Vascular Surgery Practice Questions

Q: What accounts for this patient's hand pain?

Radial artery thrombosis. ***Radial artery thrombosis*** - **Radial artery thrombosis** commonly occurs after **catheterization procedures**, **hypothenar hammer syndrome**, or **trauma**, leading to **hand ischemia** and severe pain. - Clinical features include **absent radial pulse**, **cold and pale hand**, and **positive Allen's test** showing inadequate ulnar circulation compensation. *Ulnar artery occlusion* - Would cause **hypothenar eminence** and **fourth/fifth finger ischemia**, but **radial pulse** would remain intact. - **Allen's test** would show **ulnar artery insufficiency** rather than radial artery compromise. *Wrist fracture* - Presents with **localized bone pain**, **swelling**, and **deformity** at the fracture site, not vascular compromise. - **X-rays** would show **fracture lines** and **pulses** would typically remain intact unless complicated by compartment syndrome. *Carpal tunnel syndrome* - Causes **numbness** and **tingling** in the **median nerve distribution** (thumb, index, middle fingers), not ischemic pain. - Symptoms are typically **worse at night** and **improve with hand shaking**, with **normal pulses** and **skin color**.

Q: Bilateral pulseless disease in upper limbs is caused by which of the following conditions?

Takayasu arteritis. **Explanation:** **Takayasu Arteritis (Correct Answer):** Takayasu arteritis is a chronic, large-vessel vasculitis that primarily involves the **aorta and its main branches** (such as the subclavian, carotid, and renal arteries). It is most common in young females. The inflammation leads to segmental stenosis, occlusion, or aneurysmal dilation. When the **subclavian arteries** are bilaterally involved, it results in the characteristic clinical finding of absent or diminished pulses in the upper limbs, earning it the moniker **"Pulseless Disease."** **Analysis of Incorrect Options:** * **Coarctation of Aorta:** Typically involves narrowing distal to the origin of the left subclavian artery. This results in hypertension and strong pulses in the upper limbs, but weak/delayed pulses in the lower limbs (radio-femoral delay). * **Fibromuscular Dysplasia (FMD):** A non-inflammatory, non-atherosclerotic angiopathy that primarily affects medium-sized arteries, most commonly the **renal and internal carotid arteries**. It rarely causes bilateral upper limb pulselessness. * **Buerger’s Disease (Thromboangiitis Obliterans):** An inflammatory condition strongly associated with smoking that affects **small and medium-sized vessels** of the distal extremities (hands and feet). While it causes ischemia, it does not typically present as a proximal "pulseless disease" of the entire upper limb. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in females 10 mmHg between arms is a diagnostic criterion. * **Treatment:** Glucocorticoids are the first-line medical management; bypass surgery or angioplasty is reserved for irreversible stenosis.

Q: Buerger's disease usually affects all of the following except:

Large arteries. **Explanation:** **Buerger’s Disease**, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that primarily affects the distal vasculature of the extremities. **Why "Large Arteries" is the correct answer:** Buerger’s disease is characteristically a disease of the **small and medium-sized** vessels. It typically starts in the distal arteries of the hands and feet (e.g., digital, tibial, and radial arteries) and progresses proximally. It **spares large-sized arteries** (like the aorta or iliac arteries), which is a key diagnostic differentiator from atherosclerosis. **Analysis of other options:** * **Small and Medium-sized arteries (Options A & D):** These are the primary targets of the disease. The pathology involves a highly cellular "soft" thrombus that occludes these vessels, leading to ischemia, claudication, and gangrene. * **Deep veins (Option C):** While primarily an arterial disease, Buerger’s is unique because it also involves veins and nerves. Approximately 40% of patients experience **migratory superficial thrombophlebitis**, and involvement of deep veins is a recognized component of the pan-vasculitis seen in this condition. **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing). Smoking cessation is the only way to halt disease progression. * **Demographics:** Classically seen in young males (<45 years). * **Angiographic Sign:** "Corkscrew collaterals" (Martorell’s sign) around areas of occlusion. * **Pathology:** Characterized by **microabscesses** within the thrombus, surrounded by multinucleated giant cells. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries.

