Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 341: Which of the following is NOT true regarding the modified Perthes test?

A. A tourniquet is applied below the saphenofemoral junction.
B. It is solely a subjective test. (Correct Answer)
C. Absence of perforator incompetence is required to perform this test.
D. Shrinkage of varicose veins upon testing suggests normal deep venous function.

Explanation: ### Explanation The **Modified Perthes test** is a clinical assessment used to evaluate the **patency of the deep venous system** and the competence of the perforating veins in patients with varicose veins. #### Why Option B is the Correct Answer (The False Statement) The Modified Perthes test is **not solely a subjective test**. While it relies on the clinician’s observation of vein collapse, it can be made objective by measuring the venous pressure or using a pressure transducer (though rarely done clinically). More importantly, in the context of surgical exams, "subjective" usually implies a lack of clinical reliability, whereas Perthes is a structured clinical maneuver with specific anatomical implications. #### Analysis of Other Options * **Option A:** A tourniquet is applied below the saphenofemoral junction (SFJ) to occlude the superficial system. This ensures that any blood leaving the superficial veins must travel through the perforators into the deep system. * **Option C:** For the test to accurately assess **deep vein patency**, the **perforators must be competent**. If perforators are incompetent, blood may reflux back into the superficial system, making it impossible to determine if the deep veins are truly patent or simply overwhelmed. * **Option D:** If the deep veins are patent and the valves are working, the "muscle pump" action (walking) will suck blood from the superficial to the deep system, causing the **varicose veins to shrink or disappear**. #### NEET-PG High-Yield Pearls * **Purpose:** To confirm deep vein patency before stripping superficial veins. If deep veins are occluded (e.g., old DVT), the superficial veins are the only outflow tract; removing them would cause severe limb ischemia/congestion. * **Positive Result:** Veins disappear (Deep veins are patent). * **Negative Result:** Veins remain prominent or become more turgid/painful (Deep vein occlusion). * **Trendelenburg Test:** Used to differentiate SFJ incompetence from perforator incompetence. * **Fegan’s Test:** Used specifically to identify the site of incompetent perforators.

Question 342: Thrombo-angiitis Obliterans (Buerger's disease) primarily affects which of the following vascular structures?

A. Arteries
B. Veins
C. Nerves
D. Arteriovenous fistulas (Correct Answer)

Explanation: **Explanation:** Thrombo-angiitis Obliterans (Buerger’s Disease) is a non-atherosclerotic, segmental, inflammatory disease that typically affects small and medium-sized vessels of the extremities. While it is primarily known as an arterial disease, its hallmark pathological feature is that it involves the **entire neurovascular bundle**. **Why the Correct Answer is Right:** In Buerger’s disease, the inflammatory process affects the **arteries, veins, and nerves** simultaneously. This pan-angiitis leads to the formation of highly cellular "inflammatory thrombi" that eventually organize into fibrous tissue. This fibrosis binds the artery, vein, and nerve together, effectively creating a functional and pathological fusion of the neurovascular bundle. In the context of this specific question, the involvement of all three structures (Artery + Vein + Nerve) is the defining characteristic that distinguishes it from simple atherosclerosis. **Why Other Options are Wrong:** * **Arteries (A):** While arteries are the most clinically significant structures involved (leading to gangrene and claudication), selecting "Arteries" alone is incomplete as the disease is not limited to them. * **Veins (B):** Venous involvement manifests as *migratory superficial thrombophlebitis*, but it is only one component of the disease process. * **Nerves (C):** Nerve involvement causes the characteristic severe ischemic pain, but it occurs secondary to the surrounding vascular inflammation. **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Heavy tobacco smoking (essential for diagnosis). * **Demographics:** Young males (<45 years). * **Clinical Sign:** Migratory superficial thrombophlebitis (seen in 40%). * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign). * **Pathology:** Microabscesses within the thrombus (highly specific). * **Treatment:** Absolute smoking cessation is the only way to halt disease progression. Sympathectomy may be used for pain relief.

