Ch 12: the peripheral vascular system

What percent of PAD and cardiovascular disease co-occurs in pts?

16%

How is the amplitude of arterial pulses graded?

3+ bounding, 2+ brisk, expected (normal), 1+ diminished weak 0 absent, unable to palpate

What percent of older male smokers have an AAA?

50%!

What percent of the leg venous return is carried in the deep veins? Why are they better than superficial?

90%! They are better supported by surrounding tissues.

What is the sensitivity and specificity of ABI?

95% and 99%

What test is used to assess PAD?

ABI: ankle-brachial index.

How does the size of arteries vary?

According to their distance from the heart

What can lymphatic dysfunction result in?

Accumulation of interstitial fluid = edema.

What is the trendelenburg test?

Aka retrograde filling, assesses the valvular competency of the communicating vein and the saphenous vein. Pt is supine with leg elevated 90 degrees. Occlude the great saphenous vein then ask pt to stand while keeping the vein occluded. Normally blood returns in 35 seconds completely. Competent valves block retrograde flow. After 20 seconds let go - normally no extra venous filling. If rapid filling occurs, there are incompetent valves in the communicating veins. Positive-positive is abnormal.

What is the lymph system?

An extensive vascular network that drains lymph fluid from body tissue and returns it to the venous circulation. It also is important for the immune system. Cells in the lymph nodes engulf cellular debris and bacteria and produce antibodies.

An exaggerated widened popliteal pulse suggests?

Aneurysm of the popliteal artery

Bounding carotid, radial, and femoral pulses are present in what?

Aortic insufficiency

Buttock and hip sx are associated with what arterial ischemia?

Aortoiliac

What is persistent rubor on dependency suggest?

Arterial insufficiency

Asymmetric diminished pulses occur in what? Why?

Arterial occlusion from atherosclerosis or embolism.

What does the elastic recoil and smooth muscle contraction and relaxation in the media of large and medium arteries produce?

Arterial pulsatile flow.

Where is the brachial artery palpated?

At the bend of the elbow just medial to the biceps tendon.

Lymphedema of the arms and hands can be due to what?

Axillary node dissection or radiation therapy.

Where is the posterior tibial pulse found?

Behind and slightly below the medial malleolus of the ankle.

Where is the popliteal artery palpated?

Behind the knee; passes medically behind the femur.

Where is the posterior tibial arterial pulse palpated?

Behind the medal malleolus of the ankle.

Where is the femoral artery palpated?

Below the inguinal ligament.

what arterial pulses can be palpated in the arm?

Brachial, radial, and ulnar.

Warmth and redness over the calf is..?

Cellulitis.

What lymph nodes are accessible during the physical exam?

Cervical lymph nodes: preauricular, post-auricular, tonsillar, occipital, superficial cervical, posterior cervical, supraclavicular, deep cervical, submental, and submandibular. The axillary nodes: pectoral, subscapular, lateral, central, and nodes of legs and arms.

Intermittent claudication, postural color changes, and trophic changes in the skin is usually caused by what?

Chronic arterial occlusion

Brownish discoloration or ulcer just above the malleolus suggests?

Chronic venous insufficency

Where are the vertical inguinal lymph nodes?

Clustered near the upper part of the saphenous vein - draining all that flows near it. Not usually palpable.

Asymmetric blood pressure is seen in which conditions?

Coarctation of the aorta and dissecting aortic aneurysm.

What can trigger arterial spasm?

Cold weather or cold objects usually of the hands but also of the feet.

Thigh arterial ischemia sxs are associated with which artery?

Common femoral or aortoiliac

What symptoms may be associated with an expanding hematoma from abdominal aortic aneurysm?

Compressed bowels, aortic branch arteries, and the ureters: constipation, urinary retention, flank or back pain. Especially in older smokers.

In addition to one-way valves in the veins, what keeps blood from pooling or backflowing?

Contraction of calf muscles during walking act as venous pumps squeezing blood upward against gravity.

What does calf asymmetry increase the likelihood of ?

DVT. Also consider muscle tear, trauma, Baker's cyst (posterior knee), and muscle atrophy.

What causes hair loss over the anterior tibial?

Decreased arterial perfusion.

What are risk factors for lower-extremity peripheral arterial disease for pt's 50 and younger?

Diabetes or atherosclerosis who smoke, have dyslipidemia, hypertension, or hyperhomocysteinemia.

What size are arterioles ?

