Vascular Surgery Practice Questions

Q: SEPS is a procedure used for what?

Veins. **Explanation:** **SEPS (Subfascial Endoscopic Perforator Surgery)** is a minimally invasive surgical technique used specifically in the management of **Chronic Venous Insufficiency (CVI)**. **Why Veins is the correct answer:** The primary pathology in advanced CVI (CEAP classes C4–C6) is often **perforator vein incompetence**. These veins normally allow blood to flow from the superficial to the deep venous system. When they become incompetent, high pressure from the deep veins is transmitted to the superficial system, leading to skin changes and venous ulcers. SEPS involves using an endoscope inserted into the subfascial space of the leg to visualize and ligate these incompetent perforators. This is preferred over the traditional open **Linton’s procedure**, as it significantly reduces wound healing complications in areas with compromised skin. **Why other options are incorrect:** * **Arteries:** Arterial pathologies (like PAD) are managed via bypass grafts, endarterectomy, or angioplasty. SEPS does not address arterial flow. * **Lymphatics:** Lymphedema is managed conservatively or via lymphovenous anastomosis; SEPS has no role in lymphatic drainage. * **AV Fistula:** These are connections between arteries and veins (congenital or for dialysis) and are managed by ligation or surgical creation, not subfascial endoscopy. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Most commonly used for **Venous Ulcers (CEAP Class C6)** that fail to heal with compression therapy. * **Anatomy:** It targets the **Cockett’s perforators** (lower leg). * **Advantage:** Lower risk of "wound dehiscence" compared to the open Linton’s procedure. * **Contraindications:** Presence of Deep Vein Thrombosis (DVT) or severe arterial ischemia.

Q: A 40-year-old patient is suffering from a carotid body tumor. What is the best treatment choice for this patient?

Excision of tumor. ### Explanation **Carotid Body Tumors (CBTs)**, also known as **Chemodectomas** or paragangliomas, arise from the chemoreceptor cells located at the carotid bifurcation. **1. Why Excision is the Correct Choice:** The definitive treatment for a carotid body tumor is **complete surgical excision**. Because these tumors are slow-growing but locally invasive and carry a 5–10% risk of malignancy, surgical removal is indicated upon diagnosis. The standard technique involves subadventitial resection (the **Gordon-Taylor dissection**), which allows the tumor to be "shaved" off the carotid vessels while preserving the integrity of the internal and external carotid arteries. **2. Why Other Options are Incorrect:** * **Radiotherapy (B):** CBTs are generally radioresistant. Radiotherapy is reserved only for palliative care in inoperable cases, elderly patients who cannot tolerate surgery, or for recurrent malignant disease. * **Chemotherapy (C):** There is no established role for chemotherapy in the management of benign or localized carotid body tumors. * **Carotid Artery Ligation (D):** This is avoided due to the high risk of stroke and mortality. Modern vascular surgery aims for arterial preservation or reconstruction (using saphenous vein grafts) if the artery is involved, rather than simple ligation. **3. High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is mobile horizontally but fixed vertically (due to its attachment to the carotid bifurcation). * **Lyre Sign:** On angiography, the tumor causes characteristic widening/splaying of the carotid bifurcation. * **Shamblin Classification:** Used to grade the tumor based on its involvement with the carotid vessels (Group I: minimal attachment; Group III: complete encasement). * **Pre-operative Embolization:** Often performed 24–48 hours before surgery for large tumors (Shamblin II/III) to reduce vascularity and blood loss.

Q: What is the most common complication following varicose vein surgery?

