Vascular Surgery — MCQs

Vascular Surgery Indian Medical PG Practice Questions and MCQs

Question 511: Which of the following is the preferred graft material for femoropopliteal bypass?

A. PTFE
B. Dacron
C. Reversed saphenous (Correct Answer)
D. None of the options

Explanation: ***Reversed saphenous*** - The **autologous reversed saphenous vein** is considered the **gold standard** for femoropopliteal bypass due to its superior patency rates and resistance to infection. - The vein's valves are bypassed by reversing its orientation, ensuring unidirectional blood flow. *Dacron* - **Dacron (polyethylene terephthalate)** grafts are synthetic and commonly used for large-diameter arterial bypasses, such as in the aorta, but have **inferior patency in infrainguinal bypasses** compared to autologous vein. - **Higher rates of thrombosis and infection** are observed with Dacron in smaller leg vessels due to compliance mismatch and increased anastomotic intimal hyperplasia. *PTFE* - **Polytetrafluoroethylene (PTFE)** grafts are synthetic and are an option when autologous vein is unavailable, particularly for above-knee femoropopliteal bypasses. - However, PTFE generally has **lower long-term patency rates** and a higher risk of complications like **graft thrombosis and infection** compared to autologous vein grafts. *None of the options* - This option is incorrect because the **reversed saphenous vein** is indeed a preferred and highly effective graft material for femoropopliteal bypass. - The clinical evidence strongly supports its use over synthetic alternatives when available.

Question 512: The size threshold at which the risk of rupture of an abdominal aortic aneurysm significantly increases is:

A. 5.5 cm (Correct Answer)
B. 6 cm
C. 6.5 cm
D. 7 cm

Explanation: ***5.5 cm*** - An abdominal aortic aneurysm (AAA) 5.5 cm or larger is typically the threshold for considering **elective surgical repair** due to significantly increased **rupture risk**. - For aneurysms smaller than this, the risk of surgery often outweighs the risk of rupture, making watchful waiting with surveillance more appropriate. *6 cm* - While a 6 cm AAA certainly has a very high risk of rupture, the generally accepted guideline for intervention begins at **5.5 cm** for most patients. - Delaying intervention until 6 cm could unnecessarily expose the patient to a higher risk of rupture. *6.5 cm* - An AAA of 6.5 cm carries an extremely high risk of rupture, and intervention would be strongly indicated. - This size is well past the standard **5.5 cm threshold** recommended for elective repair. *7 cm* - A 7 cm AAA is associated with a **critical and very high risk of rupture**, making immediate intervention imperative. - This size is significantly beyond the established guideline for considering elective repair, which is 5.5 cm.

Question 513: Claudication due to femoropopliteal incompetence is primarily seen in

A. Thigh
B. Calf (Correct Answer)
C. Buttocks
D. Feet

Explanation: ***Calf*** - **Femoropopliteal incompetence** refers to insufficiency in the superficial femoral and popliteal arteries. Blockage in these arteries typically results in **claudication** symptoms downstream from the obstruction. - The **calf muscles** receive their blood supply via these arteries and are therefore the primary site of pain due to inadequate blood flow during exertion, manifesting as claudication. *Thigh* - Claudication in the **thigh** is usually associated with more proximal arterial obstructions in the **aortoiliac system** or common femoral artery. - While thigh muscles are located upstream from the calf, pain would indicate a blockage higher up than the femoropopliteal segment. *Buttocks* - **Buttock claudication** points to very proximal arterial disease, specifically involving the **internal iliac arteries** or the distal aorta (**Leriche syndrome**). - This is even further upstream than the femoropopliteal arteries and would involve more significant and widespread circulatory compromise. *Feet* - While the **feet** can experience pain due to arterial insufficiency, particularly with severe disease or at rest, isolated foot claudication is less common. - **Claudication** specifically points to muscle ischemia during activity, and the robust musculature of the calf makes it the primary site when femoropopliteal arteries are involved.

Question 514: In which condition is fatal exsanguination most likely to occur?

