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ABS Vascular Surgery study materials
ABS Vascular Surgery study resources

ABS Vascular Surgery practice questions

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Question 1Aneurysmal disease (aorta and peripheral arteries)

A true aneurysm is best defined as which of the following?

  1. A focal arterial dilation that involves all three vessel wall layers Correct answer.
  2. A contained hematoma after a full-thickness arterial tear
  3. An elongated artery without an increase in diameter
  4. A focal arterial dilation caused by an isolated intimal defect

Explanation

A true aneurysm is a focal dilation involving the intima, media, and adventitia, usually defined as a diameter greater than 50% of the expected normal segment or greater than 3 cm for the infrarenal aorta. Loss of all wall layers produces a pseudoaneurysm, not a true aneurysm.

Question 2Aneurysmal disease (aorta and peripheral arteries)

According to the USPSTF, which group should undergo one-time ultrasound screening for abdominal aortic aneurysm?

  1. All adults aged 40 years with a family history of stroke
  2. Men aged 65 to 75 years who have ever smoked Correct answer.
  3. Men aged 40 to 50 years who have diabetes
  4. Women aged 50 to 60 years who have hypertension

Explanation

The USPSTF recommends one-time ultrasound screening for men aged 65 to 75 years who have ever smoked and selective screening for never-smoking men in that age range. Women are not routinely screened unless they have a family history or other high-risk features.

Question 3Aneurysmal disease (aorta and peripheral arteries)

Which triad is most characteristic of a ruptured abdominal aortic aneurysm?

  1. Claudication, absent femoral pulses, and pallor
  2. Hypotension, back or abdominal pain, and a pulsatile mass Correct answer.
  3. Abdominal pain, jaundice, and weight loss
  4. Fever, leukocytosis, and a pulsatile abdominal mass

Explanation

The classic presentation of a ruptured AAA is the triad of hypotension, back or abdominal pain, and a pulsatile abdominal mass, although all three are not always present. Prompt recognition and hemorrhage control are critical because instability predicts high mortality.

Question 4Aneurysmal disease (aorta and peripheral arteries)

A 68-year-old man has an asymptomatic infrarenal abdominal aortic aneurysm measuring 5.6 cm on CT. What is the most appropriate management?

  1. Start a beta-blocker and repeat imaging in 1 year
  2. Refer for elective aneurysm repair after preoperative assessment Correct answer.
  3. Proceed with immediate open repair without preoperative evaluation
  4. Continue ultrasound surveillance every 6 months

Explanation

Elective repair is recommended for asymptomatic infrarenal AAA when the diameter reaches 5.5 cm in men or 5.0 cm in women, or when growth is rapid. Preoperative assessment determines whether open or endovascular repair is appropriate.

Question 5Aneurysmal disease (aorta and peripheral arteries)

Which anatomic finding most strongly favors open rather than endovascular repair of an infrarenal abdominal aortic aneurysm?

  1. Bilateral common iliac arteries of 9 mm diameter
  2. A maximal aortic diameter of 5.8 cm
  3. An infrarenal neck length of 8 mm Correct answer.
  4. An infrarenal neck length of 25 mm

Explanation

EVAR requires an adequate proximal landing zone, generally at least 10 to 15 mm of nonaneurysmal infrarenal neck with acceptable angulation and mural thrombus. A very short neck increases the risk of type I endoleak and graft migration, making open repair more suitable.

Question 6Aneurysmal disease (aorta and peripheral arteries)

A type II endoleak after endovascular aneurysm repair is best described as which of the following?

  1. Blood flow through a defect in the graft fabric
  2. Persistent sac expansion without a demonstrable leak
  3. Retrograde flow from a patent inferior mesenteric or lumbar artery Correct answer.
  4. Blood flow into the sac from a proximal or distal attachment site

Explanation

Type II endoleaks arise from retrograde flow through patent branch vessels, most commonly the inferior mesenteric artery or lumbar arteries. Many regress spontaneously, but intervention is considered when the sac enlarges.

Question 7Aneurysmal disease (aorta and peripheral arteries)

An asymptomatic infrarenal abdominal aortic aneurysm measures 4.2 cm. Which surveillance interval is recommended?

  1. Every 24 months
  2. Every 6 months Correct answer.
  3. Every 12 months
  4. Every 3 months

Explanation

Surveillance intervals are based on size: 3.0 to 3.9 cm is generally followed annually, 4.0 to 4.9 cm every 6 months, and 5.0 to 5.4 cm every 3 months. A 4.2-cm aneurysm therefore falls into the 6-month group.

