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38 Multiple-Choice Questions

409

D. Placement of number 3 Fogarty balloon catheter over a .014 wire placed

through a sheath placed in the CCA above the clavicle

Correct answer: D

Chapter 20: Redo Carotid Endarterectomy

Question 1 Eighteen months following carotid endarterectomy, a 64-year-old woman develops

a focal smooth transverse high-grade stenosis in the mid-common carotid artery. This lesion is most likely caused by:

A. Recurrent atherosclerotic plaque B. Residual plaque C. Lesion as a result of clamp injury D. Result of dissection during placement of shunt during CEA

Correct answer: C

Question 2 Which of the following statements best reects the complications of symptomatic

redo CEA for atherosclerotic lesion?

A. Incidence of perioperative stroke is higher than primary CEA. B. Incidence of cranial nerve injury is same as in primary CEA. C. Incidence of neck hematoma is greater than primary CEA. D. Incidence of perioperative stroke is same, but incidence of cranial nerve

palsy is greater in patients undergoing redo CEA as compared to pri-

mary CEA.

Correct answer: D

Question 3 During redo CEA, the incision is extended proximally to aid in obtaining proximal

control by dissecting and passing the silastic vessel loop around the common carotid artery proximal to previous arteriotomy. The cranial nerve most likely to be injured during this part of the procedure is:

A. Hypoglossal B. Sympathetic chain C. Vagus D. Ansa hypoglossi

Correct answer: C

Question 4 A 74-year-old man presents to the hospital with left middle cerebral infarct with

aphasia, right supranuclear facial palsy, accid paralysis of right upper extremity, and grade 3 motor weakness of right lower extremity. His NIH stroke scale is

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S. S. Hans and A. D. Shepard

18. Imaging studies show high-grade stenosis (>70%) at the origin of left ICA.He had left CEA performed 8 years ago.

Best management option is:

A. Urgent carotid stenting. B. Urgent left CEA. C. PT, OT, and speech therapy and continue medical management only. D. PT, OT, and speech therapy. Revaluation of neuro-decit. If improved with

NIH stroke scale less than 15, consider left carotid intervention in 10–14

days after medical optimization.

Correct answer: D

Chapter 21: Vertebral Artery Transposition

Question 1 Posterior circulation territory strokes constitute what percentage of all ischemic

strokes?

A. 5–10% B. 11–15% C. 16–20% D. Just over 20%

Correct answer: D

Question 2 First portion of vertebral artery courses between:

A. Scalenus anticus and medius muscle B. Longus coli and scalenus anticus muscle C. Longus coli and scalenus medius muscle D. Scalenus medius and scalenus tertius

Correct answer: B

Question 3 A 76-year-old male presents to ER with dizziness and presyncope. The patient is in

atrial brillation with a heart rate of 110 per minute. CTA neck showed less than 50% stenosis of bilateral ICA.Right vertebral artery is hypoplastic, and left vertebral artery has 50% stenosis at its origin. CT head shows chronic white matter changes. The optimal management consists of:

A. Vertebral artery transposition into the CCA B. Urgent cardiology consult C. Urgent ENT consult D. Discharge patient on antiplatelet medication and beta-blockers

Correct answer: B

38 Multiple-Choice Questions

411

Question 4 Two days following vertebral artery-to-CCA transposition, the patient develops

70cc of milky uid in 24h. Initial management consists of:

A. Thoracic duct embolization B. Immediate exploration of the neck and ligation of the site of the leak C. Dietary modication, local compression, and octreotide D. Total parental nutrition with minimal calories from fat

Correct answer: C

Chapter 22: Carotid-Subclavian Artery Bypass

Question 1 In contemporary vascular practice, the most common indication for carotid-

subclavian bypass is:

A. Left arm ischemia secondary to proximal left subclavian artery stenosis B. Following repair of subclavian artery aneurysm in association with thoracic

outlet syndrome C. Ischemic symptoms in vertebral-basilar territory D. Prior to TEVAR in a patient with absent right vertebral artery

Correct answer: D

Question 2 Carotid-subclavian artery bypass in association with TEVAR is usually performed:

A. Simultaneously with TEVAR B. Few days prior to TEVAR C. Following TEVAR if the patient develops spinal cord ischemia D. Through subclavian-to-carotid transposition, which is more effective in

reducing the incidence of spinal cord ischemia as compared to carotid-

subclavian bypass

Correct answer: B

Question 3 Carotid-subclavian artery is preferably performed with a synthetic conduit. The

usual length of the bypass graft is:

A. 2cm B. 3cm C. 5cm D. 6cm

Correct answer: B

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Question 4 The most common nerve injury during exposure of subclavian artery for carotid-

subclavian bypass is:

A. Vagus B. Recurrent laryngeal C. Phrenic D. Internal laryngeal

Correct answer: C

Question 5 Thoracic duct stula develops 6days following carotid-subclavian artery bypass

draining 400cc of milky uid in 24h. The best strategy to control chyle leak is:

A. Medical management B. Thoracotomy and ligation of thoracic duct C. Coil embolization of thoracic duct D. Re-exploration of the neck and ligation of thoracic duct leak

Correct answer: D

Chapter 23: De-branching Operations on Supra-aortic Trunks

Question 1 Carotid-carotid bypass is planned to extend the landing zone of TEVAR.Which of

these statements describe the most optimal technique of reconstruction?