Diameter of 20-100 micrometers

What are leg veins susceptible to? Why?

Due to the thin walls: dilation, compression, ulceration and invasion by tumors.

How does the arterial intima contribute to immune and inflammatory reactions?

Elaboration of interleukins, adhesion molecules, and histocompatibility antigens.

what are PAD warning signs?

Fatigue, aching, numbness, pain that limits walking; erectile dysfunction; poor healing wounds of lower legs or feet; abdominal pain after meals - food fear or wt loss; first degree relative with an AAA.

An exaggerated, widened femoral pulse suggests?

Femoral aneurysm.

What arterial pulses can be palpated in the legs?

Femoral, popliteal, dorsalis pedis, and posterior tibial arteries.

How do you check for pitting edema?

Firmly press with your thumb for at least 2 seconds over the dorsum of the foot, behind the medial malleolus, and the shin. If a pit remains grade it.

Dry or brown-black ulcer proceed what in the lower leg?

Gangrene

What is the Allen Test?

Hand in lap, palm up, ask pt to make a fist, you compress both the radial and ulnar arteries then ask pt to open the hand. Palm is pale. Release pressure from ulnar artery -> palm should flush in 3-5s. Compress ulnar again and release radial artery to test for patency. Persisting pallor indicates occlusion.

When is bilateral edema present?

Heart failure, cirrhosis, and nephrotic syndrome.

What are risk factors for lower-extremity peripheral arterial disease for pt's 50-69?

History of smoking or diabetes.

Erectile dysfunction is associated with what arterial ischemia?

Iliac-pudendal.

Painful, pale swollen leg, together with tenderness in the groin over the femoral vein suggests?

Iliofemoral thrombosis.

What is unilateral coldness suggestive of?

Inadequate arterial perfusion.

Abdominal pain, "food fear" and wt loss suggest what?

Intestinal ischemia of celiac or superior or inferior mesenteric artery.

What are the three layers of an artery?

Intima - endothelium, media - smooth muscle, and adventitia

How does the arterial intima contribute to the regulation of thrombosis?

It synthesizes prostacyclin, plasminogen activator, and heparinlike molecules. Von Willebrand factor, plasminogen activator inhibitor.

What is an atheroma?

Lipid-filled foam cells in the intima that become fat streaks. These grow into plaques that narrow the lumen of the artery. They have a soft lipid core and a fibrous cap of smooth muscle cells and a collagen-rich matrix.

What can cause enlarged epitrochlear nodes?

Local or distal infection or generalized lymphadenopathy. Normally not palpated.

What do you do if you detect unilateral edema?

Measure the legs with measuring tape: the forefoot, smallest part of the ankle, largest part of the calf, and the mid thigh (extended) and compare. 1-2 cm variation is normal.

What is the outer layer of arteries, the adventitia composed of?

Nerve fibers and the vasa vasorum.

Is lymphadenopathy always tender?

No - it refers to enlargement of the nodes with or without tenderness.

What can be normally felt when palpating superficial inguinal lymph nodes?

Nontender, discrete inguinal nodes up to 1cm-2cm

What will you find with arteriosclerosis obliterans ?

Normal femoral pulse and decreased or absent popliteal.

Where will you find the dorsalis pedis pulse?

On the dorsum of the foot just lateral to the extenso tendon of the great toe. This can be congenitally absent or branch higher in the ankle.

Where is the dorsalis pedis artery palpated?

On the dorsum of the foot, lateral to extensor tendon of the big toe.

Where is the radial artery palpated?

On the lateral flexor surface of the forearm.

Where is the ulnar artery palpated?

On the medial flexor surface but may be obscured by overlying tissues.

Where does resistance to blood flow that is not pathologic mostly occur?

The arterioles. Resistance is inversely proportionate to the 4th power of vessel diameter

Where do the rest of the arm's lymphatics drain to if not into the epitrochlear node?

The axillary nodes. Some go directly to the infraclavicular nodes.

What is the size of a capillary?

The diameter of a single red blood cell: 7-8 microns.

What is intermittent claudication?

Pain or cramping in the legs during exertion that is relieved by rest within 10 minutes.

What are the sx of sudden arterial occlusion in the legs?

Pain, numbness, tingling. Distal limb become cold, pale and pulseless. Emergency!

Ischemic arterial sx of the lower calf are associated with which artery?

Popliteal

How is the popliteal pulse palpated?

Pt's knee flexed & relaxed. Fingertips of both hands meet midline behind the knee pressing deep. It is deep and diffuse, hard to feel.

