Vascular Surgery Practice Questions

Q: A patient presents to the emergency department with abdominal pain. What is the MOST significant diagnosis?

Superior mesenteric artery embolus. ***Superior mesenteric artery embolus*** - **Acute mesenteric ischemia** from SMA embolus requires **immediate surgical intervention** (within 6-8 hours) to prevent bowel necrosis and death. - **CT angiography** shows **filling defect** in the SMA with **decreased bowel wall enhancement** and potential **pneumatosis intestinalis**. *Superior mesenteric vein thrombosis* - Causes **venous congestion** rather than arterial ischemia, progressing more **slowly** than arterial embolus. - **CT shows thrombus** in the SMV with **bowel wall thickening** and **mesenteric edema**, but less immediately life-threatening. *Aortic dissection* - Presents with **tearing chest/back pain** radiating to the abdomen, not primarily abdominal pain. - **CT shows intimal flap** and **false lumen** in the aorta, but may not cause immediate bowel ischemia. *Leaking aortic aneurysm* - Typically presents with **hypotension** and **pulsatile abdominal mass** rather than isolated abdominal pain. - **CT shows retroperitoneal hematoma** and **aortic wall irregularity**, but bowel perfusion usually remains intact.

Q: What is the most common source of pulmonary embolism?

Deep leg veins. **Explanation:** The correct answer is **Deep leg veins (Option B)**. Pulmonary Embolism (PE) is a life-threatening condition where a blood clot (thrombus) dislodges and travels to the pulmonary arteries. Approximately **90-95% of all pulmonary emboli** originate from Deep Vein Thrombosis (DVT) of the lower extremities. Specifically, thrombi originating from the **proximal deep veins** (popliteal, femoral, and iliac veins) carry the highest risk of embolization compared to distal calf vein thrombi. **Analysis of Incorrect Options:** * **A. Hemorrhoids:** These involve the rectal venous plexus. While they can thrombose locally (causing pain), they rarely lead to PE because the venous drainage often goes into the portal system or involves small-caliber vessels where clots are unlikely to reach the pulmonary circulation in a significant size. * **C. Portal vein:** Thrombi in the portal vein (Portal Vein Thrombosis) lead to portal hypertension and intestinal ischemia. Because the portal system drains into the liver (capillary bed of the sinusoids), these clots are "filtered" by the liver and do not reach the systemic venous circulation or the lungs. **NEET-PG High-Yield Pearls:** * **Most common site for DVT:** The muscular veins of the calf (soleal sinuses), but the **most common source of PE** is the proximal leg veins (Femoral vein). * **Virchow’s Triad:** The three factors contributing to venous thrombosis are Stasis, Endothelial Injury, and Hypercoagulability. * **Gold Standard Investigation:** CT Pulmonary Angiography (CTPA) is the investigation of choice for PE. * **ECG Finding:** The most common finding is sinus tachycardia; the classic but rare sign is the **S1Q3T3 pattern**.

Q: Ankle brachial pressure index is more than 1.3 in all except?

Critical limb ischaemia. **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 a primary screening tool for Peripheral Arterial Disease (PAD). **Why Critical Limb Ischaemia (CLI) is the correct answer:** In **Critical Limb Ischaemia**, there is significant arterial stenosis or occlusion, leading to severely reduced blood flow to the distal limb. This results in a **low ABPI**, typically **less than 0.4**. A low ABPI correlates with the severity of the disease and the risk of non-healing ulcers or gangrene. **Why the other options are incorrect:** An ABPI **>1.3** indicates **falsely elevated pressures** due to **Mönckeberg’s medial sclerosis** (mural calcification). In this condition, the tunica media of the arteries becomes calcified and non-compressible, requiring excessively high cuff pressures to occlude the vessel. This is commonly seen in: * **Diabetes Mellitus:** Chronic hyperglycemia leads to accelerated medial wall calcification. * **Renal Insufficiency:** Secondary hyperparathyroidism and altered calcium-phosphate metabolism promote vascular calcification. * **Mural Calcification:** This is the underlying pathological process (medial sclerosis) that causes vessel stiffness. **High-Yield Clinical Pearls for NEET-PG:** * **Normal ABPI:** 0.9 – 1.2. * **Mild to Moderate Claudication:** 0.5 – 0.9. * **Critical Ischaemia:** 1.3):** If ABPI is abnormally high in a symptomatic patient, the next best step is to perform a **Toe-Brachial Index (TBI)**, as digital arteries are rarely affected by medial calcification. * **Rest Pain:** Usually occurs when the absolute ankle systolic pressure is **<50 mmHg**.

Q: All of the following are seen in deep vein thrombosis except?

