Vascular Surgery — MCQs

A 70-year-old woman with a history of myocardial ischemia and peripheral vascular disease presented with sudden onset of severe, rapidly increasing epigastric pain, nausea, vomiting, and minimal abdominal tenderness. She was writhing in pain, had normal bowel sounds, and a small amount of blood in her stool. Electrolyte analysis revealed a bicarbonate level of 15 mEq/L, and serum lactate was elevated, indicating tissue hypoxia and injury. A CT scan was planned. What anatomical structure is likely involved?

Q35Easy

Which of the following describes stage 3 limb ischemia as per the Fontaine classification?

Q36Easy

Which sympathetic ganglia are spared in a lumbar sympathectomy?

Q37Medium

Which of the following statements about ischemic rest pain is TRUE?

Q38Easy

In the CEAP classification of varicose veins, which stage is characterized by the 'beer bottle appearance'?

Q39Medium

A 24-year-old man complains of progressive intermittent claudication of the left leg. On examination, the popliteal, dorsalis pedis, and posterior tibial pulses are normal but disappear on dorsiflexion of the foot. What is the most likely diagnosis?

Q40Easy

Which one of the following is NOT a feature of Leriche syndrome?

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 31: Intermittent claudication is seen when the ankle-brachial index is?

A. 0.9-1.0
B. <0.3
C. 0.5-0.9 (Correct Answer)
D. >1.1

Explanation: The **Ankle-Brachial Index (ABI)** is the ratio of the systolic blood pressure at the ankle to the systolic blood pressure in the arm. It is the gold-standard bedside screening tool for Peripheral Arterial Disease (PAD). ### **Why 0.5–0.9 is Correct** An ABI between **0.5 and 0.9** indicates mild-to-moderate arterial insufficiency. At this stage, blood flow is sufficient at rest but becomes inadequate during exercise when metabolic demands of the muscles increase. This leads to **intermittent claudication**—muscle pain (usually in the calf) that occurs during walking and is relieved by rest. ### **Analysis of Incorrect Options** * **A. 0.9–1.0:** This is considered the **low-normal** range. While it may indicate very early disease, patients are typically asymptomatic. * **B. <0.3:** This indicates **severe ischemia**. At this level, patients experience **rest pain**, ulceration, or gangrene (Critical Limb Ischemia). ABI for rest pain is typically <0.5, and for impending gangrene, it is <0.3. * **D. >1.1 (or >1.3):** An ABI >1.3 suggests **non-compressible, calcified vessels**. This is commonly seen in patients with long-standing Diabetes Mellitus or Chronic Kidney Disease (Monckeberg’s medial sclerosis), rendering the ABI unreliable. ### **High-Yield NEET-PG Pearls** * **Normal ABI:** 1.0–1.2. * **Best Initial Test for PAD:** ABI. * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Treadmill Test:** If a patient has classic claudication symptoms but a normal resting ABI, perform a post-exercise ABI (a drop of >15-20% is diagnostic). * **Toe-Brachial Index (TBI):** Used when ABI is unreliable (>1.3) because digital arteries are rarely calcified. A TBI <0.7 is abnormal.

Question 32: Complications arising out of A-V fistula done for renal failure include the following EXCEPT?

A. Infection
B. Thrombosis
C. High output cardiac failure
D. Necrosis of the distal part (Correct Answer)

Explanation: **Explanation:** Arteriovenous (AV) fistulas are the gold standard for long-term hemodialysis access. While they have lower complication rates than grafts, specific sequelae can occur. **Why "Necrosis of the distal part" is the correct answer:** While AV fistulas can cause **"Steal Syndrome"** (where blood is diverted away from the distal extremity), it typically manifests as coldness, pallor, or pain during exercise (claudication). True **necrosis or gangrene** of the distal part is **extremely rare** in a standard AV fistula because the collateral circulation around the wrist and elbow is usually sufficient to prevent tissue death. If necrosis occurs, it usually implies underlying severe peripheral arterial disease rather than being a direct, common complication of the fistula itself. **Analysis of Incorrect Options:** * **Infection (A):** Although less common than in prosthetic grafts, infections can occur due to repeated needle punctures for dialysis, leading to cellulitis or abscess. * **Thrombosis (B):** This is the **most common cause of fistula failure**. It often results from hypotension, excessive compression post-dialysis, or underlying venous outflow stenosis. * **High output cardiac failure (C):** An AV fistula reduces total peripheral resistance. If the fistula flow is too high (typically >20% of cardiac output), it can lead to increased venous return and subsequent high-output heart failure. **Clinical Pearls for NEET-PG:** * **Steal Syndrome:** Most common in brachiocephalic fistulas. Management involves the **DRIL procedure** (Distal Revascularization-Interval Ligation). * **Aneurysm formation:** Repeated punctures in the same area can weaken the vessel wall, leading to pseudoaneurysms. * **Thrill and Bruit:** The presence of a palpable thrill and audible bruit is essential for a functioning fistula. Loss of these signs indicates **thrombosis**. * **Rule of 6s:** A mature fistula should have a diameter >6mm, be <6mm deep, and have a flow >600ml/min.

