Vascular Surgery Practice Questions

Q: A 68-year-old man is admitted to the coronary care unit with an acute myocardial infarction. His postinfarction course is marked by congestive heart failure and intermittent hypotension. On the fourth day in hospital, he develops severe midabdominal pain. On physical examination, blood pressure is 90/60 mm Hg and pulse is 110 beats per minute and regular; the abdomen is soft with mild generalized tenderness and distention. Bowel sounds are hypoactive; stool Hematest is positive. Which of the following is the most appropriate next step in this patient's management?

Angiography. ### Explanation The clinical presentation of a patient with a recent myocardial infarction (MI), congestive heart failure, and hypotension who develops sudden, severe abdominal pain out of proportion to physical findings (soft abdomen) is classic for **Acute Mesenteric Ischemia (AMI)**. In this specific scenario, the patient likely has **Non-occlusive Mesenteric Ischemia (NOMI)**, caused by low-flow states and compensatory vasoconstriction of the splanchnic circulation. **1. Why Angiography is Correct:** Angiography remains the **gold standard** for both the diagnosis and management of AMI. In NOMI, it reveals characteristic narrowing of multiple arterial branches. Crucially, angiography allows for **therapeutic intervention**: the infusion of vasodilators (e.g., papaverine) directly into the mesenteric artery can reverse the vasospasm, which is the primary treatment for NOMI. **2. Why Other Options are Incorrect:** * **Barium Enema & Upper GI Series:** These are contraindicated in suspected acute ischemia. They are time-consuming, carry a risk of perforation if the bowel is gangrenous, and the residual contrast interferes with subsequent angiography or CT scans. * **Ultrasonography:** While useful for evaluating the gallbladder or aorta, it is limited by bowel gas (common in ileus) and has low sensitivity for detecting distal mesenteric arterial flow or NOMI. **3. High-Yield Clinical Pearls for NEET-PG:** * **Classic Triad of AMI:** Sudden onset severe abdominal pain, minimal physical signs ("pain out of proportion"), and a high-risk cardiac history (AFib, MI, or CHF). * **NOMI vs. Embolic:** Embolic AMI (from AFib) usually affects the Superior Mesenteric Artery (SMA). NOMI occurs due to low cardiac output or vasopressors. * **Metabolic Marker:** Elevated **Serum Lactate** is a late but significant sign indicating bowel infarction. * **Gold Standard:** Selective Mesenteric Angiography.

Q: According to the Spetzler-Martin grading scale, what is the score assigned to an arteriovenous malformation with a 5 cm nidus?

2. The **Spetzler-Martin Grading System** is a clinical tool used to estimate the risk of surgical resection of an Arteriovenous Malformation (AVM). The score is calculated by summing points from three categories: **Size of the nidus**, **Eloquence of adjacent brain tissue**, and **Venous drainage pattern**. ### **Breakdown of the Scoring System:** 1. **Size of Nidus:** * Small ( 6 cm): 3 points 2. **Eloquence of adjacent brain** (e.g., motor, sensory, visual, or speech cortex): * Non-eloquent: 0 points * Eloquent: 1 point 3. **Venous Drainage:** * Superficial only: 0 points * Deep component: 1 point ### **Explanation of Options:** * **Option C (Correct):** A 5 cm nidus falls into the "Medium" category (3–6 cm), which is assigned **2 points**. * **Option A (3):** This score would be assigned if the nidus was > 6 cm. * **Option B (4) & D (5):** These represent the total cumulative score of an AVM (Grade IV or V), not the individual score for a 5 cm nidus size alone. ### **Clinical Pearls for NEET-PG:** * **Total Score:** Ranges from Grade I to V. A special **Grade VI** exists for unresectable lesions. * **Surgical Significance:** Grades I–III are generally considered candidates for surgical excision, while Grades IV–V are often managed conservatively or via multimodal therapy (radiosurgery/embolization) due to high surgical morbidity. * **Eloquence:** Includes the thalamus, hypothalamus, internal capsule, brainstem, cerebellar peduncles, and deep cerebellar nuclei.

Q: In an emergency, which artery can be safely ligated?

