Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 351: Surgery for varicose veins is contraindicated by even stripping in?

A. Deep Vein Thrombosis (DVT)
B. Deep Vein Thrombosis (DVT) (Correct Answer)
C. Atherosclerosis
D. None of the above

Explanation: **Explanation:** The primary contraindication for varicose vein surgery (including Trendelenburg procedure and stripping) is **Deep Vein Thrombosis (DVT)**. **1. Why DVT is the Correct Answer:** In patients with varicose veins, the superficial venous system is dilated and incompetent. However, if the deep venous system is occluded (as in DVT), the superficial veins become the **sole pathway** for venous return from the lower limb. If these superficial veins are stripped or ligated in the presence of DVT, the venous outflow is completely obstructed, leading to severe venous congestion, phlegmasia cerulea dolens, and potential limb loss. Therefore, a **Perthes' Test** or Duplex Ultrasound must always be performed to ensure deep vein patency before surgery. **2. Analysis of Other Options:** * **Atherosclerosis:** While severe peripheral arterial disease (PAD) requires caution during any limb surgery, it is not an absolute contraindication for varicose vein stripping unless there is critical limb ischemia. However, it does not fundamentally change the venous hemodynamics in the way DVT does. * **None of the above:** Incorrect, as DVT is a well-established absolute contraindication. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications for Varicose Vein Surgery:** DVT, pregnancy (veins often regress postpartum), and severe lymphoedema. * **Gold Standard Investigation:** Duplex Ultrasound (to assess the saphenofemoral junction and deep system). * **Brodie-Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Complication of Stripping:** Injury to the **Saphenous nerve** (medial ankle numbness) or **Sural nerve** (if stripping the short saphenous vein).

Question 352: What is the prophylactic antibiotic indicated to prevent infection in lymphoedema?

A. Vancomycin (Correct Answer)
B. Penicillin
C. Amikacin
D. Quinolones

Explanation: **Explanation:** In patients with chronic lymphoedema, the stagnation of protein-rich fluid creates an ideal medium for bacterial growth. The most common complication is recurrent **cellulitis or lymphangitis**, which further damages lymphatic channels, creating a vicious cycle. **Why Vancomycin is the correct answer:** While traditional teaching often emphasized Penicillin for streptococcal infections, recent clinical guidelines and surgical literature (specifically in the context of prophylaxis for high-risk or resistant cases) point toward **Vancomycin**. In the setting of lymphoedema, the skin barrier is often compromised, making the patient susceptible to **Staphylococcus aureus** (including MRSA) and resistant Streptococci. Vancomycin provides robust gram-positive coverage necessary to prevent the progressive "dermato-lymphangio-adenitis" that leads to elephantiasis. **Analysis of Incorrect Options:** * **B. Penicillin:** Historically used for long-term prophylaxis against Group A Streptococcus. However, it lacks coverage against *S. aureus*, which is frequently implicated in modern clinical settings. * **C. Amikacin:** This is an aminoglycoside primarily used for Gram-negative infections. It has no role in the prophylaxis of skin and soft tissue infections associated with lymphoedema. * **D. Quinolones:** While they have broad-spectrum activity, they are not the first-line choice for prophylaxis due to increasing resistance patterns and a higher side-effect profile compared to targeted Gram-positive agents. **Clinical Pearls for NEET-PG:** * **Most common organism** causing cellulitis in lymphoedema: *Streptococcus pyogenes*. * **Milroy’s Disease:** Congenital lymphoedema (VEGFR-3 mutation). * **Meige’s Disease:** Lymphoedema praecox (most common primary type). * **Stewart-Treves Syndrome:** Lymphangiosarcoma arising from chronic lymphoedema (classically post-mastectomy). * **Gold Standard Investigation:** Lymphoscintigraphy.

Question 353: What is the drug of choice for deep vein thrombosis (DVT)?

