Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 81: What is the most common site for a venous ulcer?

A. Sole of foot
B. Lower 2/3 of leg
C. Lower 1/3 of leg and ankle (Correct Answer)
D. Middle 1/3 of leg

Explanation: **Explanation:** The correct answer is **C. Lower 1/3 of leg and ankle**. Venous ulcers (stasis ulcers) primarily occur due to chronic venous insufficiency (CVI) and venous hypertension. The most common site is the **medial aspect of the lower one-third of the leg**, specifically the area just above the medial malleolus. This region is often referred to as the **"Gaiter Zone."** **Why the Lower 1/3 and Ankle?** The underlying pathophysiology involves the failure of the "calf muscle pump" and incompetent perforator veins (Cockett’s perforators). This leads to blood pooling and high ambulatory venous pressure in the distal leg. The resulting extravasation of macromolecules and fibrin cuff formation impairs oxygen diffusion, leading to skin breakdown and ulceration in this specific anatomical area. **Analysis of Incorrect Options:** * **A. Sole of foot:** This is the characteristic site for **neuropathic (trophic) ulcers**, commonly seen in Diabetes Mellitus or Leprosy, due to repeated pressure and loss of sensation. * **B & D. Lower 2/3 and Middle 1/3 of leg:** While venous changes can extend upward, the primary site of maximum venous pressure and the location of the most significant perforators (which trigger the ulceration) is the distal third. **High-Yield Clinical Pearls for NEET-PG:** * **Gaiter Zone:** The area between the mid-calf and the medial malleolus. * **Appearance:** Venous ulcers are typically shallow, irregular in shape, have a granulating base, and are relatively painless compared to arterial ulcers. * **Associated Signs:** Lipodermatosclerosis (inverted champagne bottle leg), hyperpigmentation (hemosiderin deposition), and varicose veins. * **Treatment Gold Standard:** Compression therapy (e.g., Four-layer bandage/Unna boot) is the mainstay of management once arterial insufficiency is ruled out.

Question 82: Lumbar sympathectomy is indicated for all of the following conditions EXCEPT:

A. Causalgia
B. Intermittent claudication (Correct Answer)
C. Rest pain
D. Raynaud's disease

Explanation: **Explanation:** Lumbar sympathectomy involves the surgical removal of the 2nd, 3rd, and 4th lumbar sympathetic ganglia. This procedure results in permanent vasodilation of the skin vessels and inhibition of sweating in the lower limbs. **Why Intermittent Claudication is the Correct Answer:** Intermittent claudication is pain caused by ischemia of the **skeletal muscles** during exercise. Sympathectomy primarily increases blood flow to the **skin** rather than the muscles. In fact, it may worsen claudication by causing a "steal phenomenon," where blood is diverted from the deep muscular vessels to the superficial cutaneous vessels. Therefore, it is not indicated for claudication. **Analysis of Other Options:** * **Causalgia (Complex Regional Pain Syndrome II):** Sympathectomy interrupts the pain-spasm-pain cycle and reduces sympathetic overactivity, making it a classic indication for chronic neuropathic pain. * **Rest Pain:** In patients with Buerger’s disease (TAO) or peripheral arterial disease who are unfit for bypass, sympathectomy can increase cutaneous collateral circulation, providing relief from rest pain and helping to heal small ischemic ulcers. * **Raynaud’s Disease:** While more common in the upper limbs (cervicodorsal sympathectomy), lumbar sympathectomy is indicated for severe, refractory Raynaud’s affecting the feet to prevent digital gangrene. **High-Yield Clinical Pearls for NEET-PG:** * **Primary Indication:** Distal ischemia (skin changes/ulcers) in Buerger’s Disease (TAO). * **Anatomical Landmark:** The sympathetic chain lies on the bodies of lumbar vertebrae, medial to the Psoas major muscle. * **Key Contraindication:** It is ineffective in patients with extensive gangrene or where the ankle-brachial pressure index (ABPI) is very low (<0.3), as there is no "vasomotor tone" left to relax. * **Side Effect:** Post-sympathectomy neuralgia (pain in the thigh) is a common transient complication.

