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Deputy Director, Morehouse School of Medicine

Illustrative Points the indication for tibial angioplasty is critical limb ischemia blood pressure quit drinking buy digoxin 0.25mg otc, defined as rest pain blood pressure ranges low normal high proven digoxin 0.25 mg, nonhealing ischemic ulcers, or gangrene. Critical limb ischemia requires stenosis or occlusion of all three infrapopliteal vessels, and very often multiple levels of disease in the iliac and femoral arteries. The goal of revascularization in patients with crit ical limb ischemia is to provide pulsatile flow to the foot. The introduction of low-profile coronary systems into the periph ery has to a great extent facilitated infrapopliteal interven tion. A strategy of provisional stenting rather than primary stenting with antiplatelet therapy is the current standard of care. While surgical therapy is an option, an "angioplasty first" strategy seems prudent at this time. The role of drug-eluting stents in this location, though promising, has not been defined. This 65 -year-old man with a 1 00-pack year smoking history presented with a painful foot and a non healing ulcer on the second digit of his left lower extremity. At that time, he had a severe (> 70%) stenosis of his left tibial-peroneal trunk, but this was not treated. Right common femoral access was obtained with a 4F sheath, and a 4F pigtail catheter was advanced over a 0. Aortography and lower extremity run-off were performed, with non-ionic contrast inj ected at 8 cc/second for a total of 10 seconds, using step ping-table digital subtraction angiography. The most serious of these complica tions, retroperitoneal bleeding and acute limb ischemia, are also life-threatening. The following cases will illustrate how these complications can be managed percutaneously. Single-vessel peroneal patency with high-grade stenosis in the tibioperoneal trunk. After serial bal loon inflations of up to 5 minutes each, the bleeding contin ued. Examina tion revealed a pulse of 90 bpm, cool clammy extremities, and right lower-quadrant fullness, guarding, and tenderness. A clinical diagnosis of retroperitoneal hemorrhage was made, and manual compres sion was applied to her right groin. She was urgently taken back to the catheterization laboratory for angiography and intervention. Angiography revealed contrast extravasation (bleeding) at Illustrative Points this case demonstrates the preferred approach to manage serious, hemodynamically significant vascular access bleed ing. A small amount of visible extravascular bleeding correlates with severe, life-threatening hemorrhage. Duplex scanning also cannot tell the difference between continued bleeding and a pseudo-aneurysm, or contained bleeding. In the hypotensive patient, we recommend return ing the patient to the angiography suite to determine the bleeding site, and then control the bleeding. O n examination, he had ecchymosis without hematoma over the right groin, and absent femoral pulse. A duplex ultrasound confirmed our sus picion that the right limb of his aorto-bifemoral graft has been occluded. The occlusion was traversed with an extra-stiff angled Glidewire and a 4F multipurpose catheter. An exchange length Platinum Plus coronary wire was placed in the dis tal profunda femoris; the 4F multipurpose catheter was exchanged for a 6F multipurpose coronary guiding catheter; and mechanical thrombectomy (Angioj et) was performed. After mechanical thrombectomy, multiple high-grade stenoses remain in the graft and native vessel (arrows). This appearance may suggest dissection or suturing of the posterior wall to the anterior wall of the lumen. Therefore an 8 X 29 mm self-expanding Wallstent was deployed, and positioned so that it would be below the ingui nal ligament. Illustrative Points this patient suffered an iatrogenic complication related to manual compression following an angiogram. While this complication may not be preventable, it is treatable by either mechanical thrombectomy (as in this case) or surgical throm bectomy with or without patch angioplasty or bypass.