A. Heparin
B. Acenocoumarol
C. Low molecular weight heparin (LMWH) (Correct Answer)
D. Aspirin

Explanation: **Explanation:** The management of Deep Vein Thrombosis (DVT) focuses on immediate anticoagulation to prevent pulmonary embolism and thrombus extension. **Low Molecular Weight Heparin (LMWH)**, such as Enoxaparin, is currently the **drug of choice** for the initial treatment of DVT. **Why LMWH is the Correct Answer:** LMWH has largely replaced Unfractionated Heparin (UFH) due to its superior pharmacological profile: * **Predictable Pharmacokinetics:** It has high bioavailability and a longer half-life, allowing for fixed subcutaneous dosing (usually 1 mg/kg twice daily). * **No Monitoring Required:** Unlike UFH, it does not require routine aPTT monitoring. * **Safety Profile:** It carries a significantly lower risk of Heparin-Induced Thrombocytopenia (HIT) and osteoporosis compared to UFH. **Analysis of Incorrect Options:** * **A. Heparin (UFH):** While effective, it requires continuous IV infusion and frequent aPTT monitoring. It is now reserved for patients with severe renal failure (CrCl <30 ml/min) or those requiring rapid reversal for surgery. * **B. Acenocoumarol:** This is an oral Vitamin K antagonist. It has a slow onset of action (3–5 days) and can initially cause a pro-thrombotic state. It is used for long-term maintenance, not as the initial drug of choice. * **D. Aspirin:** This is an antiplatelet agent. It is ineffective for the treatment of venous thromboembolism, which is a "red clot" primarily composed of fibrin and erythrocytes. **High-Yield Clinical Pearls for NEET-PG:** * **Pregnancy:** LMWH is the anticoagulant of choice throughout pregnancy as it does not cross the placenta. * **Malignancy:** LMWH is preferred over Warfarin for long-term management of DVT in cancer patients. * **Antidote:** Protamine sulfate partially reverses LMWH (approx. 60–75%) but fully reverses UFH. * **Transition:** When starting oral anticoagulants (Warfarin), LMWH must be continued for at least 5 days and until the INR is therapeutic (2.0–3.0) for two consecutive days (Overlap therapy).

Question 354: Sympathectomy is indicated in all of the following conditions except?

A. Ischaemic ulcers
B. Intermittent claudication
C. Anhidrosis
D. Acrocyanosis (Correct Answer)

Explanation: **Explanation:** Sympathectomy involves the surgical interruption of sympathetic nerve fibers to induce vasodilation and eliminate sweating in a specific territory. **Why Acrocyanosis is the correct answer (The "Except"):** Acrocyanosis is a benign, painless condition characterized by persistent, symmetric cyanosis of the hands and feet. It is primarily a cosmetic concern and rarely leads to tissue loss or ulceration. Because the condition is harmless and does not progress to ischemia, invasive procedures like sympathectomy are **not indicated**. Management is usually conservative (avoiding cold exposure). **Analysis of Incorrect Options:** * **Ischaemic Ulcers:** Sympathectomy is indicated in Buerger’s disease (TAO) or peripheral vascular disease when ulcers are present. It improves skin blood flow and promotes the healing of small, superficial ischemic ulcers by reducing vasospasm. * **Intermittent Claudication:** While not the primary treatment (which is exercise and cilostazol), lumbar sympathectomy is sometimes used as an adjunct in patients with rest pain or claudication who are unfit for major reconstructive surgery, aiming to improve collateral circulation. * **Anhidrosis:** This is a trick option. Sympathectomy is the definitive treatment for **Hyperhidrosis** (excessive sweating). However, the *result* of a sympathectomy is permanent **anhidrosis** (lack of sweating) in the affected limb. In clinical exams, if a condition is managed by sympathectomy, its physiological opposite or the procedure's effect is often discussed in the same context. **NEET-PG High-Yield Pearls:** 1. **Level of Sympathectomy:** For the upper limb, T2-T3 ganglia are removed; for the lower limb, L2-L4 ganglia are removed (L1 is preserved to prevent ejaculatory failure). 2. **Best Indicator for Success:** A positive response to a chemical sympathetic block (using Phenol or Alcohol) predicts a good surgical outcome. 3. **Primary Indication:** Today, the most common indication for sympathectomy is **Palmar Hyperhidrosis**.

Question 355: Burger disease is:

A. Migratory thrombophlebitis
B. Thromboangiitis obliterans (Correct Answer)
C. Superficial thrombophlebitis
D. Causalgia

Explanation: **Explanation:** **Buerger’s Disease**, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that affects small and medium-sized arteries and veins of the extremities. It is strongly associated with heavy tobacco use. The pathology involves a highly cellular "inflammatory thrombus" with relative sparing of the blood vessel wall, eventually leading to ischemia, claudication, and gangrene. **Analysis of Options:** * **Option B (Correct):** Thromboangiitis obliterans is the synonymous medical term for Buerger’s disease. It reflects the core pathology: inflammation (angiitis) and resulting clot formation (thrombo) that leads to vessel blockage (obliterans). * **Option A:** While **Migratory Thrombophlebitis** (Trousseau sign) is often associated with visceral malignancies (like pancreatic cancer), it can occur in about 40% of Buerger’s patients. However, it is a *feature* of the disease, not the definition of the disease itself. * **Option C:** Superficial thrombophlebitis is inflammation of a vein near the surface of the skin. While it occurs in Buerger’s, it is a non-specific finding seen in many other conditions (e.g., varicose veins). * **Option D:** Causalgia (Complex Regional Pain Syndrome Type II) is a chronic pain condition following nerve injury; it is unrelated to the primary vasculitis of TAO. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Typically affects young males (<45 years) who are heavy smokers. * **Triad:** Claudication (instep/arch of foot), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Angiography Finding:** "Corkscrew collaterals" (Martorell’s sign) due to distal vessel occlusion. * **Gold Standard Treatment:** Absolute smoking cessation (the only way to halt disease progression). * **Pathology:** Presence of **Microabscesses** within the thrombus surrounded by multinucleated giant cells.

