Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 291: Varicose vein surgery is contraindicated in which of the following conditions?

A. Varicose ulcers
B. Deep vein thrombosis (Correct Answer)
C. Pigmentation over the limb
D. Hemorrhoids

Explanation: **Explanation:** The primary contraindication for varicose vein surgery is **Deep Vein Thrombosis (DVT)**. In patients with DVT, the deep venous system is obstructed or incompetent. Consequently, the superficial venous system (Great and Short Saphenous veins) acts as the **essential collateral pathway** for venous return from the lower limb. If these superficial veins are surgically removed or ablated, venous outflow is severely compromised, leading to acute venous congestion, severe edema, and potential phlegmasia cerulea dolens. Before any surgery, a **Perthes’ Test** or Duplex Scan must be performed to ensure the patency of the deep veins. **Analysis of Incorrect Options:** * **Varicose Ulcers (A) & Pigmentation (C):** These are features of Chronic Venous Insufficiency (CEAP classes C4 and C6). Rather than being contraindications, they are actually **strong indications** for surgery to reduce venous hypertension and promote healing. * **Hemorrhoids (D):** While both involve dilated veins, they occur in different anatomical sites (rectal vs. lower limb). The presence of hemorrhoids has no bearing on the surgical management of lower limb varicosities. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Active DVT, pregnancy (due to hormonal changes and pelvic pressure), and severe peripheral arterial disease (ABI < 0.5). * **Gold Standard Investigation:** Duplex Ultrasound (to assess reflux and deep system patency). * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Brodie-Trendelenburg Formula:** "Singly positive" means SFJ incompetence only; "Doubly positive" means both SFJ and perforator incompetence.

Question 292: A 45-year-old man presents with progressive cervical lymph node enlargement for the past 3 months. Which is the most diagnostic investigation?

A. X-ray of soft tissues
B. Lymph node biopsy (Correct Answer)
C. Fine Needle Aspiration Cytology (FNAC)
D. None of the above

Explanation: **Explanation:** In the evaluation of persistent cervical lymphadenopathy (lasting >3 weeks), the primary goal is to differentiate between reactive, infectious (e.g., Tuberculosis), and neoplastic (e.g., Lymphoma or Metastasis) etiologies. **Why Lymph Node Biopsy is the Correct Answer:** Excisional biopsy is considered the **Gold Standard** and the most diagnostic investigation. Unlike cytology, a biopsy preserves the **node architecture**, which is critical for diagnosing lymphomas (distinguishing Hodgkin’s vs. Non-Hodgkin’s) and performing Immunohistochemistry (IHC). It provides a larger tissue sample, ensuring higher sensitivity and specificity for definitive diagnosis. **Analysis of Incorrect Options:** * **Fine Needle Aspiration Cytology (FNAC):** While FNAC is often the *initial* investigation of choice due to its speed and low cost, it is not the most diagnostic. It only provides cellular detail (cytology) and cannot evaluate the tissue architecture. It has a high false-negative rate in lymphomas. * **X-ray of Soft Tissues:** This is a non-specific imaging modality. While it may show calcifications (suggestive of healed TB) or soft tissue shadows, it cannot provide a pathological diagnosis. * **None of the above:** Incorrect, as biopsy is the definitive diagnostic tool. **NEET-PG High-Yield Pearls:** * **Initial Investigation:** FNAC is usually done first. * **Gold Standard/Definitive Investigation:** Excisional Biopsy. * **Biopsy Technique:** Excisional biopsy (removing the whole node) is preferred over incisional biopsy to prevent sampling errors and tumor seeding. * **Most common cause of chronic cervical lymphadenopathy in India:** Tuberculosis. * **Supraclavicular nodes (Virchow’s node):** Always pathological; usually indicates an underlying malignancy (e.g., Gastric Cancer).

Question 293: Atrial myxoma commonly arises from?

