Peripheral Arterial

Skin (dermal) changes

(1) Color (a) Pallor - results from deficient blood supply when legs are elevated. (b) Rubor - results from vasodilation when legs are put in a dependent position and blood pools into the arterioles due to gravity. (c) Cyanosis results from deoxygenated blood.

Brachial artery

(1) Continuation of the axillary artery originating at the level of the head of the humerus, and extending to the bend of the elbow. (2) Initially lies medial to the humerus and gradually courses anteriorly to the antecubital fossa where it bifurcates into the radial and ulnar artery.

Tissue loss

(1) Gangrene and necrosis represents the most severe form of ischemia. (2) Loss results from insufficient or absent blood supply to the tissue. (3) Ulceration is common on dorsum of foot or toes, and occasionally on the anterior tibial area: deep, regular in shape, and painful. (4) Revascularization or amputation is usually required.

the most common sites of artherosclerosis include

(1) Branches (2) Bifurcations (3) Origins of vessels

major visceral branches of the abdominal aorta include

(1) Celiac artery (axis) (2) Superior mesenteric artery (SMA) (3) Renal arteries (4) Inferior mesenteric artery (IMA)

Capillary filling

An increase in capillary refill time indicates decreased arterial perfusion.

Axillary artery

Continuation of the subclavian artery originating at the lateral border of the first rib and terminating at the lower border of the teres major muscle.

most common digital cold sensitivity condition is

Raynauds syndrome

superficial palmar arch

after the ulnar artery gives off a branch to the radial artery, it terminates as the superficial palmar arch. (a) It is the more distal of the two arches - closer to the digits.

arterial wall layers

intima, media, and adventitia.

profunda femoris provides blood to the

thigh muscles: adductor, extensor, and flexor muscles.

the subclavian artery is divided into

three segments

secondary Raynauds phenomenon

vasospasm secondary to underlying disease

primary Raynauds disease

vasospasm with no underlying disease

Hyperlipidemia

(1) High saturation of lipid fats in blood contributes to the development of atheromatous plaque.

ulnar artery

(1) Largest of the brachial artery terminal branches, it originates at the antecubital fossa and passes along the medial side of the forearm (ulnar) to the wrist where it continues into the palm to form the superficial palmar arch.

capillaries

(1) Microscopic branches of the smallest arterioles consisting of one layer; the intima. (2) Functions to supply oxygen and nutrients to the tissue and remove waste products.

symptoms of vasospastic disorders

(1) Pain (2) Paresthesia (3) Skin color changes (a) Pallor (white) (b) Cyanosis (blue) (c) Rubor (red)

six P's symptoms of acute arterial occlusion

(1) Pain (a) Severity depends on the degree of ischemia. (2) Pallor (3) Pulselessness (4) Paresthesis (5) Paralysis (6) Poikilothermia (a) Decrease in skin temperature on the affected extremity.

Ischemic rest pain

(1) Persistent pain in feet and toes due to reduced blood perfusion. (2) Usually occurs while sleeping when blood pressure is low and limb is elevated. (3) Indicates advanced arterial occlusive disease. (4) Relief can be obtained by placing the foot in a dependent position due to the increase in gravitational and hydrostatic pressure.

Claudication of lower extremity

(1) Progressive, reproducible, muscular pain in the thigh, buttock or calf after exercise. (2) Caused by decreased blood perfusion to muscle tissue during exertion and is relieved by cessation of exercise. (3) Symptoms: pain, cramping, fatigue, or tightness of the leg. (4) Level of disease is usually proximal to the location of symptoms. (a) Buttock and/or thigh pain indicates aortoiliac occlusive disease. (b) Thigh pain indicates distal external iliac artery and/or common femoral artery disease. (c) Calf pain indicates superficial femoral and/or popliteal artery disease.

radial artery

(1) Smallest of the brachial artery terminal branches, it originates at the antecubital fossa and passes along the lateral side of the forearm (radius) to the wrist where it continues into the palm to form the deep palmar arch.

smoking

(1) Strong risk factor for the development of atherosclerosis. (2) Nicotine has many harmful effects including: (a) Recurrent vasoconstriction in arterioles and capillaries (b) Increased blood pressure (c) Increased myocardial oxygen demand (d) Increased platelet aggregation (e) Increased cholesterol levels

Palpation of pulses

(1) To evaluate for pulses and aneurysms. (2) Evaluate for the presence, strength, and regularity of the pulse.

