Vascular Surgery Practice Questions

Q: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Esmolol and urgent surgery. ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.

Q: A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?

Atherosclerosis. ***Atherosclerosis*** - The patient's advanced age (73), history of **smoking**, and **coronary artery disease** are all major risk factors for atherosclerosis, the most common cause of peripheral arterial disease (PAD). - The blackening of the toes is indicative of **dry gangrene**, a form of tissue necrosis resulting from severe, chronic ischemia due to atherosclerotic occlusion of the arteries supplying the foot. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic vasculitis that typically affects **young male smokers**, usually under the age of 45. - The patient's advanced age makes Buerger's disease a much less likely diagnosis compared to atherosclerosis. *Raynaud's disease* - Raynaud's disease is characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to distinct color changes (white, blue, and red), which is not the primary presentation here. - While severe secondary Raynaud's phenomenon can lead to gangrene, it is not the most probable cause in an elderly patient with multiple risk factors for atherosclerosis. *Giant cell arteritis* - This is a **large-vessel vasculitis** that typically affects patients over 50 and presents with symptoms like headache, jaw claudication, and visual disturbances. - While it can cause limb claudication, isolated digital gangrene is a very uncommon manifestation, and the patient's presentation is classic for atherosclerotic PAD.

Q: A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? ![img-25.jpeg](img-25.jpeg)

Atherosclerosis. ***Atherosclerosis*** - Atherosclerosis is the most common cause of **peripheral artery disease (PAD)** in patients over 50, leading to stenosis of arteries and causing symptoms like **claudication** (pain on exertion). - Severe, progressive disease results in **critical limb ischemia**, characterized by insufficient blood flow to meet metabolic demands at rest, which can lead to tissue necrosis and **gangrene** (blackening of the toes) as seen in the image. *Buerger's disease* - This condition, also known as **thromboangiitis obliterans**, is a non-atherosclerotic inflammatory vasculitis that typically affects **young male smokers** (usually under 45 years old). - It characteristically involves small-to-medium-sized arteries and veins and is often associated with superficial thrombophlebitis, which is not typical for this patient's demographic. *Raynaud's disease* - This is a functional vascular disorder characterized by episodic **vasospasm** of digital arteries, usually triggered by cold or stress, leading to well-demarcated color changes (white, blue, and red). - It does not cause claudication, which is a symptom of fixed arterial obstruction, and rarely results in the extensive, progressive gangrene seen in this case. *Giant cell arteritis* - This is a vasculitis of large and medium-sized arteries, primarily affecting branches of the **carotid artery** (e.g., temporal artery), leading to headache, jaw claudication, and visual loss. - While it can involve limb arteries, isolated severe lower limb ischemia with gangrene is an uncommon presentation; **atherosclerosis** is a far more frequent cause in this age group.

Q: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

0.3. ### **Explanation** The **Ankle-Brachial Pressure Index (ABPI)** is a non-invasive tool used to assess Peripheral Arterial Disease (PAD). It is calculated by dividing the higher systolic blood pressure at the ankle (PTA or DPA) by the higher systolic blood pressure of the arms. **1. Why 0.3 is the Correct Answer:** An ABPI of **<0.3** indicates **critical limb ischemia (CLI)** and **imminent gangrene**. At this level, the perfusion pressure is insufficient to maintain tissue viability even at rest. This stage is clinically characterized by **rest pain**, non-healing ischemic ulcers, and impending tissue necrosis (gangrene). **2. Analysis of Incorrect Options:** * **0.9 (Option B):** This is the lower limit of **normal**. An ABPI between 0.9 and 1.2 is considered healthy. Values between 0.7 and 0.9 indicate mild PAD, often asymptomatic. * **0.7 (Option C):** This indicates **mild to moderate PAD**. Patients at this level typically present with **intermittent claudication** (pain on walking that relieved by rest). * **0.5 (Option D):** This signifies **severe PAD**. While patients have significant symptoms and a high risk of cardiovascular events, "imminent gangrene" is specifically associated with values dropping below 0.4 or 0.3. --- ### **High-Yield Clinical Pearls for NEET-PG / INI-CET** * **ABPI Interpretation Summary:** * **>1.2:** Calcified, non-compressible vessels (commonly seen in **Diabetes Mellitus** and elderly patients). Use Toe-Brachial Index (TBI) instead. * **0.9 – 1.2:** Normal. * **0.5 – 0.9:** Intermittent Claudication. * **<0.4:** Rest Pain. * **<0.3:** Imminent Gangrene / Critical Limb Ischemia. * **Fontaine Classification:** Remember that ABPI <0.3 correlates with Fontaine Stage IV (Ulceration/Gangrene). * **Management Tip:** Patients with ABPI <0.5 or rest pain require urgent surgical or endovascular intervention to prevent limb loss.