Internal iliac artery. **Explanation:** The safety of ligating an artery depends on the presence of **collateral circulation**. If an artery is an "end artery" or lacks sufficient collateral pathways, ligation will lead to distal ischemia and tissue necrosis. **1. Why Internal Iliac Artery is the Correct Answer:** The **Internal Iliac Artery (Hypogastric artery)** can be safely ligated, typically performed bilaterally in emergencies like massive postpartum hemorrhage (PPH) or pelvic trauma. It has an extensive network of collaterals involving the lumbar, iliolumbar, superior hemorrhoidal, and femoral artery branches (e.g., the cruciate anastomosis). Ligation reduces pelvic arterial pulse pressure by nearly 85%, allowing for clot formation without causing pelvic gangrene. **2. Why the Other Options are Incorrect:** * **Popliteal Artery:** This is a functional end artery. Ligation carries a very high risk (approx. 70-100%) of lower limb gangrene and subsequent amputation because the genicular anastomosis is usually insufficient to maintain distal viability. * **Renal Artery:** The renal artery is a true anatomical end artery. Ligation leads to immediate total infarction of the kidney as there are no significant intra-renal collaterals. * **Internal Carotid Artery (ICA):** Ligation of the ICA carries a high risk of massive cerebral infarction (stroke) and hemiplegia, as the Circle of Willis is often incomplete or unable to compensate for sudden total loss of flow in an emergency. **Clinical Pearls for NEET-PG:** * **Safe to ligate:** Internal iliac, External carotid (distal to superior thyroid), Subclavian (1st part), and Splenic artery (due to short gastric vessels). * **Unsafe to ligate:** Common carotid, Internal carotid, Popliteal, Brachial (above profunda brachii), and Renal arteries. * **Ligation site for PPH:** The internal iliac is ligated distal to its posterior division to avoid gluteal skin ischemia.

Q: In the given image, which vein is mainly affected?

Great saphenous vein. ***Great saphenous vein*** - The image displays prominent varicose veins along the **medial aspect of the leg**, which corresponds to the anatomical path of the **great saphenous vein (GSV)**. - The GSV is the most frequently affected vein in varicose vein disease due to valvular incompetence, leading to venous reflux and the characteristic tortuous dilatation seen in the picture. *Short saphenous vein* - The **short saphenous vein (SSV)** ascends along the **posterior aspect of the calf**. Varicosities primarily from the SSV would be most visible on the back of the leg. - While some posterior varicosities may be present, the predominant involvement shown is medial, making the GSV the main affected vessel. *Femoral vein* - The **femoral vein** is a major vessel of the **deep venous system**, not the superficial system. - Varicose veins are a disease of **superficial veins**; deep veins like the femoral vein do not become varicose. *Perforator veins* - **Perforator veins** connect the superficial venous system to the deep system. Their incompetence is a crucial factor in the development of venous hypertension and varicosities. - However, the large, dilated vessels visible on the skin are part of a major superficial trunk (the GSV in this case), not the perforators themselves, which are much smaller connecting vessels.

Q: Identify the type of ulcer? ![img-112.jpeg](img-112.jpeg)

Venous ulcer. ***Venous ulcer*** - These ulcers are typically located over the **medial malleolus** or within the **gaiter area**, as shown in the image, due to chronic venous insufficiency. - They characteristically have **irregular borders**, a shallow base with fibrinous exudate, and are associated with surrounding skin changes like **hemosiderin staining** (hyperpigmentation) and edema. *Arterial Ulcer* - Arterial ulcers are caused by **ischemia** and are commonly found on pressure points, tips of toes, or lateral malleolus, not the medial side. - They typically have a **punched-out appearance** with well-demarcated edges and a pale, necrotic base, and are associated with severe pain, especially with leg elevation. *Diabetic ulcer* - These are most often neuropathic and occur over **pressure points** on the plantar surface of the foot, such as the metatarsal heads or heel. - They are typically surrounded by **callus** and are often deep and painless due to underlying sensory neuropathy. *Pressure ulcer* - These ulcers develop due to **prolonged pressure** on bony prominences in immobile patients (sacrum, heels, hips). - They progress through stages and have a characteristic location over **pressure points** in bedridden patients, not typically on the medial malleolus as shown in the image.

