Vascular Surgery — MCQs

A 75-year-old man with multiple medical comorbidities develops acute mesenteric ischemia. CT angiography shows superior mesenteric artery occlusion with bowel wall thickening. His family history includes poor outcomes with major surgery. Laboratory studies show elevated lactate and leukocytosis. Evaluate the management approach considering patient factors and family concerns.

Q450

A 68-year-old man with severe peripheral arterial disease presents with rest pain and tissue loss in his right foot. Angiography shows multilevel disease with poor runoff. He has significant cardiac comorbidities and limited life expectancy. His family wants limb salvage, but he expresses preference for amputation. Evaluate the decision-making process.

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 441: Indication of Coronary artery bypass grafting (CABG) is:

A. More than 70% stenosis of proximal left anterior interventricular artery
B. More than 50% stenosis of critical left main stem
C. Deranged Stress Echocardiography report
D. Triple vessel disease (Correct Answer)

Explanation: ***Triple vessel disease*** - **Triple vessel disease** (significant stenosis in all three major coronary arteries: LAD, LCx, and RCA) is a **Class I indication for CABG** with the highest level of evidence. - CABG provides **superior long-term outcomes** compared to PCI in triple vessel disease, with better survival rates, reduced need for repeat revascularization, and more complete revascularization. - This is particularly true in patients with **diabetes** or **reduced LV function**. *More than 70% stenosis of proximal left anterior interventricular artery* - While **proximal LAD stenosis >70%** can be treated with CABG (Class IIa indication), it is often managed successfully with **PCI** (drug-eluting stents). - The choice between CABG and PCI for isolated proximal LAD disease depends on anatomy, patient comorbidities, and surgical risk factors. *More than 50% stenosis of critical left main stem* - **Left main coronary artery stenosis >50%** is actually a **Class I indication for CABG** per ACC/AHA and ESC/EACTS guidelines. - However, in the context of this question comparing multiple scenarios, **triple vessel disease** represents a more universally accepted and broader indication with the strongest evidence base for CABG superiority over PCI. - Modern guidelines do allow PCI for selected left main cases (low SYNTAX score, ostial/shaft lesions), whereas triple vessel disease more consistently favors CABG. *Deranged Stress Echocardiography report* - A **positive stress echocardiography** indicates inducible myocardial ischemia but is a **diagnostic finding**, not a specific indication for the revascularization method. - Further evaluation with **coronary angiography** is required to determine the anatomical extent of CAD and guide the choice between CABG, PCI, or medical management.

Question 442: On second day following femoral embolectomy, the leg is found to be tender, tense and dusky with feeble dorsalis pedis pulse. The most appropriate management would be:

A. Dye studies
B. Doing re-embolectomy
C. Fasciotomy (Correct Answer)
D. Anticoagulant therapy

Explanation: ***Fasciotomy*** - The symptoms (tender, tense, dusky leg with feeble dorsalis pedis pulse) occurring after revascularization strongly suggest developing **compartment syndrome**. - **Fasciotomy** is the most appropriate management to relieve pressure, restore blood flow, and prevent irreversible muscle and nerve damage. *Dye studies* - While imaging like angiography (dye studies) can assess vascular patency, they are not the immediate solution for suspected **compartment syndrome**. - Delaying definitive treatment for compartment syndrome for imaging can lead to **irreversible tissue damage**. *Doing re-embolectomy* - The problem is unlikely to be a persistent or recurrent embolus given the prior embolectomy and the presentation suggesting **compartment syndrome**, not ongoing arterial occlusion. - Repeating the procedure without addressing the underlying compartment pressure would be ineffective and potentially harmful. *Anticoagulant therapy* - Anticoagulation is crucial for preventing new clots or re-thrombosis but does not resolve the acute mechanical compression and ischemia of **compartment syndrome**. - It's part of the overall management but not the primary intervention for the immediate life-threatening limb condition described.