Question 83: What is the most common site of a peripheral aneurysm?

A. Femoral artery
B. Radial artery
C. Popliteal artery (Correct Answer)
D. Brachial artery

Explanation: **Explanation:** **1. Why Popliteal Artery is Correct:** The **popliteal artery** is the most common site for peripheral arterial aneurysms, accounting for approximately **70–80%** of all cases. These are true aneurysms, often associated with atherosclerosis. A key clinical characteristic of popliteal aneurysms is their high rate of bilateralism (50%) and their strong association with Abdominal Aortic Aneurysms (AAA); roughly 30–50% of patients with a popliteal aneurysm also have a concurrent AAA. **2. Why Other Options are Incorrect:** * **Femoral Artery:** This is the second most common site for peripheral aneurysms (specifically the common femoral artery). While frequent, it occurs less often than popliteal involvement. * **Radial and Brachial Arteries:** Aneurysms in the upper extremities are rare. When they do occur, they are often "pseudoaneurysms" resulting from trauma or iatrogenic injury (e.g., arterial cannulation or dialysis access) rather than true atherosclerotic aneurysms. **3. NEET-PG High-Yield Clinical Pearls:** * **Rule of 50s:** 50% of popliteal aneurysms are bilateral; 50% are associated with an AAA. * **Presentation:** Unlike AAA (which usually ruptures), peripheral aneurysms most commonly present with **thromboembolism** leading to acute limb ischemia ("blue toe syndrome") rather than rupture. * **Diagnosis:** Duplex Ultrasound is the initial investigation of choice; CT Angiography is used for surgical planning. * **Indication for Surgery:** Usually when the diameter exceeds **2 cm** or if the aneurysm is symptomatic (thromboembolic events).

Question 84: Which of the following conditions disappear spontaneously in the first year of life?

A. Port wine stain
B. Nevus flammeus
C. Salmon patch (Correct Answer)
D. Strawberry hemangioma

Explanation: **Explanation** The correct answer is **Salmon patch** (Option C). **Why Salmon Patch is correct:** Salmon patches (also known as *nevus simplex*) are the most common vascular lesions of infancy, present in nearly 40–50% of newborns. They are midline capillary malformations caused by ectatic dermal capillaries. These lesions typically appear as faint pink patches on the nape of the neck ("stork bite"), glabella, or eyelids ("angel's kiss"). The key clinical feature is their tendency to fade and **disappear spontaneously**, usually within the first year of life, as the skin thickens and the vessels regress. **Analysis of Incorrect Options:** * **Port wine stain (Option A):** This is a capillary malformation that is present at birth and, unlike salmon patches, **never disappears spontaneously**. It grows proportionately with the child, darkens (becomes purple), and may become thickened or nodular over time. * **Nevus flammeus (Option B):** This is the medical synonym for Port wine stain. Therefore, it persists throughout life. * **Strawberry hemangioma (Option D):** Also known as infantile hemangioma, these are proliferative vascular tumors. While they do undergo spontaneous involution, the process is much slower. They typically follow a "rule of tens": 50% resolve by age 5, 70% by age 7, and 90% by age 9. They do **not** disappear within the first year; in fact, they often undergo a rapid growth phase during the first 6–12 months. **NEET-PG High-Yield Pearls:** * **Salmon Patch:** Midline, fades by age 1. * **Port Wine Stain:** Lateral, persists for life. If in the V1/V2 distribution of the trigeminal nerve, suspect **Sturge-Weber Syndrome**. * **Strawberry Hemangioma:** GLUT-1 positive; treated with **Propranolol** if it obstructs vision or the airway. * **Kasabach-Merritt Syndrome:** Consumptive coagulopathy (thrombocytopenia) associated with rapidly growing vascular tumors (usually tufted angioma or kaposiform hemangioendothelioma, *not* simple strawberry hemangiomas).