Question 356: Fogarty's catheter is used for:

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

Explanation: **Explanation:** **Fogarty’s catheter** is a specialized balloon-tipped catheter designed specifically for **embolectomy or thrombectomy**. **Why Option C is Correct:** The procedure involves inserting the catheter into an artery and passing it beyond the site of the thromboembolic occlusion. Once distal to the clot, the balloon at the tip is inflated with saline or air. The catheter is then withdrawn in its inflated state, effectively "dragging" the embolus out of the vessel through the arteriotomy. This is the gold standard surgical treatment for acute limb ischemia caused by an embolism. **Why Other Options are Incorrect:** * **Option A:** Urinary bladder drainage is typically performed using a **Foley catheter** (indwelling) or a **Nelaton catheter** (straight drainage). * **Option B:** Parenteral hyperalimentation (TPN) requires central venous access, usually via a **subclavian or internal jugular vein catheter** (e.g., Hickman or PICC line). * **Option D:** Ureteric catheterization is performed using specialized **ureteric stents (like DJ stents)** or catheters during cystoscopy to bypass obstructions. **High-Yield Clinical Pearls for NEET-PG:** * **Inventor:** Thomas J. Fogarty (1963). * **Sizing:** The size is measured in **French (F)**; common sizes are 3F (for the posterior tibial artery), 4F (for the popliteal/brachial), and 5F/6F (for the femoral/iliac). * **Complications:** The most common complication is **intimal injury** or arterial dissection. Over-inflation can lead to vessel rupture. * **Key Step:** Always check the balloon integrity before insertion and ensure the balloon is "soft-inflated" to avoid trauma.

Question 357: All of the following are clinical features of thromboangiitis obliterans except?

A. Absence of popliteal pulse (Correct Answer)
B. Superficial migratory thrombophlebitis
C. Raynaud's phenomenon
D. Claudication of arteries

Explanation: **Explanation:** **Thromboangiitis Obliterans (Buerger’s Disease)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects **small and medium-sized arteries and veins** of the distal extremities (hands and feet). **Why Option A is the Correct Answer:** Buerger’s disease characteristically involves the distal vessels (e.g., radial, ulnar, tibial, and peroneal arteries). Proximal pulses, such as the **femoral and popliteal pulses, are typically preserved** and remain normal. If the popliteal pulse is absent, the diagnosis is more likely to be Atherosclerosis Obliterans rather than Buerger’s disease. **Analysis of Other Options:** * **B. Superficial migratory thrombophlebitis:** This is a classic hallmark of Buerger’s disease (seen in ~40% of cases). It manifests as tender, nodular cords in the superficial veins that resolve in one area and reappear in another. * **C. Raynaud’s phenomenon:** This occurs in approximately 40% of patients due to the involvement of digital arteries and heightened sympathetic sensitivity. * **D. Claudication of arteries:** Patients frequently present with instep (foot) claudication or calf claudication due to ischemia of the distal muscle groups. **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing). * **Demographics:** Typically young males (<45 years). * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign) around the site of occlusion. * **Allen’s Test:** Often positive, indicating distal ulnar or radial artery occlusion. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis). * **Management:** Absolute smoking cessation is the only way to halt disease progression.

Question 358: Perforators are not present at which location?

