Vascular Surgery — MCQs

A 58-year-old male with a history of hypertension and smoking presents with sudden severe back pain and hypotension. A CT scan reveals a 7 cm ruptured abdominal aortic aneurysm (AAA). What are the key factors in deciding whether to proceed with endovascular aneurysm repair (EVAR) or open surgical repair?

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 481: In acute limb ischemia, which finding indicates irreversible damage?

A. Pulselessness
B. Pain
C. Pallor
D. Paralysis (Correct Answer)

Explanation: ***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 482: Which of the following is the most common cause of acute mesenteric ischemia?

A. Embolism (Correct Answer)
B. Thrombosis
C. NOMI
D. Venous thrombosis

Explanation: ***Embolism*** - **Embolic occlusion** (typically from the heart, e.g., atrial fibrillation) accounts for a significant majority of acute mesenteric ischemia cases. - This typically leads to sudden onset of severe abdominal pain with minimal physical findings initially. *Thrombosis* - **Arterial thrombosis** of the mesenteric vessels is another cause but is less frequent than embolism in acute settings. - It often occurs in the context of pre-existing **atherosclerotic disease** and can present with a more gradual onset of symptoms. *NOMI* - **Nonocclusive Mesenteric Ischemia (NOMI)** is caused by severe vasoconstriction and hypoperfusion, not a physical blockage. - It is often seen in critically ill patients with conditions like **shock**, sepsis, or heart failure. *Venous thrombosis* - **Mesenteric venous thrombosis** is a less common cause of acute mesenteric ischemia compared to arterial causes. - It is often associated with hypercoagulable states and can present with more insidious abdominal pain and bowel wall edema.

Question 483: Which of the following is not true regarding the surgical treatment of varicose veins?

A. High ligation is commonly performed
B. Compression stockings are recommended after surgery
C. Phlebectomy is used
D. Sclerotherapy is curative (Correct Answer)

Explanation: ***Sclerotherapy is curative*** - **Sclerotherapy** is a procedure where a solution is injected into varicose veins to cause them to scar and collapse, but it is typically not considered **curative** on its own, especially for larger or recurrent veins. - While effective for smaller veins and spider veins, its role is often **palliative** or adjunctive, and it may require multiple sessions or be combined with other treatments to achieve long-term success. - Modern guidelines prefer endovenous ablation techniques (radiofrequency or laser) for definitive treatment of great saphenous vein incompetence. *High ligation is commonly performed* - **High ligation**, involving the surgical tie-off of the sapheno-femoral junction (SFJ), is a common component of surgical treatment for **varicose veins** to prevent reflux from the deep venous system into the superficial system. - It aims to eliminate a primary source of **venous hypertension** in the superficial veins and is often combined with stripping of the great saphenous vein. *Compression stockings are recommended after surgery* - **Compression stockings** are routinely recommended after surgical treatment of varicose veins to minimize **postoperative swelling**, reduce pain, and improve venous return. - They also play a role in preventing complications such as **thrombosis** and promoting better long-term outcomes by maintaining vein compression during healing. *Phlebectomy is used* - **Ambulatory phlebectomy** is a surgical technique used to remove varicose veins through small incisions, particularly for superficial, tortuous veins that are not easily treated by other methods. - It is often performed in conjunction with **high ligation** and stripping or as a standalone procedure for localized varicose segments.

Question 484: A 70-year-old woman presents with chronic venous insufficiency and varicose veins. Which is the most appropriate first-line interventional approach for treating her condition?

A. Endovenous laser therapy (Correct Answer)
B. Saphenous vein stripping
C. Radiofrequency ablation
D. Surgical intervention is not required.

