Peripheral Vascular System

Front 1

Palpating pulses is subjective, and the examiner may mistake his or her own pulse for that of the patient.

To prevent this, the examiner should use light touch and avoid using only the index finger for palpation,because

Back 1

this finger has the strongest arterial pulsation of all the fingers

Hint 1

The thumb should not be used for the same reason

Front 2

Doppler ultrasound device, called a transducer or probe,
may be helpful in

Back 2

detecting and assessing peripheral flow

Front 3

A continuous-wave (CW) Doppler ultrasound device may be used to

Back 3

hear (insonate) the blood flow in vessels when pulses cannot be palpated

Front 4

The depth at which blood flow can be detected by Doppler ultrasound
is determined by the frequency (in megahertz [MHz]) it generates.

The lower the frequency

Back 4

the deeper the tissue penetration

Front 5

CW Doppler is more useful as a clinical tool when
combined with ankle blood pressures, which are used to determine the ankle-brachial index (ABI), also called the ankle-arm index (AAI).
It is an objective indicator of arterial disease that allows the examiner to quantify the degree of stenosis.
With increasing degrees of arterial narrowing, there is a progressive decrease in systolic pressure distal to the involved sites.

The ABI is

Back 5

the ratio of the ankle systolic blood pressure to
the arm systolic blood pressure

Front 6

The first step in determining the ABI is to have the patient rest
in --- position for at least --- minutes

Back 6

a supine position (not seated) / 5 min

Front 7

The highest systolic pressure for each ankle (--- for the right,--- for the left) would be divided by the highest brachial pressure (---)

Back 7

80 mm Hg / 120 mm Hg / 160 mm Hg

Front 8

Right: = --- ABI
Left: = --- ABI

Back 8

0.50

0.75

Front 9

Doppler ultrasonography is used to measure brachial pressures in both arms. Both arms are evaluated because the patient may have

Back 9

-an asymptomatic stenosis in the subclavian artery

Hint 9

--- causing brachial pressure on the affected side to be 20 mm Hg or more lower than systemic pressure.

Front 10

Exercise testing is used to determine how long a patient can walk and to measure

Back 10

the ankle systolic blood pressure in response to
walking

Front 11

management of atherosclerosis

Back 11

1.RADIOLOGIC INTERVENTIONS
-

-PTA=percutaneous transluminal angioplasty

Hint 11

(PTA)

Front 12

Vascular surgical procedures for atherosclerosis are divided into 2 groups:

Back 12

1.inflow procedures
which provide blood supply from the aorta into the femoral artery

2.outflow procedures
which provide blood supply to vessels below the femoral artery

Front 13

Complications from PTA include

Back 13

-hematoma formation
-embolus
-dissection (separation of the intima) of the vessel
-bleeding

Hint 13

4

Front 14

ILOMEDIN(Iloproset)
indications:

Back 14

-severe peripheral arterial occlusive disease (PAOD), particularly those at risk of amputation and in whom surgery or angioplasty is not possible

-advanced thromboangiitis obliterans (Buerger's disease) with critical limb ischaemia in cases where revascularisation is not indicated

-patients with severe disabling Raynaud's phenomenon unresponsive to other therapies

-moderate or severe primary and secondary pulmonary hypertension such as New York Heart Association functional classes III and IV

Hint 14

4

Front 15

Ilomedin(Iloproset) side effects:

Back 15

1.Metabolism/nutrition disorders:
-anorexia

2.Nervous system disorders/ psychiatric disorders :
-dizziness, vertigo, giddiness, par-esthesia, hyper-esthesia, burning sensation, tingling, throbbing sensation, restlessness, agitation, sedation, apathy, drowsiness

3.Cardiac and vascular disorders !:
-headache, flush
(very common!!!)
-hypotensive reaction, bradycardia
(common!!!)

4.Gastrointestinal disorders:
-nausea, vomiting
(very common)

-diarrhoea, abdominal complaints, pain

5.Skin disorders:
-sweating
(very common!!!)