Rate the pulses according to their strength

(a) 0 = no pulse (b) 1 + = weak pulse (c) 2 + = normal pulse (d) 3 + = strong pulse (e) 4 + = bounding (May also indicate aneurismal)

pulse palpation locations for lower extremity

(a) Aorta (b) Groin (common femoral artery) (c) Popliteal fossa (popliteal artery) (d) Foot (posterior tibial artery and dorsalis pedis artery)

pulse palpation locations for upper extremity

(a) Carotid artery (b) Axillary artery (c) Brachial artery (d) Radial artery (e) Ulnar artery

Thoracic outlet compression syndrome (TOS)

(a) Compression of the subclavian artery, at the thoracic outlet, by the scalene muscles, cervical rib, or clavicle. (b) Symptoms can be a combination of vascular and neurologic.

Baker's cyst

(a) Cystic dilatation of the gastrocnemius-semimembranous bursa located in the popliteal fossa. Posterior and medial to the knee joint. (b) Common in patients with severe degenerative joint disease or rheumatoid arthritis. (c) Large cysts are prone to rupture causing pain, tenderness, and swelling of the calf.

Popliteal entrapment

(a) Developmental defect where there is compression of the popliteal artery by the medial head of the gastrocnemius muscle. (b) Commonly found in young males and is bilateral in V3 of patients

Takayasu's arteritis

(a) Giant cell arteritis originating at the aorta and progresses outward. (b) Known as "pulseless" disease, it is characterized by diminished pulses over a period of time.

clinical findings of coarct aorta

(a) Hypertension from decreased kidney perfusion (b) Bilaterally decreased lower extremity pulses

EIA has two dorsal branches

(a) Inferior epigastric artery (b) Deep circumflex iliac artery

Temporal arteritis

(a) Inflammation of the temporal artery causing visual changes or loss of vision

Buerger's disease - aka thromboangitis obliterans (TAO)

(a) Most common arteritis affecting the distal arteries of the hands and feet. (b) Associated with heavy cigarette smoking primarily in men younger than 40 years of age. (c) Rest pain and ischemic ulcers occur early in the disease. (d) Also associated with collagen vascular syndromes such as rheumatoid arthritis and lupus.

Vascular claudication is:

(a) Pain with exercise for a predictable distance (b) Relieved by rest (c) Always reproducible

branches of the axillary artery include:

(a) Superior thoracic artery (b) Lateral thoracic artery (c) Anterior circumflex humeral artery (d) Thoraco-acromial artery (e) Subscapular artery (f) Posterior circumflex humeral artery

branches of internal iliac artery

(a) Superior vesical (b) Middle rectal (c) Vaginal (d) Internal pudendal (e) Superior gluteal (f) Lateral sacral (g) Inferior vesical (h) Uterine (i) Obturator (j) Inferior gluteal (k) Iliolumbar

Polyarteritis nodosa

(a) Systemic disease affecting the small and medium sized arteries. (b) Inflammation destroys the media layer of the artery causing aneurysm formation. (c) Frequent renal involvement.

The major branches of the subclavian artery include:

(a) Vertebral artery (b) Thyrocervical artery (c) Dorsal scapular artery (d) Internal thoracic artery (e) Costocervical artery (f) Internal mammary artery

Temperature

(a) Warm vs. cold * Symmetrical coolness may be associated with vasoconstriction. * Asymmetrical coolness may be associated with arterial insufficiency in the leg that is cool.

secondary raynauds disease

* Referred to as Raynaud's phenomenon. * Vasospasm associated with an underlying autoimmune disease, connective tissue disease (i.e., scleroderma), or fixed obstructive disease. * Ischemia is consistently present.

Primary Raynaud's syndrome

*Intermittent digital ischemia caused by prolonged digital vasospasm from exposure to cold, chemicals (nicotine), or occupational trauma (vibration injury) to hands. * Commonly affects young women. * No known underlying disease process.

normal aorta diameter

2-3 cm, tapering at the bifurcation to approx 1.5 cm

aorta considered to be enlarged when it measures more than

3-4 cm

Vasospastic disorders

Abnormal vasospasm of digital arteries in hands or feet induced by exposure to cold.