Explanation: ***Endovenous laser therapy*** - **Endovenous thermal ablation techniques**, including **EVLT** and **radiofrequency ablation (RFA)**, are now considered the **first-line treatment** for saphenous vein incompetence causing chronic venous insufficiency. - **EVLT** uses laser energy to thermally ablate and close off the incompetent saphenous vein with high success rates (>95% occlusion at 5 years). - Advantages include: **minimally invasive**, performed under local anesthesia, **faster recovery**, less postoperative pain, and lower risk of complications compared to open surgery. - Both EVLT and RFA have **Class 1A recommendations** in international guidelines (NICE, SVS, AVF). *Radiofrequency ablation* - **RFA** is another endovenous thermal ablation technique with **equivalent efficacy** to EVLT. - While both are appropriate first-line options, this question accepts EVLT as it represents the broader category of **endovenous thermal ablation**, which has replaced open surgery as the standard of care. - In clinical practice, choice between EVLT and RFA often depends on operator preference and local availability. *Saphenous vein stripping* - **Open surgical stripping** is an older technique involving physical removal of the saphenous vein through groin and leg incisions. - Now considered **second-line** treatment, reserved for: recurrent varicosities after endovenous treatment, very tortuous veins unsuitable for catheter access, or when endovenous techniques are unavailable. - Higher morbidity: more pain, bruising, longer recovery, and increased risk of **nerve injury** (saphenous or sural nerve). *Surgical intervention is not required.* - While **conservative management** (compression stockings, leg elevation, exercise) is important for all patients, it does not correct the underlying **venous reflux**. - For symptomatic chronic venous insufficiency with documented reflux, **interventional treatment** is indicated to prevent progression, reduce symptoms (pain, swelling, skin changes), and improve quality of life.

Question 485: A 50-year-old smoker with a history of hypertension presents with a sudden onset of severe back pain. Imaging suggests a 5 cm infrarenal abdominal aortic aneurysm with signs of rupture. What is the immediate management?

A. Perform open surgical repair immediately (Correct Answer)
B. Manage conservatively with blood pressure control
C. Attempt endovascular aneurysm repair (EVAR)
D. Administer thrombolytic therapy

Explanation: ***Perform open surgical repair immediately*** - A **ruptured abdominal aortic aneurysm (AAA)** is a surgical emergency requiring immediate intervention to control bleeding and prevent exsanguination. - **Open surgical repair** remains the definitive treatment when EVAR facilities are unavailable, anatomy is unsuitable, or the patient is severely hemodynamically unstable requiring immediate laparotomy. - In many emergency settings, particularly where endovascular capabilities are limited, **open repair is the most rapidly available life-saving intervention**. *Manage conservatively with blood pressure control* - **Conservative management** is appropriate for asymptomatic, unruptured AAAs, especially those smaller than 5.5 cm, as it aims to reduce rupture risk. - In a ruptured AAA, **medical management alone is insufficient** to stop the ongoing hemorrhage and will likely lead to rapid demise. *Attempt endovascular aneurysm repair (EVAR)* - **EVAR is increasingly preferred** for ruptured AAA when anatomically suitable and available, with evidence from multiple trials (IMPROVE, AJAX) showing comparable or better outcomes than open repair. - However, EVAR requires specialized equipment, anatomical suitability (adequate neck length, appropriate iliac access), and may not be immediately available in all emergency settings. - In the acute setting with limited resources or unfavorable anatomy, **open repair remains the standard**, making this option context-dependent rather than universally applicable. *Administer thrombolytic therapy* - **Thrombolytic therapy** is used to dissolve blood clots, typically in conditions like acute myocardial infarction or ischemic stroke. - It is **absolutely contraindicated in a ruptured aneurysm** as it would worsen bleeding, accelerate hemorrhage, and be rapidly fatal.

Question 486: Which artery is commonly used for coronary artery bypass grafting (CABG)?

