Vascular Surgery — MCQs

A 40-year-old male with a history of accident 2 days back presented to the ER with complaints of redness of eye, diplopia, decreased vision, and facial pain in the distribution of ophthalmic division of trigeminal nerve. On examination: Bruit was heard over the eyes, Proptosis, Ocular pulsations, Exposure keratopathy, Pulsating exophthalmos. MRI brain was done. The artery involved in the above condition passes through which of the following structures?

Q467

Balloon valvotomy is successful in all of the following cases except –

Q468

Bullet wounds near major blood vessels should be explored only if -

Q469

Butcher's thigh is?

Q470

A young man following RTA presented with proptosis and pain in the right eye after four days. On examination, there is periorbital ecchymosis on the forehead and right eye. What is the diagnosis -

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 461: A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?

A. Ober test
B. Thomas test
C. Perthes test (Correct Answer)
D. Brodie Trendelenburg test

Explanation: ***Perthes test*** - The Perthes test assesses the **patency and competency of the deep venous system** in the leg by observing changes in superficial varicosities during muscle activity. - If the varicosities diminish or disappear with ambulation and a tourniquet applied to compress superficial veins, it indicates that the **deep veins are competent** and can handle venous return. *Ober test* - The Ober test is used to assess the **tightness of the iliotibial band**, not venous competency. - It involves abducting and extending the hip while the patient lies on their side. *Thomas test* - The Thomas test evaluates for **hip flexion contracture**, especially of the iliopsoas muscle. - It is performed by having the patient lie supine and flexing one hip fully while observing the contralateral leg. *Brodie Trendelenburg test* - The Brodie Trendelenburg test is primarily used to assess the **competency of the valves of the saphenofemoral junction and perforating veins** to distinguish between superficial and deep venous insufficiency. - It involves elevating the leg, applying a tourniquet, and then observing refilling patterns of varicose veins upon standing.

Question 462: Which of the following is the best management for radiation induced occlusive disease of carotid artery?

A. Carotid endarterectomy
B. Low dose aspirin
C. Carotid bypass procedure
D. Carotid angioplasty and stenting (Correct Answer)

Explanation: ***Carotid angioplasty and stenting*** - **Radiation-induced carotid artery disease** often involves the distal part of the carotid artery, making it less amenable to surgical endarterectomy. - **Angioplasty and stenting** offer a less invasive approach with good technical success in these challenging cases, especially given the increased fragility and fibrosis of radiated tissues. *Carotid endarterectomy* - **Carotid endarterectomy** in previously radiated fields is associated with a significantly higher risk of complications, including **cranial nerve injury**, **wound infection**, and **carotid artery rupture**, due to tissue fibrosis and scarring. - The disease often extends beyond the easily accessible segment for endarterectomy in radiation-induced cases. *Low dose aspirin* - **Low-dose aspirin** is an important component of medical therapy for **atherosclerotic disease** and **stroke prevention**, but it is insufficient as a sole treatment for symptomatic or high-grade occlusive disease of the carotid artery. - It helps manage the underlying **atherosclerotic process** but does not directly address the severe stenosis or occlusion. *Carotid bypass procedure* - **Carotid bypass procedures** are complex surgical interventions usually reserved for cases of **carotid artery occlusion** or **recurrent stenosis** after previous interventions where endarterectomy or stenting is not feasible. - While an option, it is more invasive and technically demanding than angioplasty and stenting, particularly in already radiated tissues with compromised vascular integrity.

