Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 71: Which of the following is NOT included in the treatment of femoral artery aneurysm?

A. Ultrasound guided compression of the neck of the aneurysm
B. Thrombin injection
C. Bypass graft repair
D. CT scan (Correct Answer)

Explanation: **Explanation:** The question asks for the option that is **NOT** a treatment modality for a femoral artery aneurysm. **1. Why CT scan is the correct answer:** A **CT scan (specifically CT Angiography)** is a **diagnostic imaging tool**, not a therapeutic intervention. While it is essential for planning surgery by defining the anatomy, extent, and involvement of the profunda femoris, it does not treat the aneurysm itself. In the context of "treatment," diagnostic modalities are excluded. **2. Why the other options are incorrect (Treatment Modalities):** * **Ultrasound-guided compression (UGCR):** This is a non-invasive treatment specifically used for **pseudoaneurysms** (false aneurysms), often occurring after femoral artery catheterization. Pressure is applied to the neck to induce thrombosis. * **Thrombin injection:** Ultrasound-guided thrombin injection (UGTI) is currently the gold standard for treating femoral pseudoaneurysms. It has a higher success rate and is faster than compression. * **Bypass graft repair:** This is the definitive **surgical treatment** for true femoral artery aneurysms. The aneurysm is usually excluded or resected, and arterial continuity is restored using a prosthetic (PTFE/Dacron) or autologous vein graft. **Clinical Pearls for NEET-PG:** * **Definition:** A femoral artery aneurysm is defined as a permanent localized dilation >50% of the normal vessel diameter. * **Most Common Site:** The **common femoral artery** is the most common site for peripheral artery aneurysms (after the popliteal artery). * **Association:** 50-70% of patients with a femoral artery aneurysm have a concomitant **Abdominal Aortic Aneurysm (AAA)**. Always screen the abdomen. * **Indication for Surgery:** Symptomatic aneurysms or asymptomatic aneurysms **>2.5 cm** in diameter. * **Complications:** Unlike AAA (which tends to rupture), peripheral aneurysms more commonly lead to **thromboembolism and distal ischemia**.

Question 72: Which of the following is NOT an indication for surgical repair of a symptomatic, unruptured aneurysm?

A. Painful, tender aneurysm
B. Aneurysm size less than 5 cm (Correct Answer)
C. Thrombosed aneurysm
D. Growth rate more than 5.5 cm per year

Explanation: **Explanation:** The management of Abdominal Aortic Aneurysms (AAA) is based on balancing the risk of rupture against the risks of surgical intervention. In **asymptomatic** patients, the threshold for repair is typically a diameter of **≥5.5 cm in men** and **≥5.0 cm in women**. However, the presence of **symptoms** changes the management protocol entirely, as symptoms often herald an impending rupture. **Why Option B is the Correct Answer:** An aneurysm size of less than 5 cm is generally managed conservatively with surveillance (ultrasound) if the patient is asymptomatic. However, the question asks for indications for *surgical repair*. A small size alone is a reason to **defer** surgery, not an indication for it, unless other high-risk factors (like rapid growth or symptoms) are present. **Analysis of Incorrect Options:** * **A. Painful, tender aneurysm:** This indicates expansion and "impending rupture." Regardless of size, a symptomatic aneurysm requires urgent surgical or endovascular repair. * **C. Thrombosed aneurysm:** Acute thrombosis or distal embolization ("Blue Toe Syndrome") are complications that necessitate intervention to restore distal perfusion and prevent limb loss. * **D. Growth rate more than 0.5 cm in 6 months or >1 cm per year:** Rapid expansion is a major predictor of rupture risk and is a definitive indication for surgery, even if the absolute diameter hasn't reached 5.5 cm yet. *(Note: The option mentions 5.5 cm per year, which is an extreme growth rate and thus a clear indication for surgery).* **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** CT Angiography (for surgical planning). * **Screening Tool of Choice:** Abdominal Ultrasound. * **Classic Triad of Rupture:** Hypotension, pulsatile abdominal mass, and back/abdominal pain. * **Indications for Surgery (Summary):** 1. Diameter ≥5.5 cm (Men) / ≥5.0 cm (Women). 2. Rapid expansion (>0.5 cm in 6 months). 3. Any symptomatic aneurysm (pain, tenderness). 4. Complications (thrombosis, embolism).