Where does lymph from the ulnar surface, little and ring finger, and adjacent middle finger drain into?

The epitrochlear nodes: medial surface ~3cm above the elbow.

What allows oxygen and CO2 to rapidly diffuse across a capillary?

The fact that this endothelial cell lining has no media.

Name the superficial veins?

The great saphenous vein and the small saphenous vein.

Where does the lymphatics from the superficial portion of the lower abdomen and buttock, external genitalia (not testes), the anal canal and perianal area, and lower vagina drain?

The horizontal group of lymph nodes of the superficial inguinal nodes.

What are possible causes of leg edema?

Recent DVT, chronic venous insufficiency, incompetent venous valves, and lymphedema.

What process/properties does the intima of arteries have?

Remarkable metabolic properties, helps regulate thrombosis, blood flow, and immune and inflammatory process.

How do lymphatic capillaries play a role in equilibrium?

Remove excessive fluid including protein from the interstitial space

What is Buerger's disease?

Same thing as thromboangiitis obliterans: usually a pt less than 40-45 and is a smoker. Begins with distal arteries and moves to proximal artery occlusion. Usually more than one limb involved and tends to present more in the winter.

What are risk factors for PAD?

Smoking, diabetes, hypertension, elevated cholesterol, African America, or Coronary artery disease.

What is peripheral vascular disease?

Stenosic, occlusive, and aneurysmal disease of the aorta, its visceral arterial branches, and the arteries of the lower extremities, EXCLUSIVE of the coronary arteries (which would be CHD).

Ischemic arterial SSx of the upper calf are associated with whith artery?

Superficial femoral

What is the recommended treatment for increasing walking capabilities for pt with PAD or claudication?

Supervised exercise with treatmill exercise superior to resistant training. Other important interventions: tobacco cessation, Tx hyperlipidemia, control DM and HTN, antiplatelet agents, foot care, well fitting shoes, last resort surgical revascularization.

What indicates venous peripheral vascular disease?

Swelling of feet and legs. Also ask about ulcer usually near ankles.

How does the arterial intima modulate blood flow?

Synthesis of vasoconstrictors: endothelium, angiotensin converting enzyme; vasodilators: nitric oxide and prostacyclin.

What is the law of LaPlace?

The relational that resistance is inversely proportional to the fourth power of the vessel diameter.

What do veins from the arms, head, neck and upper trunk drain into?

The superior vena cava.

What are the problems of atheromas?

They reduce blood flow, narrow the lumen, and weaken the underlying media. These plaques can rupture and precede thrombosis.

What makes veins different from arteries?

Thin walled, highly DI sensible, capacity of 2/3rds of circulating blood flow. Venous intima is nonthrombogenic endothelium. Contain unidirectional valves. The venous media contains rings of elastic ties that allow for changes in venous pressure.

What is the function of the arterial media?

This smooth muscle dilates and constricts to accommodate blood pressure and flow. The elastic fibers help this fxn.

Patients with Peripheral vascular disease risk for death due to stoke or MI increases by what?

Three fold!

What does injury to the vascular endothelium provoke?

Thrombus formation, artheromas, and vascular lesions of hypertension.

Ischemia artery sx of the foot are associated with which artery?

Tibial or peroneal.

What structure(s) protect the hand and fingers against possible arterial occlusion?

Two vascular arches within the hand connecting the radial and ulnar arteries.

What are signs of Raynaud's disease?

Typically affects the hands, feel cold with associated pallor or cyanosis due to vasospasm constricting blood flow.

Where do veins from the legs and lower trunk drain into?

Upward into the inferior vena cava.

What do arteries response to ?

Variations in cardiac output during systole and diastole.

What do prominent veins in an edematous arm suggest?

Venous obstruction.

How is pitting edema graded?

With a 4 point scale

How do you map out varicose veins?

With pt standing, palpate vein with your other hand below compressing, feeling for a pressure wave in the upper hand.

Are the superficial and deep veins connected?

Yes by perforating veins

Are the saphenous veins connected?

Yes, by anastomotic veins in the foot

What are important areas to examine for PAD?

the arm: size, symmetry, skin color, radial pulse, brachial pulse, epitrochlear lymph nodes. The abdomen: aortic width, pulsatile mass. The legs: size, symmetry, skin color, femoral pulse, inguinal lymph nodes, popliteal, dorsalis pedis, posterior tibial pulses, peripheral edema.