Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 331: Bisgard treatment is indicated for which of the following conditions?

A. Aerial ulcer
B. Venous ulcer (Correct Answer)
C. Thromboangiitis obliterans (TAO)
D. Raynaud's phenomenon

Explanation: **Explanation:** **Bisgard’s Method** is a conservative management strategy specifically designed for **Venous Ulcers** (stasis ulcers). The treatment is based on the principle of reducing venous hypertension and improving calf muscle pump efficiency. It involves a combination of: 1. **Elevation:** Keeping the limb elevated above the level of the heart to facilitate venous drainage. 2. **Compression:** Using elastic bandages or Unna boots to reduce edema. 3. **Exercise:** Active ankle movements to activate the "peripheral heart" (calf muscles). **Analysis of Options:** * **Option A (Arterial Ulcer):** These are caused by ischemia. Elevation (a key part of Bisgard's) is contraindicated here as it further reduces arterial perfusion, worsening the pain. * **Option C (TAO/Buerger’s Disease):** This is an inflammatory occlusive disease of small/medium arteries. Management focuses on smoking cessation and lumbar sympathectomy, not venous decompression. * **Option D (Raynaud’s Phenomenon):** This is a vasospastic disorder. Treatment involves avoiding cold triggers and using calcium channel blockers, not mechanical venous drainage. **High-Yield Clinical Pearls for NEET-PG:** * **Venous Ulcers:** Typically located at the **"Gaiter Zone"** (medial malleolus). They are usually painless (unless infected) and shallow with irregular borders. * **Standard of Care:** While Bisgard’s is a classic description, the modern "Gold Standard" for venous ulcer healing is **Four-layer compression bandaging**. * **Marjolin’s Ulcer:** Always remember that a long-standing non-healing venous ulcer can undergo malignant transformation into Squamous Cell Carcinoma.

Question 332: What is the most common site of aortic dissection?

A. Ascending aorta (Correct Answer)
B. Descending aorta
C. Arch of aorta
D. Infrarenal portion of aorta

Explanation: **Explanation:** Aortic dissection occurs when a tear in the inner layer of the aorta (tunica intima) allows blood to surge between the layers of the aortic wall, creating a false lumen. **Why the Ascending Aorta is Correct:** The **ascending aorta** (specifically just above the aortic valve/sinotubular junction) is the most common site for the initial intimal tear, accounting for approximately **65-70% of cases**. This is primarily due to the high hemodynamic stress and maximum "dP/dt" (rate of rise of pressure) exerted by the left ventricle directly onto this segment. In the Stanford classification, these are categorized as **Type A** dissections, which are surgical emergencies. **Analysis of Incorrect Options:** * **Descending Aorta:** This is the second most common site (Stanford Type B), typically occurring just distal to the origin of the left subclavian artery. It accounts for about 25-30% of cases and is often managed medically unless complications arise. * **Arch of Aorta:** While the dissection can involve the arch, it is rarely the primary site of the initial intimal tear compared to the ascending or descending segments. * **Infrarenal portion of aorta:** This is the most common site for **Atherosclerotic Aortic Aneurysms**, but it is an extremely rare site for the initiation of an aortic dissection. **High-Yield Clinical Pearls for NEET-PG:** * **Most common risk factor:** Hypertension (found in >70% of patients). * **Genetic association:** Marfan Syndrome is the most common predisposing connective tissue disorder (especially in younger patients). * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice in hemodynamically stable patients. * **DeBakey Classification:** Type I (Ascending + Descending), Type II (Ascending only), Type III (Descending only). * **Stanford Classification:** Type A (Involves Ascending aorta), Type B (Does not involve Ascending aorta).

Question 333: What is the most common site of aortic aneurysm rupture?

