Vascular Surgery Practice Questions

Q: A newborn girl with a family history of lymphedema presents with bilateral lower extremity swelling. What is the most likely diagnosis?

Milroy disease. **Explanation:** The correct answer is **Milroy disease** (Option C). **Why it is correct:** Milroy disease is a form of **Primary Congenital Lymphedema** (Type I). It is an autosomal dominant condition typically caused by mutations in the **FLT4 gene**, which encodes the VEGFR-3 receptor. The hallmark clinical presentation is **painless, bilateral lower extremity pitting edema present at birth** or within the first year of life. The family history mentioned in the question is a key diagnostic clue, as this condition is hereditary. **Why other options are incorrect:** * **Secondary lymphedema (A):** This is acquired due to obstruction or damage to the lymphatic system (e.g., filariasis, malignancy, or surgery). It is not typically present at birth with a family history. * **Lymphedema praecox (B):** Also known as Meige disease (Type II), this is the most common form of primary lymphedema. However, it typically presents **around puberty** (peak age 12–16 years), not at birth. * **Lymphedema tarda (D):** This refers to primary lymphedema that manifests **after the age of 35**. **High-Yield Clinical Pearls for NEET-PG:** * **Milroy Disease:** Present at birth (Congenital), FLT4 mutation, associated with "upslanting" toenails and prominent veins. * **Meige Disease:** Most common primary lymphedema; presents at puberty; associated with FOXC2 mutation (Lymphedema-distichiasis syndrome). * **Differential Diagnosis:** In a female newborn with lymphedema, always consider **Turner Syndrome** (45, XO), though it is usually associated with webbed neck and cardiac defects. * **Stem Sign:** Inability to pinch the skin on the dorsal base of the second toe; a classic sign of chronic lymphedema.

Q: For performing Coronary Artery Bypass Grafting (CABG), the Allen test is performed to assess the patency of which vessel?

Radial artery. **Explanation:** The **Allen test** is a clinical bedside maneuver used to assess the **collateral circulation** of the hand. In the context of CABG, the radial artery is frequently harvested as a high-quality arterial conduit. Before harvesting, it is mandatory to ensure that the **ulnar artery** can provide sufficient blood flow to the entire hand via the palmar arches to prevent ischemic complications. * **Why Radial Artery is correct:** The test specifically evaluates the patency of the ulnar artery and the adequacy of the palmar arch *before* sacrificing the **radial artery**. If the hand does not "flush" (reperfuse) within 5–10 seconds of releasing the ulnar artery while the radial remains compressed, the test is "positive" (abnormal), indicating poor collateral flow, and the radial artery cannot be harvested. * **Why other options are wrong:** * **Ulnar artery:** While the test *checks* the ulnar artery's function, it is performed specifically to determine if the **radial artery** can be safely removed. * **Saphenous vein:** This is a venous conduit harvested from the leg; its patency is assessed via ultrasound (Doppler), not the Allen test. * **Internal mammary artery (IMA):** Also known as the Internal Thoracic Artery, this is the "gold standard" conduit for CABG (especially for the LAD). It is harvested from the chest wall and does not require an Allen test. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Allen Test:** The version used today where the patient clenches their fist to blanch the hand before pressure is applied. * **Gold Standard:** While the Allen test is standard, **Pulse Oximetry** or **Doppler Ultrasound** are more objective methods to confirm collateral flow. * **CABG Conduits:** The Left Internal Mammary Artery (LIMA) has the highest long-term patency rate (>90% at 10 years).

Q: Which statement is NOT true about thoracic outlet syndrome?

The ulnar nerve is commonly affected.. ### Explanation Thoracic Outlet Syndrome (TOS) is a clinical condition resulting from the compression of the neurovascular bundle (brachial plexus and/or subclavian vessels) as it passes through the thoracic outlet. **Why Option A is the Correct Answer (The "NOT True" statement):** While the lower trunk of the brachial plexus (C8-T1) is the most commonly compressed neural structure, it is technically incorrect to say the **ulnar nerve** is affected. The compression occurs at the **roots or trunks** of the plexus, not the peripheral nerve itself. While symptoms often manifest in the ulnar distribution (medial forearm and hand), the pathology is proximal to the formation of the ulnar nerve. **Analysis of Other Options:** * **Option B:** Neurological features (Neurogenic TOS) account for approximately **95% of cases**, making it the most common presentation. Patients typically present with pain, paresthesia, and weakness. * **Option C:** Surgical management, such as **resection of the first rib** or a cervical rib, is a definitive treatment to decompress the space and relieve symptoms when conservative management fails. * **Option D:** **Adson’s test** (loss of radial pulse on rotating the head to the affected side during deep inspiration) is a classic clinical sign of TOS, though it has high false-positive rates in the general population. **NEET-PG High-Yield Pearls:** * **Most common site of compression:** Scalene triangle (between anterior and middle scalenes). * **Commonest cause:** Presence of a **Cervical Rib** (elongated C7 transverse process). * **Gilliatt-Sumner Hand:** Severe wasting of the thenar and hypothenar muscles seen in chronic neurogenic TOS. * **Paget-Schroetter Syndrome:** Venous TOS leading to effort-induced thrombosis of the subclavian vein.