Front 16

Ilomedin(Iloproset)
mechanism of action:

Back 16

Iloprost is a prostacyclin analogue. The following pharmacological effects have been observed:

-Inhibition of aggregation, platelet adhesion and release reaction

-dilatation of arterioles and venules, increase of capillary density and reduction of increased vascular permeability in the microcirculation

-activation of fibrinolysis, inhibition of adhesion and immigration of leucocytes after an endothelial lesion, and reduced release of oxygen free radicals

Front 17

Ilomedin(Iloproset)
administration :

Back 17

I.V

In general, the ready-to-use infusion solution is infused intravenously by means of an infusion pump .
For this purpose, the contents of an ampoule of 0.5 ml ILOMEDIN are diluted with 250 ml of a sterile physiological saline solution or a 5 % glucose solution. The contents of the ampoule and the diluent should be mixed thoroughly. In the case of an ILOMEDIN concentration of 0.2 µg/ml, the required infusion rate should be determined according to the above descibed scheme to effect a dose within the range of 0.5 to 2.0 ng/kg/min.

Front 18

Ilomedin(Iloproset)
interactions:

Back 18

-Beta bl.
-calcium antagonists and vasodilators
-ACE inh.

(additive effect on the antihypertensive activity and as the result orthostatic hypotension!)

Front 19

A 68-year-old man is brought to the emergency department with excruciating back pain that began suddenly 45 minutes ago. The pain is constant and is not exacerbated by sneezing or coughing. He is diaphoretic and has a systolic blood pressure of 90 mm Hg. There is an 8-cm pulsatile mass deep in his epigastrium, above the umbilicus. A chest x-ray film is unremarkable. Two years ago, he was diagnosed with prostatic cancer and was treated with orchiectomy and radiation. At that time, his blood pressure was normal, and he had a 6-cm, asymptomatic abdominal aortic aneurysm for which he declined treatment. Which of the following is the most likely diagnosis?

A. Dissecting thoracic aortic aneurysm
B. Fracture of lumbar pedicles with cord compression
C. Herniated disc
D. Metastatic tumor to the lumbar spine
E. Rupturing abdominal aortic aneurysm

Back 19

The correct answer is E. Abdominal aortic aneurysms have a high incidence of rupture once they reach or exceed a size of 6 cm. Often, the first manifestation is excruciating back pain, as the blood leaks into the retroperitoneal space before the aneurysm blows out into the peritoneal cavity. The combination of a big aneurysm and sudden severe back pain should always lead to this presumptive diagnosis. Looking for orthopedic or neurologic explanations can be a deadly mistake.

Dissecting thoracic aortic aneurysm (choice A) could also cause excruciating back pain, but the pain usually starts as retrosternal and later migrates down. The absence of hypertension mitigates against this diagnosis, and one would expect to see a wide mediastinum on the chest x-ray film.

Fracture of the spine with cord compression (choice B) could indeed happen to someone who recently had prostatic cancer, but the symptoms would be primarily neurologic deficits from cord compression.

The pain from a herniated disc (choice C) runs down the leg and is exacerbated by sneezing and coughing.

Metastatic tumor (choice D) is a good bet in someone with prostatic cancer. However, the pain of bony metastasis is present for weeks or months, and is constant, dull, low grade, and worse at night—not the sudden excruciating pain of this vignette.

Front 20

A 67-year-old man has had an indolent, unhealing ulcer at the heel of the right foot for several weeks. The patient began wearing a new pair of shoes shortly before the ulcer started and noticed a blister as the first anomaly at the site where the ulcer eventually developed. He indicates that neither the blister nor the ulcer ever gave him any pain. The ulcer is 3.5 cm in diameter, the ulcer base looks dirty, and there is hardly any granulation tissue. The skin around the ulcer looks normal. The patient has no sensation to pin prick anywhere in that foot. Peripheral pulses are weak but palpable. He is obese and has varicose veins, high cholesterol, and poorly controlled type 2 diabetes mellitus. Which of the following most accurately characterizes the ulcer?

A. Diabetic ulcer due to trauma, neuropathy, and microvascular disease
B. Ischemic ulcer due to arteriosclerosis
C. Ischemic ulcer due to embolization
D. Neoplastic in nature, probably squamous cell carcinoma
E. Stasis ulcer due to venous insufficiency

Back 20

The correct answer is A. Diabetic ulcers typically develop at pressure points, and the heel is a favorite location. The patient has evidence of neuropathy, and the correlation with the trauma inflicted by the new shoes is classic.

Ischemic ulcers, whether due to arteriosclerosis (choice B) or embolization (choice C) are typically seen at the tip of the toes, as far away from the heart as one can get.

Neoplasms (choice D) can indeed develop in long-standing ulcers, but the history would have been one of 10 or 20 years of healing and breaking down, before heaped up edges of cancer begin to develop.

Stasis ulcers (choice E) are seen above the malleolus, surrounded by edematous, hyperpigmented skin.