Vascular Surgery - Shelf-Life MCQs

Question 1

Which of the following is the greatest risk factor for developing an aortic aneurysm?

• Age
• History of Smoking
• History of Urolithiasis
• Metabolic Syndrome
• Male Sex

Answer 1

History of smoking

• Studies have shown that it increases the risk approximately eight times that of non-smoking adults.
• Other tobacco use also increases the risk

Additional risk factors:

• Hypertension
• Atherosclerotic disease
• Hypercholesterolemia
• Connective tissue disease - Ehlers-Danlos or Marfan’s syndrome

Urolithiasis is not a risk factor

Metabolic syndrome is a risk factor but not as great as smoking

Question 2

Does gender have an effect on the risk of developing an aortic aneurysm?

Answer 2

• Yes, men have a four to five fold increased risk of developing aortic aneurysms over that of women

Question 3

Following a femoral artery catherization - there is a pulsatile mass over the common femoral - the skin over the mass is erythematous - duplex ultrasonography shows a pocket of hypoechogenicity surrounding the artery contianing active blood flow that communicates with the underlying artery. Which is the most likely diagnosis?

• common femoral artery aneurysm
• hemangioma
• hematoma
• inguinal hernia
• pseudoaneurysm

Answer 3

Pseudoaneurysm

• Are hematomas that form outside the arterial wall, entrapped by surrounding tissue
• Hematoma communicates with the artery and will often present as a painful pulsatile mass
• Overlying skin can be edematous and erythematous
• Common causes:
  
  • Traumatic often because of medical procedures
• Diagnosed using:
  
  • Imaging such as duplex ultrasonography

**Why are the other answers wrong? **

• Common femoral artery aneurysm may also be present as a pulsate groin mass but the lesion developed in the site of recent procedure.
• Hemangioma may form - but takes time to grow - not an acute event
• Hematomas do occur - consider part of differential - but do not have active blood flow - do not communicate with artery
• Always consider inguinal hernia as a differential for patient presenting with groin mass - but in this case it developed after procedure so it’s excluded.

Question 4

A 55 year old man presents with acute onset of chest pain - described as severe and of a ‘‘tearing’’ quality - radiates to back. BP = 190/95, pulse 120 bpm and respiratory rate 20 breaths/min. Appears pale and diaphoretic. Which of the following supports diagnosis of thoracic aortic dissection?

• Difference in blood pressure between right and left arms
• Increased troponin levels
• Pain with palpation of the chest wall
• Systolic murmur on cardiac examination
• ST eleveations on ECG

Answer 4

Difference in blood pressure between right and left arms

• ​This along with patient’s clinical history suggests a diagnosis of aortic dissection.
• Other features:
  
  • Quality of pain (severe, tearing, radiating to the back between the scapulas)
  • Hypertension
• Diagnosis confirmed with:
  
  • Transesophageal echocardiography
  • Spiral CT imaging

**Why are other answers wrong? **

• Increased troponin levels would support a CARDIAC etiology for this man’s chest pain
• Pain with palpation of chest wall suggests a musculoskeletal etiology of man’s pain
• Systolic murmur does not suggest a diagnosis of aortic dissection
  
  • Occassionally dissection may involve aortic valve resulting in aortic insufficiency
    
    • If this occurs a diastolic murmur best heard in the right second intercostal space may be present
• ST elevations do not usually occur with aortic dissection - if present would support a cardiac etiology.

Question 5

50 year old woman complains of ‘bulge in stomach’ - she feels when she lies down. She denies pain or discomfort - but is worried. Past medical history is unremarkable - generally in good health. On examination - a pulsatile mass if felt below umbilicus just left of the midline. An aortic aneurysm is suspected. If confirmed which of the following features will support an elective repair of the aortic aneurysm?

• Growth of 0.2 cm per year
• History of smoking
• High risk of mortality with repair
• Palpable aneurysm
• Size of 4.7 cm in diameter

Answer 5

Size of 4.7 cm in diameter

• Patient is most likely presenting with an asymptomatic abdominal aortic aneurysm
• Elective repair for good surgical candiates provide a significant mortality benefit.
• Indications for electieve repair include a diameter greater than 5.4 cm in men and 4.5 cm in women.
• Patietns also candidates for elective repair if aneurysm enlarges greater than 0.5 cm in 6 months or 1 cm in 1 year.
• Patietns with significant co-morbidities such as congestive heart failure, severe COPD, symptomatic coronary artery disease and a life expectancy of less than 2 years - risks outweigh benefits of repair
• However, patients with significant comorbdities and aneurysms greater than 7 cm may sometimes be treated with elective repair.