Question 85: All of the following are seen in Thoracic Outlet Syndrome except?

A. Mass in the neck
B. Wasting of forearm muscles (Correct Answer)
C. Adson's test positive
D. Pallor

Explanation: **Explanation:** Thoracic Outlet Syndrome (TOS) results from the compression of neurovascular structures (brachial plexus, subclavian artery, or subclavian vein) as they pass through the superior thoracic aperture. **Why "Wasting of forearm muscles" is the correct answer:** In neurogenic TOS, the lower trunk of the brachial plexus (C8-T1) is most commonly compressed. This leads to wasting of the **intrinsic muscles of the hand** (thenar, hypothenar, and interossei), often referred to as a "Gilliatt-Sumner hand." The muscles of the **forearm** are generally spared because the nerve fibers supplying them branch off more proximally or are less affected by the specific compression at the thoracic outlet. **Analysis of other options:** * **Mass in the neck:** A cervical rib (the most common cause of TOS) or a prominent transverse process of the C7 vertebra can often be felt as a hard, palpable mass in the supraclavicular fossa. * **Adson’s test positive:** This is a classic clinical test for TOS. The patient’s radial pulse is monitored while they extend their neck and rotate the head toward the affected side during deep inspiration. A positive test is indicated by a disappearance or significant weakening of the pulse. * **Pallor:** Vascular TOS (specifically arterial) causes symptoms of ischemia due to subclavian artery compression or distal embolization. This manifests as pallor, coldness, and cyanosis of the hand. **Clinical Pearls for NEET-PG:** * **Most common type:** Neurogenic TOS (95%) > Venous > Arterial. * **Paget-Schroetter Syndrome:** Effort-induced thrombosis of the subclavian/axillary vein; a form of venous TOS. * **Roos Test:** Also known as the "Elevated Arm Stress Test" (EAST), it is considered the most reliable clinical test for TOS. * **Diagnosis:** Primarily clinical, but X-ray can identify a cervical rib, and EMG/NCS helps confirm nerve involvement.

Question 86: What is true about mesenteric vein thrombosis?

A. Peritoneal signs are always present.
B. Thrombectomy is always performed.
C. Heparin is administered. (Correct Answer)
D. All of the above.

Explanation: **Explanation:** Mesenteric Vein Thrombosis (MVT) accounts for approximately 5–15% of all cases of mesenteric ischemia. Unlike arterial occlusion, MVT often has a more insidious onset and is frequently associated with hypercoagulable states. **1. Why Option C is Correct:** The cornerstone of management for MVT is **systemic anticoagulation with Heparin**. Immediate administration of heparin prevents thrombus propagation, allows for the recruitment of collateral vessels, and reduces the risk of bowel infarction. In many cases of non-transmural ischemia, anticoagulation alone can lead to the recanalization of the venous system and clinical recovery. **2. Why Other Options are Incorrect:** * **Option A:** Peritoneal signs (rebound tenderness, guarding) are **not always present**. They only appear late in the disease progression once transmural bowel infarction and gangrene have occurred. Early MVT typically presents with "pain out of proportion to physical findings." * **Option B:** Thrombectomy is **not always performed**. Surgical or radiological thrombectomy is reserved for patients with deteriorating clinical status or those who do not respond to medical management. The primary surgical goal is usually the resection of non-viable bowel rather than venous thrombectomy. **Clinical Pearls for NEET-PG:** * **Risk Factors:** Most common is a hypercoagulable state (Protein C/S deficiency, Factor V Leiden) or portal hypertension. * **Diagnosis:** **Contrast-enhanced CT (CECT)** is the gold standard (shows a "rim sign" or filling defects in the mesenteric veins). * **Management:** If the patient is stable and has no signs of peritonitis, start Heparin immediately. If peritonitis is present, emergency laparotomy and bowel resection are mandatory. * **Prognosis:** MVT has a better prognosis and lower mortality rate compared to Mesenteric Arterial Embolism.

