Vascular Surgery Practice Questions

Q: A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?

Surgical management. ***Surgical management*** - The chest X-ray shows a **widened mediastinum** and abnormal aortic contour, highly suggestive of **aortic dissection involving the ascending aorta (Type A)**. - **Type A aortic dissection** (involving the ascending aorta) is a **surgical emergency** requiring immediate operative repair to prevent life-threatening complications such as cardiac tamponade, acute aortic regurgitation, or rupture. - The constant chest pain with these radiological findings indicates urgent surgical intervention is the definitive management. *Vasodilator* - Vasodilators **alone** should never be used in aortic dissection as they can increase aortic wall shear stress and propagate the dissection. - They must always be preceded by beta-blockade to prevent reflex tachycardia. - Vasodilators do not address the structural defect requiring surgical correction in Type A dissection. *Beta blocker* - Beta-blockers are essential for **initial medical stabilization** to reduce heart rate (target <60 bpm) and blood pressure, thereby decreasing aortic wall stress (dP/dt). - However, in **Type A dissection**, beta-blockers alone do not address the structural defect and are used as a bridge to emergency surgery, not as definitive treatment. - For Type B dissections (descending aorta), medical management with beta-blockers may be definitive in uncomplicated cases. *Beta blocker plus vasodilator* - This combination represents optimal **medical management** for blood pressure and heart rate control in aortic dissection. - In **Type B (descending) aortic dissections**, this is often the definitive treatment for uncomplicated cases. - However, in **Type A dissections** (as indicated by the widened mediastinum suggesting ascending aortic involvement), this serves only as initial stabilization before **mandatory surgical repair**, not as definitive therapy. - Surgery cannot be delayed in Type A dissection due to high mortality risk (1-2% per hour).

Q: A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?

Emergency surgical repair. ***Emergency surgical repair*** - The combination of **excruciating chest pain**, a history of **hypertension**, and **unequal radial pulses** is highly suggestive of an **acute aortic dissection**. - **Unequal radial pulses** indicate involvement of the **ascending aorta** (Type A dissection), affecting the brachiocephalic or subclavian arteries that branch proximally from the aortic arch. - **Type A aortic dissections**, involving the ascending aorta, are life-threatening emergencies requiring immediate **surgical repair** to prevent rupture, cardiac tamponade, aortic regurgitation, and organ malperfusion. *BP control and monitoring* - While **blood pressure control** is a crucial initial step in managing aortic dissection to reduce shear stress on the aorta and prevent propagation, it is insufficient as the primary treatment for an **ascending (Type A) aortic dissection**. - Continuous monitoring is necessary but cannot resolve a progressing dissection that poses an immediate threat to life. - Medical management alone is reserved for **uncomplicated Type B dissections**. *Stenting* - **Endovascular stenting** (thoracic endovascular aortic repair, TEVAR) is primarily used for **Type B aortic dissections** (involving the descending aorta) in stable patients or those with complicated features. - It is generally not the first-line treatment for **Type A dissections** due to the anatomical challenges and urgent need for surgical repair in this location. *Balloon dilatation* - **Balloon dilatation** or angioplasty is a procedure used to open narrowed arteries, typically in the context of atherosclerotic disease (e.g., coronary artery disease or peripheral artery disease). - It has no role in the management of an **aortic dissection**, which involves a tear in the aortic wall rather than a simple narrowing.

Q: Asymptomatic varicose veins would fall under which category of the CEAP classification system?