A. Arteriotomy in the Rt CCA at 12 o’clock with graft tunneled in the subcuta-

neous location with arteriotomy in the left CCA at 12 o’clock position B. Arteriotomy in the Rt CCA at 12 o’clock with graft tunneled in the retropha-

ryngeal position at 12 o’clock position in the left CCA C. Arteriotomy at 11 o’clock position in the Rt CCA with the graft in the retro-

pharyngeal position with arteriotomy at 11 o’clock position in the left CCA D. Arteriotomy at 1–2 o’clock position in the Rt CCA with graft in the retropha-

ryngeal position with arteriotomy in the left CCA at 10–11 o’clock position

Correct answer: D

Question 2 The commonest nerve injured during carotid-carotid bypass is:

A. Recurrent laryngeal nerve B. Vagus nerve C. Phrenic nerve D. External laryngeal nerve

Correct answer: B

38 Multiple-Choice Questions

413

Question 3 The incidence of stroke following ascending aorta to carotid/subclavian bypass is:

A. Less than 3% B. 3–5% C. 6–8% D. 9–10%

Correct answer: B

Chapter 24: Brachiocephalic Reconstruction

Question 1 A 61-year-old man, with a history of stable angina, is scheduled to undergo aorto-

innominate bypass for near occlusion of innominate artery (brachiocephalic) with a history of amaurosis fugax. The most important preoperative assessment should include:

A. Pulmonary function tests B. Stress echocardiogram C. Cardiac CTA for calcium score D. Coronary angiogram

Correct answer: D

Question 2 The origin of right subclavian artery is related to:

A. Recurrent laryngeal nerve B. Superior laryngeal nerve C. Phrenic nerve D. Vagus nerve

Correct answer: A

Question 3 One of the absolute contraindications for aorto-innominate bypass is:

A. Contralateral ICA occlusion B. Severe bilateral vertebral artery stenosis C. Severe stenosis right subclavian artery origin D. Severe calcication of ascending aorta

Correct answer: D

Chapter 25: Aortobifemoral Bypass Graft

Question 1 During a redo aortofemoral bypass, exposure can most easily be achieved using a:

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A. Midline celiotomy with an infra-mesocolic approach B. Midline celiotomy with right medial visceral rotation C. Left ank retroperitoneal approach D. Transverse celiotomy through an infraumbilical “smile” incision

Correct answer: C

Question 2 In a patient with a juxtarenal aortic occlusion requiring suprarenal aortic clamping,

the left renal vein can be mobilized by ligating and dividing the:

A. Lumbar branch B. Adrenal branch C. Gonadal branch D. All of the above

Correct answer: D

Question 3 When tunneling the graft limbs to the groins during aortobifemoral bypass, the

limbs should pass:

A. Lateral to the ureters. B. Posterior to the ureters. C. Anterior to the ureters. D. It does not matter in regard to orientation to the ureters.

Correct answer: B

Question 4 During the femoral anastomosis of an aortofemoral bypass, correction of disease at

the origin of the profunda femoris artery is:

A. Unnecessary B. Optional C. Important to long-term graft patency D. Desirable only if it is easy to do

Correct answer: C

Chapter 26: Thoracofemoral Bypass for Aortoiliac Occlusive Disease

Question 1 Thoracofemoral bypass graft is best indicated for:

A. Juxtarenal aortic occlusion in a 46-year-old male with hip claudication with

erectile dysfunction B. Infrarenal aortic and bilateral iliac artery occlusion with rest pain C. 6cm Infrarenal AAA with severe iliac artery occlusive disease

38 Multiple-Choice Questions

415

D. Failed aortobifemoral bypass graft in a 46-year-old female (graft occlusion

just below the renal arteries) with a history of multiple abdominal operations

presenting with ischemic rest pain

Correct answer: D

Question 2 An absolute contraindication for thoracofemoral bypass graft is:

A. Remote history of MI B. Prior multiple laparotomy incisions C. Left ventricle ejection fraction of 55% D. Circumferential distal thoracic aortic calcication

Correct answer: D

Question 3 Thoracofemoral bypass graft is planned for a 62-year-old male with a prior history

of suprapubic cystostomy for bladder pathology.

A. Right femoral limb of the graft should be brought behind the rectus abdomi-

nus in the space of Retzius. B. Right axillofemoral graft should be considered with left thoracofemoral

bypass graft. C. Right femoral graft limb is brought from the left groin in the suprapubic

subcutaneous tunnel and anastomosed to the right common femoral artery as

in a standard crossover femoral-femoral graft. D. Right femoral limb is brought through the obturator foramen and anasto-

mosed to proximal right supercial femoral artery.

