Vascular Surgery — MCQs
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A 59-year-old woman, who had a left femoral venous thrombosis during a pregnancy 30 years ago and whose left greater saphenous vein had been stripped at age 21, presents with a large, non-healing ulceration over the medial left calf. The ulcer has continuously progressed despite bed rest, elevation, and the use of a support stocking. Descending phlebography of the left leg demonstrates a patent deep venous system with free flow of dye from the groin to the foot. The first profunda femoris valve is competent. What is the most appropriate management?
What is the most common cause of lymphedema?
What is the most common cause of death in patients with Buerger's disease?
A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?
Which of the following tests is used to diagnose varicose veins?
A 74-year-old female was diagnosed with rheumatic heart disease and underwent valve replacement surgery. A few days later, she started to complain of numbness and inability to move her left leg. Femoral, popliteal, and pedal impulses were not felt on the left side, but the right side examination of the lower leg was normal. What is the most appropriate management in this patient?
What is the most common presenting symptom of acute arterial occlusion?
A patient presents with heaviness of the leg and visible veins of diameter less than 1mm over the posterior aspect of the calf. According to the CEAP classification, what category does this presentation fall under?
Which statement is true regarding the Trendelenburg operation for varicose veins?
Which vessel is most commonly used as a coronary graft?
Vascular Surgery Indian Medical PG Practice Questions and MCQs
Question 361: A 59-year-old woman, who had a left femoral venous thrombosis during a pregnancy 30 years ago and whose left greater saphenous vein had been stripped at age 21, presents with a large, non-healing ulceration over the medial left calf. The ulcer has continuously progressed despite bed rest, elevation, and the use of a support stocking. Descending phlebography of the left leg demonstrates a patent deep venous system with free flow of dye from the groin to the foot. The first profunda femoris valve is competent. What is the most appropriate management?
- A. Division of the superficial femoral vein in the groin and transposition of its distal end onto the profunda femoris vein below the level of the competent profunda valve. (Correct Answer)
- B. Saphenous venous crossover graft with anastomosis of the end of the right saphenous vein onto the side of the competent femoral vein.
- C. Ligated iliofemoral venous thrombectomy with creation of a temporary arteriovenous fistula.
- D. Subfascial ligation of perforating veins in the left calf.
Explanation: ### Explanation **Concept: Deep Venous Reflux and Valve Transposition** The patient presents with **Post-Thrombotic Syndrome (PTS)** characterized by a non-healing venous ulcer. The descending phlebogram reveals a patent but **incompetent deep venous system** (dye flows freely from groin to foot), indicating valvular destruction from the previous DVT. Since conservative management (elevation, stockings) has failed and the **profunda femoris valve is competent**, the goal is to restore valvular function to the deep system. **Why Option A is Correct:** **Venous Valve Transposition** is the procedure of choice when a patient has segmental deep venous reflux but a nearby competent valve (usually the profunda femoris or the greater saphenous vein). By dividing the incompetent superficial femoral vein (SFV) and anastomosing it to the profunda femoris vein below its competent valve, the SFV "borrows" the valvular competence of the profunda system, effectively reducing venous hypertension at the calf. **Why Other Options are Incorrect:** * **Option B (Palma Procedure):** This is a crossover graft used for **iliac vein obstruction**, not valvular reflux. This patient’s system is patent, not obstructed. * **Option C (Thrombectomy + AVF):** This is indicated for **acute** iliofemoral DVT (e.g., Phlegmasia cerulea dolens) to prevent gangrene, not for chronic post-thrombotic ulcers. * **Option D (Linton’s Procedure):** While subfascial ligation addresses incompetent perforators, it is often insufficient if the primary pathology is massive deep venous reflux. In this specific scenario, restoring deep valvular competence is the definitive surgical step. ### Clinical Pearls for NEET-PG * **Gold Standard for Reflux:** Duplex Ultrasound is the initial investigation; **Descending Phlebography** is the gold standard for grading reflux before surgery. * **CEAP Classification:** Venous ulcers are classified as **C6**. * **Surgical Hierarchy:** If a competent valve is available nearby, **Transposition** (Option A) is preferred. If no competent valves exist, a **Vein Valve Transplant** (usually from the axillary vein) is considered.
