Vascular Surgery — MCQs

A 30-year-old construction worker presented with exertional pain in his bilateral forearms and hands. There is a history of chronic cigarette smoking. On examination, faint radial and ulnar pulses were noted, with easily palpable brachial pulses. Angiography of the hand was performed. Which of the following is the best treatment for this condition?

Q329Easy

Fogarty's catheter is used for what purpose?

Q330Medium

Left sided portal hypertension is best treated by:

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 321: What is the treatment of femoral artery aneurysm?

A. Ultrasound-guided compression of the neck of the aneurysm
B. Thrombin injection
C. Bypass graft repair
D. All of the above (Correct Answer)

Explanation: **Explanation:** The management of femoral artery aneurysms depends on whether the aneurysm is **true** (involving all three layers of the arterial wall) or a **pseudoaneurysm** (false aneurysm, usually iatrogenic following catheterization). 1. **Bypass Graft Repair (Option C):** This is the gold standard for **true femoral artery aneurysms**. Because of the risk of thromboembolism and limb ischemia, symptomatic aneurysms or those >2.5 cm are treated surgically by excluding the aneurysm and restoring blood flow via a synthetic (PTFE/Dacron) or autologous vein graft. 2. **Ultrasound-guided Compression (Option A) & Thrombin Injection (Option B):** These are the primary treatments for **femoral pseudoaneurysms**. * **Compression:** Applying pressure to the "neck" of the pseudoaneurysm under USG guidance induces thrombosis within the sac. * **Thrombin Injection:** Currently the preferred minimally invasive method, where bovine thrombin is injected into the sac to cause immediate clotting. Since the question asks for the treatment of "femoral artery aneurysm" generally (covering both true and pseudo-types), **all of the above** are valid therapeutic modalities. **Clinical Pearls for NEET-PG:** * **Most common site:** The common femoral artery is the most frequent site for peripheral artery pseudoaneurysms (post-angioplasty). * **True Aneurysms:** Often associated with **Aortic Aneurysms** (50% of cases) and are frequently **bilateral** (50-70%). * **Complications:** Unlike AAA (which ruptures), peripheral aneurysms like femoral or popliteal aneurysms more commonly lead to **thrombosis and distal embolization** ("Blue Toe Syndrome"). * **Popliteal Aneurysm:** The most common peripheral true aneurysm; the "Rule of 50s" applies (50% bilateral, 50% associated with AAA).

Question 322: What does Grade I lymphedema mean?

A. Pitting edema up to the ankle
B. Pitting edema up to the knee
C. Non-pitting edema
D. Edema disappearing after overnight rest (Correct Answer)

Explanation: ### Explanation Lymphedema is classified based on the clinical progression of lymphatic insufficiency. The correct answer is **Option D** because Grade I lymphedema is characterized by its **reversibility**. #### 1. Why Option D is Correct **Grade I (Spontaneous Reversible Stage)** represents the earliest clinical stage of lymphedema. At this stage, there is an accumulation of protein-rich fluid, but tissue fibrosis has not yet occurred. The hallmark of Grade I is that the edema is **pitting** and **disappears or significantly reduces with limb elevation or overnight rest**. #### 2. Why Other Options are Incorrect * **Options A & B:** The grading of lymphedema is based on the **pathophysiological state of the tissue** (pitting vs. non-pitting, reversibility, and skin changes) rather than the anatomical height (ankle vs. knee) of the swelling. * **Option C:** **Non-pitting edema** is characteristic of **Grade II and Grade III**. As the disease progresses, chronic inflammation leads to the deposition of fat and connective tissue (fibrosis). Once fibrosis sets in, the edema becomes "brawny" and no longer pits on pressure. #### 3. Clinical Pearls for NEET-PG (ISL Staging) The International Society of Lymphology (ISL) staging is high-yield for exams: * **Stage 0 (Latent):** Subclinical state; lymphatic transport is impaired, but no visible edema is present. * **Stage I (Reversible):** Pitting edema; subsides with elevation. * **Stage II (Irreversible):** Non-pitting edema; does not resolve with elevation; early fibrosis. * **Stage III (Lymphostatic Elephantiasis):** Severe non-pitting edema with significant skin changes (acanthosis, thickening, warty overgrowths/papillomatosis). **Key Diagnostic Note:** The **Stemmer’s Sign** (inability to pinch a fold of skin at the base of the second toe) is a classic clinical test for diagnosing lymphedema.