**Why are other answers wrong? **

• Growth of 0.2 cm does not necessiate repair
• History of smoking is not an indication of elective repair
• Patients with high mortality from repair are not candidates
• Aneurysms are more likely to be palpable when patients are thin or with large size - hence not a part of criteria for elective repair.

Question 6

68 year old woman presents to surgical clinic with pain in right calf after walking 30 feet. Pain goes away on rest - reappears with additional walking. She has a history of smoking - 1/2 a pack for last 40 years. PMH - diabetes, obesity and recent UTI. BP = 130/80. Doppler pulses found in extremities and ABPI are 0.6 in left and 0.5 in the right. What is next best step in management?

• Anticoagulation with warfarin
• Arteriogram of her right leg
• Femoral-popliteal bypass surgery
• Observation
• Smoking cessation and exercise.

Answer 6

Smoking cessation and exercise

• Presenting with symptoms of claudication
  
  • intermittent claudication is caused by atherosclerotic blockage in the peripheral arteries
  • Separate entity than neurogenic claudication (presents similarly)
• First line tratment includes smoking cessation and aggressive exercise regimen
• Walking improves circulation and help collateral circulation form.
• Medications such as anti-platelet agents (NICE recommend clopidegerol then aspirin), lipid lowering agents and pain relievers may be used in management
• Surgery is a last resort

**Why are other answers wrong? **

• Warfarin not shown to prevent cardiac complications of peripheral artery disease
• Arteriogram may reveal atherosclerotic disease - test is invasive - not necessary to diagnose intermittent claudication
• Bypass surgery performed only when disease is severe - surgery is never a first line treatment for vascular conditions.
• Observation not appropriate as patient has risk factors that should be addressed.

Question 7

What is the most common acute complication in a patient who sufers from a popliteal artery aneurysm?

• Arteriovenous fistula formation
• Distal ischemia secondary to compartment syndrome
• Hematoma formation
• Rupture
• Thromboembolism

Answer 7

**Thromboembolism **

• Thrombosis occurs in as many as 55% of patients with popliteal aneurysms.

**Why are other answers wrong? **

• AV fistula formation may rarely occur in peripheral aneurysms but much less common than thromboembolism
• If distal ischemia occurs in patient with popliteal aneurysm - it is usually a result of thromboembolism rather than compartment syndrome
• Hematoma is not a common acute complication of popliteal aneurysm
• Rupture is a feared and deadly complication but an uncommon one - rupture results in amputation of the limb in 50% to 70% of patients.

Question 8

25 year old woman has headaches, dizziness and occasional chest pain. Once had high blood pressure during a pre-employment physical. Reports that mother had similar symptoms - died of a stroke at 34. Temperature is 37.2, BP is 175/90, pulse is 65 bpm and respiratory rate is 18/min. Her cardiovascular exam is unremarkable. Bruits are auscultated on both sides of umbilicus. What is the likely diagnosis?

• Atherosclerosis
• Connective tissue disease
• Essential hypertension
• Fibrovascular dysplasia
• Kawasaki disease

Answer 8

Fibrovascular dysplasia

• Suspect this in young adult with HTN and narrowing of renal arteries.
• It is an autosomal dominant disorder characterised by fibrous thickening of the arterial vessel walls.
• Most common cause of acquired renovascular hypertension
• Most common artery affected by this is the carotid artery - however renal arteries can be affected.
• Renal artery stenosis results in activation of renin-angiotensin system and water retention - further exacerbate the hypertension.

**Why are other answers wrong? **

• Atherosclerosis is more likely in older patients but unlikely in young woman
• Connective tissue disease is an unlikely cause of bilateral renal bruits
• Essential hypertension may result in similar symptoms if severe but more common amongst the elderly - unusual to have bilateral renal bruits
• Kawasaki more important amongst causes of renovascular hypertension in children.

Question 9

75 year old brought to A&E - after falling off char while having dinner. Complains of blurry vision. PMH - hyperlipidemia, coronary artery disease (CAD). On exam has limited function of right hand. After 24 hours, vision and strength are back to normal. CT head shows no ischaemic changes - blood glucose is normal. What is the most likely diagnosis?

• Normal old age
• Severe dementia
• Stroke
• Temporal arteritis
• TIA

Answer 9

TIA

• Symptoms typically last less than an hour but may last as long as 24 hours.
• Have no evidence of ischaemic damage

**Why are other answers wrong? **

• Patient’s presentation not a feature of normal aging.
• Severe dementia can present with neurological manifestation - does not present in an acute reversible manner such as this
• If patient suffered a stroke - there would be evidence of permanent neurologic change or evidence of ischemia on imaging.
• Temporal arteritis may present with blurry vision, but limited motor function is not a feature.

Question 10

What is the most common cause and risk factors for a TIA?

Answer 10

Most common cause:

• Atherosclerotic emboli from carotids

Risk factors include:

• Family history
• Age 55
• Older men
• African-american race
• HTN
• Diabetes
• Known atherosclerotic disease

Question 11

Which of the following is not a risk factor for development of peripheral arterial disease?

• Age over 50
• Hypertension
• Obesity
• Smoking
• Venous insufficiency

Answer 11

Venous insufficiency

• Condition caused by impaired venous valves resulting in pooling, dilated peripheral veins and retrograde flow of venous blood

Question 12

What are the common symptoms of venous insuffiency?

Answer 12

1. Pruritus
2. Swelling
3. Burning aching
4. Leg fatigue
5. Hyper-pigmentation of the legs

Question 13

What are the risk factors for venous insufficiency?

Answer 13

1. Age over 50
2. Hypertension
3. Obesity
4. Smoking
5. Diabetes
6. Hyperlipidemia
7. Hypercoagulable states

Question 14

Which of the following medications has been shown to increase walking distance, improve HDL cholesterol, decrease triglycerides and improve quality of life in patients suffering from intermittent claudication?

• Altepase
• Aspirin
• Cilostazol
• Heparin
• Simvastatin

Answer 14

Cilostazol

• A selective inhibitor of type 3 phosphodiesterase used for intermittent claudication.
• Studies show it increases the amount of pain-free walking distance, improves HDL cholesterol by up to 13%, reduces triglycerides by up to 16% and significantly improves the quality of life in patients suffering from intermittent claudication

**Why are other answers wrong? **

• Alteplase is a thrombolytic drug that may be used in acute episodes of vascular occlusion - not appropriate in this case
• Aspirin is a first line agent for treatment of this condition - however has not shown to increase amount of pain-free walking distance.
• No benefit has been established for use of heparin for this condition.
• Simvastatin has been shown to improve HDL and decrease triglycerides - its main effect is on LDL cholesterol and decreasing cardiovascular disease.
  
  • Not known for benefiting walking distance or quality of life.
    *

Question 15

Which of the following is the most common site for an aneurysm in the cerebral blood supply?

• Anterior cerebral
• Internal carotid
• Middle cerebral
• Posterior cerebral
• Superior cerebellar artery

Answer 15

Anterior cerebral artery

• Most common site for a cerebral aneurysm is the anterior cerebral

Question 16

What is the hemodynamic profile of a patient following the placement of an arteriovenous fistula?

Answer 16

• Arteriovenous fistulas are known to induce severeal hemodynamic changes.
• An AV fistula shunts oxygenated blood directly into venous circulation
• Arterial conductance increases
  
  • Cardiac output mus increase
• Decreased total systemic vascular resistance
• Increased cardiac output
• Increased stroke volume
• Increased heart rate

Question 17

59 year old man is referred to the surgery clinic after his GP heard a bruit over his left carotid artery. Is asymptomatic - although admits he is currently on medication for ‘‘high cholesterol’’. Doppler reveals 75% stenosis on the left and 30% stenosis on the right. Which of the following is the next best step in management of this patient’s carotid stenosis?

• Anticoagulation
• Bilateral carotid endarterectomy
• Left carotid endarterectomy
• Observation
• Right carotid endarterectomy

Answer 17

**Left carotid endarterectomy **

• Studies show a significant benefit of surgical intervention in preventing morbidity and mortality with over 70% stenosis in asymptomatic stenosis
  
  • If patient is symptomatic, the stenosis threshold may sometimes be lowered

**Why are other answers wrong? **

• Although anticoagulation with medications such as aspirin may be appropriate for long term management - this patient has over 70% stenosis in the left side - needs surgery
• Patient has 30% stenosis on right hand side - does not qualify for surgery
• Observation not appropriate - there is significant stenosis on left carotids and atherosclerotic disease in the left.