Question 8Aneurysmal disease (aorta and peripheral arteries)

Which feature most suggests an inflammatory abdominal aortic aneurysm?

  1. Perianeurysmal fibrosis with ureteral entrapment and high ESR Correct answer.
  2. Rapid enlargement after a febrile illness with positive blood cultures
  3. A saccular aneurysm at the aortic arch
  4. A thin, calcified aortic wall with a normal erythrocyte sedimentation rate

Explanation

Inflammatory AAAs are characterized by a thickened aortic wall, dense perianeurysmal fibrosis, and involvement of adjacent structures such as the ureters, often with elevated ESR or CRP. They are distinct from mycotic aneurysms, which are infected and typically saccular with positive cultures.

Question 9Aneurysmal disease (aorta and peripheral arteries)

A 70-year-old man presents with fever, back pain, and a 4.5-cm saccular thoracic aortic aneurysm. Blood cultures grow Salmonella. Which term best describes this aneurysm?

  1. Dissecting aneurysm
  2. Atherosclerotic fusiform aneurysm
  3. Inflammatory aneurysm
  4. Mycotic aneurysm Correct answer.

Explanation

A mycotic aneurysm is an infected aneurysm, often saccular and rapidly progressive, and Salmonella is a classic organism. Treatment requires prolonged antibiotics and surgical or endovascular reconstruction.

Question 10Aneurysmal disease (aorta and peripheral arteries)

Which statement about popliteal artery aneurysms is correct?

  1. They occur most often in women younger than 40 years
  2. They rarely thrombose or embolize
  3. They are the most common peripheral aneurysms Correct answer.
  4. They are usually observed until they reach 4 cm

Explanation

Popliteal artery aneurysms are the most common peripheral aneurysms, are bilateral in a substantial proportion of patients, and are associated with abdominal aortic aneurysms. Repair is generally recommended at 2 cm or when symptoms develop because of the risk of thrombosis and embolization.

Question 11Aneurysmal disease (aorta and peripheral arteries)

Three days after cardiac catheterization, a patient has a pulsatile groin mass. Duplex shows a narrow neck communicating with the femoral artery. What is the most appropriate initial treatment for a small, asymptomatic pseudoaneurysm?

  1. Systemic thrombolysis
  2. Thrombin injection Correct answer.
  3. Immediate open operative repair
  4. Ligation of the femoral artery

Explanation

Small, asymptomatic femoral pseudoaneurysms can be managed with ultrasound-guided compression or thrombin injection, which promotes thrombosis of the sac. Surgery is reserved for large, expanding, infected, or skin-threatening lesions or when less invasive treatment fails.

Question 12Aneurysmal disease (aorta and peripheral arteries)

For an asymptomatic degenerative aneurysm of the ascending aorta, elective repair is generally recommended at which diameter?

  1. 4.0 cm
  2. 5.5 cm Correct answer.
  3. 4.5 cm
  4. 7.0 cm

Explanation

Elective repair of a degenerative ascending aortic aneurysm is generally recommended at 5.5 cm, with lower thresholds for patients with connective tissue disorders or rapid growth. Descending thoracic aneurysms are typically repaired at 6.0 cm.

Question 13Aneurysmal disease (aorta and peripheral arteries)

A patient with a type B aortic dissection has refractory hypertension and visceral malperfusion but no rupture. Which management strategy is most appropriate?

  1. Observation with serial CT scans only
  2. Thoracic endovascular stent grafting Correct answer.
  3. Emergent open ascending aortic replacement
  4. Thrombolysis of the false lumen

Explanation

Complicated type B dissection, including malperfusion or refractory hypertension, is managed with thoracic endovascular aortic repair to cover the primary tear and restore true-lumen flow. Uncomplicated type B dissection is initially managed medically.

Question 14Aneurysmal disease (aorta and peripheral arteries)

Six months after EVAR, CT shows a new contrast collection at the proximal attachment site and the sac has enlarged by 8 mm. What is the most likely endoleak type and appropriate management?

  1. Type V endoleak; open conversion
  2. Type I endoleak; proximal cuff placement Correct answer.
  3. Type II endoleak; observe with repeat imaging
  4. Type IV endoleak; no intervention needed

Explanation

Contrast at the proximal attachment site with sac enlargement indicates a type I endoleak, which means the proximal seal is inadequate. Treatment aims to re-establish the seal with a proximal extension cuff, balloon angioplasty, or other endovascular adjunct.

