Vascular Surgery Practice Questions

Q: A policeman of 45 years presented with Lipodermatosclerosis over lower medial aspect of left leg, along with a healed venous ulcer. As per the CEAP (Clinical-etiology-anatomy-pathophysiology) classification his clinical classification will be:

C5. **C5 (healed venous ulcer)** - The CEAP classification for **C5** indicates the presence of a **healed venous ulcer**, which matches the patient's presentation of a healed ulcer. - The associated **lipodermatosclerosis** is a skin change often preceding or accompanying venous ulcers. *C4b (lipodermatosclerosis, atrophie blanche)* - **C4b** represents **lipodermatosclerosis** and **atrophie blanche**, which are skin changes due to chronic venous insufficiency. - While the patient has lipodermatosclerosis, the presence of a *healed ulcer* further elevates the classification to C5, as it signifies a more advanced stage of venous disease. *C6 (active venous ulcer)* - **C6** denotes an **active, open venous ulcer**. - The patient's ulcer is explicitly stated as "healed," making C6 an incorrect classification. *C4a (pigmentation or eczema)* - **C4a** refers to skin changes such as **pigmentation** or **venous eczema**. - While the patient might have some pigmentation associated with lipodermatosclerosis, the presence of a *healed ulcer* indicates a more severe clinical stage than C4a.

Q: Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:

Persistent hypertension. ***Persistent hypertension*** - **Hypertension** is a **risk factor** for carotid artery disease but is not a direct indication for carotid endarterectomy in symptomatic patients. - Carotid endarterectomy aims to treat **carotid stenosis** causing neurological symptoms, not to manage blood pressure. *Hemianopia* - **Hemianopia** is a **visual field defect** that can be caused by cerebral ischemia resulting from carotid artery stenosis, making it a neurological symptom indicating potential benefit from endarterectomy. - It suggests that the **carotid artery** is supplying an area of the brain that could be at risk for stroke. *Dysphasia* - **Dysphasia** (difficulty with speech) is a classic **neurological symptom** of cerebral ischemia, often associated with carotid artery stenosis affecting the dominant hemisphere. - This symptom strongly indicates that the patient's **carotid disease** is causing clinically significant effects, warranting consideration of endarterectomy. *Monocular blindness* - **Amaurosis fugax**, or transient monocular blindness, is a **transient ischemic attack (TIA)** symptom caused by emboli from the carotid artery reaching the retinal artery. - It is a significant **warning sign** of impending stroke and is a strong indication for carotid endarterectomy in symptomatic patients with appropriate stenosis.

Q: Which of the following statements regarding lymphoedema are correct? 1. Patients experience constant dull ache and even severe pain sometimes 2. Manual lymphatic drainage has a role 3. Primary lymphoedema is caused by congenital lymphatic dysplasia 4. Nonne Milroy's disease is a type of primary lymphoedema Select the correct answer using the code given below:

1, 2, 3 and 4. ***1, 2, 3 and 4*** - All four statements are correct regarding lymphoedema. Patients often experience **constant dull ache and severe pain** due to the swelling and tissue changes. - **Manual lymphatic drainage (MLD)** is a key component of complete decongestive therapy for lymphoedema, aiming to reduce swelling and improve lymphatic flow. **Primary lymphoedema** is indeed caused by **congenital lymphatic dysplasia**, which refers to abnormalities in lymphatic system development from birth. **Milroy's disease** (also known as Nonne-Milroy disease) is a specific type of primary lymphoedema characterized by early-onset lymphatic dysfunction. *1 and 2 only* - This option is incomplete as statements 3 and 4 are also correct. - It correctly identifies the role of manual lymphatic drainage and the presence of pain in lymphoedema but omits other accurate facts. *3 and 4 only* - This option is incomplete as statements 1 and 2 are also correct. - While correctly identifying the nature of primary lymphoedema and Milroy's disease, it misses other important aspects of lymphoedema. *1, 2, and 3 only* - This option is incomplete because statement 4, concerning Milroy's disease as a type of primary lymphoedema, is also correct. - It provides correct information about pain, MLD, and the cause of primary lymphoedema but omits a specific example of primary lymphoedema.

