Vascular Surgery Practice Questions

Q: The best material for below-inguinal arterial graft is:

Saphenous vein graft (upside-down). ***Saphenous vein graft (upside-down)*** - The **autologous saphenous vein** is the material of choice for below-inguinal arterial bypasses due to its superior patency rates compared to synthetic grafts. - It is often harvested and implanted **'upside-down' (reversed)** to ensure the valves do not obstruct blood flow, or can be used *in situ* after rendering the valves incompetent. - Five-year patency rates for autologous vein grafts exceed 70-80% for femoropopliteal bypasses. *Cryopreserved vein* - **Cryopreserved saphenous vein allografts** are an alternative when autologous vein is unavailable or inadequate. - However, they have **significantly lower patency rates** compared to autologous vein grafts due to immunological responses and structural degradation. - They are generally reserved for salvage situations or as a bridge in limb-threatening ischemia. *Dacron* - **Dacron (polyethylene terephthalate)** grafts are primarily used for large-diameter arterial replacements, such as in **aortic bypasses**, and are less suitable for smaller, high-resistance vessels below the inguinal ligament. - They tend to have higher rates of **thrombosis** and infection when used in infra-inguinal positions compared to vein grafts. *PTFE* - **Polytetrafluoroethylene (PTFE)** grafts have lower patency rates than autologous vein grafts, particularly in smaller diameter vessels and below-knee positions, due to issues like **intimal hyperplasia** at the anastomoses. - While suitable when autologous vein is unavailable, it is generally considered inferior for below-inguinal peripheral arterial disease, with 3-year patency rates around 50-60% for above-knee and 30-40% for below-knee positions.

Q: A young man with tuberculosis presents with massive recurrent hemoptysis. For angiographic treatment, which vascular structure should be evaluated first?

Bronchial artery. ***Bronchial artery*** - The **bronchial arteries** are the primary source of blood supply to the conducting airways, and in conditions like **tuberculosis**, they often become hypertrophied and tortuous, leading to **massive hemoptysis**. - Angiographic embolization of these abnormal bronchial arteries is a common and effective treatment for persistent or massive hemoptysis, especially in patients with chronic inflammatory lung diseases. *Pulmonary artery* - The **pulmonary artery** carries deoxygenated blood to the lungs for gas exchange and is less commonly the source of hemoptysis, unless there is a **pulmonary artery aneurysm**, fistula, or erosion. - While pulmonary hemorrhage can occur, it typically presents differently and is not the primary source of massive recurrent hemoptysis in tuberculosis. *Pulmonary vein* - The **pulmonary veins** carry oxygenated blood from the lungs back to the left atrium and are almost never the source of hemoptysis. - Hemoptysis originates from the arterial system due to rupture of high-pressure vessels into the airways. *Superior vena cava* - The **superior vena cava** is a large vein that drains deoxygenated blood from the upper body into the right atrium and is not directly involved in the pulmonary circulation supplying the airways. - It would not be a source of hemoptysis; symptoms related to SVC obstruction would be **upper body edema** and plethora.

Q: TRIVEX is a percutaneous technique of:

Transilluminated powered phlebectomy. ***Transilluminated powered phlebectomy*** - **TRIVEX** is an acronym for **Transilluminated Powered Phlebectomy**, a minimally invasive surgical technique for removing varicose veins. - This procedure uses a specialized device that combines **transillumination** to visualize veins beneath the skin and a powered resection tool to excise them. *Sclerotherapy* - **Sclerotherapy** involves injecting a chemical solution into varicose veins to cause irritation and eventual collapse, rather than mechanical removal. - It is typically used for smaller **spider veins** and **reticular veins**. *Vein stripping* - **Vein stripping** is a traditional surgical method that involves completely removing a varicose vein through large incisions, often requiring general anesthesia. - TRIVEX is a less invasive approach compared to this conventional method of vein removal. *Endovenous laser ablation* - **Endovenous laser ablation (EVLA)** uses laser energy to heat and close varicose veins from within, which is a different mechanism from mechanical removal. - This technique primarily targets larger saphenous veins and involves threading a **laser fiber** into the vein.

Q: According to the Spetzler-Martin grading scale, what score is assigned for the SIZE component of a 5 cm arteriovenous malformation (AVM)?

Score of 2. ***Score of 2*** - A 5 cm AVM falls into the **medium size category** (3-6 cm) according to the Spetzler-Martin grading scale. - This specific size range is assigned a score of **2** for the size component. - The Spetzler-Martin scale evaluates three components: size, eloquence of adjacent brain, and venous drainage. *Score of 3* - This score is assigned to **large AVMs (greater than 6 cm)** for the size component. - A 5 cm AVM does not meet this threshold and therefore receives a score of 2, not 3. *Score of 4* - This is not a valid score for the size component in the Spetzler-Martin grading system. - The size component only assigns scores of 1 (small, 6 cm). *Score of 5* - This is not a score assigned for the size component of an AVM in the Spetzler-Martin grading scale. - While Grade V is the highest overall grade (scores 5-6), the size component itself only ranges from 1 to 3 points.