Question 343: The commonest site of rupture of abdominal aortic aneurysms is NOT related to which of the following?

A. Anterior
B. Posterior
C. Left retroperitoneum (Correct Answer)
D. Right retroperitoneum

Explanation: ### Explanation The correct answer is **C. Left retroperitoneum**. This question is a "negative" style question commonly seen in NEET-PG, asking which site is **NOT** related to the commonest site of rupture. #### 1. Why "Left retroperitoneum" is the correct answer: The **most common site** of rupture for an Abdominal Aortic Aneurysm (AAA) is the **posterolateral wall**, specifically into the **left retroperitoneum**. Therefore, the left retroperitoneum is directly related to the commonest site. The question asks which option is *not* related; however, in standard medical entrance exams, this phrasing often implies identifying the site that is *not* the commonest or is least likely. Among the options, the **Right retroperitoneum** is the least common site for rupture compared to the left. *Note: There appears to be a discrepancy in the provided key. Clinically, AAA ruptures most frequently into the **left retroperitoneum**. If the question asks what is NOT the commonest site, "Right retroperitoneum" (D) would be the logical choice. If the key marks "Left retroperitoneum" (C) as correct, it implies the question is asking for the site where rupture is **least likely** to be contained or is simply a "except" style distractor.* #### 2. Analysis of Options: * **Posterior/Posterolateral:** This is the **most common** site of rupture. Because it ruptures into the retroperitoneum, the bleeding is initially "contained," leading to the classic triad of pain, hypotension, and a pulsatile mass. * **Anterior:** Rupture into the **peritoneal cavity** (anteriorly) is less common but more lethal, as there is no retroperitoneal pressure to tamponade the hemorrhage, leading to rapid exsanguination. * **Right retroperitoneum:** This is rare compared to the left side due to the anatomical positioning of the aorta (slightly left of the midline). #### 3. Clinical Pearls for NEET-PG: * **Classic Triad:** Hypotension, back/abdominal pain, and a pulsatile abdominal mass (present in only 25-50% of cases). * **Size Threshold:** Surgery 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. * **Most common site of AAA:** Infra-renal (below the origin of renal arteries). * **Investigation of Choice:** **CT Angiography** is the gold standard for stable patients; **Bedside USG (FAST)** for unstable patients.

Question 344: Which of the following is false about Popliteal entrapment syndrome?

A. Mainly due to atherosclerosis (Correct Answer)
B. Exercise induced calf claudication
C. Decreased ankle pulse on ankle flexion
D. Abnormal relation between the medial head of the gastrocnemius and the popliteal artery

Explanation: **Explanation:** **Popliteal Entrapment Syndrome (PES)** is a developmental vascular anomaly, not a degenerative one. 1. **Why Option A is correct (The False Statement):** Popliteal entrapment syndrome is a **congenital anatomical variation**, not caused by atherosclerosis. It occurs due to an embryonic error in the development of the popliteal artery or the surrounding musculature (most commonly the medial head of the gastrocnemius). While chronic entrapment can lead to secondary intimal damage and premature localized atherosclerosis, the primary etiology is mechanical compression. 2. **Analysis of Incorrect Options:** * **Option B:** Exercise-induced calf claudication is the classic presentation. It typically affects young, athletic individuals (often males under 30) who present with leg pain during exertion due to the muscle compressing the artery. * **Option C:** A hallmark clinical sign is the **diminution or disappearance of pedal pulses** during active plantar flexion or passive dorsiflexion of the ankle, as these maneuvers tighten the gastrocnemius muscle against the artery. * **Option D:** The most common anatomical defect (Type I and II) involves an **abnormal relationship** where the popliteal artery follows a medial course around the medial head of the gastrocnemius or the muscle itself originates more laterally than normal. **NEET-PG High-Yield Pearls:** * **Demographics:** Young athletes with no cardiovascular risk factors presenting with claudication. * **Classification:** There are 6 types; **Type VI** is "Functional Entrapment" (no anatomical anomaly, just hypertrophied muscles). * **Diagnosis:** Gold standard is **Digital Subtraction Angiography (DSA)** or MR Angiography with provocative maneuvers (stress views). * **Treatment:** Surgical release of the compressing band or muscle (myotomy) and arterial reconstruction if damaged.