Question 18

68 year old man presents with pain in his legs during walking. Pain decreases with rest - comes back when walking again. Smoked 2 packs of cigarettes per day for the last 40 years. Has hypertension and obesity. Temperature - 36.9, BP - 135/85 mmHg, pulse 67 bpm and respiratory rate 15 breaths/min. On examination, pulses in his distal lower extremities are not palpable. Which of the following is the next best step in diagnosis?

• Angiography
• Ankle-brachial index
• Computed tomographic angiography
• Electrocardiogram
• Magnetic resonance angiography

Answer 18

**Ankle-brachial index **

• Inexpensive and noninvasive test for diagnosing peripheral vascular insufficiency
• Measures systolic arterial pressure at ankle and brachial artery using Doppler
• Normal ABI is about 1.
• Mild claudication - 0.6-0.8
• Severe claudication - Less than 0.5
• Pain at rest and tissue necrosis may occur with ABIs less than 0.3

**Why are other answers wrong? **

• Angiography is the gold standard for diagnosing peripheral arterial disease (PAD) - invasive and reserved for patients undergoing surgical treatment
• CT angiograph be used in certain settings but not as an initial test for diagnosis in this case
• Patients with PAD have cardiac pathology but this patient has no evidence of ischemic heart changes - no need for ECG
• MR angiography is again useful in some settings - but it is expensive and not the initial test in the work-up

Question 19

59 year old woman with family history of breast cancer has BP 145/85, pulse 70bpm and respiratory rate 13 breaths/min. On examination - several large ulcers starting at the mid-calf and extending down to the lateral malleolus. Skin in her lower extremities is flaking, is thick, has brown discoloration. What is the most likely diagnosis?

• Arterial insufficiency
• Diabetic ulcers
• Gout
• Trauma
• Venous insufficiency

Answer 19

Venous insufficiency

• Most likely suffering from venous stasis
• Symptoms indicate chronic venous insufficiency
  
  • swelling in lower legs
  • achiness
  • venous eczema
  • stasis ulcers

**Why are other answers wrong? **

• Ulcers of arterial insufficiency are usually located on the dorsum of the feet or toes
  
  • Ulcer base is covered with granulation tissue and bleeds very little with manipulation
  • Will show signs of arterial insufficiency such as hairlessness, pale cold skin and absent pulses
• Diabetic ulcers result from diabetic neuropathy and poor wound healing- usually occur over bony prominences in the extremities
• Tophaecous gout often occurs in the big toe and may result in ulceration - patient’s presentation not consistent with diagnosis
• Traumatic woulds follow a history of trauma.

Question 20

How can you distinguish a stasis ulcer?

Answer 20

By their location (starting at the mid-calf and extending down to the lateral/medial malleolus) and shallow ulcer bed.

Question 21

75 year old man presents with cramping in his legs. Pain getting worse over the last year - begins after 10 minutes of walking and goes away with rest. PMH - CAD and diabetes. On examination - skin on distal extremities are dry and flaky with loss of hair. Pedal pulses are diminished. Patien’s ankle-brachial index is 1.3. Which of the following is the most likely cause of this patient’s symptoms?:

• DVT
• Neurogenic claudication
• Peripheral arterial disease
• Restless leg syndrome
• Venous insufficiency

Answer 21

Peripheral arterial disease

• Patient presentation is classical for arterial insufficiency
• ABI is usually decreased in such patients - although may be falsely elevated due to calcification and stiffening of his peripheral arteries (due to Diabetes)

**Why are other answers wrong? **

• Symptoms such as pain, swelling, redness and warmth suggest a diagnosis of deep vein thrombosis are not present in the case
• Neurogenic claudication (often caused by spinal stenosis) may be confused with intermittent claudication, neurogenic claudication will improve with hip flexion and worsen with extension.
• Restless leg syndrome is a disorder defined by the urge or need to move legs to stop unwanted sensation.
  
  • This patient does not describe symptoms consistent with this diagnosis.
• Venous insufficiency does not present with symptoms of intermittent cramping with exercise.

