Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 41: Syndrome of internal iliac artery occlusion is manifested by?

A. Pain in calf
B. Absent pulse at the dorsalis pedis artery (Correct Answer)
C. Intermittent claudication
D. Gangrene

Explanation: The **Internal Iliac Artery (Hypogastric Artery)** primarily supplies the pelvic organs, perineum, and gluteal region. However, in the context of vascular surgery and clinical examination, internal iliac artery occlusion is a critical component of **Leriche Syndrome** (Aortoiliac occlusive disease). ### Why the Correct Answer is Right: **B. Absent pulse at the dorsalis pedis artery:** While the internal iliac artery does not directly continue into the leg, its occlusion is rarely isolated in clinical scenarios. It is most commonly associated with **Aortoiliac disease**. In such cases, the proximal obstruction (at the bifurcation or common iliac level) leads to a significant drop in perfusion pressure throughout the distal limb. The **Dorsalis Pedis pulse**, being the most distal palpable pulse, is the first to disappear when there is a significant proximal inflow obstruction. ### Why Other Options are Wrong: * **A. Pain in calf:** Calf pain is the hallmark of **Superficial Femoral Artery (SFA)** occlusion. Internal iliac occlusion typically presents with **buttock or thigh claudication** rather than calf pain. * **C. Intermittent claudication:** While this occurs, it is a non-specific symptom. In internal iliac disease, the claudication is specifically localized to the **buttocks and hips**. * **D. Gangrene:** Gangrene is a sign of critical limb ischemia (CLI) or acute embolic events. Chronic occlusion of the internal iliac artery usually allows for collateral circulation to develop, making frank gangrene an uncommon primary manifestation unless multiple levels of occlusion exist. ### High-Yield Clinical Pearls for NEET-PG: * **Leriche Syndrome Triad:** 1. Claudication of buttocks/thighs, 2. Impotence (due to internal iliac/pudendal artery involvement), and 3. Absent/diminished femoral pulses. * **Vasculogenic Impotence:** The internal iliac artery gives off the **internal pudendal artery**; thus, bilateral internal iliac occlusion is a major cause of erectile dysfunction. * **Collateral Pathway:** If the external iliac is blocked, the internal iliac can provide collateral flow to the lower limb via the obturator and gluteal branches connecting to the profunda femoris.

Question 42: Which of the following statements is true regarding fat embolism?

A. Most patients with major trauma involving long bones have urinary fat globules. (Correct Answer)
B. All patients with urinary fat globules develop fat embolism.
C. Peak incidence of respiratory insufficiency for pulmonary fat embolism is around day 7 after injury.
D. Heparin as an anticoagulant decreases mortality and morbidity in fat embolism syndrome.

Explanation: **Explanation:** **Fat Embolism Syndrome (FES)** is a clinical diagnosis following orthopedic trauma, most commonly associated with long bone fractures (e.g., femur). 1. **Why Option A is Correct:** Fat globules are released into the systemic circulation following marrow injury. Approximately **50-90% of patients** with major long bone fractures will have fat globules in their urine (lipuria) or sputum. While common, their presence is a marker of fat embolization but does not necessarily mean the patient has the clinical "syndrome." 2. **Why Other Options are Incorrect:** * **Option B:** The presence of urinary fat globules is a sensitive but **non-specific** finding. Most patients with these globules remain asymptomatic; only about 1–3% develop the clinical Fat Embolism Syndrome (characterized by the triad of respiratory distress, petechiae, and neurological symptoms). * **Option C:** The peak incidence of respiratory insufficiency in FES is typically **24 to 72 hours** after the initial injury, not day 7. * **Option D:** Heparin was historically used to clear lipemic serum, but it is **no longer recommended**. It increases the risk of bleeding in trauma patients and can actually increase the levels of toxic free fatty acids, potentially worsening lung injury. **High-Yield Clinical Pearls for NEET-PG:** * **Gurd’s Criteria:** Used for diagnosis. Major criteria include axillary/subconjunctival **petechial rash** (pathognomonic), respiratory insufficiency, and CNS depression. * **Snowstorm Appearance:** Classic finding on Chest X-ray (diffuse bilateral pulmonary infiltrates). * **Management:** Primarily **supportive** (Oxygenation/Ventilation). The most effective preventive measure is **early operative fixation** of the fracture (within 24 hours). * **Schonfeld’s Criteria:** Another scoring system used to quantify the severity of FES.

