Vascular Surgery Practice Questions

Q: A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?

Arteriovenous fistula. ### Explanation The clinical presentation of **local gigantism** (limb hypertrophy) combined with **pulsatile veins** is a classic hallmark of a **Congenital Arteriovenous (AV) Fistula**. **1. Why Arteriovenous Fistula is correct:** An AV fistula is an abnormal communication between an artery and a vein, bypassing the capillary bed. * **Local Gigantism:** If the fistula is present before the fusion of epiphyses (congenital), the increased blood flow and venous congestion stimulate the periosteum and growth plates, leading to limb lengthening and soft tissue hypertrophy. * **Pulsatile Veins:** High-pressure arterial blood is shunted directly into the low-pressure venous system. This causes the veins to become dilated, tortuous, and exhibit visible pulsations (arterialization of veins). **2. Why the other options are incorrect:** * **Varicose Veins:** While veins are dilated, they are caused by valvular incompetence, not arterial shunting. They do not pulsate and do not cause bony overgrowth or limb gigantism. * **Buerger Disease (Thromboangiitis Obliterans):** This is an occlusive inflammatory disease of small and medium-sized arteries. It typically presents with ischemia, rest pain, and gangrene, rather than limb hypertrophy or venous pulsations. * **Tumour:** While some vascular tumors (like hemangiomas) can cause localized swelling, they do not typically present with generalized limb gigantism and widespread pulsatile venous systems. **Clinical Pearls for NEET-PG:** * **Nicoladoni-Branham Sign:** Bradycardia occurs upon manual compression of the AV fistula (due to a sudden increase in peripheral resistance and vagal reflex). * **Machinery Murmur:** A continuous bruit (heard throughout systole and diastole) is often audible over the site of the fistula. * **Complications:** Long-standing large AV fistulae can lead to **high-output heart failure** due to increased venous return.

Q: Which of the following tests is used to diagnose varicose veins?

All of the above. To diagnose varicose veins and assess the underlying pathophysiology (venous insufficiency), a series of clinical tests are performed to evaluate the competency of valves and the site of reflux. **Explanation of Options:** * **A. Cough-impulse test (Morrissey’s Test):** This test evaluates **Saphenofemoral Junction (SFJ) incompetency**. When the patient coughs, an impulse or thrill is felt over the SFJ (located 2.5 cm below and lateral to the pubic tubercle) due to the retrograde flow of blood through incompetent valves. * **B. Trendelenburg test:** This is the gold standard clinical test to differentiate between **SFJ incompetency** and **perforator incompetency**. * *Trendelenburg I:* Assesses SFJ competency by observing rapid filling from above when the tourniquet is released. * *Trendelenburg II:* Assesses perforator competency by observing filling from below while the tourniquet is still applied. * **C. Schwartz test (Tap test):** This test confirms the presence of a continuous column of blood in a varicose vein. When the lower part of the vein is tapped, an impulse is felt by the palpating hand at the proximal end, indicating **incompetent valves** between the two points. **Conclusion:** Since all three tests are standard clinical bedside methods to diagnose and localize the site of valvular reflux in varicose veins, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Perthes Test:** Used to check the patency of the **Deep Venous System**. If pain increases or varicosities bulge during walking with a tourniquet, it indicates deep vein occlusion (a contraindication for surgery). * **Fegan’s Test:** Used to identify the exact site of **incompetent perforators** by palpating "blow-outs" or gaps in the deep fascia. * **Gold Standard Investigation:** While clinical tests are high-yield for exams, **Duplex Ultrasound** is the investigation of choice in modern practice.

Q: A 74-year-old female was diagnosed with rheumatic heart disease and underwent valve replacement surgery. A few days later, she started to complain of numbness and inability to move her left leg. Femoral, popliteal, and pedal impulses were not felt on the left side, but the right side examination of the lower leg was normal. What is the most appropriate management in this patient?