Q: Lymphoedema is due to all except?

Increased lymphatic contractility. **Explanation:** Lymphedema is a chronic condition characterized by the accumulation of protein-rich interstitial fluid due to a failure of the lymphatic drainage system. **Why Option A is the correct answer:** In lymphedema, there is a **decrease** in lymphatic contractility, not an increase. As the disease progresses, the lymphatic vessels (lymphangions) become dilated and the smooth muscle in their walls undergoes fatigue and eventual atrophy. This leads to ineffective pumping and stasis of lymph fluid. Therefore, "Increased lymphatic contractility" is the exception. **Analysis of other options:** * **B. Lymphatic obliteration by infection:** This is a classic cause of secondary lymphedema. Recurrent infections (like cellulitis) or parasitic infestations (like *Wuchereria bancrofti* in Filariasis) cause inflammation and fibrosis, physically blocking the lymph channels. * **C. Increased collagen formation:** Chronic lymphostasis triggers an inflammatory response. This stimulates fibroblasts, leading to excessive collagen deposition and **subcutaneous fibrosis** (non-pitting edema), a hallmark of late-stage lymphedema. * **D. Lymphatic valvular insufficiency:** As lymph vessels dilate due to proximal obstruction or congenital weakness, the valves become incompetent. This leads to the backflow (reflux) of lymph, further worsening the edema. **NEET-PG High-Yield Pearls:** * **Most common cause worldwide:** Filariasis (*Wuchereria bancrofti*). * **Most common cause in developed countries:** Post-mastectomy (axillary lymph node dissection) for breast cancer. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; it is a pathognomonic clinical sign of lymphedema. * **Stewart-Treves Syndrome:** A rare, highly aggressive angiosarcoma arising in a limb with chronic lymphedema.

Q: Milroy's disease is characterized by which of the following?

Congenital lymphedema. **Explanation:** Milroy’s disease is a specific form of **Primary Lymphedema**, classified as **Lymphedema Congenita**. It is an autosomal dominant condition typically caused by a mutation in the **FLT4 gene**, which encodes the Vascular Endothelial Growth Factor Receptor-3 (VEGFR-3). This mutation leads to the hypoplasia or failure of development of lymphatic vessels. **Why the correct answer is right:** * **Option C:** Milroy’s disease is defined by the presence of lymphedema at birth or within the first year of life. It typically presents as bilateral, non-pitting edema of the lower limbs and is the classic example of congenital primary lymphedema. **Why the other options are wrong:** * **Option A & B:** These represent **Secondary Lymphedema**. Filariasis (caused by *Wuchereria bancrofti*) is the most common cause of secondary lymphedema worldwide, while post-cellulitic edema occurs due to lymphatic destruction following recurrent infections. * **Option D:** This is also a form of secondary lymphedema, commonly seen after radical lymph node dissections (e.g., post-mastectomy lymphedema). **High-Yield Clinical Pearls for NEET-PG:** * **Classification by Age of Onset:** * **Lymphedema Congenita:** Present at birth (e.g., Milroy’s Disease). * **Lymphedema Praecox:** Most common primary type; appears during puberty/before age 35 (e.g., **Meige’s Disease**). * **Lymphedema Tarda:** Appears after age 35. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe; a pathognomonic clinical sign for lymphedema. * **Imaging:** **Lymphoscintigraphy** is the gold standard investigation for evaluating the lymphatic system.

Q: What is the most common site of lymphangiosarcoma?

