Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 421: Trendelenburg's test is done for the detection of:

A. Perforator incompetency
B. Deep vein patency
C. Saphenofemoral incompetency (Correct Answer)
D. Site of perforators

Explanation: **Explanation:** The **Trendelenburg test** (also known as the Brodie-Trendelenburg test) is a classic clinical examination used to differentiate between valvular incompetence at the saphenofemoral junction (SFJ) and incompetence of the communicating perforators. **1. Why Option C is Correct:** The test is performed by elevating the patient's leg to empty the veins and applying a tourniquet (or manual pressure) at the SFJ (just below the inguinal ligament). When the patient stands, if the veins remain empty but fill rapidly from above once the pressure is released, it indicates **Saphenofemoral Incompetency**. This is known as a **Trendelenburg Positive** result. **2. Analysis of Incorrect Options:** * **Option A (Perforator Incompetency):** While the Trendelenburg test can suggest perforator issues (if veins fill rapidly *while* the tourniquet is still applied—Trendelenburg Doubly Positive), the **Multiple Tourniquet Test** is the specific clinical test designed to localize multiple sites of perforator incompetence. * **Option B (Deep Vein Patency):** This is assessed using **Perthes' Test**. If a patient walks with a tourniquet in place and the superficial varicosities become more prominent or painful, it suggests deep vein thrombosis (DVT) or obstruction. * **Option D (Site of Perforators):** The specific site of incompetent perforators is best identified using the **Fegan’s Test** (palpating "blow-outs" or gaps in the fascia) or the Multiple Tourniquet Test. **Clinical Pearls for NEET-PG:** * **Trendelenburg I:** Only SFJ incompetence (fills from above after release). * **Trendelenburg II:** Both SFJ and perforator incompetence (fills while constricted AND after release). * **Gold Standard Investigation:** Today, clinical tests are largely superseded by **Duplex Ultrasound**, which is the investigation of choice for mapping venous reflux and anatomy. * **Schwartz Test:** Used to detect the direction of flow (tap test) but is less reliable than Trendelenburg.

Question 422: In the given image, which vein is mainly affected?

A. Perforator veins
B. Femoral vein
C. Great saphenous vein (Correct Answer)
D. Short saphenous vein

Explanation: ***Great saphenous vein*** - The image displays prominent varicose veins along the **medial aspect of the leg**, which corresponds to the anatomical path of the **great saphenous vein (GSV)**. - The GSV is the most frequently affected vein in varicose vein disease due to valvular incompetence, leading to venous reflux and the characteristic tortuous dilatation seen in the picture. *Short saphenous vein* - The **short saphenous vein (SSV)** ascends along the **posterior aspect of the calf**. Varicosities primarily from the SSV would be most visible on the back of the leg. - While some posterior varicosities may be present, the predominant involvement shown is medial, making the GSV the main affected vessel. *Femoral vein* - The **femoral vein** is a major vessel of the **deep venous system**, not the superficial system. - Varicose veins are a disease of **superficial veins**; deep veins like the femoral vein do not become varicose. *Perforator veins* - **Perforator veins** connect the superficial venous system to the deep system. Their incompetence is a crucial factor in the development of venous hypertension and varicosities. - However, the large, dilated vessels visible on the skin are part of a major superficial trunk (the GSV in this case), not the perforators themselves, which are much smaller connecting vessels.

Question 423: A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?

A. Non endothermal non tumescent ablation
B. Open surgery
C. Compression
D. Endothermal ablation (Correct Answer)

Explanation: ***Endothermal ablation***- Guidelines recommend **endothermal ablation** (e.g., **EVLA** or **RFA**) as the first-line definitive treatment for symptomatic varicose veins (C2-C6), especially those causing **C4a skin changes** due to underlying reflux.- This technique is minimally invasive, highly effective at eliminating **saphenous vein reflux**, and leads to faster recovery and reduced recurrence rates compared to surgery.*Compression*- Compression therapy is mandated for all CEAP classifications (C0 to C6) but only serves as **conservative management** to alleviate symptoms and manage edema and skin changes (C4a).- It does not address the underlying **venous valve incompetence** leading to the venous hypertension and is therefore not the definitive preferred treatment.*Non endothermal non tumescent ablation*- These techniques, such as **mechanochemical ablation** (MOCA) or **cyanoacrylate glue**, are effective and avoid the need for general anesthesia or tumescent local anesthesia, making them suitable alternatives.- However, endothermal modalities are often preferred as first-line due to extensive long-term data supporting their effectiveness and durability in treating major **truncal reflux**.*Open surgery*- **High ligation and stripping** used to be the gold standard but is now generally reserved for complex cases where ablation is not technically feasible, such as large tributary veins or extreme **tortuosity**.- Open surgery involves greater morbidity, longer hospital stays, and potentially higher risks of **injury to nerves** (e.g., saphenous nerve) compared to endothermal methods.

