Vascular Surgery Practice Questions

Q: Which statement is NOT true regarding Buerger's disease?

Veins and nerves are never involved. **Explanation:** Buerger’s disease, also known as **Thromboangiitis Obliterans (TAO)**, is a non-atherosclerotic, segmental, inflammatory disease that affects small and medium-sized arteries and veins of the extremities. **Why Option D is the correct answer (The False Statement):** Contrary to the statement, Buerger’s disease is characterized by **panangiitis**, meaning it involves the entire neurovascular bundle. It affects not only the arteries but also the **veins** (presenting as migratory superficial thrombophlebitis in 40% of cases) and the **nerves** (leading to severe ischemic pain and paresthesia). The inflammation often leads to perivascular fibrosis, binding the artery, vein, and nerve together. **Analysis of Incorrect Options (True Statements):** * **Option A & B:** TAO typically affects **young males** (though incidence in females is rising) usually **below the age of 45-50**. * **Option C:** **Tobacco use** (smoking or chewing) is the most critical predisposing and aggravating factor. The disease progression is directly linked to continued tobacco exposure, and smoking cessation is the only way to halt the disease. **NEET-PG High-Yield Pearls:** * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign) due to vascular recanalization. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis). * **Clinical Triad:** Distal ischemia (claudication/ulcers), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Allen’s Test:** Often positive, indicating involvement of the radial or ulnar arteries.

Q: Artificially high readings of Ankle-Brachial Pressure Index (ABPI) can be caused by which of the following conditions?

Arteriosclerosis with calcified arteries. ### Explanation **1. Why Option A is Correct:** The Ankle-Brachial Pressure Index (ABPI) is calculated by dividing the systolic blood pressure at the ankle by the systolic blood pressure at the arm. In patients with **Arteriosclerosis with calcified arteries** (commonly seen in **Diabetes Mellitus** and **Chronic Kidney Disease**), the tunica media of the arterial wall becomes stiff and non-compressible. This is known as **Mönckeberg’s medial calcific sclerosis**. During ABPI measurement, the blood pressure cuff cannot easily compress these "pipe-stem" arteries. Consequently, an abnormally high pressure is required to occlude the vessel, leading to a falsely elevated ABPI reading (typically **>1.3 or 1.4**), which does not accurately reflect the actual perfusion pressure. **2. Why Other Options are Incorrect:** * **B & C (Ischemic Ulcers & Intermittent Claudication):** These are clinical manifestations of Peripheral Arterial Disease (PAD). In these conditions, arterial narrowing typically leads to a **decrease** in ankle systolic pressure, resulting in a **low ABPI** (usually <0.9). * **D (Deep Vein Thrombosis):** DVT is a pathology of the venous system. ABPI is a diagnostic tool specifically designed to evaluate the arterial system; DVT does not directly cause arterial wall calcification or falsely high arterial pressure readings. **3. Clinical Pearls for NEET-PG:** * **Normal ABPI Range:** 0.9 – 1.2. * **Critical Limb Ischemia:** Usually associated with an ABPI ** 1.3) due to calcification, the next best step is to perform a **Toe-Brachial Index (TBI)**, as digital arteries are less prone to medial calcification. * **High-Yield Association:** Falsely high ABPI = Diabetes Mellitus = Mönckeberg’s sclerosis.

Q: What is the earliest sign of deep vein thrombosis?

Calf tenderness. **Explanation:** Deep Vein Thrombosis (DVT) typically originates in the calf veins. Understanding the chronological progression of its clinical features is crucial for NEET-PG. **Why Calf Tenderness is the Correct Answer:** **Calf tenderness** is recognized as the **earliest clinical sign** of DVT. It occurs due to the acute inflammatory response triggered by the formation of a thrombus within the deep venous system. This inflammation irritates the surrounding tissues and vessel walls, leading to localized pain and tenderness upon palpation, often before significant venous obstruction or systemic symptoms develop. **Analysis of Incorrect Options:** * **Rise in temperature:** This is a systemic or localized inflammatory response that usually occurs after the initial thrombus formation and localized tenderness have manifested. * **Swelling of calf muscle:** Swelling (edema) is a result of significant venous outflow obstruction. It typically follows tenderness as the clot propagates or causes enough resistance to increase hydrostatic pressure. * **Homan’s sign:** Defined as pain in the calf on dorsiflexion of the foot. While classic, it is **neither sensitive nor specific** and is often a later finding. It is now discouraged in clinical practice as it may theoretically dislodge a clot, leading to pulmonary embolism. **Clinical Pearls for NEET-PG:** * **Moses Sign:** Pain on squeezing the calf muscles from side to side (earlier than Homan’s). * **Neuhof’s Sign:** Tenderness and "thickness" or lack of mobility of the calf muscles. * **Gold Standard Investigation:** Contrast Venography (rarely used now). * **Investigation of Choice:** Duplex Ultrasound (Color Doppler). * **Wells Criteria:** Used clinically to determine the pre-test probability of DVT.