Question 463: All are absolute indications for amputation except,

A. Frost bite (Correct Answer)
B. Buerger's gangrene
C. Gas gangrene
D. Diabetic gangrene

Explanation: ***Frost bite*** - While severe **frostbite** can lead to amputation, it is not an absolute indication as initial management often involves **rapid rewarming**, observation, and conservative measures to preserve tissue. - Amputation is typically considered only after the full extent of tissue damage is clear, and conservative treatments have failed or severe infection develops. *Buerger's gangrene* - **Buerger's disease (thromboangiitis obliterans)** is a progressive inflammatory obliterative disease of small and medium-sized arteries and veins, mainly affecting the limbs. - **Gangrene** in Buerger's disease is often severe and progressive, frequently leading to **autoamputation** or surgical amputation to prevent spread and manage pain. *Gas gangrene* - **Gas gangrene** is a rapidly progressive and life-threatening infection caused by Clostridium species, which produces toxins and gas in tissues. - It necessitates urgent and aggressive treatment, including **radical débridement** or **amputation** to remove infected tissue and prevent sepsis. *Diabetic gangrene* - **Diabetic gangrene** arises from severe peripheral artery disease and neuropathy in diabetic patients, compromising blood supply and sensation. - The compromised blood flow and presence of infection often result in tissue necrosis requiring **amputation** to prevent further spread of infection and systemic complications.

Question 464: All of the following are true with respect to ligation of internal iliac artery except -

A. Bleeding is always controlled with it (Correct Answer)
B. Collateral circulation is established later between middle sacral and lateral sacral arteries
C. The artery should be ligated and not transected
D. For hemostasis, anterior division is to be ligated

Explanation: ***Bleeding is always controlled with it*** - Ligation of the internal iliac artery reduces **pulse pressure** and **blood flow** to the pelvic organs but does not guarantee complete cessation of bleeding. - Significant **collateral circulation** within the pelvis can maintain bleeding, especially from multiple sites or larger vessels. *Collateral circulation is established later between middle sacral and lateral sacral arteries* - This statement is true; these vessels are part of the vast **collateral network** that can supply the pelvic organs after internal iliac artery ligation. - The **middle sacral artery** (a branch of the aorta) and **lateral sacral arteries** (branches of the internal iliac) form anastomoses that become more prominent over time. *The artery should be ligated and not transected* - This is true because ligation (tying off) reduces blood flow without disrupting the vessel wall, preserving **vascular integrity**. - **Transecting** the artery would create two open ends, potentially leading to immediate or delayed hemorrhage and making subsequent control more challenging. *For hemostasis, anterior division is to be ligated* - This is true because the **anterior division** of the internal iliac artery supplies most of the pelvic organs implicated in obstetric and gynecological hemorrhage. - Ligation of the anterior division effectively reduces blood flow to the uterus, vagina, and bladder with less impact on essential structures than ligating the main trunk or posterior division.

Question 465: Foot ulcers secondary to arterial insufficiency are successfully treated by all of the following techniques except:

A. Elevation of the affected extremity (Correct Answer)
B. Antibiotic administration
C. Bed rest
D. Debridement of devitalized tissue

Explanation: ***Elevation of the affected extremity*** - Elevating an extremity with arterial insufficiency will **further reduce arterial blood flow** to the foot, exacerbating ischemia and slowing ulcer healing. - This intervention decreases the **hydrostatic pressure**, which is already compromised due to inadequate arterial supply, making it detrimental. *Antibiotic administration* - Foot ulcers, especially those with impaired circulation, are highly susceptible to **infection**, which necessitates antibiotic treatment. - Antibiotics help to **control bacterial growth** in the ulcer, preventing systemic infection and facilitating the healing process. *Bed rest* - **Reducing weight-bearing** and overall activity through bed rest can decrease metabolic demands on the ischemic limb. - This allows the limited blood supply to be more effectively utilized for **tissue repair and healing**, rather than supporting activity. *Debridement of devitalized tissue* - **Necrotic tissue** in an ulcer provides a medium for bacterial growth and impedes wound healing. - Debridement involves removing non-viable tissue **to promote a clean wound bed**, making it more amenable to healing and reducing infection risk.

Question 466: A 40-year-old male with a history of accident 2 days back presented to the ER with complaints of redness of eye, diplopia, decreased vision, and facial pain in the distribution of ophthalmic division of trigeminal nerve. On examination: Bruit was heard over the eyes, Proptosis, Ocular pulsations, Exposure keratopathy, Pulsating exophthalmos. MRI brain was done. The artery involved in the above condition passes through which of the following structures?

A. Optic canal
B. Cavernous sinus (Correct Answer)
C. Superior orbital fissure
D. Foramen rotundum

Explanation: ***Cavernous sinus*** - The symptoms described (redness, diplopia, decreased vision, facial pain in the ophthalmic division of the trigeminal nerve, bruit over eyes, proptosis, ocular pulsations, pulsating exophthalmos after trauma) are highly suggestive of a **carotid-cavernous fistula**. - In a carotid-cavernous fistula, the **internal carotid artery** (or one of its branches) tears within the **cavernous sinus**, establishing an abnormal communication that shunts high-pressure arterial blood into the venous system of the orbit. *Optic canal* - The **optic canal** primarily transmits the **optic nerve** (cranial nerve II) and the **ophthalmic artery**. - While it's closely related to orbital structures, the internal carotid artery does not pass through the optic canal itself in a way that would lead to a carotid-cavernous fistula within this structure. *Superior orbital fissure* - The **superior orbital fissure** is a passageway for several nerves (**oculomotor III, trochlear IV, ophthalmic V1, abducens VI**) and the **superior ophthalmic vein**. - Although these structures are affected by a carotid-cavernous fistula, the internal carotid artery itself does not traverse this fissure. *Foramen rotundum* - The **foramen rotundum** transmits the **maxillary nerve** (V2), the second division of the trigeminal nerve. - This structure is not involved in the direct pathology of a carotid-cavernous fistula, nor does the internal carotid artery pass through it.

Question 467: Balloon valvotomy is successful in all of the following cases except –

A. Congenital pulmonary stenosis
B. Congenital aortic stenosis
C. Mitral stenosis in pregnancy
D. Calcified mitral stenosis (Correct Answer)

Explanation: ***Calcified mitral stenosis*** - **Heavily calcified valves** are generally considered a contraindication for balloon valvotomy due to the high risk of **valve tearing**, embolism, and suboptimal results. - The rigid, non-compliant nature of heavily calcified valves prevents effective leaflet separation, reducing the chances of a successful procedure and increasing the risk of adverse events. *Congenital pulmonary stenosis* - **Balloon pulmonary valvotomy** is the treatment of choice for most cases of symptomatic congenital pulmonary stenosis with a significant gradient. - It effectively dilates the stenotic valve, leading to a good prognosis and long-term results. *Congenital aortic stenosis* - **Balloon aortic valvotomy** is often performed for severe congenital aortic stenosis, especially in infants and young children, to relieve obstruction. - While it can be associated with some risk of aortic regurgitation, it is a viable option to improve hemodynamics. *Mitral stenosis in pregnancy* - **Balloon mitral valvotomy** is a safe and effective treatment for symptomatic severe mitral stenosis during pregnancy, especially if medical management fails. - It can significantly improve maternal and fetal outcomes by reducing pulmonary congestion and improving cardiac output.

Question 468: Bullet wounds near major blood vessels should be explored only if -

A. The wound is in close proximity to a major blood vessel
B. There is any suspicion of possible vascular involvement
C. Routine exploration is indicated for all penetrating wounds near vessels
D. There are hard signs of vascular injury (active hemorrhage, expanding hematoma, absent distal pulses, palpable thrill/bruit) (Correct Answer)

Explanation: ***There are hard signs of vascular injury (active hemorrhage, expanding hematoma, absent distal pulses, palpable thrill/bruit)*** - **Hard signs** indicate a high likelihood of significant vascular trauma requiring immediate surgical exploration to prevent severe complications such as limb ischemia or exsanguination. - These signs include **active pulsatile hemorrhage**, rapidly **expanding hematoma**, **absent or diminished distal pulses**, presence of a **thrill or bruit**, and **signs of distal ischemia**. *The wound is in close proximity to a major blood vessel* - Proximity alone is a **soft sign** of vascular injury and warrants further investigation, but not immediate routine surgical exploration. - Many wounds near major vessels do not result in vascular injury; direct exploration without other indications would lead to unnecessary surgeries. *There is any suspicion of possible vascular involvement* - **Suspicion** would prompt diagnostic imaging (e.g., CT angiography) or observation, but not an immediate surgical exploration unless hard signs are present. - Suspicions can be based on soft signs such as a stable hematoma, history of significant bleeding at the scene, or bony injury near a vessel. *Routine exploration is indicated for all penetrating wounds near vessels* - **Routine exploration** of all penetrating wounds near vessels is not recommended as it carries risks of iatrogenic injury and surgical complications, and many such wounds do not involve vascular damage. - Clinical guidelines emphasize selective management based on signs and symptoms, differentiating between hard and soft signs of injury to guide intervention.

Question 469: Butcher's thigh is?

A. Accidental injury to major vessels in thigh or groin (Correct Answer)
B. Subcutaneous lipodermatosclerosis
C. Bursa in adductor canal
D. Vastus lateralis rupture

Explanation: ***Accidental injury to major vessels in thigh or groin*** - **Butcher's thigh** refers to a significant traumatic injury that involves the major blood vessels and nerves in the thigh or groin region. - This type of injury can lead to severe **hemorrhage** and neurological deficits, often requiring immediate surgical intervention. *Subcutaneous lipodermatosclerosis* - **Lipodermatosclerosis** is a condition characterized by **skin hardening** and pigmentation, typically in the lower legs, often associated with chronic venous insufficiency. - It does not describe an acute traumatic vascular injury to the thigh. *Bursa in adductor canal* - A **bursa** is a fluid-filled sac that reduces friction between tissues; while bursae can develop in various locations, a bursa in the adductor canal is uncommon and not referred to as "butcher's thigh". - This condition would typically present as a localized swelling or pain, not as an acute, severe vascular injury. *Vastus lateral rupture* - A **vastus lateralis rupture** is a tear in one of the quadriceps muscles located on the lateral side of the thigh. - This is a muscular injury, not a vascular injury, and would present with pain, swelling, and loss of function specific to the muscle.

Question 470: A young man following RTA presented with proptosis and pain in the right eye after four days. On examination, there is periorbital ecchymosis on the forehead and right eye. What is the diagnosis -

A. Internal carotid artery aneurysm
B. Fracture of sphenoid
C. Carotico-cavernous fistula (Correct Answer)
D. Cavernous sinus thrombosis

Explanation: ***Carotico-cavernous fistula*** - A carotico-cavernous fistula (CCF) following trauma, such as a **road traffic accident (RTA)**, is characterized by a direct connection between the **internal carotid artery** and the **cavernous sinus**. - **Key diagnostic feature**: CCF typically presents with a **delayed onset (3-5 days post-trauma)**, which matches this patient's 4-day timeline perfectly. - This leads to arterial blood flowing into the venous system, causing symptoms like **proptosis**, **pain**, chemosis (conjunctival congestion), and **periorbital ecchymosis** due to venous congestion and orbital swelling. - Additional classic features include pulsating exophthalmos, orbital bruit, and conjunctival injection. *Internal carotid artery aneurysm* - An internal carotid artery (ICA) aneurysm can cause symptoms due to compression of adjacent structures (e.g., cranial nerves) or rupture. - While it can occur post-trauma, it typically does not directly lead to the rapid onset of **proptosis** and orbital congestion seen in this case without rupture into the cavernous sinus, which would then become a CCF. - ICA aneurysms usually present with cranial nerve palsies or headache rather than isolated proptosis. *Fracture of sphenoid* - A sphenoid fracture can produce various neurological deficits depending on the fracture's location and extent, potentially involving cranial nerves, optic chiasm, or internal carotid artery. - However, isolated sphenoid fractures are less likely to cause **progressive proptosis** developing over days without other signs like vision loss, diplopia, or CSF leakage. - The **delayed presentation** argues against a simple fracture and suggests a vascular complication like CCF. *Cavernous sinus thrombosis* - Cavernous sinus thrombosis (CST) is usually caused by an **infection** (e.g., from sinusitis, facial cellulitis) and presents with fever, severe headache, and characteristic cranial nerve palsies (**III, IV, V1, V2, VI**), often bilateral. - While CST can cause **proptosis** and orbital pain, the absence of fever and infectious signs, along with the **traumatic history**, makes CCF a more probable diagnosis. - CST typically has a more acute presentation (hours to 1-2 days) compared to the 4-day delay seen here.

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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