Question 362: What is the most common cause of lymphedema?
- A. Filariasis (Correct Answer)
- B. Lymph node dissection in malignancies
- C. Bacterial infection
- D. Congenital
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 Filariasis is correct:** Globally, **Filariasis** (caused by *Wuchereria bancrofti*) is the **most common cause of secondary lymphedema**. The adult worms reside in the lymphatic vessels, causing chronic inflammation, fibrosis, and eventual permanent obstruction. This leads to the characteristic "elephantiasis," primarily affecting the lower extremities and scrotum. **Analysis of Incorrect Options:** * **B. Lymph node dissection:** This is the most common cause of secondary lymphedema in **developed countries** (specifically post-mastectomy with axillary clearance for breast cancer). However, on a global scale, filariasis remains more prevalent. * **C. Bacterial infection:** While recurrent cellulitis or lymphangitis can damage lymphatics and worsen existing lymphedema, they are usually secondary complications rather than the primary global cause. * **D. Congenital:** Primary lymphedema (e.g., Milroy’s disease, Meige’s disease) is rare, accounting for less than 10% of all cases. **High-Yield Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the second toe; a pathognomonic clinical sign of lymphedema. * **Stewart-Treves Syndrome:** A rare, highly aggressive **angiosarcoma** that develops in a limb with long-standing chronic lymphedema (most commonly post-mastectomy). * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for evaluating the lymphatic system. * **Treatment:** The mainstay is **Complex Decongestive Therapy (CDT)**, which includes manual lymphatic drainage and compression bandaging. Surgical options like Lymphaticovenular anastomosis (LVA) are reserved for refractory cases.
Question 363: What is the most common cause of death in patients with Buerger's disease?
- A. Gangrene
- B. Pulmonary embolism
- C. Myocardial infarction (Correct Answer)
- D. Carcinoma of the lung
Explanation: **Explanation:** **Buerger’s Disease (Thromboangiitis Obliterans)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects small and medium-sized arteries and veins of the extremities. It is strongly associated with heavy tobacco use. **Why Myocardial Infarction is the correct answer:** While Buerger’s disease is traditionally considered a peripheral vascular disease, patients are typically heavy smokers. This chronic tobacco exposure leads to accelerated systemic atherosclerosis. Although the disease itself causes significant morbidity in the limbs (ulcers/amputations), the **most common cause of mortality** in these patients is **Myocardial Infarction (MI)** due to underlying coronary artery disease. **Analysis of Incorrect Options:** * **A. Gangrene:** This is the most common *complication* and cause of morbidity (leading to amputations), but it is rarely a direct cause of death unless it leads to secondary overwhelming sepsis. * **B. Pulmonary Embolism:** While Buerger’s involves superficial thrombophlebitis, it rarely involves the deep venous system to an extent that causes fatal pulmonary embolism. * **D. Carcinoma of the Lung:** Although these patients are heavy smokers and at high risk for lung cancer, statistically, cardiovascular events (MI) occur earlier and more frequently as the primary cause of death. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Claudication (often involving the arch of the foot), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) due to recanalization of the vessels. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis). * **Management:** The only definitive treatment to prevent disease progression is **absolute smoking cessation**. Sympathectomy may be used for symptomatic relief of rest pain.
Question 364: A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?
