Peripheral Arterial Disease — MCQs
Which of the following is the preferred graft material for femoropopliteal bypass?
ABPI increases artificially in
Buerger's disease is associated with
A 45-year-old male having a long history of cigarette smoking presented with gangrene of the left foot, which was treated with an amputation. Representative sections from the specimen revealed the presence of arterial thrombus with neutrophilic infiltrate in the arterial wall, as well as inflammation extending into the adjacent veins and nerves. What is the most probable diagnosis?
A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
In acute limb ischemia, which finding indicates irreversible damage?
What type of ulcer is shown below?
What is the most common site of peripheral aneurysm?
Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?
The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:
Peripheral Arterial Disease Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is the preferred graft material for femoropopliteal bypass?
- A. PTFE
- B. Dacron
- C. Reversed saphenous (Correct Answer)
- D. None of the options
Explanation: ***Reversed saphenous*** - The **autologous reversed saphenous vein** is considered the **gold standard** for femoropopliteal bypass due to its superior patency rates and resistance to infection. - The vein's valves are bypassed by reversing its orientation, ensuring unidirectional blood flow. *Dacron* - **Dacron (polyethylene terephthalate)** grafts are synthetic and commonly used for large-diameter arterial bypasses, such as in the aorta, but have **inferior patency in infrainguinal bypasses** compared to autologous vein. - **Higher rates of thrombosis and infection** are observed with Dacron in smaller leg vessels due to compliance mismatch and increased anastomotic intimal hyperplasia. *PTFE* - **Polytetrafluoroethylene (PTFE)** grafts are synthetic and are an option when autologous vein is unavailable, particularly for above-knee femoropopliteal bypasses. - However, PTFE generally has **lower long-term patency rates** and a higher risk of complications like **graft thrombosis and infection** compared to autologous vein grafts. *None of the options* - This option is incorrect because the **reversed saphenous vein** is indeed a preferred and highly effective graft material for femoropopliteal bypass. - The clinical evidence strongly supports its use over synthetic alternatives when available.
Question 2: ABPI increases artificially in
- A. Ischemic limb ulcers
- B. Intermittent claudication syndrome
- C. Deep vein thrombosis (DVT)
- D. Conditions causing arterial calcification (Correct Answer)
Explanation: ***Conditions causing arterial calcification*** - In cases of **arterial calcification**, particularly in conditions like **diabetes** and **chronic kidney disease**, the blood vessels become stiff and non-compressible. - This stiffness leads to falsely elevated ankle systolic pressures because the cuff cannot effectively compress the calcified arteries, resulting in an artificially high **Ankle-Brachial Pressure Index (ABPI)** reading [2]. *Ischemic limb ulcers* - **Ischemic limb ulcers** are a direct consequence of **peripheral artery disease (PAD)**, which is characterized by reduced blood flow to the extremities [2]. - In these conditions, the ABPI would be **decreased** (typically < 0.9), indicating impaired blood supply, not an increase [2]. *Intermittent claudication syndrome* - **Intermittent claudication** is a classic symptom of **peripheral artery disease (PAD)**, where pain occurs in the legs during exercise due to insufficient blood flow [1]. - This syndrome is associated with a **reduced ABPI**, as arterial narrowing limits oxygen delivery to the muscles during exertion [1]. *Deep vein thrombosis (DVT)* - **Deep vein thrombosis (DVT)** is a condition involving a blood clot in a deep vein, typically in the legs. - DVT does not directly cause an artificial increase in ABPI; it primarily affects venous return and can cause swelling and pain, but not elevated arterial pressure readings [2].
Question 3: Buerger's disease is associated with
- A. Alcoholism
- B. Smoking (Correct Answer)
- C. Trauma
- D. Cold environment
Explanation: ***Smoking*** - Buerger's disease, or **thromboangiitis obliterans**, is strongly associated with **cigarette smoking**, leading to vasculitis and ischemia. - The cessation of smoking often leads to significant improvement in symptoms and cessation of disease progression. *Cold environment* - While cold exposure can exacerbate **peripheral vascular conditions**, it is not a primary cause or association of Buerger's disease. - The disease is primarily linked to **vasculitis** due to smoking, not environmental factors. *Trauma* - Trauma can cause vascular injury but is not a recognized association with Buerger's disease. - This disease is characterized by **segmental vasculitis** primarily related to **tobacco exposure**. *Alcoholism* - Although **alcoholism** can lead to various health issues, it is not specifically linked to Buerger's disease. - The primary risk factor is **smoking**, with alcoholic effects on the vasculature differing from those in Buerger's.