Claudication. **Explanation:** Deep Vein Thrombosis (DVT) is a condition characterized by the formation of a blood clot within the deep venous system, most commonly in the lower limbs. The fundamental pathophysiology involves **venous obstruction** and inflammation. **Why Claudication is the Correct Answer:** Claudication is a hallmark symptom of **Peripheral Arterial Disease (PAD)**, not venous disease. It refers to cramp-like muscle pain that occurs predictably during exercise and is relieved by rest. This occurs because narrowed arteries cannot meet the increased oxygen demand of exercising muscles. In DVT, the pathology is venous congestion, not arterial insufficiency; therefore, classic claudication is absent. **Analysis of Incorrect Options:** * **Pain:** This is a common symptom of DVT, typically described as a dull ache or heaviness in the calf or thigh, exacerbated by weight-bearing. * **Discoloration:** Venous stasis leads to skin changes. In acute DVT, the limb may appear slightly cyanotic (blue) or erythematous (red) due to congestion. In severe cases, it can progress to *Phlegmasia cerulea dolens*. * **Swelling:** Unilateral leg edema is the most sensitive clinical sign of DVT, resulting from increased hydrostatic pressure behind the venous obstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** Stasis, Endothelial injury, and Hypercoagulability are the three factors predisposing to DVT. * **Homan’s Sign:** Calf pain on dorsiflexion of the foot (low sensitivity and specificity). * **Moses Sign:** Pain on squeezing the calf muscles from side to side. * **Gold Standard Investigation:** Contrast Venography (rarely used now). * **Investigation of Choice:** Duplex Ultrasound (Compression Ultrasonography). * **Phlegmasia Alba Dolens:** "Milk leg" – massive iliofemoral DVT causing a pale, white limb (associated with pregnancy).

Q: Grade 4 clinically in varicose veins is characterised by all except?

Ulceration. This question tests your knowledge of the **CEAP Classification**, which is the gold standard for describing the clinical severity of chronic venous disorders. ### **Explanation** The CEAP classification categorizes varicose veins from C0 to C6 based on clinical signs. **Grade 4 (C4)** is specifically characterized by **skin changes** resulting from chronic venous hypertension, but it does **not** include active or healed ulcers. * **Why Option C is the correct answer:** Ulceration is classified under Grade 5 and Grade 6. Specifically, **C5** represents a healed venous ulcer, while **C6** represents an active venous ulcer. Therefore, ulceration is "excepted" from Grade 4. ### **Analysis of Incorrect Options (Features of Grade 4)** Grade 4 is subdivided into 4a and 4b: * **Option D (Pigmentation):** Part of C4a. It occurs due to haemosiderin deposition from extravasated red blood cells. * **Option A (Eczema):** Part of C4a. Also known as stasis dermatitis, it presents as erythema, scaling, and itching. * **Option B (Lipodermatosclerosis):** Part of C4b. This refers to chronic inflammation and fibrosis of the skin and subcutaneous fat, often leading to the "inverted champagne bottle" appearance of the leg. Atrophie blanche is also included in C4b. ### **High-Yield Clinical Pearls for NEET-PG** * **C0:** No visible or palpable signs of venous disease. * **C1:** Telangiectasia (spider veins) or reticular veins (<3mm). * **C2:** Varicose veins (≥3mm). * **C3:** Edema (without skin changes). * **C4:** Skin changes (Pigmentation, Eczema, Lipodermatosclerosis). * **C5:** Healed venous ulcer. * **C6:** Active venous ulcer. * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Gold Standard Investigation:** Duplex Ultrasound (Doppler).

Q: A patient presented with pulsating varicose veins of the lower limb. On examination, he was having cutaneous hemangioma involving the face with enlarged toes. What is the most probable diagnosis?

Klippel-Trenaunay syndrome. ### Explanation The correct diagnosis is **Klippel-Trenaunay Syndrome (KTS)**. This is a rare congenital vascular disorder characterized by a classic triad: 1. **Port-wine stain** (Capillary malformation/Cutaneous hemangioma). 2. **Venous malformations** (typically presenting as "pulsating" or atypical varicose veins). 3. **Soft tissue and bony hypertrophy** (leading to limb overgrowth or enlarged toes/macrodactyly). In this case, the combination of cutaneous hemangiomas, varicose veins, and enlarged toes (local hypertrophy) fits the classic presentation of KTS. #### Why the other options are incorrect: * **Tricuspid Regurgitation:** While it can cause "pulsating" neck veins (systolic v-waves) and peripheral edema, it does not cause localized limb hypertrophy or cutaneous hemangiomas. * **Deep Vein Thrombosis (DVT):** DVT presents with acute limb swelling, pain, and tenderness. It does not involve congenital hemangiomas or bony overgrowth. * **Kasabach-Merritt Syndrome:** This involves a rapidly growing vascular tumor (usually a tufted angioma or kaposiform hemangioendothelioma) that leads to **consumptive coagulopathy** and severe thrombocytopenia. It is not characterized by limb hypertrophy. #### NEET-PG High-Yield Pearls: * **KTS vs. Parkes-Weber Syndrome:** If the patient also has significant **Arteriovenous Fistulas (AVFs)** leading to high-output heart failure, the diagnosis shifts to Parkes-Weber Syndrome. * **Servelle-Martorell Syndrome:** Characterized by limb **hypotrophy** (shortening) due to intraosseous vascular malformations, contrasting with the hypertrophy seen in KTS. * **Management:** Primarily conservative (compression stockings). Surgery is reserved for complications due to the high risk of recurrence and bleeding.

