The Peripheral Vascular System

Transcription

1 The Peripheral Vascular System

2 Anatomy and Physiology

3 Arteries Arteries contain 3 concentric layers of tissue: - the intima - the media - the adventitia

4 The intima The endothelium of the intima has metabolic properties, it synthetizes: - regulators of thrombosis (i.e. prostacyclin, plasminogen activator and heparinlike molecules) - prothrombotic molecules (i.e. plasminogen activator inhibitor) - modulates blood flow and vascular reactivity (vasoconstrictors like endothelin - vasodilators like prostacyclin)

5 It also regulates: Immune and inflammatory reactions through elaboration of: - interleukins - adhesion molecules - histocompatibility antigens

6 The media and adventitia The media is composed of SMOOTH MUSCLE CELL that dilate and constrict to accommodate blood pressure flow Small arterioles called the VASA VASORUM perfuse the media The adventitia is composed of connective tissue containing nerve fibers and the vasa vasorum

7 Arteria pulses palpable in the arms: - The brachial artery - The radial artery - The ulnar artery

8 Pulses palpable in the leg: - The femoral artery - The popliteal artery - The dorsalis pedis artery - The posterior tibial artery

9 Veins Veins are thin-walled and highly distensible The venous intima consists of NONTHROMBOGENIC ENDOTHELIUM Protruding into the lumen are VALVES the promote unidirectional venous return The media contains elastic tissue and smooth muscle that change vein caliber in response to venous pressure

10 Veins from the arm, upper trunk and head and neck drains into the SUPERIOR VENA CAVA Veins from the legs and lower trunk drain upward into the INFERIOR VENA CAVA

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12 The superficial vein of the leg include: - The great saphenous vein - The small saphenous vein

13 The lymphatic system Drains lymph fluid from body tissue and returns it to the venous circulation Lymph fluid is filtered through lymph nodes (only superficial ones are accessible to physical examination) Vascular and immune function

14 Lymphatics of upper limb EPITROCHLEAR NODES drain from the ulnar surface of the foreharm and hand AXILLARY NODES drain the rest of the arm

15 Lymphatics of lower limb The SUPERFICIAL INGUINAL NODES include 2 groups: The horizontal group (below the inguinal ligament) The vertical group (near the upper part of the saphenous vein)

16 The horizontal group drains: - superficial portion of the lower abdomen and buttock - external genitalia (not the testes) - anal canal - perianal area and the lower vagina The vertical group drains a corresponding region of the leg

17 Lymphatics of lower limb Lymphatics from the portion of the leg drained by the small saphenous vein join the deep system at the popliteal space

18 Peripheral vascular disorders

19 Common or concerning symptoms Abdominal, flank, or back pain Pain in the arms or legs Intermittent claudication Cold, numbness, pallor in the legs; hair loss Swelling in calves, legs, or feet Color change in fingertips or toes in cold weather Swelling with redness or tenderness

20 Peripheral arterial disease Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis affecting 12% to 29% of community populations Prevalence increases with age and presence of cardiovascular risk factors

21 Risk factors for lower extremity PAD Age 50, or younger if diabetes or atherosclerosis risk factor of smoking, dyslipidemia, hypertension, or hyperhomocysteinemia Age 50 to 69 and history of smoking or diabetes Age 70 or older Leg symptoms with exertion or ischemic rest pain Abnormal lower pulses Known atherosclerotic coronary, carotid, or renal artery disease

22 PAD warning signs Fatigue, aching, nubness or pain that limits walking or exertion in the legs; in case identify the location Any poorly healing or nonhealing wounds of legs or feet Any pain present when at rest in the lower leg or foot and changes when standing or supine Abdominal pain after meals and associated food fear and weight loss (suggest intestinal ischemia of the celiac or superior or inferior mesenteric arteries) Any first-degree relatives with an abdominal aortic aneurysm (prevalence is of 15% to 28%)

23 SYMPTOM LOCATION suggests the site of arterial ischemia: Buttock, hip: aortoiliac Erectile dysfunction: iliac- pudendal Thigh: common femoral or aortoiliac Upper calf: superficial femoral Lower calf: popliteal Foot: tibial or peroneal

24 Abdominal Aortic Aneurysm (AAA) AAA is defined as an infrarenal aortic diameter 3cm It s found in over 50% of older male smokers Rupture and mortality increases when the aortic diameter extends 5.5cm Palpation is useful when the diameter reaches 4cm