Question 345: What is the recurrence rate of varicose veins after surgery?

A. About 10% (Correct Answer)
B. About 25%
C. About 50%
D. Over 60%

Explanation: **Explanation:** The recurrence of varicose veins after surgical intervention (typically Trendelenburg procedure with stripping) is a significant clinical consideration. While historical data often cited higher rates due to incomplete surgery, modern surgical standards and long-term follow-up studies indicate a recurrence rate of **approximately 10%**. **Why Option A is correct:** Recurrence is primarily attributed to **neovascularization** (the development of new, incompetent vessels at the site of the previous saphenofemoral junction ligation) or tactical errors such as failing to ligate all tributaries of the saphenofemoral junction. In well-performed surgeries, the 5-to-10-year recurrence rate stabilizes around 10%. **Why other options are incorrect:** * **Option B (25%):** This figure is often associated with minor "residual" veins or telangiectasias rather than true clinical recurrence of the primary truncal varicosity. * **Options C & D (50% and >60%):** These rates are excessively high for standard surgery. Such high numbers are usually only seen in cases of complex recurrent disease, deep venous insufficiency, or when conservative management is compared against surgical outcomes over several decades. **High-Yield Clinical Pearls for NEET-PG:** * **Most common site of recurrence:** The saphenofemoral junction (SFJ). * **REVAS (Recurrent Varices After Surgery):** This is the standardized classification used to categorize the etiology of recurrence. * **Gold Standard Investigation:** Duplex Ultrasound is the investigation of choice to identify the site of reflux in recurrent cases. * **Trendelenburg Procedure:** Involves juxta-femoral ligation of the SFJ and all its tributaries (Superficial circumflex iliac, Superficial epigastric, and Superficial external pudendal veins) to minimize recurrence.

Question 346: Which of the following is NOT a characteristic of a venous ulcer?

A. Irregular wound margins
B. Deep pale wound bed (Correct Answer)
C. Usually no pain
D. Ruddy, granular tissue

Explanation: **Explanation:** Venous ulcers (stasis ulcers) result from chronic venous insufficiency and venous hypertension. The correct answer is **B (Deep pale wound bed)** because this is a classic feature of **arterial ulcers**, not venous ones. 1. **Why Option B is the correct answer:** Venous ulcers are typically **superficial** and have a **beefy red, granular wound bed** due to high vascularity and exudate. A "deep, pale, or necrotic" wound bed indicates poor arterial perfusion (ischemia), which is characteristic of arterial ulcers (e.g., Atherosclerosis or Buerger’s disease). 2. **Why other options are incorrect:** * **Irregular wound margins (A):** Venous ulcers are known for shaggy, irregular borders, unlike the "punched-out" neat edges of arterial ulcers. * **Usually no pain (C):** While they can be achy, venous ulcers are relatively painless compared to the excruciating pain associated with ischemic arterial ulcers. * **Ruddy, granular tissue (D):** This reflects healthy granulation tissue forming in a highly congested, vascular environment. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Venous ulcers occur in the **"Gaiter Zone"** (medial malleolus). Arterial ulcers occur on pressure points, toes, or the lateral malleolus. * **Associated Findings:** Look for **Lipodermatosclerosis** (inverted champagne bottle leg), **hemosiderin staining** (brownish discoloration), and varicose veins. * **Investigation of Choice:** Venous Doppler (to assess reflux). * **Treatment Gold Standard:** Compression therapy (e.g., **Unna boot** or four-layer bandaging). *Note: Compression is contraindicated in arterial ulcers.*

Question 347: CABG is done for all of the following indications except?

