Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 411: Which of the following statements regarding venous thrombosis is true?

A. It affects only the deep venous system.
B. The most important factor for the development of deep venous thrombosis is hospital admission. (Correct Answer)
C. A coralline thrombus is a platelet aggregate surrounded by white blood cells.
D. Lung infarction is a common complication of deep venous thrombosis.

Explanation: ### Explanation **Correct Option: B** Hospital admission is considered the single most significant risk factor for the development of Deep Venous Thrombosis (DVT). This is due to the convergence of **Virchow’s Triad**: stasis (prolonged bed rest/immobilization), hypercoagulability (systemic inflammation or malignancy), and potential endothelial injury (surgery or catheters). Statistically, more than 50% of DVT cases occur in patients who are currently hospitalized or have been recently discharged. **Incorrect Options:** * **Option A:** Venous thrombosis is not exclusive to the deep system; it frequently affects the **superficial venous system** (Superficial Thrombophlebitis), often associated with varicose veins or IV cannulation. * **Option C:** A **coralline thrombus** (or "Zahn’s lines") consists of alternating layers of **platelets and fibrin**, not white blood cells. These layers form in flowing blood and help distinguish a pre-mortem thrombus from a post-mortem clot. * **Option D:** While Pulmonary Embolism (PE) is a common and dreaded complication of DVT, **lung infarction** is actually **uncommon** (occurring in <10% of PE cases). This is because the lungs have a dual blood supply (pulmonary and bronchial arteries). **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, Endothelial Injury, Hypercoagulability. * **Most common site for DVT:** Deep veins of the calf (Soleal sinuses). * **Gold Standard Investigation:** Contrast Venography (though Duplex Ultrasound is the initial investigation of choice). * **Homan’s Sign:** Calf pain on dorsiflexion of the foot (low sensitivity/specificity). * **Phlegmasia Cerulea Dolens:** A limb-threatening emergency characterized by massive iliofemoral thrombosis causing cyanosis and ischemia.

Question 412: Non-pitting edema which does not reduce on elevation of the limb belongs to which grade of lymphedema?

A. Latent
B. Grade I
C. Grade II (Correct Answer)
D. Grade III

Explanation: ### Explanation Lymphedema is classified based on the progression of tissue changes and the response to conservative management (elevation). The correct answer is **Grade II** because it marks the transition from fluid accumulation to irreversible tissue fibrosis. **1. Why Grade II is correct:** In **Grade II (Spontaneously Irreversible)** lymphedema, the edema becomes **non-pitting** due to the proliferation of adipocytes and the deposition of collagen (fibrosis). Crucially, at this stage, the swelling **does not reduce with limb elevation** because the structural changes in the subcutaneous tissue prevent the fluid from draining via gravity. **2. Analysis of Incorrect Options:** * **A. Latent (Stage 0):** There is impaired lymph transport, but no visible edema is present. The patient may feel "heaviness" in the limb. * **B. Grade I (Spontaneously Reversible):** This is early-stage edema characterized by **pitting**. The swelling is protein-rich but **reduces significantly or disappears with limb elevation**. * **D. Grade III (Lymphostatic Elephantiasis):** This is the end-stage. It presents with massive swelling, non-pitting edema, and significant skin changes such as **acanthosis, hyperkeratosis, and warty overgrowths**. **3. Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch a fold of skin at the base of the second toe or finger. It is a pathognomonic clinical sign of lymphedema. * **Gold Standard Investigation:** **Lymphoscintigraphy** is the investigation of choice to evaluate the lymphatic system. * **Management:** The mainstay of treatment is **Complex Decongestive Therapy (CDT)**, which includes manual lymphatic drainage, compression bandaging, and exercise. * **Surgery:** Charles’ procedure (excision of skin and subcutaneous tissue) is reserved for severe Grade III cases.

Question 413: What is the most common cause of gangrene of the foot in a 30-year-old chronic smoker farmer?