Question 424: A patient presents with calf pain while walking a certain distance. The pain is severe enough that he must stop and rest before continuing. According to Boyd's grading, which of the following grades best describes this condition?

A. B. Grade 2
B. C. Grade 3 (Correct Answer)
C. D. Grade 4
D. A. Grade 1

Explanation: ***Correct: Grade 3*** - This grade signifies that the **claudication pain is severe enough to force the patient to stop and rest**, indicating moderately severe peripheral artery disease (PAD) - The distance the patient can walk before stopping is typically **short**, distinguishing it from less severe grades - This matches the clinical scenario where the patient "must stop and rest before continuing" *Incorrect: Grade 1* - This is the mildest form, where the patient experiences **claudication pain only after long distances** of walking - The pain is typically **not severe** and does not significantly interfere with regular walking pace or necessitate stopping - Patient can complete usual walking activities without stopping *Incorrect: Grade 2* - In this stage, pain occurs after a **moderate distance**, but the patient is usually able to continue walking by **slowing their pace** without immediately having to stop - It represents a mild to moderate level of **ischemia** induced by exercise - Key difference: patient can continue walking (albeit slowly) without complete rest *Incorrect: Grade 4* - This grade represents **critical limb ischemia (CLI)**, characterized by **pain at rest** and/or the presence of **ischemic ulcers or gangrene** - It is the most severe grade of PAD, often requiring urgent revascularization - Pain occurs even without walking

Question 425: Which is the least commonly used graft for coronary artery bypass graft (CABG)?

A. Radial artery
B. Long saphenous vein
C. Internal mammary artery
D. Intercostal artery (Correct Answer)

Explanation: ***Intercostal artery***- This artery is **rarely used** in CABG due to its small caliber, difficult harvesting, and high risk of **graft spasm**.- Its use is generally restricted to highly unusual circumstances or when all major **arterial** and **venous conduits** are unavailable. *Long saphenous vein*- The **long saphenous vein (LSV)** is the most common venous graft and is frequently used, particularly for targets other than the LAD.- Though easily accessible and long, LSV grafts have significantly lower long-term patency rates compared to arterial grafts due to susceptibility to **intimal hyperplasia** and atherosclerosis. *Internal mammary artery* - The **Internal Mammary Artery (IMA)** (or Internal Thoracic Artery) is universally considered the **gold standard** graft, particularly for the Left Anterior Descending (LAD) artery.- It offers the highest long-term patency (often >90% at 10 years), making it the most commonly preferred graft, not the least common. *Radial artery*- The **radial artery (RA)** is widely used as a second arterial conduit, offering excellent long-term patency rates superior to vein grafts but slightly less than the IMA.- Preoperative evaluation using the **Allen's test** is necessary to confirm adequate collateral circulation via the ulnar artery before harvesting.

Question 426: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

A. Urgent surgery
B. Blood transfusion
C. Wait and watch
D. Esmolol and urgent surgery (Correct Answer)

Explanation: ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.

Question 427: Imminent gangrene is seen at which Ankle-Brachial Pressure Index (ABPI)?

A. 0.3 (Correct Answer)
B. 0.9
C. 0.7
D. 0.5

Explanation: ***Correct: 0.3*** - An ABPI value of ≤ **0.4** is indicative of **severe peripheral artery disease (PAD)**, which is associated with critical limb ischemia (CLI). - **Critical Limb Ischemia (CLI)** is defined as ABI < **0.4** or toe pressure < 30 mmHg, which corresponds to severe compromise in blood flow, often leading to **imminent gangrene** or rest pain. *Incorrect: 0.5* - An ABPI of **0.5** to **0.9** indicates **moderate PAD**. At this stage, patients typically experience **intermittent claudication** during exertion, but not imminent rest pain or tissue loss. - While significant, it does not represent the severe flow reduction required for *imminent* tissue necrosis like gangrene. *Incorrect: 0.7* - An ABPI of **0.7** falls within the range of **mild to moderate PAD** (0.5–0.9), where symptoms are usually limited to claudication. - This value indicates only moderate compromise in blood supply, far above the threshold for **critical limb ischemia**. *Incorrect: 0.9* - An ABPI of **0.9** to **1.3** is considered **normal** or almost normal. Values below 0.9 signify the presence of PAD. - This level of blood flow provides adequate perfusion and certainly poses **no risk of gangrene**.

Question 428: A 56-year-old man presents with the following pathology shown in the image, which of the following is correct?

