VASCULAR SURGERY
Question 1 of 52
A 73 year old man develops an acutely ischaemic limb. He was previously a stable claudicant. The decision is made to
attempt intra-arterial thrombolysis. Which of the following agents should be used?
Alteplase
Urokinase
Streptokinase
Anistreplase
Kabikinase
ANS:
Question 2-4 of 52
Theme: Arterial lesions
A. Popliteal artery
B. Vertebral artery
C. Aorto-iliac disease
D. Superior mesenteric artery
E. Right common iliac artery
F. Left common iliac artery
G. Internal iliac arteries
H. Subclavian artery
I. Carotid artery
J. Coeliac axis
Please select the most likely site for the arterial lesion described. Each option may be used once, more than once or not
at all.
2. A patient presents with dysphagia lusoria.
ANS:
3. A patient presents with median arcuate ligament syndrome.
ANS:
4. A patient presents with May-Turner syndrome.
ANS:
Question 5 of 52
A 77 year old hypertensive man presents with abdominal pain presents to their local hospital (there are no vascular
surgeons) where a leaking abdominal aortic aneurysm is found. What is the most appropriate course of action?
Commence aggressive fluid resuscitation and transfer to a vascular unit
Aim to maintain stable systolic Bp and transfer to a vascular unit
Undertake a laparotomy
Admit to a surgical ward for close observation and rescan at 24 hours
Arrange for urgent vascular outpatient appointment
ANS:
Question 6-8 of 52
Theme: Endoleaks with endovascular aortic surgery
A
Type IA endoleak
.
B
Type II endoleak
.
C
Type IB endoleak
.
D
Type III endoleak
.
E. Type IV endoleak
F. Type V endoleak
Please select the type of endoleak associated with the scenario given. Each option may be used once, more than once or
not at all.
6. An endoleak that accounts for up to 60% of all endoleaks.
ANS:
7. An endoleak that occurs when blood escapes from the component separation of a
multicomponent stent graft.
ANS:
8. An endoleak type that is classically a high pressure leak from the proximal end of
an endovascular graft.
ANS:
Question 9 of 52
What is the commonest cause of a type II endoleak following endovascular stent graft placement within the abdominal
aorta?
Back bleeding from the coeliac axis
Back bleeding from the inferior mesenteric artery
Component separation of the iliac limb of the graft
Proximal migration of the graft
Inadequate seal at the proximal end of the graft
ANS:
Question 10 of 52
What is the commonest aneurysm encountered in the extremity?
Radial
Popliteal
Femoral
Brachial
Carotid
ANS:
Question 11 of 52
In the MRC asymptomatic carotid artery surgery trial, what was the overall rate of stroke in those who had undergone
surgery in the previous 5 years?
6%
3%
12%
20%
25%
ANS:
Question 12 of 52
A 23 year old lady presents with hyperhidrosis of the palms. She is keen to undergo a thoracoscopic sympathectomy to
treat the disorder. Which ganglia should be divided to best address her symptoms?
Ganglia at T1 only
Ganglia at T1 and T2
Ganglia at T4
Ganglia at T3 and T4
Ganglia at T2 and T3
ANS:
Question 13 of 52
A 52 year old male is referred to urology clinic with impotence. He is known to have hypertension. He does not have any
morning erections. On further questioning the patient reports pain in his buttocks, this worsens on mobilising. On
examination there is some muscle atrophy. The penis and scrotum are normal. What is the most likely diagnosis?
Leriche syndrome
S3-S4 cord lesion
Pudendal nerve lesion
Psychological impotence
Beta blocker induced impotence
ANS:
Question 14-16 of 52
Theme: Compression stockings
A. 50-60 mmHg
B. 14-17 mmHg
C. 5-10 mmHg
D. 45-55 mmHg
E. 18-24 mmHg
F. 10-20 mmHg
G. 25-35 mmHg
Please select the level of compression provided by the following classes of compression stockings according to the UK
standard of compression.
14. Class II compression stockings
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15. Class I compression stockings
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16. Class III compression stockings
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Question 17 of 52
A 22 year old man is referred to the surgical clinic. He has been complaining of varicose veins for many years. On
examination he has extensive varicosities of the right leg, there are areas of marked port wine staining. The
saphenofemoral junction is competent on doppler assessment. What is the most likely underlying diagnosis?