C2 (Varicose veins). ***C2 (Varicose veins)*** - The CEAP classification uses 'C' for clinical manifestations, with **C2 specifically indicating the presence of varicose veins**. - Since the patient has **asymptomatic varicose veins**, C2 accurately captures this clinical state without implying more severe complications. - Varicose veins are classified as C2 **regardless of whether they are symptomatic or asymptomatic**. *C1 (Telangiectasias or reticular veins)* - C1 refers to smaller veins, such as **telangiectasias (spider veins)** and **reticular veins**, which are distinct from the larger, tortuous varicose veins. - These are less prominent venous abnormalities compared to varicose veins. *C3 (Edema)* - C3 indicates the **presence of edema** due to venous insufficiency. - The question specifies **asymptomatic varicose veins** without mention of edema, making C3 incorrect. *C4 (Skin changes)* - C4 denotes **skin changes** related to chronic venous insufficiency, such as pigmentation, eczema, or lipodermatosclerosis. - These are more advanced signs of venous disease and are not present in a patient with only varicose veins without complications.

Q: A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?

Brodie Trendelenburg test. ***Brodie Trendelenburg test*** - This test evaluates **venous valve competence** at the saphenofemoral junction (SFJ) by observing the rate of venous refilling after emptying the superficial veins in the supine position and then standing. - Quick refilling of veins upon standing, particularly after compression of the SFJ, suggests **SFJ incompetence**. *Fegan's test* - This test is used to locate **incompetent perforating veins** by palpating for defects in the fascia after emptying the veins and applying compression. - It does not directly assess the competence of the saphenofemoral junction. *Modified Perthes test* - The Perthes test assesses the **patency of deep veins** and the competence of perforating veins by observing the disappearance of superficial veins during exercise with a tourniquet applied. - It primarily differentiates between superficial and deep venous insufficiency, not specifically SFJ incompetence. *Morrissey test* - This test (also known as the percussion test) involves percussing an incompetent vein distally and palpating proximally to detect a transmitted thrill, indicating **venous incompetence**. - While it helps identify reflux, it is less specific for SFJ incompetence compared to the Brodie Trendelenburg test.

Q: During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?

Left renal artery. ***Left renal artery*** - The **left renal artery** arises from the aorta usually just below the superior mesenteric artery, making it susceptible to injury during an **abdominal aortic aneurysm (AAA) repair** if the aneurysm extends proximally. - Its proximity to the typical location of AAA, often near or involving the **infrarenal aorta**, necessitates careful identification and protection during clamping or graft placement. *Celiac trunk* - The **celiac trunk** originates higher up from the aorta, typically at the level of **T12-L1 vertebrae**, well above the common infrarenal AAA repair site. - While important, it is generally less directly threatened during a typical infrarenal AAA repair compared to arteries immediately adjacent to or within the aneurysm sac. *Right renal artery* - The **right renal artery** also originates from the aorta near the level of the renal veins, but it is typically located more posteriorly and usually passes behind the inferior vena cava. - Although it can be at risk, the left renal artery's course is often more anterior and directly in the field of dissection for the **aortic neck** during AAA repair. *Superior mesenteric artery* - The **superior mesenteric artery (SMA)** originates from the aorta proximal to the renal arteries, typically around the L1 vertebral level. - While crucial, its origin is usually cephalad to the infrarenal aneurysm neck, making it generally less prone to direct injury during infrarenal AAA repair, though flow must be monitored.

Q: A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?

Renal arteries and common iliac arteries. ***Renal arteries and common iliac arteries*** - The most common location for **abdominal aortic aneurysms (AAAs)** is the **infrarenal aorta**, specifically between the renal arteries and the common iliac arteries. - This segment accounts for **~95% of all AAAs** due to decreased elastin content, hemodynamic stress, and reduced vasa vasorum. - The patient's presentation with **flank/back pain**, a **pulsatile abdominal mass**, and risk factors like **hypertension** and **smoking** are highly suggestive of an infrarenal AAA [1]. *Superior mesenteric artery and renal arteries* - This region defines the **suprarenal aorta**, which is less commonly affected by aneurysms than the infrarenal segment. - Suprarenal aneurysms account for only **~5% of AAAs** and are typically more complex to manage. *Diaphragm and renal arteries* - This encompasses a significant portion of the **thoracoabdominal aorta**, including the suprarenal segment. - While thoracoabdominal aneurysms can occur, they are much less common than infrarenal AAAs and often have different etiologies. *Superior mesenteric artery and common iliac arteries* - This range is anatomically imprecise and spans too broad a region, including both suprarenal and infrarenal segments. - The **superior mesenteric artery** originates anteriorly from the aorta (typically at L1), well above the most common aneurysm site immediately distal to the renal arteries (L1-L2). - The highest risk is specifically localized to the segment **below the renal arteries**, not this entire broad region. *Diaphragm and superior mesenteric artery* - This describes the **supraceliac and proximal suprarenal aorta**, an area significantly less prone to aneurysms compared to the infrarenal segment. - Aneurysms in this more proximal segment are rare and often have different etiologies (e.g., connective tissue disorders).