Question 43: What is the indication for surgery in asymptomatic patients with abdominal aortic aneurysm?

A. Transverse diameter > 3 cm
B. Transverse diameter > 5.5 cm (Correct Answer)
C. Transverse diameter > 7.5 cm
D. No need for surgery unless symptomatic

Explanation: **Explanation:** The management of an Abdominal Aortic Aneurysm (AAA) is based on balancing the risk of spontaneous rupture against the risks associated with surgical repair (EVAR or open surgery). 1. **Why Option B is Correct:** In asymptomatic patients, the threshold for elective surgical intervention is a **transverse diameter of ≥ 5.5 cm in men** and **≥ 5.0 cm in women**. Large-scale clinical trials (like the UKSAT and ADAM trials) demonstrated that for aneurysms smaller than 5.5 cm, the risk of rupture is lower than the operative mortality risk, making surveillance the preferred strategy. Once the diameter exceeds 5.5 cm, the risk of rupture increases exponentially. 2. **Why Other Options are Incorrect:** * **Option A (> 3 cm):** A diameter of > 3.0 cm is the diagnostic criteria for an AAA, but it is not an indication for surgery. These patients require serial ultrasound surveillance. * **Option C (> 7.5 cm):** This is dangerously high. The risk of rupture for an aneurysm > 7.0 cm is approximately 30% per year; surgery should have been performed much earlier. * **Option D:** Waiting for symptoms (pain, tenderness) is incorrect because the first "symptom" of an AAA is often fatal rupture. **High-Yield Clinical Pearls for NEET-PG:** * **Expansion Rate:** Regardless of size, an expansion of **> 0.5 cm in 6 months** or **> 1 cm in 1 year** is an absolute indication for surgery. * **Symptomatic AAA:** Any symptomatic aneurysm (back/abdominal pain or tenderness) requires **urgent/emergent repair** regardless of the diameter. * **Investigation of Choice:** **Ultrasound** is used for screening and surveillance; **Contrast-Enhanced CT (CECT)** is the gold standard for preoperative planning. * **Most Common Site:** Infra-renal (below the origin of renal arteries).

Question 44: Lumbar sympathectomy is the treatment for which of the following conditions?

A. Trophic ulcer
B. Distal ischemia affecting the skin of the toes with rest pain (Correct Answer)
C. Arteriovenous fistula
D. Diabetic neuropathy

Explanation: **Explanation:** Lumbar sympathectomy involves the excision of the 2nd, 3rd, and 4th lumbar sympathetic ganglia. The primary physiological effect is the abolition of vasomotor tone, leading to **vasodilation** of the cutaneous vessels in the lower limb. **Why Option B is Correct:** The procedure increases blood flow specifically to the **skin** rather than the muscles. Therefore, it is most effective for patients with **distal ischemia** (e.g., Buerger’s disease or atherosclerotic peripheral arterial disease) who present with skin changes, cold digits, or **rest pain**. By diverting blood to the cutaneous circulation, it helps relieve rest pain and may assist in the healing of small superficial ischemic ulcers. **Why Other Options are Incorrect:** * **A. Trophic Ulcer:** These are typically neurotrophic (common in leprosy or diabetes) and occur due to repeated trauma to an insensitive limb. Sympathectomy does not restore sensation and is not the primary treatment. * **C. Arteriovenous (AV) Fistula:** Treatment involves surgical closure or embolization of the fistula. Sympathectomy has no role in managing abnormal vascular communications. * **D. Diabetic Neuropathy:** This is a metabolic/degenerative nerve condition. Sympathectomy actually mimics a "pseudosympathectomy" effect already seen in late-stage diabetes (autonomic neuropathy), so it provides no therapeutic benefit. **High-Yield Clinical Pearls for NEET-PG:** * **Indication:** Best suited for **Buerger’s disease (TAO)** with rest pain where distal bypass is not feasible. * **Level of Ganglionectomy:** L2-L4 is standard. Removing **L1** in males can lead to **loss of ejaculation** (retrograde ejaculation) due to interference with the internal urethral sphincter. * **Success Predictor:** A positive response to a chemical sympathetic block (using Phenol/Alcohol) predicts a good surgical outcome. * **Limitation:** It does **not** improve **intermittent claudication**, as it does not increase blood flow to the calf muscles.