A. Left ventricle
B. Left atrium (Correct Answer)
C. Right ventricle
D. Right atrium

Explanation: **Explanation:** Atrial myxoma is the most common primary cardiac tumor in adults. It is a benign, mesenchymal tumor that typically presents with the "classic triad" of constitutional symptoms (fever, weight loss), embolic phenomena, and obstructive symptoms mimicking mitral stenosis. **Why the Left Atrium is Correct:** Approximately **75-80% of cardiac myxomas arise in the left atrium**. They most commonly originate from the **interatrial septum**, specifically at the border of the **fossa ovalis**. Their location allows them to frequently prolapse through the mitral valve during diastole, causing a characteristic "tumor plop" sound on auscultation. **Why the Other Options are Incorrect:** * **Right Atrium (Option D):** This is the second most common site, accounting for about 15-20% of cases. While significant, it is far less frequent than left atrial involvement. * **Ventricles (Options A & C):** Ventricular myxomas are rare, representing less than 5% of all cases. Primary tumors in the ventricles are more likely to be rhabdomyomas (especially in children) or fibromas. **High-Yield Clinical Pearls for NEET-PG:** * **Carney Complex:** An autosomal dominant syndrome (PRKAR1A gene mutation) characterized by atrial myxomas, spotty skin pigmentation (lentigines), and endocrine overactivity. * **Diagnosis:** Transthoracic Echocardiography (TTE) is the initial screening tool of choice; Transesophageal Echocardiography (TEE) provides better detail. * **Treatment:** Prompt surgical excision is the treatment of choice due to the high risk of systemic embolization or sudden cardiac death. * **Histology:** Features "myxoma cells" (stellate or spindle-shaped) embedded in a glycosaminoglycan-rich stroma.

Question 294: What is the maximum recommended tourniquet time for the upper limb?

A. 30 minutes
B. 60 minutes
C. 90 minutes
D. 120 minutes (Correct Answer)

Explanation: ### Explanation The use of a pneumatic tourniquet is a standard procedure in orthopedic and vascular surgeries to create a bloodless surgical field. The correct answer is **120 minutes (2 hours)**. **1. Why 120 minutes is correct:** The primary concern with tourniquet use is ischemia-reperfusion injury and nerve compression. Research indicates that skeletal muscle can tolerate up to 2 hours of ischemia without significant permanent damage. Beyond this "golden period," the risk of metabolic acidosis, rhabdomyolysis, and permanent nerve palsy (tourniquet paralysis) increases significantly. If the surgery exceeds this duration, a "breathing period" (deflation for 10–20 minutes) is required to allow for tissue reperfusion and washout of metabolic waste before re-inflation. **2. Why the other options are incorrect:** * **30 & 60 minutes:** These durations are well within the safety margin. While safe, they do not represent the *maximum* recommended threshold for the upper limb. * **90 minutes:** While some surgeons prefer a 90-minute limit for the upper limb to be extra cautious, the standard consensus in major surgical textbooks (like Sabiston or Bailey & Love) and orthopedic guidelines (Campbell’s) defines the safe upper limit as 120 minutes. **3. Clinical Pearls for NEET-PG:** * **Pressure Settings:** For the upper limb, the cuff should be inflated to **50–100 mmHg above the systolic blood pressure**. (Lower limb requires higher pressure: 100–150 mmHg above systolic). * **Nerve Vulnerability:** The **Radial nerve** is the most common nerve injured by tourniquet compression in the upper limb. * **Post-Tourniquet Syndrome:** Characterized by edema, pallor, and stiffness after deflation; it is usually related to the duration of ischemia rather than the pressure applied. * **Contraindications:** Avoid in patients with Sickle Cell Anemia (risk of crisis) or severe peripheral vascular disease.

Question 295: Pressure on an artery proximal to a fistula leading to diminished swelling is known as which sign?