Question 33: A 45-year-old woman presents with right lower extremity swelling and multiple varicosities two months after undergoing cardiac catheterization via a right femoral approach. Examination reveals a bruit over the right groin. What is the most likely diagnosis?

A. Femoral artery thrombosis
B. Superficial venous insufficiency
C. Arteriovenous (AV) fistula (Correct Answer)
D. Pseudoaneurysm

Explanation: ### Explanation **Correct Answer: C. Arteriovenous (AV) fistula** **Why it is correct:** An acquired arteriovenous fistula (AVF) is a known complication of percutaneous arterial access (like cardiac catheterization). It occurs when a needle track creates a persistent communication between the femoral artery and the adjacent femoral vein. * **Pathophysiology:** High-pressure arterial blood shunts into the low-pressure venous system. * **Clinical Presentation:** This leads to **venous hypertension**, manifesting as limb swelling and secondary varicose veins. The hallmark physical finding is a **continuous bruit** (often described as "machinery-like") and a palpable thrill over the site of injury. **Why incorrect options are wrong:** * **A. Femoral artery thrombosis:** This would present with signs of acute or chronic limb ischemia (the "6 Ps": pain, pallor, pulselessness, etc.) rather than swelling and varicosities. * **B. Superficial venous insufficiency:** While this causes varicosities, it is usually a chronic, primary degenerative process. The sudden onset following a groin procedure and the presence of a localized bruit point specifically to a vascular injury. * **D. Pseudoaneurysm:** This also occurs post-catheterization but represents a contained hematoma communicating with the artery. It typically presents as a **painful, pulsatile mass** with a **systolic bruit** (not continuous) and a characteristic "to-and-fro" murmur. It does not typically cause distal venous hypertension/varicosities. **NEET-PG High-Yield Pearls:** * **Diagnosis:** Duplex Ultrasound is the initial investigation of choice (shows turbulent flow between vessels). Gold standard is Angiography. * **Bruit Characteristics:** AVF = Continuous bruit; Pseudoaneurysm = Systolic bruit. * **Nicoladoni-Branham Sign:** Bradycardia produced by manual compression of the artery proximal to an AV fistula (due to sudden increase in systemic vascular resistance). * **Complication:** Large, long-standing AVFs can lead to high-output cardiac failure.

Question 34: A 70-year-old woman with a history of myocardial ischemia and peripheral vascular disease presented with sudden onset of severe, rapidly increasing epigastric pain, nausea, vomiting, and minimal abdominal tenderness. She was writhing in pain, had normal bowel sounds, and a small amount of blood in her stool. Electrolyte analysis revealed a bicarbonate level of 15 mEq/L, and serum lactate was elevated, indicating tissue hypoxia and injury. A CT scan was planned. What anatomical structure is likely involved?