- A. Varicose veins
- B. Arteriovenous fistula (Correct Answer)
- C. Buerger disease
- D. Tumour
Explanation: ### Explanation The clinical presentation of **local gigantism** (limb hypertrophy) combined with **pulsatile veins** is a classic hallmark of a **Congenital Arteriovenous (AV) Fistula**. **1. Why Arteriovenous Fistula is correct:** An AV fistula is an abnormal communication between an artery and a vein, bypassing the capillary bed. * **Local Gigantism:** If the fistula is present before the fusion of epiphyses (congenital), the increased blood flow and venous congestion stimulate the periosteum and growth plates, leading to limb lengthening and soft tissue hypertrophy. * **Pulsatile Veins:** High-pressure arterial blood is shunted directly into the low-pressure venous system. This causes the veins to become dilated, tortuous, and exhibit visible pulsations (arterialization of veins). **2. Why the other options are incorrect:** * **Varicose Veins:** While veins are dilated, they are caused by valvular incompetence, not arterial shunting. They do not pulsate and do not cause bony overgrowth or limb gigantism. * **Buerger Disease (Thromboangiitis Obliterans):** This is an occlusive inflammatory disease of small and medium-sized arteries. It typically presents with ischemia, rest pain, and gangrene, rather than limb hypertrophy or venous pulsations. * **Tumour:** While some vascular tumors (like hemangiomas) can cause localized swelling, they do not typically present with generalized limb gigantism and widespread pulsatile venous systems. **Clinical Pearls for NEET-PG:** * **Nicoladoni-Branham Sign:** Bradycardia occurs upon manual compression of the AV fistula (due to a sudden increase in peripheral resistance and vagal reflex). * **Machinery Murmur:** A continuous bruit (heard throughout systole and diastole) is often audible over the site of the fistula. * **Complications:** Long-standing large AV fistulae can lead to **high-output heart failure** due to increased venous return.
Question 365: Which of the following tests is used to diagnose varicose veins?
- A. Cough-impulse test
- B. Trendelenburg test
- C. Schwartz test
- D. All of the above (Correct Answer)
Explanation: To diagnose varicose veins and assess the underlying pathophysiology (venous insufficiency), a series of clinical tests are performed to evaluate the competency of valves and the site of reflux. **Explanation of Options:** * **A. Cough-impulse test (Morrissey’s Test):** This test evaluates **Saphenofemoral Junction (SFJ) incompetency**. When the patient coughs, an impulse or thrill is felt over the SFJ (located 2.5 cm below and lateral to the pubic tubercle) due to the retrograde flow of blood through incompetent valves. * **B. Trendelenburg test:** This is the gold standard clinical test to differentiate between **SFJ incompetency** and **perforator incompetency**. * *Trendelenburg I:* Assesses SFJ competency by observing rapid filling from above when the tourniquet is released. * *Trendelenburg II:* Assesses perforator competency by observing filling from below while the tourniquet is still applied. * **C. Schwartz test (Tap test):** This test confirms the presence of a continuous column of blood in a varicose vein. When the lower part of the vein is tapped, an impulse is felt by the palpating hand at the proximal end, indicating **incompetent valves** between the two points. **Conclusion:** Since all three tests are standard clinical bedside methods to diagnose and localize the site of valvular reflux in varicose veins, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Perthes Test:** Used to check the patency of the **Deep Venous System**. If pain increases or varicosities bulge during walking with a tourniquet, it indicates deep vein occlusion (a contraindication for surgery). * **Fegan’s Test:** Used to identify the exact site of **incompetent perforators** by palpating "blow-outs" or gaps in the deep fascia. * **Gold Standard Investigation:** While clinical tests are high-yield for exams, **Duplex Ultrasound** is the investigation of choice in modern practice.
Question 366: A 74-year-old female was diagnosed with rheumatic heart disease and underwent valve replacement surgery. A few days later, she started to complain of numbness and inability to move her left leg. Femoral, popliteal, and pedal impulses were not felt on the left side, but the right side examination of the lower leg was normal. What is the most appropriate management in this patient?