A. Raynaud's disease
B. Myocardial infarction
C. Atherosclerosis
D. Thromboangiitis obliterans (Correct Answer)

Explanation: **Explanation:** The correct answer is **Thromboangiitis obliterans (TAO)**, also known as **Buerger’s disease**. **Why it is correct:** TAO is a non-atherosclerotic, segmental, inflammatory disease that primarily affects small and medium-sized arteries and veins of the extremities. The clinical profile provided—a **young male (under 40-45 years)** who is a **heavy smoker**—is the classic demographic for this condition. In India, it is frequently seen in farmers who smoke *bidis*. The pathophysiology involves a hypersensitivity to tobacco, leading to distal ischemia, rest pain, and eventually gangrene of the digits. **Why other options are incorrect:** * **A. Raynaud's disease:** This is a functional vasospastic disorder, more common in young females. While it causes color changes (pallor, cyanosis, rubor), it rarely progresses to frank gangrene of the foot. * **B. Myocardial infarction:** While an MI can lead to a mural thrombus causing an embolic limb occlusion, it is an acute event and not the most common cause of chronic progressive gangrene in this specific age group. * **C. Atherosclerosis:** This is the most common cause of peripheral arterial disease in the **elderly** (usually >50-60 years) and is associated with risk factors like diabetes, hypertension, and dyslipidemia. In a 30-year-old, TAO is statistically more likely than atherosclerosis. **High-Yield Clinical Pearls for NEET-PG:** * **Triad of TAO:** Claudication (often involving the arch of the foot), Raynaud’s phenomenon, and Migratory Superficial Thrombophlebitis. * **Angiographic finding:** "Corkscrew collaterals" (Martorell’s sign) around the site of 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. Sympathectomy may be used for pain relief.

Question 414: Milroy's disease is a type of lymphedema which is:

A. Familial (Correct Answer)
B. Secondary to filariasis
C. Secondary to erysipelas
D. A sequela to white leg

Explanation: **Explanation:** **Milroy’s disease** is a congenital form of primary lymphedema. It is an **autosomal dominant (familial)** condition characterized by the hypoplasia of lymphatic vessels. It typically presents at birth or within the first year of life (Lymphedema Congenita). The underlying molecular defect is often a mutation in the **FLT4 gene**, which encodes the Vascular Endothelial Growth Factor Receptor-3 (VEGFR-3). **Analysis of Options:** * **A. Familial (Correct):** As an autosomal dominant condition, it runs in families. It is the most common cause of primary lymphedema present at birth. * **B. Secondary to filariasis:** Filariasis (caused by *Wuchereria bancrofti*) is the most common cause of **secondary** lymphedema worldwide, but it is an acquired parasitic infection, not Milroy’s disease. * **C. Secondary to erysipelas:** Recurrent streptococcal infections (erysipelas) can cause lymphatic destruction leading to secondary lymphedema, whereas Milroy’s is a primary developmental defect. * **D. A sequela to white leg:** "White leg" (Phlegmasia alba dolens) refers to total deep vein thrombosis (DVT) of the iliofemoral segment. While it causes massive edema, it is a venous pathology, not a congenital lymphatic one. **High-Yield Clinical Pearls for NEET-PG:** * **Classification of Primary Lymphedema:** 1. **Milroy’s Disease:** Congenital (at birth), familial/autosomal dominant. 2. **Meige’s Disease:** Lymphedema Praecox (starts at puberty), most common primary type overall. 3. **Lymphedema Tarda:** Occurs after age 35. * **Clinical Sign:** **Stemmer’s Sign** (inability to pinch the skin on the dorsal surface of the base of the second toe) is a classic diagnostic feature of lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for confirming the diagnosis.

Question 415: Chronic lymphedema of the limb is predisposed to all of the following except?

