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Vascular Surgery Ultimate Exam
Question 1. Which of the following best describes the relationship between shear stress and endothelial nitric oxide production? A) Increased shear stress decreases nitric oxide synthesis. B) Decreased shear stress stimulates nitric oxide release. C) Elevated shear stress up-regulates endothelial nitric oxide synthase (eNOS). D) Shear stress has no effect on nitric oxide production. Answer: C Explanation: Laminar shear stress activates eNOS, increasing nitric oxide release, which promotes vasodilation and inhibits atherogenesis. Question 2. In the pathogenesis of atherosclerosis, which cellular event is the earliest detectable change in the arterial wall? A) Fibrous cap formation B) Lipid core development C) Endothelial dysfunction D) Calcification Answer: C Explanation: Endothelial dysfunction precedes lipid infiltration and is the initiating lesion that allows LDL entry and inflammatory cell adhesion. Question 3. Which antiplatelet agent irreversibly inhibits the P2Y receptor and requires a loading dose of 300 mg for acute coronary syndromes? A) Aspirin B) Clopidogrel C) Ticagrelor
Vascular Surgery Ultimate Exam
D) Prasugrel Answer: B Explanation: Clopidogrel is a thienopyridine that irreversibly blocks P2Y12; a 300 mg loading dose is standard for ACS. Question 4. Warfarin therapy is monitored using which laboratory test, and what is the therapeutic INR range for most indications? A) aPTT; 1.5–2. B) PT/INR; 2.0–3. C) Platelet count; 150–400 ×10⁹/L D) D-dimer; <0.5 μg/mL Answer: B Explanation: Warfarin prolongs PT; the INR is used to standardize results, with a typical therapeutic range of 2.0–3.0. Question 5. Factor V Leiden mutation predisposes to thrombosis by which mechanism? A) Increased antithrombin activity B) Resistance to activated protein C C) Enhanced fibrinolysis D) Decreased tissue factor expression Answer: B Explanation: The Leiden mutation creates a factor V variant that is resistant to inactivation by activated protein C, promoting a hypercoagulable state. Question 6. During embryologic development, the left fourth aortic arch gives rise to which adult vessel? A) Right subclavian artery
Vascular Surgery Ultimate Exam
Question 9. Which duplex finding is diagnostic for deep vein thrombosis (DVT) in the femoral vein? A) Respiratory variation in flow velocity B) Absence of compressibility with probe pressure C) High-resistance arterial waveform D) Continuous forward flow during Valsalva maneuver Answer: B Explanation: Non-compressibility of the vein is the primary sonographic criterion for DVT. Question 10. In CTA interpretation of an abdominal aortic aneurysm (AAA), the “neck” is defined as: A) The distal segment of the aneurysm sac B) The segment of aorta distal to the renal arteries C) The proximal non-dilated aortic segment used for graft fixation D) The area of maximal sac diameter Answer: C Explanation: The aneurysm neck is the healthy aortic segment proximal to the sac where the endograft seals. Question 11. According to the CREST trial, carotid endarterectomy (CEA) compared with carotid artery stenting (CAS) in symptomatic patients showed a lower risk of: A) Myocardial infarction B) Stroke C) Death D) Restenosis at 5 years Answer: B
Vascular Surgery Ultimate Exam
Explanation: CREST demonstrated a higher peri-procedural stroke rate with CAS versus CEA, while MI rates were higher with CEA. Question 12. In carotid endarterectomy, eversion technique primarily differs from conventional patch angioplasty by: A) Using a synthetic patch to enlarge the lumen B) Performing a longitudinal arteriotomy and rotating the artery C) Placing a vein patch harvested from the saphenous vein D) Utilizing a stent-covered graft intra-operatively Answer: B Explanation: The eversion method involves transecting the ICA, everting the plaque, and re-anastomosing without a patch. Question 13. Which of the following is a contraindication to carotid artery stenting (CAS) in the elective setting? A) Asymptomatic stenosis < 60 % B) Contralateral carotid occlusion C) Age > 80 years D) Prior neck radiation Answer: D Explanation: Prior neck radiation increases the risk of restenosis and embolization, making CAS less favorable. Question 14. Fibromuscular dysplasia (FMD) most commonly affects which arterial segment? A) Proximal internal carotid artery B) Mid-to-distal renal artery C) Distal aortic arch
Vascular Surgery Ultimate Exam
A) Ascending aorta only B) Arch and descending thoracic aorta C) Descending thoracic aorta distal to the left subclavian artery D) Entire aorta from root to iliac bifurcation Answer: C Explanation: Type B is confined to the descending aorta distal to the left subclavian origin; Type A includes the ascending aorta. Question 18. Which endoleak type is caused by inadequate proximal seal of an EVAR graft? A) Type I B) Type II C) Type III D) Type IV Answer: A Explanation: Type I endoleaks result from failure of graft attachment at either the proximal (Ia) or distal (Ib) sealing zones. Question 19. The WIfI classification for chronic limb-threatening ischemia incorporates which three components? A) Wound, Ischemia, and Infection B) Weight loss, Intermittent claudication, and Frailty C) Wound size, Intravascular pressure, and Flow rate D) White blood count, INR, and Fibrinogen level Answer: A Explanation: WIfI stands for Wound, Ischemia, and Infection; it guides revascularization urgency.