- A. CT angiogram of bilateral lower extremities
- B. Embolectomy of the left femoral artery (Correct Answer)
- C. Duplex imaging of the left lower extremity arteries
- D. CT angiogram of the left lower extremity
Explanation: ### Explanation This patient presents with the classic **"6 Ps"** of **Acute Limb Ischemia (ALI)**: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Given her history of rheumatic heart disease and recent valve surgery, the most likely diagnosis is an **arterial embolism** (likely originating from the heart). #### 1. Why Embolectomy is Correct In a patient with clear clinical signs of acute limb ischemia (numbness, paralysis, and absent pulses), the limb is threatened. **Immediate surgical intervention** is required to restore blood flow and prevent permanent tissue loss or amputation. **Fogarty catheter embolectomy** of the femoral artery is the gold standard treatment for an acute embolic occlusion. In such emergencies, clinical diagnosis is sufficient to proceed directly to the operating room without delaying for imaging. #### 2. Why Other Options are Incorrect * **A, C, & D (Imaging - CT Angiogram/Duplex):** While these are useful diagnostic tools for chronic ischemia or stable cases, they cause **unnecessary delay** in a patient with neurological deficits (paralysis/numbness). In ALI, "time is muscle." Imaging should only be performed if the diagnosis is in doubt or if the limb is currently viable (Rutherford Grade I). #### 3. Clinical Pearls for NEET-PG * **Most common source of emboli:** Left Atrium (due to Atrial Fibrillation) or prosthetic heart valves. * **Most common site of embolus lodgment:** Femoral artery bifurcation (followed by iliac and popliteal arteries). * **Rutherford Classification:** If a patient has "Paralysis" and "Sensory loss," it is classified as **Rutherford IIb (Immediately Threatened)**, requiring urgent surgery. * **Gold Standard Treatment:** Fogarty embolectomy catheter. * **Initial Medical Step:** Once ALI is suspected, immediate anticoagulation with **IV Heparin** should be started to prevent clot propagation while preparing for surgery.
Question 367: What is the most common presenting symptom of acute arterial occlusion?
- A. Pain (Correct Answer)
- B. Pallor
- C. Pulselessness
- D. Paralysis
Explanation: **Explanation:** Acute arterial occlusion is a surgical emergency characterized by the sudden cessation of blood flow to an extremity. The clinical presentation is classically described by the **"6 Ps"**: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). **Why Pain is the Correct Answer:** **Pain** is the **earliest and most common** presenting symptom. It occurs due to sudden tissue ischemia and the accumulation of metabolic byproducts (like lactic acid) stimulating nociceptors. The pain is typically sudden in onset, severe, and "out of proportion" to physical findings initially. **Analysis of Incorrect Options:** * **B. Pallor:** While an early sign, it usually follows the onset of pain. The limb appears "waxy white" due to the empty superficial capillaries. * **C. Pulselessness:** This is a diagnostic hallmark found on examination, but it is a physical sign rather than a subjective "presenting symptom" reported by the patient. * **D. Paralysis:** This is a **late and ominous sign** indicating advanced ischemia with muscle and nerve death. Along with paresthesia, it suggests a non-viable or threatened limb requiring immediate intervention. **Clinical Pearls for NEET-PG:** * **Golden Period:** Revascularization should ideally occur within **6 hours** to prevent irreversible muscle damage (myonecrosis). * **Most Common Source:** The most common cause of acute embolic occlusion is **Atrial Fibrillation** (emboli usually lodge at the **femoral artery bifurcation**). * **First-line Management:** Immediate anticoagulation with **IV Heparin** to prevent clot propagation, followed by definitive imaging (CT Angiography) or surgery (Fogarty catheter embolectomy).
Question 368: A patient presents with heaviness of the leg and visible veins of diameter less than 1mm over the posterior aspect of the calf. According to the CEAP classification, what category does this presentation fall under?
- A. C0
- B. C1 (Correct Answer)
- C. C2
- D. C3
Explanation: **Explanation:** The **CEAP classification** is the international standard for describing chronic venous disorders. The "C" component (Clinical signs) ranges from C0 to C6 based on the severity of visible manifestations. **Why C1 is the correct answer:** The patient presents with visible veins of **diameter less than 1 mm**. In the CEAP system: * **Telangiectasias (Spider veins):** Confluence of dilated intradermal venules with a diameter **< 1 mm**. * **Reticular veins:** Dilated bluish subdermal veins, usually **1 mm to 3 mm** in diameter. Both telangiectasias and reticular veins are categorized under **C1**. **Analysis of Incorrect Options:** * **C0:** No visible or palpable signs of venous disease (though the patient may have symptoms like heaviness). * **C2:** **Varicose veins**, defined as subcutaneous dilated veins **≥ 3 mm** in diameter. * **C3:** Presence of **Edema** (typically pitting) of venous origin at the ankle or leg. **High-Yield Clinical Pearls for NEET-PG:** * **C4:** Skin changes (C4a: Pigmentation/Eczema; C4b: Lipodermatosclerosis/Atrophie blanche). * **C5:** Healed venous ulcer. * **C6:** **Active** venous ulcer (the most severe clinical stage). * **Gold Standard Investigation:** Duplex Ultrasound is the first-line investigation for chronic venous insufficiency to assess reflux and anatomy. * **Trendelenburg Test:** Used clinically to differentiate between saphenofemoral incompetence and perforator incompetence.