Question 15Aneurysmal disease (aorta and peripheral arteries)

A 72-year-old woman with a known 5.0-cm abdominal aortic aneurysm presents with sudden severe back pain and syncope. Blood pressure is 90/60 mm Hg. CT shows a retroperitoneal hematoma. Which factor most strongly determines immediate mortality?

  1. The patient's sex
  2. The presence of hypertension
  3. Hemodynamic instability Correct answer.
  4. The aneurysm diameter on prior imaging

Explanation

Hemodynamic instability from rupture is the strongest predictor of early death because it reflects ongoing hemorrhage and shock. Immediate resuscitation and hemorrhage control, by open or endovascular repair, are required.

Question 16Aneurysmal disease (aorta and peripheral arteries)

An asymptomatic isolated common iliac artery aneurysm is generally repaired at what diameter?

  1. 5.5 cm
  2. 2.5 cm
  3. 3.0 to 3.5 cm Correct answer.
  4. 2.0 cm

Explanation

Isolated iliac artery aneurysms are generally repaired at 3.0 to 3.5 cm because rupture risk rises with diameter. The 5.5-cm threshold applies to infrarenal aortic aneurysms, not iliac aneurysms.

Question 17Aneurysmal disease (aorta and peripheral arteries)

A saccular aneurysm is characterized by which of the following?

  1. A contained rupture with no endothelial lining
  2. A localized outpouching involving only part of the vessel wall Correct answer.
  3. Circumferential dilation involving the entire vessel circumference
  4. A dissection plane within the media

Explanation

A saccular aneurysm is a focal outpouching that involves only a portion of the arterial circumference, whereas a fusiform aneurysm dilates the entire circumference. Saccular aneurysms may be degenerative, mycotic, or traumatic.

Question 18Aneurysmal disease (aorta and peripheral arteries)

Which factor is most strongly associated with the development and rupture of abdominal aortic aneurysms?

  1. High dietary fiber intake
  2. Regular aerobic exercise
  3. Smoking Correct answer.
  4. Female sex

Explanation

Smoking is the strongest modifiable risk factor for AAA development, growth, and rupture. Male sex, older age, hypertension, and a family history also contribute.

Question 19Aneurysmal disease (aorta and peripheral arteries)

Two years after open abdominal aortic repair with a Dacron graft, a patient presents with fever, abdominal pain, and perigraft fluid on CT. What is the most appropriate management?

  1. Percutaneous drainage alone
  2. Observation with repeat CT in 6 months
  3. Lifelong oral antibiotics without surgery
  4. Graft excision with revascularization Correct answer.

Explanation

Aortic graft infection is a serious condition that generally requires graft excision, debridement, and revascularization, either by extra-anatomic bypass or in situ replacement with an appropriate graft. Antibiotics alone or drainage alone do not eradicate the infected graft.

Question 20Aneurysmal disease (aorta and peripheral arteries)

An 82-year-old man with a 6.0-cm abdominal aortic aneurysm has severe COPD and a hostile abdomen from prior surgery. CT shows a suitable infrarenal neck and iliac access. Which repair strategy is preferred?

  1. Endovascular aneurysm repair Correct answer.
  2. Open repair through a midline incision
  3. Continued observation until symptoms develop
  4. Laparoscopic aortic clipping

Explanation

EVAR is preferred for many high-risk patients with suitable anatomy because it has lower perioperative morbidity and mortality than open repair. A hostile abdomen and severe COPD increase open repair risk.

Question 21Arterial occlusive disease of the aorta and its branches

Which triad characterizes Leriche syndrome?

  1. Rest pain, toe ulcer, absent popliteal pulse
  2. Abdominal pain, weight loss, pulsatile mass
  3. Buttock claudication, palpable femoral pulses, paresthesia
  4. Claudication, absent femoral pulses, impotence Correct answer.

Explanation

Leriche syndrome is chronic infrarenal aortoiliac occlusion. Reduced inflow causes thigh or buttock claudication, femoral pulses become impalpable, and pelvic hypoperfusion leads to erectile dysfunction. Rest pain and tissue loss suggest more distal or advanced limb ischemia rather than the classic triad.

Question 22Arterial occlusive disease of the aorta and its branches

Which ankle-brachial index value is diagnostic of peripheral arterial disease?