A. Radial artery
B. Internal thoracic artery (Correct Answer)
C. Gastroepiploic artery
D. Femoral artery

Explanation: **Internal thoracic artery** - The **internal thoracic artery** (also known as the internal mammary artery) is the **most preferred conduit for CABG** due to its excellent long-term patency rates. - Its resistance to atherosclerosis and good size matching with coronary arteries make it ideal for bypassing blocked coronary vessels. *Radial artery* - The **radial artery** is a common alternative conduit, particularly for multi-vessel bypass. - However, it has a **higher rate of spasm** compared to the internal thoracic artery, which can affect graft patency. *Gastroepiploic artery* - The **gastroepiploic artery** is primarily used in cases where other conduits (internal thoracic, radial, saphenous vein) are unavailable or unsuitable. - Its use is **more technically challenging** and typically reserved for re-do CABG or patients with limited options. *Femoral artery* - The **femoral artery** is a large artery in the leg and is **not suitable for CABG**. - It is typically used for procedures related to peripheral arterial disease, not for direct bypass of coronary arteries.

Question 487: Which intervention is most appropriate for a patient with symptomatic chronic mesenteric ischemia?

A. Diet modification
B. Endovascular angioplasty with stenting (Correct Answer)
C. Administration of vasodilators
D. Laparoscopic bowel resection

Explanation: ***Endovascular angioplasty with stenting*** - This intervention directly addresses the underlying cause of **chronic mesenteric ischemia**, which is typically **stenosis** or occlusion of the mesenteric arteries. - It is a **minimally invasive** procedure that can restore adequate blood flow to the bowel, alleviating symptoms such as **postprandial abdominal pain** and **weight loss**. *Diet modification* - While important for managing symptoms in many gastrointestinal disorders, **diet modification** alone does not address the underlying **vascular insufficiency** in chronic mesenteric ischemia. - It may temporarily reduce symptoms by decreasing the metabolic demand on the ischemic bowel, but it cannot reverse the disease progression or prevent complications like **bowel infarction**. *Administration of vasodilators* - **Vasodilators** may offer some symptomatic relief by increasing blood flow to existing vessels, but they often have limited efficacy because the primary issue is **fixed arterial stenosis** rather than vasospasm. - They do not address the structural blockage of the mesenteric arteries, and their use is generally reserved for acute settings or when revascularization is not an option. *Laparoscopic bowel resection* - **Laparoscopic bowel resection** is a surgical procedure to remove segments of the bowel. It is indicated for complications such as **bowel infarction** or obstruction, not for the primary treatment of chronic mesenteric ischemia itself. - This intervention is a treatment for the consequences of severe, unmanaged ischemia, rather than a solution for the underlying **vascular insufficiency**.

Question 488: In a patient with an abdominal aortic aneurysm, which symptom would indicate an imminent risk of rupture?

A. Back pain
B. Pulsatile abdominal mass
C. Sudden, severe abdominal pain (Correct Answer)
D. Constipation

Explanation: ***Sudden, severe abdominal pain*** - This symptom, particularly when acute and intense, often signifies a **rapid expansion** or impending rupture of the abdominal aortic aneurysm (AAA). - It indicates that the aortic wall is under extreme stress, and immediate medical intervention is critical to prevent a catastrophic rupture. *Back pain* - While back pain can be a symptom of an expanding AAA, it is often a more **chronic or gradual symptom** and does not necessarily indicate an *imminent* rupture. - Many conditions can cause back pain, and it is less specific for an acute, life-threatening event compared to sudden, severe abdominal pain. *Pulsatile abdominal mass* - A palpable pulsatile abdominal mass is a **classic sign** of an AAA, but its presence alone does not indicate imminent rupture. - This finding suggests the presence of an aneurysm but does not necessarily denote acute instability or a heightened risk of rupture *at that exact moment*. *Constipation* - Constipation is a common gastrointestinal symptom that is **unrelated to the pathology** or acute complications of an abdominal aortic aneurysm. - It does not suggest any increased risk of aneurysm rupture and should not be considered an indicator of an imminent vascular event.

Question 489: A 75-year-old man presents with a pulsatile abdominal mass and back pain. Ultrasound confirms an abdominal aortic aneurysm measuring 6 cm. What is the recommended management?