25 Risk factors of AAA Smoking Age 65 or older Family history Coronary artery disease PAD Hypertension Hyperlipidemia

26 Painful peripheral vascular disorders Arterial Disorders Atherosclerosis (ateriosclerosis obliterans) Acute Arterial Occlusion Intermittent claudication Rest pain Raynaud s Disease and Phenomenon

27 Painful peripheral vascular disorders Superficial Thrombophlebitis Venous Disorders Deep Venous Thrombosis (DVT) Chronic Venous Insufficiency (deep)

28 Painful peripheral vascular disorders Thromboangiitis Obliterans (Buerger s Disease) Compartment Syndrome Acute Lymphangitis

29 Techniques of peripheral arterial examination

30 Important areas of examination The arms The abdomen The legs Size, symmetry, skin color Aortic width Size, symmetry, skin color Redial pulse, brachial pulse Epitrochlear lymph nodes Pulsatile mass Femoral pulse and inguinal lymph nodes Popliteal, dorsalis pedis and posterior tibial pulses Peripheral edema

31 Key components of peripheral arterial examination Measure blood pressure in both arms Palpate carotid upstoke, ausculatate for bruits Auscultate for aortic, renal and femoral bruits; palpate aorta and determine maximanl diameter Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries Inspect ankles and feet color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin changes, hypertrophic nails

32 Arms Inspect both arms, notice: Size, symmetry and any swelling Venous pattern Color and texture of the skin and the color of the nails beds

33 Palpate the RADIAL PULSE

34 If you suspect arterial insufficiency feel for the BRACHIAL PULSE

35 Feel for one or more EPITROCHLEAR NODES If a node is present note its size, consistency and tenderness Epitrochlear nodes are difficult or impossible to identify in most normally healthy people

36 Abdomen Listen for the AORTIC, RENAL AND FEMORAL BRUITS

37 Palpate and estimate the width of the abdominal aorta in the epigastric area (especially in older adults due to higher risk of AAA) Assess for a pulsatile mass

38 Legs Inspect both legs. Notice: Size, symmetry and any swelling Venous pattern and nay venous enlargement Any pigmentation, rashes, scars or ulcers Color and texture of the skin, the color of the nails beds, and the distribution of hair

39 Palpate the SUPERFICIAL INGUINAL NODES: Note their size, consistency and tenderness Nontender discrete inguinal nodes up to 1-2cm in diameter are frequently palpable in normal people

40 The peripheral arteries The FEMORAL PULSE

41 The POPLITEAL PULSE

42 The peripheral arteries The DORSALIS PEDIS PULSE

43 The POSTERIOR TIBIAL PULSE

44 The peripheral veins Note the color of the skin Look for edema Check for pitting edema (depression caused by pressure from your thumb for at least 2 sec)

45 If EDEMA is present look for possible causes in the peripheral vascualr system: recent deep venous thrombosis (DVT), chronic venous insufficiency from previous deep DVT or incompetence of the venous valves, lymphedema Try to identify any venous tenderness that may accompany DVT (may have no demonstrable signs) Ask the pt to stand and inspect the saphenous system for varicosities

46 Special Techniques

47 Evaluating the arterial supply to the hand Ulnar, radial and brachial pulse The Allen test

48 Postural color changes of chronic arterial insufficiency If pain or diminished pulses suggest arterial insufficiency look for postural color changes: Raise both legs until maximal pallor of the feet (within 1min) Ask the pz to sit up (legs dangling down)

49 Note the time required for: - Return of pinkness (about 10 sec) - Filling veins of feet and ankles (about 15 sec)

50 Mapping varicose veins Transmit pressure waves along the bloodfilled veins with pt standing

51 Evaluating the competency of venous valves Assess the vascular competency in communicating veins and saphenous system:

52 Pt supine, elevate legs about 90 Occlude the great saphenous vein in the upper tigh by manual compression (enough to occlude the vein but not the deeper vessels) Ask the pt to stand While keeping the vein occluded watch for venous filling in the leg

53 Normally the saphenous vein fills from below (about 35 sec) Rapid filling of superficial veins (while the saphenous is occluded) indicate incompetent valves in communicating veins

54 After the pt stands for 20 sec release the compression and look for sudden additional venous filling Normally there is none (competent valves block retrogade flow)