Question 73: Which one of the following reagents is not used as a sclerosant in the treatment of bleeding varices?

A. Ethyl alcohol (Correct Answer)
B. Ethanolamine oleate
C. Phenol
D. Sodium morrhuate

Explanation: In the management of esophageal varices, **Sclerotherapy** involves injecting a chemical agent (sclerosant) into or around the varix to induce thrombosis, inflammation, and eventual fibrosis. ### **Explanation of the Correct Answer** **A. Ethyl alcohol:** While ethanol is a potent dehydrating agent, it is **not** used as a sclerosant for bleeding esophageal varices. Its use is primarily restricted to the percutaneous ablation of vascular malformations (like hemangiomas) or certain tumors. If used in the esophagus, it causes excessive tissue necrosis and carries a high risk of transmural perforation. ### **Analysis of Incorrect Options** * **B. Ethanolamine oleate:** This is one of the most commonly used sclerosants for varices. It is a synthetic surfactant that causes endothelial damage and localized thrombosis. * **C. Phenol:** Specifically used as **5% Phenol in almond oil**, it is a classic sclerosant. While more common in the treatment of hemorrhoids, it has historically been used for variceal sclerotherapy. * **D. Sodium morrhuate:** A mixture of sodium salts of fatty acids derived from cod liver oil. It is an effective sclerosing agent that initiates an inflammatory response leading to vein obliteration. ### **High-Yield Clinical Pearls for NEET-PG** * **Mechanism:** Sclerosants work by causing endothelial damage, which triggers the extrinsic coagulation pathway. * **Other Sclerosants:** **Sodium Tetradecyl Sulfate (STDS)** and **Polidocanol** are other frequently used agents. Polidocanol is often preferred due to a lower incidence of post-procedure pain and ulceration. * **Current Gold Standard:** Endoscopic Variceal Ligation (EVL) or **"Banding"** has largely replaced sclerotherapy as the first-line treatment for esophageal varices due to fewer complications (like esophageal strictures or perforation). * **Drug of Choice for Acute Bleed:** Octreotide or Terlipressin (Pharmacological management).

Question 74: What is the most common site of rupture of an Abdominal Aortic Aneurysm?

A. Laterally into the left retroperitoneum (Correct Answer)
B. Laterally into the right retroperitoneum
C. Posteriorly into the posterior retroperitoneum
D. Anteriorly into the peritoneum (intraperitoneal)

Explanation: **Explanation:** The most common site of rupture for an Abdominal Aortic Aneurysm (AAA) is **laterally into the left retroperitoneum**. **1. Why the Left Retroperitoneum?** The abdominal aorta is a retroperitoneal structure located slightly to the left of the midline. Anatomically, the left posterolateral wall of the aorta is the most common site of wall stress and subsequent rupture. When it ruptures here, the hemorrhage is initially contained by the retroperitoneal space. This "containment" is clinically significant because it may result in a temporary tamponade effect, allowing the patient to survive long enough to reach the hospital (presenting with the classic triad of pain, hypotension, and a pulsatile mass). **2. Analysis of Incorrect Options:** * **Option B:** The aorta lies to the left of the IVC; therefore, a right-sided rupture is anatomically less frequent. * **Option C:** While posterior ruptures occur, the lateral/posterolateral direction is the path of least resistance compared to the dense pre-vertebral fascia. * **Option D:** **Intraperitoneal rupture** (Anterior) is the second most common site. Unlike retroperitoneal ruptures, these are not contained, leading to massive exsanguination and sudden death before reaching medical care. **3. NEET-PG High-Yield Pearls:** * **Classic Triad:** Hypotension, back/abdominal pain, and a pulsatile abdominal mass (present in only ~25-50% of cases). * **Most common site of AAA:** Infrarenal (below the origin of renal arteries). * **Screening:** Ultrasound is the investigation of choice for screening; CT Angiography is the gold standard for surgical planning. * **Surgical Threshold:** Repair is generally indicated if the diameter is **>5.5 cm in men** or **>5.0 cm in women**, or if it grows >0.5 cm in 6 months.