Coarctation of the aorta

Congenital narrowing of the aortic arch or thoracic aorta

Atherosclerosis

Formation of atheromatous plaque within the arterial wall that reduces or occludes the artery lumen. b. Arterial walls thicken, harden, and lose their elasticity.

bruit

French word for "noise", indicates turbulent blood flow that may be caused by a stenosis within the artery. (3) A bruit is a vibration that is transmitted to surrounding tissue and is caused by flow disturbances within the vessel. These "vibrations" or "thrills" may be due to a fistula, post stenotic turbulence, or a dialysis graft.

Trophic changes

Indicates poor tissue nutrition from arterial insufficiency. * Hair loss over toes and dorsum of foot * Thin, shiny, smooth or scaly skin * Thickened, brittle toenails

abdominal aorta courses inferior from the diaphragm to

L-4 (at the umbilicus) where it bifurcates into the common iliac arteries.

external iliac artery is

Longer than the hA.

arterioles

Smallest arterial vessel consisting of two arterial wall layers: the intima and media.

Auscultation of pulses

Using a stethoscope, evaluate for the presence, duration, and strength of bruit.

Posterior tibial artery (PTA)

a branch of the tibio-peroneal trunk. (1) Courses posterior to the tibia, behind the medial malleolus. (2) Terminates into the medial and lateral plantar arteries in the foot, below the medial malleolus (inner ankle). (3) Supplies blood to the sole of the foot.

embolism

a. A blood clot or foreign substance that travels in the blood stream of an artery and lodges in a distal vessel of smaller diameter causing a blockage. b. An embolism may be a solid, liquid, or gas.

aneuysm

a. Bulge or dilatation in an artery resulting from a weakening in the arterial wall structure. b. Thrombus may form within the lumen of an aneurysm and lead to occlusion or arterial embolism. c. Rupture may occur causing extensive hemorrhage.

uncontrollable risk factors

a. Increased age b. Family history c. Male gender d. Thrombophilia - hereditary risk toward the development of blood clots

deep palmar arch

after the radial artery gives off a branch to the ulnar artery, it terminates as the deep palmar arch. (a) It is the more proximal of the two arches - closer to the wrist. g. Digital arteries of the hand (1) Arise from the palmar arch to supply blood to the fingers. (2) Each palmar digital artery has two dorsal branches.

True aneurysm involves

all three layers of arterial wall. Types include: (1) Fusiform aneurysm (2) Saccular aneurysm

the hA (internal iliac) bifurcates into

anterior and posterior internal iliac arteries. These arteries give rise to multiple branches that provide important collateral pathways in the presence of external iliac obstruction.

Peroneal artery

arises at the distal end of the tibio-peroneal trunk. (1) Courses along the medial border of the fibula terminating as the external calcaneal artery. (2) Supplies blood to the lateral aspect of the leg and the heel of the foot.

Dissection (arterial) - occurs when

blood tears through the intima and enters the media wall causing a longitudinal splitting of the artery wall.

both subclavian arteries are located posterior to the

clavicle and course between the anterior and middle scalene muscle and the first rib.

Popliteal artery (PopA)

continuation of the SFA beginning at the adductor hiatus inferior to where the SFA gives rise to the genicular artery. (1) Descends lateral and terminates at the popliteus muscle, dividing into the anterior tibial artery and tibio-peroneal trunk. (2) Has multiple genicular branches that supply blood to the knee region. (3) Major branches include the gastrocnemius arteries which supply the gastrocnemius muscle in the calf.

lateral dorsal digital artery

courses on the lateral border of each finger.

medial dorsal digital artery

courses on the medial border of each finger.

controllable risk factors for peripheral arterial disease

diabetes, HTN, hyperlipidemia, smoking

acute arterial occlusion commonly caused from an

embolus, thrombosis, or trauma

Anterior tibial artery (ATA)

first branch off the distal popliteal artery. (1) Courses between the tibia and fibula, anteriorly along the interosseous membrane, terminating as the dorsalis pedal artery on the anterior surface of the foot. (2) Supplies blood to the anterior lateral aspect of the leg and portions of the foot. (3) Dorsalis pedis artery (DPA) - originates as the terminal portion of the ATA on the dorsum of the foot and travels toward the base of the great toe.

