Vascular Surgery Practice Questions

Q: A continuous murmur is found in which arterial disease?

Arteriovenous Fistula. ### Explanation **Correct Answer: C. Arteriovenous Fistula** **Mechanism:** A continuous murmur (often described as a **"machinery murmur"** or **bruit**) occurs in an **Arteriovenous (AV) Fistula** because there is a persistent pressure gradient between the high-pressure arterial system and the low-pressure venous system throughout the entire cardiac cycle. Since the pressure in the artery remains higher than in the vein during both systole and diastole, blood flows continuously through the abnormal communication, creating constant turbulence heard as a continuous murmur. **Analysis of Incorrect Options:** * **A. Atherosclerosis:** Typically produces a **systolic bruit** due to turbulent flow through a narrowed (stenosed) lumen. During diastole, the flow velocity usually drops below the threshold required to produce an audible sound. * **B. Dissecting Aortic Aneurysm:** This usually presents with a tearing chest pain. While it may cause an early diastolic murmur (due to secondary aortic regurgitation), it does not produce a continuous murmur. * **D. Thromboangiitis obliterans (Buerger’s Disease):** This is an inflammatory occlusive disease of small and medium-sized arteries. It leads to absent pulses rather than murmurs. **High-Yield Clinical Pearls for NEET-PG:** 1. **Nicoladoni-Branham Sign:** Bradycardia occurs when an AV fistula is compressed (due to a sudden increase in peripheral resistance and reflex vagal stimulation). 2. **Thrill:** A palpable vibration (thrill) is often present over an AV fistula, corresponding to the murmur. 3. **Congenital vs. Acquired:** Congenital AV fistulae are often multiple and small; acquired ones (e.g., trauma or iatrogenic for dialysis) are usually single and large. 4. **Differential Diagnosis:** Other causes of continuous murmurs include **Patent Ductus Arteriosus (PDA)** and **Venous Hum**.

Q: What is the most common cause of pseudaneurysm of the aorta?

Trauma. ### Explanation **Correct Answer: B. Trauma** A **pseudaneurysm** (false aneurysm) occurs when there is a breach in all three layers of the arterial wall (intima, media, and adventitia), leading to a contained hematoma surrounded by fibrous tissue rather than the vessel wall itself. In the aorta, the most common cause of a pseudaneurysm is **trauma**, specifically **blunt deceleration injuries** (e.g., motor vehicle accidents or falls from height). The injury typically occurs at the **aortic isthmus** (just distal to the origin of the left subclavian artery), where the mobile arch meets the fixed descending aorta. Chronic pseudaneurysms can also develop post-surgically at anastomotic sites. **Why other options are incorrect:** * **Smoking (A) and Age-related degeneration (D):** These are the primary risk factors for **true aneurysms** (e.g., Abdominal Aortic Aneurysm), where all three layers of the vessel wall remain intact but are dilated and weakened. * **Marfan’s Syndrome (C):** This is a genetic connective tissue disorder characterized by cystic medial necrosis. It typically leads to **true aneurysms** of the ascending aorta or **aortic dissection**, not primary pseudaneurysms. **High-Yield Clinical Pearls for NEET-PG:** * **True vs. False:** A true aneurysm involves all 3 layers; a false aneurysm is a pulsatile hematoma communicating with the lumen. * **Most common site of traumatic aortic rupture:** Aortic isthmus. * **Radiological Sign:** On a chest X-ray, look for a **widened mediastinum** (>8cm) as a sign of traumatic aortic injury. * **Iatrogenic causes:** Femoral artery pseudaneurysms are common after cardiac catheterization, but for the **aorta**, blunt trauma remains the classic etiology.