Question 75: What is the recommended treatment for acute lymphangitis?

A. Antibiotics and rest (Correct Answer)
B. Immediate lymphangiography
C. Immediate multiple incisions
D. No special treatment

Explanation: **Explanation:** **Acute Lymphangitis** is a bacterial infection (most commonly caused by **Streptococcus pyogenes**) of the peripheral lymphatic channels. It typically presents as painful, red, linear streaks extending from a site of infection toward regional lymph nodes. **Why Option A is Correct:** The primary management is medical, not surgical. Since the underlying cause is almost always a pyogenic bacterial infection, **systemic antibiotics** (usually targeting Gram-positive cocci, such as penicillin or cephalosporins) are the mainstay of treatment. **Rest and elevation** of the affected limb help reduce edema and promote lymphatic drainage, preventing further spread of the infection. **Why the Other Options are Incorrect:** * **Option B (Lymphangiography):** This is a diagnostic imaging modality used to visualize lymphatic vessels. It is contraindicated in acute infection as it can worsen the inflammation and spread the pathogen. * **Option C (Multiple Incisions):** Acute lymphangitis is a non-suppurative spreading infection. Incisions are contraindicated unless a localized abscess has formed. Premature surgery can lead to non-healing wounds or secondary infection. * **Option D (No treatment):** Untreated lymphangitis can rapidly progress to bacteremia, sepsis, and death. **Clinical Pearls for NEET-PG:** * **Most common organism:** *Streptococcus pyogenes* (Group A Strep). * **Classic sign:** Red streaks ("blood poisoning" in lay terms) with associated painful regional lymphadenopathy. * **Differential Diagnosis:** Do not confuse with **thrombophlebitis** (which presents with a palpable cord and no red streaks). * **Complication:** If neglected, it can lead to **abscess formation** or **septicaemia**.

Question 76: Which artery is commonly involved in a cirsoid aneurysm?

A. Occipital
B. Superficial temporal (Correct Answer)
C. Internal carotid
D. External carotid

Explanation: **Explanation:** A **cirsoid aneurysm** is not a true aneurysm but rather a high-flow **arteriovenous malformation (AVM)** or fistula occurring in the subcutaneous tissues of the scalp. It is characterized by a pulsating, "bag of worms" appearance of dilated, tortuous vessels. 1. **Why Superficial Temporal is Correct:** The **superficial temporal artery** is the most common feeding vessel involved in cirsoid aneurysms. Due to its superficial location and proximity to the skull, it is highly susceptible to trauma (the most common cause) and congenital vascular anomalies. The lesion typically involves communications between this artery and the scalp veins. 2. **Analysis of Incorrect Options:** * **Occipital Artery:** While it can occasionally contribute to a cirsoid aneurysm (especially in larger, posterior scalp lesions), it is significantly less common than the superficial temporal artery. * **Internal Carotid Artery (ICA):** The ICA is a deep, major vessel supplying the brain. Cirsoid aneurysms are specifically extracranial scalp lesions. * **External Carotid Artery (ECA):** While the superficial temporal artery is a *branch* of the ECA, the question asks for the specific artery involved. The ECA itself is a deep neck structure and does not form the superficial "bag of worms" characteristic of this condition. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Pulsatile scalp mass, audible bruit, and occasionally "machinery-like" murmurs. * **Complications:** Hemorrhage (can be life-threatening), skin necrosis, and headache. * **Diagnosis:** Digital Subtraction Angiography (DSA) is the gold standard to map the feeders. * **Treatment:** Surgical excision or endovascular embolization. Simple ligation of the external carotid is ineffective due to extensive collateral circulation.

Question 77: Which of the following is NOT true about thoracic outlet syndrome?

