Vascular Surgery Practice Questions

Q: Which of the following is false regarding Kasabach syndrome?

Coagulopathy is absent.. **Explanation:** **Kasabach-Merritt Syndrome (KMS)** is a rare, life-threatening condition characterized by the association of a rapidly growing vascular tumor with **consumptive coagulopathy**. **1. Why Option B is the Correct Answer (The False Statement):** The hallmark of Kasabach-Merritt Syndrome is severe **consumptive coagulopathy**. Within the abnormal architecture of the vascular tumor, there is intense platelet sequestration and activation of the clotting cascade. This leads to the depletion of platelets, fibrinogen, and other clotting factors, often resulting in Disseminated Intravascular Coagulation (DIC). Therefore, stating that coagulopathy is absent is medically incorrect. **2. Analysis of Other Options:** * **Options A & C:** KMS typically arises as a complication of specific vascular tumors. While historically associated with "giant hemangiomas," it is now more accurately linked to **Kaposiform hemangioendothelioma** or **Tufted angioma**. * **Option D:** **Thrombocytopenia** is a cardinal feature. Platelets are trapped and destroyed within the tumor (sequestration), leading to profound low platelet counts and a high risk of spontaneous bleeding. **High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad:** Large vascular tumor + Thrombocytopenia + Consumptive Coagulopathy (low fibrinogen, elevated D-dimer). * **Most Common Site:** Trunk and extremities; however, it can occur retroperitoneally. * **Treatment:** The first-line medical therapy is often **Sirolimus** (mTOR inhibitor) or Corticosteroids. Surgery is rarely feasible due to the infiltrative nature and bleeding risk. * **Distinction:** It is *not* usually seen with common infantile (strawberry) hemangiomas.

Q: Visceral aneurysm is most commonly seen in which of the following locations?

Splenic. **Explanation:** Visceral artery aneurysms (VAAs) are rare but clinically significant due to their risk of rupture. Among all visceral locations, the **Splenic artery** is the most common site, accounting for approximately **60%** of all visceral aneurysms. **1. Why Splenic Artery is Correct:** Splenic artery aneurysms (SAAs) are most frequently seen in women, particularly during pregnancy, due to hormonal changes (estrogen/progesterone) and increased portal congestion which weaken the arterial wall. Other risk factors include portal hypertension and medial fibromuscular dysplasia. They are often asymptomatic until they rupture, which classically presents as a "double-rupture" phenomenon into the lesser sac and then the peritoneal cavity. **2. Analysis of Incorrect Options:** * **Hepatic Artery (B):** This is the second most common site (approx. 20%). They are often associated with trauma, infection (mycotic), or vasculitis. * **Renal Artery (C):** These account for about 15-20% of cases. While significant, they are less frequent than splenic aneurysms. * **Coronary Artery (D):** These are not classified as "visceral" aneurysms in the standard surgical context; they are cardiac/vascular and are most commonly associated with Kawasaki disease in children or atherosclerosis in adults. **Clinical Pearls for NEET-PG:** * **Rule of 2cm:** Treatment (surgical or endovascular) for SAAs is generally indicated if the aneurysm is **>2 cm**, symptomatic, or if the patient is **pregnant/planning pregnancy** (due to high maternal and fetal mortality rates upon rupture). * **Most common site overall:** Splenic Artery. * **Most common cause of Hepatic Aneurysm:** Historically infection/trauma; currently, iatrogenic causes (post-procedure) are rising. * **Celiac Artery Aneurysms:** These are the rarest among the major visceral branches.

Q: What is the management of a case of iliac artery embolism?

Embolectomy. **Explanation:** The management of acute limb ischemia caused by an arterial embolism is a surgical emergency. The definitive treatment for an **iliac artery embolism** is an **Embolectomy**, typically performed using a **Fogarty balloon catheter**. **1. Why Embolectomy is Correct:** An embolism causes sudden, complete mechanical obstruction of the vessel. To salvage the limb and prevent irreversible gangrene, the clot must be physically removed to restore distal perfusion. For iliac involvement, a retrograde embolectomy is usually performed via a femoral artery incision (Fogarty technique). This is the gold standard for large-vessel acute embolic events. **2. Why Other Options are Incorrect:** * **Injection of vasodilators:** While they may help reduce associated vasospasm, they cannot bypass or dissolve a large mechanical obstruction like an iliac embolus. * **Hypotensive therapy:** This is contraindicated. Maintaining adequate systemic blood pressure is vital to encourage collateral circulation. Hypotension would worsen ischemia. * **Sympathectomy:** This procedure aims to increase skin blood flow in chronic peripheral vascular disease (Buerger’s disease). It has no role in the acute management of a major arterial embolism. **Clinical Pearls for NEET-PG:** * **The 6 P’s of Acute Ischemia:** Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). * **Fogarty Catheter:** The most important tool in embolectomy. It is usually inflated with saline or air. * **Time Window:** Irreversible muscle damage begins after **6 hours** of total ischemia. * **Source:** The most common source of an iliac embolus is the heart (Atrial Fibrillation or post-MI mural thrombus). * **Post-op:** Always monitor for **Reperfusion Injury** (Hyperkalemia, Myoglobinuria, and Compartment Syndrome).

