A 70-year-old man with severe aortic stenosis and coronary artery disease requires both cardiac surgery and removal of a large abdominal aortic aneurysm. He has limited physiologic reserve and high surgical risk. The cardiac surgeon recommends TAVR first, while the vascular surgeon suggests simultaneous repair. Evaluate the optimal staging and approach.
Q452
A 60-year-old diabetic man with end-stage renal disease presents with acute limb ischemia of the right leg. He has a thrombosed arteriovenous fistula, is on hemodialysis, and has limited vascular access options. Angiography shows acute thrombosis of a previously placed femoral-popliteal bypass graft. He faces competing needs for limb salvage and dialysis access. Evaluate the management priority and approach.
Q453
Surgery was performed as shown in the image below. What is the name of the procedure?
Q454
A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
Q455
Asymptomatic varicose veins would fall under which category of the CEAP classification system?
Q456
A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?
Q457
During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?
Q458
A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?
Q459
A 71-year-old man comes to the physician for a routine health maintenance examination. He feels well. He goes for a 30-minute walk three times a week and does not experience any shortness of breath or chest or leg pain on exertion. He has not had any weakness, numbness, or vision disturbance. He has diabetes that is well controlled with insulin injections. He had smoked one pack of cigarettes every day for 40 years but quit 5 years ago. He appears healthy and well nourished. His temperature is 36.3°C (97.3°F), pulse is 75/min, and blood pressure is 136/78 mm Hg. Physical examination shows normal heart sounds. There are systolic bruits over the neck bilaterally. Physical and neurologic examinations show no other abnormalities. Fasting serum studies show:
Total cholesterol 210 mg/dL
HDL cholesterol 28 mg/dL
LDL cholesterol 154 mg/dL
Triglycerides 140 mg/dL
Glucose 102 mg/dL
Duplex ultrasonography of the carotid arteries shows a 85% stenosis on the left and a 55% stenosis on the right side. Which of the following is the most appropriate next step in management?
Q460
A 45-year-old policeman presents with pain in the right leg after duty. On examination, the pulse in the right popliteal fossa is absent, and there is pain in the right buttock. The left side is normal. At which level is the blockage?
Vascular Surgery Indian Medical PG Practice Questions and MCQs
Question 451: A 70-year-old man with severe aortic stenosis and coronary artery disease requires both cardiac surgery and removal of a large abdominal aortic aneurysm. He has limited physiologic reserve and high surgical risk. The cardiac surgeon recommends TAVR first, while the vascular surgeon suggests simultaneous repair. Evaluate the optimal staging and approach.
A. Simultaneous cardiac and vascular surgery
B. AAA repair followed by staged cardiac surgery
C. Endovascular repair of both conditions
D. TAVR followed by staged AAA repair (Correct Answer)
Explanation: ***TAVR followed by staged AAA repair***
- In patients with **severe aortic stenosis** and **limited physiological reserve**, addressing the cardiac issue first via **TAVR** helps improve cardiac function and reduce perioperative risk for subsequent vascular surgery.
- Staging the AAA repair after cardiac optimization allows for better patient tolerance and reduces the overall **surgical burden** in a high-risk individual.
*Simultaneous cardiac and vascular surgery*
- This approach carries an exceptionally high risk of **morbidity and mortality** due to the combined physiological stress of two major procedures in a patient with limited reserve.
- The increased operative time, blood loss, and systemic inflammatory response can lead to severe **postoperative complications** like myocardial infarction, renal failure, and stroke.
*AAA repair followed by staged cardiac surgery*
- Repairing the AAA first would expose the patient to the risks of major vascular surgery while still having **severe aortic stenosis**, which dramatically increases the risk of **cardiac complications** (e.g., myocardial ischemia, sudden death) during and after the procedure.
- The patient's **limited physiological reserve** makes performing a major surgery with uncorrected severe cardiac pathology highly dangerous.