Q: A 71-year-old man comes to the physician for a routine health maintenance examination. He feels well. He goes for a 30-minute walk three times a week and does not experience any shortness of breath or chest or leg pain on exertion. He has not had any weakness, numbness, or vision disturbance. He has diabetes that is well controlled with insulin injections. He had smoked one pack of cigarettes every day for 40 years but quit 5 years ago. He appears healthy and well nourished. His temperature is 36.3°C (97.3°F), pulse is 75/min, and blood pressure is 136/78 mm Hg. Physical examination shows normal heart sounds. There are systolic bruits over the neck bilaterally. Physical and neurologic examinations show no other abnormalities. Fasting serum studies show: Total cholesterol 210 mg/dL HDL cholesterol 28 mg/dL LDL cholesterol 154 mg/dL Triglycerides 140 mg/dL Glucose 102 mg/dL Duplex ultrasonography of the carotid arteries shows a 85% stenosis on the left and a 55% stenosis on the right side. Which of the following is the most appropriate next step in management?

Left carotid endarterectomy. ***Left carotid endarterectomy*** - The patient has **asymptomatic carotid artery stenosis** with a **left-sided stenosis of 85%**. For asymptomatic patients, carotid endarterectomy is indicated for stenosis between 70% and 99% if the patient has a life expectancy of at least 5 years and the periprocedural stroke and death rate is low (<3%). - This patient, despite his age, is **active and healthy**, has no neurological deficits, and his comorbidities (well-controlled diabetes, history of smoking but quit 5 years ago) are unlikely to significantly increase surgical risk beyond the benefit of stroke prevention for severe stenosis. *Carotid artery stenting* - While carotid artery stenting (CAS) is an alternative to endarterectomy, it is generally preferred in patients who are **high-risk for endarterectomy** due to specific anatomical or medical comorbidities, or in cases of **restenosis after endarterectomy**. - In asymptomatic patients, **endarterectomy** is generally favored over stenting, especially for stroke prevention, as large trials have shown a slightly higher periprocedural stroke risk with stenting. *Aspirin therapy only* - While **aspirin and statin therapy** are crucial for patients with carotid artery disease to reduce cardiovascular events, they are **insufficient as sole treatment** for severe asymptomatic carotid stenosis (85%). - Medical therapy alone does not provide the same level of stroke risk reduction as interventional approaches for high-grade stenosis. *Bilateral carotid endarterectomy* - A **bilateral procedure** is not indicated at this time. The right carotid stenosis is 55%, which in an asymptomatic patient, is typically managed with **medical therapy** rather than surgical intervention. - Performing endarterectomy on the right side at this time would expose the patient to unnecessary surgical risk without clear benefit for immediate stroke prevention.

Q: A 45-year-old policeman presents with pain in the right leg after duty. On examination, the pulse in the right popliteal fossa is absent, and there is pain in the right buttock. The left side is normal. At which level is the blockage?

