Vascular Surgery Practice Questions

Q: Claudication due to femoropopliteal incompetence is primarily seen in

Calf. ***Calf*** - **Femoropopliteal incompetence** refers to insufficiency in the superficial femoral and popliteal arteries. Blockage in these arteries typically results in **claudication** symptoms downstream from the obstruction. - The **calf muscles** receive their blood supply via these arteries and are therefore the primary site of pain due to inadequate blood flow during exertion, manifesting as claudication. *Thigh* - Claudication in the **thigh** is usually associated with more proximal arterial obstructions in the **aortoiliac system** or common femoral artery. - While thigh muscles are located upstream from the calf, pain would indicate a blockage higher up than the femoropopliteal segment. *Buttocks* - **Buttock claudication** points to very proximal arterial disease, specifically involving the **internal iliac arteries** or the distal aorta (**Leriche syndrome**). - This is even further upstream than the femoropopliteal arteries and would involve more significant and widespread circulatory compromise. *Feet* - While the **feet** can experience pain due to arterial insufficiency, particularly with severe disease or at rest, isolated foot claudication is less common. - **Claudication** specifically points to muscle ischemia during activity, and the robust musculature of the calf makes it the primary site when femoropopliteal arteries are involved.

Q: The size threshold at which the risk of rupture of an abdominal aortic aneurysm significantly increases is:

5.5 cm. ***5.5 cm*** - An abdominal aortic aneurysm (AAA) 5.5 cm or larger is typically the threshold for considering **elective surgical repair** due to significantly increased **rupture risk**. - For aneurysms smaller than this, the risk of surgery often outweighs the risk of rupture, making watchful waiting with surveillance more appropriate. *6 cm* - While a 6 cm AAA certainly has a very high risk of rupture, the generally accepted guideline for intervention begins at **5.5 cm** for most patients. - Delaying intervention until 6 cm could unnecessarily expose the patient to a higher risk of rupture. *6.5 cm* - An AAA of 6.5 cm carries an extremely high risk of rupture, and intervention would be strongly indicated. - This size is well past the standard **5.5 cm threshold** recommended for elective repair. *7 cm* - A 7 cm AAA is associated with a **critical and very high risk of rupture**, making immediate intervention imperative. - This size is significantly beyond the established guideline for considering elective repair, which is 5.5 cm.

Q: May-Thurner or Cockett syndrome involves:

Left iliac vein compression. ***Correct: Left iliac vein compression*** - May-Thurner syndrome, also known as Cockett syndrome, specifically describes the **compression of the left common iliac vein** by the overlying right common iliac artery. - This anatomical compression can lead to **venous outflow obstruction**, increasing the risk of deep vein thrombosis (DVT) in the left leg. *Incorrect: Internal iliac artery obstruction* - This condition involves an artery and is unrelated to May-Thurner syndrome, which is a **venous compression disorder**. - Obstruction of the internal iliac artery would typically cause symptoms of **pelvic ischemia** or erectile dysfunction, not venous DVT. *Incorrect: Common iliac artery obstruction* - Obstruction of the common iliac artery is an **arterial occlusion** that would cause peripheral artery disease symptoms in the leg, such as claudication or rest pain. - It does not involve the compression of a vein by an artery, which is characteristic of May-Thurner syndrome. *Incorrect: Internal iliac vein obstruction* - While this is a venous issue, May-Thurner syndrome specifically involves the **common iliac vein**, not the internal iliac vein. - Obstruction of the internal iliac vein would typically present with symptoms related to pelvic venous congestion, distinct from the left lower extremity DVT associated with May-Thurner syndrome.

Q: Surgery in varicose veins is NOT attempted in the presence of which of the following?

Deep vein thrombosis. ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery

Q: What is the basis for the classification of aortic dissection?