A. Sclerotherapy is the best treatment
B. Telangiectasia is rare
C. No possibility of venous ulcer
D. Lipodermatosclerosis/eczema can occur (Correct Answer)

Explanation: ***Lipodermatosclerosis/eczema can occurs*** - The image suggests features of **chronic venous insufficiency (CVI)**, including skin discoloration (hyperpigmentation/hemosiderin deposition) and induration, which are classic features leading to **lipodermatosclerosis** and **venous eczema** (C4 changes in CEAP classification). - Lipodermatosclerosis involves inflammation and fibrosis of the skin and subcutaneous fat in the gaiter area due to prolonged **venous hypertension**. *Sclerotherapy is the best treatment* - Sclerotherapy is typically indicated for **small varicose veins** or **telangiectasias**. - For CVI causing advanced skin changes (like lipodermatosclerosis), the best initial treatment is usually **compression therapy** and addressing the source of reflux (e.g., endovenous ablation). *Telangiectasia is rare* - **Telangiectasias** (spider veins) are very common in patients with CVI and often represent the earliest visible sign of **venous disease** (C1 in CEAP classification). - The presence of more advanced skin changes (like those shown) indicates significant venous hypertension, often accompanied by microcirculatory changes including telangiectasia. *No possibility of venous ulcer* - The changes seen (hyperpigmentation and probable underlying induration/atrophy) are stages C4/C5 of the CEAP classification, which are **immediate precursors** to or associated with **venous leg ulcers** (C6). - Venous hypertension is the underlying cause for both the skin changes and the development of **venous ulcers**, making the possibility very real in this patient.

Question 429: Which one of the following is correct regarding splenic artery aneurysm?

A. It is generally multiple in number.
B. It is caused due to blunt trauma to the abdomen.
C. It is twice as common in men.
D. It is most commonly located in the middle third of the splenic artery. (Correct Answer)

Explanation: ***It is most commonly located in the middle third of the splenic artery.*** - The **splenic artery** is the most common site for **visceral artery aneurysms**, accounting for approximately 60% of all visceral aneurysms. - These aneurysms are most commonly located in the **middle third (50-60%)** of the splenic artery, followed by the distal third (20-30%) and proximal third (10-20%). - The middle segment's tortuosity and hemodynamic stress may contribute to aneurysm formation. - Though distal aneurysms are more prone to rupture, the **middle third remains the most frequent location**. *It is generally multiple in number.* - **Solitary aneurysms** are more common (60-80% of cases) than multiple aneurysms. - **Multiple splenic artery aneurysms** occur in 20-30% of cases and are associated with conditions like **fibromuscular dysplasia**, portal hypertension, or systemic vasculitis. *It is caused due to blunt trauma to the abdomen.* - **Splenic artery aneurysms** are rarely caused by blunt abdominal trauma. - Most are **degenerative or atherosclerotic** in origin (>60% of cases). - Other etiologies include **fibromuscular dysplasia**, portal hypertension, pancreatitis, and connective tissue disorders. - Blunt trauma typically causes **acute splenic injury** (laceration, hematoma) rather than aneurysm formation. *It is twice as common in men.* - **Splenic artery aneurysms** are approximately **four times more common in women** than in men (4:1 female-to-male ratio). - This female predominance is attributed to **multiparity** (which increases arterial wall stress), hormonal factors, and the association with **fibromuscular dysplasia**.

Question 430: Which one of the following statements is not correct regarding thoracic outlet syndrome?

A. Resection of First rib is effective treatment
B. It is associated with Horner's syndrome
C. Radial nerve is involved (Correct Answer)
D. It is a rare condition

Explanation: ***Radial nerve is involved*** - Thoracic outlet syndrome (TOS) primarily involves compression of the **brachial plexus** (specifically the lower trunk C8-T1), subclavian artery, or subclavian vein. - The **radial nerve** is derived from the posterior cord (C5-T1) of the brachial plexus, but the classic presentation of TOS does not typically involve isolated or predominant radial nerve symptoms. Instead, TOS symptoms more commonly affect the **ulnar nerve distribution** (C8-T1) due to compression of the lower trunk of the brachial plexus. *Resection of First rib is effective treatment* - **First rib resection** is a well-established surgical treatment option for thoracic outlet syndrome, aiming to decompress the neurovascular structures. - This procedure alleviates pressure on the **brachial plexus** and **subclavian vessels**, leading to symptom improvement in many patients. *It is associated with Horner's syndrome* - **Horner's syndrome** can be associated with thoracic outlet pathology, particularly tumors like **Pancoast tumors**, which can compress the sympathetic chain at the thoracic outlet. - While not a direct feature of typical TOS, conditions affecting the thoracic outlet region can impact the **cervical sympathetic ganglion** leading to Horner's syndrome (ptosis, miosis, anhidrosis). *It is a rare condition* - Thoracic outlet syndrome is generally considered a **relatively rare condition**, although its true incidence might be underestimated due to diagnostic challenges. - It is often a diagnosis of exclusion, requiring careful clinical evaluation and imaging to rule out other causes of **neck, shoulder, and arm pain**.

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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Vasculitis

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