Question 323: What is true about primary lymphedema?

A. Lymphangiosarcoma may occur (Correct Answer)
B. Associated with Milroy's disease
C. Onset between 2-35 years indicates lymphedema tarda
D. Onset greater than 35 years indicates praecox variety

Explanation: **Explanation:** Primary lymphedema results from congenital developmental abnormalities of the lymphatic system (hypoplasia, hyperplasia, or aplasia). **1. Why Option A is correct:** **Lymphangiosarcoma** (Stewart-Treves Syndrome) is a rare, highly aggressive malignancy that develops in the setting of long-standing chronic lymphedema. While more commonly associated with post-mastectomy secondary lymphedema, it is a recognized, albeit rare, complication of primary lymphedema. **2. Analysis of Incorrect Options:** * **Option B:** While Milroy’s disease is a type of primary lymphedema, the statement is technically incomplete or less "true" as a general rule compared to the risk of malignancy. However, in many competitive exams, this is a distractor because primary lymphedema is a *category*, and Milroy is just one *subtype* (congenital). * **Option C & D (Classification by Age of Onset):** These options swap the definitions. * **Lymphedema Congenita:** Present at birth (e.g., Milroy’s disease). * **Lymphedema Praecox:** Onset between **puberty and age 35** (most common type, often associated with Meige’s disease). * **Lymphedema Tarda:** Onset **after age 35**. **Clinical Pearls for NEET-PG:** * **Most common type:** Lymphedema Praecox (80% of primary cases), predominantly affecting females. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic physical finding. * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for diagnosing structural and functional lymphatic defects. * **Management:** Initial treatment is conservative (Complex Decongestive Therapy). Surgery (e.g., Charles procedure or lymphovenous anastomosis) is reserved for refractory cases.

Question 324: What is the primary treatment for an acute femoral embolus?

A. Warfarin
B. Heparin
C. Immediate embolectomy (Correct Answer)
D. Embolectomy after 5 days of bed rest

Explanation: **Explanation:** Acute limb ischemia (ALI) caused by an arterial embolus is a surgical emergency. The primary goal of treatment is the immediate restoration of blood flow to prevent irreversible tissue necrosis, nerve damage, and limb loss. **Why Immediate Embolectomy is Correct:** The femoral artery is the most common site for peripheral arterial emboli. Once the diagnosis is made clinically (the "6 Ps": Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia), **immediate surgical embolectomy** using a **Fogarty balloon catheter** is the gold standard. This procedure rapidly removes the mechanical obstruction, minimizing the "warm ischemia time." **Why Other Options are Incorrect:** * **Warfarin (A):** This is an oral anticoagulant used for long-term prophylaxis (e.g., preventing future clots in patients with Atrial Fibrillation). It takes days to reach therapeutic levels and has no role in the acute clearance of an existing large-vessel embolus. * **Heparin (B):** While IV Heparin is initiated immediately to prevent *propagation* of the clot and distal thrombosis, it does not dissolve the existing embolus. It is an adjunct to surgery, not the definitive primary treatment for a major femoral embolus. * **Embolectomy after 5 days (D):** Delaying surgery is contraindicated. Irreversible muscle damage begins within 4–6 hours of total ischemia. Waiting 5 days would invariably lead to gangrene and necessitate amputation. **NEET-PG High-Yield Pearls:** * **Golden Period:** Revascularization should ideally occur within **6 hours** to salvage the limb. * **Fogarty Catheter:** Always remember this name; it is the specific instrument used for embolectomy. * **Most Common Source:** Most systemic emboli originate from the **heart** (usually due to Atrial Fibrillation or post-MI mural thrombi). * **Post-Op Complication:** Be alert for **Reperfusion Injury**, which can lead to Compartment Syndrome, hyperkalemia, and myoglobinuria (acute renal failure).