Question 87: What is the most common cause of renal artery stenosis in individuals above 50 years of age?

A. Atherosclerosis (Correct Answer)
B. Fibromuscular dysplasia (FMD)
C. Takayasu arteritis
D. Renal cell carcinoma (RCC)

Explanation: **Explanation:** **1. Why Atherosclerosis is the correct answer:** Atherosclerosis is the most common cause of Renal Artery Stenosis (RAS) overall, accounting for approximately **90% of cases**. It primarily affects individuals **above 50 years of age**, particularly those with pre-existing risk factors such as smoking, diabetes, and hypertension. The lesion typically involves the **proximal one-third (ostial)** of the renal artery and is caused by the buildup of plaque that narrows the vessel lumen, leading to renovascular hypertension and ischemic nephropathy. **2. Why the other options are incorrect:** * **Fibromuscular Dysplasia (FMD):** This is the second most common cause of RAS but typically affects **younger females (20–40 years)**. It involves the distal two-thirds of the renal artery and presents with a characteristic "string of beads" appearance on angiography. * **Takayasu Arteritis:** Also known as "pulseless disease," this is a large-vessel vasculitis that can involve the renal artery ostium. However, it is much rarer than atherosclerosis and usually affects young Asian women under 40. * **Renal Cell Carcinoma (RCC):** While a tumor may compress the renal artery externally, it is not a primary cause of intrinsic renal artery stenosis. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Digital Subtraction Angiography (DSA). * **Initial Screening Tool:** Duplex Ultrasound or CT Angiography. * **Classic Presentation:** Resistant hypertension, sudden onset of flash pulmonary edema, or an abdominal bruit. * **Treatment:** Medical management (ACE inhibitors/ARBs—*caution: contraindicated in bilateral RAS*), or Revascularization (PTRA with stenting) if medical therapy fails.

Question 88: Which surgical blade number is most useful for performing a tracheotomy?

A. 10
B. 11 (Correct Answer)
C. 15
D. 22

Explanation: **Explanation:** The correct answer is **11**. **1. Why Blade No. 11 is the Correct Choice:** Blade No. 11 is a triangular, pointed blade with a sharp hypotenuse, often referred to as a "stab blade." In a tracheotomy (specifically the formal surgical procedure or an emergency cricothyroidotomy), the primary requirement is a precise, controlled **stab incision** into the trachea or cricothyroid membrane. Its pointed tip allows for easy penetration of the tough tracheal rings or fibroelastic membrane, and its straight edge allows for the upward extension of the incision to accommodate the tracheostomy tube. **2. Analysis of Incorrect Options:** * **Blade No. 10:** This is the standard large, curved blade used for making long, deep incisions in skin and muscle (e.g., laparotomy). It lacks the fine point needed for the precise "stab" required in airway management. * **Blade No. 15:** This is a small, curved blade used for delicate work or small skin incisions (e.g., plastic surgery or biopsies). While it can be used for the skin incision in a tracheotomy, it is less efficient than No. 11 for the actual tracheal entry. * **Blade No. 22:** This is a larger version of the No. 10 blade, used for heavy-duty incisions in thick skin or fascia. It is too bulky for the delicate anatomy of the neck and trachea. **3. High-Yield Clinical Pearls for NEET-PG:** * **Blade No. 11** is also the blade of choice for **Incision and Drainage (I&D)** of abscesses and for performing **arteriotomies** (e.g., in embolectomy or vascular bypass). * **Tracheostomy Site:** Usually performed between the **2nd and 3rd or 3rd and 4th tracheal rings**. * **Emergency Airway:** In an acute "cannot intubate, cannot ventilate" scenario, a **cricothyroidotomy** is preferred over a tracheostomy as it is faster and anatomically more superficial.

Question 89: A middle-aged man presents with a scalp swelling noticed since childhood. The neck swelling has a 'bag of worms' appearance and a bruit is heard over it. What is the most likely diagnosis?