Correct answer: C

Chapter 27: Aortomesenteric Bypass Graft

Question 1 A 68-year-old female with a history of vague periumbilical abdominal pain for

6months with no association to the intake of meals and without weight loss is seen in the clinic. CTA abdomen and pelvis shows 50% stenosis of celiac and SMA.Optimal management consists of:

A. SMA stenting B. Celiac and SMA stenting C. Med. management with follow-up CTA imaging in 1year D. Med. management and duplex imaging of visceral arteries in 1year

Correct answer: D

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Question 2 A 58-year-old female with classic symptoms of intestinal angina with signicant

weight loss has a 50% stenosis of small-diameter celiac artery, complete occlusion of proximal 6cm SMA, and occlusion of IMA.Percutaneous revascularization of SMA was unsuccessful. Her cardiac risk is acceptable. Optimal management consists of:

A. Antegrade bypass from supraceliac aorta to SMA using a prosthetic graft B. Retrograde bypass from infrarenal aorta to SMA using a prosthetic graft C. Retrograde bypass from infrarenal aorta to SMA using greater saphenous vein D. Trapdoor endarterectomy of paravisceral aorta

Correct answer: A

Question 3 A 78-year-old female with symptoms of intestinal angina with signicant weight

loss has occlusion of celiac artery and occlusion of proximal 5cm SMA with patent IMA. Supraceliac aorta shows severe calcication. Infrarenal aorta is small in caliber (10mm diameter) but has small posterior plaque. Optimal management consists of:

A. Antegrade bypass from supraceliac aorta to SMA B. Bypass to celiac and SMA using retroperitoneal ank approach via ninth ICS C. Retrograde bypass using ringed prosthetic graft from infrarenal aorta or right

common iliac artery to SMA D. Retrograde bypass from infrarenal aorta to SMA using greater saphenous vein

Correct answer: C

Question 4 A 76-year-old male with a history of prior CABG presents with symptoms of intes-

tinal angina with occlusions of celiac and SMA.Endovascular management is unsuccessful. Optimal management consists of:

A. Antegrade aortoceliac and SMA bypass B. Retrograde bypass from infrarenal aorta to SMA C. Retrograde stenting of SMA D. Trapdoor aortic endarterectomy

Correct answer: D

Chapter 28: Aortorenal Bypass and Renal Artery Reconstruction

Question 1 Results of CORAL study comparing medical therapy with renal artery stent-

ing showed:

A. Benet of stenting in improving GFR B. Benet of stenting in modest BP improvement

38 Multiple-Choice Questions

417

C. Benet of stenting in control of BP as well as GFR D. That renal stenting had high incidence of technical complications

Correct answer: B

Question 2 A 45-year-old man underwent renal artery stenting for uncontrollable BP on mul-

tiple antihypertensive medications. He has developed recurrent in-stent stenosis, which has been treated with angioplasty twice in the past, without improvement in BP with one episode of ash pulmonary edema. The optimal management option is:

A. Covered renal stent B. Repeat angioplasty with drug-eluting balloon C. Renal endarterectomy D. Aortorenal bypass graft

Correct answer: D

Question 3 The best approach for isolated left aortorenal bypass is:

A. Left retroperitoneal approach B. Medial visceral rotation C. Infra-mesocolic approach D. Use of splenic artery for left renal artery bypass

Correct answer: C

Chapter 29: Crossover Femoral-Femoral Bypass Graft and Iliofemoral Bypass Graft

Question 1 The optimal site for femoral anastomosis during performance of crossover fem-fem

graft in the femoral artery should be:

A. Under the inguinal ligament at the junction of external iliac and common

femoral artery B. Supercial femoral artery C. Distal common femoral artery D. Deep femoral (profunda) artery

Correct answer: C

Question 2 A crossover femoral-femoral graft is being planned in a patient with a history of

extensive scarring in the suprapubic region. The best alternative to subcutaneous suprapubic tunnel is:

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A. Excision of burn scar and prosthetic graft coverage with rectus abdominis ap B. Tunnel in prevesical space C. Excision of burn scar and gracilis ap D. Performing of bilateral axillofemoral graft instead of crossover femoral-

femoral graft

Correct answer: B

Question 3 During performance of crossover femoral-femoral graft:

A. The distal anastomosis should always be performed on to deep femoral artery B. Distal anastomosis should always be performed to supercial femoral artery C. Distal anastomosis should be performed to distal common femoral artery

extending to proximal supercial femoral artery D. Always perform femoral endarterectomy with patch graft prior to distal

anastomosis

Correct answer: C

Chapter 30: Axillofemoral Bypass Graft

Question 1 Factors affecting the patency of an axillary-femoral graft are:

A. Type of graft (Dacron vs. externally supported PTFE) B. Patient’s age C. Graft performed on elective basis or as emergency D. Presence or absence of supercial femoral disease

Correct answer: D

Question 2 5-Year patency of iliofemoral bypass graft is:

A. Greater than 90% B. 80–90% C. 71–89% D. Less than 70%

Correct answer: A

Question 3 Patient presented with unilateral lymph leak 5 days after axillofemoral bypass graft.

Optimal management consists of:

A. Antibiotics B. Local care and low-fat diet

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