Q: Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:

Long term patency rates are superior (>90% at 10 years). ***Long term patency rates are superior (>90% at 10 years)*** - The superior **long-term patency rates** (over 90% at 10 years) of the **Left Internal Mammary Artery (LIMA)** when anastomosed to the **Left Anterior Descending (LAD) artery** are the primary reason for it being the conduit of choice. - This excellent patency is attributed to its **endothelial** properties and **resistance to atherosclerosis**, contributing to improved patient outcomes and survival. *Atherosclerosis is never seen in this vessel* - While the LIMA is significantly **more resistant to atherosclerosis** compared to saphenous veins, it is not entirely immune. - Atherosclerosis can still occur in the LIMA, though it is far less common and less severe than in other graft conduits. *It is very easy to harvest* - Harvesting the LIMA requires a skilled surgical technique and is **not considered "very easy."** - It involves careful dissection to preserve the conduit's integrity and includes potential complications like **sternal wound infections** due to altered blood supply. *It is close to LAD* - While the anatomical proximity of the LIMA to the LAD is a favorable factor, making the anastomosis geographically convenient, it is **not the primary reason** for its widespread use. - The primary driving factor is the superior long-term patency, which directly impacts patient morbidity and mortality.

Q: A 52-year-old man with end-stage renal disease on hemodialysis presents with his arteriovenous fistula no longer functioning. Physical examination shows a thrill and bruit over the fistula site, but dialysis access is inadequate. What is the most likely cause of fistula dysfunction?

Stenosis of the venous outflow. ***Stenosis of the venous outflow*** - A palpable **thrill and bruit** indicate blood flow through the fistula, but inadequate access points to an obstruction preventing efficient dialysis. - **Venous outflow stenosis** is the most common cause of AV fistula dysfunction and inadequate blood flow, as it restricts venous return, increasing pressure within the fistula. *Arterial steal syndrome* - This typically presents with **distal ischemia**, such as pain, pallor, and numbness in the hand, due to blood being "stolen" from the limb by the fistula. - It does not directly explain inadequate dialysis access or maintenance of a thrill/bruit, which imply patent flow through the fistula. *Infection of the fistula* - Infection would typically manifest with signs of **inflammation**, such as redness, warmth, swelling, pain, and potentially fever or purulent discharge. - Although infection can lead to fistula dysfunction, the presence of a thrill and bruit without any inflammatory signs makes it less likely to be the primary cause of inadequate access in this scenario. *Thrombosis of the fistula* - **Thrombosis** would result in the loss of both the thrill and the bruit, indicating no blood flow through the fistula. - Since the patient still has a thrill and bruit, thrombosis is unlikely to be the cause of dysfunction.

Q: A 68-year-old man with a 6 cm abdominal aortic aneurysm presents with sudden onset of severe back pain and hypotension. CT shows a retroperitoneal hematoma. His blood pressure is 90/60 mmHg, and heart rate is 110/min. What is the most critical factor in determining immediate management?

Hemodynamic stability. **Hemodynamic stability** - The patient's **hypotension (90/60 mmHg)** and **tachycardia (110/min)** indicate **hemodynamic instability**, which is a sign of ongoing bleeding and impending shock in a ruptured abdominal aortic aneurysm (AAA). - Immediate management focuses on stabilizing the patient through **fluid resuscitation** and preparing for **emergent surgical repair** to prevent further blood loss and organ damage. - In ruptured AAA, **hemodynamic status** is the primary determinant of management urgency and approach. *Presence of retroperitoneal hematoma* - While the retroperitoneal hematoma confirms the **rupture of the AAA**, it describes the consequence of bleeding rather than the immediate physiological state requiring urgent intervention. - The hematoma itself does not dictate the *immediacy* of intervention as much as the patient's **hemodynamic response** to the bleeding. *Size of the aneurysm* - The **6 cm aneurysm size** is a risk factor for rupture, but once rupture has occurred, the immediate management is driven by the acute clinical picture rather than the initial size. - While important for risk stratification of intact aneurysms, it's less critical than hemodynamic status in an actively rupturing scenario. *Age of the patient* - The patient's age (68 years) is a factor in overall surgical risk assessment but does not determine the **immediacy or type of intervention** for an acute rupture. - **Emergent repair** is indicated regardless of age if the patient can tolerate surgery.

Q: A 75-year-old man with multiple medical comorbidities develops acute mesenteric ischemia. CT angiography shows superior mesenteric artery occlusion with bowel wall thickening. His family history includes poor outcomes with major surgery. Laboratory studies show elevated lactate and leukocytosis. Evaluate the management approach considering patient factors and family concerns.