Question 443: Bisgaard treatment refers to that of:

A. An ischaemic ulcer
B. Venous ulcer (Correct Answer)
C. An in-growing toe nail
D. Ruptured tendo achillis

Explanation: ***Venous ulcer*** - **Bisgaard treatment** is a historical surgical technique specifically developed for the management of **chronic venous ulcers**. - This treatment aims to improve venous return and reduce venous hypertension by surgically addressing incompetent perforator veins and superficial venous reflux. *An ischaemic ulcer* - **Ischaemic ulcers** are caused by arterial insufficiency and require interventions to improve arterial blood flow, such as revascularization. - Bisgaard treatment is not appropriate for ischaemic ulcers as it does not address the underlying **arterial occlusive disease**. *An in-growing toe nail* - An **ingrown toenail** is a common podiatric condition typically treated with local procedures like nail avulsion or matrixectomy. - Bisgaard treatment is a complex vascular surgical procedure and bears no relevance to the treatment of an ingrown toenail. *Ruptured tendo achillis* - A **ruptured Achilles tendon** is an orthopaedic injury that requires surgical repair or conservative management involving immobilization. - Bisgaard treatment is exclusively for venous ulcer disease and has no role in the management of tendon injuries.

Question 444: A policeman of 45 years presented with Lipodermatosclerosis over lower medial aspect of left leg, along with a healed venous ulcer. As per the CEAP (Clinical-etiology-anatomy-pathophysiology) classification his clinical classification will be:

A. C5 (Correct Answer)
B. C4b
C. C6
D. C4a

Explanation: **C5 (healed venous ulcer)** - The CEAP classification for **C5** indicates the presence of a **healed venous ulcer**, which matches the patient's presentation of a healed ulcer. - The associated **lipodermatosclerosis** is a skin change often preceding or accompanying venous ulcers. *C4b (lipodermatosclerosis, atrophie blanche)* - **C4b** represents **lipodermatosclerosis** and **atrophie blanche**, which are skin changes due to chronic venous insufficiency. - While the patient has lipodermatosclerosis, the presence of a *healed ulcer* further elevates the classification to C5, as it signifies a more advanced stage of venous disease. *C6 (active venous ulcer)* - **C6** denotes an **active, open venous ulcer**. - The patient's ulcer is explicitly stated as "healed," making C6 an incorrect classification. *C4a (pigmentation or eczema)* - **C4a** refers to skin changes such as **pigmentation** or **venous eczema**. - While the patient might have some pigmentation associated with lipodermatosclerosis, the presence of a *healed ulcer* indicates a more severe clinical stage than C4a.

Question 445: Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:

A. Persistent hypertension (Correct Answer)
B. Hemianopia
C. Dysphasia
D. Monocular blindness

Explanation: ***Persistent hypertension*** - **Hypertension** is a **risk factor** for carotid artery disease but is not a direct indication for carotid endarterectomy in symptomatic patients. - Carotid endarterectomy aims to treat **carotid stenosis** causing neurological symptoms, not to manage blood pressure. *Hemianopia* - **Hemianopia** is a **visual field defect** that can be caused by cerebral ischemia resulting from carotid artery stenosis, making it a neurological symptom indicating potential benefit from endarterectomy. - It suggests that the **carotid artery** is supplying an area of the brain that could be at risk for stroke. *Dysphasia* - **Dysphasia** (difficulty with speech) is a classic **neurological symptom** of cerebral ischemia, often associated with carotid artery stenosis affecting the dominant hemisphere. - This symptom strongly indicates that the patient's **carotid disease** is causing clinically significant effects, warranting consideration of endarterectomy. *Monocular blindness* - **Amaurosis fugax**, or transient monocular blindness, is a **transient ischemic attack (TIA)** symptom caused by emboli from the carotid artery reaching the retinal artery. - It is a significant **warning sign** of impending stroke and is a strong indication for carotid endarterectomy in symptomatic patients with appropriate stenosis.