A. Adson's test is used for diagnosis.
B. It may be caused by a cervical rib.
C. Pain, numbness, and paresthesia in the involved extremity occur.
D. The lower trunks of the brachial plexus are commonly affected. (Correct Answer)

Explanation: **Explanation:** Thoracic Outlet Syndrome (TOS) is a clinical condition resulting from the compression of neurovascular structures (brachial plexus and/or subclavian vessels) as they pass through the superior thoracic aperture. **Why Option D is the correct answer (The False Statement):** In neurogenic TOS, which accounts for over 90% of cases, the **lower trunk (C8-T1)** of the brachial plexus is the structure **most commonly** affected. The question asks for the statement that is *NOT* true; however, Option D as phrased in many standard question banks is often a "trick" or misprint. In medical reality, the lower trunk is indeed the most frequently involved. If this option is marked as "Not True" in a specific key, it is usually because the compression involves the **ventral rami** forming the trunk rather than the trunk itself, or it is a distractor. *Note: In the context of this specific MCQ, if D is the intended answer, it contradicts standard surgical teaching (Sabiston/Bailey), where lower trunk involvement is a hallmark.* **Analysis of other options:** * **Option A:** **Adson’s test** is a classic provocative maneuver where the patient extends the neck and turns the head toward the affected side while taking a deep breath; a loss of radial pulse suggests TOS. * **Option B:** A **cervical rib** (an accessory rib arising from C7) is a well-known anatomical predisposition that narrows the interscalene triangle, leading to compression. * **Option C:** These are the classic **sensory symptoms** of neurogenic TOS, typically following an ulnar nerve distribution due to C8-T1 involvement. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Neurogenic (95%), followed by Venous (Paget-Schroetter syndrome), and Arterial (least common). * **Most common site of compression:** Interscalene triangle. * **Physical Exam:** Look for the **Gilliatt-Sumner hand** (atrophy of the thenar and hypothenar eminence). * **Roos Test:** The "Elevated Arm Stress Test" (EAST) is considered the most reliable provocative maneuver.

Question 78: What is the most accurate method for measuring portal hypertension?

A. Doppler ultrasound
B. Hepatic venography (Correct Answer)
C. CT
D. MRI

Explanation: **Explanation:** The gold standard and most accurate method for measuring portal hypertension is the measurement of the **Hepatic Venous Pressure Gradient (HVPG)** via **Hepatic Venography**. **1. Why Hepatic Venography is Correct:** Portal hypertension is defined as a pathological increase in portal venous pressure. Direct measurement (transhepatic or transvenous) is invasive and risky. Therefore, the indirect measurement of the pressure gradient between the portal vein and the inferior vena cava is used. During hepatic venography, a catheter is wedged into a small hepatic vein to measure the **Wedge Hepatic Venous Pressure (WHVP)**, which reflects sinusoidal pressure. The HVPG is calculated as: * **HVPG = WHVP – Free Hepatic Venous Pressure (FHVP)** * Normal HVPG: 1–5 mmHg. * Clinically significant portal hypertension: **≥10 mmHg** (predicts development of varices). * Risk of variceal bleed: **≥12 mmHg**. **2. Why Other Options are Incorrect:** * **A. Doppler Ultrasound:** This is the **initial/screening investigation** of choice. It can show indirect signs (reversal of flow, dilated portal vein, splenomegaly), but it cannot provide an accurate numerical pressure measurement. * **C & D. CT and MRI:** These are excellent for visualizing anatomy, collateral vessels (portosystemic shunts), and liver morphology, but they are static imaging modalities and cannot measure intravascular pressures. **3. Clinical Pearls for NEET-PG:** * **Gold Standard:** Hepatic Venography (HVPG). * **Best Screening Tool:** Upper GI Endoscopy (to look for esophageal varices). * **First-line Imaging:** Doppler Ultrasound. * **HVPG in Pre-hepatic Portal Hypertension:** In conditions like Portal Vein Thrombosis, the HVPG remains **normal** because the site of resistance is before the sinusoids.

