Vascular Surgery Practice Questions

Q: Tobey-Ayer test is positive in which of the following conditions?

Lateral sinus thrombosis. ***Lateral sinus thrombosis*** - The **Tobey-Ayer test** (or Queckenstedt's maneuver) assesses the patency of the **internal jugular vein** by observing changes in CSF pressure during compression. - In **lateral sinus thrombosis**, compression of the unaffected internal jugular vein leads to a rise in CSF pressure, but compression of the affected side yields **no or a blunted rise**, indicating obstruction. *Subarachnoid haemorrhage* - This condition involves bleeding into the subarachnoid space, which can elevate **intracranial pressure (ICP)**, but it isn't directly diagnosed by a differential CSF pressure response to jugular compression. - The primary diagnostic methods are **CT scans** and **lumbar puncture** showing xanthochromia. *Petrositis* - Also known as Gradenigo's syndrome, petrositis is an infection of the **petrous apex** of the temporal bone, often presenting with ear discharge, facial pain, and abducens nerve palsy. - While it's a complication of otitis media, it does not typically involve obstruction of the internal jugular vein or present with a positive Tobey-Ayer test. *Cerebral abscess* - A cerebral abscess is a localized collection of pus within the brain parenchyma, which can cause **localized neurological deficits** and increased ICP. - The Tobey-Ayer test would not specifically diagnose a cerebral abscess, as it assesses venous outflow from the brain rather than focal brain lesions.

Q: Deep vein thrombosis is MOST common after which of the following procedures?

Total hip replacement. ***Total hip replacement*** - **Total hip replacement surgery** is a significant risk factor for DVT due to extensive tissue trauma, prolonged immobility, and potential damage to venous endothelium during the procedure. - The incidence of **postoperative DVT** can be as high as 40-60% without prophylaxis, earning it a classification as a **very high-risk procedure** for VTE. *Neurosurgery* - While neurosurgery carries a risk of DVT, it is generally **lower compared to major orthopedic surgeries** like total hip replacement. - The focus in neurosurgery often revolves around avoiding **intracranial bleeding**, which can limit the intensity of anticoagulant prophylaxis. *Gastrectomy* - Gastrectomy, a major abdominal surgery, does increase the risk of DVT, but typically **less profoundly than total hip replacement**. - Risk factors like **anesthesia duration** and degree of inflammation contribute to DVT risk, but not to the same extent as direct trauma to large veins in the lower extremities. *Prostatic operation* - **Prostatic operations**, such as prostatectomy, carry a moderate risk of DVT, but this risk is generally **lower than that associated with major orthopedic procedures**. - The risk is influenced by factors such as **surgical time**, patient age, and the presence of malignancy, but the extent of venous stasis and damage is typically less severe.

Q: Classical indication of gamma knife amongst the following is:

Arterio-venous malformation. ***Arterio-venous malformation*** - Gamma Knife radiosurgery is a well-established and highly effective treatment for **intracranial arterio-venous malformations (AVMs)**, particularly those that are small to medium-sized and surgically inaccessible. - It works by delivering a highly focused dose of radiation to the abnormal blood vessels, causing them to gradually scar and occlude over time. *Hepatocellular carcinoma* - Gamma Knife radiosurgery is primarily designed and used for treating **intracranial lesions**, not peripheral solid organ tumors like hepatocellular carcinoma. - Treatment for hepatocellular carcinoma typically involves systemic therapies, surgical resection, or other localized interventions like transarterial chemoembolization (TACE) or radiofrequency ablation. *Tuberculoma* - Tuberculoma is an infectious granulomatous lesion, usually managed with **anti-tubercular drug therapy**. - Radiosurgery is not the primary treatment for infectious processes unless there's a specific indication for mass effect not responding to medical therapy, which is rare. *Glioblastoma* - While radiation therapy is a cornerstone of glioblastoma treatment, **Gamma Knife radiosurgery** is generally not a primary treatment for diffuse, infiltrative tumors like glioblastoma, especially at initial diagnosis. - It may be considered as an adjuvant or salvage therapy for small, recurrent lesions or focal recurrences, but its role is limited due to the infiltrative nature of the disease.

Q: Tobey-Ayer test and Crowe-Beck test are used for?