Q: Diabetic gangrene is caused by:

Atherosclerosis. **Explanation:** The primary underlying mechanism for diabetic gangrene is **macrovascular disease**, specifically **Atherosclerosis**. In diabetic patients, atherosclerosis occurs at an earlier age, progresses more rapidly, and is often multisegmental. It typically involves the infra-popliteal vessels (tibial and peroneal arteries). Chronic hyperglycemia leads to endothelial dysfunction and the formation of advanced glycation end-products (AGEs), which accelerate plaque formation. This results in arterial narrowing, ischemia, and eventually tissue necrosis (gangrene). **Analysis of Options:** * **A. Vasospasm:** This is a functional narrowing of vessels (e.g., Raynaud’s phenomenon) rather than a structural blockage. While microvascular dysfunction exists in diabetes, vasospasm is not the primary cause of the frank tissue death seen in diabetic gangrene. * **B. Peripheral Neuritis:** While diabetic neuropathy is a major *predisposing* factor for foot ulcers (due to loss of protective sensation and foot deformities), it does not directly cause gangrene. Neuropathy leads to the "Neuropathic Foot," but it is the ischemia from atherosclerosis that leads to the "Ischemic/Gangrenous Foot." **NEET-PG High-Yield Pearls:** * **The Diabetic Foot Triad:** Consists of **Ischemia** (Atherosclerosis), **Neuropathy** (Sensory/Motor/Autonomic), and **Infection**. * **Vessel Involvement:** Unlike smokers (who often have aorto-iliac disease), diabetics characteristically show **distal involvement** (vessels below the knee). * **Monckeberg’s Sclerosis:** Diabetics often have medial calcific sclerosis, which can lead to falsely elevated Ankle-Brachial Index (ABI) readings. * **Gas Gangrene vs. Diabetic Gangrene:** Diabetic gangrene is often a "wet gangrene" due to secondary polymicrobial infection, whereas gas gangrene is specifically caused by *Clostridium perfringens*.

Q: Buerger's disease is not associated with which of the following?

Involvement of large-sized arteries primarily. **Explanation:** **Buerger’s Disease (Thromboangiitis Obliterans - TAO)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the **small and medium-sized arteries** and veins of the upper and lower extremities. 1. **Why Option C is the Correct Answer:** Buerger’s disease characteristically spares large-sized arteries (like the aorta or iliac arteries). It is defined by its involvement of distal vessels, typically starting at the **tibial and radial arteries**. Therefore, the statement that it involves large-sized arteries primarily is incorrect. 2. **Analysis of Other Options:** * **Option A:** It classically affects **young males** (usually <40-45 years, often under 30) who are heavy smokers. * **Option B:** Unlike other vasculitides, TAO involves both arteries and veins. **Migratory superficial thrombophlebitis** is a hallmark clinical finding in about 40% of patients. * **Option C:** On angiography, while the disease is distal, proximal "corrugation" or a "standing wave" appearance can sometimes be seen in the femoral or brachial arteries due to sympathetic overactivity, though the classic finding is "corkscrew collaterals" (Martorell’s sign). **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Tobacco use (smoking or chewing) is essential for diagnosis and progression. * **Pathology:** Characterized by a **highly cellular, "inflammatory" thrombus** with relative sparing of the blood vessel wall (internal elastic lamina remains intact). * **Triad:** Distal ischemia (claudication/gangrene), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Angiographic Sign:** "Corkscrew" collaterals (vessels of Martorell). * **Treatment:** Absolute smoking cessation is the only way to prevent amputation. Sympathectomy may be used for pain relief.

Q: What is the most common cause of upper limb lymphedema?

