Vascular Surgery Practice Questions

Q: What is the most common cause of lymphedema?

Filariasis. **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.

Q: A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?

Arteriovenous fistula. ### 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.

Q: Which of the following tests is used to diagnose varicose veins?

All of the above. 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.

Q: 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?

Embolectomy of the left femoral artery. ### 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.

Q: What is the most common presenting symptom of acute arterial occlusion?

Pain. **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).

Q: 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?

C1. **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.

Q: Which vessel is most commonly used as a coronary graft?

Saphenous vein. **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.

Q: Which statement is true regarding the Trendelenburg operation for varicose veins?

Flush ligation of the superficial varicose vein. ### 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 1

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?

Accepted Answer

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.

Answer

Saphenous venous crossover graft with anastomosis of the end of the right saphenous vein onto the side of the competent femoral vein.

Answer

Ligated iliofemoral venous thrombectomy with creation of a temporary arteriovenous fistula.

Answer

Subfascial ligation of perforating veins in the left calf.

Question 2

What is the most common cause of lymphedema?

Accepted Answer

Filariasis

Answer

Lymph node dissection in malignancies

Answer

Bacterial infection

Answer

Congenital

Question 3

What is the most common cause of death in patients with Buerger's disease?

Accepted Answer

Myocardial infarction

Answer

Gangrene

Answer

Pulmonary embolism

Answer

Carcinoma of the lung

Question 4

A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?

Accepted Answer

Arteriovenous fistula

Answer

Varicose veins

Answer

Buerger disease

Answer

Tumour

Question 5

Which of the following tests is used to diagnose varicose veins?

Accepted Answer

All of the above

Answer

Cough-impulse test

Answer

Trendelenburg test

Answer

Schwartz test

Question 6

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?

Accepted Answer

Embolectomy of the left femoral artery

Answer

CT angiogram of bilateral lower extremities

Answer

Duplex imaging of the left lower extremity arteries

Answer

CT angiogram of the left lower extremity

Question 7

What is the most common presenting symptom of acute arterial occlusion?

Accepted Answer

Pain

Answer

Pallor

Answer

Pulselessness

Answer

Paralysis

Question 8

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?

Accepted Answer

C1

Answer

C0

Answer

C2

Answer

C3

Question 9

Which vessel is most commonly used as a coronary graft?

Accepted Answer

Saphenous vein

Answer

Femoral vein

Answer

Axillary vein

Answer

Cubital vein

Question 10

Which statement is true regarding the Trendelenburg operation for varicose veins?

Accepted Answer

Flush ligation of the superficial varicose vein

Answer

Stripping of the superficial varicose vein

Answer

Ligation of the perforators

Answer

Ligation of small tributaries at the distal end of the superficial varicose vein

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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