A. Closed fracture of femur shaft
B. Open fracture of femur & tibia
C. Partial transection of artery (Correct Answer)
D. Complete transection of artery

Explanation: ***Partial transection of artery*** - A **partial transection** of an artery is associated with the **highest risk of fatal exsanguination** compared to complete transection. - In partial transection, the vessel wall is incompletely severed, which **prevents arterial retraction** and **inhibits vasospasm** - the two key mechanisms that help control bleeding. - The arterial edges remain tethered and held apart, allowing **unimpeded, continuous bleeding** from the open defect in the vessel wall. - This is a **well-established surgical principle**: "An artery that is partially transected bleeds more than one that is completely transected." *Complete transection of artery* - While a **complete transection** initially causes severe hemorrhage, the completely severed artery ends can **retract into surrounding tissues**. - The smooth muscle in the arterial wall undergoes **vasospasm**, causing the lumen to narrow significantly. - These two protective mechanisms (retraction + vasospasm) help **reduce the rate of bleeding** compared to partial transection. - This is why complete transection may sometimes allow time for clot formation and temporary hemostasis. *Closed fracture of femur shaft* - A **closed fracture of the femur shaft** can cause significant internal bleeding (up to 1-2 liters) into surrounding soft tissues. - However, the **intact fascial compartments** create a tamponade effect that limits ongoing blood loss. - The bleeding is from cancellous bone and smaller vessels, not from a major arterial injury with continuous high-pressure flow. *Open fracture of femur & tibia* - An **open fracture** involves substantial trauma with potential for major blood loss from bone, soft tissue, and associated vascular injuries. - However, unless there is a specific **major arterial injury** (partial or complete transection), the bleeding is primarily from cancellous bone and smaller vessels. - The open wound allows external hemorrhage but does not inherently carry the same risk as a partially transected major artery with prevented vasospasm.

Question 515: Surgery in varicose veins is NOT attempted in the presence of which of the following?

A. Deep vein thrombosis (Correct Answer)
B. Multiple incompetent perforators
C. Varicose veins with leg ulcer
D. None of the above

Explanation: ***Deep vein thrombosis*** - **Surgery in varicose veins is absolutely contraindicated in the presence of DVT** (both acute and chronic) - In **acute DVT**, the deep venous system is already compromised, and removing superficial veins could further impair venous return and worsen the thrombotic state - In **chronic DVT with post-thrombotic syndrome**, the deep veins may be occluded or heavily damaged, and the superficial varicosities often serve as **crucial collateral vessels** to maintain venous drainage—their removal would be detrimental - Surgery should only be considered after complete resolution of acute DVT and adequate anticoagulation *Multiple incompetent perforators* - **NOT a contraindication**—incompetent perforators are actually a common indication for surgical treatment - Incompetent perforators contribute to venous insufficiency and recurrent varicose veins - Can be addressed surgically with **subfascial endoscopic perforator surgery (SEPS)** or endovenous ablation techniques - Their presence often indicates need for more comprehensive treatment alongside superficial venous surgery *Varicose veins with leg ulcer* - **NOT a contraindication**—venous leg ulcers are actually an **indication for varicose vein surgery** - Leg ulcers result from chronic venous hypertension due to venous insufficiency - Surgical treatment (saphenous vein ablation, ligation and stripping, or sclerotherapy) reduces venous hypertension and improves venous drainage - Surgery promotes ulcer healing and prevents recurrence when combined with appropriate wound care *None of the above* - Incorrect because **Deep Vein Thrombosis (DVT) is a well-established contraindication** to varicose vein surgery

Question 516: May-Thurner or Cockett syndrome involves:

A. Left iliac vein compression (Correct Answer)
B. Internal iliac artery obstruction
C. Common iliac artery obstruction
D. Internal iliac vein obstruction