Q: A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?

Endothermal ablation. ***Endothermal ablation***- Guidelines recommend **endothermal ablation** (e.g., **EVLA** or **RFA**) as the first-line definitive treatment for symptomatic varicose veins (C2-C6), especially those causing **C4a skin changes** due to underlying reflux.- This technique is minimally invasive, highly effective at eliminating **saphenous vein reflux**, and leads to faster recovery and reduced recurrence rates compared to surgery.*Compression*- Compression therapy is mandated for all CEAP classifications (C0 to C6) but only serves as **conservative management** to alleviate symptoms and manage edema and skin changes (C4a).- It does not address the underlying **venous valve incompetence** leading to the venous hypertension and is therefore not the definitive preferred treatment.*Non endothermal non tumescent ablation*- These techniques, such as **mechanochemical ablation** (MOCA) or **cyanoacrylate glue**, are effective and avoid the need for general anesthesia or tumescent local anesthesia, making them suitable alternatives.- However, endothermal modalities are often preferred as first-line due to extensive long-term data supporting their effectiveness and durability in treating major **truncal reflux**.*Open surgery*- **High ligation and stripping** used to be the gold standard but is now generally reserved for complex cases where ablation is not technically feasible, such as large tributary veins or extreme **tortuosity**.- Open surgery involves greater morbidity, longer hospital stays, and potentially higher risks of **injury to nerves** (e.g., saphenous nerve) compared to endothermal methods.

Q: A patient presents with calf pain while walking a certain distance. The pain is severe enough that he must stop and rest before continuing. According to Boyd's grading, which of the following grades best describes this condition?

C. Grade 3. ***Correct: Grade 3*** - This grade signifies that the **claudication pain is severe enough to force the patient to stop and rest**, indicating moderately severe peripheral artery disease (PAD) - The distance the patient can walk before stopping is typically **short**, distinguishing it from less severe grades - This matches the clinical scenario where the patient "must stop and rest before continuing" *Incorrect: Grade 1* - This is the mildest form, where the patient experiences **claudication pain only after long distances** of walking - The pain is typically **not severe** and does not significantly interfere with regular walking pace or necessitate stopping - Patient can complete usual walking activities without stopping *Incorrect: Grade 2* - In this stage, pain occurs after a **moderate distance**, but the patient is usually able to continue walking by **slowing their pace** without immediately having to stop - It represents a mild to moderate level of **ischemia** induced by exercise - Key difference: patient can continue walking (albeit slowly) without complete rest *Incorrect: Grade 4* - This grade represents **critical limb ischemia (CLI)**, characterized by **pain at rest** and/or the presence of **ischemic ulcers or gangrene** - It is the most severe grade of PAD, often requiring urgent revascularization - Pain occurs even without walking

Q: Which is the least commonly used graft for coronary artery bypass graft (CABG)?

Intercostal artery. ***Intercostal artery***- This artery is **rarely used** in CABG due to its small caliber, difficult harvesting, and high risk of **graft spasm**.- Its use is generally restricted to highly unusual circumstances or when all major **arterial** and **venous conduits** are unavailable. *Long saphenous vein*- The **long saphenous vein (LSV)** is the most common venous graft and is frequently used, particularly for targets other than the LAD.- Though easily accessible and long, LSV grafts have significantly lower long-term patency rates compared to arterial grafts due to susceptibility to **intimal hyperplasia** and atherosclerosis. *Internal mammary artery* - The **Internal Mammary Artery (IMA)** (or Internal Thoracic Artery) is universally considered the **gold standard** graft, particularly for the Left Anterior Descending (LAD) artery.- It offers the highest long-term patency (often >90% at 10 years), making it the most commonly preferred graft, not the least common. *Radial artery*- The **radial artery (RA)** is widely used as a second arterial conduit, offering excellent long-term patency rates superior to vein grafts but slightly less than the IMA.- Preoperative evaluation using the **Allen's test** is necessary to confirm adequate collateral circulation via the ulnar artery before harvesting.