Question 446: Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:

A. Atherosclerosis is never seen in this vessel
B. It is very easy to harvest
C. It is close to LAD
D. Long term patency rates are superior (>90% at 10 years) (Correct Answer)

Explanation: ***Long term patency rates are superior (>90% at 10 years)*** - The superior **long-term patency rates** (over 90% at 10 years) of the **Left Internal Mammary Artery (LIMA)** when anastomosed to the **Left Anterior Descending (LAD) artery** are the primary reason for it being the conduit of choice. - This excellent patency is attributed to its **endothelial** properties and **resistance to atherosclerosis**, contributing to improved patient outcomes and survival. *Atherosclerosis is never seen in this vessel* - While the LIMA is significantly **more resistant to atherosclerosis** compared to saphenous veins, it is not entirely immune. - Atherosclerosis can still occur in the LIMA, though it is far less common and less severe than in other graft conduits. *It is very easy to harvest* - Harvesting the LIMA requires a skilled surgical technique and is **not considered "very easy."** - It involves careful dissection to preserve the conduit's integrity and includes potential complications like **sternal wound infections** due to altered blood supply. *It is close to LAD* - While the anatomical proximity of the LIMA to the LAD is a favorable factor, making the anastomosis geographically convenient, it is **not the primary reason** for its widespread use. - The primary driving factor is the superior long-term patency, which directly impacts patient morbidity and mortality.

Question 447: A 52-year-old man with end-stage renal disease on hemodialysis presents with his arteriovenous fistula no longer functioning. Physical examination shows a thrill and bruit over the fistula site, but dialysis access is inadequate. What is the most likely cause of fistula dysfunction?

A. Arterial steal syndrome
B. Infection of the fistula
C. Stenosis of the venous outflow (Correct Answer)
D. Thrombosis of the fistula

Explanation: ***Stenosis of the venous outflow*** - A palpable **thrill and bruit** indicate blood flow through the fistula, but inadequate access points to an obstruction preventing efficient dialysis. - **Venous outflow stenosis** is the most common cause of AV fistula dysfunction and inadequate blood flow, as it restricts venous return, increasing pressure within the fistula. *Arterial steal syndrome* - This typically presents with **distal ischemia**, such as pain, pallor, and numbness in the hand, due to blood being "stolen" from the limb by the fistula. - It does not directly explain inadequate dialysis access or maintenance of a thrill/bruit, which imply patent flow through the fistula. *Infection of the fistula* - Infection would typically manifest with signs of **inflammation**, such as redness, warmth, swelling, pain, and potentially fever or purulent discharge. - Although infection can lead to fistula dysfunction, the presence of a thrill and bruit without any inflammatory signs makes it less likely to be the primary cause of inadequate access in this scenario. *Thrombosis of the fistula* - **Thrombosis** would result in the loss of both the thrill and the bruit, indicating no blood flow through the fistula. - Since the patient still has a thrill and bruit, thrombosis is unlikely to be the cause of dysfunction.

Question 448: A 68-year-old man with a 6 cm abdominal aortic aneurysm presents with sudden onset of severe back pain and hypotension. CT shows a retroperitoneal hematoma. His blood pressure is 90/60 mmHg, and heart rate is 110/min. What is the most critical factor in determining immediate management?

A. Hemodynamic stability (Correct Answer)
B. Presence of retroperitoneal hematoma
C. Size of the aneurysm
D. Age of the patient

Explanation: **Hemodynamic stability** - The patient's **hypotension (90/60 mmHg)** and **tachycardia (110/min)** indicate **hemodynamic instability**, which is a sign of ongoing bleeding and impending shock in a ruptured abdominal aortic aneurysm (AAA). - Immediate management focuses on stabilizing the patient through **fluid resuscitation** and preparing for **emergent surgical repair** to prevent further blood loss and organ damage. - In ruptured AAA, **hemodynamic status** is the primary determinant of management urgency and approach. *Presence of retroperitoneal hematoma* - While the retroperitoneal hematoma confirms the **rupture of the AAA**, it describes the consequence of bleeding rather than the immediate physiological state requiring urgent intervention. - The hematoma itself does not dictate the *immediacy* of intervention as much as the patient's **hemodynamic response** to the bleeding. *Size of the aneurysm* - The **6 cm aneurysm size** is a risk factor for rupture, but once rupture has occurred, the immediate management is driven by the acute clinical picture rather than the initial size. - While important for risk stratification of intact aneurysms, it's less critical than hemodynamic status in an actively rupturing scenario. *Age of the patient* - The patient's age (68 years) is a factor in overall surgical risk assessment but does not determine the **immediacy or type of intervention** for an acute rupture. - **Emergent repair** is indicated regardless of age if the patient can tolerate surgery.