A. Thickening of the skin
B. Recurrent soft tissue infections
C. Marjolin's ulcer (Correct Answer)
D. Sarcoma

Explanation: **Explanation:** The correct answer is **C. Marjolin's ulcer**. **Why Marjolin’s Ulcer is the exception:** A Marjolin’s ulcer is a **Squamous Cell Carcinoma (SCC)** that arises in areas of chronic irritation, specifically **chronic burn scars (cicatrix)**, chronic osteomyelitis sinuses, or long-standing venous ulcers. It is not a typical complication of chronic lymphedema. In lymphedema, the skin remains intact (though thickened) unless secondary infection occurs, whereas Marjolin’s ulcer requires a pre-existing scar or chronic wound. **Analysis of other options:** * **Thickening of the skin:** Chronic lymphatic stasis leads to the accumulation of protein-rich fluid in the subcutaneous tissue. This triggers fibroblast proliferation and collagen deposition, resulting in non-pitting edema, hyperkeratosis, and **pachyderma** (elephantiasis). * **Recurrent soft tissue infections:** Lymphedematous limbs have impaired local immune surveillance (the "lymphostatic encephalopathy"). This predisposes patients to recurrent bouts of **cellulitis and lymphangitis**, often caused by *Streptococcus* species. * **Sarcoma:** A dreaded long-term complication of chronic lymphedema (especially post-mastectomy) is **Stewart-Treves Syndrome**, which is a cutaneous **Angiosarcoma**. **NEET-PG High-Yield Pearls:** * **Stewart-Treves Syndrome:** Angiosarcoma developing in a limb with chronic lymphedema (usually 10+ years after radical mastectomy). * **Stemmer’s Sign:** Inability to pinch a fold of skin at the base of the second toe; a pathognomonic clinical sign for lymphedema. * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for diagnosing lymphatic obstruction. * **Milroy’s Disease:** Congenital lymphedema present at birth (VEGFR-3 mutation).

Question 416: What is not true regarding venous ulcers?

A. Managed by stripping of the superficial saphenous venous system.
B. May be associated with Klippel-Trenaunay syndrome.
C. Found in elderly males. (Correct Answer)
D. Biopsy is required for long-standing ulcers.

Explanation: **Explanation:** Venous ulcers (stasis ulcers) are the most common type of chronic lower limb ulceration, resulting from chronic venous insufficiency (CVI) and ambulatory venous hypertension. **Why Option C is the correct answer (False statement):** Venous ulcers are **more common in females** than in males. While they do occur in the elderly, the gender predilection is distinctly female (often cited as a 3:1 ratio). This is due to factors such as pregnancy-induced venous changes and hormonal influences on vein wall integrity. **Analysis of other options:** * **Option A:** Management focuses on reducing venous hypertension. If the underlying cause is superficial venous reflux (incompetent Great Saphenous Vein), **stripping or endovenous ablation** of the superficial system is a definitive treatment to prevent recurrence. * **Option B:** **Klippel-Trenaunay Syndrome (KTS)** is a triad of port-wine stains, varicose veins, and bony/soft tissue hypertrophy. Patients with KTS have significant venous malformations and insufficiency, which frequently leads to the development of venous ulcers. * **Option D:** Long-standing venous ulcers carry a risk of malignant transformation into a squamous cell carcinoma, known as a **Marjolin’s ulcer**. Therefore, a biopsy is mandatory for any chronic, non-healing, or atypical ulcer to rule out malignancy. **High-Yield Clinical Pearls for NEET-PG:** * **Location:** Typically found in the **"Gaiter Zone"** (medial malleolus). * **Characteristics:** Shallow, irregular borders, beefy red granulation tissue, and painless (unless infected). * **Associated Findings:** Lipodermatosclerosis (inverted champagne bottle appearance), haemosiderin staining (hyperpigmentation), and atrophie blanche. * **Gold Standard Investigation:** Duplex Ultrasound. * **Primary Treatment:** Four-layer compression bandaging (after ruling out arterial disease via ABPI).

Question 417: Which nerve is compressed by an aneurysm of the posterior communicating artery?