Question 369: Which statement is true regarding the Trendelenburg operation for varicose veins?
- A. Stripping of the superficial varicose vein
- B. Flush ligation of the superficial varicose vein (Correct Answer)
- C. Ligation of the perforators
- D. Ligation of small tributaries at the distal end of the superficial varicose vein
Explanation: ### Explanation The **Trendelenburg operation**, also known as **Juxtafemoral Flush Ligation**, is a classic surgical procedure for varicose veins caused by **Saphenofemoral Junction (SFJ) incompetence**. **1. Why Option B is Correct:** The core principle of the Trendelenburg operation is the **flush ligation** of the Great Saphenous Vein (GSV) at its confluence with the Common Femoral Vein. To prevent recurrence through collateral circulation, all tributaries at the SFJ (Superficial circumflex iliac, Superficial epigastric, Superficial external pudendal, Deep external pudendal, and Postero-medial/Antero-lateral thigh veins) must also be divided. Ligation must be "flush" to ensure no stump is left behind, as a stump can lead to the development of recurrent varicosities (neovascularization). **2. Why Other Options are Incorrect:** * **Option A:** Stripping of the vein (Babcock’s procedure) is often performed *in addition* to the Trendelenburg operation to remove the refluxing GSV trunk, but the Trendelenburg operation itself refers specifically to the ligation at the SFJ. * **Option C:** Ligation of perforators is known as **Cockett and Dodd’s operation** (subfascial ligation). It addresses incompetent communicating veins rather than the SFJ. * **Option D:** Ligation of distal tributaries is ineffective if the proximal SFJ incompetence is not addressed, as the high-pressure reflux from the deep system would persist. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Used to differentiate between SFJ incompetence and perforator incompetence. * **Gold Standard:** While the Trendelenburg operation is historically significant, **Endovenous Thermal Ablation (EVLA/RFA)** is now the first-line treatment for GSV reflux. * **Complication:** The most common nerve injured during GSV stripping is the **Saphenous nerve** (at the ankle/mid-calf).
Question 370: Which vessel is most commonly used as a coronary graft?
- A. Femoral vein
- B. Saphenous vein (Correct Answer)
- C. Axillary vein
- D. Cubital vein
Explanation: **Explanation:** The **Great Saphenous Vein (GSV)** is the most commonly used conduit for Coronary Artery Bypass Grafting (CABG). Its popularity stems from its long length, ease of accessibility, and the fact that its removal typically results in minimal morbidity to the lower limb. While the **Internal Thoracic Artery (ITA)** is the "gold standard" for the Left Anterior Descending (LAD) artery due to superior long-term patency, the GSV remains the primary choice for multi-vessel grafting because it can provide multiple segments of graft material. **Analysis of Incorrect Options:** * **A. Femoral Vein:** This is a deep vein of the leg. Harvesting it would severely compromise venous return from the lower limb, leading to chronic venous insufficiency and significant edema. * **C. Axillary Vein:** This is a major deep vein of the upper limb. It is not used for grafting due to its large caliber, deep anatomical location, and the risk of severe arm swelling post-harvest. * **D. Cubital Vein:** These veins (like the median cubital) are superficial but are generally too short, thin-walled, and prone to phlebitis from prior venipunctures to be used as reliable arterial conduits. **Clinical Pearls for NEET-PG:** * **Gold Standard:** The **Left Internal Mammary Artery (LIMA)** has the highest 10-year patency rate (>90%) and is the graft of choice for the LAD. * **Reversal:** When using the Saphenous Vein, it must be **reversed** (or valves must be lysed) to ensure blood flow is not obstructed by venous valves. * **Radial Artery:** Often used as the second choice for arterial grafting, but requires a preoperative **Allen’s Test** to ensure adequate ulnar collateral circulation. * **Harvesting Technique:** Endoscopic Vein Harvesting (EVH) is now preferred over open harvesting to reduce wound complications.
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