A. Plexiform neurofibroma
B. Toxic nodular goitre
C. Varicocele
D. Cirsoid aneurysm (Correct Answer)

Explanation: **Explanation:** The correct answer is **Cirsoid Aneurysm**. **1. Why Cirsoid Aneurysm is correct:** A cirsoid aneurysm is not a true aneurysm but a **congenital arteriovenous malformation (AVM)** involving the scalp, most commonly the superficial temporal artery and its associated veins. * **Pathophysiology:** Direct communication between high-pressure arteries and low-pressure veins leads to massive dilatation and tortuosity of the vessels. * **Clinical Presentation:** It typically presents as a pulsatile, "bag of worms" swelling on the scalp. The presence of a **bruit** or thrill is a pathognomonic sign of the underlying arteriovenous shunt. While congenital, they often enlarge during puberty or following minor trauma. **2. Why the other options are incorrect:** * **Plexiform Neurofibroma:** While it also has a "bag of worms" feel (classic for Neurofibromatosis Type 1), it is a nerve sheath tumor. It is **non-pulsatile** and lacks a bruit. * **Toxic Nodular Goitre:** This presents as a neck swelling (thyroid) associated with hyperthyroidism. While a bruit can be heard in Graves' disease due to hypervascularity, it does not occur on the scalp or have a "bag of worms" texture. * **Varicocele:** This occurs in the **scrotum** (pampiniform plexus), not the scalp. While it shares the "bag of worms" description, the anatomical location makes it incorrect. **Clinical Pearls for NEET-PG:** * **Classic Triad:** Scalp swelling + "Bag of worms" feel + Pulsations/Bruit = Cirsoid Aneurysm. * **Treatment:** Selective embolization followed by surgical excision is the preferred management. * **Differential Diagnosis:** Always differentiate from a plexiform neurofibroma by checking for pulsations and the "emptying sign" (present in vascular malformations).

Question 90: Which of the following is the least common finding in lymphedema?

A. Ulcer (Correct Answer)
B. Pitting
C. Chronic eczema
D. Swelling

Explanation: **Explanation:** Lymphedema is a chronic condition caused by the accumulation of protein-rich interstitial fluid due to impaired lymphatic drainage. Understanding the progression of the disease is key to identifying its clinical features. **1. Why "Ulcer" is the correct answer:** Unlike chronic venous insufficiency (CVI), where venous hypertension leads to stasis and subsequent **venous ulcers** (typically above the medial malleolus), **ulceration is extremely rare in lymphedema.** The skin in lymphedema becomes thickened and fibrotic (hyperkeratosis), which actually provides a tough barrier. Ulcers only occur in lymphedema if there is secondary malignancy (Lymphangiosarcoma/Stewart-Treves Syndrome) or severe neglected infection. **2. Analysis of Incorrect Options:** * **Swelling (D):** This is the hallmark and earliest finding. It typically starts distally (dorsum of the foot) and progresses proximally. * **Pitting (B):** In the **early stages (Stage I)**, lymphedema is pitting. As the disease progresses to Stage II and III, protein accumulation triggers fibroblast proliferation, leading to non-pitting edema due to fibrosis. Since it occurs in the early phase, it is a common finding. * **Chronic Eczema (C):** Long-standing stasis of lymph causes chronic skin changes, including dermatitis, eczema, and "peau d'orange" appearance due to cutaneous fibrosis. **Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch a fold of skin on the base of the second toe. It is a **pathognomonic** sign of lymphedema. * **Squaring of Toes:** A characteristic finding in lymphedema due to increased pressure. * **Primary vs. Secondary:** Globally, **Filariasis** (Wuchereria bancrofti) is the most common cause of secondary lymphedema. In developed nations, it is post-mastectomy axillary lymph node dissection. * **Milroy’s Disease:** Congenital lymphedema present at birth (VEGFR3 mutation).

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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