Level of aorta affected. ***Level of aorta affected*** - The classification of aortic dissection is **primarily based on the anatomical location** of the dissection within the aorta. - **Stanford Classification** (most commonly used): Based on whether the **ascending aorta** is involved (Type A) or not involved (Type B) - this is fundamentally about the **level/location**. - **DeBakey Classification**: Based on the **site of origin** (ascending vs descending) and whether it propagates - the primary determinant is still which **level** of the aorta is involved. - While extent matters, the **initial classification decision** hinges on identifying **which segment (level)** of the aorta contains the dissection. *Type of dissection* - Classification systems do **not** primarily categorize by the type of pathology (e.g., intimal tear, intramural hematoma, penetrating atherosclerotic ulcer). - The established **Stanford and DeBakey systems** focus on **anatomical location and extent**, not the histological or pathological type of the dissection. *Extent of aorta affected* - While extent is an **important component** of classification (especially in DeBakey system which distinguishes localized vs extensive dissection), it is **secondary to location**. - The **primary decision point** in classification is determining **which level of the aorta** is involved (ascending vs descending), and then extent further refines the classification. - For example, Stanford Type A includes all dissections involving the ascending aorta **regardless of extent** - the level takes precedence. *None of the options* - This is incorrect because well-established classification systems (Stanford A/B and DeBakey I/II/III) clearly exist. - These systems are **based on anatomical criteria**, with the **level (location) of aortic involvement** being the fundamental basis for classification.

Q: IVC filter is used in the following situations except -

As primary treatment for acute DVT. ***As primary treatment for acute DVT*** - The **primary treatment** for **acute deep vein thrombosis (DVT)** is **anticoagulation therapy** (heparin, warfarin, or DOACs) to prevent clot propagation and embolization. - An **IVC filter** is **NOT primary therapy**—it is reserved for specific situations and does not treat the underlying thrombosis. - **Indications for IVC filter include:** - Absolute **contraindication to anticoagulation** (active bleeding, recent hemorrhagic stroke) - **Recurrent PE despite adequate anticoagulation** - Complications from anticoagulation therapy - Therefore, using IVC filter as primary treatment for acute DVT is **incorrect and not indicated**. *Negligible size of emboli* - While IVC filters trap **large emboli**, the concept of "negligible size emboli" is not a standard clinical consideration for filter placement. - IVC filters are indicated based on **risk of PE** and **contraindications to anticoagulation**, not based on emboli size assessment. *To reduce symptoms* - **IVC filters** do not reduce symptoms of DVT such as pain, swelling, or discomfort. - They function as a **mechanical barrier** to prevent emboli from reaching pulmonary circulation. - Symptom management requires anticoagulation, compression therapy, and leg elevation. *To prevent progress of native blood vessel disease* - IVC filters do not influence progression of underlying **vascular disease** such as atherosclerosis or chronic venous insufficiency. - Their sole function is **mechanical prevention of PE**, not disease modification.

Q: Which of the following conditions is least likely to lead to gangrene?

Varicose veins. ***Varicose veins*** - **Varicose veins** are characterized by **venous insufficiency** and primarily lead to **venous ulcers** and skin changes due to chronic venous hypertension, but they **rarely directly cause gangrene**. - Gangrene fundamentally results from **arterial insufficiency** (lack of oxygenated blood flow), which is not the primary pathophysiology of varicose veins. - While severe chronic venous stasis can predispose to secondary complications like infections or tissue breakdown, true gangrene from varicose veins alone is exceptionally rare. *Atherosclerosis* - Atherosclerosis is actually a **common cause of gangrene**, particularly in elderly patients and those with diabetes. - Progressive arterial occlusion leads to **critical limb ischemia** and subsequent **tissue necrosis**. - Accounts for a significant proportion of lower limb gangrene cases, especially in the context of peripheral arterial disease. *Frostbite* - **Frostbite** causes direct tissue injury through freezing, leading to **cellular damage** and **vascular occlusion**. - Ice crystal formation destroys cells and causes thrombosis of blood vessels. - Gangrene is a **common and severe complication** of significant frostbite injuries. *Buerger's disease* - **Buerger's disease (thromboangiitis obliterans)** involves widespread inflammation and **thrombosis of small and medium-sized arteries and veins**, particularly in the extremities. - The recurrent inflammation and subsequent occlusion of vessels are a **primary cause of severe ischemia** and gangrene. - Classically seen in young male smokers, with gangrene being a hallmark complication.

