Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 51: The Allen test is used for what purpose?

A. Thoracic outlet syndrome
B. Radial or ulnar artery patency (Correct Answer)
C. Varicose veins
D. Ulnar nerve injury

Explanation: **Explanation:** The **Allen test** is a clinical bedside maneuver used to assess the **patency of the radial and ulnar arteries** and the adequacy of the **dual blood supply (collateral circulation)** to the hand via the palmar arches. **Why Option B is Correct:** The test is performed by asking the patient to clench their fist while the clinician applies pressure over both the radial and ulnar arteries at the wrist. When the hand is opened, it appears pale. The clinician then releases pressure from one artery (e.g., the ulnar artery). If the hand flushes (returns to a pink color) within 5–15 seconds, it indicates that the ulnar artery is patent and the palmar arch is intact. This is mandatory before procedures like **Radial Artery Cannulation** or harvesting the radial artery for a CABG to ensure the hand remains perfused if the radial artery is compromised. **Why Other Options are Incorrect:** * **A. Thoracic Outlet Syndrome:** This is evaluated using tests like **Adson’s test**, Roos test, or Wright’s test, which look for compression of the neurovascular bundle at the neck/shoulder. * **C. Varicose Veins:** Venous insufficiency in the lower limbs is assessed using the **Trendelenburg test**, Perthes test, or the Multiple Tourniquet test. * **D. Ulnar Nerve Injury:** This is assessed using the **Froment’s sign** (book test) or by checking for sensory loss in the medial 1.5 fingers and motor weakness of the intrinsic hand muscles. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen Test:** Performed on unconscious patients or those unable to cooperate; the clinician clenches the patient's fist for them. * **Normal Refill Time:** Usually <7 seconds. A result >10–15 seconds is considered "Abnormal/Positive," indicating inadequate collateral circulation. * **Gold Standard:** While the Allen test is a standard clinical screening tool, **Doppler Ultrasound** is the gold standard for assessing palmar arch patency.

Question 52: Which of the following statements is NOT true regarding thoracic outlet syndrome?

A. The radial nerve is commonly affected. (Correct Answer)
B. Neurological features are most common.
C. Resection of the first rib relieves symptoms.
D. A positive Adson's test is indicative of the condition.

Explanation: Thoracic Outlet Syndrome (TOS) involves the compression of neurovascular structures as they pass through the superior thoracic aperture. **Why Option A is the Correct Answer (The False Statement):** In neurogenic TOS, the **lower trunk of the brachial plexus (C8-T1)** is the structure most frequently compressed. This primarily affects the **ulnar nerve** distribution, leading to wasting of the intrinsic muscles of the hand (Gilliatt-Sumner hand) and numbness in the medial forearm/hand. The radial nerve (derived from C5-T1, but primarily associated with the posterior cord) is rarely involved in isolation. **Analysis of Other Options:** * **Option B:** Neurological features are indeed the most common presentation (95% of cases), characterized by pain, paresthesia, and weakness. Venous (Paget-Schroetter syndrome) and arterial involvements are much rarer. * **Option C:** Resection of the first rib (often via a transaxillary approach) is the definitive surgical treatment. It decompresses the space between the clavicle and the first rib, relieving pressure on the plexus and vessels. * **Option D:** Adson’s test is a classic clinical maneuver where the patient’s arm is abducted and the head is turned toward the affected side while taking a deep breath. A disappearance or weakening of the radial pulse suggests compression, supporting the diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Most common cause:** Cervical rib (found in <1% of the population, but a frequent culprit in TOS). * **Scalene Triangle:** The most common site of compression (between the anterior and middle scalene muscles). * **Differential Diagnosis:** Must be distinguished from Pancoast tumor or Carpal Tunnel Syndrome. * **Imaging:** Chest X-ray is the initial investigation to look for a cervical rib or elongated C7 transverse process.

Question 53: Which of the following is NOT an indication for sympathectomy?