Embolectomy of the left femoral artery. ### Explanation This patient presents with the classic **"6 Ps"** of **Acute Limb Ischemia (ALI)**: Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Given her history of rheumatic heart disease and recent valve surgery, the most likely diagnosis is an **arterial embolism** (likely originating from the heart). #### 1. Why Embolectomy is Correct In a patient with clear clinical signs of acute limb ischemia (numbness, paralysis, and absent pulses), the limb is threatened. **Immediate surgical intervention** is required to restore blood flow and prevent permanent tissue loss or amputation. **Fogarty catheter embolectomy** of the femoral artery is the gold standard treatment for an acute embolic occlusion. In such emergencies, clinical diagnosis is sufficient to proceed directly to the operating room without delaying for imaging. #### 2. Why Other Options are Incorrect * **A, C, & D (Imaging - CT Angiogram/Duplex):** While these are useful diagnostic tools for chronic ischemia or stable cases, they cause **unnecessary delay** in a patient with neurological deficits (paralysis/numbness). In ALI, "time is muscle." Imaging should only be performed if the diagnosis is in doubt or if the limb is currently viable (Rutherford Grade I). #### 3. Clinical Pearls for NEET-PG * **Most common source of emboli:** Left Atrium (due to Atrial Fibrillation) or prosthetic heart valves. * **Most common site of embolus lodgment:** Femoral artery bifurcation (followed by iliac and popliteal arteries). * **Rutherford Classification:** If a patient has "Paralysis" and "Sensory loss," it is classified as **Rutherford IIb (Immediately Threatened)**, requiring urgent surgery. * **Gold Standard Treatment:** Fogarty embolectomy catheter. * **Initial Medical Step:** Once ALI is suspected, immediate anticoagulation with **IV Heparin** should be started to prevent clot propagation while preparing for surgery.

Q: A patient presents with heaviness of the leg and visible veins of diameter less than 1mm over the posterior aspect of the calf. According to the CEAP classification, what category does this presentation fall under?

C1. **Explanation:** The **CEAP classification** is the international standard for describing chronic venous disorders. The "C" component (Clinical signs) ranges from C0 to C6 based on the severity of visible manifestations. **Why C1 is the correct answer:** The patient presents with visible veins of **diameter less than 1 mm**. In the CEAP system: * **Telangiectasias (Spider veins):** Confluence of dilated intradermal venules with a diameter **< 1 mm**. * **Reticular veins:** Dilated bluish subdermal veins, usually **1 mm to 3 mm** in diameter. Both telangiectasias and reticular veins are categorized under **C1**. **Analysis of Incorrect Options:** * **C0:** No visible or palpable signs of venous disease (though the patient may have symptoms like heaviness). * **C2:** **Varicose veins**, defined as subcutaneous dilated veins **≥ 3 mm** in diameter. * **C3:** Presence of **Edema** (typically pitting) of venous origin at the ankle or leg. **High-Yield Clinical Pearls for NEET-PG:** * **C4:** Skin changes (C4a: Pigmentation/Eczema; C4b: Lipodermatosclerosis/Atrophie blanche). * **C5:** Healed venous ulcer. * **C6:** **Active** venous ulcer (the most severe clinical stage). * **Gold Standard Investigation:** Duplex Ultrasound is the first-line investigation for chronic venous insufficiency to assess reflux and anatomy. * **Trendelenburg Test:** Used clinically to differentiate between saphenofemoral incompetence and perforator incompetence.

Q: Which statement is true regarding the Trendelenburg operation for varicose veins?

Flush ligation of the superficial varicose vein. ### Explanation The **Trendelenburg operation**, also known as **Juxtafemoral Flush Ligation**, is a classic surgical procedure for varicose veins caused by **Saphenofemoral Junction (SFJ) incompetence**. **1. Why Option B is Correct:** The core principle of the Trendelenburg operation is the **flush ligation** of the Great Saphenous Vein (GSV) at its confluence with the Common Femoral Vein. To prevent recurrence through collateral circulation, all tributaries at the SFJ (Superficial circumflex iliac, Superficial epigastric, Superficial external pudendal, Deep external pudendal, and Postero-medial/Antero-lateral thigh veins) must also be divided. Ligation must be "flush" to ensure no stump is left behind, as a stump can lead to the development of recurrent varicosities (neovascularization). **2. Why Other Options are Incorrect:** * **Option A:** Stripping of the vein (Babcock’s procedure) is often performed *in addition* to the Trendelenburg operation to remove the refluxing GSV trunk, but the Trendelenburg operation itself refers specifically to the ligation at the SFJ. * **Option C:** Ligation of perforators is known as **Cockett and Dodd’s operation** (subfascial ligation). It addresses incompetent communicating veins rather than the SFJ. * **Option D:** Ligation of distal tributaries is ineffective if the proximal SFJ incompetence is not addressed, as the high-pressure reflux from the deep system would persist. **Clinical Pearls for NEET-PG:** * **Trendelenburg Test:** Used to differentiate between SFJ incompetence and perforator incompetence. * **Gold Standard:** While the Trendelenburg operation is historically significant, **Endovenous Thermal Ablation (EVLA/RFA)** is now the first-line treatment for GSV reflux. * **Complication:** The most common nerve injured during GSV stripping is the **Saphenous nerve** (at the ankle/mid-calf).

Q: Which of the following is NOT a preferred site for planning vascular access for maintenance hemodialysis?