Vascular Surgery Ultimate Exam
Question 20. In a patient with Rutherford category 5 acute limb ischemia, the most appropriate initial therapy is: A) Systemic anticoagulation alone B) Catheter-directed thrombolysis C) Immediate surgical embolectomy D) Observation and serial examinations Answer: C Explanation: Category 5 denotes major tissue loss; urgent surgical embolectomy (or bypass) is required to salvage the limb. Question 21. Popliteal artery entrapment syndrome is best diagnosed with: A) Ankle-brachial index B) Static duplex ultrasound C) Dynamic duplex ultrasound during active plantarflexion D) CTA of the lower extremity Answer: C Explanation: Dynamic duplex during plantarflexion reveals flow obstruction characteristic of muscular entrapment. Question 22. Which of the following statements regarding mesenteric ischemia is correct? A) Chronic mesenteric ischemia typically presents with acute abdominal pain after meals. B) Acute mesenteric ischemia caused by non-occlusive hypoperfusion is best treated with immediate thrombectomy. C) The gold-standard diagnostic test for chronic mesenteric ischemia is mesenteric duplex ultrasound with post-prandial flow assessment. D) Endovascular stenting is contraindicated in mesenteric arterial disease.
Vascular Surgery Ultimate Exam
C) Skin changes (e.g., pigmentation, eczema) D) Active venous ulcer Answer: D Explanation: C4 denotes venous ulceration; C3 is skin changes, C2 is varicose veins, C1 is telangiectasias. Question 26. May-Thurner syndrome is caused by compression of the left common iliac vein between: A) Right common iliac artery and lumbar vertebrae B) Left common iliac artery and right psoas muscle C) Right common iliac artery and left psoas muscle D) Right common iliac artery and left common iliac artery Answer: A Explanation: The right common iliac artery overlies the left common iliac vein against the vertebral body, leading to compression. Question 27. In the management of phlegmasia cerulea dolens, the first-line treatment is: A) Compression stockings B) Systemic anticoagulation alone C) Immediate catheter-directed thrombolysis or surgical thrombectomy D) Oral warfarin therapy Answer: C Explanation: Phlegmasia cerulea dolens is a limb-threatening DVT; rapid reperfusion via thrombolysis or thrombectomy is required. Question 28. The “Fistula First” initiative primarily promotes the creation of which type of vascular access for hemodialysis?
Vascular Surgery Ultimate Exam
A) Synthetic graft (ePTFE) B) Tunneled cuffed catheter C) Autologous arteriovenous fistula (AVF) D) Central venous catheter in the subclavian vein Answer: C Explanation: AVFs have lower infection and thrombosis rates compared with grafts or catheters, hence the preference. Question 29. In a patient with an AVF that develops steal syndrome, the most appropriate initial maneuver is: A) Immediate ligation of the fistula B) Banding of the outflow vein to reduce flow C) Placement of a central venous catheter for dialysis D) Switching to peritoneal dialysis Answer: B Explanation: Surgical banding reduces fistula flow, alleviating distal ischemia while preserving access. Question 30. Hard signs of extremity vascular injury include all EXCEPT: A) Pulsatile bleeding B) Expanding hematoma C) Diminished distal pulses D) Isolated calf swelling without neurovascular deficits Answer: D Explanation: Isolated calf swelling without neurovascular compromise is a soft sign; hard signs require immediate exploration.