A. A
B. B
C. C (Correct Answer)
D. D

Explanation: ***C (Superior Mesenteric Artery)*** - The **pain out of proportion to physical findings** with **elevated lactate** and **metabolic acidosis** (bicarbonate 15 mEq/L) are classic for **acute mesenteric ischemia** affecting the SMA territory. - Patient's history of **myocardial ischemia** and **peripheral vascular disease** are significant risk factors for **mesenteric arterial thrombosis** or embolism, with the SMA being most commonly affected due to its anatomy and flow characteristics. *A (Celiac Artery)* - Celiac artery occlusion typically causes **chronic mesenteric ischemia** with **postprandial pain** and **weight loss**, not acute presentation. - The **extensive collateral circulation** from the celiac trunk usually prevents acute ischemic symptoms unless there's concurrent SMA involvement. *B (Inferior Mesenteric Artery)* - IMA territory ischemia rarely presents with **severe acute symptoms** due to **abundant collateral circulation** from the middle colic and internal iliac arteries. - **Left-sided colonic ischemia** from IMA involvement typically presents with **left lower quadrant pain** and **bloody diarrhea**, not epigastric pain. *D (Portal Vein)* - **Portal vein thrombosis** presents with **gradual onset** of **ascites**, **splenomegaly**, and **variceal bleeding**, not acute severe abdominal pain. - **Elevated lactate** and **metabolic acidosis** are uncommon in portal vein thrombosis unless there's concurrent **bowel infarction** from arterial compromise.

Question 35: Which of the following describes stage 3 limb ischemia as per the Fontaine classification?

A. Well compensated intermittent claudication
B. Poorly compensated intermittent claudication
C. Rest pain (Correct Answer)
D. Ischemic ulcer

Explanation: The **Fontaine classification** is a clinical tool used to stage the severity of Chronic Limb-Threatening Ischemia (CLTI) based on symptoms. ### **Explanation of the Correct Answer** **Stage 3** is characterized by **Rest Pain**. This occurs when the arterial supply is so severely compromised that it cannot meet the metabolic demands of the tissues even at rest. The pain is typically worse at night when the patient is supine (loss of gravity-assisted flow) and is often relieved by hanging the foot over the edge of the bed. ### **Analysis of Incorrect Options** * **Option A & B (Intermittent Claudication):** These represent **Stage 2**. In Fontaine’s system, Stage 2 is subdivided based on walking distance: * **Stage 2a:** Claudication distance > 200 meters (Well compensated). * **Stage 2b:** Claudication distance < 200 meters (Poorly compensated). * **Option D (Ischemic Ulcer):** This represents **Stage 4**, which involves trophic changes such as non-healing ulcers or gangrene. ### **High-Yield Facts for NEET-PG** * **Stage 1:** Asymptomatic (often identified by a reduced Ankle-Brachial Index). * **Critical Limb Ischemia (CLI):** Defined as Fontaine stages 3 and 4. * **Rutherford Classification:** An alternative 7-stage (0-6) system used in clinical trials that incorporates objective findings (e.g., treadmill tests). * **Clinical Pearl:** Rest pain usually signifies a systolic pressure < 50 mmHg at the ankle or < 30 mmHg at the toe. Always check for the "Buerger’s angle" (angle of circulatory insufficiency) during physical examination.

Question 36: Which sympathetic ganglia are spared in a lumbar sympathectomy?

A. L1 (Correct Answer)
B. L2
C. L3
D. L4

Explanation: **Explanation:** Lumbar sympathectomy involves the excision of the sympathetic chain to increase peripheral blood flow, primarily used in conditions like Buerger’s disease (TAO) or peripheral arterial disease. **Why L1 is spared:** The **L1 sympathetic ganglion** must be preserved, especially in males, because it provides the preganglionic sympathetic fibers to the **hypogastric plexus**. These fibers control the contraction of the internal urethral sphincter and the smooth muscle of the vas deferens/seminal vesicles. Excision of the L1 ganglion leads to **retrograde ejaculation** and potential impotence. Therefore, a standard lumbar sympathectomy typically involves the removal of the **L2, L3, and L4** ganglia. **Analysis of Incorrect Options:** * **B (L2), C (L3), and D (L4):** These ganglia are the primary targets for excision. Removing these segments effectively denervates the lower limb vessels (vasodilation) and sweat glands (anhidrosis) without affecting the pelvic autonomic functions associated with L1. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Most common indication is **Buerger’s disease** (Thromboangiitis Obliterans) with rest pain or small areas of gangrene. * **Anatomical Landmark:** The sympathetic chain lies on the bodies of the lumbar vertebrae, **medial to the Psoas major** muscle. On the right side, it lies behind the Inferior Vena Cava (IVC). * **Clinical Test:** A successful sympathectomy results in a **warm and dry foot** (due to loss of vasomotor and sudomotor tone). * **Post-Op Complication:** The most common complication is **post-sympathectomy neuralgia** (pain in the groin/thigh), which is usually self-limiting.