Q: A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Esmolol and urgent surgery. ***Esmolol and urgent surgery*** - The CT image shows an intimal flap in the ascending aorta, confirming a **Stanford Type A aortic dissection**. This is a surgical emergency requiring immediate intervention. - The initial management goals are to lower heart rate and blood pressure to reduce aortic wall shear stress. This is achieved with intravenous **beta-blockers** (like **esmolol**), followed by urgent surgical repair. *Urgent surgery* - While surgery is the definitive treatment, it should not be performed without first medically stabilizing the patient. - Failure to control **blood pressure** and **heart rate** pre-operatively increases the risk of dissection propagation or aortic rupture during induction of anesthesia or the surgical procedure itself. *Wait and watch* - A **Type A aortic dissection** is a life-threatening condition with a very high mortality rate (approximately 1-2% per hour for the first 48 hours) if left untreated. - Delaying treatment drastically increases the risk of fatal complications such as **cardiac tamponade**, **acute aortic regurgitation**, or **malperfusion syndromes**. *Blood transfusion* - Blood transfusion is not the primary treatment unless the patient is hemodynamically unstable due to massive hemorrhage from an aortic rupture. - The priority is to prevent rupture and further dissection through **hemodynamic control** and definitive **surgical repair**, not to replace blood volume unless significant loss has already occurred.

Question 1

A 68-year-old man is admitted to the coronary care unit with an acute myocardial infarction. His postinfarction course is marked by congestive heart failure and intermittent hypotension. On the fourth day in hospital, he develops severe midabdominal pain. On physical examination, blood pressure is 90/60 mm Hg and pulse is 110 beats per minute and regular; the abdomen is soft with mild generalized tenderness and distention. Bowel sounds are hypoactive; stool Hematest is positive. Which of the following is the most appropriate next step in this patient's management?

Accepted Answer

Angiography

Answer

Barium enema

Answer

Upper gastrointestinal series

Answer

Ultrasonography

Question 2

According to the Spetzler-Martin grading scale, what is the score assigned to an arteriovenous malformation with a 5 cm nidus?

Accepted Answer

2

Answer

3

Answer

4

Answer

5

Question 3

In an emergency, which artery can be safely ligated?

Accepted Answer

Internal iliac artery

Answer

Popliteal artery

Answer

Renal artery

Answer

Internal carotid artery

Question 4

Trendelenburg's test is done for the detection of:

Accepted Answer

Saphenofemoral incompetency

Answer

Perforator incompetency

Answer

Deep vein patency

Answer

Site of perforators

Question 5

In the given image, which vein is mainly affected?

Accepted Answer

Great saphenous vein

Answer

Perforator veins

Answer

Femoral vein

Answer

Short saphenous vein

Question 6

Identify the type of ulcer? ![img-112.jpeg](img-112.jpeg)

Accepted Answer

Venous ulcer

Answer

Arterial Ulcer

Answer

Diabetic ulcer

Answer

Pressure ulcer

Question 7

A patient with dilated tortuous veins of the leg presented to the OPD and is diagnosed with varicose vein of grade C4a. What is the best preferred treatment?

Accepted Answer

Endothermal ablation

Answer

Non endothermal non tumescent ablation

Answer

Open surgery

Answer

Compression

Question 8

A patient presents with calf pain while walking a certain distance. The pain is severe enough that he must stop and rest before continuing. According to Boyd's grading, which of the following grades best describes this condition?

Accepted Answer

C. Grade 3

Answer

B. Grade 2

Answer

D. Grade 4

Answer

A. Grade 1

Question 9

Which is the least commonly used graft for coronary artery bypass graft (CABG)?

Accepted Answer

Intercostal artery

Answer

Radial artery

Answer

Long saphenous vein

Answer

Internal mammary artery

Question 10

A male patient presented with a sudden onset tearing type of chest pain radiating to the back, shortness of breath, and nausea. CT chest image is given. What is the most appropriate next step in the management of this patient?

Accepted Answer

Esmolol and urgent surgery

Answer

Urgent surgery

Answer

Blood transfusion

Answer

Wait and watch

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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