  1. 1.10
  2. 0.95
  3. 0.85 Correct answer.
  4. 1.45

Explanation

An ABI of 0.90 or less is abnormal and supports a diagnosis of peripheral arterial disease. Values from 0.91 to 0.99 are borderline, while values above 1.40 suggest noncompressible calcified vessels. Therefore 0.85 is the diagnostic value among the choices.

Question 23Arterial occlusive disease of the aorta and its branches

Intermittent claudication is best characterized by which pattern?

  1. Continuous rest pain relieved by dependency
  2. Pain on standing that improves with walking
  3. Sudden pain with pallor and paresthesia
  4. Reproducible cramping with walking, relieved by rest Correct answer.

Explanation

Claudication is exertional muscle cramping caused by inadequate oxygen delivery during exercise. It occurs at a reproducible walking distance and resolves within minutes of stopping, reflecting restoration of the oxygen supply-demand balance. Continuous rest pain or sudden pallor and paresthesia suggest more advanced or acute ischemia.

Question 24Arterial occlusive disease of the aorta and its branches

Thromboangiitis obliterans (Buerger disease) is most strongly associated with which exposure?

  1. Chronic kidney disease
  2. Cigarette smoking Correct answer.
  3. Hyperhomocysteinemia
  4. Diabetes mellitus

Explanation

Buerger disease is a segmental inflammatory occlusive disease of distal small and medium vessels that occurs almost exclusively in tobacco users. Smoking cessation is the most important intervention because continued use leads to progressive ischemia and amputation. Diabetes, hyperhomocysteinemia, and kidney disease are atherosclerotic risk factors rather than the defining association.

Question 25Arterial occlusive disease of the aorta and its branches

Cilostazol improves walking distance in claudication through which mechanism?

  1. Phosphodiesterase III inhibition Correct answer.
  2. COX-1 inhibition
  3. Beta-2 receptor agonism
  4. Direct thrombin inhibition

Explanation

Cilostazol inhibits phosphodiesterase III, raising cyclic AMP and producing vasodilation and platelet inhibition. It is the most effective oral agent for improving walking distance in stable claudication. It is contraindicated in heart failure because of its inotropic and chronotropic effects.

Question 26Arterial occlusive disease of the aorta and its branches

Occlusion of the common iliac artery most typically produces claudication in which distribution?

  1. Thigh and buttock Correct answer.
  2. Forearm
  3. Calf only
  4. Foot and toes

Explanation

The common iliac artery supplies the pelvis and lower limb, so occlusion produces thigh and buttock claudication. More distal superficial femoral artery disease classically causes calf claudication, while tibial disease causes foot claudication. Forearm claudication points to upper extremity arterial disease.

Question 27Arterial occlusive disease of the aorta and its branches

A 68-year-old with diabetes has an ABI of 1.45 and toe pain. What is the best explanation for the elevated index?

  1. Medial arterial calcification making the ABI falsely high Correct answer.
  2. Normal ABI excluding arterial disease
  3. Venous insufficiency
  4. Exercise-induced vasospasm

Explanation

Medial calcinosis in diabetes makes tibial arteries resistant to cuff compression, producing a falsely elevated ABI above 1.40. In this setting, toe-brachial index, pulse volume recording, or duplex ultrasound is needed to assess perfusion. An elevated ABI does not exclude arterial disease.

Question 28Arterial occlusive disease of the aorta and its branches

A 72-year-old with atrial fibrillation develops severe abdominal pain out of proportion to examination, and CT angiography shows a superior mesenteric artery embolus. Which feature best fits this presentation?

  1. Pain localized to the right lower quadrant with rebound
  2. Pain out of proportion to abdominal tenderness Correct answer.
  3. Pain relieved by eating
  4. Pain with bloody diarrhea and tenesmus

Explanation

Early acute mesenteric ischemia often causes severe pain with a relatively benign abdominal examination because ischemia precedes transmural infarction. Atrial fibrillation is a classic embolic source to the superior mesenteric artery. Bloody diarrhea and peritonitis are later findings and may indicate irreversible bowel injury.

Question 29Arterial occlusive disease of the aorta and its branches

Chronic mesenteric ischemia classically presents with which symptom pattern?