He was taken to the catheterization laboratory and right femoral artery access was obtained with a 6F sheath hypertension jnc 8 summary buy discount digoxin on line. Coronary and bypass graft angiography did not reveal any treatable culprit lesions heart attack 80 blockage cheap digoxin generic. Using a 4F internal mammary artery diagnostic catheter, telescoped through a 55 em 6F hockey stick guide, the renal arteries were a traumatically engaged. Both the right and the left renal arteries were stented with balloon-expandable stents (6 X 1 8 m m for both) over 0. The patient remains asymptomatic without recurrent hospitalizations and on dya zide and metoprolol 5 years after renal stenting. Bilateral aorto-ostial renal artery stenosis (arrows) as demonstrated by cineangiography at the time of cardiac catheterization. It also illustrates how the lesions of renal artery stenosis often comprise aortic plaque that encroaches upon the renal ostia rather than plaque originating in the renal arteries themselves. For this reason, we recom mend very careful cannulation of the renal arteries using a 4 to 6F diagnostic catheter rather than a guiding catheter to avoid the risk of atheroembolism. Furthermore, as this case also illustrates, the teaching point is that even though this patient presented with an acute coronary syndrome, the clues of poorly controlled hyperten sion on multiple medications, history of recurrent heart fail ure episodes, and mildly abnormal renal function all pointed to the fact that he likely had renovascular disease. The key is to be able to recognize these patients and to be able to treat their problems. Prior to her discharge the patient became normo tensive on the same medications she had been on before the procedure, her lungs cleared, her peripheral edema improved, and her serum creatinine improved to 1. Illustrative Points this case illustrates the role of unilateral renal artery stenosis in patients with hypertensive crisis and acute volume over load. The presumption is that long-term hypertension and nephrosclerosis have damaged the contralateral patent renal artery. Opening the obstructed kidney brings more functional nephrons online and reduces production of renin. Radial access for renal artery intervention is a good technique to avoid femoral or brachial artery vascular complications, but o ccasionally requires longer catheters (l 2S em 6F guiding catheters and 1 S O em length bal loon and stent catheters). In this case, the conventional 100 em guide catheter and 1 3 S em length balloon and stent catheters were long enough to reach her renal artery. To redu ce the size of the radial artery entry site, we o ften use a sheathless technique of telescoping a 4F catheter through a 6F guide catheter. The risk of atheroemboli complicating renal artery intervention may be much more common than previously suspected. Hence, embolic protection devices should be con sidered for patients with impaired renal function and who have suitable anatomy. There may also be a role for aggressive platelet inhibition in protecting the renal microcirculation, though we require more data to confirm this. Her blood pressure in the right arm was 1 88/1 08 mmHg, respiratory rate 18 per minute, and her pulse rate was 68 beats per minute. Her physi cal examination was remarkable for bibasilar crackles and 2 + edema of feet and ankles. An abdominal du plex ultrasound examination ruled out obstructive nephropa thy but suggested a critical narrowing of the right renal artery. She was brought to the catheterization suite with a plan to open the right renal artery stenosis. In order to maximize the safety of this procedure, a radial artery approach was cho sen, use of radiographic contrast was limited, and embolic protection was used. The 6F guide catheter was advanced over the 4F diagnostic catheter to engage the right renal artery. The diagnostic catheter was removed, and the lesion was crossed with a filterwire (Boston Scientific). For common iliac bifurcation lesions, kissing balloon expandable stents have become the preferred option. Right renal artery angiogram with a c 4F multipurpose catheter demonstrat ing a critical ostial narrowing.

Moreover arrhythmia technology institute south carolina buy cheap digoxin 0.25 mg, after the second year blood pressure up generic digoxin 0.25 mg fast delivery, the rate of resection for recurrent respiratory infection diminishes, and there were no resections in those older than 5 years of age. Furthermore, the majority of lesions identified are small and appear to Answer 7 a. Answer 1 In macrocystic lung lesions, the ultrasound features include a cystic lesion(s) of varying size in the thorax with or without Self-Assessment e33 continue to reduce in size as the lung grows in early life, with up to 5. A complication rate of 5% to 23% in elective procedures carried out on asymptomatic infants has been described, and these include air leak, infection, effusion and death in one case. Type 2 Type 2 Type 3 Type 0 Type 1 Type 1 Question 5 Which are true regarding microcystic lung lesions In intralobar pulmonary sequestration, the lesion lies within the visceral pleura. Extralobar pulmonary sequestrations always communicate with the gastrointestinal tract. All cystic lung lesions require regular antenatal follow-up to assess for hydrops and mediastinal shift. Left-sided pulmonary agenesis carries a mortality risk twice that of right-sided agenesis. In right-sided cases, liver herniation is an independent predictor of postnatal outcome. Gastroschisis is often relatively straightforward to repair but is associated with feeding difficulties in both the immediate neonatal period and infancy. Groups disagree about best management, but it is possible to delay repair and manage expectantly in most circumstances. Observed to expected lung area to head circumference ratio in the prediction of survival in fetuses with isolated diaphragmatic hernia. A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia. Fetal tracheal occlusion for severe pulmonary hypoplasia in isolated congenital diaphragmatic hernia: a systematic review and meta-analysis of survival. In general, fetuses with very large kidneys or severe oligohydramnios are likely to have a poor outcome. With normal amniotic fluid volumes and moderately enlarged kidneys (<4 standard deviations), the prognosis seems to be better with a high probability of survival without significant morbidity in infancy. Typically seen late in pregnancy, these foci are defined by their effect on acoustic shadowing. Chapter 33 Question 1 What are the sonographic characteristics of severe and terminal fetal renal impairment The circumference of the chest must not be below 50% to 60% of the abdominal circumference. Answer 1 Progressive development of severe oligohydramnios in a fetus with a uropathy is suggestive of terminal renal failure. The presence of hyperechogenic renal parenchyma, significant thinning of the cortex (<3 mm), loss of corticomedullar differentiation and cortical cysts are signs of severe renal damage. Answer 2 e Answer 2 Pyelectasis is defined as a dilation of the renal pelvis only, whereas hydronephrosis consists of a dilatation of both the renal pelvis and the calyces. Measuring the anteroposterior diameter of the renal pelvis is the generally accepted method to quantify pyelectasis. A consensus on the ideal threshold value to diagnose urinary tract dilation is lacking, but the most accepted cutoff values are 4 mm in the second trimester and 7 mm in the third. Answer 3 d Answer 3 the diagnosis of the underlying cause and the counselling of the parents on the long-term prognosis in cases of bilateral, isolated hyperechogenic kidneys without a family history or renal cysts can be challenging. Isolated hyperechogenic kidneys are most Question 4 For each of the following sonographic findings, choose which diagnosis fits best: a. Chapter 35 Question 1 It is important to diagnose micro- or retrognathia prenatally to a.