Q: Varicose vein surgery is contraindicated in which of the following conditions?

Deep vein thrombosis. **Explanation:** The primary contraindication for varicose vein surgery is **Deep Vein Thrombosis (DVT)**. In patients with DVT, the deep venous system is obstructed or incompetent. Consequently, the superficial venous system (Great and Short Saphenous veins) acts as the **essential collateral pathway** for venous return from the lower limb. If these superficial veins are surgically removed or ablated, venous outflow is severely compromised, leading to acute venous congestion, severe edema, and potential phlegmasia cerulea dolens. Before any surgery, a **Perthes’ Test** or Duplex Scan must be performed to ensure the patency of the deep veins. **Analysis of Incorrect Options:** * **Varicose Ulcers (A) & Pigmentation (C):** These are features of Chronic Venous Insufficiency (CEAP classes C4 and C6). Rather than being contraindications, they are actually **strong indications** for surgery to reduce venous hypertension and promote healing. * **Hemorrhoids (D):** While both involve dilated veins, they occur in different anatomical sites (rectal vs. lower limb). The presence of hemorrhoids has no bearing on the surgical management of lower limb varicosities. **High-Yield Clinical Pearls for NEET-PG:** * **Absolute Contraindications:** Active DVT, pregnancy (due to hormonal changes and pelvic pressure), and severe peripheral arterial disease (ABI < 0.5). * **Gold Standard Investigation:** Duplex Ultrasound (to assess reflux and deep system patency). * **Trendelenburg Test:** Used to differentiate between saphenofemoral incompetence and perforator incompetence. * **Brodie-Trendelenburg Formula:** "Singly positive" means SFJ incompetence only; "Doubly positive" means both SFJ and perforator incompetence.

Q: What does Grade 1 lymphedema signify?

Edema that disappears after overnight rest. Lymphedema is classified based on the severity of lymphatic dysfunction and the resulting tissue changes. The grading system (often referred to as the **International Society of Lymphology (ISL) Stages**) is a high-yield topic for NEET-PG. ### **Explanation of the Correct Answer** **Grade 1 (Stage I) Lymphedema** is characterized by **reversible edema**. At this stage, the protein-rich fluid has accumulated, but there is no significant tissue fibrosis. The hallmark of this stage is that the swelling is **pitting** in nature and, most importantly, **disappears or significantly reduces with limb elevation or overnight rest**. ### **Analysis of Incorrect Options** * **Options A & B (Pitting up to ankle/knee):** These describe the *anatomical extent* of edema rather than the *grade*. Grading is determined by the pathophysiology of the tissue (reversibility and fibrosis) rather than just the height of the swelling. * **Option C (Non-pitting edema):** This signifies **Grade 2 (Stage II)** or **Grade 3 (Stage III)** [1]. In these later stages, chronic inflammation leads to the deposition of connective tissue and fat (fibrosis). Because the tissue becomes "hardened," it no longer pits when pressure is applied [1]. ### **Clinical Pearls for NEET-PG** * **Stage 0 (Latent):** Impaired lymph transport exists, but no visible edema is present. * **Stage I (Spontaneously Reversible):** Pitting edema; subsides with elevation [2]. * **Stage II (Spontaneously Irreversible):** Non-pitting edema; significant fibrosis; does not resolve with elevation [1][2]. * **Stage III (Lymphostatic Elephantiasis):** Severe non-pitting edema with trophic skin changes (acanthosis, warty overgrowths, and thickening) [1]. * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the base of the second toe. A positive sign is diagnostic of lymphedema.

Q: Which type of catheter is used for the removal of an embolus from blood vessels?

Removal of embolus from blood vessels. The question refers to the **Fogarty Catheter**, which is a specialized balloon-tipped catheter designed specifically for arterial embolectomy. ### **Explanation of the Correct Answer** The **Fogarty catheter** (Option C) is the gold standard for removing an embolus or thrombus from the vascular system. It is inserted past the site of the clot; the balloon is then inflated and the catheter is withdrawn, effectively "dragging" the embolus out of the vessel. This procedure is a critical intervention in cases of acute limb ischemia. ### **Analysis of Incorrect Options** * **Option A (Drainage of the urinary bladder):** This is typically performed using a **Foley catheter** (indwelling) or a **Nelaton catheter** (straight drainage). While these also use balloons for retention, they are not designed for endovascular use. * **Option B (Parenteral hyperalimentation):** This requires central venous access, usually via a **Central Venous Catheter (CVC)** or a **PICC line**, to deliver high-osmolarity nutrient solutions directly into the superior vena cava. * **Option C (Ureteric catheterization):** This involves the use of **Double-J (DJ) stents** or simple ureteric catheters to bypass obstructions or provide a template for healing. ### **High-Yield Clinical Pearls for NEET-PG** * **Inventor:** Thomas J. Fogarty (1963). * **Mechanism:** It is a "blind" procedure usually done under local anesthesia. * **Size:** Measured in **French (F)**; common sizes range from 2F to 7F. * **Complications:** Intimal injury, vessel perforation, or distal embolization of fragments. * **Key Identification:** Look for a thin, flexible catheter with a small, high-pressure balloon at the tip in surgical instrument images.

Q: A male patient presented with progressive swelling of the upper limb. Examination reveals proximal limb swelling that is non-pitting, with thickened overlying skin. What is the next best step in the management of this patient?

Night blood test for worms. ### Explanation **1. Why "Night blood test for worms" is correct:** The clinical presentation of progressive, non-pitting edema with skin thickening (hyperkeratosis/elephantiasis) in the upper limb is characteristic of **Lymphatic Filariasis**, most commonly caused by *Wuchereria bancrofti*. In endemic regions like India, this is the most frequent cause of secondary lymphedema. The definitive diagnosis relies on demonstrating microfilariae in the peripheral blood. Since these parasites exhibit **nocturnal periodicity** (circulating in the blood between 10 PM and 2 AM), a night blood smear is the gold standard initial diagnostic step to confirm active infection. **2. Why other options are incorrect:** * **PCR:** While highly sensitive, it is expensive and not the standard "next best step" in a clinical setting compared to the cost-effective and traditional smear. * **X-Ray:** This has limited utility in lymphedema. It may show soft tissue thickening or "calcified worms" in chronic cases, but it does not aid in active diagnosis. * **Lymphoscintigraphy:** This is the **gold standard investigation for assessing lymphatic flow** and structural anatomy. However, it is usually reserved for cases where the diagnosis is unclear or when surgical intervention (like lymphovenous anastomosis) is planned. It does not identify the underlying parasitic cause. **3. Clinical Pearls for NEET-PG:** * **Most common cause of Lymphedema (Global):** Filariasis. * **Most common cause of Lymphedema (Developed countries):** Post-mastectomy/axillary lymph node dissection. * **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. * **Milroy’s Disease:** Congenital lymphedema (present at birth) due to VEGFR-3 mutation. * **Drug of Choice:** Diethylcarbamazine (DEC) 6mg/kg for 12 days.

Question 1

Stenosis of which of the following vessels is associated with the highest patency rates following angioplasty or stenting?

Accepted Answer

Iliac artery

Answer

Medial circumflex artery

Answer

Superficial femoral artery

Answer

Popliteal artery

Question 2

Which statement is NOT true regarding Buerger's disease?

Accepted Answer

Veins and nerves are never involved

Answer

Men are usually involved

Answer

Occurs below 50 years of age

Answer

Smoking is a predisposing factor

Question 3

Deep vein thrombosis is seen in all except one?

Accepted Answer

Subungual melanoma

Answer

Prolonged immobilization

Answer

Pregnancy

Answer

Major surgical operation

Question 4

Artificially high readings of Ankle-Brachial Pressure Index (ABPI) can be caused by which of the following conditions?

Accepted Answer

Arteriosclerosis with calcified arteries

Answer

Ischemic ulcers

Answer

Intermittent claudication

Answer

Deep Vein Thrombosis

Question 5

What is the earliest sign of deep vein thrombosis?

Accepted Answer

Calf tenderness

Answer

Rise in temperature

Answer

Swelling of calf muscle

Answer

Homan's sign

Question 6

Varicose vein surgery is contraindicated in which of the following conditions?

Accepted Answer

Deep vein thrombosis

Answer

Varicose ulcers

Answer

Pigmentation over the limb

Answer

Hemorrhoids

Question 7

What does Grade 1 lymphedema signify?

Accepted Answer

Edema that disappears after overnight rest

Answer

Pitting edema up to the ankle

Answer

Pitting edema up to the knee

Answer

Non-pitting edema

Question 8

Which type of catheter is used for the removal of an embolus from blood vessels?

Accepted Answer

Removal of embolus from blood vessels

Answer

Drainage of the urinary bladder

Answer

Parenteral hyperalimentation

Answer

Ureteric catheterization

Question 9

A male patient presented with progressive swelling of the upper limb. Examination reveals proximal limb swelling that is non-pitting, with thickened overlying skin. What is the next best step in the management of this patient?

Accepted Answer

Night blood test for worms

Answer

PCR

Answer

X-Ray

Answer

Lymphoscintigraphy

Question 10

In the immediate post-operative period, an increase in D-dimer levels is most commonly noticed due to which of the following?

Accepted Answer

Deep vein thrombosis

Answer

Pulmonary embolism

Answer

Disseminated intravascular coagulation

Answer

Normal physiological response

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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