Endovascular revascularization followed by assessment. ***Endovascular revascularization followed by assessment*** - Given the patient's **multiple comorbidities** and family concerns about poor surgical outcomes, **endovascular revascularization** offers a less invasive approach to restore blood flow. - This strategy allows for **reassessment of bowel viability** after revascularization, potentially avoiding immediate extensive bowel resection in a high-risk patient. *Immediate surgical revascularization and bowel resection* - While traditional, **immediate open surgery** carries significant risks of morbidity and mortality, especially in a 75-year-old with multiple comorbidities and features of severe ischemia (elevated lactate, leukocytosis). - The family's history of **poor outcomes with major surgery** strengthens the rationale against this aggressive initial approach unless endovascular options fail or are contraindicated. *Time-limited trial of medical management* - A **time-limited trial of medical management** (e.g., vasodilators) might be considered for non-occlusive mesenteric ischemia or less severe presentations, but **superior mesenteric artery occlusion** is a surgical emergency. - This patient has clear signs of **bowel ischemia** (thickening, elevated lactate), indicating that delay could lead to irreversible bowel necrosis and peritonitis. *Conservative management with anticoagulation* - **Anticoagulation** alone is insufficient treatment for acute **arterial occlusion** with established ischemia, as it does not address the immediate need for revascularization. - Conservative management risks progression to **bowel necrosis**, leading to peritonitis, sepsis, and a much higher mortality rate.

Q: A 70-year-old man with severe aortic stenosis and coronary artery disease requires both cardiac surgery and removal of a large abdominal aortic aneurysm. He has limited physiologic reserve and high surgical risk. The cardiac surgeon recommends TAVR first, while the vascular surgeon suggests simultaneous repair. Evaluate the optimal staging and approach.

TAVR followed by staged AAA repair. ***TAVR followed by staged AAA repair*** - In patients with **severe aortic stenosis** and **limited physiological reserve**, addressing the cardiac issue first via **TAVR** helps improve cardiac function and reduce perioperative risk for subsequent vascular surgery. - Staging the AAA repair after cardiac optimization allows for better patient tolerance and reduces the overall **surgical burden** in a high-risk individual. *Simultaneous cardiac and vascular surgery* - This approach carries an exceptionally high risk of **morbidity and mortality** due to the combined physiological stress of two major procedures in a patient with limited reserve. - The increased operative time, blood loss, and systemic inflammatory response can lead to severe **postoperative complications** like myocardial infarction, renal failure, and stroke. *AAA repair followed by staged cardiac surgery* - Repairing the AAA first would expose the patient to the risks of major vascular surgery while still having **severe aortic stenosis**, which dramatically increases the risk of **cardiac complications** (e.g., myocardial ischemia, sudden death) during and after the procedure. - The patient's **limited physiological reserve** makes performing a major surgery with uncorrected severe cardiac pathology highly dangerous. *Endovascular repair of both conditions* - While **TAVR** (transcatheter aortic valve replacement) is feasible for severe aortic stenosis, and **EVAR** (endovascular aneurysm repair) is an option for AAA, simultaneous endovascular repair of both conditions in the same setting is not standard practice. - The patient also has **coronary artery disease** requiring separate management (PCI or CABG), which adds complexity that makes staged repair after cardiac optimization the safer approach.

Q: A 60-year-old diabetic man with end-stage renal disease presents with acute limb ischemia of the right leg. He has a thrombosed arteriovenous fistula, is on hemodialysis, and has limited vascular access options. Angiography shows acute thrombosis of a previously placed femoral-popliteal bypass graft. He faces competing needs for limb salvage and dialysis access. Evaluate the management priority and approach.

Immediate thrombectomy of bypass graft. **Immediate thrombectomy of bypass graft** - **Acute limb ischemia** is an emergent condition threatening limb viability, making **revascularization** the immediate priority. - A **thrombosed femoral-popliteal bypass graft** needs urgent intervention to restore blood flow and prevent irreversible tissue damage. *Simultaneous revascularization and dialysis access procedure* - While both are critical, attempting both simultaneously can be complex and prolong operative time, potentially compromising the acutely ischemic limb. - The **acute limb ischemia** requires immediate attention, and delaying it for a concurrent access procedure could lead to limb loss. *Thrombolysis followed by new AV access creation* - **Thrombolysis** can take several hours to days to achieve vessel patency, which is too slow for **acute limb ischemia** where time is critical. - Creating a new **AV access** is a separate, non-emergent procedure that should not delay limb salvage. *Endovascular intervention with temporary dialysis catheter* - While a **temporary dialysis catheter** can bridge the access need, **endovascular intervention** for a thrombosed bypass graft may not be as effective or rapid as surgical thrombectomy, especially in acute settings. - The priority remains rapid restoration of flow, which a surgical approach often best provides for an acutely thrombosed bypass graft.

Q: What type of ulcer is shown below?