A. Oculomotor nerve (Correct Answer)
B. Optic nerve
C. Hypophysis cerebri
D. Trochlear nerve

Explanation: The **Posterior Communicating Artery (PCoA)** is a vital component of the Circle of Willis, connecting the internal carotid artery to the posterior cerebral artery. ### Why Oculomotor Nerve (CN III) is Correct The **Oculomotor nerve** emerges from the midbrain and passes directly lateral to the PCoA as it travels toward the cavernous sinus. Due to this close anatomical proximity, an aneurysm at the junction of the PCoA and the Internal Carotid Artery (ICA) frequently compresses the nerve. * **Clinical Presentation:** This typically manifests as **"surgical third nerve palsy,"** characterized by ptosis, a "down and out" eye position, and—crucially—a **dilated, non-reactive pupil**. The pupillary fibers are superficial and are compressed first by the external pressure of the aneurysm. ### Why Other Options are Incorrect * **Optic Nerve (CN II):** Located more medially and anteriorly. It is more commonly compressed by aneurysms of the Anterior Communicating Artery (ACoA) or ophthalmic artery. * **Hypophysis Cerebri (Pituitary Gland):** This is a midline structure located in the sella turcica. While large carotid aneurysms can cause erosion, it is not the primary structure compressed by a PCoA aneurysm. * **Trochlear Nerve (CN IV):** Although it also passes near the tentorial notch, it is located further lateral and posterior to the PCoA compared to the Oculomotor nerve. ### High-Yield NEET-PG Pearls * **Rule of Pupil:** In CN III palsy, a **dilated pupil** suggests a surgical cause (aneurysm/compression), whereas a **pupil-sparing** palsy suggests a medical cause (diabetes/ischemia). * **Most Common Site of Aneurysm:** The Anterior Communicating Artery (ACoA) is the most common site overall, but PCoA is the most common site causing a cranial nerve palsy. * **Subarachnoid Hemorrhage (SAH):** Sudden "thunderclap headache" with CN III palsy is a neurosurgical emergency.

Question 418: Which of the following is NOT a feature of mycotic aneurysm?

A. Bacterial endocarditis is a common etiology.
B. It is commonly a fusiform aneurysm. (Correct Answer)
C. The aorta and visceral vessels are commonly affected.
D. A multilobed aneurysm with a narrow neck is characteristic.

Explanation: **Explanation:** A **mycotic aneurysm** is an infected arterial aneurysm caused by the bacterial seeding of the arterial wall. Despite the name "mycotic" (coined by Osler due to its mushroom-like appearance), it is almost always **bacterial** in origin, not fungal. **1. Why Option B is the Correct Answer (The False Statement):** Mycotic aneurysms are typically **saccular** (eccentric, pouch-like) rather than fusiform. The infection causes focal destruction of the arterial wall, leading to a localized bulge. Fusiform aneurysms (circumferential dilation) are more characteristic of atherosclerotic or degenerative etiologies. **2. Analysis of Other Options:** * **Option A:** **Bacterial endocarditis** is the classic etiology. Septic emboli from heart valves travel through the bloodstream and lodge in the *vasa vasorum* of healthy arteries or directly onto a diseased intima. * **Option C:** While any artery can be involved, the **aorta**, **visceral arteries** (like the superior mesenteric artery), and intracranial arteries are the most common sites of involvement. * **Option D:** On imaging (like CT angiography), mycotic aneurysms often appear as **multilobed** or "nobby" masses with a **narrow neck** connecting them to the parent artery, reflecting the rapid, irregular destruction of the vessel wall. **Clinical Pearls for NEET-PG:** * **Most common organism:** *Staphylococcus aureus* and *Salmonella* (especially in the elderly or immunocompromised). * **Clinical Triad:** Fever, pulsatile mass, and positive blood cultures. * **Imaging Choice:** CT Angiography is the gold standard for diagnosis. * **Management:** Requires long-term intravenous antibiotics and surgical debridement with revascularization (often using extra-anatomic bypass to avoid infected fields).

