Vascular Surgery Practice Questions

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

Great saphenous vein. ***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.

Q: 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?

Endothermal ablation. ***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.

Q: 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?

C. Grade 3. ***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

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

Intercostal artery. ***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.

Q: 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?

Esmolol and urgent surgery. ***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.

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

0.3. ### **Explanation** The **Ankle-Brachial Pressure Index (ABPI)** is a non-invasive tool used to assess Peripheral Arterial Disease (PAD). It is calculated by dividing the higher systolic blood pressure at the ankle (PTA or DPA) by the higher systolic blood pressure of the arms. **1. Why 0.3 is the Correct Answer:** An ABPI of **<0.3** indicates **critical limb ischemia (CLI)** and **imminent gangrene**. At this level, the perfusion pressure is insufficient to maintain tissue viability even at rest. This stage is clinically characterized by **rest pain**, non-healing ischemic ulcers, and impending tissue necrosis (gangrene). **2. Analysis of Incorrect Options:** * **0.9 (Option B):** This is the lower limit of **normal**. An ABPI between 0.9 and 1.2 is considered healthy. Values between 0.7 and 0.9 indicate mild PAD, often asymptomatic. * **0.7 (Option C):** This indicates **mild to moderate PAD**. Patients at this level typically present with **intermittent claudication** (pain on walking that relieved by rest). * **0.5 (Option D):** This signifies **severe PAD**. While patients have significant symptoms and a high risk of cardiovascular events, "imminent gangrene" is specifically associated with values dropping below 0.4 or 0.3. --- ### **High-Yield Clinical Pearls for NEET-PG / INI-CET** * **ABPI Interpretation Summary:** * **>1.2:** Calcified, non-compressible vessels (commonly seen in **Diabetes Mellitus** and elderly patients). Use Toe-Brachial Index (TBI) instead. * **0.9 – 1.2:** Normal. * **0.5 – 0.9:** Intermittent Claudication. * **<0.4:** Rest Pain. * **<0.3:** Imminent Gangrene / Critical Limb Ischemia. * **Fontaine Classification:** Remember that ABPI <0.3 correlates with Fontaine Stage IV (Ulceration/Gangrene). * **Management Tip:** Patients with ABPI <0.5 or rest pain require urgent surgical or endovascular intervention to prevent limb loss.

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

Lipodermatosclerosis/eczema can occur. ***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.

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

Radial nerve is involved. ***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**.

Question 1

Trendelenburg's test is done for the detection of:

Accepted Answer

Saphenofemoral incompetency

Answer

Perforator incompetency

Answer

Deep vein patency

Answer

Site of perforators

Question 2

In the given image, which vein is mainly affected?

Accepted Answer

Great saphenous vein

Answer

Perforator veins

Answer

Femoral vein

Answer

Short saphenous vein

Question 3

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?

Accepted Answer

Endothermal ablation

Answer

Non endothermal non tumescent ablation

Answer

Open surgery

Answer

Compression

Question 4

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?

Accepted Answer

C. Grade 3

Answer

B. Grade 2

Answer

D. Grade 4

Answer

A. Grade 1

Question 5

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

Accepted Answer

Intercostal artery

Answer

Radial artery

Answer

Long saphenous vein

Answer

Internal mammary artery

Question 6

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?

Accepted Answer

Esmolol and urgent surgery

Answer

Urgent surgery

Answer

Blood transfusion

Answer

Wait and watch

Question 7

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

Accepted Answer

0.3

Answer

0.9

Answer

0.7

Answer

0.5

Question 8

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

Accepted Answer

Lipodermatosclerosis/eczema can occur

Answer

Sclerotherapy is the best treatment

Answer

Telangiectasia is rare

Answer

No possibility of venous ulcer

Question 9

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

Accepted Answer

It is most commonly located in the middle third of the splenic artery.

Answer

It is generally multiple in number.

Answer

It is caused due to blunt trauma to the abdomen.

Answer

It is twice as common in men.

Question 10

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

Accepted Answer

Radial nerve is involved

Answer

Resection of First rib is effective treatment

Answer

It is associated with Horner's syndrome

Answer

It is a rare condition

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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