Iliac. ***Iliac*** - Pain in the **right buttock** suggests a blockage in the **internal iliac artery** or its branches, which supply the gluteal muscles. - The absence of a pulse in the right **popliteal fossa** indicates significant arterial obstruction proximal to this level, consistent with an iliac artery lesion. *Popliteal* - A popliteal blockage would primarily cause symptoms below the knee, and would not explain **buttock pain**. - A popliteal pulse would be absent, but pulses proximal to the popliteal artery (like femoral) would generally be present. *Aortoiliac* - A blockage at the **aortoiliac** level might affect both legs or cause more widespread symptoms, but the description specifies the right leg. - While buttock pain can occur in aortoiliac occlusion, it often presents with bilateral claudication or erectile dysfunction (Leriche syndrome), which are not mentioned here. *Femoral* - A femoral blockage would cause symptoms in the thigh and calf, and would not explain **buttock pain** due to the collateral circulation. - The **femoral pulse** would be absent, but the pain distribution doesn't directly point to an isolated femoral lesion as the primary cause of buttock pain.

Q: A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?

Perthes test. ***Perthes test*** - The Perthes test assesses the **patency and competency of the deep venous system** in the leg by observing changes in superficial varicosities during muscle activity. - If the varicosities diminish or disappear with ambulation and a tourniquet applied to compress superficial veins, it indicates that the **deep veins are competent** and can handle venous return. *Ober test* - The Ober test is used to assess the **tightness of the iliotibial band**, not venous competency. - It involves abducting and extending the hip while the patient lies on their side. *Thomas test* - The Thomas test evaluates for **hip flexion contracture**, especially of the iliopsoas muscle. - It is performed by having the patient lie supine and flexing one hip fully while observing the contralateral leg. *Brodie Trendelenburg test* - The Brodie Trendelenburg test is primarily used to assess the **competency of the valves of the saphenofemoral junction and perforating veins** to distinguish between superficial and deep venous insufficiency. - It involves elevating the leg, applying a tourniquet, and then observing refilling patterns of varicose veins upon standing.

Q: Which of the following is the best management for radiation induced occlusive disease of carotid artery?

Carotid angioplasty and stenting. ***Carotid angioplasty and stenting*** - **Radiation-induced carotid artery disease** often involves the distal part of the carotid artery, making it less amenable to surgical endarterectomy. - **Angioplasty and stenting** offer a less invasive approach with good technical success in these challenging cases, especially given the increased fragility and fibrosis of radiated tissues. *Carotid endarterectomy* - **Carotid endarterectomy** in previously radiated fields is associated with a significantly higher risk of complications, including **cranial nerve injury**, **wound infection**, and **carotid artery rupture**, due to tissue fibrosis and scarring. - The disease often extends beyond the easily accessible segment for endarterectomy in radiation-induced cases. *Low dose aspirin* - **Low-dose aspirin** is an important component of medical therapy for **atherosclerotic disease** and **stroke prevention**, but it is insufficient as a sole treatment for symptomatic or high-grade occlusive disease of the carotid artery. - It helps manage the underlying **atherosclerotic process** but does not directly address the severe stenosis or occlusion. *Carotid bypass procedure* - **Carotid bypass procedures** are complex surgical interventions usually reserved for cases of **carotid artery occlusion** or **recurrent stenosis** after previous interventions where endarterectomy or stenting is not feasible. - While an option, it is more invasive and technically demanding than angioplasty and stenting, particularly in already radiated tissues with compromised vascular integrity.

Question 1

A patient presents with constant chest pain, and the radiological finding is as shown in the image. What is the most appropriate management?

Accepted Answer

Surgical management

Answer

Vasodilator

Answer

Beta blocker

Answer

Beta blocker plus vasodilator

Question 2

A hypertensive patient presents with excruciating chest pain and unequal radial pulses. Which of the following is the correct management for this patient?

Accepted Answer

Emergency surgical repair

Answer

BP control and monitoring

Answer

Stenting

Answer

Balloon dilatation

Question 3

Asymptomatic varicose veins would fall under which category of the CEAP classification system?