A. Descending thoracic aorta
B. Aortic arch
C. Aortic root
D. Infrarenal aorta (Correct Answer)

Explanation: **Explanation** The correct answer is **D. Infrarenal aorta.** **Why it is correct:** Abdominal Aortic Aneurysms (AAA) are significantly more common than thoracic aneurysms, and approximately **90-95% of AAAs occur in the infrarenal segment** (below the origin of the renal arteries). This area is anatomically predisposed to aneurysm formation and subsequent rupture due to: 1. **Reduced Elastin:** There is a progressive decrease in the elastin-to-collagen ratio from the proximal to the distal aorta. 2. **Vasa Vasorum Deficiency:** The infrarenal aorta has fewer vasa vasorum in the tunica media compared to the thoracic aorta, making it more dependent on luminal diffusion and more susceptible to ischemic weakening. 3. **Reflected Pressure Waves:** Hemodynamic stress is higher at the aortic bifurcation. **Why the other options are incorrect:** * **A. Descending thoracic aorta:** While common in the context of aortic dissections (Stanford Type B), it is a less frequent site for degenerative aneurysmal rupture compared to the infrarenal segment. * **B. Aortic arch & C. Aortic root:** These sites are more commonly associated with genetic connective tissue disorders (e.g., Marfan syndrome) or syphilis. While life-threatening, they represent a much smaller percentage of total aortic aneurysm ruptures in the general population. **High-Yield Clinical Pearls for NEET-PG:** * **Risk Factors:** Smoking is the strongest risk factor for AAA development and rupture. * **Screening:** USG is the investigation of choice for screening; CT Angiography is the gold standard for surgical planning. * **Rupture Triad:** Hypotension, pulsatile abdominal mass, and back/abdominal pain. * **Surgical Threshold:** Intervention (EVAR or Open Repair) is generally indicated when the diameter exceeds **5.5 cm in men** or **5.0 cm in women**, or if it grows >0.5 cm in 6 months.

Question 334: What ankle-brachial index indicates imminent necrosis?

A. Greater than 1
B. 0.8-1.0
C. 0.5-0.8
D. Less than 0.3 (Correct Answer)

Explanation: **Explanation:** The Ankle-Brachial Index (ABI) 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. **Why D is correct:** An **ABI < 0.3** indicates **Critical Limb Ischemia (CLI)**. At this level, the resting perfusion pressure is insufficient to maintain tissue viability. This leads to rest pain, ischemic ulceration, and **imminent necrosis or gangrene**. This is a surgical emergency requiring urgent revascularization to prevent amputation. **Analysis of Incorrect Options:** * **A. Greater than 1:** This is considered normal (1.0–1.4). However, values >1.4 suggest non-compressible, calcified vessels (Mönckeberg’s arteriosclerosis), commonly seen in diabetics. * **B. 0.8–1.0:** This range represents normal to very mild arterial disease, usually asymptomatic. * **C. 0.5–0.8:** This indicates **claudication**. Patients typically experience pain during exercise (e.g., walking) that is relieved by rest, but tissue necrosis is not yet imminent. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ABI:** 1.0 – 1.4. * **Intermittent Claudication:** ABI 0.5 – 0.9. * **Rest Pain:** ABI 0.3 – 0.5. * **Gangrene/Necrosis:** ABI < 0.3. * **Treadmill Test:** Used if ABI is normal but claudication is clinically suspected; a drop in ABI after exercise confirms PAD. * **Toe-Brachial Index (TBI):** More reliable than ABI in diabetic patients with calcified, non-compressible vessels.

Question 335: Calf compartment pressure rises to _________ on walking?

