Vascular Surgery Practice Questions

Q: Which of the following treatments would you recommend for this patient?

Compression stockings. ***Compression stockings*** - **Compression therapy** is the cornerstone treatment for **chronic venous insufficiency** and **venous leg ulcers**, improving venous return and reducing edema. - **Graduated compression** (30-40 mmHg) promotes wound healing by reducing **venous hypertension** and improving tissue oxygenation. *Topical antibiotic ointment* - Not indicated for **uncomplicated venous ulcers** as they are typically not infected and may lead to **antibiotic resistance**. - Can cause **contact dermatitis** and **sensitization** in patients with chronic wounds and compromised skin barrier. *Apply hydrogen peroxide* - **Cytotoxic** to healthy tissue and **impairs wound healing** by damaging fibroblasts and granulation tissue. - Creates **oxygen radicals** that can delay epithelialization and worsen the wound bed environment. *Oral antibiotics* - Only indicated if there are **clinical signs of infection** (increased pain, purulent discharge, erythema, warmth). - **Inappropriate** for clean venous ulcers as it promotes **antibiotic resistance** without addressing the underlying **venous pathophysiology**.

Q: Burger disease is:

Thromboangiitis obliterans. **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. It is strongly associated with heavy tobacco use. The pathology involves a highly cellular "inflammatory thrombus" with relative sparing of the blood vessel wall, eventually leading to ischemia, claudication, and gangrene. **Analysis of Options:** * **Option B (Correct):** Thromboangiitis obliterans is the synonymous medical term for Buerger’s disease. It reflects the core pathology: inflammation (angiitis) and resulting clot formation (thrombo) that leads to vessel blockage (obliterans). * **Option A:** While **Migratory Thrombophlebitis** (Trousseau sign) is often associated with visceral malignancies (like pancreatic cancer), it can occur in about 40% of Buerger’s patients. However, it is a *feature* of the disease, not the definition of the disease itself. * **Option C:** Superficial thrombophlebitis is inflammation of a vein near the surface of the skin. While it occurs in Buerger’s, it is a non-specific finding seen in many other conditions (e.g., varicose veins). * **Option D:** Causalgia (Complex Regional Pain Syndrome Type II) is a chronic pain condition following nerve injury; it is unrelated to the primary vasculitis of TAO. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Typically affects young males (<45 years) who are heavy smokers. * **Triad:** Claudication (instep/arch of foot), Raynaud’s phenomenon, and Migratory superficial thrombophlebitis. * **Angiography Finding:** "Corkscrew collaterals" (Martorell’s sign) due to distal vessel occlusion. * **Gold Standard Treatment:** Absolute smoking cessation (the only way to halt disease progression). * **Pathology:** Presence of **Microabscesses** within the thrombus surrounded by multinucleated giant cells.

Q: All of the following are clinical features of thromboangiitis obliterans except?

Absence of popliteal pulse. **Explanation:** **Thromboangiitis Obliterans (Buerger’s Disease)** is a non-atherosclerotic, segmental, inflammatory disease that primarily affects **small and medium-sized arteries and veins** of the distal extremities (hands and feet). **Why Option A is the Correct Answer:** Buerger’s disease characteristically involves the distal vessels (e.g., radial, ulnar, tibial, and peroneal arteries). Proximal pulses, such as the **femoral and popliteal pulses, are typically preserved** and remain normal. If the popliteal pulse is absent, the diagnosis is more likely to be Atherosclerosis Obliterans rather than Buerger’s disease. **Analysis of Other Options:** * **B. Superficial migratory thrombophlebitis:** This is a classic hallmark of Buerger’s disease (seen in ~40% of cases). It manifests as tender, nodular cords in the superficial veins that resolve in one area and reappear in another. * **C. Raynaud’s phenomenon:** This occurs in approximately 40% of patients due to the involvement of digital arteries and heightened sympathetic sensitivity. * **D. Claudication of arteries:** Patients frequently present with instep (foot) claudication or calf claudication due to ischemia of the distal muscle groups. **NEET-PG High-Yield Pearls:** * **Strongest Risk Factor:** Heavy tobacco use (smoking or chewing). * **Demographics:** Typically young males (<45 years). * **Angiographic Finding:** "Corkscrew collaterals" (Martorell’s sign) around the site of occlusion. * **Allen’s Test:** Often positive, indicating distal ulnar or radial artery occlusion. * **Pathology:** Characterized by a "highly cellular thrombus" with microabscesses, but the internal elastic lamina remains intact (unlike atherosclerosis). * **Management:** Absolute smoking cessation is the only way to halt disease progression.

Q: Perforators are not present at which location?

Below inguinal ligament. **Explanation:** Perforating veins are essential vascular structures that connect the superficial venous system to the deep venous system by piercing the deep fascia. The flow is normally directed from the superficial to the deep system, aided by the calf muscle pump. **Why "Below inguinal ligament" is the correct answer:** The inguinal ligament marks the region of the **Saphenofemoral Junction (SFJ)**. While the Great Saphenous Vein joins the Common Femoral Vein here, this is considered a **terminal junction**, not a "perforator." Anatomically, there are no significant named perforators located immediately below the inguinal ligament. Perforators are primarily concentrated in the lower leg and mid-thigh where the muscle pump mechanism is most active. **Analysis of incorrect options:** * **Ankle:** This area contains the **Kockett’s perforators** (Lower, Middle, and Upper), which connect the posterior arch vein to the deep veins. They are the most common site for primary valvular incompetence leading to venous ulcers. * **Medial Calf:** This region houses the **Boyd’s perforators**, located just below the knee, connecting the Great Saphenous Vein to the Tibial veins. * **Distal to Calf:** This area includes the **Sherman’s** and **24-cm perforators**, which are vital components of the venous drainage system in the lower leg. **High-Yield Clinical Pearls for NEET-PG:** 1. **Hunterian Perforator:** Located in the proximal 1/3rd of the thigh (adductor canal). 2. **Dodd’s Perforator:** Located in the distal 1/3rd of the thigh. 3. **Cockett’s Perforators:** Most clinically significant for the development of "Gaiter Zone" changes and venous ulcers. 4. **Direction of Flow:** In health, flow is **Superficial → Deep**. In varicose veins (incompetent perforators), the flow becomes **Deep → Superficial** (high-pressure leak).

Q: Fogarty's catheter is used for?

Removal of blood clots from the arteries. **Explanation:** **Fogarty’s catheter** is a specialized embolectomy catheter primarily used for the **removal of blood clots (emboli or thrombi) from the arterial system**. It consists of a thin, hollow tube with an inflatable balloon at the tip. During a procedure (embolectomy), the catheter is passed beyond the clot, the balloon is inflated, and the catheter is withdrawn, effectively "dragging" the clot out of the vessel to restore distal blood flow. **Analysis of Options:** * **Option B (Correct):** This is the classic use of the Fogarty catheter in vascular surgery to treat acute limb ischemia. * **Option A & C (Incorrect):** Urethral catheterization and bladder drainage typically utilize **Foley catheters** (for indwelling drainage) or **Robinson/Nelaton catheters** (for straight drainage). While both Foley and Fogarty catheters have balloons, the Fogarty is much thinner and designed for vascular lumens, not the urinary tract. * **Option D (Incorrect):** Total Parenteral Nutrition (TPN) requires central venous access via specialized catheters like **Hickman, Broviac, or PICC lines**, which are designed for long-term infusion rather than mechanical clot removal. **High-Yield Clinical Pearls for NEET-PG:** * **Inventor:** Developed by Dr. Thomas J. Fogarty in 1961; it revolutionized vascular surgery. * **Sizing:** Fogarty catheters are sized in **French (F)** units (e.g., 2F to 7F). A common rule of thumb: the French size divided by 3 equals the diameter in millimeters. * **Balloon Inflation:** The balloon should always be inflated with **saline or air** (as per manufacturer) and never over-inflated to avoid arterial rupture or intimal damage. * **Other Uses:** Occasionally used in biliary surgery (to remove gallstones from the common bile duct) or to remove foreign bodies from the airway/esophagus.

Q: In Deep Venous Thrombosis (DVT), which of the following findings is typically NOT seen?

High fever. **Explanation:** Deep Venous Thrombosis (DVT) is characterized by the formation of a blood clot within the deep veins, most commonly in the lower limbs. The clinical presentation is primarily driven by venous obstruction and a localized inflammatory response. **Why High Fever is the Correct Answer:** While a **low-grade fever** (mild pyrexia) can occur due to the inflammatory process associated with thrombus formation, a **high-grade fever** is typically absent. If a patient presents with a high fever, clinicians should suspect alternative diagnoses such as cellulitis or an infected thrombus (septic thrombophlebitis). **Analysis of Incorrect Options:** * **Pain (C) and Tenderness (D):** These are the most common presenting symptoms. Pain results from the distension of the vein wall and perivascular inflammation. Tenderness is usually localized over the course of the involved deep vein (e.g., the calf or thigh). * **Increased Local Skin Temperature (B):** Venous congestion leads to pooling of blood and localized inflammation, which manifests as warmth (calor) and erythema at the affected site. **Clinical Pearls for NEET-PG:** * **Virchow’s Triad:** The three factors contributing to DVT are Stasis, Hypercoagulability, and Endothelial injury. * **Homan’s Sign:** Pain in the calf on dorsiflexion of the foot. Though classic, it is non-specific and potentially dangerous (risk of dislodging a clot). * **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 (highly sensitive and specific). * **Phlegmasia Cerulea Dolens:** A limb-threatening complication of DVT characterized by massive edema, cyanosis, and severe pain.

Q: What is the most common cause of lymphedema?

Filariasis. **Explanation:** Lymphedema is the accumulation of protein-rich fluid in the interstitial space due to impaired lymphatic drainage. It is classified into primary (congenital) and secondary (acquired) causes. **Why Filariasis is correct:** Globally, **Filariasis** (caused by *Wuchereria bancrofti*) is the **most common cause of secondary lymphedema**. The adult worms reside in the lymphatic vessels, causing chronic inflammation, fibrosis, and eventual permanent obstruction. This leads to the characteristic "elephantiasis," primarily affecting the lower extremities and scrotum. **Analysis of Incorrect Options:** * **B. Lymph node dissection:** This is the most common cause of secondary lymphedema in **developed countries** (specifically post-mastectomy with axillary clearance for breast cancer). However, on a global scale, filariasis remains more prevalent. * **C. Bacterial infection:** While recurrent cellulitis or lymphangitis can damage lymphatics and worsen existing lymphedema, they are usually secondary complications rather than the primary global cause. * **D. Congenital:** Primary lymphedema (e.g., Milroy’s disease, Meige’s disease) is rare, accounting for less than 10% of all cases. **High-Yield Clinical Pearls for NEET-PG:** * **Stemmer’s Sign:** Inability to pinch the skin on the dorsal surface of the second toe; a pathognomonic clinical sign of lymphedema. * **Stewart-Treves Syndrome:** A rare, highly aggressive **angiosarcoma** that develops in a limb with long-standing chronic lymphedema (most commonly post-mastectomy). * **Investigation of Choice:** **Lymphoscintigraphy** is the gold standard for evaluating the lymphatic system. * **Treatment:** The mainstay is **Complex Decongestive Therapy (CDT)**, which includes manual lymphatic drainage and compression bandaging. Surgical options like Lymphaticovenular anastomosis (LVA) are reserved for refractory cases.

Question 1

Which of the following treatments would you recommend for this patient?

Accepted Answer

Compression stockings

Answer

Topical antibiotic ointment

Answer

Apply hydrogen peroxide

Answer

Oral antibiotics

Question 2

Sympathectomy is indicated in all of the following conditions except?

Accepted Answer

Acrocyanosis

Answer

Ischaemic ulcers

Answer

Intermittent claudication

Answer

Anhidrosis

Question 3

Burger disease is:

Accepted Answer

Thromboangiitis obliterans

Answer

Migratory thrombophlebitis

Answer

Superficial thrombophlebitis

Answer

Causalgia

Question 4

All of the following are clinical features of thromboangiitis obliterans except?

Accepted Answer

Absence of popliteal pulse

Answer

Superficial migratory thrombophlebitis

Answer

Raynaud's phenomenon

Answer

Claudication of arteries

Question 5

Perforators are not present at which location?

Accepted Answer

Below inguinal ligament

Answer

Ankle

Answer

Medial calf

Answer

Distal to calf

Question 6

Fogarty's catheter is used for?

Accepted Answer

Removal of blood clots from the arteries

Answer

Urethral catheterization

Answer

Bladder drainage

Answer

Total Parenteral Nutrition (TPN)

Question 7

In Deep Venous Thrombosis (DVT), which of the following findings is typically NOT seen?

Accepted Answer

High fever

Answer

Increased local skin temperature at the affected site

Answer

Pain

Answer

Tenderness

Question 8

A 59-year-old woman, who had a left femoral venous thrombosis during a pregnancy 30 years ago and whose left greater saphenous vein had been stripped at age 21, presents with a large, non-healing ulceration over the medial left calf. The ulcer has continuously progressed despite bed rest, elevation, and the use of a support stocking. Descending phlebography of the left leg demonstrates a patent deep venous system with free flow of dye from the groin to the foot. The first profunda femoris valve is competent. What is the most appropriate management?

Accepted Answer

Division of the superficial femoral vein in the groin and transposition of its distal end onto the profunda femoris vein below the level of the competent profunda valve.

Answer

Saphenous venous crossover graft with anastomosis of the end of the right saphenous vein onto the side of the competent femoral vein.

Answer

Ligated iliofemoral venous thrombectomy with creation of a temporary arteriovenous fistula.

Answer

Subfascial ligation of perforating veins in the left calf.

Question 9

What is the most common cause of lymphedema?

Accepted Answer

Filariasis

Answer

Lymph node dissection in malignancies

Answer

Bacterial infection

Answer

Congenital

Question 10

What is the most common cause of death in patients with Buerger's disease?

Accepted Answer

Myocardial infarction

Answer

Gangrene

Answer

Pulmonary embolism

Answer

Carcinoma of the lung

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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