Question 22

57 year old referred to clinic with worsening pain in the lower 1/3 of calf. Pain is so severe it prevents him from working. Exercises and quit smoking 7 mths ago. Current medications include clopidogrel, hydrochlorothiazide and simvastatin.

On examination - patient’s distal pulses not felt. An arteriogram demonstrates occlusion of superficial femoral and poplitel arteries. Intact flow is seen distal to the blockage. Which of the following is the most appropriate management?

• Amputation
• Anticoagulation
• Aortofemoral bypass
• Femoropopliteal bypass
• Observation

Answer 22

Femoropopliteal bypass

• Drastically improves lifestyle in cases with severe debilitating claudication disease
• After successful reconstruction patient will require frequent examinations for patency of the graft and medications to reduce atherosclerotic disease.

**Why are other answers wrong? **

• Amputation is not appropriate as tissue distal to blockage is not necrotic or containing irreversible ischemia
• Patient is taking anticoagulation without seeing improvement
• An aortofemoral bypass would not help as the blockage is distal to the femoral artery.
• Observation alone is not appropriate for disabling claudication.

Question 23

67 year old man has hip replacement. Operative and immediate postoperative course is unremarkable. Week after surgery - complains of low grade fevers and left leg pain extending from medial thigh to the calf. On examination, the pain is worse with dorsiflexion of the foot. There is a mild discoloration of the left lower extremity and pain with palpation of the calf muscle. Which of the following is the next best step in management?

• Compression ultrasonography
• D-dimer assay
• Helical computed axial tomography
• Observation
• Ventilation-perfusion scan

Answer 23

Compression ultrasonography

• Patient has a high likelihood of DVT - need venous ultrasonography for diagnosis.
• First step in diagnosis in cases with moderate to high likelihood of DVT

**Why are other answers wrong? **

• D-dimer is a degradation product of cross-linked fibrin found in blood clots
  
  • typically elevated in DVT
  • However, due to the many other conditions that can result in an elevation in the D-dimer levels - this test is not specific for DVT
• Helical CT is the first line test for diagnosis of PE (aka CTPA)
• Observation not correct choice because of likelihood of DVT
• Ventilation perfusion is appropriate in cases with PE

Question 24

52 year old woman underwent cholecystectomy for gallbladder disease - complains of left leg pain - severel days after operation. Has stage 3 lung cancer with metastasis to colon, diabetes, anaemia secondary to mild gastrointestinal bleeding. On examination, palpable cord noted on the lateral aspect of left calf - leg is warm and swollen. What is the next best step in management?

• Anticoagulation with heparin
• Anticoagulation with heparin followed by warfarin
• Aspirin
• Low molecular weight heparin
• Vena cava filter
  *

Answer 24

Vena cava filter

• Patient most likely suffering from DVT following surgery
• Recent surgery involving risk of bleeding along with co-morbidities such as lung cancer and GI bleeding means anticoagulation is contra-indicated
• IVC filters are generally placed percutaneously and accessed through the femoral or jugular vein approach.

Question 25

71 year old woman comes to A&E after ‘‘passing out’’ - arrives complaining of abdominal pain. She is in acute distress and appears pale and diaphoretic. BP is 95/65, pulse 125 bpm and respirations 20 breaths/minute. An abdominal examination reveals moderate diffuse tenderness and a pulsatile mass in the lower mid-abdomen. Which of the following is the most likely diagnosis?

• Aortic dissection
• Ruptured abdominal aortic aneurysm
• Seizure
• Splanchnic ischemia
• Stroke

Answer 25

**Ruptured abdominal aortic aneurysm **

• Patietn’s symptoms of syncope and abdominal pain along with physical examination findings are strong evidence for ruptured abdominal aortic aneurysm
• Surgically repaired ASAP
• If diagnosis in doubt and patient stable then CT or ultrasound can assist in diagnosis.

**Why are other answers wrong? **

• Abdominal aortic dissections are rare events outside of trauma and involve separation of the layers of the abdominal aortic wall.
  
  • BP is usually stable.
• Although a seizure might explain this patient’s initial syncope - the rest of her presentation is not explained by a seizure.
• Although splanchnic ischemia could explain the abdominal pain - it would not present with a pulsatile abdominal mass and hemodynamic instability.
• While the stroke could explain the patient’s loss of consciousness - it would not explain the rest of her symptoms.