Deep vein thrombosis
Klippel-Trenaunay syndrome
Varicose veins due to sapheno-popliteal junction incompetence
Sturge - Weber syndrome
Angiosarcoma
ANS:
Question 18 of 52
A 65 year old man is to undergo a below knee amputation. What is the minimum length of bone to conserve below the
knee joint?
10cm
15cm
5cm
20cm
25cm
ANS:
Question 19 of 52
Where are most cirsoid aneurysms located?
Scalp
Thigh
Trunk
Abdomen
Back
ANS:
Question 20-22 of 52
Theme: Aneurysmal disease
A. Discharge
B. Repeat USS in 12 months
C. Repeat USS in 6 months
D. Repeat USS in 3 months
E. CT scanning in 3 months
F. Routine vascular surgical referral
G. Emergency admission under vascular surgeons
H. Urgent outpatient clinic appointment within 2 weeks
I. Urgent outpatient clinic appointment within 6 weeks
Please select the most appropriate management for the following patients. Each option may be used once, more than
once or not at all.
20. A 65 year old man is screened as part of the UK abdominal aortic aneurysm
screening programme. He is identified as having an aortic diameter of 4cm.
ANS:
21. A 65 year old man is screened as part of the UK abdominal aortic aneurysm
screening programme. He is identified as having an aortic diameter of 5.8cm.
ANS:
22. A 65 year old man is screened as part of the UK abdominal aortic aneurysm
screening programme. He is identified as having an aortic diameter of 2.9cm.
ANS:
Question 23 of 52
A 73 year old man presents with intermittent claudication and is found to have a significant stenosis affecting the
midpoint of the common iliac artery. It measures 2cm in length and there is a maximum of 90% stenosis. What is the most
appropriate course of action?
Arrange a femoro-femoral cross over graft
Arrange an angioplasty and insertion of metallic stent
Arrange an axillo-femoral bypass graft
Arrange an iliac artery endarterectomy
Arrange an aorto-femoral bypass graft
ANS:
Question 24 of 52
A 70 year old man is investigated following a transient ischaemic attack and found to have an 80% stenosis of the
ipsilateral carotid artery. Apart from treated hypertension, he has not other medical co-morbidities. What is the most
appropriate long term management?
Carotid endarterectomy within 2 weeks
Carotid endarterectomy 3 months from the time the patient has recovered
Insertion of expanding metallic endovascular stent
Optimal medical management and duplex surveillance of the carotid artery
Balloon angioplasty of the carotid artery stenosis
ANS:
Question 25 of 52
What is the largest accepted size for a 'normal' abdominal aorta on ultrasound scanning?
3cm
1.8cm
2cm
4cm
3.5cm
ANS:
Question 26-28 of 52
Theme: Causes of arterial occlusion
A. Vasculitis
B. Steal syndrome
C. Thrombosis
D. Foreign body embolus
E. Clot embolus
F. Vasospasm
G. Direct arterial injury
Please select the most likely underlying cause for the scenario provided. Each option may be used once, more than once
or not at all.
26. A 73 year old lady develops a cold, pulseless hand 3 days following a myocardial
infarction.
ANS:
27. A 6 year old child has suffered a displaced supracondylar humeral fracture. On
examination they have a cold and insensate hand with absent pulses.
ANS:
28. A 26 year old man who smokes heavily develops aching, crampy pains in his legs.
On examination distal limb pulses are diminished.
ANS:
Question 29 of 52
A 67 year old man is undergoing intra-arterial thrombolysis with alteplase. The nursing staff are concerned about how
long to wait after stopping the infusion prior to removing the sheath. What is the half-life of this drug?
5 minutes
15 minutes
25 minutes
30 minutes
120 minutes
ANS:
Question 30 of 52
A 60 year old man is noted to have a common iliac aneurysm. It is decided to pursue a policy of surveillance. At which of
the sizes listed below should surveillance cease and surgery be performed?
1.5cm
2.5cm
3cm
2cm
3.5cm
ANS:
Question 31 of 52
A 28 year old lady presents with a long history of postprandial epigastric pain, weight loss and occasional vomiting. The
pain is relieved slightly by lying in her left hand side. Investigation with an OGD and small bowel MRI scan was
unremarkable. An upper GI contrast study was performed which demonstrates a band like extrinsic compression of the
third part of the duodenum and a slightly high insertion of the fourth part of the duodenum. What is the most likely
diagnosis?