Q: Most common complication of cardiac catheterization is:

Vascular Access Site Bleeding. ***Vascular Access Site Bleeding*** - This is the **most common complication** of cardiac catheterization, occurring in 2-6% of procedures due to the invasive nature of puncturing an artery or vein for catheter insertion. - Complications can range from a **small hematoma or bruising** to more serious issues like pseudoaneurysm formation or arteriovenous fistula. - Risk factors include larger sheath size, anticoagulation, and femoral access (compared to radial access). *Arrhythmia* - While rhythm disturbances can occur during catheterization, especially when the catheter irritates the myocardium, they are **less frequent** than access site complications. - Most arrhythmias are **transient** and resolve spontaneously without intervention. - Common types include PVCs, NSVT, and rarely sustained ventricular arrhythmias. *Contrast reaction* - Reactions to contrast media can occur, ranging from mild (e.g., rash, itching) to severe (e.g., anaphylaxis). - However, with modern non-ionic, low-osmolar contrast agents and careful patient screening, these are **not the most common complications**. - Incidence of severe reactions is less than 0.1% with modern agents. *Perforation of heart chamber* - This is a **rare but serious complication** (incidence <0.1%) that can lead to cardiac tamponade. - It is typically associated with complex procedures, stiff guidewires, or difficult anatomical features. - Its incidence is significantly lower than access site bleeding.

Q: Nicoladoni-Branham's sign is seen in:

Arteriovenous fistula. ***Arteriovenous fistula*** - The **Nicoladoni-Branham's sign** (or Branham's sign) is a bradycardia and a decrease in pulse pressure that occurs upon manual compression of an **arteriovenous fistula**. - This sign is due to the sudden increase in **systemic vascular resistance** and venous return to the heart, which activates baroreceptors, leading to reflex bradycardia. *Buerger's disease* - This disease, also known as **Thromboangiitis obliterans**, is characterized by vasculitis leading to thrombosis and obstruction of small and medium-sized arteries and veins, primarily in the limbs. - It presents with **intermittent claudication**, digital ischemia, and pain, but does not involve the Nicoladoni-Branham's sign. *Raynaud's disease* - Raynaud's phenomenon involves **vasospasm** of arterioles, usually in the fingers and toes, triggered by cold or emotional stress, causing color changes (pallor, cyanosis, rubor). - It is a functional vascular disorder and does not involve an abnormal connection between arteries and veins that would elicit Branham's sign. *Peripheral aneurysm* - A peripheral aneurysm is a localized **dilation of an artery** outside the aorta, commonly in the popliteal or femoral arteries. - While it can cause local symptoms like pain, thrombosis, or embolization, it does not involve the characteristic hemodynamic changes that lead to Nicoladoni-Branham's sign.

Q: Tobey Ayer test is positive in

Spinal subarachnoid block. ***Spinal subarachnoid block*** - The **Queckenstedt-Tobey test** (or Tobey Ayer test) evaluates **CSF flow** by observing changes in CSF pressure upon **jugular vein compression**. - In a spinal subarachnoid block, compression of the jugular veins will show a **blunted or absent rise** in CSF pressure, indicating obstruction. *Spinal cord compression* - While spinal cord compression can lead to a subarachnoid block, the Tobey Ayer test primarily detects the **blockage of CSF flow**, not the compression itself. - The test helps in localizing the obstruction but is not specific to the **etiology of compression**. *Spinal stenosis* - **Spinal stenosis** refers to the narrowing of the spinal canal, which can *potentially* cause a CSF flow impediment. - However, the Tobey Ayer test directly assesses the **CSF dynamics** and flow blockage, it doesn't diagnose the underlying anatomical narrowing. *Normal CSF dynamics* - In individuals with normal CSF dynamics, jugular compression would result in a **rapid and significant rise** in CSF pressure, followed by a quick return to baseline upon release. - The absence of such a response is indicative of a **pathological CSF flow disturbance**.

Q: What is the treatment of choice for extrahepatic portal thrombosis?

Splenorenal shunt. ***Splenorenal shunt*** - A **distal splenorenal shunt (DSRS)**, or **Warren shunt**, is the preferred **surgical shunt procedure** for managing **portal hypertension** in **extrahepatic portal vein thrombosis (EHPVT)**. - This procedure connects the **splenic vein** to the **left renal vein**, bypassing the obstructed portal vein and decompressing **gastroesophageal varices** while attempting to preserve hepatopetal flow. - **When used:** Second-line therapy when endoscopic management fails or as definitive surgical management in selected cases. - **Advantage:** Selectively decompresses varices while maintaining some mesenteric flow to the liver, reducing risk of hepatic encephalopathy compared to total shunts. *Mesocaval shunt* - Connects the **superior mesenteric vein** to the **inferior vena cava (IVC)**. - Less preferred for EHPVT due to higher **thrombosis rates**, technical complexity, and complete diversion of portal flow. *Portocaval shunt* - Connects the **portal vein** directly to the **inferior vena cava**. - Generally avoided in EHPVT because it completely diverts all portal blood flow away from the liver, leading to **hepatic encephalopathy** and impaired liver function. - Creates a **total (non-selective) shunt** with higher morbidity. *Mesorenal shunt* - Connects the **superior mesenteric vein** to the **left renal vein**. - Rarely performed; does not offer advantages over distal splenorenal shunt and is technically more challenging. **Note:** Modern management of EHPVT emphasizes **endoscopic variceal ligation** and medical therapy as first-line treatment, with **Meso-Rex bypass (Rex shunt)** increasingly preferred when surgical intervention is needed as it restores physiological portal flow. Traditional shunts like DSRS are now reserved for cases where these options are not feasible.