*Endovascular repair of both conditions*
- While **TAVR** (transcatheter aortic valve replacement) is feasible for severe aortic stenosis, and **EVAR** (endovascular aneurysm repair) is an option for AAA, simultaneous endovascular repair of both conditions in the same setting is not standard practice.
- The patient also has **coronary artery disease** requiring separate management (PCI or CABG), which adds complexity that makes staged repair after cardiac optimization the safer approach.
Question 452: A 60-year-old diabetic man with end-stage renal disease presents with acute limb ischemia of the right leg. He has a thrombosed arteriovenous fistula, is on hemodialysis, and has limited vascular access options. Angiography shows acute thrombosis of a previously placed femoral-popliteal bypass graft. He faces competing needs for limb salvage and dialysis access. Evaluate the management priority and approach.
A. Simultaneous revascularization and dialysis access procedure
B. Immediate thrombectomy of bypass graft (Correct Answer)
C. Thrombolysis followed by new AV access creation
D. Endovascular intervention with temporary dialysis catheter
Explanation: **Immediate thrombectomy of bypass graft**
- **Acute limb ischemia** is an emergent condition threatening limb viability, making **revascularization** the immediate priority.
- A **thrombosed femoral-popliteal bypass graft** needs urgent intervention to restore blood flow and prevent irreversible tissue damage.
*Simultaneous revascularization and dialysis access procedure*
- While both are critical, attempting both simultaneously can be complex and prolong operative time, potentially compromising the acutely ischemic limb.
- The **acute limb ischemia** requires immediate attention, and delaying it for a concurrent access procedure could lead to limb loss.
*Thrombolysis followed by new AV access creation*
- **Thrombolysis** can take several hours to days to achieve vessel patency, which is too slow for **acute limb ischemia** where time is critical.
- Creating a new **AV access** is a separate, non-emergent procedure that should not delay limb salvage.
*Endovascular intervention with temporary dialysis catheter*
- While a **temporary dialysis catheter** can bridge the access need, **endovascular intervention** for a thrombosed bypass graft may not be as effective or rapid as surgical thrombectomy, especially in acute settings.
- The priority remains rapid restoration of flow, which a surgical approach often best provides for an acutely thrombosed bypass graft.
Question 453: Surgery was performed as shown in the image below. What is the name of the procedure?
A. Below knee amputation
B. Above knee amputation
C. Lisfranc amputation
D. Chopart amputation (Correct Answer)
Explanation: ***Chopart amputation***
- The image shows a disarticulation through the **talonavicular and calcaneocuboid joints**, which defines a **Chopart amputation**.
- This procedure removes the distal foot while preserving the **calcaneus and talus**, forming a stump that allows for some ankle motion.
*Below knee amputation*
- A below-knee amputation involves transection of the tibia and fibula, preserving the knee joint, which is much more proximal than shown in the image.
- This type of amputation removes a significant portion of the lower leg, with the foot entirely removed, unlike the partial foot amputation depicted.
*Above knee amputation*
- An above-knee amputation involves disarticulation or transection through the femur, completely removing the lower leg and knee joint.
- This is a much more extensive amputation than what is illustrated, which is confined to the foot.
*Lisfranc amputation*
- A Lisfranc amputation is a disarticulation through the **tarsometatarsal joints**, removing the metatarsals and phalanges but preserving the tarsal bones.
- The image clearly shows the incision more proximally, at the midtarsal level, specifically through the talonavicular and calcaneocuboid joints, not the tarsometatarsal joints.
Question 454: A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?
A. Emergency surgical repair (Correct Answer)
B. BP control and monitoring
C. Stenting
D. Balloon dilatation
Explanation: ***Emergency surgical repair***
- The combination of **excruciating chest pain**, a history of **hypertension**, and **unequal radial pulses** is highly suggestive of an **acute aortic dissection**.