Nutcracker syndrome
Median arcuate ligament syndrome
Superior mesenteric artery compression syndrome
Arteria lusoria
Psychosomatic vomiting
ANS:
Question 32-34 of 52
Theme: Peripheral vascular disease management
A. Medical therapy alone
Medical therapy for risk factors together with naftidrofuryl
B.
oxalate
C. Medical therapy for risk factors and exercise programme
D. Angioplasty and insertion of drug eluting stent
E. Angioplasty and insertion of bare metal stent
F. Angioplasty alone
G. Aorto-femoral bypass graft
H. Femoro-distal bypass graft
I. Primary amputation
J. Axillo-femoral bypass graft
Please select the most appropriate management for the following patients. Each option may be used once, more than
once or not at all.
32. A 68 year old man presents with intermittent claudication with an exercise
distance of 15 yards. He is an ex-smoker and is currently taking aspirin 75mg and
simvastatin 40mg. On examination, he has an ulcer on the medial aspect of his
hallux. His ABPI is 0.4. Imaging confirms complete occlusion of the common and
external iliac systems with reasonable refilling of the common femoral artery via
collaterals.
ANS:
33. A 67 year old man presents with short distance claudication and an ulcer affecting
the middle toe of his right foot. His ABPI is 0.5. Imaging confirms a 3cm occlusion
of his external iliac artery.
ANS:
34. A 65 year old man presents with intermittent claudication when he walks for 90
yards. He is an ex-smoker (of 2 weeks duration). But has no other co-morbidities.
On examination he has ABPI's of 0.65.
ANS:
Question 35-37 of 52
Theme: Management of lymphoedema
A. Long term low dose frusemide
B. Homans procedure
Multilayer compression
C.
stockings
D. Charles procedure
E. Long term high dose frusemide
F. Lymphovenous anastomosis
Please select the most appropriate management for these patients with swollen limbs. Each option may be used once,
more than once or not at all.
35. A 52 year old lady develops lower leg swelling following redo varicose vein surgery. There is evidence of swelling of
the left leg up to the knee. The overlying skin appears healthy.
ANS:
36. A 57 year old lady has suffered from lymphoedema for many years. The left leg is swollen to the mid-thigh. Severe limb
deformity has developed as a result of process and in spite of compression hosiery. Lymphoscintigraphy shows no
patent lymphatics in the proximal leg. The overlying skin is healthy.
ANS:
37. A 38 year old lady is troubled by lymphoedema that occurred following a block dissection of the groin for malignant
melanoma many years previously. Despite therapy with compression bandages she has persistent lower leg swelling
impairing her activities of daily living. She has no evidence of recurrent malignancy. Lymphoscintigraphy
demonstrates occlusion of the groin lymphatics. However, the distal lymphatic system appears healthy.
ANS:
Question 38-40 of 52
Theme: Management of leg ulceration
A. Amputation
B. Compression dressings
C. Angioplasty
D. Skin grafting
E. Punch biopsy
F. Myocutaneous flap
G. Modified compression bandages
H. Tru cut biopsy
I. Excision biopsy
Please select the most appropriate management for the limb ulcers described below. Each option may be used once,
more than once or not at all.
38. A 68 year old lady presents with a chronic ulcer on the posteromedial aspect of
her lower leg. She suffered from a DVT many years ago and the ulcer appeared
following minor trauma. On examination she has a wide shallow ulcer with a moist
base and slightly irregular border. She has foot pulses and normal ABPI.
ANS:
39. A 73 year old lady has suffered from a large ulcer on the posterior aspect of her
lower leg for many years. It has been treated by the district nurses with
hydrocolloid dressings with a good result. However, over the past 8 weeks the
ulcer has become progressively larger and has developed an exophytic centre.
ANS:
40. A 78 year old lady is referred to the vascular clinic. She was admitted to casualty
following a large pretibial laceration. This has been slow to heal and she has a 7 x
7 cm area of ulceration on the anterior aspect of her leg. She has normal foot
pulses.
ANS:
Question 41 of 52
A 72 year old man presents with rest pain and on examination has an ulcer on his hallux. He is an ex-smoker and his
medication includes aspirin and simvastatin. A duplex scan is performed and this demonstrates a 5 cm occlusion of his
superficial femoral artery. Which procedure would achieve the best long term patency rate?
Femoro-popliteal bypass graft using PTFE
Angioplasty and insertion of drug eluting stent
Angioplasty alone
Femoro-popliteal bypass graft using autologous vein
SFA endarterectomy
ANS:
Question 42 of 52
A cervical rib is due to which of the following?