Q: Diagnosis of thoracic outlet syndrome is made by which one of the following?

Clinical evaluation. **Explanation:** Thoracic Outlet Syndrome (TOS) is primarily a **clinical diagnosis**. It refers to the compression of the neurovascular bundle (brachial plexus, subclavian artery, or subclavian vein) as it passes through the thoracic outlet. 1. **Why Clinical Evaluation is Correct:** The diagnosis is established through a detailed history and provocative physical examination maneuvers. Since over 90% of TOS cases are **neurogenic** (involving the brachial plexus), they often do not show structural abnormalities on routine imaging. Clinical tests like **Adson’s test**, **Roos test (Elevated Arm Stress Test)**, and **Wright’s test** are the mainstays for identifying the site of compression. 2. **Why Other Options are Incorrect:** * **CT Scan & MRI:** These are supportive investigations used to rule out differential diagnoses (like cervical disc prolapse) or to identify anatomical predispositions (like a cervical rib or fibrous bands). However, they cannot confirm the functional compression that occurs during movement. * **Angiography:** This is only indicated in **Vascular TOS** (Arterial or Venous), which accounts for less than 5% of cases. It is not the primary diagnostic tool for the most common neurogenic variety. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type:** Neurogenic TOS (95%). * **Most common site of compression:** Interscalene triangle. * **Adson’s Test:** Loss of radial pulse when the patient extends the neck and turns the head *toward* the affected side while taking a deep breath. * **Roos Test:** The most reliable screening test (patient opens/closes hands for 3 minutes with arms abducted). * **Cervical Rib:** The most common bony abnormality associated with TOS.

Question 1

Which of the following antibiotics is the drug of choice in the treatment of lymphedema?

Accepted Answer

Penicillin

Answer

Amikacin

Answer

Metronidazole

Answer

Ceftazidime

Question 2

A patient presents to the emergency department with abdominal pain. What is the MOST significant diagnosis?

Accepted Answer

Superior mesenteric artery embolus

Answer

Superior mesenteric vein thrombosis

Answer

Aortic dissection

Answer

Leaking aortic aneurysm

Question 3

What is the most common source of pulmonary embolism?

Accepted Answer

Deep leg veins

Answer

Hemorrhoids

Answer

Portal vein

Answer

None of the above

Question 4

Which of the following is NOT a clinical test used to assess perforator vein incompetence?

Accepted Answer

Morrisey's cough impulse test

Answer

Pratt's test

Answer

Trendelenburg-II test

Answer

Fegan test

Question 5

Ankle brachial pressure index is more than 1.3 in all except?

Accepted Answer

Critical limb ischaemia

Answer

Diabetes mellitus

Answer

Mural calcification

Answer

Renal insufficiency

Question 6

What is the initial therapy for documented deep venous thrombosis in a post-operative patient?

Accepted Answer

Intravenous heparin therapy

Answer

Subcutaneous heparin therapy

Answer

Thrombolytic therapy with urokinase

Answer

Aspirin therapy

Question 7

All of the following are seen in deep vein thrombosis except?

Accepted Answer

Claudication

Answer

Pain

Answer

Discoloration

Answer

Swelling

Question 8

Grade 4 clinically in varicose veins is characterised by all except?

Accepted Answer

Ulceration

Answer

Eczema

Answer

Lipodermatosclerosis

Answer

Pigmentation

Question 9

A patient presented with pulsating varicose veins of the lower limb. On examination, he was having cutaneous hemangioma involving the face with enlarged toes. What is the most probable diagnosis?

Accepted Answer

Klippel-Trenaunay syndrome

Answer

Tricuspid regurgitation

Answer

Deep vein thrombosis (DVT)

Answer

Kasabach-Merritt syndrome

Question 10

Diagnosis of thoracic outlet syndrome is made by which one of the following?

Accepted Answer

Clinical evaluation

Answer

CT scan

Answer

MRI

Answer

Angiography

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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