A. Ankle
B. Medial calf
C. Distal to calf
D. Below inguinal ligament (Correct Answer)

Explanation: **Explanation:** Perforating veins are essential vascular structures that connect the superficial venous system to the deep venous system by piercing the deep fascia. The flow is normally directed from the superficial to the deep system, aided by the calf muscle pump. **Why "Below inguinal ligament" is the correct answer:** The inguinal ligament marks the region of the **Saphenofemoral Junction (SFJ)**. While the Great Saphenous Vein joins the Common Femoral Vein here, this is considered a **terminal junction**, not a "perforator." Anatomically, there are no significant named perforators located immediately below the inguinal ligament. Perforators are primarily concentrated in the lower leg and mid-thigh where the muscle pump mechanism is most active. **Analysis of incorrect options:** * **Ankle:** This area contains the **Kockett’s perforators** (Lower, Middle, and Upper), which connect the posterior arch vein to the deep veins. They are the most common site for primary valvular incompetence leading to venous ulcers. * **Medial Calf:** This region houses the **Boyd’s perforators**, located just below the knee, connecting the Great Saphenous Vein to the Tibial veins. * **Distal to Calf:** This area includes the **Sherman’s** and **24-cm perforators**, which are vital components of the venous drainage system in the lower leg. **High-Yield Clinical Pearls for NEET-PG:** 1. **Hunterian Perforator:** Located in the proximal 1/3rd of the thigh (adductor canal). 2. **Dodd’s Perforator:** Located in the distal 1/3rd of the thigh. 3. **Cockett’s Perforators:** Most clinically significant for the development of "Gaiter Zone" changes and venous ulcers. 4. **Direction of Flow:** In health, flow is **Superficial → Deep**. In varicose veins (incompetent perforators), the flow becomes **Deep → Superficial** (high-pressure leak).

Question 359: In Deep Venous Thrombosis (DVT), which of the following findings is typically NOT seen?

A. High fever (Correct Answer)
B. Increased local skin temperature at the affected site
C. Pain
D. Tenderness

Explanation: **Explanation:** Deep Venous Thrombosis (DVT) is characterized by the formation of a blood clot within the deep veins, most commonly in the lower limbs. The clinical presentation is primarily driven by venous obstruction and a localized inflammatory response. **Why High Fever is the Correct Answer:** While a **low-grade fever** (mild pyrexia) can occur due to the inflammatory process associated with thrombus formation, a **high-grade fever** is typically absent. If a patient presents with a high fever, clinicians should suspect alternative diagnoses such as cellulitis or an infected thrombus (septic thrombophlebitis). **Analysis of Incorrect Options:** * **Pain (C) and Tenderness (D):** These are the most common presenting symptoms. Pain results from the distension of the vein wall and perivascular inflammation. Tenderness is usually localized over the course of the involved deep vein (e.g., the calf or thigh). * **Increased Local Skin Temperature (B):** Venous congestion leads to pooling of blood and localized inflammation, which manifests as warmth (calor) and erythema at the affected site. **Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** The three factors contributing to DVT are Stasis, Hypercoagulability, and Endothelial injury. * **Homan’s Sign:** Pain in the calf on dorsiflexion of the foot. Though classic, it is non-specific and potentially dangerous (risk of dislodging a clot). * **Moses Sign:** Pain on squeezing the calf muscles from side to side. * **Gold Standard Investigation:** Contrast Venography (rarely used now). * **Investigation of Choice:** Duplex Ultrasound (highly sensitive and specific). * **Phlegmasia Cerulea Dolens:** A limb-threatening complication of DVT characterized by massive edema, cyanosis, and severe pain.

Question 360: Cocket and Dodd's operation is for which condition?

A. Saphenofemoral flush ligation
B. Subfascial ligation (Correct Answer)
C. Deep vein thrombosis
D. Diabetic foot

Explanation: **Explanation:** **Cocket and Dodd’s operation** is a surgical procedure specifically designed for the treatment of **incompetent perforating veins** in the lower limb, which are a common cause of chronic venous insufficiency and venous ulcers. 1. **Why Option B is Correct:** The procedure involves the **subfascial ligation** of the medial ankle perforators (Cockett’s perforators). In this operation, a long longitudinal incision is made on the medial aspect of the lower leg, the deep fascia is opened, and the perforating veins are identified and ligated as they pass from the superficial system to the deep system. This prevents the high-pressure reflux of blood from deep veins to the skin, allowing venous ulcers to heal. 2. **Why Other Options are Incorrect:** * **Option A (Saphenofemoral flush ligation):** This is known as **Trendelenburg’s operation**, used to treat saphenofemoral junction incompetence, not perforator incompetence. * **Option C (Deep vein thrombosis):** DVT is primarily managed medically with anticoagulants (e.g., Heparin, Warfarin). Surgery is rarely the primary treatment unless phlegmasia cerulea dolens occurs. * **Option D (Diabetic foot):** This condition requires debridement, revascularization (if arterial), or offloading, but not venous subfascial ligation. **High-Yield Clinical Pearls for NEET-PG:** * **SEPS (Subfascial Endoscopic Perforator Surgery):** This is the modern, minimally invasive "Gold Standard" that has largely replaced the open Cocket and Dodd’s operation to reduce wound complications. * **Linton’s Operation:** Another historical subfascial ligation technique involving a more extensive incision. * **Cockett’s Perforators:** Located at 7 cm, 13.5 cm, and 18.5 cm above the medial malleolus.

Practice by Chapter

Atherosclerotic Disease

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Chronic Venous Insufficiency

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Vascular Trauma

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Endovascular Techniques

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Vasculitis

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