Lateral sinus thrombosis. ***Lateral sinus thrombosis*** - The **Tobey-Ayer test** and **Crowe-Beck test** are classical methods used to diagnose **lateral sinus thrombosis**. - These tests rely on observing changes in **cerebrospinal fluid (CSF) pressure** upon compression of the jugular veins, which will be altered in the presence of a thrombus. *Subarachnoid hemorrhage* - Diagnosed primarily by **CT scan of the head** and analysis of **CSF for xanthochromia**. - While CSF is involved, these specific tests are not used for its diagnosis. *Petrositis* - This is an inflammation of the **petrous apex** of the temporal bone, often diagnosed with **CT or MRI** imaging. - The Tobey-Ayer and Crowe-Beck tests are not relevant to its diagnosis. *Cerebral abscess* - A localized collection of pus within the brain, diagnosed with **contrast-enhanced CT or MRI** of the brain. - These specific tests are irrelevant for the diagnostic workup of a cerebral abscess.

Q: A 65-year-old woman, two days after knee implant surgery, complains of calf pain and swelling in her leg. She later develops breathlessness and dies suddenly in the ward. What is the most probable cause?

Pulmonary embolism. ***Pulmonary embolism*** - The combination of **calf pain** and **swelling** post-surgery indicates a probable **deep vein thrombosis (DVT)**, which can dislodge and travel to the lungs. - The sudden onset of **breathlessness** and death is characteristic of a **massive pulmonary embolism**, where a large clot obstructs blood flow to the lungs and heart. *Stroke* - A stroke typically presents with **focal neurological deficits**, such as sudden weakness, numbness, or speech difficulties, which are not described here. - While post-operative stroke is possible, sudden death with preceding calf pain and swelling is not typical for its presentation. *Myocardial infarction* - A **myocardial infarction** (heart attack) would likely involve chest pain, radiating pain, and EKG changes, though silent MIs can occur. - While a life-threatening event, the preceding DVT symptoms and breathlessness point more towards a pulmonary cause of sudden death, especially in a post-surgical patient. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is characterized by widespread inflammation in the lungs leading to severe hypoxemia, often developing over hours to days. - While it causes severe breathlessness, the rapid onset of death and the clear indicators of a preceding DVT make ARDS less likely as the immediate cause of sudden demise.

Q: The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:

ePTFE. ***ePTFE (Expanded Polytetrafluoroethylene)*** - **ePTFE** is the preferred synthetic graft for femoropopliteal bypass when autologous vein is unavailable - Offers good **biocompatibility** and relative resistance to **thrombosis** - Provides superior patency rates in above-knee femoropopliteal bypasses compared to other synthetic materials (5-year patency ~50-60%) - The expanded structure allows tissue ingrowth and better integration *Dacron (Polyethylene terephthalate)* - Generally used for **larger diameter vessels** (e.g., aortoiliac grafts) - Has **inferior patency rates** in smaller diameter femoropopliteal position compared to ePTFE - More prone to kinking and associated with higher rates of intimal hyperplasia in peripheral circulation *Saphenous vein* - The autologous saphenous vein is the **gold standard** for femoropopliteal bypass with superior long-term patency (5-year patency ~70-80%) - However, this question specifically asks for synthetic material when vein is unavailable or unsuitable - Not always available or of adequate quality in all patients *PTFE (non-expanded)* - **Non-expanded PTFE** lacks the porous structure of ePTFE - Not used for vascular grafts due to absence of tissue ingrowth capability - The **expanded** form is specifically engineered for vascular applications

Q: Following endarterectomy on the right common carotid, a patient is found to be blind in the right eye. It appears that a small thrombus embolized during surgery and lodged in the artery supplying the retina. Which artery would be blocked?

Central artery of the retina. ***Central artery of the retina*** - The **central artery of the retina** is a branch of the **ophthalmic artery** that supplies blood to the inner two-thirds of the retina, including the **photoreceptors** and **ganglion cells**. - Its occlusion, often due to an **embolus** like in this scenario, leads to sudden, **painless monocular vision loss**, often described as a "curtain" coming down, which aligns with **blindness in the right eye**. *Nasociliary artery* - The **nasociliary artery** supplies structures like the **ethmoid sinuses**, **dura mater**, and part of the **nasal cavity**. - It does not directly supply the **optic nerve** or the **retina** and its occlusion would not cause blindness. *Infraorbital artery* - The **infraorbital artery** supplies structures in the **maxilla**, **lower eyelid**, and part of the **cheek**. - Its occlusion would primarily affect these areas and would not result in **blindness**. *Lacrimal artery* - The **lacrimal artery** primarily supplies the **lacrimal gland**, which produces tears, as well as parts of the **eyelids** and **conjunctiva**. - While it's a branch of the ophthalmic artery, its occlusion would not directly cause **blindness** by affecting the retina or optic nerve.