  1. Postprandial abdominal pain, food fear, weight loss Correct answer.
  2. Nocturnal diarrhea
  3. Left upper quadrant pain radiating to the back
  4. Painless jaundice

Explanation

Chronic mesenteric ischemia causes intestinal angina, with cramping abdominal pain after meals leading to food avoidance and weight loss. Symptomatic disease usually requires significant stenosis or occlusion of at least two of the three main mesenteric vessels. Painless jaundice and isolated nocturnal diarrhea are not typical.

Question 30Arterial occlusive disease of the aorta and its branches

Which finding favors fibromuscular dysplasia over atherosclerotic renal artery stenosis?

  1. Young woman with mid-to-distal renal artery beading Correct answer.
  2. Bilateral ostial lesions
  3. Older man with an ostial lesion
  4. Calcified aortic plaque at the ostium

Explanation

Fibromuscular dysplasia typically affects younger women and produces a string-of-beads appearance in the mid-to-distal renal artery. Atherosclerotic renal artery stenosis usually involves the ostium or proximal segment in older patients with diffuse aortic plaque. Ostial disease and calcified aortic plaque therefore favor atherosclerosis.

Question 31Arterial occlusive disease of the aorta and its branches

A 28-year-old woman from East Asia has absent radial pulses, arm claudication, and an elevated erythrocyte sedimentation rate. What is the most likely diagnosis?

  1. Atherosclerotic subclavian stenosis
  2. Giant cell arteritis
  3. Buerger disease
  4. Takayasu arteritis Correct answer.

Explanation

Takayasu arteritis is a large-vessel vasculitis that typically affects young women of East Asian descent and involves the aorta and its major branches. Absent upper extremity pulses, arm claudication, and elevated inflammatory markers are characteristic. Giant cell arteritis occurs in older adults, and Buerger disease affects distal small vessels in smokers.

Question 32Arterial occlusive disease of the aorta and its branches

Axillobifemoral bypass is most appropriate in which setting?

  1. Acute aortic dissection
  2. Aortic graft infection with a hostile abdomen Correct answer.
  3. First-line therapy for claudication
  4. Bilateral iliac stenoses in a young patient

Explanation

Extra-anatomic bypass avoids a contaminated or hostile abdominal field and is therefore useful for aortic graft infection or severe abdominal adhesions. It has lower long-term patency than anatomic aortobifemoral reconstruction. It is not first-line therapy for claudication or typical iliac stenoses.

Question 33Arterial occlusive disease of the aorta and its branches

Which revascularization strategy offers the most durable long-term patency for bilateral aortoiliac occlusive disease in a good-risk patient?

  1. Axillobifemoral bypass
  2. Iliac balloon angioplasty alone
  3. Aortobifemoral bypass Correct answer.
  4. Femoral-femoral crossover

Explanation

Aortobifemoral bypass is the anatomic gold standard for extensive bilateral aortoiliac disease, with five-year patency commonly reported around 85% to 90%. Extra-anatomic and crossover grafts have lower patency and are reserved for patients who cannot undergo anatomic reconstruction. Angioplasty alone is inadequate for diffuse bilateral occlusion.

Question 34Arterial occlusive disease of the aorta and its branches

According to the TASC II classification, a short focal common iliac stenosis (TASC A lesion) is best managed by which approach?

  1. Endovascular angioplasty with or without stent Correct answer.
  2. Aortobifemoral bypass
  3. Primary amputation
  4. Lumbar sympathectomy

Explanation

TASC A aortoiliac lesions are short and focal, and endovascular therapy has outcomes comparable to open surgery with lower morbidity. Angioplasty with selective stenting is therefore the preferred first approach. Open bypass is reserved for more extensive TASC C or D disease.

Question 35Arterial occlusive disease of the aorta and its branches

A 60-year-old has dizziness with left arm exercise and a 25 mmHg interarm blood pressure difference. Duplex shows retrograde left vertebral flow. What is the diagnosis?

  1. Vertebral artery dissection
  2. Thoracic outlet syndrome
  3. Carotid sinus syndrome
  4. Subclavian steal syndrome Correct answer.

Explanation

Proximal subclavian stenosis reduces antegrade vertebral flow, and arm exercise can reverse flow down the vertebral artery, producing vertebrobasilar symptoms. A significant interarm blood pressure difference supports subclavian stenosis. Carotid sinus syndrome and vertebral dissection do not produce this exercise-related reversal pattern.

Question 36Arterial occlusive disease of the aorta and its branches

Which finding defines chronic limb-threatening ischemia?