Question 45: What is the investigation of choice for detecting small para-aortic lymph nodes?

A. Ultrasound scan
B. CT scan (Correct Answer)
C. Lymphangiography
D. Aeriography

Explanation: **Explanation:** The **CT scan (Computed Tomography)** is the investigation of choice for detecting small para-aortic lymph nodes due to its superior spatial resolution and ability to visualize the retroperitoneum clearly. It allows for the precise measurement of node size (typically considered significant if >10 mm in the short axis) and assessment of their relationship with major vessels like the aorta and IVC. Contrast-enhanced CT (CECT) further helps differentiate nodes from vascular structures. **Analysis of Options:** * **Ultrasound (A):** While useful for screening, it is often limited by overlying bowel gas and patient habitus, making it unreliable for detecting "small" nodes deep in the retroperitoneum. * **Lymphangiography (C):** Historically used to visualize lymphatic architecture, it is an invasive, technically demanding procedure that has been almost entirely replaced by non-invasive cross-sectional imaging (CT/MRI). * **Arteriography (D):** This is used to visualize the lumen of arteries. It does not visualize lymph nodes unless they are large enough to displace major vessels, which would not apply to "small" nodes. **Clinical Pearls for NEET-PG:** * **Gold Standard for Staging:** CT is the standard for staging most intra-abdominal malignancies (e.g., Testicular tumors, Renal Cell Carcinoma) to check for para-aortic involvement. * **PET-CT:** While CT detects size, PET-CT is superior for detecting metastasis in normal-sized nodes by assessing metabolic activity. * **MRI:** Equivalent to CT in accuracy but usually reserved for patients with contrast allergies or for specific pelvic nodal staging.

Question 46: Surgical treatment (ligation or stripping) is preferred for GSV diameter equal to or greater than what measurement?

A. 2 cm (Correct Answer)
B. 3 cm
C. 4 cm
D. 5 cm

Explanation: ### Explanation The management of varicose veins has evolved significantly with the advent of endovenous thermal ablation (EVLA/RFA). However, the diameter of the **Great Saphenous Vein (GSV)** remains a critical factor in determining the surgical approach. **Why 2 cm is the correct answer:** Standard endovenous techniques (Laser or Radiofrequency ablation) are highly effective for moderate venous diameters. However, when the GSV diameter at the saphenofemoral junction (SFJ) or the proximal thigh exceeds **2 cm (20 mm)**, the risk of failure with thermal ablation increases significantly. Large diameters are associated with higher rates of **recanalization** and technical difficulty in achieving a complete "seal" of the vessel. In such cases, traditional **High Ligation and Stripping (HL/S)** is preferred to ensure definitive closure and reduce the risk of recurrence. **Analysis of Incorrect Options:** * **3 cm, 4 cm, and 5 cm:** While these diameters certainly necessitate surgical intervention, they are far beyond the established threshold. A vein measuring 2 cm is already considered "giant" or "aneurysmal" in the context of venous reflux; waiting for it to reach 3–5 cm would lead to severe chronic venous insufficiency (CVI) and skin changes (lipodermatosclerosis). **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Duplex Ultrasound is the investigation of choice for varicose veins. * **CEAP Classification:** Used to grade chronic venous disorders (C0: No signs, C2: Varicose veins, C6: Active ulcer). * **Trendelenburg Test:** Used clinically to differentiate between SFJ incompetence and perforator incompetence. * **Complication of Stripping:** Injury to the **Saphenous nerve** (sensory loss on the medial aspect of the leg/foot) is a high-yield surgical complication.