Question 325: Lumbar sympathectomy is not indicated in which of the following conditions?

A. Healing of ulcer over great toe
B. Claudication (Correct Answer)
C. Rest pain
D. Buerger's disease

Explanation: **Explanation:** Lumbar sympathectomy involves the excision of the 2nd, 3rd, and 4th lumbar sympathetic ganglia. The primary physiological effect is the removal of sympathetic vasoconstrictor tone, leading to **vasodilation of the cutaneous (skin) vasculature**. **Why Claudication is the Correct Answer:** Intermittent claudication is caused by ischemia in the **skeletal muscles** during exercise. Lumbar sympathectomy primarily increases blood flow to the skin, not the deep muscle beds. In fact, it may worsen claudication by causing a "steal phenomenon," where blood is diverted from the relatively ischemic muscles to the dilated cutaneous vessels. Therefore, it is not indicated for claudication. **Analysis of Other Options:** * **Healing of ulcer (Option A):** By increasing cutaneous blood flow, sympathectomy improves the microcirculation required for the healing of small, superficial ischemic ulcers. * **Rest pain (Option B):** It is indicated for the relief of rest pain in patients with non-reconstructable arterial disease, as it helps improve skin perfusion and provides a degree of sympathetic denervation (pain relief). * **Buerger’s disease (Option D):** Also known as Thromboangiitis Obliterans (TAO), this condition primarily affects distal small and medium-sized vessels. Lumbar sympathectomy is a classic palliative treatment for TAO to improve distal skin circulation and manage pain. **High-Yield Pearls for NEET-PG:** * **Primary Indication:** Distal ischemia (skin) where bypass surgery is not feasible. * **Level of Ganglionectomy:** L2-L4 is standard. L1 is preserved in males to prevent **loss of ejaculation**. * **Predictive Test:** A successful chemical sympathetic block (using phenol or alcohol) before surgery indicates a likely positive surgical outcome. * **Rule of Thumb:** Sympathectomy helps the **skin**, not the **muscle**.

Question 326: Milroy's disease is an example of:

A. Primary lymphedema (Correct Answer)
B. Secondary lymphedema
C. Both
D. None

Explanation: **Explanation:** **Milroy’s disease** is a classic example of **Primary Lymphedema**. It is a congenital condition, typically inherited in an autosomal dominant fashion, characterized by the malformation or hypoplasia of lymphatic vessels. 1. **Why Option A is correct:** Primary lymphedema occurs due to intrinsic genetic or developmental defects in the lymphatic system. Milroy’s disease is specifically categorized as **Congenital Lymphedema (Type I)** because it is present at birth or manifests within the first year of life. It is frequently associated with mutations in the **VEGFR-3** gene, leading to lymphatic hypoplasia. 2. **Why Option B is incorrect:** Secondary lymphedema is caused by extrinsic factors that damage an otherwise normal lymphatic system. The most common cause worldwide is **Filariasis** (*Wuchereria bancrofti*), while in developed nations, it is most commonly due to malignancy or post-surgical lymph node dissection (e.g., post-mastectomy). 3. **Why Options C & D are incorrect:** Milroy’s disease has a specific genetic etiology, placing it strictly within the primary category. **High-Yield Clinical Pearls for NEET-PG:** * **Classification of Primary Lymphedema:** * **Milroy’s Disease:** Congenital (at birth); VEGFR-3 mutation. * **Meige’s Disease (Lymphedema Praecox):** Most common primary type; manifests at puberty; FOXC2 mutation. * **Lymphedema Tarda:** Manifests 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 diagnostic clinical finding for lymphedema. * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for evaluating the lymphatic system.

Question 327: A 72-year-old woman presents with a fall after an episode of dizziness, accompanied by 3 days of low-back pain. She is hypotensive and has cold, clammy extremities. A pulsating mass is palpable on abdominal examination. Following resuscitation, what is the next most appropriate step in management?

A. Peritoneal lavage
B. Immediate abdominal exploration (Correct Answer)
C. CT scan of the abdomen
D. Abdominal aortogram

Explanation: **Explanation:** The clinical presentation of a **pulsatile abdominal mass, hypotension (shock), and back pain** in an elderly patient is the classic triad of a **Ruptured Abdominal Aortic Aneurysm (AAA)**. This is a surgical emergency with extremely high mortality. **1. Why Immediate Abdominal Exploration is Correct:** In a patient with a suspected ruptured AAA who is **hemodynamically unstable** (hypotension, cold/clammy extremities), time is the most critical factor. Resuscitation should occur simultaneously with immediate transfer to the operating room for a laparotomy to control the aorta. Delaying surgery for imaging increases the risk of exsanguination and death. **2. Why Other Options are Incorrect:** * **CT scan of the abdomen:** While CT is the gold standard for diagnosing an intact AAA or a stable leak, it is **contraindicated** in an unstable patient. Moving an unstable patient to the radiology suite can be fatal. * **Abdominal aortogram:** This is an invasive procedure used for planning endovascular repair (EVAR) in stable patients. It has no role in the emergency management of a ruptured AAA in an unstable patient. * **Peritoneal lavage (DPL):** This is used to detect hemoperitoneum in blunt abdominal trauma. In this case, the diagnosis is clinically evident, and DPL would waste time and potentially miss a retroperitoneal bleed. **Clinical Pearls for NEET-PG:** * **Classic Triad of Ruptured AAA:** Hypotension, back/flank pain, and a pulsatile mass (present in <50% of cases). * **Management Rule:** Stable patient → CT Scan; Unstable patient → Immediate Surgery. * **Most common site:** Infrarenal (90% of AAAs). * **Screening:** USG is the investigation of choice for screening; CT is best for preoperative planning.

Question 328: A 30-year-old construction worker presented with exertional pain in his bilateral forearms and hands. There is a history of chronic cigarette smoking. On examination, faint radial and ulnar pulses were noted, with easily palpable brachial pulses. Angiography of the hand was performed. Which of the following is the best treatment for this condition?

A. Enoxaparin
B. Prednisolone
C. Warfarin
D. Smoking cessation (Correct Answer)

Explanation: ***Smoking cessation*** - This is **Buerger's disease** (thromboangiitis obliterans), a condition almost exclusively seen in **young male smokers** with distal limb ischemia. - **Smoking cessation** is the only definitive treatment that can halt disease progression and prevent further vascular occlusion, as continued smoking leads to irreversible vessel damage. *Enoxaparin* - **Low molecular weight heparin** is not effective in Buerger's disease as this is primarily an **inflammatory vasculitis** rather than a thrombotic condition. - The pathophysiology involves **segmental inflammation** of small and medium arteries, not typical thromboembolic disease requiring anticoagulation. *Prednisolone* - **Corticosteroids** have limited efficacy in Buerger's disease and are not considered first-line treatment. - While inflammation is present, the primary driver is **tobacco use**, and immunosuppression does not address the underlying cause or significantly improve outcomes. *Warfarin* - **Oral anticoagulation** is ineffective in treating the underlying **thromboangiitis obliterans** pathology. - The characteristic **corkscrew collaterals** and **segmental vessel occlusion** seen on angiography are due to inflammatory vessel wall changes, not embolic phenomena requiring anticoagulation.

Question 329: Fogarty's catheter is used for what purpose?