Question 4: A 45-year-old male having a long history of cigarette smoking presented with gangrene of the left foot, which was treated with an amputation. Representative sections from the specimen revealed the presence of arterial thrombus with neutrophilic infiltrate in the arterial wall, as well as inflammation extending into the adjacent veins and nerves. What is the most probable diagnosis?
- A. Takayasu arteritis
- B. Giant cell arteritis
- C. Hypersensitivity angiitis
- D. Thromboangiitis obliterans (Correct Answer)
Explanation: ***Thromboangiitis obliterans*** - This condition is strongly linked to **heavy smoking** and is characterized by segmental, thrombosing inflammation of medium-sized and small arteries, along with associated veins and nerves, leading to **gangrene** in the extremities [1]. - The presence of **arterial thrombus with neutrophilic infiltrate** in the arterial wall, and inflammation extending to adjacent **veins and nerves**, is a classic histopathological finding [1]. *Takayasu arteritis* - This is a **large-vessel vasculitis** primarily affecting the aorta and its main branches, leading to **absent pulses** ("pulseless disease") and claudication in the upper extremities [2]. - It typically does not involve the small and medium-sized arteries of the distal extremities or present with inflammation extending to adjacent veins and nerves as described. *Giant cell arteritis* - This is a **large-vessel vasculitis** predominantly affecting the temporal arteries and other arteries originating from the aorta in individuals over 50 years of age, presenting with **headache**, **jaw claudication**, and **visual disturbances** [2]. - Histopathology reveals **granulomatous inflammation** with giant cells, not the neutrophilic infiltrate and involvement of veins/nerves seen in this case [2]. *Hypersensitivity angiitis* - This refers to **leukocytoclastic vasculitis** affecting small vessels (arterioles, capillaries, venules) and is often associated with drug reactions or systemic diseases, typically presenting with **palpable purpura** [3]. - It primarily involves small vessels and lacks the characteristic segmental thrombosing inflammation of arteries, veins, and nerves seen in the given scenario, nor is it definitively linked to smoking leading to gangrene [3]. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 280-281. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of Infancy and Childhood, pp. 516-517. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Cardiovascular Disease, pp. 279-280.
Question 5: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
- A. Grade I (Mild claudication)
- B. Grade II (Moderate claudication) (Correct Answer)
- C. Grade III (Severe claudication)
- D. Grade IV (Ischemic rest pain)
Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).
Question 6: In acute limb ischemia, which finding indicates irreversible damage?
- A. Pulselessness
- B. Pain
- C. Pallor
- D. Paralysis (Correct Answer)
Explanation: ***Paralysis*** - **Paralysis** (loss of motor function) in acute limb ischemia signifies severe and prolonged ischemia leading to **nerve and muscle infarction**, indicating irreversible damage to the limb. - This symptom represents **Stage III ischemia** (Rutherford Classification), typically requiring amputation. *Pulselessness* - **Pulselessness** is a cardinal sign of acute limb ischemia, indicating a lack of blood flow, but it does not alone confirm irreversible damage. - While critical, blood flow can often be restored, and viability saved if treated promptly before nerve and muscle death occurs. *Pain* - **Pain** is one of the earliest and most common symptoms of acute limb ischemia, resulting from tissue hypoxia. - Though an indicator of significant ischemia, pain itself does not signify irreversible damage and is often present in reversible stages. *Pallor* - **Pallor** (whiteness) of the limb is due to reduced arterial blood flow and is a characteristic sign of acute limb ischemia. - Like pulselessness and pain, pallor is an early sign of ischemia and does not solely indicate irreversible tissue damage.
Question 7: What type of ulcer is shown below?
- A. Venous ulcer
- B. Arterial ulcer (Correct Answer)
- C. Trophic ulcer
- D. Diabetic foot
Explanation: ***Arterial ulcer*** - The image depicts an ulcer with a **punched-out appearance**, often found on the toes, heels, or shin, indicative of **arterial insufficiency**. - The surrounding skin appears **pale** and might show signs of **trophic changes** (e.g., hair loss, shiny skin), consistent with poor arterial blood supply. *Venous ulcer* - Venous ulcers typically occur around the **medial malleolus**, are superficial, and have irregular borders with a **"gaiter" appearance** (brawny edema and hyperpigmentation). - The ulcer bed is usually ruddy red with **exudate** and the surrounding skin often shows signs of **venous stasis changes**. *Trophic ulcer* - "Trophic ulcer" is a broad term for an ulcer caused by **poor nutrition** or nerve supply, and can encompass arterial or neuropathic ulcers. - This term is less specific than identifying the underlying vascular etiology shown in the image. *Diabetic foot* - Diabetic foot ulcers often occur on **pressure points** of the foot, such as the plantar surface or the heel, and can be neuropathic or neuro-ischemic. - While this image could potentially be associated with diabetes due to microvascular complications, the **punched-out, ischemic appearance** more strongly points to an arterial origin which can occur independently of diabetes.