Vascular Surgery Ultimate Exam
Explanation: Removal of the infected graft and extra-anatomic bypass reduces reinfection risk. Question 34. Statins reduce atherosclerotic plaque progression primarily by: A) Inhibiting platelet aggregation B) Blocking the renin-angiotensin system C) Lowering LDL-cholesterol and exerting anti-inflammatory effects D) Directly increasing nitric oxide synthase activity Answer: C Explanation: Statins lower LDL and modulate inflammation, stabilizing plaques. Question 35. A patient with a type II endoleak after EVAR is best managed initially with: A) Immediate open conversion B) Observation, as many type II leaks seal spontaneously C) Coil embolization of the feeding lumbar artery D) Placement of a new endograft proximally Answer: B Explanation: Type II endoleaks often resolve; intervention is reserved for sac expansion > 5 mm or persistent leakage. Question 36. During an open abdominal aortic aneurysm repair, the most common cause of intra-operative renal insufficiency is: A) Prolonged aortic cross-clamping without renal protection B) Excessive intra-operative fluid administration C) Use of heparin intra-operatively
Vascular Surgery Ultimate Exam
D) Post-operative hypertension Answer: A Explanation: Ischemia from suprarenal or supraceliac clamping without protective measures leads to acute renal injury. Question 37. Which of the following is the hallmark imaging finding of aortic dissection on CT angiography? A) Double-lumen with an intimal flap separating true and false lumens B) Uniform aortic dilation without intramural contrast C) Calcified atherosclerotic plaque within the aortic wall D) Periaortic fluid collection only Answer: A Explanation: The intimal flap creates two lumens; CT angiography visualizes this classic sign. Question 38. In a patient with symptomatic > 80 % carotid stenosis who is high-risk for surgery, which endovascular approach offers cerebral protection without distal embolic filters? A) Standard carotid stenting with distal filter B) Transcarotid artery revascularization (TCAR) using flow-reversal C) Balloon angioplasty alone D) Carotid endarterectomy under local anesthesia Answer: B Explanation: TCAR utilizes flow reversal from the carotid to the femoral vein, providing embolic protection without a filter. Question 39. The most common cause of non-occlusive mesenteric ischemia (NOMI) is:
Vascular Surgery Ultimate Exam
Question 42. Which of the following best describes the “string-of-beads” appearance on angiography? A) Atherosclerotic plaque with ulceration B) Fibromuscular dysplasia of the renal artery C) Dissecting aneurysm of the aorta D) Chronic total occlusion of the femoral artery Answer: B Explanation: Alternating stenoses and aneurysmal dilatations in FMD produce the characteristic radiographic pattern. Question 43. A patient with Buerger disease (thromboangiitis obliterans) is most likely to present with: A] Bilateral atherosclerotic coronary disease B] Segmental occlusion of tibial arteries in a heavy smoker under 45 years C] Isolated mesenteric artery stenosis D] Renal artery fibromuscular dysplasia Answer: B Explanation: Buerger disease affects young male smokers, causing distal extremity ischemia with segmental arterial occlusions. Question 44. During a peripheral arterial bypass, which conduit choice provides the best long-term patency for infra-inguinal femoropopliteal bypass? A) Polytetrafluoroethylene (PTFE) graft B) Dacron graft C) Autologous reversed great saphenous vein D) Synthetic heparin-bonded graft Answer: C
Vascular Surgery Ultimate Exam
Explanation: Autologous vein conduits have superior patency rates compared with synthetic grafts for below-knee bypasses. Question 45. The primary indication for placement of an inferior vena cava (IVC) filter is: A] Chronic venous insufficiency B] Recurrent pulmonary embolism despite therapeutic anticoagulation C] Acute deep vein thrombosis in the femoral vein only D] Portal hypertension Answer: B Explanation: IVC filters are reserved for patients with contraindications to anticoagulation or recurrent PE despite adequate therapy. Question 46. In the WIfI classification, a patient with a small ulcer (≤ 2 cm), ABI 0.5, and no infection would be assigned which ischemia grade? A] Grade 0 (no ischemia) B] Grade 1 (mild) C] Grade 2 (moderate) D] Grade 3 (severe) Answer: C Explanation: ABI 0.5 corresponds to moderate ischemia (grade 2) in the WIfI system. Question 47. Which anticoagulant is a direct factor Xa inhibitor that does not require routine laboratory monitoring? A] Warfarin B] Heparin C] Apixaban
Vascular Surgery Ultimate Exam
B] Atherosclerotic stenosis in older adults C] Renal artery aneurysm D] Renal vein thrombosis Answer: B Explanation: Atherosclerotic renal artery stenosis accounts for the majority of renovascular hypertension in the elderly. Question 51. In the treatment of a symptomatic splenic artery aneurysm > 3 cm, the preferred endovascular approach is: A] Coil embolization of the aneurysm sac B] Covered stent placement across the aneurysm C] Surgical ligation via laparotomy D] Observation with serial imaging Answer: A Explanation: Coil embolization effectively excludes the aneurysm while preserving splenic perfusion through collateral flow. Question 52. Which of the following is a typical clinical feature of Paget-Schroetter syndrome? A] Chronic venous stasis ulcer of the lower leg B] Acute upper extremity DVT in a healthy, athletic individual C] Bilateral lower extremity edema due to IVC obstruction D] Pulsatile neck mass with bruit Answer: B Explanation: Paget-Schroetter (effort thrombosis) occurs in the subclavian vein of young athletes after repetitive arm activity.
Vascular Surgery Ultimate Exam
Question 53. The primary advantage of a fenestrated endograft for a juxtarenal AAA is: A] Ability to treat aneurysms extending into the renal arteries while preserving renal perfusion B] Simpler deployment compared with standard grafts C] Lower cost than open repair D] Elimination of need for contrast during the procedure Answer: A Explanation: Fenestrations align with renal artery ostia, allowing sealing proximal to the aneurysm without sacrificing renal flow. Question 54. During an aortobifemoral bypass, the optimal conduit material for the aortic limb is: A] PTFE graft B] Dacron graft C] Autologous femoral vein D] Cryopreserved allograft Answer: A Explanation: PTFE provides durability and resistance to infection for the high-flow aortic component of the bypass. Question 55. Which of the following best describes the sensitivity and specificity of duplex ultrasound for detecting > 70 % carotid stenosis? A] Sensitivity 50 %, specificity 90 % B] Sensitivity 85 %, specificity 95 % C] Sensitivity 70 %, specificity 70 % D] Sensitivity 95 %, specificity 50 % Answer: B