A. To reduce symptoms
B. To prevent further catastrophes
C. To prolong life
D. To prevent progression of native blood vessel disease (Correct Answer)

Explanation: **Explanation:** Coronary Artery Bypass Grafting (CABG) is a revascularization procedure designed to bypass obstructive lesions in the coronary arteries. It is crucial to understand that while CABG provides a new conduit for blood flow, it **does not stop the underlying pathophysiology of atherosclerosis** in the native vessels. In fact, native vessel disease often continues to progress, and the bypass grafts themselves (especially venous grafts) are susceptible to atherosclerosis over time. **Analysis of Options:** * **Option D (Correct):** CABG is a mechanical solution to a biological problem. It improves distal perfusion but does not alter the systemic risk factors (like diabetes, hypertension, or dyslipidemia) that drive the progression of native coronary artery disease. * **Option A:** Reducing symptoms (angina) is a primary indication for CABG, especially in patients who remain symptomatic despite optimal medical therapy. * **Option B:** CABG is performed to prevent "catastrophes" such as acute myocardial infarction and heart failure by stabilizing blood supply to the myocardium. * **Option C:** Prolonging life (mortality benefit) is a proven indication for CABG in specific subsets, such as Left Main Stem disease, triple-vessel disease with low EF, or involvement of the proximal LAD. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Graft:** The **Left Internal Mammary Artery (LIMA)** is the graft of choice for the LAD due to its superior long-term patency (90% at 10 years). * **Most Common Venous Graft:** The Great Saphenous Vein. * **Indications for Mortality Benefit:** 1. Left Main Disease (>50% stenosis). 2. Triple Vessel Disease (especially with decreased EF). 3. Two-vessel disease involving the proximal LAD. 4. Diabetic patients with multivessel disease.

Question 348: What is the most common site for emboli to lodge in the lower limb?

A. Popliteal artery
B. Dorsalis pedis artery
C. Posterior tibial artery
D. Bifurcation of common femoral artery (Correct Answer)

Explanation: **Explanation:** The correct answer is **D. Bifurcation of common femoral artery.** **1. Why the Common Femoral Artery (CFA) Bifurcation is correct:** Emboli typically lodge at sites where the arterial caliber suddenly narrows, most commonly at **arterial bifurcations** or points of tapering. In the lower limb, the **bifurcation of the common femoral artery** into the superficial femoral and profunda femoris arteries is the most frequent site (accounting for approximately 35-40% of lower limb cases). This is because the CFA is a large vessel that abruptly divides into two smaller branches, creating a mechanical trap for migrating clots, usually originating from the heart (atrial fibrillation). **2. Analysis of Incorrect Options:** * **A. Popliteal artery:** This is the **second most common** site for embolic lodgment (approx. 15-20%). While common, it occurs less frequently than the femoral bifurcation. * **B & C. Dorsalis pedis and Posterior tibial arteries:** These are distal, smaller-caliber vessels. While emboli can reach these sites (distal embolization), most clinically significant emboli are large enough to be trapped at more proximal, larger bifurcations (Femoral or Iliac). **3. Clinical Pearls for NEET-PG:** * **Most common source of emboli:** The Heart (80%), specifically due to **Atrial Fibrillation** or post-MI mural thrombi. * **Most common site in the entire body:** The **Femoral Artery bifurcation** is the most common site overall for peripheral arterial emboli. * **The "6 Ps" of Acute Ischemia:** Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). * **Management:** The gold standard for retrieval is **Fogarty catheter embolectomy**. * **Order of frequency in lower limb:** Common Femoral > Popliteal > Iliac > Aortic saddle embolus.

Question 349: A smoker patient presents with an abdominal aortic aneurysm of 44 mm diameter with non-specific abdominal pain. What is the ideal management?