A. Drainage of the urinary bladder
B. Parenteral hyperalimentation
C. Removal of embolus from blood vessels (Correct Answer)
D. Ureteric catheterization

Explanation: ### Explanation **Correct Answer: C. Removal of embolus from blood vessels** The **Fogarty catheter** is a specialized balloon-tipped catheter designed specifically for **embolectomy** or thrombectomy. **Mechanism:** The catheter is inserted into an artery and advanced past the site of the clot (embolus). Once distal to the obstruction, the balloon at the tip is inflated with saline or air. The catheter is then slowly withdrawn; the inflated balloon "sweeps" the embolus out of the vessel through the arteriotomy site, restoring blood flow. This is the gold-standard surgical treatment for **Acute Limb Ischemia (ALI)**. --- ### Analysis of Incorrect Options: * **A. Drainage of the urinary bladder:** This is typically performed using a **Foley catheter** (self-retaining) or a **Nelaton catheter** (straight drainage). * **B. Parenteral hyperalimentation:** This requires a **Central Venous Catheter (CVC)** or a PICC line to deliver Total Parenteral Nutrition (TPN) into high-flow veins. * **D. Ureteric catheterization:** This involves specialized **Double-J (DJ) stents** or ureteric catheters used during cystoscopy to bypass obstructions or identify ureters during surgery. --- ### High-Yield Clinical Pearls for NEET-PG: * **Inventor:** Developed by **Thomas J. Fogarty** in 1961. * **Sizing:** Fogarty catheters are sized using the **French (F) scale**. Common sizes include 3F (for posterior tibial/ulnar arteries), 4F (for brachial/popliteal), and 5F/6F (for femoral/iliac). * **Color Coding:** They are often color-coded by size (e.g., 2F is transparent, 3F is green, 4F is red, 5F is white). * **Complications:** The most common complications include **intimal injury (dissection)**, vessel rupture, or distal embolization of fragments. * **Triple-Lumen Fogarty:** Some variants allow for distal heparin injection or angiography while the balloon is in place.

Question 330: Left sided portal hypertension is best treated by:

A. Splenectomy (Correct Answer)
B. Portocaval shunt
C. Lienorenal shunt
D. Splenorenal shunt

Explanation: **Explanation:** **Left-sided portal hypertension** (also known as **Sinistral Portal Hypertension**) is a unique clinical entity where portal hypertension is localized to the splenic portion of the portal venous system. **1. Why Splenectomy is the Correct Answer:** The underlying pathophysiology is almost always **Splenic Vein Thrombosis (SVT)**, most commonly secondary to chronic pancreatitis, pancreatic pseudocysts, or pancreatic tumors. Because the splenic vein is blocked, blood from the spleen is diverted through the short gastric veins into the gastric fundus, leading to **isolated gastric varices** (with a normal liver and patent portal vein). Since the spleen is the "source" of the increased venous pressure in this localized circuit, a **Splenectomy** is curative. It removes the high-pressure inflow and effectively decompresses the gastric varices. **2. Why Incorrect Options are Wrong:** * **Portocaval, Lienorenal, and Splenorenal shunts (B, C, D):** These are surgical decompression procedures used for **generalized portal hypertension** (e.g., Cirrhosis). In left-sided portal hypertension, the systemic portal pressure is normal, and the liver function is preserved. Performing a major shunt is unnecessary, overly invasive, and fails to address the localized pathology of the splenic vein. **3. Clinical Pearls for NEET-PG:** * **Classic Triad:** Isolated gastric varices (without esophageal varices), splenomegaly, and normal liver function tests. * **Most Common Cause:** Chronic Pancreatitis (due to the proximity of the splenic vein to the pancreas). * **Key Diagnostic Finding:** "Isolated Gastric Varices" on endoscopy is a major red flag for SVT. * **Treatment Rule:** If the patient is asymptomatic, observation may be considered; however, if bleeding occurs, **Splenectomy** is the gold standard treatment.

Practice by Chapter

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Chronic Venous Insufficiency

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Vascular Trauma

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