A. Intermittent claudication (Correct Answer)
B. Ischemic pain
C. Rest pain
D. Buerger disease

Explanation: ### Explanation **Concept Overview:** Lumbar sympathectomy involves the destruction of the sympathetic chain (L2-L4) to eliminate vasoconstrictor tone. This results in **vasodilation of the skin vessels** rather than the muscle vessels. **Why Intermittent Claudication is NOT an indication:** Intermittent claudication is pain caused by ischemia in the **skeletal muscles** during exercise. Sympathectomy primarily increases blood flow to the **skin and subcutaneous tissues**, not the deep muscles. In fact, sympathectomy can theoretically worsen claudication via a "steal phenomenon," where blood is diverted away from the ischemic muscle toward the dilated cutaneous vascular bed. Therefore, it is ineffective and contraindicated for claudication. **Analysis of Other Options:** * **Ischemic Pain & Rest Pain:** These represent advanced peripheral arterial disease (Critical Limb Ischemia). Sympathectomy helps by increasing cutaneous collateral circulation, which can alleviate rest pain and promote the healing of small ischemic ulcers. * **Buerger’s Disease (Thromboangiitis Obliterans):** This is the **most common indication** for sympathectomy. Since it primarily affects distal small and medium-sized arteries, sympathectomy helps reduce vasospasm and improve distal skin perfusion, providing symptomatic relief. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Effect:** Increases skin blood flow; has no effect on muscle blood flow. * **Ideal Candidate:** A patient with distal arterial occlusion (e.g., Buerger's) where reconstructive surgery is not possible. * **Level of Block:** For the lower limb, the **L2, L3, and L4** ganglia are targeted. L1 is preserved in males to prevent loss of ejaculation. * **Success Predictor:** A positive response to a temporary chemical sympathetic block (using Phenol or Alcohol) suggests a good surgical outcome.

Question 54: All statements are true about Paget-Schroetter syndrome except?

A. Also known as venous thoracic outlet syndrome
B. Associated with jugular-subclavian venous thrombosis (Correct Answer)
C. History of performing prolonged activities
D. Results in damage to the subclavian vein

Explanation: **Explanation:** **Paget-Schroetter Syndrome (PSS)**, also known as **"Effort Thrombosis,"** is a specific type of primary upper extremity deep vein thrombosis (UEDVT). **Why Option B is the Correct Answer (The False Statement):** While PSS involves the **subclavian and axillary veins**, it is specifically characterized by thrombosis at the level of the **costoclavicular space** (between the first rib and the clavicle). It is **not** typically associated with jugular vein involvement. The term "jugular-subclavian venous thrombosis" is more characteristic of secondary causes, such as central venous catheterization or malignancy (Trousseau’s syndrome), rather than the mechanical "effort-induced" etiology of PSS. **Analysis of Other Options:** * **Option A:** PSS is indeed the vascular manifestation of **Venous Thoracic Outlet Syndrome (vTOS)**, where the vein is compressed by anatomical structures (first rib, clavicle, or scalene muscles). * **Option C:** It typically occurs in young, healthy athletes (e.g., swimmers, pitchers, weightlifters) following **vigorous or repetitive overhead activities** that lead to microtrauma of the vessel wall. * **Option D:** Repetitive compression results in **intimal damage** to the subclavian vein, triggering the coagulation cascade and subsequent thrombus formation. **NEET-PG High-Yield Pearls:** * **Clinical Presentation:** Sudden onset of "blue-arm" (cyanosis), swelling, and prominent collateral veins over the shoulder (Urschel’s sign). * **Diagnosis:** Duplex Ultrasound is the initial investigation; **Catheter-directed Venography** is the gold standard. * **Treatment Triad:** 1. Catheter-directed thrombolysis, 2. Anticoagulation, and 3. **Surgical decompression** (First rib resection) to prevent recurrence.

Question 55: Which of the following venous abnormalities is indicated for surgery?