Q: Which statement is true about aortic transaction?

Most commonly associated with deceleration injury. **Explanation:** **Aortic Transection** (Traumatic Aortic Disruption) is a life-threatening emergency typically resulting from blunt chest trauma. **1. Why Option A is correct:** The primary mechanism is a **sudden deceleration injury** (e.g., high-speed motor vehicle accidents or falls from heights). During deceleration, the mobile heart and ascending aorta move forward, while the descending aorta is fixed to the posterior chest wall. This creates a powerful **shearing force** at the **Aortic Isthmus** (the junction between the fixed arch and mobile descending aorta, just distal to the left subclavian artery), which is the most common site of injury (90%). **2. Why other options are incorrect:** * **Option B:** While mortality is high (80% die at the scene), the question asks for the "most true" characteristic regarding its nature/etiology. In modern exams, "High mortality" is considered a clinical outcome rather than a defining diagnostic feature. * **Option C:** While surgery was historically the definitive treatment, **Endovascular Aneurysm Repair (TEVAR)** has now become the preferred first-line management over open surgery due to lower morbidity. * **Option D:** **CT Angiography (CTA)** is now the gold standard and investigation of choice due to its high sensitivity and speed. Conventional aortography is invasive and rarely used today. **Clinical Pearls for NEET-PG:** * **Most common site:** Aortic Isthmus (distal to the origin of the left subclavian artery). * **X-ray findings:** Widened mediastinum (>8cm), loss of aortic knob contour, and deviation of the nasogastric tube to the right. * **Management:** Initial stabilization involves "permissive hypotension" (keeping SBP ~100 mmHg) using Beta-blockers (Esmolol) to prevent complete rupture before definitive TEVAR.

Q: Cirsoid aneurysm affects which of the following arteries?

All of the above. **Explanation:** A **Cirsoid aneurysm** is not a true aneurysm but rather a rare, acquired **arteriovenous malformation (AVM)** or fistula occurring in the scalp. It consists of a direct communication between high-pressure arteries and low-pressure veins without an intervening capillary bed. **Why "All of the above" is correct:** The scalp is highly vascular, and these malformations are typically fed by the major branches of the external carotid artery. The **superficial temporal artery** is the most common feeder, but the **occipital artery** and **posterior auricular artery** are frequently involved, often simultaneously. Because these lesions are usually multi-pedicular (supplied by multiple vessels), all the listed arteries can be affected. **Clinical Features & High-Yield Facts:** * **Presentation:** It presents as a pulsatile, "worm-like" swelling under the scalp (hence the name *cirsoid*, meaning "varix-like"). * **Pathognomonic Signs:** Patients often complain of a persistent headache or a "bruit" (rushing sound) in the ear. On examination, a **palpable thrill** and an audible bruit are present. * **Diagnostic Clue:** The swelling characteristically empties on pressing the feeding vessels and refills rapidly upon release. * **Management:** Pre-operative angiography is essential to map the feeders. Treatment involves surgical excision or endovascular embolization. **NEET-PG Pearl:** While the **superficial temporal artery** is the *most common* single artery involved, in the context of a "Which of the following" question, remember that cirsoid aneurysms are typically **multi-arterial** involving any or all branches of the external carotid artery supplying the scalp.

Q: Which of the following statements about the SEPS procedure is false?

A vascular clip is applied above the level of deep fascia.. **Explanation:** **SEPS (Subfascial Endoscopic Perforator Surgery)** is a minimally invasive surgical technique used to treat chronic venous insufficiency (CVI), specifically targeting incompetent perforating veins. **1. Why Option C is the Correct (False) Statement:** The fundamental principle of SEPS is to ligate perforating veins in the **subfascial space** (the space between the deep fascia and the muscle). In this procedure, an endoscope and instruments are inserted beneath the deep fascia. Therefore, the vascular clips are applied to the perforators **below the level of the deep fascia**, not above it. Applying clips above the fascia would fail to address the segment of the vein that connects the superficial and deep systems. **2. Analysis of Other Options:** * **Option A:** This is true. SEPS is specifically indicated for patients with **incompetent perforators**, especially those with advanced venous disease (CEAP classes C4–C6) like venous ulcers or lipodermatosclerosis. * **Option B:** This is true. The procedure utilizes a **laparoscopic-like setup** with a camera (endoscope) and a balloon dissector to create space under the fascia, allowing for visualization and ligation of the veins. **Clinical Pearls for NEET-PG:** * **Indication:** Primarily used for **venous ulcers (CEAP C6)** where traditional open surgery (Linton’s procedure) is avoided due to high wound complication rates in diseased skin. * **Advantage over Linton’s:** SEPS significantly reduces wound infection and skin necrosis because the incisions are made in healthy proximal skin, away from the ulcer site. * **Contraindications:** Arterial insufficiency (ABI < 0.5) and deep vein thrombosis (DVT). * **Key Anatomy:** Perforators connect the superficial system (Great/Small Saphenous) to the deep system (Femoral/Popliteal) by piercing the deep fascia.