A. 20-30 mmHg
B. 60-80 mmHg
C. 80-100 mmHg
D. 200-300 mmHg (Correct Answer)

Explanation: ### Explanation **The Correct Answer is D: 200-300 mmHg** **Underlying Medical Concept:** The calf muscles (gastrocnemius and soleus) act as the **"Peripheral Heart."** During walking, the contraction of these muscles within the tight, non-distensible deep fascia of the leg creates a powerful pumping mechanism. This contraction significantly increases the intramuscular pressure to levels between **200-300 mmHg**. This high pressure is physiological and essential to overcome gravity, compress the deep veins, and propel venous blood upward toward the heart. Once the muscle relaxes, the pressure drops, allowing blood to flow from the superficial system to the deep system via perforators. **Analysis of Incorrect Options:** * **Option A (20-30 mmHg):** This represents the normal resting pressure of a muscle compartment. If resting pressure exceeds 30 mmHg persistently, it is suggestive of **Compartment Syndrome**. * **Option B & C (60-100 mmHg):** While these pressures are higher than resting levels, they are insufficient to effectively empty the deep venous system against the hydrostatic pressure of the blood column in a standing adult. **High-Yield Clinical Pearls for NEET-PG:** * **Venous Pump Efficiency:** A normal calf muscle pump can reduce the venous pressure at the ankle from 90 mmHg (standing) to less than 30 mmHg during walking. * **Ambulatory Venous Hypertension:** Failure of this pump (due to muscle weakness or valvular incompetence) leads to chronic venous insufficiency and venous ulcers. * **Compartment Syndrome:** Diagnosis is clinical, but a **Delta pressure** (Diastolic BP minus Compartment pressure) of **<30 mmHg** is a strong indication for fasciotomy. * **Deep Posterior Compartment:** This is the most common site for compartment syndrome in the leg.

Question 336: An IVC filter is indicated in all of the following conditions except?

A. Massive emboli
B. Negligible size of emboli (Correct Answer)
C. Repeated emboli
D. None of the above

Explanation: **Explanation:** The primary purpose of an **Inferior Vena Cava (IVC) filter** is to provide a mechanical barrier that prevents large, clinically significant thrombi from traveling from the lower extremities or pelvis to the pulmonary arteries. **1. Why "Negligible size of emboli" is the correct answer:** IVC filters are designed to trap large clots that could cause hemodynamic instability or death. If emboli are of "negligible size," they are unlikely to cause significant pulmonary compromise. Furthermore, the risks associated with filter insertion (such as IVC thrombosis, migration, or perforation) outweigh the benefits when the embolic burden is clinically insignificant. **2. Analysis of Incorrect Options:** * **Massive emboli:** This is a classic indication. If a patient has already suffered a massive pulmonary embolism (PE) and has a remaining proximal DVT, a filter is often indicated to prevent a second, potentially fatal event, especially if anticoagulation is contraindicated or has failed. * **Repeated emboli:** Recurrent PE despite adequate therapeutic anticoagulation is a **standard absolute indication** for IVC filter placement. It signifies "breakthrough" embolization that medical management cannot control. **Clinical Pearls for NEET-PG:** * **Absolute Indications:** 1. Contraindication to anticoagulation (e.g., active bleeding, recent neurosurgery). 2. Complications of anticoagulation (e.g., heparin-induced thrombocytopenia). 3. Failure of anticoagulation (recurrent PE despite therapeutic levels). * **Relative Indications:** Large free-floating iliocaval thrombus, prophylaxis in high-risk trauma/orthopedic patients, or patients with limited cardiopulmonary reserve. * **Placement:** Usually placed at the level of **L2-L3**, just below the opening of the renal veins, to prevent renal vein thrombosis. * **Complication:** The most common long-term complication of an IVC filter is an **increased risk of DVT** due to stasis at the filter site.

Question 337: What is the most common cause of lymphedema of the upper limb?