- **Unequal radial pulses** indicate involvement of the **ascending aorta** (Type A dissection), affecting the brachiocephalic or subclavian arteries that branch proximally from the aortic arch.
- **Type A aortic dissections**, involving the ascending aorta, are life-threatening emergencies requiring immediate **surgical repair** to prevent rupture, cardiac tamponade, aortic regurgitation, and organ malperfusion.
*BP control and monitoring*
- While **blood pressure control** is a crucial initial step in managing aortic dissection to reduce shear stress on the aorta and prevent propagation, it is insufficient as the primary treatment for an **ascending (Type A) aortic dissection**.
- Continuous monitoring is necessary but cannot resolve a progressing dissection that poses an immediate threat to life.
- Medical management alone is reserved for **uncomplicated Type B dissections**.
*Stenting*
- **Endovascular stenting** (thoracic endovascular aortic repair, TEVAR) is primarily used for **Type B aortic dissections** (involving the descending aorta) in stable patients or those with complicated features.
- It is generally not the first-line treatment for **Type A dissections** due to the anatomical challenges and urgent need for surgical repair in this location.
*Balloon dilatation*
- **Balloon dilatation** or angioplasty is a procedure used to open narrowed arteries, typically in the context of atherosclerotic disease (e.g., coronary artery disease or peripheral artery disease).
- It has no role in the management of an **aortic dissection**, which involves a tear in the aortic wall rather than a simple narrowing.
Question 455: Asymptomatic varicose veins would fall under which category of the CEAP classification system?
A. C1 (Telangiectasias or reticular veins)
B. C2 (Varicose veins) (Correct Answer)
C. C3 (Edema)
D. C4 (Skin changes)
Explanation: ***C2 (Varicose veins)***
- The CEAP classification uses 'C' for clinical manifestations, with **C2 specifically indicating the presence of varicose veins**.
- Since the patient has **asymptomatic varicose veins**, C2 accurately captures this clinical state without implying more severe complications.
- Varicose veins are classified as C2 **regardless of whether they are symptomatic or asymptomatic**.
*C1 (Telangiectasias or reticular veins)*
- C1 refers to smaller veins, such as **telangiectasias (spider veins)** and **reticular veins**, which are distinct from the larger, tortuous varicose veins.
- These are less prominent venous abnormalities compared to varicose veins.
*C3 (Edema)*
- C3 indicates the **presence of edema** due to venous insufficiency.
- The question specifies **asymptomatic varicose veins** without mention of edema, making C3 incorrect.
*C4 (Skin changes)*
- C4 denotes **skin changes** related to chronic venous insufficiency, such as pigmentation, eczema, or lipodermatosclerosis.
- These are more advanced signs of venous disease and are not present in a patient with only varicose veins without complications.
Question 456: A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?
A. Fegan's test
B. Brodie Trendelenburg test (Correct Answer)
C. Modified Perthes test
D. Morrissey test
Explanation: ***Brodie Trendelenburg test***
- This test evaluates **venous valve competence** at the saphenofemoral junction (SFJ) by observing the rate of venous refilling after emptying the superficial veins in the supine position and then standing.
- Quick refilling of veins upon standing, particularly after compression of the SFJ, suggests **SFJ incompetence**.
*Fegan's test*
- This test is used to locate **incompetent perforating veins** by palpating for defects in the fascia after emptying the veins and applying compression.
- It does not directly assess the competence of the saphenofemoral junction.
*Modified Perthes test*
- The Perthes test assesses the **patency of deep veins** and the competence of perforating veins by observing the disappearance of superficial veins during exercise with a tourniquet applied.
- It primarily differentiates between superficial and deep venous insufficiency, not specifically SFJ incompetence.
*Morrissey test*
- This test (also known as the percussion test) involves percussing an incompetent vein distally and palpating proximally to detect a transmitted thrill, indicating **venous incompetence**.
- While it helps identify reflux, it is less specific for SFJ incompetence compared to the Brodie Trendelenburg test.
Question 457: During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?
A. Left renal artery (Correct Answer)
B. Celiac trunk
C. Right renal artery
D. Superior mesenteric artery
Explanation: ***Left renal artery***
- The **left renal artery** arises from the aorta usually just below the superior mesenteric artery, making it susceptible to injury during an **abdominal aortic aneurysm (AAA) repair** if the aneurysm extends proximally.
- Its proximity to the typical location of AAA, often near or involving the **infrarenal aorta**, necessitates careful identification and protection during clamping or graft placement.
*Celiac trunk*
- The **celiac trunk** originates higher up from the aorta, typically at the level of **T12-L1 vertebrae**, well above the common infrarenal AAA repair site.
- While important, it is generally less directly threatened during a typical infrarenal AAA repair compared to arteries immediately adjacent to or within the aneurysm sac.
*Right renal artery*
- The **right renal artery** also originates from the aorta near the level of the renal veins, but it is typically located more posteriorly and usually passes behind the inferior vena cava.
- Although it can be at risk, the left renal artery's course is often more anterior and directly in the field of dissection for the **aortic neck** during AAA repair.
*Superior mesenteric artery*
- The **superior mesenteric artery (SMA)** originates from the aorta proximal to the renal arteries, typically around the L1 vertebral level.
- While crucial, its origin is usually cephalad to the infrarenal aneurysm neck, making it generally less prone to direct injury during infrarenal AAA repair, though flow must be monitored.
Question 458: A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?
A. Superior mesenteric artery and renal arteries
B. Diaphragm and renal arteries
C. Renal arteries and common iliac arteries (Correct Answer)
D. Superior mesenteric artery and common iliac arteries
E. Diaphragm and superior mesenteric artery
Explanation: ***Renal arteries and common iliac arteries***
- The most common location for **abdominal aortic aneurysms (AAAs)** is the **infrarenal aorta**, specifically between the renal arteries and the common iliac arteries.
- This segment accounts for **~95% of all AAAs** due to decreased elastin content, hemodynamic stress, and reduced vasa vasorum.
- The patient's presentation with **flank/back pain**, a **pulsatile abdominal mass**, and risk factors like **hypertension** and **smoking** are highly suggestive of an infrarenal AAA [1].
*Superior mesenteric artery and renal arteries*
- This region defines the **suprarenal aorta**, which is less commonly affected by aneurysms than the infrarenal segment.
- Suprarenal aneurysms account for only **~5% of AAAs** and are typically more complex to manage.
*Diaphragm and renal arteries*
- This encompasses a significant portion of the **thoracoabdominal aorta**, including the suprarenal segment.
- While thoracoabdominal aneurysms can occur, they are much less common than infrarenal AAAs and often have different etiologies.
*Superior mesenteric artery and common iliac arteries*
- This range is anatomically imprecise and spans too broad a region, including both suprarenal and infrarenal segments.
- The **superior mesenteric artery** originates anteriorly from the aorta (typically at L1), well above the most common aneurysm site immediately distal to the renal arteries (L1-L2).
- The highest risk is specifically localized to the segment **below the renal arteries**, not this entire broad region.
*Diaphragm and superior mesenteric artery*
- This describes the **supraceliac and proximal suprarenal aorta**, an area significantly less prone to aneurysms compared to the infrarenal segment.
- Aneurysms in this more proximal segment are rare and often have different etiologies (e.g., connective tissue disorders).
Question 459: A 71-year-old man comes to the physician for a routine health maintenance examination. He feels well. He goes for a 30-minute walk three times a week and does not experience any shortness of breath or chest or leg pain on exertion. He has not had any weakness, numbness, or vision disturbance. He has diabetes that is well controlled with insulin injections. He had smoked one pack of cigarettes every day for 40 years but quit 5 years ago. He appears healthy and well nourished. His temperature is 36.3°C (97.3°F), pulse is 75/min, and blood pressure is 136/78 mm Hg. Physical examination shows normal heart sounds. There are systolic bruits over the neck bilaterally. Physical and neurologic examinations show no other abnormalities. Fasting serum studies show:
Total cholesterol 210 mg/dL
HDL cholesterol 28 mg/dL
LDL cholesterol 154 mg/dL
Triglycerides 140 mg/dL
Glucose 102 mg/dL
Duplex ultrasonography of the carotid arteries shows a 85% stenosis on the left and a 55% stenosis on the right side. Which of the following is the most appropriate next step in management?
A. Carotid artery stenting
B. Aspirin therapy only
C. Bilateral carotid endarterectomy
D. Left carotid endarterectomy (Correct Answer)
Explanation: ***Left carotid endarterectomy***
- The patient has **asymptomatic carotid artery stenosis** with a **left-sided stenosis of 85%**. For asymptomatic patients, carotid endarterectomy is indicated for stenosis between 70% and 99% if the patient has a life expectancy of at least 5 years and the periprocedural stroke and death rate is low (<3%).
- This patient, despite his age, is **active and healthy**, has no neurological deficits, and his comorbidities (well-controlled diabetes, history of smoking but quit 5 years ago) are unlikely to significantly increase surgical risk beyond the benefit of stroke prevention for severe stenosis.
*Carotid artery stenting*
- While carotid artery stenting (CAS) is an alternative to endarterectomy, it is generally preferred in patients who are **high-risk for endarterectomy** due to specific anatomical or medical comorbidities, or in cases of **restenosis after endarterectomy**.
- In asymptomatic patients, **endarterectomy** is generally favored over stenting, especially for stroke prevention, as large trials have shown a slightly higher periprocedural stroke risk with stenting.
*Aspirin therapy only*
- While **aspirin and statin therapy** are crucial for patients with carotid artery disease to reduce cardiovascular events, they are **insufficient as sole treatment** for severe asymptomatic carotid stenosis (85%).
- Medical therapy alone does not provide the same level of stroke risk reduction as interventional approaches for high-grade stenosis.
*Bilateral carotid endarterectomy*
- A **bilateral procedure** is not indicated at this time. The right carotid stenosis is 55%, which in an asymptomatic patient, is typically managed with **medical therapy** rather than surgical intervention.
- Performing endarterectomy on the right side at this time would expose the patient to unnecessary surgical risk without clear benefit for immediate stroke prevention.
Question 460: A 45-year-old policeman presents with pain in the right leg after duty. On examination, the pulse in the right popliteal fossa is absent, and there is pain in the right buttock. The left side is normal. At which level is the blockage?
A. Popliteal
B. Aortoiliac
C. Iliac (Correct Answer)
D. Femoral
Explanation: ***Iliac***
- Pain in the **right buttock** suggests a blockage in the **internal iliac artery** or its branches, which supply the gluteal muscles.
- The absence of a pulse in the right **popliteal fossa** indicates significant arterial obstruction proximal to this level, consistent with an iliac artery lesion.
*Popliteal*
- A popliteal blockage would primarily cause symptoms below the knee, and would not explain **buttock pain**.
- A popliteal pulse would be absent, but pulses proximal to the popliteal artery (like femoral) would generally be present.
*Aortoiliac*
- A blockage at the **aortoiliac** level might affect both legs or cause more widespread symptoms, but the description specifies the right leg.
- While buttock pain can occur in aortoiliac occlusion, it often presents with bilateral claudication or erectile dysfunction (Leriche syndrome), which are not mentioned here.
*Femoral*
- A femoral blockage would cause symptoms in the thigh and calf, and would not explain **buttock pain** due to the collateral circulation.
- The **femoral pulse** would be absent, but the pain distribution doesn't directly point to an isolated femoral lesion as the primary cause of buttock pain.