Q: What is the most common visceral artery aneurysm?

Splenic artery. **Explanation:** Visceral artery aneurysms (VAAs) are rare but clinically significant due to their risk of rupture. Among all VAAs, the **Splenic Artery Aneurysm (SAA)** is the most common, accounting for approximately **60%** of all cases. **1. Why Splenic Artery is Correct:** The splenic artery is the most frequent site for visceral aneurysms. They are significantly more common in **females** (4:1 ratio), often associated with conditions that increase splenic blood flow or weaken the arterial wall, such as **multiple pregnancies** (due to hormonal changes and portal congestion), portal hypertension, and medial fibrodysplasia. **2. Why Other Options are Incorrect:** * **Hepatic Artery:** This is the **second most common** visceral artery aneurysm, accounting for about 20% of cases. They are more common in males and are often associated with trauma, infection, or vasculitis. * **Gastric/Gastroepiploic Arteries:** These are extremely rare, accounting for less than 4% of all VAAs. They are usually intramural and often present with GI bleeding rather than intraperitoneal rupture. **3. High-Yield Clinical Pearls for NEET-PG:** * **The "Double Rupture" Phenomenon:** SAA can initially rupture into the lesser sac (tamponade effect) and then later into the general peritoneal cavity through the Foramen of Winslow. * **Pregnancy Risk:** While most SAAs are asymptomatic, the risk of rupture increases significantly during the **third trimester of pregnancy**, carrying a high maternal and fetal mortality rate. * **Indications for Surgery:** Treatment is generally indicated if the aneurysm is **>2 cm**, if the patient is **pregnant** or planning pregnancy, or if the patient is symptomatic. * **Imaging:** Digital Subtraction Angiography (DSA) remains the gold standard for diagnosis and planning intervention.

Q: Lisker's sign is seen in which condition?

Deep Vein Thrombosis (DVT). **Explanation:** **Lisker's sign** is a clinical sign used in the diagnosis of **Deep Vein Thrombosis (DVT)**. It is characterized by **tenderness elicited upon percussion of the anterior surface of the tibia**. The underlying medical concept is that the vibration or pressure from percussion irritates the inflamed deep veins (specifically the posterior tibial veins) lying in close proximity to the bone, causing localized pain. **Analysis of Options:** * **Deep Vein Thrombosis (Correct):** Along with Lisker’s sign, DVT is associated with several eponymous signs resulting from venous inflammation and calf muscle compression. * **Buerger’s Disease (Thromboangiitis Obliterans):** This is an inflammatory vasculitis of small and medium-sized arteries. It is characterized by the **Adson’s test** (for thoracic outlet) or **Allen’s test**, but not Lisker's sign. * **Coarctation of the Aorta:** This presents with radio-femoral delay and rib notching. * **Arteriovenous (AV) Fistula:** This is associated with **Nicoladoni-Branham sign** (bradycardia upon compression of the fistula), not percussion tenderness. **High-Yield Clinical Pearls for NEET-PG:** In the context of DVT, remember these other eponymous signs frequently tested: 1. **Homan’s Sign:** Pain in the calf on dorsiflexion of the foot (most famous but least specific). 2. **Moses’ Sign:** Pain on squeezing the calf muscles from side to side (anteroposteriorly). 3. **Lowenberg’s Sign:** Pain elicited when a blood pressure cuff wrapped around the calf is inflated to 80–100 mmHg. 4. **Pratt’s Sign:** Presence of prominent "sentinel" veins over the pretibial area.

Q: Which of the following is included in the definition of critical limb ischemia?

Rest pain. **Explanation:** Critical Limb Ischemia (CLI) represents the end-stage of peripheral arterial disease (PAD), where the blood supply is insufficient to meet the metabolic demands of the tissue at rest. **Why the correct answer is right:** According to the **Fontaine Classification (Stage III and IV)** and the **Rutherford Classification (Categories 4, 5, and 6)**, CLI is defined by the presence of chronic ischemic **rest pain** (typically requiring opiate analgesia for >2 weeks) or tissue loss (ulceration or gangrene). It is objectively confirmed by hemodynamic parameters showing severely reduced perfusion, specifically an **ankle pressure 50 mm Hg:** This is incorrect because the diagnostic threshold for CLI is an ankle pressure **less than** 50 mm Hg. Pressures above this level generally suggest compensated ischemia. * **C. Intermittent claudication:** This represents Fontaine Stage II. While it indicates PAD, it is not "critical" because the blood supply is adequate at rest and only becomes insufficient during exercise. * **D. Well preserved tissues:** CLI is characterized by the breakdown of tissue (Fontaine Stage IV), leading to non-healing ischemic ulcers or gangrene. **High-Yield Clinical Pearls for NEET-PG:** * **The "6 Ps"** (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia) refer to **Acute** Limb Ischemia, which is a surgical emergency, whereas CLI is a **chronic** condition. * **Buerger’s Test:** A positive test (elevation pallor and dependent rubor) is a classic clinical sign of CLI. * **Management:** The primary goal in CLI is urgent revascularization (endovascular or bypass) to prevent limb loss (amputation).

Q: Which of the following types of dissecting aneurysm does NOT involve the ascending aorta?

Stanford type B. Aortic dissection is classified based on the anatomical location of the intimal tear and the extent of the dissection. The two primary systems used are the **Stanford** and **DeBakey** classifications. ### **Explanation of the Correct Answer** **A. Stanford type B:** This classification is based solely on whether the **ascending aorta** is involved. * **Stanford Type A:** Involves the ascending aorta (regardless of the site of the primary tear). * **Stanford Type B:** Involves only the descending aorta (distal to the left subclavian artery) and **spares the ascending aorta**. Therefore, Type B is the correct answer. ### **Explanation of Incorrect Options** * **B. Stanford type A:** By definition, this involves the ascending aorta. It is a surgical emergency due to the risk of coronary artery occlusion, aortic regurgitation, and cardiac tamponade. * **C. DeBakey type I:** This involves the **ascending aorta**, the arch, and extends into the descending aorta. * **D. DeBakey type II:** This is confined strictly to the **ascending aorta**. ### **High-Yield NEET-PG Pearls** * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice for diagnosis. * **Management Rule:** * **Stanford Type A (DeBakey I & II):** Requires urgent **Surgical** repair. * **Stanford Type B (DeBakey III):** Primarily managed **Medically** (blood pressure control using Beta-blockers like Labetalol) unless complications like ischemia or rupture occur. * **Risk Factors:** Hypertension (most common), Marfan Syndrome, and Bicuspid aortic valve. * **Clinical Sign:** "Tearing" chest pain radiating to the back with a blood pressure discrepancy between arms.

Question 1

A newborn girl with a family history of lymphedema presents with bilateral lower extremity swelling. What is the most likely diagnosis?

Accepted Answer

Milroy disease

Answer

Secondary lymphedema

Answer

Lymphedema praecox

Answer

Lymphedema tarda

Question 2

For performing Coronary Artery Bypass Grafting (CABG), the Allen test is performed to assess the patency of which vessel?

Accepted Answer

Radial artery

Answer

Ulnar artery

Answer

Saphenous vein

Answer

Internal mammary artery

Question 3

Which of the following is true regarding subclavian steal syndrome?

Accepted Answer

The blood pressure is decreased on the ipsilateral side.

Answer

The flow of blood in the vertebral arteries is normal.

Answer

The patients commonly present with claudication features.

Answer

The patients commonly present with neurological features.

Question 4

Which statement is NOT true about thoracic outlet syndrome?

Accepted Answer

The ulnar nerve is commonly affected.

Answer

Neurological features are the most common presentation.

Answer

Resection of the first rib can relieve symptoms.

Answer

A positive Adson's test is indicative of the condition.

Question 5

Regarding vascular surgery distal to the popliteal artery, which of the following statements is true?

Accepted Answer

All the above

Answer

Suture with polypropylene

Answer

6-0 suture is used

Answer

Needle pass from within outwards

Question 6

What is the most common visceral artery aneurysm?

Accepted Answer

Splenic artery

Answer

Hepatic artery

Answer

Gastric artery

Answer

None of the above

Question 7

Lisker's sign is seen in which condition?

Accepted Answer

Deep Vein Thrombosis (DVT)

Answer

Berger's disease

Answer

Coarctation of the aorta

Answer

Arteriovenous fistula

Question 8

Which of the following is included in the definition of critical limb ischemia?

Accepted Answer

Rest pain

Answer

Ankle blood pressure >50 mm Hg

Answer

Intermittent claudication

Answer

Well preserved tissues

Question 9

What is the most common cause of acute arterial occlusion?

Accepted Answer

Emboli from atrial fibrillation

Answer

Pulmonary emboli

Answer

Atherosclerosis plaque

Answer

Thrombosis of an aneurysm

Question 10

Which of the following types of dissecting aneurysm does NOT involve the ascending aorta?

Accepted Answer

Stanford type B

Answer

Stanford type A

Answer

DeBakey type I

Answer

DeBakey type II

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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