Question 79: All are true about intermittent claudication except:

A. Most common in calf muscle
B. Pain is positional (Correct Answer)
C. Atherosclerosis is an important predisposing factor
D. Relieved by rest

Explanation: **Explanation:** Intermittent claudication is the hallmark symptom of chronic lower limb ischemia, typically caused by **Peripheral Arterial Disease (PAD)**. It is defined as reproducible muscle pain, cramping, or fatigue that occurs during exercise and is relieved by rest. **Why "Pain is positional" is the correct (false) statement:** Claudication pain is **exertional**, not positional. It is triggered by an imbalance between oxygen supply and demand in the muscles during metabolic activity. In contrast, **positional pain** (pain relieved by hanging the leg over the bed or aggravated by elevation) is a feature of **Critical Limb Ischemia (Rest Pain)** or venous disease, but not stable intermittent claudication. **Analysis of other options:** * **A. Most common in calf muscle:** True. The superficial femoral artery is the most common site of occlusion in PAD, leading to claudication in the calf (the muscle group distal to the obstruction). * **C. Atherosclerosis is an important predisposing factor:** True. Systemic atherosclerosis is the primary etiology. Risk factors include smoking, diabetes mellitus, hypertension, and hyperlipidemia. * **D. Relieved by rest:** True. By definition, claudication pain subsides within 2–5 minutes of standing still (the "stop-walk-stop" cycle), as metabolic demand returns to baseline. **High-Yield Clinical Pearls for NEET-PG:** * **Boyd’s Classification:** Used to grade the severity of intermittent claudication. * **Leriche Syndrome:** Triad of claudication (hip/buttock), impotence, and absent femoral pulses due to aortoiliac occlusion. * **Ankle-Brachial Index (ABI):** The best initial diagnostic test. Claudicants typically have an ABI between **0.5 and 0.9**. * **Management:** The first-line treatment for stable claudication is **supervised exercise therapy** and smoking cessation, not surgery.

Question 80: False elevation of Ankle-Brachial Pressure Index (ABPI) is seen in:

A. Deep Vein Thrombosis (DVT)
B. Acute limb ischemia
C. Chronic Venous Insufficiency
D. Calcified vessel walls (Correct Answer)

Explanation: **Explanation:** The **Ankle-Brachial Pressure Index (ABPI)** is the ratio of the systolic blood pressure at the ankle to the systolic blood pressure in the arm. It is the gold-standard screening tool for Peripheral Arterial Disease (PAD). **Why Option D is Correct:** The correct answer is **Calcified vessel walls**. In conditions like **Diabetes Mellitus** and **Chronic Kidney Disease (CKD)**, patients often develop **Mönckeberg’s medial calcific sclerosis**. This leads to stiff, non-compressible arteries. When the blood pressure cuff is inflated, these rigid vessels resist compression, requiring abnormally high pressures to occlude the artery. This results in a falsely elevated ankle pressure and an ABPI often **>1.3 or 1.4**, which does not reflect the actual perfusion status. **Why Other Options are Incorrect:** * **A & C (DVT and Chronic Venous Insufficiency):** These are venous pathologies. While they may cause leg edema (making it difficult to find a signal), they do not typically cause arterial wall hardening or false elevations in arterial pressure readings. * **B (Acute Limb Ischemia):** This is a surgical emergency characterized by a sudden decrease in arterial flow (the "6 Ps"). In this condition, the ABPI would be **decreased** (often unmeasurable), not falsely elevated. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ABPI:** 0.9 – 1.2. * **Intermittent Claudication:** 0.5 – 0.9. * **Rest Pain/Critical Limb Ischemia:** <0.4. * **Falsely Elevated (>1.3):** Indicates calcified vessels. In such cases, the **Toe-Brachial Index (TBI)** is more reliable as digital arteries are rarely calcified. * **Buerger’s Test:** A clinical alternative where the limb is elevated until it blanches (vascular angle). An angle <20° indicates severe ischemia.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

Practice Questions

Peripheral Arterial Disease

Practice Questions

Carotid Artery Disease

Practice Questions

Venous Thromboembolism

Practice Questions

Chronic Venous Insufficiency

Practice Questions

Mesenteric Vascular Disease

Practice Questions

Vascular Trauma

Practice Questions

Vascular Access for Hemodialysis

Practice Questions

Endovascular Techniques

Practice Questions

Diabetic Foot Vascular Disease

Practice Questions

Vasculitis

Practice Questions

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