Q: Which of the following conditions is primarily treated by sympathectomy?

Hyperhidrosis. ***Hyperhidrosis*** - **Sympathectomy** (especially thoracic sympathectomy) is a definitive treatment for severe, localized **hyperhidrosis** (excessive sweating) that has not responded to conservative therapies. - The procedure aims to interrupt the sympathetic nerves responsible for stimulating sweat glands, commonly in the palms, soles, or axillae. *Buerger's disease* - While **sympathectomy** was historically used, its efficacy in **Buerger's disease** (thromboangiitis obliterans) is questionable and largely replaced by smoking cessation and other treatments for limb salvage. - The primary issue is **inflammation** and **thrombosis** of small and medium-sized arteries and veins, not primarily sympathetic overactivity. *Acrocyanosis* - **Acrocyanosis** is a benign condition characterized by persistent, painless, blue discoloration of the extremities due to vasospasm of small skin arteries and arterioles. - Treatment is generally reassurance and avoidance of cold, and **sympathectomy** is rarely, if ever, indicated or effective due to the non-progressive and cosmetic nature of the condition. *Raynaud's disease* - **Raynaud's disease** is a vasospastic disorder, but **sympathectomy** is usually reserved for severe cases with impending tissue loss or critical ischemia that fail medical management. - Medical management with calcium channel blockers is the primary treatment, as the condition involves episodic vasospasm of digital arteries.

Question 1

Claudication due to femoropopliteal incompetence is primarily seen in

Accepted Answer

Calf

Answer

Thigh

Answer

Buttocks

Answer

Feet

Question 2

The size threshold at which the risk of rupture of an abdominal aortic aneurysm significantly increases is:

Accepted Answer

5.5 cm

Answer

6 cm

Answer

6.5 cm

Answer

7 cm

Question 3

In which condition is fatal exsanguination most likely to occur?

Accepted Answer

Partial transection of artery

Answer

Closed fracture of femur shaft

Answer

Open fracture of femur & tibia

Answer

Complete transection of artery

Question 4

May-Thurner or Cockett syndrome involves:

Accepted Answer

Left iliac vein compression

Answer

Internal iliac artery obstruction

Answer

Common iliac artery obstruction

Answer

Internal iliac vein obstruction

Question 5

Surgery in varicose veins is NOT attempted in the presence of which of the following?

Accepted Answer

Deep vein thrombosis

Answer

Multiple incompetent perforators

Answer

Varicose veins with leg ulcer

Answer

None of the above

Question 6

What is the basis for the classification of aortic dissection?

Accepted Answer

Level of aorta affected

Answer

Type of dissection

Answer

Extent of aorta affected

Answer

None of the options

Question 7

Volkmann's contracture: which artery is involved in this condition?

Accepted Answer

Brachial artery

Answer

Radial

Answer

Ulnar

Answer

Anterior interosseous artery

Question 8

IVC filter is used in the following situations except -

Accepted Answer

As primary treatment for acute DVT

Answer

To reduce symptoms

Answer

Negligible size of emboli

Answer

To prevent progress of native blood vessel disease

Question 9

Which of the following conditions is least likely to lead to gangrene?

Accepted Answer

Varicose veins

Answer

Atherosclerosis

Answer

Frost bite

Answer

Burger's disease

Question 10

Which of the following conditions is primarily treated by sympathectomy?

Accepted Answer

Hyperhidrosis

Answer

Buerger's disease

Answer

Acrocyanosis

Answer

Raynaud's disease

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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