Q: Primary vascular access of choice in chronic kidney disease is:

Radio-cephalic fistula. ***Radio-cephalic fistula*** - The **radio-cephalic fistula** is the preferred primary vascular access in **chronic kidney disease** patients because it has the longest patency rates and lowest complication rates. - It is often created at the **wrist** and involves an anastomosis between the **radial artery** and the **cephalic vein**. *PTFE graft* - **PTFE grafts** are typically used when autologous veins are unsuitable for fistula creation due to poor quality or prior failures. - They tend to have **lower patency rates** and **higher infection rates** compared to native fistulas. *Brachio-cephalic fistula* - A **brachio-cephalic fistula** is usually considered a secondary option when a radio-cephalic fistula is not feasible. - It is created in the **upper arm** and generally has a **shorter lifespan** and potentially more complications than a wrist fistula. *Permcath* - A **Permcath** (tunneled central venous catheter) is a temporary or short-term access option, often used for immediate dialysis needs or when no other vascular access is possible. - It carries a **high risk of infection** and central venous stenosis, making it unsuitable for long-term primary vascular access.

Q: In acute limb ischemia, which finding indicates irreversible damage?

Paralysis. ***Paralysis*** - **Paralysis** (loss of motor function) in acute limb ischemia signifies severe and prolonged ischemia leading to **nerve and muscle infarction**, indicating irreversible damage to the limb. - This symptom represents **Stage III ischemia** (Rutherford Classification), typically requiring amputation. *Pulselessness* - **Pulselessness** is a cardinal sign of acute limb ischemia, indicating a lack of blood flow, but it does not alone confirm irreversible damage. - While critical, blood flow can often be restored, and viability saved if treated promptly before nerve and muscle death occurs. *Pain* - **Pain** is one of the earliest and most common symptoms of acute limb ischemia, resulting from tissue hypoxia. - Though an indicator of significant ischemia, pain itself does not signify irreversible damage and is often present in reversible stages. *Pallor* - **Pallor** (whiteness) of the limb is due to reduced arterial blood flow and is a characteristic sign of acute limb ischemia. - Like pulselessness and pain, pallor is an early sign of ischemia and does not solely indicate irreversible tissue damage.

Question 1

Tobey-Ayer test is positive in which of the following conditions?

Accepted Answer

Lateral sinus thrombosis

Answer

Subarachnoid haemorrhage

Answer

Petrositis

Answer

Cerebral abscess

Question 2

Deep vein thrombosis is MOST common after which of the following procedures?

Accepted Answer

Total hip replacement

Answer

Neurosurgery

Answer

Gastrectomy

Answer

Prostatic operation

Question 3

Classical indication of gamma knife amongst the following is:

Accepted Answer

Arterio-venous malformation

Answer

Hepatocellular carcinoma

Answer

Tuberculoma

Answer

Glioblastoma

Question 4

Tobey-Ayer test and Crowe-Beck test are used for?

Accepted Answer

Lateral sinus thrombosis

Answer

Subarachnoid hemorrhage

Answer

Petrositis

Answer

Cerebral abscess

Question 5

A 65-year-old woman, two days after knee implant surgery, complains of calf pain and swelling in her leg. She later develops breathlessness and dies suddenly in the ward. What is the most probable cause?

Accepted Answer

Pulmonary embolism

Answer

Stroke

Answer

Myocardial infarction

Answer

ARDS

Question 6

The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:

Accepted Answer

ePTFE

Answer

Dacron

Answer

Xenograft

Answer

Saphenous vein

Answer

PTFE (non-expanded)

Answer

Cryopreserved vein graft

Answer

Polyethylene terephthalate (PET)

Answer

Allograft

Question 7

A patient is on follow-up for recurrent abdominal pain. USG reveals an aortic aneurysm of 40 mm. What should be the next immediate step?

Accepted Answer

Establish surveillance protocol with repeat imaging in 6-12 months.

Answer

Initiate medical management with beta-blockers.

Answer

Perform surgical intervention immediately.

Answer

Start antihypertensive therapy immediately.

Question 8

Following endarterectomy on the right common carotid, a patient is found to be blind in the right eye. It appears that a small thrombus embolized during surgery and lodged in the artery supplying the retina. Which artery would be blocked?

Accepted Answer

Central artery of the retina

Answer

Nasociliary artery

Answer

Infraorbital artery

Answer

Lacrimal artery

Question 9

Primary vascular access of choice in chronic kidney disease is:

Accepted Answer

Radio-cephalic fistula

Answer

PTFE graft

Answer

Brachio-cephalic fistula

Answer

Permcath

Question 10

In acute limb ischemia, which finding indicates irreversible damage?

Accepted Answer

Paralysis

Answer

Pulselessness

Answer

Pain

Answer

Pallor

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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