Filariasis. **Explanation:** The correct answer is **Filariasis (Option A)**. Lymphedema is caused by the obstruction or dysfunction of the lymphatic system, leading to the accumulation of protein-rich fluid in the interstitial space. Globally and in endemic regions like India, **Filariasis** (caused primarily by *Wuchereria bancrofti*) is the most common cause of secondary lymphedema for both upper and lower limbs. The adult worms reside in the lymph nodes and vessels, causing chronic inflammation, fibrosis, and eventual obstruction of the lymphatic flow. **Analysis of Incorrect Options:** * **B. Congenital abnormalities:** These cause *primary* lymphedema (e.g., Milroy’s disease). While significant, they are statistically much rarer than secondary causes like infection. * **C. Neck surgery:** While radical neck dissections can lead to localized edema of the face or neck, they are not a leading cause of generalized upper limb lymphedema. * **D. Post-mastectomy irradiation:** This is the most common cause of upper limb lymphedema in **developed/Western countries** due to the disruption of axillary lymph nodes. However, on a global scale and specifically in the context of Indian medical exams, Filariasis remains the leading etiology overall. **High-Yield Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe/finger; a pathognomonic sign of lymphedema. * **Investigation of Choice:** Lymphoscintigraphy is the gold standard for evaluating the lymphatic system. * **Stewart-Treves Syndrome:** A rare, highly aggressive angiosarcoma that develops in a limb with long-standing chronic lymphedema (most commonly post-mastectomy). * **Treatment:** The mainstay is Complex Decongestive Therapy (CDT), which includes manual lymphatic drainage and compression bandaging.

Q: What is the treatment of choice in recurrent venous thrombosis leading to pulmonary embolism despite intensive anticoagulation?

Inferior vena caval filters. ### **Explanation** The management of venous thromboembolism (VTE) primarily relies on anticoagulation. However, in specific scenarios where medical therapy fails or cannot be used, mechanical intervention is required. **Why Option D is Correct:** The primary indication for the insertion of an **Inferior Vena Cava (IVC) Filter** is to prevent life-threatening pulmonary embolism (PE) in patients where: 1. **Anticoagulation is contraindicated** (e.g., active major bleeding). 2. **Anticoagulation has failed** (recurrent PE despite therapeutic levels of anticoagulation, as seen in this question). 3. **Complications of anticoagulation** occur, necessitating its cessation. The filter acts as a mechanical sieve, trapping large emboli from the lower extremities before they reach the pulmonary circulation. **Why Other Options are Incorrect:** * **A. Fibrinolysis (tPA):** Indicated for "Massive PE" (hemodynamically unstable patients with hypotension). It dissolves existing clots but does not prevent recurrence in the setting of failed anticoagulation. * **B. Pulmonary Embolectomy:** A surgical or catheter-based intervention reserved for patients with massive PE who have contraindications to thrombolysis or where thrombolysis has failed. * **C. Pulmonary Thromboendarterectomy:** The definitive treatment for **Chronic Thromboembolic Pulmonary Hypertension (CTEPH)**, not acute recurrent PE. ### **Clinical Pearls for NEET-PG:** * **Most common site for IVC filter placement:** Just infra-renal (to prevent renal vein thrombosis). * **Most common complication:** Access site thrombosis; however, the most significant long-term risk is an increased incidence of **Deep Vein Thrombosis (DVT)**. * **Greenfield Filter:** A classic stainless steel, cone-shaped filter known for maintaining patency even when filled to 70% of its capacity. * **Absolute Contraindication for IVC Filter:** Total occlusion of the IVC.

Q: An arteriovenous fistula can be safely ligated if which of the following tests is positive?