Post-mastectomy edema of arm. **Explanation:** **Lymphangiosarcoma** is a rare, highly aggressive malignant tumor arising from the endothelial lining of lymphatic vessels. **Why Option C is correct:** The most common clinical setting for lymphangiosarcoma is chronic, long-standing lymphedema. Specifically, it is most frequently associated with **Stewart-Treves Syndrome**. This syndrome refers to the development of lymphangiosarcoma in an arm affected by chronic lymphedema following a radical mastectomy with axillary lymph node dissection (usually for breast cancer). The tumor typically appears 10–20 years after the initial surgery as persistent cutaneous nodules or purple-red patches. **Why other options are incorrect:** * **A & B (Liver and Spleen):** While primary angiosarcomas can occur in the liver (often associated with vinyl chloride or thorotrast exposure) and the spleen, these are blood vessel malignancies (hemangiosarcomas), not primary lymphangiosarcomas. * **D (Retroperitoneum):** This is a common site for other sarcomas (like liposarcoma or leiomyosarcoma), but it is an extremely rare site for primary lymphangiosarcoma. **High-Yield Clinical Pearls for NEET-PG:** * **Stewart-Treves Syndrome:** Classic triad = Post-mastectomy + Chronic Lymphedema + Lymphangiosarcoma. * **Latent Period:** Usually occurs **10 years** or more after surgery. * **Clinical Presentation:** Look for "bruise-like" lesions or purple subcutaneous nodules on a lymphedematous limb that do not resolve. * **Prognosis:** Extremely poor due to early hematogenous metastasis (most commonly to the lungs). * **Treatment:** Radical amputation of the limb is often required, but survival rates remain low.

Question 1

An 85-year-old gentleman complains of leg pain while lying down, which lessens when he hangs the foot out of bed. What is the most likely cause?

Accepted Answer

Peripheral vascular disease

Answer

Psychiatric illness

Answer

L4-L5 disc prolapse

Answer

Osteoarthritis of the knee

Question 2

Which of the following is NOT indicated for an arterial leg ulcer?

Accepted Answer

Elevation of the limb

Answer

Debridement

Answer

Head end of the bed raised

Answer

Low-dose aspirin

Question 3

What accounts for this patient's hand pain?

Accepted Answer

Radial artery thrombosis

Answer

Ulnar artery occlusion

Answer

Wrist fracture

Answer

Carpal tunnel syndrome

Question 4

Bilateral pulseless disease in upper limbs is caused by which of the following conditions?

Accepted Answer

Takayasu arteritis

Answer

Coarctation of aorta

Answer

Fibromuscular dysplasia

Answer

Buerger's disease

Question 5

Buerger's disease usually affects all of the following except:

Accepted Answer

Large arteries

Answer

Medium sized arteries

Answer

Deep veins

Answer

Small sized arteries

Question 6

Which of the following does NOT cause lymphoedema?

Accepted Answer

Lymphogranuloma venereum

Answer

Syphilis

Answer

Tuberculosis

Answer

Filariasis

Question 7

Lymphoedema is due to all except?

Accepted Answer

Increased lymphatic contractility

Answer

Lymphatic obliteration by infection

Answer

Increased collagen formation in subcutaneous tissue

Answer

Lymphatic valvular insufficiency

Question 8

A 55-year-old man suffers from an acute myocardial infarction after occlusion of the left anterior descending coronary artery. The patient undergoes coronary bypass surgery 3 days later. Which of the following is the most frequent cause of saphenous vein graft failure several years following coronary bypass surgery?

Accepted Answer

Atherosclerosis

Answer

Acute inflammation

Answer

Graft-versus-host disease

Answer

Metastatic calcification

Question 9

Milroy's disease is characterized by which of the following?

Accepted Answer

Congenital lymphedema

Answer

Edema due to filariasis

Answer

Post-cellulitic lymphedema

Answer

Lymphedema following surgery

Question 10

What is the most common site of lymphangiosarcoma?

Accepted Answer

Post-mastectomy edema of arm

Answer

Liver

Answer

Spleen

Answer

Retroperitoneum

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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