Saphenofemoral fistula. **Explanation:** The primary goal of vascular access for maintenance hemodialysis is to provide a durable, high-flow system with minimal complications. The **Saphenofemoral fistula** (Option D) is **NOT** a preferred site because lower limb accesses are associated with significantly higher rates of infection, thrombosis, and limb-threatening ischemia compared to upper limb sites. Furthermore, their proximity to the groin increases the risk of surgical site contamination. **Analysis of Options:** * **A. Nondominant extremity:** This is preferred to preserve the patient's quality of life and functionality of their dominant hand during the hours spent in dialysis sessions. * **B. Upper limb:** The upper limb is the gold standard site for access. It has lower infection rates and better patency compared to the lower limb or central venous catheters. * **C. Radiocephalic AV fistula (Brescia-Cimino):** This is the **first-choice** access site. It is the most distal possible site, which preserves proximal veins for future use and has the lowest complication rate. **Clinical Pearls for NEET-PG:** * **Order of preference for AV Fistula (AVF):** Radiocephalic (distal) > Brachiocephalic (proximal) > Brachiobasilic (transposition). * **Rule of 6s for Maturation:** A fistula is ready when it has a flow of >600 mL/min, diameter >6 mm, and is <6 mm deep from the skin, usually evaluated at 6 weeks. * **Steal Syndrome:** A complication where blood is diverted away from the distal extremity; it is more common in proximal (brachial) fistulas than distal ones.

Q: What is the management of a case of iliac artery embolism?

Embolectomy. **Explanation:** The management of acute limb ischemia caused by an arterial embolism is a surgical emergency. The definitive treatment for an **iliac artery embolism** is an **Embolectomy**, typically performed using a **Fogarty balloon catheter**. **1. Why Embolectomy is Correct:** An embolism causes sudden, complete mechanical obstruction of the vessel. To salvage the limb and prevent irreversible gangrene, the clot must be physically removed to restore distal perfusion. For iliac involvement, a retrograde embolectomy is usually performed via a femoral artery incision (Fogarty technique). This is the gold standard for large-vessel acute embolic events. **2. Why Other Options are Incorrect:** * **Injection of vasodilators:** While they may help reduce associated vasospasm, they cannot bypass or dissolve a large mechanical obstruction like an iliac embolus. * **Hypotensive therapy:** This is contraindicated. Maintaining adequate systemic blood pressure is vital to encourage collateral circulation. Hypotension would worsen ischemia. * **Sympathectomy:** This procedure aims to increase skin blood flow in chronic peripheral vascular disease (Buerger’s disease). It has no role in the acute management of a major arterial embolism. **Clinical Pearls for NEET-PG:** * **The 6 P’s of Acute Ischemia:** Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (coldness). * **Fogarty Catheter:** The most important tool in embolectomy. It is usually inflated with saline or air. * **Time Window:** Irreversible muscle damage begins after **6 hours** of total ischemia. * **Source:** The most common source of an iliac embolus is the heart (Atrial Fibrillation or post-MI mural thrombus). * **Post-op:** Always monitor for **Reperfusion Injury** (Hyperkalemia, Myoglobinuria, and Compartment Syndrome).

Q: Cirsoid aneurysm affects which of the following arteries?

All of the above. **Explanation:** A **Cirsoid aneurysm** is not a true aneurysm but rather a rare, acquired **arteriovenous malformation (AVM)** or fistula occurring in the scalp. It consists of a direct communication between high-pressure arteries and low-pressure veins without an intervening capillary bed. **Why "All of the above" is correct:** The scalp is highly vascular, and these malformations are typically fed by the major branches of the external carotid artery. The **superficial temporal artery** is the most common feeder, but the **occipital artery** and **posterior auricular artery** are frequently involved, often simultaneously. Because these lesions are usually multi-pedicular (supplied by multiple vessels), all the listed arteries can be affected. **Clinical Features & High-Yield Facts:** * **Presentation:** It presents as a pulsatile, "worm-like" swelling under the scalp (hence the name *cirsoid*, meaning "varix-like"). * **Pathognomonic Signs:** Patients often complain of a persistent headache or a "bruit" (rushing sound) in the ear. On examination, a **palpable thrill** and an audible bruit are present. * **Diagnostic Clue:** The swelling characteristically empties on pressing the feeding vessels and refills rapidly upon release. * **Management:** Pre-operative angiography is essential to map the feeders. Treatment involves surgical excision or endovascular embolization. **NEET-PG Pearl:** While the **superficial temporal artery** is the *most common* single artery involved, in the context of a "Which of the following" question, remember that cirsoid aneurysms are typically **multi-arterial** involving any or all branches of the external carotid artery supplying the scalp.

Q: Chronic lymphoedema of a limb is predisposed to all of the following except?

Marjolin's ulcer. ### Explanation **Correct Answer: C. Marjolin's ulcer** **Why Marjolin’s Ulcer is the Correct Answer:** A **Marjolin’s ulcer** is a squamous cell carcinoma (SCC) that arises in areas of **chronic scarring, non-healing wounds, or burn scars**. While chronic lymphoedema involves chronic skin changes, it is not typically associated with the specific cicatrization (scarring) process that leads to a Marjolin’s ulcer. Therefore, it is the "except" in this list. **Analysis of Other Options:** * **A. Thickening of the skin:** Chronic lymphostasis leads to the accumulation of protein-rich fluid, which stimulates fibroblast proliferation. This results in **hyperkeratosis and brawny induration** (non-pitting edema), often progressing to *elephantiasis*. * **B. Recurrent soft tissue infections:** Lymphoedema impairs local immune surveillance. The protein-rich stagnant fluid acts as an excellent culture medium for bacteria, leading to frequent episodes of **cellulitis and lymphangitis** (often caused by *Streptococcus*). * **D. Sarcoma:** A dreaded complication of long-standing chronic lymphoedema is **Stewart-Treves Syndrome**, which is an **angiosarcoma** arising in the affected limb (most classically seen after radical mastectomy). **High-Yield NEET-PG Pearls:** * **Stewart-Treves Syndrome:** Usually occurs 10–15 years after a radical mastectomy. It presents as purple-red nodules on the skin. * **Stemmer’s Sign:** Inability to pinch a fold of skin at the base of the second toe; a pathognomonic clinical sign of lymphoedema. * **Marjolin’s Ulcer Key Fact:** It is most commonly a **well-differentiated Squamous Cell Carcinoma** and is known for being more aggressive than standard SCC. * **Investigation of Choice:** Lymphoscintigraphy is the gold standard for diagnosing the cause of lymphoedema.

Question 1

A patient presented with local gigantism of the leg and increased pulsations of the lower limb veins. What is the most probable diagnosis?

Accepted Answer

Arteriovenous fistula

Answer

Varicose veins

Answer

Buerger disease

Answer

Tumour

Question 2

Which of the following tests is used to diagnose varicose veins?

Accepted Answer

All of the above

Answer

Cough-impulse test

Answer

Trendelenburg test

Answer

Schwartz test

Question 3

A 74-year-old female was diagnosed with rheumatic heart disease and underwent valve replacement surgery. A few days later, she started to complain of numbness and inability to move her left leg. Femoral, popliteal, and pedal impulses were not felt on the left side, but the right side examination of the lower leg was normal. What is the most appropriate management in this patient?

Accepted Answer

Embolectomy of the left femoral artery

Answer

CT angiogram of bilateral lower extremities

Answer

Duplex imaging of the left lower extremity arteries

Answer

CT angiogram of the left lower extremity

Question 4

A patient presents with heaviness of the leg and visible veins of diameter less than 1mm over the posterior aspect of the calf. According to the CEAP classification, what category does this presentation fall under?

Accepted Answer

C1

Answer

C0

Answer

C2

Answer

C3

Question 5

Which statement is true regarding the Trendelenburg operation for varicose veins?

Accepted Answer

Flush ligation of the superficial varicose vein

Answer

Stripping of the superficial varicose vein

Answer

Ligation of the perforators

Answer

Ligation of small tributaries at the distal end of the superficial varicose vein

Question 6

A 30-year-old woman in her last trimester of pregnancy suddenly develops massive swelling of the left lower extremity. Which of the following would be the most appropriate workup and treatment at this time?

Accepted Answer

Duplex ultrasonography and heparin

Answer

Venography and heparin

Answer

Duplex ultrasonography, heparin, and vena caval filter

Answer

Duplex ultrasonography, heparin, and warfarin (Coumadin)

Question 7

Which of the following is NOT a preferred site for planning vascular access for maintenance hemodialysis?

Accepted Answer

Saphenofemoral fistula

Answer

Nondominant extremity

Answer

Upper limb

Answer

Radiocephalic AV fistula

Question 8

What is the management of a case of iliac artery embolism?

Accepted Answer

Embolectomy

Answer

Injection of vasodilators

Answer

Hypotensive therapy

Answer

Sympathectomy

Question 9

Cirsoid aneurysm affects which of the following arteries?

Accepted Answer

All of the above

Answer

Superficial temporal artery

Answer

Occipital artery

Answer

Posterior auricular artery

Question 10

Chronic lymphoedema of a limb is predisposed to all of the following except?

Accepted Answer

Marjolin's ulcer

Answer

Thickening of the skin

Answer

Recurrent soft tissue infections

Answer

Sarcoma

Vascular Surgery — MCQs

Vascular Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?