Question 37: Which of the following statements about ischemic rest pain is TRUE?

A. 1. More at night, 3. Increases upon elevation of limb, and 5. Often associated with trophic changes are true, while 2 and 4 are false.
B. 2. Usually confined to forefoot, 3. Increases upon elevation of limb, and 4. Relieved by dependent position are true, while 1 and 5 are false.
C. 1. More at night, 2. Usually confined to forefoot, 3. Increases upon elevation of limb, and 4. Relieved by dependent position are true, while 5 is false.
D. All statements are true. (Correct Answer)

Explanation: **Explanation:** Ischemic rest pain is a hallmark of **Critical Limb Ischemia (CLI)**, representing Fontaine Stage III or Rutherford Category 4 disease. It occurs when resting blood flow is insufficient to meet the basic metabolic demands of tissues. **Why all statements are true:** 1. **More at night:** During sleep, the beneficial effect of gravity is lost, and cardiac output/blood pressure naturally decrease, further reducing distal perfusion. 2. **Confined to forefoot:** Pain is typically felt in the most distal parts of the limb (toes and metatarsal heads) where perfusion pressure is lowest. 3. **Increases upon elevation:** Elevating the limb removes the hydrostatic pressure that aids arterial flow, worsening the ischemia. 4. **Relieved by dependent position:** Patients often hang their legs over the side of the bed or sleep in a chair. This uses gravity to increase hydrostatic pressure, improving capillary perfusion. 5. **Trophic changes:** Chronic ischemia leads to visible signs like hair loss, brittle nails, shiny/scaly skin, and muscle atrophy. **Analysis of Options:** Options A, B, and C are incorrect because they exclude one or more of the defining clinical features of rest pain. In NEET-PG, rest pain is classically described by the triad of **nocturnal occurrence, relief by dependency, and distal localization.** **Clinical Pearls for NEET-PG:** * **Fontaine Classification:** Stage I (Asymptomatic), II (Claudication), III (Rest Pain), IV (Ulcer/Gangrene). * **Ankle-Brachial Index (ABI):** Rest pain usually occurs when the ABI is **<0.4**. * **Differential Diagnosis:** Must be distinguished from diabetic neuropathy (which is usually burning/numb and not relieved by dependency) and night cramps. * **Management:** Rest pain is a surgical emergency requiring urgent revascularization to prevent limb loss.

Question 38: In the CEAP classification of varicose veins, which stage is characterized by the 'beer bottle appearance'?

A. C1
B. C2
C. C4a
D. C4b (Correct Answer)

Explanation: The **CEAP classification** is the international standard for describing Chronic Venous Disorders. The "beer bottle appearance" (also known as **inverted champagne bottle leg**) is a classic clinical sign of advanced venous disease. ### **Explanation of the Correct Answer** **C4b** represents advanced skin changes due to chronic venous hypertension. It is characterized by **Lipodermatosclerosis (LDS)** and **Atrophie blanche**. * **Pathophysiology:** Chronic inflammation and fibrosis of the dermis and subcutaneous fat (LDS) cause the lower third of the leg to become hard and constricted. * **Appearance:** The proximal calf remains relatively normal or becomes edematous, while the ankle area becomes narrow and fibrotic. This creates the characteristic **"inverted champagne bottle"** or **"beer bottle"** shape. ### **Analysis of Incorrect Options** * **C1:** Refers to **Telangiectasia** (spider veins) or reticular veins (<3mm). No significant skin changes are present. * **C2:** Refers to **Varicose veins** (dilated, tortuous veins >3mm). This is a purely vascular stage without skin involvement. * **C4a:** Represents early skin changes such as **pigmentation** (hemosiderin staining) or **venous eczema**. While skin is affected, the deep structural fibrosis (LDS) required for the bottle appearance has not yet occurred. ### **High-Yield Clinical Pearls for NEET-PG** * **CEAP Mnemonic:** **C**linical, **E**tiological, **A**natomical, **P**athophysiological. * **C3:** Characterized by **Edema** without skin changes. * **C5 vs. C6:** C5 is a **healed** venous ulcer; C6 is an **active** venous ulcer. * **Gaiter Zone:** The area between the mid-calf and the malleolus where venous ulcers and C4 changes most commonly occur. * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence.

Question 39: A 24-year-old man complains of progressive intermittent claudication of the left leg. On examination, the popliteal, dorsalis pedis, and posterior tibial pulses are normal but disappear on dorsiflexion of the foot. What is the most likely diagnosis?

A. Embolic occlusion
B. Thromboangiitis obliterans
C. Atherosclerosis obliterans
D. Popliteal artery entrapment syndrome (Correct Answer)

Explanation: **Explanation:** The correct diagnosis is **Popliteal Artery Entrapment Syndrome (PAES)**. This condition occurs due to an abnormal anatomical relationship between the popliteal artery and the surrounding myofascial structures in the popliteal fossa (most commonly the medial head of the gastrocnemius muscle). **Why it is correct:** The hallmark of PAES is **intermittent claudication in a young, otherwise healthy patient** without cardiovascular risk factors. The pathognomonic clinical sign is the presence of normal distal pulses at rest that **disappear or diminish with provocative maneuvers** such as active plantarflexion or passive dorsiflexion of the foot. These movements cause the anomalous muscle or fibrous band to compress the artery, leading to acute ischemia. **Why incorrect options are wrong:** * **Embolic occlusion:** Presents as acute-onset limb ischemia (the 6 P's: Pain, Pallor, Pulselessness, etc.) rather than progressive claudication. Pulses would not reappear at rest. * **Thromboangiitis obliterans (Buerger’s disease):** Typically affects small and medium-sized vessels in young smokers. It presents with rest pain and ischemic ulcers; pulses do not change with foot positioning. * **Atherosclerosis obliterans:** This is the most common cause of claudication but typically occurs in older patients with risk factors (smoking, diabetes, hypertension). Pulses, if absent, do not fluctuate with ankle movement. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in young athletic males (ratio 15:1). * **Classification:** Type I (Medial deviation of artery), Type II (Abnormal muscle insertion), Type III (Accessory muscle slip). * **Diagnosis:** Gold standard is **Digital Subtraction Angiography (DSA)** or MR Angiography with provocative maneuvers. * **Treatment:** Surgical decompression (myotomy) to prevent permanent arterial damage or aneurysm formation.

Question 40: Which one of the following is NOT a feature of Leriche syndrome?

A. Absent femoral pulse
B. Gluteal claudication
C. Continuous bruit over the abdominal aorta (Correct Answer)
D. Impotence

Explanation: **Leriche syndrome**, also known as **aortoiliac occlusive disease**, is characterized by the chronic atherosclerotic blockage of the infrarenal abdominal aorta and/or the common iliac arteries. ### Why Option C is Correct A **continuous bruit** is characteristic of an arteriovenous fistula (where blood flows throughout the cardiac cycle). In Leriche syndrome, the pathology is an **obstructive** atherosclerotic plaque. While a *systolic* bruit might be heard over a partially stenosed artery, a continuous bruit is not a feature of chronic arterial occlusion. In many advanced cases, the vessel is completely occluded, resulting in no bruit at all. ### Explanation of Other Features * **Absent femoral pulses (Option A):** Since the obstruction is at the level of the aortic bifurcation or common iliac arteries, blood flow to the lower extremities is severely compromised, leading to weak or absent pulses in the groin and distally. * **Gluteal claudication (Option B):** Ischemia in the distribution of the internal iliac arteries leads to pain in the buttocks and thighs during exertion. This is a hallmark of proximal (aortoiliac) disease. * **Impotence (Option D):** Also known as erectile dysfunction, this occurs due to decreased blood flow into the internal pudendal arteries (branches of the internal iliacs). ### NEET-PG High-Yield Pearls * **The Classic Triad:** 1. Claudication (buttock/thigh), 2. Absent/diminished femoral pulses, 3. Erectile dysfunction. * **Risk Factors:** Most common in elderly males with a history of heavy smoking and hyperlipidemia. * **Diagnosis:** The "Gold Standard" is Digital Subtraction Angiography (DSA), though CT Angiography is the preferred initial imaging. * **Management:** Lifestyle modification and smoking cessation are vital. Surgical options include Aortobifemoral bypass (gold standard for extensive disease) or endovascular stenting for focal lesions.

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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