Question 47: Lymphangiography of the leg is performed by?

A. An injection of sodium diatrizoate subcutaneously between the toes
B. Injecting sodium diatrizoate retrogradely under pressure into a small vein on the dorsum of the foot
C. Dissecting lymphatics through an incision on the dorsum of the foot (Correct Answer)
D. The use of an infusion pump

Explanation: **Explanation:** Lymphangiography is a specialized imaging technique used to visualize the lymphatic system. Unlike venography, lymphatics are not easily accessible via percutaneous puncture because they are thin-walled, colorless, and carry low-pressure fluid. **Why Option C is Correct:** To perform lymphangiography, the lymphatics must first be identified. This is achieved by injecting a vital dye (like **Patent Blue V**) subcutaneously into the first web space of the toes. The dye is taken up by the lymphatics, making them visible as blue streaks. A transverse incision is then made on the **dorsum of the foot**, and a visible lymphatic vessel is **surgically dissected** and cannulated with a fine needle or catheter for the injection of an oil-based contrast medium (e.g., Lipiodol). **Analysis of Incorrect Options:** * **Option A:** Subcutaneous injection of contrast (sodium diatrizoate) will not enter the lymphatic channels in sufficient concentration to provide a diagnostic image; it would merely result in local tissue opacification. * **Option B:** Retrograde injection into a vein is the technique for **venography**, not lymphangiography. Lymphatic flow is unidirectional (towards the nodes) due to valves. * **Option C:** While an infusion pump is often used to deliver the contrast at a slow, controlled rate (to prevent lymphatic rupture), it is a *tool* used during the procedure, not the *method* of performing the access itself. **High-Yield Clinical Pearls for NEET-PG:** * **Contrast Agent:** Lipiodol (Ethiodized oil) is the preferred contrast. * **Primary Use:** Historically used for staging lymphomas and investigating lymphedema, though largely replaced by CT/MRI and Lymphoscintigraphy today. * **Complication:** A rare but serious complication is **lipid pulmonary embolism**, as the oil-based contrast eventually enters the thoracic duct and the venous circulation. * **Lymphoscintigraphy:** The modern "gold standard" for functional imaging, using Technetium-99m labeled sulfur colloid.

Question 48: Boyd's classification is with regard to what condition?

A. Limb ischemia
B. Arterial stenosis (Correct Answer)
C. Claudication
D. AV fistula

Explanation: **Explanation:** **Boyd’s Classification** is a clinical grading system used to assess the severity of **Arterial Stenosis** (specifically in the context of Chronic Occlusive Peripheral Arterial Disease). It categorizes the progression of arterial narrowing based on the patient's functional limitations and the physiological response to exercise. * **Grade I:** Mild stenosis; the patient experiences claudication only after heavy or prolonged exercise. * **Grade II:** Moderate stenosis; claudication occurs after walking a standard distance (e.g., 500 yards) at a normal pace. * **Grade III:** Severe stenosis; the patient experiences claudication after walking a very short distance (e.g., 50-100 yards). * **Grade IV:** Critical stenosis/occlusion; characterized by rest pain, ulceration, or gangrene. **Why other options are incorrect:** * **Limb Ischemia:** While stenosis leads to ischemia, "Limb Ischemia" (specifically Acute Limb Ischemia) is typically classified using the **Rutherford Classification**. * **Claudication:** Claudication is a *symptom* of arterial stenosis. While Boyd’s grades are based on claudication distances, the classification fundamentally describes the degree of underlying arterial disease. The most common classification specifically for claudication is the **Fontaine Classification**. * **AV Fistula:** Arteriovenous fistulas are typically classified based on their morphology or by the **Nicoladoni-Branham sign** (clinical test), not by Boyd’s criteria. **High-Yield Clinical Pearls for NEET-PG:** * **Boyd’s Perforators:** Do not confuse Boyd’s classification with **Boyd’s Perforating Veins**, which connect the long saphenous vein to the deep veins just below the knee (medial tibia). * **Fontaine vs. Rutherford:** Fontaine (Stages I-IV) and Rutherford (Categories 0-6) are the more commonly tested classifications for Peripheral Arterial Disease (PAD) in modern exams. * **Adson’s Test:** Often tested alongside vascular topics; it is used to diagnose Thoracic Outlet Syndrome.