A. Filariasis
B. Bacterial infection
C. Congenital anomaly
D. Post mastectomy (Correct Answer)

Explanation: **Explanation:** Lymphedema is the accumulation of protein-rich fluid in the interstitial space due to impaired lymphatic drainage. It is classified into primary (congenital) and secondary (acquired) causes. **Why "Post mastectomy" is correct:** In the context of the **upper limb**, secondary lymphedema is far more common than primary causes. Globally, and specifically in clinical practice, the most frequent cause of upper limb lymphedema is **iatrogenic injury** following breast cancer surgery. This occurs due to **Axillary Lymph Node Dissection (ALND)** or radiotherapy to the axilla, which disrupts the lymphatic channels draining the arm. While Sentinel Lymph Node Biopsy (SLNB) has reduced the incidence, post-mastectomy lymphedema remains the leading cause for this specific anatomical site. **Analysis of Incorrect Options:** * **Filariasis (Option A):** While *Wuchereria bancrofti* is the most common cause of secondary lymphedema **worldwide**, it predominantly affects the **lower limbs** and scrotum due to gravity and the tropism of the parasite for inguinal/pelvic nodes. * **Bacterial infection (Option B):** Recurrent cellulitis or lymphangitis can damage lymphatic vessels (leading to a vicious cycle of worsening edema), but it is usually a *complication* or secondary factor rather than the primary underlying cause. * **Congenital anomaly (Option C):** Primary lymphedema (e.g., Milroy’s disease, Lymphedema praecox) is rare compared to acquired causes and more frequently involves the lower extremities. **Clinical Pearls for NEET-PG:** * **Most common cause of lymphedema worldwide:** Filariasis. * **Most common cause of lymphedema in developed countries:** Malignancy and its treatment (Surgery/Radiation). * **Stewart-Treves Syndrome:** A rare, highly aggressive **angiosarcoma** that develops in a limb with long-standing chronic lymphedema (most classically post-mastectomy). * **Stemmer’s Sign:** Inability to pinch the skin on the dorsum of the second toe/finger; a pathognomonic physical finding for lymphedema.

Question 338: Which of the following is seen in popliteal entrapment syndrome?

A. Evidence of atherosclerosis
B. Exercise-induced calf claudications (Correct Answer)
C. Abnormal relation between the popliteal artery and the lateral head of the gastrocnemius muscle
D. Decreased ankle pulses with ankle extension

Explanation: **Explanation:** **Popliteal Entrapment Syndrome (PES)** is a developmental anomaly where the popliteal artery has an abnormal relationship with the surrounding myofascial structures in the popliteal fossa, most commonly the **medial head of the gastrocnemius muscle**. 1. **Why Option B is Correct:** The primary clinical manifestation is **exercise-induced calf claudication**. During exercise, the contraction of the gastrocnemius muscle causes extrinsic compression of the popliteal artery, leading to distal ischemia. This typically affects young, athletic individuals (often males under 30) who lack traditional cardiovascular risk factors. 2. **Why the other options are incorrect:** * **Option A:** PES is a mechanical/anatomical compression, not an atherosclerotic process. However, chronic untreated entrapment can lead to secondary intimal damage, post-stenotic dilatation, or aneurysm formation. * **Option C:** The classic anatomical defect involves an abnormal relationship with the **medial head** of the gastrocnemius (e.g., the artery passing medial to or through the muscle), not the lateral head. * **Option D:** On physical examination, pulses are often normal at rest but disappear or decrease with **active plantarflexion** or **passive dorsiflexion** of the ankle (not extension), as these maneuvers tighten the gastrocnemius muscle against the artery. **High-Yield Clinical Pearls for NEET-PG:** * **Patient Profile:** Young athlete with "claudication-like" pain. * **Gold Standard Diagnosis:** Digital Subtraction Angiography (DSA) or MR Angiography (showing medial deviation of the artery). * **Classification:** There are 6 types (Type I-VI); Type I is the most common (medial deviation of the artery). * **Management:** Surgical release of the compressing tendon/muscle (myotomy) to prevent permanent arterial damage or thrombosis.

Question 339: Which of the following is NOT used as graft material in peripheral vascular disease?