Question 449: A 75-year-old man with multiple medical comorbidities develops acute mesenteric ischemia. CT angiography shows superior mesenteric artery occlusion with bowel wall thickening. His family history includes poor outcomes with major surgery. Laboratory studies show elevated lactate and leukocytosis. Evaluate the management approach considering patient factors and family concerns.

A. Conservative management with anticoagulation
B. Time-limited trial of medical management
C. Immediate surgical revascularization and bowel resection
D. Endovascular revascularization followed by assessment (Correct Answer)

Explanation: ***Endovascular revascularization followed by assessment*** - Given the patient's **multiple comorbidities** and family concerns about poor surgical outcomes, **endovascular revascularization** offers a less invasive approach to restore blood flow. - This strategy allows for **reassessment of bowel viability** after revascularization, potentially avoiding immediate extensive bowel resection in a high-risk patient. *Immediate surgical revascularization and bowel resection* - While traditional, **immediate open surgery** carries significant risks of morbidity and mortality, especially in a 75-year-old with multiple comorbidities and features of severe ischemia (elevated lactate, leukocytosis). - The family's history of **poor outcomes with major surgery** strengthens the rationale against this aggressive initial approach unless endovascular options fail or are contraindicated. *Time-limited trial of medical management* - A **time-limited trial of medical management** (e.g., vasodilators) might be considered for non-occlusive mesenteric ischemia or less severe presentations, but **superior mesenteric artery occlusion** is a surgical emergency. - This patient has clear signs of **bowel ischemia** (thickening, elevated lactate), indicating that delay could lead to irreversible bowel necrosis and peritonitis. *Conservative management with anticoagulation* - **Anticoagulation** alone is insufficient treatment for acute **arterial occlusion** with established ischemia, as it does not address the immediate need for revascularization. - Conservative management risks progression to **bowel necrosis**, leading to peritonitis, sepsis, and a much higher mortality rate.

Question 450: A 68-year-old man with severe peripheral arterial disease presents with rest pain and tissue loss in his right foot. Angiography shows multilevel disease with poor runoff. He has significant cardiac comorbidities and limited life expectancy. His family wants limb salvage, but he expresses preference for amputation. Evaluate the decision-making process.

A. Defer decision to vascular surgery specialist
B. Attempt endovascular intervention as compromise
C. Proceed with amputation per patient preference
D. Multidisciplinary discussion with patient and family (Correct Answer)

Explanation: ***Multidisciplinary discussion with patient and family*** - This approach ensures that all medical perspectives (vascular surgery, palliative care, primary care) are considered, along with the patient's **autonomy** and family's concerns, leading to an **ethical** and well-informed decision. - Given the patient's limited life expectancy and significant comorbidities, prioritizing his wishes while involving the family and explaining the medical realities helps reconcile conflicting desires and reach a consensus. *Defer decision to vascular surgery specialist* - While essential for technical assessment, deferring solely to a specialist ignores the patient's explicit wishes and the family's input, which are crucial for **patient-centered care**. - This approach might lead to an overly technical solution without adequately addressing the patient's overall quality of life or **palliative needs**. *Attempt endovascular intervention as compromise* - While it may seem like a compromise, this option could lead to multiple failed procedures given the **multilevel disease** and **poor runoff**, potentially increasing suffering without successful limb salvage. - This path disregards the patient's clear preference for amputation and prioritizes a medical intervention that may not align with his **overall goals of care** considering his comorbidities and limited life expectancy. *Proceed with amputation per patient preference* - Although the patient's preference is paramount, proceeding immediately without a thorough multidisciplinary discussion might leave the family feeling unheard and could result in regret if other options or palliative care aspects were not fully explored. - It's important to ensure the patient's decision is fully informed and stable, and that the family has an opportunity to understand the rationale and implications, promoting **shared decision-making**.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

Practice Questions

Venous Thromboembolism

Practice Questions

Chronic Venous Insufficiency

Practice Questions

Mesenteric Vascular Disease

Practice Questions

Vascular Trauma

Practice Questions

Vascular Access for Hemodialysis

Practice Questions

Endovascular Techniques

Practice Questions

Diabetic Foot Vascular Disease

Practice Questions

Vasculitis

Practice Questions

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