Explanation: ***Correct: Left iliac vein compression*** - May-Thurner syndrome, also known as Cockett syndrome, specifically describes the **compression of the left common iliac vein** by the overlying right common iliac artery. - This anatomical compression can lead to **venous outflow obstruction**, increasing the risk of deep vein thrombosis (DVT) in the left leg. *Incorrect: Internal iliac artery obstruction* - This condition involves an artery and is unrelated to May-Thurner syndrome, which is a **venous compression disorder**. - Obstruction of the internal iliac artery would typically cause symptoms of **pelvic ischemia** or erectile dysfunction, not venous DVT. *Incorrect: Common iliac artery obstruction* - Obstruction of the common iliac artery is an **arterial occlusion** that would cause peripheral artery disease symptoms in the leg, such as claudication or rest pain. - It does not involve the compression of a vein by an artery, which is characteristic of May-Thurner syndrome. *Incorrect: Internal iliac vein obstruction* - While this is a venous issue, May-Thurner syndrome specifically involves the **common iliac vein**, not the internal iliac vein. - Obstruction of the internal iliac vein would typically present with symptoms related to pelvic venous congestion, distinct from the left lower extremity DVT associated with May-Thurner syndrome.

Question 517: What is the basis for the classification of aortic dissection?

A. Type of dissection
B. Level of aorta affected (Correct Answer)
C. Extent of aorta affected
D. None of the options

Explanation: ***Level of aorta affected*** - The classification of aortic dissection is **primarily based on the anatomical location** of the dissection within the aorta. - **Stanford Classification** (most commonly used): Based on whether the **ascending aorta** is involved (Type A) or not involved (Type B) - this is fundamentally about the **level/location**. - **DeBakey Classification**: Based on the **site of origin** (ascending vs descending) and whether it propagates - the primary determinant is still which **level** of the aorta is involved. - While extent matters, the **initial classification decision** hinges on identifying **which segment (level)** of the aorta contains the dissection. *Type of dissection* - Classification systems do **not** primarily categorize by the type of pathology (e.g., intimal tear, intramural hematoma, penetrating atherosclerotic ulcer). - The established **Stanford and DeBakey systems** focus on **anatomical location and extent**, not the histological or pathological type of the dissection. *Extent of aorta affected* - While extent is an **important component** of classification (especially in DeBakey system which distinguishes localized vs extensive dissection), it is **secondary to location**. - The **primary decision point** in classification is determining **which level of the aorta** is involved (ascending vs descending), and then extent further refines the classification. - For example, Stanford Type A includes all dissections involving the ascending aorta **regardless of extent** - the level takes precedence. *None of the options* - This is incorrect because well-established classification systems (Stanford A/B and DeBakey I/II/III) clearly exist. - These systems are **based on anatomical criteria**, with the **level (location) of aortic involvement** being the fundamental basis for classification.

Question 518: Volkmann's contracture: which artery is involved in this condition?

A. Radial
B. Ulnar
C. Brachial artery (Correct Answer)
D. Anterior interosseous artery

Explanation: ***Brachial artery*** - **Volkmann's contracture** is an ischemic contracture of the forearm muscles, classically caused by injury or compression of the **brachial artery** - The most common cause is **supracondylar fracture of the humerus** in children, which can damage or compress the brachial artery - Brachial artery injury → **forearm ischemia** → **compartment syndrome** in the anterior (flexor) compartment → muscle necrosis → **ischemic contracture** - The **brachial artery** is the main arterial supply to the forearm, and its compromise leads to the widespread ischemia necessary for Volkmann's contracture - **Clinical features**: Flexion deformity of the wrist and fingers, claw hand, sensory loss in the distribution of median and ulnar nerves *Anterior interosseous artery* - The **anterior interosseous artery** is a branch of the common interosseous artery (from the ulnar artery) that supplies deep forearm muscles - While it contributes to forearm circulation, **isolated injury** to this smaller branch vessel does not typically cause the extensive ischemia required for Volkmann's contracture - The primary vascular pathology in Volkmann's contracture involves the **main arterial trunk** (brachial artery), not its distal branches *Radial* - The **radial artery** is one of the two terminal branches of the brachial artery in the forearm - It primarily supplies the **lateral compartment** and contributes to hand circulation - Isolated radial artery injury does not cause Volkmann's contracture, as the ulnar artery provides collateral circulation - The pathology requires compromise of the **main arterial supply** proximal to the forearm *Ulnar* - The **ulnar artery** is the other terminal branch of the brachial artery - It supplies the **medial forearm** and hand - Similar to radial artery, isolated ulnar artery injury has collateral compensation from the radial artery - Volkmann's contracture requires **proximal arterial compromise** (brachial artery level) affecting the entire forearm blood supply