Q: What is the next step in the management of a young basketball player who develops an acute onset of subclavian vein thrombosis (effort thrombosis) after heavy exercise?

Thrombolytic therapy. ***Thrombolytic therapy (Catheter-directed thrombolysis)*** - In **Paget-Schroetter syndrome** (effort thrombosis), young active patients presenting within **14 days** of symptom onset are candidates for **catheter-directed thrombolysis (CDT)** after initial anticoagulation - This approach aims to restore venous patency and prevent **post-thrombotic syndrome**, which occurs in up to 50% of conservatively managed cases - **Standard protocol**: Immediate therapeutic anticoagulation → CDT (if eligible) → subsequent thoracic outlet decompression (first rib resection) → rehabilitation - CDT is preferred over systemic thrombolysis due to lower bleeding risk and higher success rates in restoring patency - **Key point**: While anticoagulation is initiated immediately, definitive management in young athletes involves thrombolysis followed by surgical decompression *Physical therapy and rehabilitation* - Rehabilitation is **essential after definitive treatment** (post-thrombolysis and post-surgical decompression) but not the immediate next step - Starting rehabilitation without addressing the acute thrombosis would risk clot propagation, pulmonary embolism, and permanent venous damage *Antibiotics* - Antibiotics treat bacterial infections and have **no role in thrombosis** management - Paget-Schroetter syndrome is a **mechanical compression** issue (thoracic outlet obstruction) causing hypercoagulability, not an infectious process - Use of antibiotics would delay appropriate treatment *Anti-inflammatory drugs for pain management* - NSAIDs may provide symptomatic relief but do **not address the underlying thrombus** - Pain management alone would be inadequate and potentially dangerous, allowing thrombus propagation - Anti-inflammatory drugs do not prevent post-thrombotic syndrome or restore venous patency

Question 1

Which one of the following statements best describes a pseudoaneurysm?

Accepted Answer

Focal dilation of vessel in which intimal and medial layers are disrupted and the dilated segment is lined by adventitia

Answer

Apparent dilation of a vessel due to intrinsic narrowing proximal and distal to the point of apparent narrowing

Answer

Dilation of a vessel, though not to the size necessary to be diagnosed as a true aneurysm

Answer

Focal dilation of a vessel only involving one portion of the circumference

Question 2

The best material for below-inguinal arterial graft is:

Accepted Answer

Saphenous vein graft (upside-down)

Answer

Cryopreserved vein

Answer

Dacron

Answer

PTFE

Question 3

A young man with tuberculosis presents with massive recurrent hemoptysis. For angiographic treatment, which vascular structure should be evaluated first?

Accepted Answer

Bronchial artery

Answer

Superior vena cava

Answer

Pulmonary artery

Answer

Pulmonary vein

Question 4

TRIVEX is a percutaneous technique of:

Accepted Answer

Transilluminated powered phlebectomy

Answer

Vein stripping

Answer

Sclerotherapy

Answer

Endovenous laser ablation

Question 5

According to the Spetzler-Martin grading scale, what score is assigned for the SIZE component of a 5 cm arteriovenous malformation (AVM)?

Accepted Answer

Score of 2

Answer

Score of 3

Answer

Score of 4

Answer

Score of 5

Question 6

Most common complication of cardiac catheterization is:

Accepted Answer

Vascular Access Site Bleeding

Answer

Arrhythmia

Answer

Contrast reaction

Answer

Perforation of heart chamber

Question 7

Nicoladoni-Branham's sign is seen in:

Accepted Answer

Arteriovenous fistula

Answer

Raynaud's disease

Answer

Peripheral aneurysm

Answer

Buerger's disease

Question 8

Tobey Ayer test is positive in

Accepted Answer

Spinal subarachnoid block

Answer

Spinal cord compression

Answer

Normal CSF dynamics

Answer

Spinal stenosis

Question 9

What is the treatment of choice for extrahepatic portal thrombosis?

Accepted Answer

Splenorenal shunt

Answer

Mesorenal shunt

Answer

Portocaval shunt

Answer

Mesocaval shunt

Question 10

What is the next step in the management of a young basketball player who develops an acute onset of subclavian vein thrombosis (effort thrombosis) after heavy exercise?

Accepted Answer

Thrombolytic therapy

Answer

Antibiotics

Answer

Physical therapy and rehabilitation

Answer

Anti-inflammatory drugs for pain management

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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