A. Dacron graft
B. Vein
C. PTFE
D. PVC (Correct Answer)

Explanation: **Explanation:** In peripheral vascular surgery, graft materials must be biocompatible, non-thrombogenic, durable, and resistant to infection. **PVC (Polyvinyl Chloride)** is a rigid plastic commonly used for medical tubing (like IV sets) and construction, but it is **not** used as a vascular graft because it is thrombogenic, lacks the necessary compliance, and can leach toxic plasticizers into the bloodstream. **Analysis of Options:** * **Dacron (Polyester):** A synthetic material used primarily for **large-diameter, high-flow vessels** (e.g., Aorto-iliac bypass). It requires "pre-clotting" unless coated with collagen or albumin to prevent leakage through the fabric pores. * **Vein (Autologous):** The **Gold Standard** for peripheral bypass, especially below the knee. The **Great Saphenous Vein (GSV)** is most commonly used due to its superior patency rates and resistance to infection. * **PTFE (Polytetrafluoroethylene/Gore-Tex):** A synthetic material preferred for **medium-sized vessels** or when a suitable autologous vein is unavailable. It is non-porous and does not require pre-clotting. **High-Yield Clinical Pearls for NEET-PG:** * **Best Graft Material:** Autologous vein (Great Saphenous Vein) is always superior to synthetic grafts for distal bypasses. * **Dacron vs. PTFE:** Dacron is preferred for **aortic** surgery; PTFE is often preferred for **axillo-femoral** or **femoropopliteal** bypasses when the vein is unavailable. * **Infection Risk:** Synthetic grafts (Dacron/PTFE) have a much higher risk of infection compared to autologous veins. If a graft becomes infected, it usually requires complete removal. * **Anastomosis:** The most common site of failure for synthetic grafts is **intimal hyperplasia** at the distal anastomosis.

Question 340: Which of the following is NOT a true statement about arterial occlusion in the leg?

A. Rest pain in limbs
B. Pain in limbs on taking the very first step (Correct Answer)
C. Pain relieved by standing still
D. Pain in limbs on walking

Explanation: **Explanation:** The clinical presentation of chronic arterial occlusion in the lower limbs is characterized by **Intermittent Claudication**. This is defined as pain, cramping, or fatigue in the muscles that occurs during exercise and is consistently relieved by rest. **Why Option B is the Correct Answer (The False Statement):** Pain occurring on the **very first step** is characteristic of **Osteoarthritis** (specifically "start-up pain") or inflammatory conditions like Plantar Fasciitis, rather than vascular disease. In arterial occlusion, the blood supply is sufficient for resting metabolic needs but fails to meet the increased oxygen demand of contracting muscles during exertion. Therefore, it takes a certain distance of walking (the claudication distance) for metabolic byproducts (like lactic acid) to accumulate and trigger pain. **Analysis of Other Options:** * **Option D (Pain on walking):** This is the hallmark of intermittent claudication. As the patient walks, the demand-supply mismatch leads to ischemic muscle pain. * **Option C (Relieved by standing still):** Vascular claudication typically subsides within 2–5 minutes of stopping the activity (standing still), as the oxygen debt is repaid. * **Option A (Rest pain):** This signifies **Critical Limb Ischemia (CLI)**. It occurs when the occlusion is so severe that blood flow is insufficient even at rest. It typically affects the forefoot and is worsened by elevation. **NEET-PG High-Yield Pearls:** * **Leriche Syndrome Triad:** Bilateral claudication, Impotence, and absent femoral pulses (Aortoiliac occlusion). * **Buerger’s Disease (TAO):** Common in young male smokers; involves small/medium vessels and often presents with migratory thrombophlebitis. * **Fontaine Classification:** Stage I (Asymptomatic), Stage II (Claudication), Stage III (Rest pain), Stage IV (Ulceration/Gangrene). * **Ankle-Brachial Index (ABI):** Normal is 0.9–1.2; Rest pain usually occurs when ABI <0.4.

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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