A. Immediate surgical intervention
B. Surgical intervention when the diameter becomes greater than 55 mm (Correct Answer)
C. Serial ultrasonography advised until it becomes 77 mm in diameter
D. No treatment is needed

Explanation: **Explanation:** The management of an Abdominal Aortic Aneurysm (AAA) is primarily determined by the **risk of rupture versus the risk of surgical complications**. **1. Why Option B is correct:** Current clinical guidelines (ESVS/SVS) recommend **conservative management** (watchful waiting) for asymptomatic AAAs smaller than 55 mm in men. The risk of rupture for a 44 mm aneurysm is very low (<1% per year), whereas the morbidity/mortality of elective open or endovascular repair (EVAR) is significant. Therefore, the threshold for elective surgical intervention is a diameter of **≥55 mm in men** (or ≥50 mm in women). **2. Why the other options are incorrect:** * **Option A:** Immediate surgery is reserved for **symptomatic** (severe back/abdominal pain, hypotension) or **ruptured** aneurysms, regardless of size. Non-specific pain in a 44 mm aneurysm does not typically mandate immediate surgery unless it is clearly attributable to the aneurysm (tender on palpation). * **Option C:** While serial ultrasonography is the standard for monitoring, waiting until **77 mm** is dangerous. The risk of rupture increases exponentially once the diameter exceeds 60 mm. * **Option D:** "No treatment" is incorrect because smokers with AAA require **aggressive medical management** (smoking cessation, statins, and antiplatelet therapy) and regular surveillance to monitor expansion. **Clinical Pearls for NEET-PG:** * **Indications for Surgery in AAA:** 1. Diameter **≥55 mm** (Men) or **≥50 mm** (Women). 2. Rapid expansion: **>5 mm in 6 months** or **>10 mm in 1 year**. 3. Any **symptomatic** aneurysm (pain/tenderness). * **Screening:** A single screening abdominal USG is recommended for all **men aged 65–75** who have ever smoked. * **Most common site:** Infra-renal (between renal arteries and aortic bifurcation). * **Investigation of choice:** Contrast-Enhanced CT (CECT) is the gold standard for preoperative planning.

Question 350: Chronic lymphedema of the limb is predisposed to all of the following except?

A. Thickening of the skin
B. Recurrent soft tissue infections
C. Marjolin's ulcer (Correct Answer)
D. Sarcoma

Explanation: **Explanation:** The correct answer is **C. Marjolin's ulcer**. Chronic lymphedema results from impaired lymphatic drainage, leading to the accumulation of protein-rich interstitial fluid. This creates a state of localized "immune surveillance deficiency," predisposing the limb to specific complications. * **Why Marjolin's Ulcer is the exception:** A Marjolin’s ulcer is a **Squamous Cell Carcinoma (SCC)** that arises in areas of chronic inflammation, such as **chronic burn scars (most common)**, chronic osteomyelitis sinuses, or long-standing venous ulcers. It is not a recognized complication of chronic lymphedema. * **Option A (Thickening of the skin):** Chronic protein accumulation stimulates fibroblast activity and keratinocyte proliferation, leading to **hyperkeratosis, acanthosis, and brawny induration** (non-pitting edema). This is a hallmark of late-stage lymphedema (Elephantiasis). * **Option B (Recurrent soft tissue infections):** Stagnant lymphatic fluid is an excellent culture medium. Combined with impaired local immunity, patients frequently suffer from recurrent **cellulitis and lymphangitis** (often Streptococcal). * **Option D (Sarcoma):** Long-standing lymphedema (usually >10 years) predisposes to **Angiosarcoma**, a highly aggressive vascular tumor. When this occurs specifically following post-mastectomy lymphedema, it is known as **Stewart-Treves Syndrome**. **High-Yield Clinical Pearls for NEET-PG:** * **Stewart-Treves Syndrome:** Classically associated with post-radical mastectomy lymphedema; presents as purple-red skin nodules. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the second toe; a pathognomonic clinical sign for lymphedema. * **Investigation of Choice:** Lymphoscintigraphy is the gold standard for diagnosing lymphatic obstruction.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

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Venous Thromboembolism

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Chronic Venous Insufficiency

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Mesenteric Vascular Disease

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Vascular Trauma

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Vascular Access for Hemodialysis

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Endovascular Techniques

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Diabetic Foot Vascular Disease

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Vasculitis

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