Q: A 56-year-old man presents with the following pathology shown in the image, which of the following is correct?

Lipodermatosclerosis/eczema can occur. ***Lipodermatosclerosis/eczema can occurs*** - The image suggests features of **chronic venous insufficiency (CVI)**, including skin discoloration (hyperpigmentation/hemosiderin deposition) and induration, which are classic features leading to **lipodermatosclerosis** and **venous eczema** (C4 changes in CEAP classification). - Lipodermatosclerosis involves inflammation and fibrosis of the skin and subcutaneous fat in the gaiter area due to prolonged **venous hypertension**. *Sclerotherapy is the best treatment* - Sclerotherapy is typically indicated for **small varicose veins** or **telangiectasias**. - For CVI causing advanced skin changes (like lipodermatosclerosis), the best initial treatment is usually **compression therapy** and addressing the source of reflux (e.g., endovenous ablation). *Telangiectasia is rare* - **Telangiectasias** (spider veins) are very common in patients with CVI and often represent the earliest visible sign of **venous disease** (C1 in CEAP classification). - The presence of more advanced skin changes (like those shown) indicates significant venous hypertension, often accompanied by microcirculatory changes including telangiectasia. *No possibility of venous ulcer* - The changes seen (hyperpigmentation and probable underlying induration/atrophy) are stages C4/C5 of the CEAP classification, which are **immediate precursors** to or associated with **venous leg ulcers** (C6). - Venous hypertension is the underlying cause for both the skin changes and the development of **venous ulcers**, making the possibility very real in this patient.

Q: What is the most probable diagnosis of a patient whose clinical presentation is shown below?

Venous ulcer. ***Venous ulcer*** - The image shows a large, irregularly shaped ulcer on the medial aspect of the lower leg/ankle, surrounded by **hyperpigmentation** (hemosiderin staining) and **lipodermatosclerosis** (fibrosis and hardening of the skin), which are classic signs of chronic venous insufficiency. - The presence of **exudate** and a **granulating base** is also consistent with venous ulcers, often found in areas of venous stasis. *Diabetic foot* - Diabetic foot ulcers typically occur over **pressure points** on the plantar surface of the foot or toes (e.g., metatarsal heads, heels) and are often associated with **neuropathy** and ischemia. - They tend to have a **punched-out appearance** with **calloused borders** and are frequently painless due to neuropathy, which are not clearly evident here. *Arterial ulcer* - Arterial ulcers are typically found on the **distal extremities**, such as the toes, foot, or lateral malleolus, and are usually **painful**, especially at night or with elevation. - They often have a **"punched-out" appearance** with **pale, ischemic bases**, are surrounded by **atrophic skin**, and are associated with absent or diminished pulses, none of which are consistent with the image. *Buerger's foot* - Buerger's disease (**thromboangiitis obliterans**) is an inflammatory vasculitis primarily affecting small and medium-sized arteries and veins in the extremities, often presenting with **severe pain**, **ischemic ulcers** on digits, and **gangrene**, usually in young male smokers. - The widespread superficial changes and location on the lower leg/ankle, rather than digits, differentiate this presentation from Buerger's disease.

Q: Identify the type of ulcer shown on the heel of the foot.

Arterial ulcer. ***Correct Option: Arterial ulcer*** - Arterial ulcers are typically found on the **distal parts of the extremities**, such as the toes, feet, and bony prominences like the heel, where blood supply is most compromised. - They often appear as **punched-out lesions** with a pale, necrotic base, minimal granulation tissue, and **well-demarcated edges**, as seen in the image. - Clinical features include **pain** (especially at rest or elevation), **pale or cyanotic skin**, **absent pulses**, and **hair loss** over the affected area. *Incorrect Option: Venous ulcer* - Venous ulcers usually occur around the **medial malleolus (ankle bone)**, not typically on the heel. - They present with an **irregular shape**, a red, granular base, and are surrounded by **edematous, hyperpigmented skin** (brawny edema), which is not visible here. - Associated features include **varicose veins**, **edema**, and **lipodermatosclerosis**. *Incorrect Option: Neuropathic ulcer* - Neuropathic ulcers commonly develop on the **pressure points of the foot**, such as the plantar surface (sole) or under the metatarsal heads, in patients with peripheral neuropathy (e.g., diabetes). - They often have a **callused rim** and are **painless** due to nerve damage, and are not typically seen on the heel in this manner. - The heel can be affected in neuropathic ulcers, but they present with surrounding callus and occur at pressure-bearing areas. *Incorrect Option: Bazin's ulcer* - Bazin's ulcer, or erythema induratum, is a form of **panniculitis** (inflammation of subcutaneous fat) that typically affects the **calves of young to middle-aged women**. - It presents as multiple, tender, subcutaneous nodules that can ulcerate, which is a different clinical picture than the focal, well-defined ulcer on the heel shown. - Historically associated with **tuberculosis**, though most cases are now idiopathic.