Arterial ulcer. ***Arterial ulcer*** - The image depicts an ulcer with a **punched-out appearance**, often found on the toes, heels, or shin, indicative of **arterial insufficiency**. - The surrounding skin appears **pale** and might show signs of **trophic changes** (e.g., hair loss, shiny skin), consistent with poor arterial blood supply. *Venous ulcer* - Venous ulcers typically occur around the **medial malleolus**, are superficial, and have irregular borders with a **"gaiter" appearance** (brawny edema and hyperpigmentation). - The ulcer bed is usually ruddy red with **exudate** and the surrounding skin often shows signs of **venous stasis changes**. *Trophic ulcer* - "Trophic ulcer" is a broad term for an ulcer caused by **poor nutrition** or nerve supply, and can encompass arterial or neuropathic ulcers. - This term is less specific than identifying the underlying vascular etiology shown in the image. *Diabetic foot* - Diabetic foot ulcers often occur on **pressure points** of the foot, such as the plantar surface or the heel, and can be neuropathic or neuro-ischemic. - While this image could potentially be associated with diabetes due to microvascular complications, the **punched-out, ischemic appearance** more strongly points to an arterial origin which can occur independently of diabetes.

Question 1

A policeman of 45 years presented with Lipodermatosclerosis over lower medial aspect of left leg, along with a healed venous ulcer. As per the CEAP (Clinical-etiology-anatomy-pathophysiology) classification his clinical classification will be:

Accepted Answer

C5

Answer

C4b

Answer

C6

Answer

C4a

Question 2

Indications for carotid endarterectomy in symptomatic patients are all of the following EXCEPT:

Accepted Answer

Persistent hypertension

Answer

Hemianopia

Answer

Dysphasia

Answer

Monocular blindness

Question 3

Which of the following statements regarding lymphoedema are correct?

1. Patients experience constant dull ache and even severe pain sometimes
2. Manual lymphatic drainage has a role
3. Primary lymphoedema is caused by congenital lymphatic dysplasia
4. Nonne Milroy's disease is a type of primary lymphoedema

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3 and 4

Answer

1 and 2 only

Answer

3 and 4 only

Answer

1, 2 and 3 only

Question 4

Left Internal Mammary Artery (LIMA) has become the conduit of choice for Left Anterior Descending (LAD) artery during coronary artery bypass grafting because:

Accepted Answer

Long term patency rates are superior (>90% at 10 years)

Answer

Atherosclerosis is never seen in this vessel

Answer

It is very easy to harvest

Answer

It is close to LAD

Question 5

A 52-year-old man with end-stage renal disease on hemodialysis presents with his arteriovenous fistula no longer functioning. Physical examination shows a thrill and bruit over the fistula site, but dialysis access is inadequate. What is the most likely cause of fistula dysfunction?

Accepted Answer

Stenosis of the venous outflow

Answer

Arterial steal syndrome

Answer

Infection of the fistula

Answer

Thrombosis of the fistula

Question 6

A 68-year-old man with a 6 cm abdominal aortic aneurysm presents with sudden onset of severe back pain and hypotension. CT shows a retroperitoneal hematoma. His blood pressure is 90/60 mmHg, and heart rate is 110/min. What is the most critical factor in determining immediate management?

Accepted Answer

Hemodynamic stability

Answer

Presence of retroperitoneal hematoma

Answer

Size of the aneurysm

Answer

Age of the patient

Question 7

A 75-year-old man with multiple medical comorbidities develops acute mesenteric ischemia. CT angiography shows superior mesenteric artery occlusion with bowel wall thickening. His family history includes poor outcomes with major surgery. Laboratory studies show elevated lactate and leukocytosis. Evaluate the management approach considering patient factors and family concerns.

Accepted Answer

Endovascular revascularization followed by assessment

Answer

Conservative management with anticoagulation

Answer

Time-limited trial of medical management

Answer

Immediate surgical revascularization and bowel resection

Question 8

A 70-year-old man with severe aortic stenosis and coronary artery disease requires both cardiac surgery and removal of a large abdominal aortic aneurysm. He has limited physiologic reserve and high surgical risk. The cardiac surgeon recommends TAVR first, while the vascular surgeon suggests simultaneous repair. Evaluate the optimal staging and approach.

Accepted Answer

TAVR followed by staged AAA repair

Answer

Simultaneous cardiac and vascular surgery

Answer

AAA repair followed by staged cardiac surgery

Answer

Endovascular repair of both conditions

Question 9

A 60-year-old diabetic man with end-stage renal disease presents with acute limb ischemia of the right leg. He has a thrombosed arteriovenous fistula, is on hemodialysis, and has limited vascular access options. Angiography shows acute thrombosis of a previously placed femoral-popliteal bypass graft. He faces competing needs for limb salvage and dialysis access. Evaluate the management priority and approach.

Accepted Answer

Immediate thrombectomy of bypass graft

Answer

Simultaneous revascularization and dialysis access procedure

Answer

Thrombolysis followed by new AV access creation

Answer

Endovascular intervention with temporary dialysis catheter

Question 10

What type of ulcer is shown below?

Accepted Answer

Arterial ulcer

Answer

Venous ulcer

Answer

Trophic ulcer

Answer

Diabetic foot

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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