Accepted Answer

C2 (Varicose veins)

Answer

C1 (Telangiectasias or reticular veins)

Answer

C3 (Edema)

Answer

C4 (Skin changes)

Question 4

A patient presents with dull aching pain and tortuous veins in both lower limbs. Which test would be appropriate for evaluating saphenofemoral junction (SFJ) incompetence?

Accepted Answer

Brodie Trendelenburg test

Answer

Fegan's test

Answer

Modified Perthes test

Answer

Morrissey test

Question 5

During a surgical procedure to repair an abdominal aortic aneurysm, the surgeon must be careful to avoid injury to which of the following arterial structures that originates near the level of the renal vessels?

Accepted Answer

Left renal artery

Answer

Celiac trunk

Answer

Right renal artery

Answer

Superior mesenteric artery

Question 6

A 72-year-old man presents to his primary care physician because he has been having flank and back pain for the last 8 months. He said that it started after he fell off a chair while doing yard work, but it has been getting progressively worse over time. He reports no other symptoms and denies any weight loss or tingling in his extremities. His medical history is significant for poorly controlled hypertension and a back surgery 10 years ago. He drinks socially and has smoked 1 pack per day since he was 20. His family history is significant for cancer, and he says that he is concerned that his father had similar symptoms before he was diagnosed with multiple myeloma. Physical exam reveals a painful, pulsatile enlargement in the patient's abdomen. Between which of the following locations has the highest risk of developing this patient's disorder?

Accepted Answer

Renal arteries and common iliac arteries

Answer

Superior mesenteric artery and renal arteries

Answer

Diaphragm and renal arteries

Answer

Superior mesenteric artery and common iliac arteries

Answer

Diaphragm and superior mesenteric artery

Question 7

A 71-year-old man comes to the physician for a routine health maintenance examination. He feels well. He goes for a 30-minute walk three times a week and does not experience any shortness of breath or chest or leg pain on exertion. He has not had any weakness, numbness, or vision disturbance. He has diabetes that is well controlled with insulin injections. He had smoked one pack of cigarettes every day for 40 years but quit 5 years ago. He appears healthy and well nourished. His temperature is 36.3°C (97.3°F), pulse is 75/min, and blood pressure is 136/78 mm Hg. Physical examination shows normal heart sounds. There are systolic bruits over the neck bilaterally. Physical and neurologic examinations show no other abnormalities. Fasting serum studies show:
Total cholesterol 210 mg/dL
HDL cholesterol 28 mg/dL
LDL cholesterol 154 mg/dL
Triglycerides 140 mg/dL
Glucose 102 mg/dL
Duplex ultrasonography of the carotid arteries shows a 85% stenosis on the left and a 55% stenosis on the right side. Which of the following is the most appropriate next step in management?

Accepted Answer

Left carotid endarterectomy

Answer

Carotid artery stenting

Answer

Aspirin therapy only

Answer

Bilateral carotid endarterectomy

Question 8

A 45-year-old policeman presents with pain in the right leg after duty. On examination, the pulse in the right popliteal fossa is absent, and there is pain in the right buttock. The left side is normal. At which level is the blockage?

Accepted Answer

Iliac

Answer

Popliteal

Answer

Aortoiliac

Answer

Femoral

Question 9

A patient with varicose veins came to the hospital; an intern was on duty. Which test should he perform to assess the competency of deep veins?

Accepted Answer

Perthes test

Answer

Ober test

Answer

Thomas test

Answer

Brodie Trendelenburg test

Question 10

Which of the following is the best management for radiation induced occlusive disease of carotid artery?

Accepted Answer

Carotid angioplasty and stenting

Answer

Carotid endarterectomy

Answer

Low dose aspirin

Answer

Carotid bypass procedure

Vascular Surgery — MCQs

Vascular Surgery — MCQs

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