Question 419: According to the Spetzler-Martin grading scale, what is the score assigned to an arteriovenous malformation with a 5 cm nidus?

A. 3
B. 4
C. 2 (Correct Answer)
D. 5

Explanation: The **Spetzler-Martin Grading System** is a clinical tool used to estimate the risk of surgical resection of an Arteriovenous Malformation (AVM). The score is calculated by summing points from three categories: **Size of the nidus**, **Eloquence of adjacent brain tissue**, and **Venous drainage pattern**. ### **Breakdown of the Scoring System:** 1. **Size of Nidus:** * Small (< 3 cm): 1 point * **Medium (3–6 cm): 2 points** * Large (> 6 cm): 3 points 2. **Eloquence of adjacent brain** (e.g., motor, sensory, visual, or speech cortex): * Non-eloquent: 0 points * Eloquent: 1 point 3. **Venous Drainage:** * Superficial only: 0 points * Deep component: 1 point ### **Explanation of Options:** * **Option C (Correct):** A 5 cm nidus falls into the "Medium" category (3–6 cm), which is assigned **2 points**. * **Option A (3):** This score would be assigned if the nidus was > 6 cm. * **Option B (4) & D (5):** These represent the total cumulative score of an AVM (Grade IV or V), not the individual score for a 5 cm nidus size alone. ### **Clinical Pearls for NEET-PG:** * **Total Score:** Ranges from Grade I to V. A special **Grade VI** exists for unresectable lesions. * **Surgical Significance:** Grades I–III are generally considered candidates for surgical excision, while Grades IV–V are often managed conservatively or via multimodal therapy (radiosurgery/embolization) due to high surgical morbidity. * **Eloquence:** Includes the thalamus, hypothalamus, internal capsule, brainstem, cerebellar peduncles, and deep cerebellar nuclei.

Question 420: In an emergency, which artery can be safely ligated?

A. Internal iliac artery (Correct Answer)
B. Popliteal artery
C. Renal artery
D. Internal carotid artery

Explanation: **Explanation:** The safety of ligating an artery depends on the presence of **collateral circulation**. If an artery is an "end artery" or lacks sufficient collateral pathways, ligation will lead to distal ischemia and tissue necrosis. **1. Why Internal Iliac Artery is the Correct Answer:** The **Internal Iliac Artery (Hypogastric artery)** can be safely ligated, typically performed bilaterally in emergencies like massive postpartum hemorrhage (PPH) or pelvic trauma. It has an extensive network of collaterals involving the lumbar, iliolumbar, superior hemorrhoidal, and femoral artery branches (e.g., the cruciate anastomosis). Ligation reduces pelvic arterial pulse pressure by nearly 85%, allowing for clot formation without causing pelvic gangrene. **2. Why the Other Options are Incorrect:** * **Popliteal Artery:** This is a functional end artery. Ligation carries a very high risk (approx. 70-100%) of lower limb gangrene and subsequent amputation because the genicular anastomosis is usually insufficient to maintain distal viability. * **Renal Artery:** The renal artery is a true anatomical end artery. Ligation leads to immediate total infarction of the kidney as there are no significant intra-renal collaterals. * **Internal Carotid Artery (ICA):** Ligation of the ICA carries a high risk of massive cerebral infarction (stroke) and hemiplegia, as the Circle of Willis is often incomplete or unable to compensate for sudden total loss of flow in an emergency. **Clinical Pearls for NEET-PG:** * **Safe to ligate:** Internal iliac, External carotid (distal to superior thyroid), Subclavian (1st part), and Splenic artery (due to short gastric vessels). * **Unsafe to ligate:** Common carotid, Internal carotid, Popliteal, Brachial (above profunda brachii), and Renal arteries. * **Ligation site for PPH:** The internal iliac is ligated distal to its posterior division to avoid gluteal skin ischemia.

Practice by Chapter

Atherosclerotic Disease

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Aortic Aneurysms

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Peripheral Arterial Disease

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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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