Q: To create a porto-caval shunt in a patient with portal hypertension, which of the following venous anastomoses should be performed?

Left splenic vein to left renal vein. **Explanation:** The primary goal of a porto-caval shunt is to decompress the portal venous system by diverting blood into the systemic circulation (Inferior Vena Cava - IVC). **Why Option D is Correct:** The **Left splenic vein to left renal vein** anastomosis is known as the **Warren Shunt (Distal Splenorenal Shunt)**. This is a selective shunt where the splenic vein is disconnected from the portal vein and joined to the left renal vein. It selectively decompresses esophageal varices while maintaining portal blood flow to the liver, thereby reducing the risk of hepatic encephalopathy compared to total shunts. **Analysis of Incorrect Options:** * **Option A:** Connecting the superior mesenteric vein to the inferior mesenteric vein is a **porto-portal** anastomosis. It does not provide a systemic outlet and thus cannot decompress the portal system. * **Option B:** The right and left gastric veins are both components of the portal system. Joining them does not create a shunt into the systemic circulation. * **Option C:** While this connects a portal tributary to the IVC, it is not a standard surgical procedure. The right gastric vein is typically too small for a technically feasible or hemodynamically significant shunt. **High-Yield Clinical Pearls for NEET-PG:** * **Non-selective Shunts:** Include the **Eck Shunt** (End-to-side Portacaval) and the **Side-to-side Portacaval Shunt**. These carry a high risk of hepatic encephalopathy. * **TIPS (Transjugular Intrahepatic Portosystemic Shunt):** A radiological procedure connecting the hepatic vein to a branch of the portal vein. It is the preferred treatment for refractory variceal bleeding. * **H-Shunt:** A synthetic graft (usually PTFE) placed between the Superior Mesenteric Vein (SMV) and the IVC.

Question 1

A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?

Accepted Answer

Duplex ultrasonography and heparin

Answer

Venography and heparin

Answer

Duplex ultrasonography, heparin, and vena caval filter

Answer

Duplex ultrasonography, heparin, and warfarin (Coumadin)

Question 2

Which of the following is false regarding Kasabach syndrome?

Accepted Answer

Coagulopathy is absent.

Answer

May be a complication of a hemangioma.

Answer

Due to complication of hemangioma.

Answer

Thrombocytopenia is present.

Question 3

Visceral aneurysm is most commonly seen in which of the following locations?

Accepted Answer

Splenic

Answer

Renal

Answer

Hepatic

Answer

Coronary

Question 4

What is the management of a case of iliac artery embolism?

Accepted Answer

Embolectomy

Answer

Injection of vasodilators

Answer

Hypotensive therapy

Answer

Sympathectomy

Question 5

A 50-year-old man with aortic stenosis is exercising for 11 minutes according to the Bruce protocol. Exercise stopped due to fatigue, and the transaortic pressure gradient is 60 mm Hg. What is the best management?

Accepted Answer

Observation

Answer

Angiogram

Answer

Aortic valve replacement

Answer

Aortic balloon valvuloplasty

Question 6

Which statement is true about aortic transaction?

Accepted Answer

Most commonly associated with deceleration injury

Answer

High mortality

Answer

Surgery is the definitive treatment

Answer

Aortography is the gold standard

Question 7

Cirsoid aneurysm affects which of the following arteries?

Accepted Answer

All of the above

Answer

Superficial temporal artery

Answer

Occipital artery

Answer

Posterior auricular artery

Question 8

Obstruction at the bifurcation of the aorta leads to which of the following clinical manifestations?

Accepted Answer

Claudication of the buttocks and thighs

Answer

Retrograde ejaculation

Answer

Gangrene

Answer

Pallor of the lower limb

Question 9

Which of the following statements about the SEPS procedure is false?

Accepted Answer

A vascular clip is applied above the level of deep fascia.

Answer

It is used for incompetent perforators.

Answer

The procedure is performed with the help of an endoscope.

Answer

None of the above.

Question 10

To create a porto-caval shunt in a patient with portal hypertension, which of the following venous anastomoses should be performed?

Accepted Answer

Left splenic vein to left renal vein

Answer

Superior mesenteric vein to inferior mesenteric vein

Answer

Right gastric vein to left gastric vein

Answer

Right gastric vein to inferior vena cava

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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