Ecchymosis. **Explanation:** The correct answer is **Ecchymosis (Option A)**. **1. Why Ecchymosis is correct:** Ecchymosis (bruising) is the **most common** complication following varicose vein surgery, particularly after Trendelenburg procedure with stripping of the Great Saphenous Vein (GSV). It occurs due to the tearing of small tributary veins during the stripping process, leading to localized extravasation of blood into the subcutaneous tissues. While it is benign and usually resolves within 2–3 weeks, it occurs in nearly all patients to some degree. **2. Why the other options are incorrect:** * **Deep Vein Thrombosis (DVT):** This is the most **serious/dreaded** complication, but it is relatively rare (occurring in <1% of cases) due to early post-operative mobilization. * **Recurrence of varicosity:** This is a common **long-term** complication (occurring in 20–30% of cases over 10 years), often due to neovascularization or inadequate initial ligation. However, it is not as frequent in the immediate post-operative period as ecchymosis. * **Venous ulcer:** This is a clinical manifestation of chronic venous insufficiency (CVI), not a direct complication of the surgery itself. In fact, surgery is often performed to *heal* such ulcers. **3. High-Yield Clinical Pearls for NEET-PG:** * **Most common complication:** Ecchymosis/Bruising. * **Most common nerve injured:** **Saphenous nerve** (during stripping below the knee), leading to numbness along the medial aspect of the leg/foot. * **Most common nerve injured in Short Saphenous Vein surgery:** Sural nerve. * **Most common site of recurrence:** The saphenofemoral junction (due to tactical error or neovascularization). * **Gold Standard Investigation:** Venous Duplex Ultrasound.

Q: A 40-year-old woman is suspected of having a carotid body tumor. Which one of the following is most characteristic of such a tumor?

They arise from structures that respond to changes in PO2.. **Explanation:** **Carotid Body Tumors (CBTs)**, also known as chemodectomas or paragangliomas, are the most common head and neck paragangliomas. **1. Why Option D is Correct:** The carotid body is a **chemoreceptor** located at the bifurcation of the common carotid artery. Its primary physiological role is to sense changes in arterial blood gas composition, specifically responding to **decreased PO2 (hypoxia)**, increased PCO2, and decreased pH. Tumors arising from these structures retain their identity as chemoreceptors. **2. Why Other Options are Incorrect:** * **Option A:** While they are paragangliomas, carotid body tumors are usually **non-functional** (less than 5% secrete catecholamines). This distinguishes them from adrenal pheochromocytomas. * **Option B:** They are actually **more common at high altitudes**. Chronic hypoxia at high altitudes leads to compensatory hyperplasia of the carotid body, increasing the risk of tumor development. * **Option C:** Structures that respond to changes in blood volume/pressure are **baroreceptors** (located in the carotid sinus). The carotid body is a chemoreceptor, not a baroreceptor. **3. High-Yield Clinical Pearls for NEET-PG:** * **Fontaine’s Sign:** The tumor is vertically fixed but **horizontally mobile** (because it is attached to the carotid bifurcation). * **Lyre Sign:** On angiography, there is a characteristic widening/splaying of the carotid bifurcation. * **Shamblin Classification:** Used to grade the tumor based on its involvement/encasement of the carotid vessels. * **Inheritance:** Most are sporadic, but familial cases (often bilateral) are associated with **SDHD gene mutations**. * **Treatment:** Surgical excision is the gold standard; preoperative embolization may be used to reduce vascularity.

Q: Allen test detects insufficiency of which artery?

Radial artery. **Explanation:** The **Allen test** is a clinical bedside assessment used to evaluate the **patency of the arterial supply to the hand**, specifically the adequacy of the collateral circulation between the radial and ulnar arteries via the palmar arches. **Why Radial Artery is the Correct Answer:** The test is most commonly performed before procedures that involve instrumentation of the radial artery (e.g., **Arterial Blood Gas (ABG) sampling** or radial artery cannulation). By compressing both the radial and ulnar arteries and then releasing only the ulnar artery, the clinician observes the "blush" (return of color) to the palm. If the hand remains pale, it indicates **ulnar artery insufficiency**, meaning the hand is dependent solely on the **radial artery**. Therefore, the test is designed to detect if the radial artery is the "insufficient" or "sole" provider, preventing ischemic complications if that radial artery were to be damaged during a procedure. **Analysis of Incorrect Options:** * **B. Ulnar artery:** While the test involves the ulnar artery, the primary clinical goal is to ensure the ulnar artery is *functional* so that the radial artery can be safely accessed. * **C. Popliteal artery:** This is located behind the knee; its patency is assessed via the popliteal pulse or the Foucher’s sign (for cysts). * **D. Aorta:** Aortic patency is assessed via central pulses, blood pressure differentials, or imaging (CT/MRI). **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen Test:** The standard version used today where only the ulnar artery is released. A "positive" or normal result is a return of color within **5–15 seconds**. * **Indication:** Mandatory before radial artery harvesting for **CABG** or radial artery cannulation. * **Alternative:** If the Allen test is inconclusive, **Pulse Oximetry** or **Doppler ultrasound** can be used to confirm collateral flow.

Q: Non-pitting edema which does not reduce on elevation of the limb belongs to which grade of lymphedema?

Grade II. ### Explanation Lymphedema is classified based on the progression of tissue changes and the response to conservative management (elevation). The correct answer is **Grade II** because it marks the transition from fluid accumulation to irreversible tissue fibrosis. **1. Why Grade II is correct:** In **Grade II (Spontaneously Irreversible)** lymphedema, the edema becomes **non-pitting** due to the proliferation of adipocytes and the deposition of collagen (fibrosis). Crucially, at this stage, the swelling **does not reduce with limb elevation** because the structural changes in the subcutaneous tissue prevent the fluid from draining via gravity. **2. Analysis of Incorrect Options:** * **A. Latent (Stage 0):** There is impaired lymph transport, but no visible edema is present. The patient may feel "heaviness" in the limb. * **B. Grade I (Spontaneously Reversible):** This is early-stage edema characterized by **pitting**. The swelling is protein-rich but **reduces significantly or disappears with limb elevation**. * **D. Grade III (Lymphostatic Elephantiasis):** This is the end-stage. It presents with massive swelling, non-pitting edema, and significant skin changes such as **acanthosis, hyperkeratosis, and warty overgrowths**. **3. Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch a fold of skin at the base of the second toe or finger. It is a pathognomonic clinical sign of lymphedema. * **Gold Standard Investigation:** **Lymphoscintigraphy** is the investigation of choice to evaluate the lymphatic system. * **Management:** The mainstay of treatment is **Complex Decongestive Therapy (CDT)**, which includes manual lymphatic drainage, compression bandaging, and exercise. * **Surgery:** Charles’ procedure (excision of skin and subcutaneous tissue) is reserved for severe Grade III cases.

Q: Milroy's disease is a type of lymphedema which is:

Familial. **Explanation:** **Milroy’s disease** is a congenital form of primary lymphedema. It is an **autosomal dominant (familial)** condition characterized by the hypoplasia of lymphatic vessels. It typically presents at birth or within the first year of life (Lymphedema Congenita). The underlying molecular defect is often a mutation in the **FLT4 gene**, which encodes the Vascular Endothelial Growth Factor Receptor-3 (VEGFR-3). **Analysis of Options:** * **A. Familial (Correct):** As an autosomal dominant condition, it runs in families. It is the most common cause of primary lymphedema present at birth. * **B. Secondary to filariasis:** Filariasis (caused by *Wuchereria bancrofti*) is the most common cause of **secondary** lymphedema worldwide, but it is an acquired parasitic infection, not Milroy’s disease. * **C. Secondary to erysipelas:** Recurrent streptococcal infections (erysipelas) can cause lymphatic destruction leading to secondary lymphedema, whereas Milroy’s is a primary developmental defect. * **D. A sequela to white leg:** "White leg" (Phlegmasia alba dolens) refers to total deep vein thrombosis (DVT) of the iliofemoral segment. While it causes massive edema, it is a venous pathology, not a congenital lymphatic one. **High-Yield Clinical Pearls for NEET-PG:** * **Classification of Primary Lymphedema:** 1. **Milroy’s Disease:** Congenital (at birth), familial/autosomal dominant. 2. **Meige’s Disease:** Lymphedema Praecox (starts at puberty), most common primary type overall. 3. **Lymphedema Tarda:** Occurs 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 classic diagnostic feature of lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for confirming the diagnosis.

Q: What is not true regarding venous ulcers?

Found in elderly males.. **Explanation:** Venous ulcers (stasis ulcers) are the most common type of chronic lower limb ulceration, resulting from chronic venous insufficiency (CVI) and ambulatory venous hypertension. **Why Option C is the correct answer (False statement):** Venous ulcers are **more common in females** than in males. While they do occur in the elderly, the gender predilection is distinctly female (often cited as a 3:1 ratio). This is due to factors such as pregnancy-induced venous changes and hormonal influences on vein wall integrity. **Analysis of other options:** * **Option A:** Management focuses on reducing venous hypertension. If the underlying cause is superficial venous reflux (incompetent Great Saphenous Vein), **stripping or endovenous ablation** of the superficial system is a definitive treatment to prevent recurrence. * **Option B:** **Klippel-Trenaunay Syndrome (KTS)** is a triad of port-wine stains, varicose veins, and bony/soft tissue hypertrophy. Patients with KTS have significant venous malformations and insufficiency, which frequently leads to the development of venous ulcers. * **Option D:** Long-standing venous ulcers carry a risk of malignant transformation into a squamous cell carcinoma, known as a **Marjolin’s ulcer**. Therefore, a biopsy is mandatory for any chronic, non-healing, or atypical ulcer to rule out malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Typically found in the **"Gaiter Zone"** (medial malleolus). * **Characteristics:** Shallow, irregular borders, beefy red granulation tissue, and painless (unless infected). * **Associated Findings:** Lipodermatosclerosis (inverted champagne bottle appearance), haemosiderin staining (hyperpigmentation), and atrophie blanche. * **Gold Standard Investigation:** Duplex Ultrasound. * **Primary Treatment:** Four-layer compression bandaging (after ruling out arterial disease via ABPI).

Question 1

SEPS is a procedure used for what?

Accepted Answer

Veins

Answer

Arteries

Answer

Lymphatics

Answer

AV fistula

Question 2

A 40-year-old patient is suffering from a carotid body tumor. What is the best treatment choice for this patient?

Accepted Answer

Excision of tumor

Answer

Radiotherapy

Answer

Chemotherapy

Answer

Carotid artery ligation both proximal and distal to the tumor

Question 3

What is the most common complication following varicose vein surgery?

Accepted Answer

Ecchymosis

Answer

Deep vein thrombosis

Answer

Recurrence of varicosity

Answer

Venous ulcer

Question 4

A 40-year-old woman is suspected of having a carotid body tumor. Which one of the following is most characteristic of such a tumor?

Accepted Answer

They arise from structures that respond to changes in PO2.

Answer

They secrete catecholamines.

Answer

They are more common at sea level.

Answer

They arise from structures that respond to changes in blood volume.

Question 5

Allen test detects insufficiency of which artery?

Accepted Answer

Radial artery

Answer

Ulnar artery

Answer

Popliteal artery

Answer

Aorta

Question 6

A 55-year-old man with recent onset of atrial fibrillation presents with a cold, pulseless left lower extremity. He complains of left leg paresthesia and is unable to dorsiflex his toes. Following a successful popliteal embolectomy, with restoration of palpable pedal pulses, the patient is still unable to dorsiflex his toes. What is the next step in management?

Accepted Answer

Immediate fasciotomy

Answer

Electromyography (EMG)

Answer

Measurement of anterior compartment pressure

Answer

Elevation of the left leg

Question 7

Which of the following statements regarding venous thrombosis is true?

Accepted Answer

The most important factor for the development of deep venous thrombosis is hospital admission.

Answer

It affects only the deep venous system.

Answer

A coralline thrombus is a platelet aggregate surrounded by white blood cells.

Answer

Lung infarction is a common complication of deep venous thrombosis.

Question 8

Non-pitting edema which does not reduce on elevation of the limb belongs to which grade of lymphedema?

Accepted Answer

Grade II

Answer

Latent

Answer

Grade I

Answer

Grade III

Question 9

Milroy's disease is a type of lymphedema which is:

Accepted Answer

Familial

Answer

Secondary to filariasis

Answer

Secondary to erysipelas

Answer

A sequela to white leg

Question 10

What is not true regarding venous ulcers?

Accepted Answer

Found in elderly males.

Answer

Managed by stripping of the superficial saphenous venous system.

Answer

May be associated with Klippel-Trenaunay syndrome.

Answer

Biopsy is required for long-standing ulcers.

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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