A. Deep vein incompetence with DVT (Correct Answer)
B. Deep vein incompetence without DVT
C. Varicosity > 3 mm in diameter
D. Varicosity < 3 mm in diameter

Explanation: ### Explanation The management of venous disorders depends on the severity of symptoms, the presence of complications, and the underlying pathophysiology. **Why Option A is Correct:** Deep vein incompetence (DVI) associated with Deep Vein Thrombosis (DVT) or its sequelae (Post-Thrombotic Syndrome) often leads to severe venous hypertension. While initial management is conservative (compression therapy), surgical intervention is indicated when there is **recalcitrant venous ulceration** or severe symptomatic reflux that fails medical management. In the context of this question, the presence of DVT/Post-thrombotic changes represents a more advanced stage of venous disease where surgical options like **valvuloplasty** or **venous bypass (e.g., Palma procedure)** are considered to alleviate high pressure and prevent limb-threatening complications. **Analysis of Incorrect Options:** * **Option B:** Deep vein incompetence without DVT is often managed conservatively with Grade II compression stockings. Surgery is rarely the first line unless it leads to intractable ulcers (CEAP C6). * **Option C & D:** The diameter of a varix alone is not an absolute indication for surgery. According to the **CEAP classification**, surgery is indicated for symptomatic varicosities, skin changes (lipodermatosclerosis), or healed/active ulcers, regardless of whether they are >3 mm or <3 mm. Small telangiectasias (<1 mm) and reticular veins (1-3 mm) are primarily treated with sclerotherapy for cosmetic reasons. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Duplex Ultrasound is the initial investigation of choice for both DVT and Varicose Veins. * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and deep vein reflux. * **Brodie-Trendelenburg Test:** Specifically identifies the site of perforator incompetence. * **CEAP Classification:** Remember that **C4 (skin changes)**, **C5 (healed ulcer)**, and **C6 (active ulcer)** are the primary clinical triggers for considering surgical or endovenous intervention.

Question 56: Lumbar sympathectomy can be recommended in all of the following conditions except?

A. Hyperhydrosis
B. Causalgia
C. Buerger's disease
D. Erectile dysfunction (Correct Answer)

Explanation: **Explanation:** Lumbar sympathectomy involves the surgical removal or destruction of the sympathetic chain (usually L2-L4 ganglia). This procedure results in **vasodilation** and the **abolition of sweating** in the lower limbs. **Why Erectile Dysfunction is the Correct Answer:** Erectile dysfunction is a **complication** (side effect) of bilateral lumbar sympathectomy, not an indication for it. The sympathetic nerves (specifically the L1-L2 fibers) are involved in the emission phase of ejaculation. Damage to these fibers during bilateral surgery can lead to **retrograde ejaculation** or erectile dysfunction. Therefore, it is never "recommended" as a treatment for this condition. **Analysis of Incorrect Options (Indications):** * **Hyperhidrosis:** Lumbar sympathectomy is a definitive treatment for severe plantar hyperhidrosis (excessive sweating of the feet) because it interrupts the sudomotor fibers. * **Causalgia (Complex Regional Pain Syndrome Type II):** By interrupting the sympathetic pain pathways and reducing vasomotor tone, sympathectomy helps alleviate the burning pain associated with nerve injuries. * **Buerger’s Disease (Thromboangiitis Obliterans):** It is indicated in patients with distal ischemia (rest pain or small ulcers) where bypass surgery is not feasible. It helps by increasing skin blood flow and promoting the healing of ischemic ulcers. **High-Yield Clinical Pearls for NEET-PG:** * **Level of Resection:** For lower limb involvement, the **L2, L3, and L4** ganglia are typically removed. The **L1 ganglion is preserved** in males to prevent loss of ejaculation. * **The "Warm Foot" Sign:** A successful sympathectomy results in a warm, dry foot due to the loss of vasoconstrictor and sudomotor tone. * **Paradoxical Gangrene:** A rare complication where blood is shunted away from already ischemic areas to healthier skin areas (steal phenomenon) immediately after surgery. * **Most common indication today:** Ischemic rest pain or distal digital ulcers in non-reconstructable peripheral arterial disease.

Question 57: Which of the following statements is NOT true regarding Buerger's disease?

A. It is common in the lower extremities.
B. Superficial thrombophlebitis is common.
C. Cigarette cessation is the definitive treatment. (Correct Answer)
D. It usually affects individuals below 30 years of age.

Explanation: **Explanation:** Buerger’s disease, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that most commonly affects small and medium-sized arteries and veins of the extremities. **Why Option C is the correct answer (The "Not True" statement):** While smoking cessation is the **most critical step** and the only way to halt the progression of the disease, it is technically not a "definitive treatment" in the surgical sense. Once critical limb ischemia or gangrene has set in, smoking cessation alone cannot reverse the established vascular damage or tissue loss. There is no definitive "cure" or surgical gold standard; management is supportive and focused on prevention. **Analysis of Incorrect Options:** * **Option A:** True. Buerger’s disease characteristically involves the distal arteries of the **lower extremities** (e.g., tibial and dorsalis pedis) and the upper extremities. * **Option B:** True. **Migratory superficial thrombophlebitis** is a hallmark clinical feature, occurring in approximately 40-50% of patients. * **Option C:** True. The disease typically affects **young male smokers**, usually presenting before the age of 40-45, with many cases starting **below 30 years of age**. **NEET-PG High-Yield Pearls:** * **Angiographic Finding:** Classic **"Corkscrew collaterals"** (Martorell’s sign) are seen due to the occlusion of distal vessels. * **Pathology:** Unlike atherosclerosis, the **Internal Elastic Lamina is preserved**. A highly characteristic feature is the "microabscess" within the thrombus. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries. * **Treatment:** Absolute cessation of tobacco (including smokeless tobacco and nicotine replacements) is mandatory. Sympathectomy may be used for pain relief, but revascularization is rarely possible due to the distal nature of the disease.

Question 58: Obstruction at the bifurcation of the aorta leads to which of the following?

A. Rubor on putting the leg in a dependent position
B. Retrograde ejaculation
C. Gangrene of the foot (Correct Answer)
D. Pallor of the lower limb

Explanation: ### Explanation **Concept:** Obstruction at the bifurcation of the aorta is most commonly associated with **Leriche Syndrome** (Aortoiliac Occlusive Disease). This condition is characterized by a triad of: 1. **Intermittent claudication** of the buttocks and thighs. 2. **Erectile dysfunction** (impotence) due to decreased blood flow to the internal iliac arteries. 3. **Absent or diminished femoral pulses.** **Why Gangrene of the Foot is the Correct Answer:** Chronic, high-grade obstruction at the aortic bifurcation leads to **Critical Limb Ischemia (CLI)**. When collateral circulation fails to compensate for the lack of distal perfusion, it results in rest pain, non-healing ulcers, and eventually **gangrene of the foot**. While other symptoms occur, gangrene is a definitive clinical consequence of the severe, end-stage ischemia caused by such a proximal obstruction. **Analysis of Incorrect Options:** * **A & D (Rubor and Pallor):** These are signs of peripheral vascular disease (Buerger’s test), but they are transient postural changes rather than the definitive "end-result" of a major bifurcation obstruction. * **B (Retrograde Ejaculation):** This is typically a complication of **aortic surgery** (due to damage to the superior hypogastric plexus) or diabetes, rather than the obstructive process itself. The obstruction causes *impotence* (failure of erection), not retrograde ejaculation. **High-Yield Clinical Pearls for NEET-PG:** * **Leriche Syndrome Triad:** Claudication + Impotence + Absent Femoral Pulses. * **Most common site of atherosclerotic occlusion:** Superficial Femoral Artery (within the Adductor/Hunter’s canal). * **Investigation of Choice:** Digital Subtraction Angiography (DSA) is the gold standard, but CT Angiography is the initial diagnostic modality. * **Management:** Aortobifemoral bypass is the classic surgical treatment for extensive aortoiliac disease.

Question 59: Which of the following agents is NOT used for sclerotherapy in varicose veins?

A. Ethanolamine oleate
B. Sodium tetradecyl sulfate
C. Polidocanol
D. Mannitol (Correct Answer)

Explanation: **Explanation:** Sclerotherapy is a minimally invasive procedure used to treat varicose veins and telangiectasias. It involves injecting a **sclerosant** agent into the vein, which causes endothelial damage, localized thrombosis, and eventual fibrosis (obliteration) of the vessel. **Why Mannitol is the Correct Answer:** **Mannitol** is an osmotic diuretic used to reduce intracranial pressure or intraocular pressure. It does not possess the detergent or chemical properties required to induce endothelial injury and venous fibrosis. Therefore, it has no role in sclerotherapy. **Analysis of Incorrect Options (Common Sclerosants):** * **Sodium Tetradecyl Sulfate (STS):** A detergent-based sclerosant and the most commonly used agent. it works by macerating the vascular endothelium. * **Polidocanol:** A non-ionic detergent sclerosant. It is popular because it has a lower risk of skin necrosis if extravasated and possesses local anesthetic properties, making the injection less painful. * **Ethanolamine Oleate:** A synthetic fatty acid often used for sclerotherapy of esophageal varices and occasionally for peripheral varicose veins. **High-Yield Clinical Pearls for NEET-PG:** 1. **Mechanism:** Sclerosants are classified into **Detergents** (STS, Polidocanol), **Osmotic agents** (Hypertonic saline), and **Chemical irritants** (Chromated glycerin). 2. **Complications:** The most common side effects include hyperpigmentation (hemosiderin staining), superficial thrombophlebitis, and rarely, deep vein thrombosis (DVT) or tissue necrosis. 3. **Foam Sclerotherapy (Tessari Technique):** Mixing the sclerosant with air to create a foam increases the surface area of contact with the endothelium, allowing for lower concentrations to be used effectively. 4. **Contraindications:** Pregnancy, acute DVT, and severe systemic illness.

Question 60: The Hunterian Ligature operation is performed for what condition?

A. Aneurysm (Correct Answer)
B. Varicose veins
C. Arteriovenous fistulas
D. Acute arterial ischemia

Explanation: **Explanation:** The **Hunterian Ligature** (proximal ligation) is a classic surgical technique historically used for the treatment of **aneurysms**, specifically popliteal aneurysms. **1. Why Aneurysm is correct:** Introduced by John Hunter in 1785, the procedure involves ligating the artery (the superficial femoral artery in the adductor/Hunter’s canal) at a site **proximal** to the aneurysm. The physiological principle is to reduce the high-pressure pulsatile flow into the aneurysmal sac without completely cutting off circulation. This encourages gradual thrombosis of the aneurysm while allowing collateral circulation to maintain limb viability, thereby preventing the high risk of gangrene associated with ligation immediately above the sac (Anel’s ligation). **2. Why other options are incorrect:** * **Varicose veins:** These are treated with Trendelenburg ligation (juxtafemoral ligation) or stripping, not Hunterian ligation. * **Arteriovenous fistulas:** These require excision or repair of the communication (e.g., Nicoladoni-Branham sign assessment), as proximal ligation alone can worsen ischemia via "steal phenomenon." * **Acute arterial ischemia:** This is an emergency requiring embolectomy (Fogarty catheter) or thrombolysis; ligation would worsen the ischemia. **3. High-Yield Clinical Pearls for NEET-PG:** * **Hunter’s Canal (Adductor Canal):** Located in the middle third of the thigh; contains the femoral artery, femoral vein, and saphenous nerve. * **Evolution of Aneurysm Surgery:** * *Antyllus:* Proximal and distal ligation with evacuation. * *Anel’s:* Ligation immediately proximal to the sac. * *Hunter’s:* Ligation well proximal to the sac (in healthy tissue). * *Matas (Endoaneurysmorrhaphy):* Internal repair of the sac. * **Modern Standard:** Today, aneurysms are typically managed with **interposition grafts** or **endovascular stenting (EVAR)**.

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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