Hyperplasia of the annulus fibrosus
Proliferation of the nucleus pulposus
Fusion of the transverse processes of the 6th and 7th cervical vertebrae
An accessory cervical vertebra
Elongation of the transverse processes of the 7th cervical vertebra
ANS:
Question 43 of 52
A 63 year old man with a long occlusion of his superficial femoral artery and rest pain undergoes a femoro-popliteal
bypass graft using vein. Assuming his risk factors are addressed, what is the approximate 5 year patency rate of the
graft?
66%
50%
90%
80%
40%
ANS:
Question 44 of 52
A 33 year old lady undergoes a thoracoscopic sympathectomy to treat hyperhidrosis of the palms. She is disappointed
that following surgery, her hyperhidrosis has persisted. What is the most likely explanation?
The surgeon did not divide the T4 ganglion
The surgeon did not visualize the nerve of Kuntz between T1 and T2
The surgeon failed to identify an aberrant nerve between the T3 and T4 ganglion
The patient is fabricating their symptoms
The surgeon did not divide the T3 ganglion completely
ANS:
Question 45 of 52
A 65 year old man is undergoing an endovascular repair of an unruptured 6cm infrarenal abdominal aortic aneurysm. At
the conclusion of the procedure a check angiogram is performed and a type II low flow endoleak is identified. What is the
most appropriate course of action?
Immediate laparotomy and open repair
Transbrachial angiographic endocoil insertion
Repeat imaging in 3 months
Delayed elective abdominal aortic aneurysm
CT angiogram prior to discharge from hospital
ANS:
Question 46-48 of 52
Theme: Acute limb ischaemia
A. Primary amputation
B. Transfemoral embolectomy with prophylactic fasciotomy
C. Trans popliteal embolectomy with fasciotomy
D. Trans popliteal embolectomy without fasciotomy
E. Transfemoral embolectomy without fasciotomy
F. Angiogram
G. Systemic heparin infusion alone
H. Peripheral thrombolysis
Please select the most appropriate management for the following patients presenting with acutely ischaemic limbs. Each
option may be used once, more than once or not at all.
46. A 76 year old man presents with a painful left leg. The pain began suddenly and
with no previous history. On examination he has a pale left leg with no palpable
femoral pulse and loss of sensation. The pulses in the contra lateral limb are
normal. It is now three hours since the pain first started.
ANS:
47. A 56 year old man presents with a painful left leg. The pain has been present for
the past 8 hours although it has also been present (though less severe) about a
week ago. At that stage he noted that his hallux had turned blue. This resolved
spontaneously. On examination he has a weakly palpable femoral pulse on the
affected side but no pulses palpable distal to this. His sensation is mildly
impaired.
ANS:
48. A 78 year old lady is found by carers with a severely painful left leg. On
examination she has no palpable pulses and the limb is cold, insensate and
mottled. The mottling does not blanch with pressure.
ANS:
Question 49 of 52
A 38 year old lady attends the clinic. She smokes 5 cigarettes per day. She has been suffering from upper limb Raynauds
for the past few months and her symptoms persist despite taking nifedipine. What is the most useful next step?
Do a Roos test
CT angiography
Start an ACE inhibitor
Stop smoking
Blood pressure measurements in both arms
ANS:
Question 50 of 52
An obese 83 year old man who has type 2 diabetes and continues to smoke undergoes a femoro-distal bypass using
PTFE. Not unsurprisingly, he develops a wound infection. What is the most likely causative organism?
Klebsiella
Streptococcus
Staphylococcus
E-Coli
Bacteroides
ANS:
Question 51 of 52
What is the most common cause of mesenteric infarction?
Mesenteric vein thrombosis
Acute embolism affecting the superior mesenteric artery
Acute on chronic thrombus of the superior mesenteric artery
Sub intimal dissection of the superior mesenteric artery
Proximal migration of abdominal aortic aneurysm
ANS:
Question 51 of 52
A 66 year old man presents with pain in his left leg. On examination, he has a dusky forefoot and a palpable popliteal
artery aneurysm. What is the most appropriate initial management?
Systemic heparinisation alone
Above knee amputation
Intra arterial thrombolysis followed by early surgical bypass
Popliteal embolectomy, exclusion of the aneurysm and bypass
Transfemoral embolectomy and femoro-distal bypass
ANS:
