgical procedure for managing varicose veins?

A. Stripping (Correct Answer)
B. Multiple subcutaneous ligatures
C. Subfascial ligatures
D. Division and ligation of the superficial venous system

Explanation: **Explanation:** The primary surgical objective in treating varicose veins is to eliminate the source of venous reflux and remove the diseased superficial veins. **Stripping** (specifically Trendelenburg procedure followed by stripping of the Great Saphenous Vein) remains the traditional gold-standard surgical approach. **Why Stripping is Correct:** Stripping involves the physical removal of the Great Saphenous Vein (GSV) or Small Saphenous Vein (SSV) from the leg. By removing the incompetent venous trunk, it effectively eliminates the hydrostatic pressure column that causes varicosities, significantly reducing the rate of recurrence compared to ligation alone. **Analysis of Incorrect Options:** * **Multiple subcutaneous ligatures:** This technique (often part of ambulatory phlebectomy) addresses only the visible tributaries but does not treat the underlying saphenofemoral incompetence, leading to high recurrence. * **Subfascial ligatures (Cockett and Dodd's procedure):** This is specifically used to treat incompetent **perforating veins** (usually in the "gaiter area") rather than the primary truncal varicosity itself. * **Division and ligation of the superficial system:** While ligation (Trendelenburg procedure) is a crucial first step to disconnect the saphenofemoral junction, performing ligation *without* stripping is associated with a much higher incidence of recurrence due to collateral formation. **High-Yield Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Brodie-Trendelenburg Procedure:** Juxtafemoral flush ligation of the GSV and its five tributaries. * **Modern Shift:** While stripping is the classic surgical answer, **Endovenous Thermal Ablation (EVLA or RFA)** is now the preferred first-line treatment in modern clinical guidelines due to faster recovery and fewer complications. * **Complication:** The most common nerve injured during GSV stripping is the **Saphenous nerve** (causing numbness on the medial aspect of the leg/foot).

Question 27: Nicoladini's Branham sign is seen in which of the following conditions?

A. Aortic dissection
B. Buerger's disease
C. Aneurysm
D. Arteriovenous fistula (Correct Answer)

Explanation: **Explanation:** **Nicoladini-Branham sign** is a classic clinical finding diagnostic of a large, long-standing **Arteriovenous (AV) fistula**. **Why the correct answer is right:** In an AV fistula, blood shunts directly from the high-pressure arterial system to the low-pressure venous system, bypassing the capillary bed. This leads to increased venous return and a compensatory increase in cardiac output (tachycardia). When the fistula is manually compressed (occluded), the shunting stops. This results in an immediate increase in peripheral resistance and a sudden surge in vagal tone, leading to **reflex bradycardia** and a rise in blood pressure. This physiological response is the Nicoladini-Branham sign. **Why the incorrect options are wrong:** * **Aortic dissection:** Characterized by a tear in the tunica intima; clinical signs include "tearing" chest pain and pulse deficits, not reflex bradycardia upon compression. * **Buerger's disease (Thromboangiitis obliterans):** An inflammatory occlusive disease of small/medium arteries. It presents with claudication and gangrene; the relevant clinical test is **Allen’s test** or **Buerger’s test** (postural color changes). * **Aneurysm:** While an aneurysm may present with a pulsatile mass, it does not involve a shunt. Compression of an aneurysm does not typically elicit a reflex heart rate change. **High-Yield Clinical Pearls for NEET-PG:** * **AV Fistula Triad:** Pulsatile mass, palpable thrill, and continuous "machinery" murmur (bruit). * **Proximal vs. Distal:** Proximal to the fistula, the artery is dilated and thin-walled; distal to it, there may be features of chronic ischemia. * **Complication:** Large AV fistulas can lead to **High-Output Cardiac Failure** due to the persistent increase in venous return.

Question 28: Acute vascular ischemia manifests as?

A. Pulselessness (Correct Answer)
B. Syncope
C. Flushing
D. Oedema

Explanation: **Explanation:** Acute Limb Ischemia (ALI) is a surgical emergency caused by a sudden decrease in arterial limb perfusion. The clinical diagnosis is classically based on the **"6 Ps"**, which represent the hallmark signs of arterial occlusion. **Why Pulselessness is Correct:** Pulselessness (Option A) is one of the cardinal "6 Ps." When an embolus or thrombus obstructs an artery, blood flow distal to the occlusion ceases, leading to the loss of palpable pulses. This is often the most objective finding in early ischemia. The other 5 Ps include: **Pain** (sudden and severe), **Pallor** (pale skin), **Poikilothermia** (cold limb), **Paresthesia** (numbness), and **Paralysis** (loss of motor function). **Why Incorrect Options are Wrong:** * **Syncope (B):** This refers to a transient loss of consciousness, usually due to global cerebral hypoperfusion, not peripheral vascular occlusion. * **Flushing (C):** Ischemic limbs are typically pale (Pallor) or mottled (cyanotic). Flushing or rubor is more characteristic of chronic limb ischemia (Buerger’s test) or inflammatory conditions like cellulitis. * **Oedema (D):** Swelling is a feature of **Venous** obstruction (e.g., DVT) or Reperfusion Injury. In acute arterial ischemia, the limb is typically "empty" of fluid, not edematous. **NEET-PG High-Yield Pearls:** * **Golden Period:** Revascularization should ideally occur within **6 hours** to prevent irreversible muscle necrosis. * **Earliest Sign:** Pain is usually the first symptom. * **Worst Prognostic Sign:** Paralysis and Paresthesia indicate advanced nerve/muscle ischemia and potential irreversibility. * **Investigation of Choice:** Digital Subtraction Angiography (DSA) is the gold standard, but treatment (Heparinization) should not be delayed for imaging if the diagnosis is clinically clear.

Question 29: Pseudoaneurysm in a drug abuser is typically seen in which artery?

A. Radial
B. Brachial
C. Femoral (Correct Answer)
D. Carotid

Explanation: **Explanation:** **1. Why Femoral is Correct:** In intravenous (IV) drug abusers, the **femoral artery** is the most common site for pseudoaneurysm formation. This occurs due to "groin hitting"—the practice of injecting drugs directly into the femoral vein when peripheral veins become sclerosed. Because the femoral artery lies immediately lateral to the vein within the femoral sheath, accidental arterial puncture is frequent. Unlike a true aneurysm, a pseudoaneurysm (false aneurysm) is a pulsatile hematoma contained only by the surrounding fibrous tissue or adventitia, resulting from persistent leakage of blood through the arterial wall defect. **2. Analysis of Incorrect Options:** * **Radial/Brachial Artery:** While these are common sites for peripheral IV access, they are less frequently used for deep "blind" injections by drug abusers compared to the femoral vessels. Pseudoaneurysms here are more commonly iatrogenic (e.g., post-catheterization). * **Carotid Artery:** Injection into the neck ("pocket shots") is extremely dangerous and less common than groin injections. It carries a high risk of immediate stroke, airway compromise, or air embolism. **3. Clinical Pearls for NEET-PG:** * **Clinical Presentation:** A pulsatile, painful mass in the groin, often associated with a "to-and-fro" murmur on auscultation. * **Gold Standard Diagnosis:** Duplex Ultrasonography (shows the characteristic "Yin-Yang" sign of turbulent flow). * **Complications:** The most feared complication is **infected (mycotic) pseudoaneurysm**, which carries a high risk of rupture and limb loss. * **Management:** Small, non-infected cases may be treated with ultrasound-guided thrombin injection. However, in drug abusers, surgical debridement and arterial repair (or ligation) are often required due to the high risk of underlying infection.

Question 30: Passive forcible dorsiflexion of the foot with the knee extended causes pain in the calf. What is this sign called?

A. Moses sign
B. Homan's sign (Correct Answer)
C. Schwartz sign
D. Fegan's test

Explanation: **Explanation:** **Homan’s sign** is a classic clinical sign used in the assessment of Deep Vein Thrombosis (DVT). It is elicited by performing **passive dorsiflexion of the foot** while the **knee is extended**. This maneuver stretches the gastrocnemius and soleus muscles, which in turn compresses the inflamed deep veins of the calf, resulting in pain. While historically popular, it is now considered unreliable due to low sensitivity and specificity, and there is a theoretical risk of dislodging a clot (embolization). **Analysis of Incorrect Options:** * **Moses sign:** This involves squeezing the calf muscles against the tibia. Pain on anteroposterior compression (but not lateral compression) suggests DVT. * **Schwartz sign (Hackney’s test):** Used in the assessment of varicose veins. A tap on the lower part of a long saphenous vein produces a palpable impulse at the saphenofemoral junction if the valves are incompetent. * **Fegan’s test:** Used to identify the site of incompetent perforators in varicose veins. The patient stands until veins are prominent, then lies down with the leg elevated; the clinician palpates for "blow-outs" or circular defects in the deep fascia. **NEET-PG High-Yield Pearls:** * **Gold Standard Investigation for DVT:** Colour Doppler Ultrasound (Duplex Scan). * **Virchow’s Triad:** Stasis, Hypercoagulability, and Endothelial injury (the three factors contributing to venous thrombosis). * **Pratt’s Sign:** Presence of prominent "sentinel" veins in the pretibial area, another clinical indicator of DVT. * **Clinical Utility:** Clinical signs like Homan’s are insufficient for diagnosis; the **Wells Score** is the preferred clinical tool to determine the probability of DVT.

Practice by Chapter

Atherosclerotic Disease

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Aortic Aneurysms

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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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