Question 49: What is the commonest cause of arteriovenous fistulae?

A. Congenital (Correct Answer)
B. Traumatic
C. Surgical creation
D. Tumor erosion

Explanation: **Explanation:** Arteriovenous (AV) fistulae are abnormal communications between an artery and a vein that bypass the capillary bed. **Why Congenital is the Correct Answer:** Congenital AV fistulae are the **most common** type overall. They result from the failure of the embryonic vascular plexus to differentiate into distinct arteries and veins during the third to fourth week of development. These are often multiple, small, and diffuse, frequently involving an entire limb or organ (e.g., Klippel-Trenaunay Syndrome). Because they are developmental anomalies present from birth (though they may manifest later), they represent the largest statistical group of AV communications. **Analysis of Incorrect Options:** * **Traumatic:** This is the most common cause of **acquired** AV fistulae. They typically result from penetrating injuries (stab or gunshot wounds) where an adjacent artery and vein are damaged simultaneously. * **Surgical creation:** These are iatrogenic fistulae (e.g., Brescia-Cimino fistula) created intentionally for hemodialysis access. While common in renal wards, they do not surpass congenital cases in the general population. * **Tumor erosion:** This is a rare cause where a malignant tumor (e.g., renal cell carcinoma) erodes through the walls of adjacent vessels. **High-Yield Clinical Pearls for NEET-PG:** * **Nicoladoni-Branham Sign:** Pressure applied to the artery proximal to an AV fistula leads to a decrease in heart rate (bradycardia). This is due to the sudden increase in peripheral resistance and subsequent vagal stimulation. * **Hemodynamic Effects:** AV fistulae lead to **increased cardiac output** and can eventually cause high-output heart failure. * **Physical Exam:** A continuous "machinery" murmur and a palpable thrill are classic findings over the site of the fistula.

Question 50: Which of the following is NOT true about abdominal aortic aneurysm?

A. Atherosclerosis is the commonest cause.
B. It most commonly arises from the infrarenal aorta. (Correct Answer)
C. For asymptomatic aneurysms, repair is indicated if the diameter is >5.5 cm.
D. Endovascular placement of an aortic stent is used for repair.

Explanation: **Explanation:** The question asks for the statement that is **NOT true** regarding Abdominal Aortic Aneurysm (AAA). However, based on surgical facts, **Option B is actually a true statement**, making the question technically flawed or suggesting a typo in the provided key. In standard surgical teaching, over 90% of AAAs are infrarenal. **1. Analysis of Options:** * **Option A (True):** Atherosclerosis is the most common etiology. It leads to the degradation of elastin and collagen in the tunica media, weakening the arterial wall. * **Option B (True):** The infrarenal aorta is the most common site for AAA. This is due to a lower density of vasa vasorum and a higher proportion of elastic fiber breakdown in this segment. * **Option C (True):** The standard threshold for elective surgical intervention in asymptomatic males is **>5.5 cm**. For females, the threshold is often lower (**>5.0 cm**) due to a higher risk of rupture at smaller diameters. * **Option D (True):** Endovascular Aneurysm Repair (EVAR) using a stent-graft is a standard minimally invasive alternative to open surgery, provided the anatomical criteria (like a suitable "neck") are met. **2. Clinical Pearls for NEET-PG:** * **Risk Factors:** Smoking is the strongest risk factor; male gender and family history are also significant. * **Screening:** A one-time USG is recommended for men aged 65–75 who have ever smoked. * **Indications for Surgery:** 1. Diameter >5.5 cm (Men) / >5.0 cm (Women). 2. Rapid expansion (>0.5 cm in 6 months or >1 cm in 1 year). 3. Any symptomatic aneurysm (pain/tenderness) regardless of size. * **Classic Triad of Rupture:** Hypotension, pulsatile abdominal mass, and back/abdominal pain.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

Practice Questions

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

Practice Questions

Vasculitis

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