Question 519: IVC filter is used in the following situations except -

A. To reduce symptoms
B. As primary treatment for acute DVT (Correct Answer)
C. Negligible size of emboli
D. To prevent progress of native blood vessel disease

Explanation: ***As primary treatment for acute DVT*** - The **primary treatment** for **acute deep vein thrombosis (DVT)** is **anticoagulation therapy** (heparin, warfarin, or DOACs) to prevent clot propagation and embolization. - An **IVC filter** is **NOT primary therapy**—it is reserved for specific situations and does not treat the underlying thrombosis. - **Indications for IVC filter include:** - Absolute **contraindication to anticoagulation** (active bleeding, recent hemorrhagic stroke) - **Recurrent PE despite adequate anticoagulation** - Complications from anticoagulation therapy - Therefore, using IVC filter as primary treatment for acute DVT is **incorrect and not indicated**. *Negligible size of emboli* - While IVC filters trap **large emboli**, the concept of "negligible size emboli" is not a standard clinical consideration for filter placement. - IVC filters are indicated based on **risk of PE** and **contraindications to anticoagulation**, not based on emboli size assessment. *To reduce symptoms* - **IVC filters** do not reduce symptoms of DVT such as pain, swelling, or discomfort. - They function as a **mechanical barrier** to prevent emboli from reaching pulmonary circulation. - Symptom management requires anticoagulation, compression therapy, and leg elevation. *To prevent progress of native blood vessel disease* - IVC filters do not influence progression of underlying **vascular disease** such as atherosclerosis or chronic venous insufficiency. - Their sole function is **mechanical prevention of PE**, not disease modification.

Question 520: Which of the following conditions is least likely to lead to gangrene?

A. Varicose veins (Correct Answer)
B. Atherosclerosis
C. Frost bite
D. Burger's disease

Explanation: ***Varicose veins*** - **Varicose veins** are characterized by **venous insufficiency** and primarily lead to **venous ulcers** and skin changes due to chronic venous hypertension, but they **rarely directly cause gangrene**. - Gangrene fundamentally results from **arterial insufficiency** (lack of oxygenated blood flow), which is not the primary pathophysiology of varicose veins. - While severe chronic venous stasis can predispose to secondary complications like infections or tissue breakdown, true gangrene from varicose veins alone is exceptionally rare. *Atherosclerosis* - Atherosclerosis is actually a **common cause of gangrene**, particularly in elderly patients and those with diabetes. - Progressive arterial occlusion leads to **critical limb ischemia** and subsequent **tissue necrosis**. - Accounts for a significant proportion of lower limb gangrene cases, especially in the context of peripheral arterial disease. *Frostbite* - **Frostbite** causes direct tissue injury through freezing, leading to **cellular damage** and **vascular occlusion**. - Ice crystal formation destroys cells and causes thrombosis of blood vessels. - Gangrene is a **common and severe complication** of significant frostbite injuries. *Buerger's disease* - **Buerger's disease (thromboangiitis obliterans)** involves widespread inflammation and **thrombosis of small and medium-sized arteries and veins**, particularly in the extremities. - The recurrent inflammation and subsequent occlusion of vessels are a **primary cause of severe ischemia** and gangrene. - Classically seen in young male smokers, with gangrene being a hallmark complication.

Practice by Chapter

Atherosclerotic Disease

Practice Questions

Aortic Aneurysms

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Peripheral Arterial Disease

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Carotid Artery Disease

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Venous Thromboembolism

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Chronic Venous Insufficiency

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Mesenteric Vascular Disease

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Vascular Trauma

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Vascular Access for Hemodialysis

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Endovascular Techniques

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Diabetic Foot Vascular Disease

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Vasculitis

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