The receptors generally are concentrated in small pits on the outer surface of the cell membrane arrhythmia pathophysiology safe digoxin 0.25mg, called coated pits blood pressure homeostasis buy cheap digoxin 0.25 mg on line. On the inside of the cell membrane beneath these pits is a latticework of fibrillar protein called clathrin, as well as other proteins, perhaps including contractile filaments of actin and myosin. Once the protein molecules have bound with the receptors, the surface properties of the local membrane change in such a way that the entire pit invaginates inward, and fibrillar proteins surrounding the invaginating pit cause its borders to close over the attached proteins, as well as over a small amount of extracellular fluid. Immediately thereafter, the invaginated portion of the membrane breaks away from the surface of the cell, forming a pinocytotic vesicle inside the cytoplasm of the cell. What causes the cell membrane to go through the necessary contortions to form pinocytotic vesicles is still unclear. This process also requires the presence of calcium ions in the extracellular fluid, which probably react with contractile protein filaments beneath the coated pits to provide the force for pinching the vesicles away from the cell membrane. Phagocytosis occurs in much the same way as pinocytosis, except that it involves large particles rather than molecules. Only certain cells have the capability of phagocytosis-notably, tissue macrophages and some white blood cells. The products of digestion are small molecules of substances such as amino acids, glucose, and phosphates that can diffuse through the membrane of the vesicle into the cytoplasm. What is left of the digestive vesicle, called the residual body, represents indigestible substances. In most cases, the residual body is finally excreted through the cell membrane by a process called exocytosis, which is essentially the opposite of endocytosis. Thus, the pinocytotic and phagocytic vesicles containing lysosomes can be called the digestive organs of the cells. Digestion of substances in pinocytotic or phagocytic vesicles by enzymes derived from lysosomes. Phagocytosis is initiated when a particle such as a bacterium, dead cell, or tissue debris binds with receptors on the surface of the phagocyte. In the case of bacteria, each bacterium is usually already attached to a specific antibody; it is the antibody that attaches to the phagocyte receptors, dragging the bacterium along with it. This intermediation of antibodies is called opsonization, which is discussed in Chapters 34 and 35. The edges of the membrane around the points of attachment evaginate outward within a fraction of a second to surround the entire particle; then, progressively more and more membrane receptors attach to the particle ligands. All this occurs suddenly in a zipper-like manner to form a closed phagocytic vesicle. Actin and other contractile fibrils in the cytoplasm surround the phagocytic vesicle and contract around its outer edge, pushing the vesicle to the interior. The contractile proteins then pinch the stem of the vesicle so completely that the vesicle separates from the cell membrane, leaving the vesicle in the cell interior in the same way that pinocytotic vesicles are formed. For example, this regression occurs in the uterus after pregnancy, in muscles during long periods of inactivity, and in mammary glands at the end of lactation. Another special role of the lysosomes is the removal of damaged cells or damaged portions of cells from tissues. Damage to the cell-caused by heat, cold, trauma, chemicals, or any other factor-induces lysosomes to rupture. The released hydrolases immediately begin to digest the surrounding organic substances. If the damage is slight, only a portion of the cell is removed, and the cell is then repaired. In this way, the cell is completely removed, and a new cell of the same type is formed, ordinarily by mitotic reproduction of an adjacent cell to take the place of the old one. The lysosomes also contain bactericidal agents that can kill phagocytized bacteria before they cause cellular damage. These agents include the following: (1) lysozyme, which dissolves the bacterial cell wall; (2) lysoferrin, which binds iron and other substances before they can promote bacterial growth; and (3) acid at a pH of about 5. Thus, a digestive vesicle is formed inside the cell cytoplasm in which the vesicular hydrolases begin hydrolyzing the 22 Lysosomes play a key role in the process of autophagy, which literally means "to eat oneself. Worn-out cell organelles are transferred to lysosomes by double- membrane structures called autophagosomes, which are formed in the cytosol. Invagination of the lysosomal membrane and the formation of vesicles provides another pathway for cytosolic structures to be transported into the lumen of lysosomes.