Question 8: What is the most common site of peripheral aneurysm?
- A. Popliteal artery (Correct Answer)
- B. Brachial artery
- C. Femoral artery
- D. Radial artery
Explanation: ***Popliteal artery*** - **Popliteal artery aneurysms** are the most common type of peripheral artery aneurysm, accounting for about **70-80% of all cases**. - They are often **bilateral (50-70%)** and can be associated with **abdominal aortic aneurysms (30-50%)**. - Most commonly occur in **elderly males** with atherosclerotic disease. *Femoral artery* - Although **femoral artery aneurysms** are the **second most common** type of peripheral aneurysm, they account for only **20-25%** of cases. - They often occur in the **common femoral artery** and may be associated with atherosclerotic disease. - Less likely to be bilateral compared to popliteal aneurysms. *Brachial artery* - **Brachial artery aneurysms** are relatively rare and often result from **trauma, iatrogenic injury, or infection**. - They are not considered a common site for peripheral aneurysms. *Radial artery* - **Radial artery aneurysms** are quite uncommon and are typically caused by **trauma, repetitive motion, or iatrogenic injury**. - They are rarely spontaneous and do not represent a common site for peripheral aneurysms.
Question 9: Which of these is a palliative shunt procedure created between the left subclavian artery and pulmonary artery to treat cyanotic congenital heart disease?
- A. Waterston's shunt
- B. Lieno renal shunt
- C. Gott’s shunt
- D. Blalock-Taussig shunt (Correct Answer)
Explanation: **Blalock-Taussig shunt** - This procedure creates a **systemic-to-pulmonary artery shunt** by anastomosing a systemic artery (often the **subclavian artery**) to the pulmonary artery, increasing **pulmonary blood flow**. - It is a palliative measure for **cyanotic congenital heart diseases** where there is reduced pulmonary blood flow, such as **Tetralogy of Fallot**. *Waterston's shunt* - This is an older, no longer commonly used palliative shunt connecting the **ascending aorta to the right pulmonary artery**. - It was associated with a high incidence of complications, including **pulmonary overcirculation** and **pulmonary vascular disease**. *Lieno renal shunt* - This refers to a shunt created between the **splenic vein (lienal vein)** and the **left renal vein**. - It is primarily used to treat **portal hypertension** by decompressing the portal venous system, not congenital heart disease. *Gott's shunt* - This involves a **temporary bypass shunt** often used during **thoracic aortic surgery** to protect the spinal cord from ischemia. - It maintains blood flow to the distal aorta during aortic clamping and is not related to congenital heart disease palliation.
Question 10: The ideal synthetic material used for femoropopliteal bypass when autologous vein is unavailable is:
- A. Dacron
- B. Xenograft
- C. Saphenous vein
- D. PTFE (non-expanded)
- E. Cryopreserved vein graft
- F. ePTFE (Correct Answer)
- . Polyethylene terephthalate (PET)
- . Allograft
Explanation: ***ePTFE (Expanded Polytetrafluoroethylene)*** - **ePTFE** is the preferred synthetic graft for femoropopliteal bypass when autologous vein is unavailable - Offers good **biocompatibility** and relative resistance to **thrombosis** - Provides superior patency rates in above-knee femoropopliteal bypasses compared to other synthetic materials (5-year patency ~50-60%) - The expanded structure allows tissue ingrowth and better integration *Dacron (Polyethylene terephthalate)* - Generally used for **larger diameter vessels** (e.g., aortoiliac grafts) - Has **inferior patency rates** in smaller diameter femoropopliteal position compared to ePTFE - More prone to kinking and associated with higher rates of intimal hyperplasia in peripheral circulation *Saphenous vein* - The autologous saphenous vein is the **gold standard** for femoropopliteal bypass with superior long-term patency (5-year patency ~70-80%) - However, this question specifically asks for synthetic material when vein is unavailable or unsuitable - Not always available or of adequate quality in all patients *PTFE (non-expanded)* - **Non-expanded PTFE** lacks the porous structure of ePTFE - Not used for vascular grafts due to absence of tissue ingrowth capability - The **expanded** form is specifically engineered for vascular applications
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