Allen's Test. **Explanation:** The correct answer is **Allen’s Test**. In the context of vascular surgery, an arteriovenous (AV) fistula (often created for hemodialysis) typically involves the radial or brachial artery. Before ligating or surgically intervening on such a fistula, it is mandatory to ensure that the distal limb has adequate collateral circulation. **Allen’s Test** assesses the patency of the radial and ulnar arteries and the adequacy of the palmar arch. A "positive" (normal) Allen’s test indicates that the ulnar artery can independently maintain perfusion to the hand if the radial artery is compromised or ligated, making the procedure safe. **Analysis of Incorrect Options:** * **Henle-Coenen Sign:** This is used to assess collateral circulation *during* surgery for an aneurysm or AV fistula. After clamping the artery proximal to the lesion, if there is distal pulsation or back-bleeding, the sign is positive, suggesting ligation is safe. However, Allen's test is the standard non-invasive clinical test used for this purpose in the upper limb. * **Trendelenburg Test:** Used in the evaluation of varicose veins to assess the competency of the saphenofemoral valve and perforator veins. * **Schwartz Test (Tap Test):** Used to detect valvular incompetence in the great saphenous vein by tapping the vein and feeling for a transmitted impulse distally. **Clinical Pearls for NEET-PG:** * **Modified Allen’s Test:** Performed by compressing both radial and ulnar arteries, having the patient clench their fist until the palm blanches, then releasing the ulnar artery. Return of color within 5–15 seconds is normal. * **Nicoladoni-Branham Sign:** A diagnostic sign for AV fistula where bradycardia occurs upon manual compression of the fistula (due to sudden increase in peripheral resistance and baroreceptor reflex). * **Machinery Murmur:** The classic continuous murmur heard over an AV fistula.

Question 1

A continuous murmur is found in which arterial disease?

Accepted Answer

Arteriovenous Fistula

Answer

Atherosclerosis

Answer

Dissecting aortic aneurysm

Answer

Thromboangiitis obliterans

Question 2

What is the most common cause of pseudaneurysm of the aorta?

Accepted Answer

Trauma

Answer

Smoking

Answer

Marfan's Syndrome

Answer

Age-related degeneration

Question 3

Diabetic gangrene is caused by:

Accepted Answer

Atherosclerosis

Answer

Vasospasm

Answer

Peripheral neuritis

Answer

None of the above

Question 4

A 67-year-old man presents with a 3.0x3.5 cm abdominal aortic aneurysm detected by community ultrasound screening. Physical examination reveals a palpable, pulsatile, nontender abdominal mass just above the umbilicus. The patient has a history of hypertension, hyperlipidemia, and tobacco use. What is the best recommendation for this patient?

Accepted Answer

Serial follow-up with ultrasound, CT, or MRI, with the major determinant for surgery being aneurysmal size greater than 5.5 cm.

Answer

Watchful waiting until the first onset of abdominal pain.

Answer

Surgery is indicated now, with the patient's hypertension and tobacco use representing excess operative risk.

Answer

Serial follow-up with ultrasound, CT, or MRI, with the major determinant for surgery being involvement of a renal artery.

Question 5

Lumbar sympathectomy is of value in the management of which of the following conditions?

Accepted Answer

Distal ischemia affecting the skin of the toes

Answer

Intermittent claudication

Answer

Arteriovenous fistula

Answer

Back pain

Question 6

Buerger's disease is not associated with which of the following?

Accepted Answer

Involvement of large-sized arteries primarily

Answer

Affects males under the age of 30 years

Answer

Thrombophlebitis of deep or superficial veins

Answer

Characteristic 'corrugation' of femoral arteries on angiography

Question 7

Lipodermatosclerosis is most commonly seen at which aspect of the leg?

Accepted Answer

Medial aspect of leg

Answer

Anterior aspect of leg

Answer

Anterior aspect of thigh

Answer

Posterior aspect of thigh

Question 8

What is the most common cause of upper limb lymphedema?

Accepted Answer

Filariasis

Answer

Congenital abnormalities

Answer

Neck surgery

Answer

Post-mastectomy irradiation

Question 9

What is the treatment of choice in recurrent venous thrombosis leading to pulmonary embolism despite intensive anticoagulation?

Accepted Answer

Inferior vena caval filters

Answer

Fibrinolysis treatment with tissue plasminogen activator

Answer

Pulmonary embolectomy

Answer

Pulmonary thromboendarterectomy

Question 10

An arteriovenous fistula can be safely ligated if which of the following tests is positive?

Accepted Answer

Allen's Test

Answer

Henle-Coenen sign

Answer

Trendelenburg test

Answer

Schwartz Test

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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