  1. Rest pain or tissue loss with severe hemodynamic impairment Correct answer.
  2. ABI of 0.95
  3. Diminished pedal pulses alone
  4. Claudication at 200 meters

Explanation

Chronic limb-threatening ischemia requires ischemic rest pain or tissue loss plus objective evidence of severe limb hypoperfusion, such as a very low ankle pressure or toe pressure. It represents a limb at risk of amputation without revascularization. Claudication and isolated pulse abnormalities do not meet the definition.

Question 37Arterial occlusive disease of the aorta and its branches

A young woman has postprandial epigastric pain and weight loss. Duplex shows elevated celiac artery velocities that increase with expiration. What is the most likely diagnosis?

  1. Median arcuate ligament syndrome Correct answer.
  2. Chronic pancreatitis
  3. Superior mesenteric artery embolism
  4. Abdominal aortic aneurysm

Explanation

Median arcuate ligament syndrome results from compression of the celiac axis by the diaphragmatic ligament, and stenosis worsens during expiration. It causes postprandial pain and weight loss in the absence of another cause. Diagnosis is one of exclusion after organic gastrointestinal and vascular disease are excluded.

Question 38Arterial occlusive disease of the aorta and its branches

A 24-year-old man has upper extremity hypertension, weak femoral pulses, and rib notching on chest radiograph. What is the diagnosis?

  1. Coarctation of the aorta Correct answer.
  2. Aortic dissection
  3. Takayasu arteritis
  4. Subclavian steal

Explanation

Coarctation of the aorta typically occurs distal to the left subclavian artery, causing upper extremity hypertension and diminished lower extremity pulses. Enlarged intercostal collaterals erode the ribs and produce notching on radiography. Bicuspid aortic valve is a common associated anomaly.

Question 39Arterial occlusive disease of the aorta and its branches

A patient with a prior aortobifemoral graft presents with a self-limited upper gastrointestinal bleed and fever. What is the most appropriate next step?

  1. Oral anticoagulation
  2. Elective colonoscopy
  3. Urgent CT angiography and vascular surgery consultation Correct answer.
  4. Reassurance and outpatient endoscopy

Explanation

A herald bleed in a patient with an aortic graft raises concern for an aortoenteric fistula, which can rapidly progress to catastrophic hemorrhage. Urgent CT angiography and vascular surgery involvement are needed for diagnosis and operative planning. Endoscopy may be considered but should not delay definitive vascular evaluation.

Question 40Arterial occlusive disease of the aorta and its branches

In chronic infrarenal aortic occlusion, which collateral pathway is most important for lower limb perfusion?

  1. Internal thoracic–epigastric–external iliac Correct answer.
  2. Celiac–SMA–inferior mesenteric
  3. Renal–lumbar–iliac
  4. Subclavian–vertebral–basilar

Explanation

When the infrarenal aorta occludes, blood from the subclavian axis reaches the legs through the internal thoracic, superior epigastric, and inferior epigastric arteries into the external iliac system. Other routes include lumbar-to-iliolumbar collaterals and the inferior mesenteric to rectal arcade. The internal thoracic–epigastric pathway is a major contributor to limb perfusion.

Question 41Cerebrovascular and neurovascular disease of the neck

In the NASCET method for grading internal carotid artery stenosis, the narrowest residual lumen is compared with which reference diameter?

  1. The normal external carotid at its origin
  2. The normal common carotid at the bifurcation
  3. The normal ICA distal to the stenosis Correct answer.
  4. The estimated normal diameter of the bulb

Explanation

The NASCET method compares the narrowest residual lumen with the diameter of the normal internal carotid artery beyond the stenosis, avoiding the diseased bulb. This produces lower stenosis values than methods that use an estimated bulb diameter.

Question 42Cerebrovascular and neurovascular disease of the neck

For a patient with a recent hemispheric transient ischemic attack and ipsilateral internal carotid stenosis, which NASCET stenosis range confers the greatest absolute benefit from carotid endarterectomy?

  1. 70% to 99% Correct answer.
  2. Less than 30%
  3. 30% to 49%
  4. 50% to 69%

Explanation

Carotid endarterectomy provides the greatest absolute stroke reduction for symptomatic 70% to 99% stenosis. The 50% to 69% group has a smaller benefit, and stenoses below 50% do not benefit.

Question 43Cerebrovascular and neurovascular disease of the neck

A pulsatile, mobile neck mass is found to separate the internal and external carotid arteries on angiography. Which diagnosis is most likely?