Q: The following test was performed on the patient. Which is correct about the patient?

Pain decreases on standing still. ***Pain decreases on standing still*** - The image depicts the measurement of **Ankle-Brachial Index (ABI)**, a diagnostic test for **Peripheral Artery Disease (PAD)**. - **Intermittent claudication** is the hallmark symptom of PAD, characterized by cramping pain in the legs that develops **after walking a certain distance** and is **relieved by rest** (standing still). - This occurs because the narrowed arteries cannot supply adequate blood flow during exercise, causing muscle ischemia and pain that resolves when activity ceases. *Pain is present on first step of walking* - This is **incorrect** for claudication, which requires time to develop as muscles become ischemic during sustained activity. - Pain on the **first step** would suggest **musculoskeletal pathology** (arthritis, plantar fasciitis) or **neurological issues** (nerve compression), not vascular claudication. - Claudication distance is a key diagnostic feature - patients can walk a reproducible distance before pain begins. *Pain is present at rest* - **Rest pain** indicates **critical limb ischemia**, a severe form of PAD where blood flow is inadequate even at rest. - This represents advanced arterial disease beyond simple claudication and requires urgent evaluation for revascularization. - Rest pain typically affects the forefoot and is worse at night when lying flat. *Pain increases on limb dependency* - Actually, **limb dependency (hanging the leg down)** typically **relieves pain** in severe PAD by using gravity to improve distal perfusion. - Patients with critical limb ischemia often sleep with legs dependent or dangle feet off the bed for relief. - This is opposite to **venous insufficiency**, where elevation improves symptoms.

Question 1

A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Accepted Answer

Esmolol and urgent surgery

Answer

Urgent surgery

Answer

Blood transfusion

Answer

Wait and watch

Question 2

A 73 year old male smoker with a past history of coronary artery disease presents with blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis?

Accepted Answer

Atherosclerosis

Answer

Giant cell arteritis

Answer

Buerger's disease

Answer

Raynaud's disease

Question 3

A 60-year-old male presents with claudication and blackening of the toes. An image of the foot is shown below. What is the most likely diagnosis? ![img-25.jpeg](img-25.jpeg)

Accepted Answer

Atherosclerosis

Answer

Buerger's disease

Answer

Raynaud's disease

Answer

Giant cell arteritis

Question 4

Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

Accepted Answer

0.3

Answer

0.9

Answer

0.7

Answer

0.5

Question 5

A 56-year-old man presents with the following pathology shown in the image, which of the following is correct?

Accepted Answer

Lipodermatosclerosis/eczema can occur

Answer

Sclerotherapy is the best treatment

Answer

Telangiectasia is rare

Answer

No possibility of venous ulcer

Question 6

History of pulsatile mass in the neck. Digital angiography image shown. Not filling on carotid compression. But refilling on releasing pressure. What is the diagnosis?

Accepted Answer

Carotid Body tumour

Answer

Haemangioma

Answer

Carotid Aneurysm

Answer

AV fistula

Question 7

What is the most probable diagnosis of a patient whose clinical presentation is shown below?

Accepted Answer

Venous ulcer

Answer

Diabetic foot

Answer

Arterial ulcer

Answer

Buerger's foot

Question 8

Identify the type of ulcer shown on the heel of the foot.

Accepted Answer

Arterial ulcer

Answer

Venous ulcer

Answer

Neuropathic ulcer

Answer

Bazin's ulcer

Question 9

The following test was performed on the patient. Which is correct about the patient?

Accepted Answer

Pain decreases on standing still

Answer

Pain is present at rest

Answer

Pain is present on first step of walking

Answer

Pain increases on limb dependency

Question 10

Which one of the following is correct regarding splenic artery aneurysm?

Accepted Answer

It is most commonly located in the middle third of the splenic artery.

Answer

It is generally multiple in number.

Answer

It is caused due to blunt trauma to the abdomen.

Answer

It is twice as common in men.

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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