A. Murray sign
B. Frei sign
C. Darrier sign
D. Branham sign (Correct Answer)

Explanation: ### Explanation **Branham’s Sign (also known as Nicoladoni-Branham sign)** is a classic clinical finding in patients with a large, chronic **Arteriovenous (AV) Fistula**. When digital pressure is applied to the artery proximal to the fistula, the shunting of blood from the high-pressure arterial system to the low-pressure venous system is suddenly halted. This leads to: 1. **Diminished swelling and thrill** over the fistula site. 2. **Reflex Bradycardia** (slowing of the heart rate) and a rise in systemic blood pressure. * **Mechanism:** Closing the shunt increases total peripheral resistance and effective circulating volume, stimulating baroreceptors which trigger a vagal response to slow the heart rate. #### Analysis of Incorrect Options: * **A. Murray Sign:** This is not a standard vascular sign. It is sometimes associated with the "Murray’s Law" regarding vessel branching but has no clinical relevance to AV fistula compression. * **B. Frei Sign:** This is not a recognized vascular sign. (Note: *Frey's Syndrome* refers to gustatory sweating after parotid surgery). * **C. Darrier Sign:** This is a **dermatological sign** where rubbing a lesion (mastocytoma) leads to localized urticaria/wheal formation due to histamine release from mast cells. #### High-Yield Clinical Pearls for NEET-PG: * **Machinery Murmur:** AV fistulas are characterized by a continuous "bruit" or machinery-like murmur heard throughout systole and diastole. * **Proximal vs. Distal:** Proximal to the fistula, the artery dilates (due to increased flow); distal to the fistula, there may be signs of ischemia (Steal Syndrome). * **Complication:** Large AV fistulas can lead to **High-Output Cardiac Failure** due to the persistent decrease in systemic vascular resistance.

Question 296: In the immediate post-operative period, an increase in D-dimer levels is most commonly noticed due to which of the following?

A. Deep vein thrombosis (Correct Answer)
B. Pulmonary embolism
C. Disseminated intravascular coagulation
D. Normal physiological response

Explanation: **Explanation:** The correct answer is **Deep Vein Thrombosis (A)**. D-dimer is a fibrin degradation product (FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. In the immediate post-operative period, patients are in a pro-thrombotic state due to Virchow’s triad (stasis from immobility, endothelial injury from surgery, and hypercoagulability). While D-dimer levels can rise due to the surgical trauma itself (Option D), a significant and pathological increase in the immediate post-operative period is most clinically associated with the development of **Deep Vein Thrombosis (DVT)**. **Analysis of Options:** * **B. Pulmonary Embolism:** While PE also causes elevated D-dimer, it is usually a sequela of DVT. In the immediate post-op period, the formation of the thrombus in the deep veins (DVT) typically precedes the embolic event. * **C. Disseminated Intravascular Coagulation (DIC):** DIC causes extremely high D-dimer levels due to widespread systemic clotting and lysis, but it is a complex consumptive coagulopathy usually triggered by sepsis or massive hemorrhage, not a "common" post-operative finding compared to DVT. * **D. Normal physiological response:** Surgery does cause a baseline rise in D-dimer due to wound healing and local fibrin deposition; however, in the context of standardized testing for vascular surgery, a significant elevation is treated as a marker for venous thromboembolism (VTE). **High-Yield Pearls for NEET-PG:** 1. **Negative Predictive Value:** The primary clinical utility of D-dimer is its **high negative predictive value**. A normal D-dimer level can help rule out DVT/PE in low-probability patients. 2. **Gold Standard:** While D-dimer is a screening tool, **Duplex Ultrasonography** is the investigation of choice for DVT, and **CT Pulmonary Angiography (CTPA)** is the gold standard for PE. 3. **Wells Criteria:** Always use D-dimer results in conjunction with clinical scoring systems like the Wells Score to determine the next diagnostic step.

Question 297: Injection sclerotherapy for varicose veins uses which agent?

A. Phenol (Correct Answer)
B. Absolute alcohol
C. 70% alcohol
D. All of the above

Explanation: **Explanation:** **Injection Sclerotherapy** is a technique used for the management of small varicose veins (telangiectasias and reticular veins) and sometimes for residual varicosities post-surgery. The procedure involves injecting a chemical irritant (sclerosing agent) into the vein, which causes endothelial damage, localized thrombosis, and eventual fibrosis (obliteration) of the vessel. **Why Phenol is Correct:** Phenol (specifically **5% Phenol in Almond Oil**) is a classic chemical sclerosing agent. It acts by inducing intense local irritation and protein denaturation of the vessel wall. While newer agents like Polidocanol and Sodium Tetradecyl Sulfate (STS) are more commonly used today due to fewer side effects, Phenol remains a recognized option in surgical textbooks and historical NEET-PG patterns. **Why Other Options are Incorrect:** * **Absolute Alcohol:** While a potent sclerosing agent, it is primarily used for the embolization of **Arteriovenous Malformations (AVMs)** or renal artery ablation. It is too caustic for routine varicose vein sclerotherapy as it carries a high risk of skin necrosis and nerve damage. * **70% Alcohol:** This concentration is used as an antiseptic (rubbing alcohol) but lacks the potency required to induce the permanent endothelial destruction needed for sclerotherapy. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Agents:** Currently, **Sodium Tetradecyl Sulfate (STS)** and **Polidocanol** (a detergent-based agent) are the most preferred sclerosing agents worldwide. * **Mechanism:** Sclerotherapy converts a high-pressure venous channel into a solid fibrous cord. * **Fegan’s Technique:** A specific method of sclerotherapy where the injection is performed into the "empty vein" while the leg is elevated. * **Contraindications:** Pregnancy, acute Deep Vein Thrombosis (DVT), and significant peripheral arterial disease. * **Complication:** The most common minor complication is **hyperpigmentation** (hemosiderin staining) along the course of the vein.

Question 298: What is the most common cause of abdominal aortic aneurysm?

A. Trauma
B. Vasculitis
C. Syphilis
D. Atherosclerosis (Correct Answer)

Explanation: **Explanation:** An **Abdominal Aortic Aneurysm (AAA)** is defined as a permanent pathological dilation of the abdominal aorta with a diameter >3 cm or >50% of its normal size. **Why Atherosclerosis is the Correct Answer:** Atherosclerosis is the most common underlying etiology for AAA. The process involves the formation of atherosclerotic plaques which lead to chronic inflammation and the recruitment of macrophages. These cells release **Matrix Metalloproteinases (MMPs)**, specifically MMP-2 and MMP-9, which degrade elastin and collagen in the tunica media. This weakens the aortic wall, causing it to bulge under arterial pressure. **Analysis of Incorrect Options:** * **Trauma:** While trauma can cause "pseudoaneurysms" or acute aortic dissections, it is a rare cause of true chronic abdominal aneurysms. * **Vasculitis:** Conditions like Takayasu arteritis or Giant Cell Arteritis can affect the aorta, but they more commonly involve the aortic arch and its branches rather than the infrarenal abdominal aorta. * **Syphilis:** Tertiary syphilis (endarteritis obliterans of vasa vasorum) classically causes aneurysms of the **ascending thoracic aorta**, not the abdominal aorta. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Most AAAs are **infrarenal** (90%), located between the renal arteries and the aortic bifurcation. * **Risk Factors:** Smoking is the strongest modifiable risk factor; others include male gender, age >65, and family history. * **Screening:** USG is the investigation of choice for screening; CT Angiography is the gold standard for surgical planning. * **Surgical Threshold:** Repair is generally indicated if the diameter is **>5.5 cm in men** or **>5.0 cm in women**, or if it grows >0.5 cm in 6 months.

Question 299: Lumbar sympathectomy is indicated in:

A. Intermittent claudication
B. Thromboangiitis obliterans (TAO) with skin changes
C. Buerger's disease
D. Raynaud's disease (Correct Answer)

Explanation: **Explanation:** **Lumbar Sympathectomy** involves the surgical removal of the 2nd, 3rd, and 4th lumbar sympathetic ganglia. This procedure results in permanent vasodilation and the abolition of sweating in the lower limbs by interrupting the sympathetic vasoconstrictor fibers. **Why Raynaud’s Disease is the Correct Answer:** Raynaud’s disease is characterized by episodic digital vasospasm. While cervical sympathectomy is used for the upper limbs, **lumbar sympathectomy** is indicated for Raynaud’s phenomenon affecting the **lower limbs** (though less common). It works by reducing sympathetic tone, thereby preventing the vasospastic triggers that cause ischemia and pain. **Analysis of Incorrect Options:** * **Intermittent Claudication (A):** Sympathectomy primarily increases blood flow to the **skin**, not the muscles. Since claudication is a result of muscle ischemia during exercise, sympathectomy provides no clinical benefit. * **Buerger’s Disease / TAO (B & C):** While historically used for Buerger’s disease (Thromboangiitis obliterans), modern guidelines state it is **not** the primary indication. It is only considered a palliative measure for rest pain or small superficial ulcers when revascularization is impossible. It does not stop the progression of the disease, which is driven by inflammatory thrombosis. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** The most successful indication for lumbar sympathectomy is **distal vasospastic disorders** and **hyperhidrosis** of the soles. * **Anatomical Landmark:** The sympathetic chain lies on the bodies of lumbar vertebrae, medial to the Psoas major muscle. * **The "Rule of Skin":** Always remember that sympathectomy improves **cutaneous (skin) circulation** but has no effect on **collateral circulation** or **muscle blood flow**. * **Complication:** In males, bilateral excision of the L1 ganglion can lead to **loss of ejaculation** (retrograde ejaculation). Therefore, the L1 ganglion is usually preserved.

Question 300: Dacron is a type of graft. What is its classification?

A. Nontextile synthetic
B. Textile synthetic (Correct Answer)
C. Nontextile biologic
D. Textile biologic

Explanation: **Explanation:** Vascular grafts are categorized based on their material (synthetic vs. biologic) and their construction method (textile vs. nontextile). **1. Why "Textile Synthetic" is correct:** **Dacron** is the brand name for **polyethylene terephthalate (PET)**, a synthetic polyester. It is classified as a **textile** graft because it is constructed by interlacing yarns through either **knitting or weaving**. * **Knitted Dacron:** More flexible and porous; requires "pre-clotting" to prevent blood leakage through the interstices (though modern versions are often collagen-coated). * **Woven Dacron:** Stronger with smaller pores; used primarily for high-pressure areas like the thoracic aorta as it does not require pre-clotting. **2. Why other options are incorrect:** * **Nontextile synthetic:** This refers to **ePTFE (Expanded Polytetrafluoroethylene)**, commonly known as Gore-Tex. Unlike Dacron, ePTFE is manufactured by stretching a solid sheet of polymer to create a microporous structure, not by weaving fibers. * **Biologic grafts (Textile/Nontextile):** These are derived from living tissues. Examples include **Autografts** (Great Saphenous Vein), **Allografts** (cadaveric veins), or **Xenografts** (bovine pericardium). These are naturally occurring structures, not manufactured textiles. **High-Yield Clinical Pearls for NEET-PG:** * **Dacron** is the gold standard for **large-vessel** reconstruction (e.g., Aortic Aneurysms). * **ePTFE** is preferred for **smaller-diameter** peripheral bypasses when a suitable vein is unavailable. * **Infection Risk:** Synthetic grafts are highly susceptible to infection; in an infected field, autologous vein grafts are the preferred choice. * **Porosity:** Knitted grafts have higher porosity, promoting better "neointima" formation compared to woven grafts.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

Practice Questions

Venous Thromboembolism

Practice Questions

Chronic Venous Insufficiency

Practice Questions

Mesenteric Vascular Disease

Practice Questions

Vascular Trauma

Practice Questions

Vascular Access for Hemodialysis

Practice Questions

Endovascular Techniques

Practice Questions

Diabetic Foot Vascular Disease

Practice Questions

Vasculitis

Practice Questions

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