  1. Carotid artery aneurysm
  2. Branchial cleft cyst
  3. Vagal schwannoma
  4. Carotid body tumor Correct answer.

Explanation

A carotid body tumor arises at the bifurcation and characteristically separates the internal and external carotid arteries, producing the lyre sign. Its pulsatile, mobile nature reflects its vascularity.

Question 44Cerebrovascular and neurovascular disease of the neck

A patient has dizziness with arm exertion and a blood pressure 25 mmHg lower in the left arm. Duplex shows retrograde flow in the left vertebral artery. What is the most likely lesion?

  1. Left internal carotid stenosis
  2. Left vertebral origin occlusion
  3. Left common carotid occlusion
  4. Proximal left subclavian stenosis Correct answer.

Explanation

A proximal subclavian stenosis reduces pressure distal to the vertebral origin, causing retrograde vertebral flow and posterior circulation symptoms. The arm blood pressure differential supports this level of lesion.

Question 45Cerebrovascular and neurovascular disease of the neck

Which noninvasive study is the preferred initial screening test for cervical carotid stenosis?

  1. Magnetic resonance angiography
  2. Computed tomography angiography
  3. Duplex ultrasonography Correct answer.
  4. Digital subtraction angiography

Explanation

Duplex ultrasonography is noninvasive, inexpensive, and highly sensitive for cervical carotid stenosis, making it the preferred initial screening test. Cross-sectional angiography is reserved for confirmation or operative planning.

Question 46Cerebrovascular and neurovascular disease of the neck

A patient develops ipsilateral headache, seizures, and severe hypertension 3 days after carotid endarterectomy, with no new infarct on imaging. What is the most likely diagnosis?

  1. Carotid dissection
  2. Cerebral hyperperfusion Correct answer.
  3. Ischemic stroke from thrombosis
  4. Postoperative neck hematoma

Explanation

Cerebral hyperperfusion syndrome typically occurs days after carotid endarterectomy with headache, seizures, and hypertension out of proportion to any infarct. It results from loss of cerebral autoregulation in a chronically hypoperfused hemisphere.

Question 47Cerebrovascular and neurovascular disease of the neck

After left carotid endarterectomy, a patient's tongue deviates to the left on protrusion. Which nerve was injured?

  1. Left glossopharyngeal nerve
  2. Left vagus nerve
  3. Left hypoglossal nerve Correct answer.
  4. Left marginal mandibular nerve

Explanation

The hypoglossal nerve lies near the carotid bifurcation and can be injured during carotid endarterectomy. Tongue deviation is toward the side of injury because the genioglossus loses resting tone.

Question 48Cerebrovascular and neurovascular disease of the neck

A 40-year-old develops unilateral neck pain and Horner syndrome after chiropractic manipulation; imaging shows a tapered internal carotid stenosis. Which initial treatment is recommended?

  1. Observation with repeat imaging only
  2. Antithrombotic therapy alone Correct answer.
  3. Urgent carotid artery stenting
  4. Immediate surgical exploration and repair

Explanation

Extracranial carotid dissection is initially managed with antithrombotic therapy, either antiplatelet or anticoagulant, to prevent thromboembolic stroke. Surgery and stenting are reserved for selected cases with recurrent symptoms despite therapy.

Question 49Cerebrovascular and neurovascular disease of the neck

A 35-year-old woman has a string-of-beads appearance in the mid cervical internal carotid artery. What is the most likely diagnosis?

  1. Fibromuscular dysplasia Correct answer.
  2. Takayasu arteritis
  3. Atherosclerotic plaque
  4. Carotid dissection

Explanation

Fibromuscular dysplasia commonly produces a string-of-beads appearance from alternating webs and dilatations in the mid to distal cervical internal carotid artery. It typically affects young women and spares the carotid bulb.

Question 50Cerebrovascular and neurovascular disease of the neck

A patient has a nondisabling hemispheric stroke and 80% ipsilateral carotid stenosis. When should carotid endarterectomy ideally be performed?

  1. Within 2 weeks of the event Correct answer.
  2. Only after complete neurologic recovery
  3. At 6 to 12 weeks
  4. After 6 months of medical therapy

Explanation

Carotid endarterectomy offers the greatest benefit when performed soon after a nondisabling carotid territory event, ideally within 2 weeks. Delaying surgery allows recurrent stroke during the highest-risk period.