A. Monitoring with serial ultrasounds
B. Lifestyle modification
C. Endovascular aneurysm repair (Correct Answer)
D. Open surgical repair

Explanation: ***Endovascular aneurysm repair (EVAR)*** - A **6 cm AAA with back pain** suggests **impending rupture** and requires **urgent intervention**. - EVAR is generally preferred for large AAAs in elderly patients when **anatomically suitable**, offering **lower perioperative mortality** (1-2% vs 4-5% for open repair) and faster recovery. - The **minimally invasive approach** reduces physiological stress, making it ideal for a 75-year-old patient. - **Important:** If hemodynamically unstable or anatomy is unfavorable for EVAR, open repair becomes necessary. *Open surgical repair* - Remains the **gold standard** for ruptured AAA when EVAR is not feasible (unfavorable anatomy, lack of expertise, or hemodynamic instability requiring immediate control). - Involves **higher perioperative morbidity** (cardiac events, bleeding, infection) and longer recovery, especially in elderly patients. - However, it is a valid and sometimes necessary option for symptomatic AAAs. *Monitoring with serial ultrasounds* - Appropriate only for **asymptomatic AAAs <5.5 cm** where rupture risk is lower than surgical risk. - A **6 cm AAA with back pain** is symptomatic and at high rupture risk (annual rupture rate >10-20%), making surveillance inappropriate. - Immediate intervention is required to prevent fatal rupture. *Lifestyle modification* - Important for **preventing aneurysm growth** (smoking cessation, BP control, statin therapy) in small asymptomatic AAAs. - **Cannot address** the immediate rupture risk of a large, symptomatic 6 cm AAA. - Should be adjunctive to surgical repair, not a replacement for it.

Question 490: A 58-year-old male with a history of hypertension and smoking presents with sudden severe back pain and hypotension. A CT scan reveals a 7 cm ruptured abdominal aortic aneurysm (AAA). What are the key factors in deciding whether to proceed with endovascular aneurysm repair (EVAR) or open surgical repair?

A. Patient's hemodynamic stability, anatomy of the aneurysm, and access to EVAR equipment (Correct Answer)
B. Patient's hemodynamic stability and anatomy of the aneurysm
C. Access to EVAR equipment and patient's age
D. Surgeon's experience with EVAR procedures

Explanation: ***Patient's hemodynamic stability, anatomy of the aneurysm, and access to EVAR equipment*** - **Hemodynamic stability** is crucial; unstable patients may benefit from more rapid intervention, potentially open repair, or require stabilization before EVAR. - The **anatomy of the aneurysm** (e.g., neck length, angulation, iliac artery access) dictates suitability for EVAR, as specific morphological criteria must be met for stent-graft placement. - **Access to EVAR equipment and trained personnel** is also a practical consideration for emergency intervention. *Patient's hemodynamic stability and anatomy of the aneurysm* - While **hemodynamic stability** and **aneurysm anatomy** are critical factors, access to specialized EVAR equipment and facilities is also a practical determinant of whether EVAR can even be attempted, especially in an emergent setting. - This option overlooks the logistical requirements necessary for performing an **EVAR procedure**. *Access to EVAR equipment and patient's age* - **Access to EVAR equipment** is important, but **patient's age** is generally less critical than factors like physiological status, comorbidities, and aneurysm morphology when deciding between EVAR and open repair for ruptured AAAs. - Younger patients may tolerate open surgery better, but age alone does not preclude EVAR if anatomy is suitable. *Surgeon's experience with EVAR procedures* - While **surgeon experience** is important for procedural success and outcomes, it is considered secondary to the immediate patient-centered and anatomical factors. - In emergency settings, the decision primarily hinges on the **patient's hemodynamic status**, **aneurysm anatomical suitability**, and **immediate availability of EVAR resources**, rather than being driven by surgeon preference based on experience alone. - Institutional protocols typically guide whether EVAR or open repair should be attempted based on the factors in the correct answer.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

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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