Plantar arch

formed from the deep plantar artery (branch of the dorsalis pedis) and the lateral plantar artery (branch of the posterior tibial artery). (1) Gives rise to the dorsal metatarsal branches which supply blood to the digits of the foot.

first segment of the subclavian artery

from its origin to the medial border of the scalenus anterior muscle.

third segment of the subclavian artery

from the lateral border of the scalenus anterior muscle to the outer border of the first rib.

plaque may become altered by

hemorrhage, cell necrosis, or ulceration.

HTN

high blood pressure (1) Associated with the development of atherosclerosis, HTN causes an increase in intraluminal arterial wall stress.

False aneurysm or pseudoaneurysm is a

hole in the arterial wall causing blood to escape and form a pulsating hematoma in the tissue around the vessel. (1) There must be a communication channel from the main artery to the pulsatile structure in the tissue for it to be a pseudoaneurysm.

Arteritis

inflammatory process of the arterial wall

intima

innermost layer consisting of a single layer of endothelial cells.

common iliac arteries branch into the

internal and external iliac arteries at the lumbosacral junction.

The first branch of the subclavian artery is the

internal mammary artery, which is often used for coronary artery bypass grafts (CABG)

abdominal aorta located

left of midline and anterior to the spine.

Pseudoclaudication

leg pain with exercise that is not due to vascular obstruction but may mimic symptoms of true vascular claudication. (a) Usually neurogenic or musculoskeletal in etiology. * Not predictable. * Only relieved if rest is non-weight bearing.

right common iliac artery is

longer than the left and crosses anterior to the left iliac vein.

media

middle layer consisting of smooth muscle cells and elastic connective tissue; arranged in a circular pattern providing the additional strength to an artery.

vaso vasorum

minute internal vessels that penetrate the adventitia to supply nutrients to the media and adventitial layer.

Superficial femoral artery (SFA)

originates approximately 4 cm below the inguinal ligament, arising from the common femoral artery. It courses along the anteromedial portion of the thigh. At the level of the adductor hiatus, in the tendon of Hunter's canal, it gives rise to the genicular artery (an important collateral pathway) and then continues as the popliteal artery.

Deep femoral (profunda femoris) artery

originates at the bifurcation of the CFA. Courses posterolateral at its origin and continues medial to the femur where it terminates in the distal third of the thigh as the perforating artery.

External iliac artery (EIA)

originates at the bifurcation of the common iliac arteries (internal iliac artery origin).

internal iliac artery (aka hypogastric art)

originates at the bifurcation of the common iliac artery (external iliac artery origin).

Common femoral artery (CFA)

originates at the inguinal ligament; is a continuation of the EIA. Courses lateral to the common femoral vein and divides into the deep femoral artery and superficial femoral artery.

Common iliac artery (CIA)

originates at the level of the fourth lumbar vertebra, from the bifurcation of the distal abdominal aorta.

Left subclavian artery

originates from the aortic arch.

Right subclavian artery

originates from the innominate artery (brachiocephalic artery).

adventitia

outermost layer consisting of connective tissue which provides strength and structure to the artery.

second segment of the subclavian artery

posterior to the scalenus anterior muscle.

EIA courses along the inner border of the

psoas muscle from the bifurcation of the common iliac to the inguinal ligament where they become the common femoral arteries.

Tibio-peroneal trunk

second branch off the distal popliteal artery (1) This very short segment quickly gives rise to the posterior tibial artery and peroneal artery.

the profunda femoris communicates with

the common femoral artery and distal with the popliteal artery via its muscular branches which are a critical collateral source in superficial femoral artery obstruction.

diabetes alters

the progression and distribution of atherosclerotic disease. (1) Contributes to hardening of the arterial wall structure and loss of wall elasticity making the artery incompressible. (a) Referred to as medial calcinosis. (2) Leads to small vessel disease of the lower leg. (3) Increases incidence of gangrenous changes and amputations. (4) Increases incidence of trauma due to neuropathy.

the internal iliac artery (HA) supplies blood to

the walls and viscera of the pelvis, buttock, genitals, and medial thigh.