13. Peripheral Arterial And Venous Disease

Question 1

What direction is venous blood flow in the lower limbs?

Answer 1

Superficial to deep

Question 2

What structure are deep veins found in in the lower leg?

Answer 2

Muscle

Question 3

What structure are superficial veins found in in the lower limb?

Answer 3

Fat

Question 4

What does the external iliac vein become as you move down the leg?

Answer 4

Femoral vein, popliteal vein.

Question 5

What part of the left does the long saphenous vein run down?

Answer 5

Medial

Question 6

What part of the leg does the short saphenous vein run down?

Answer 6

Lateral

Question 7

Where can you always find a vein as there is no anatomical variation form person to person?

Answer 7

Long saphenous vein anterior to the medial malleolus

Question 8

How does the calf muscle pump work?

Answer 8

Deep veins and perforator beings lie in muscle, so when muscle contracts pushes blood into deep vein and upwards, towards the heart.

Question 9

What is the definition of varicose veins?

Answer 9

Tortuous, twisted, or lengthened veins

Question 10

What causes varicose veins pathophysiologically?

Answer 10

Vein wall is inherently weak, leads to dilation and separation of valve cusps, so become incompetent.

Question 11

What are the 4 main symptoms of varicose veins?

Answer 11

Heaviness, tension, aching, itching.

Question 12

When the symptoms of varicose veins are along the vein itself, what is this significantly associated with?

Answer 12

Trunk varices.

Question 13

What 2 complications can result from the varicose vein itself?

Answer 13

Haemorrhage.

Thrombophlebitis.

Question 14

What 5 complications can result form venous hypertension (which then leads to varicose veins)?

Answer 14

Oedema.
Skin pigmentation.
Varicose eczema.
Lipodermatosclerosis.
Venous ulceration.

Question 15

What is thrombophlebitis?

Answer 15

Venous thrombosis producing inflammatory response including pain.

Question 16

What happens to fat in lipodermatosclerosis?

Answer 16

Fat becomes really hard.

Question 17

What leads to venous ulceration?

Answer 17

Venous hypertension

Question 18

What is venous hypertension a result of?

Answer 18

Calf muscle pump failure

Question 19

What are the 3 main causes of calf muscle pump failure?

Answer 19

Failure of calf muscle contraction eg immobility, obesity.
Deep vein incompetence.
Volume overload - superficial vein incompetence.

Question 20

How does superficial vein incompetence lead to calf muscle pump failure?

Answer 20

If valve at branch between deep and superficial vein incompetent, then when blood enters deep veins from superficial via perforating vein, and calf muscle pump pushes blood upwards towards heart, some leaks back into superficial vein via incompetent valve. Over time pooling to blood and calf muscle pump failure.

Question 21

What is Virchow’s triad and what are the 3 components? What type of thrombosis does each lead to?

Answer 21

3 broad categories of factors that are thought to contribute to thrombosis.
Changes in the lining of the vessel wall - arterial thrombosis.
Changes in the flow of the blood - stasis leads to envoys thrombosis.
Changes in the constituents of blood.

Question 22

Give 2 examples of other factors, which usually one needs to be present with stasis to lead to venous thrombosis.

Answer 22

Surgery, oral contraceptive pill, dehydration, cancer.

Question 23

In which vein does DVT usually occur?

Answer 23

Popliteal vein

Question 24

What does arterial thrombosis in response to bleeding involve? Wherefore what are arterial thrombi rich in?

Answer 24

Vasoconstriction, platelets, extrinsic then intrinsic pathway.
Rich in platelets.

Question 25

What does venous thrombosis in response to bleeding involve? Wherefore what are venous thrombi rich in?

Answer 25

Venoconstriction, intrinsic pathway then extrinsic (does not involve platelets in a major way). Fibrin rich.

Question 26

What type of response does DVT cause?

Answer 26

Inflammatory response

Question 27

What are the 3 main symptoms of DVT?

Answer 27

Pain (cannot walk). Swelling. Blue-red skin discolouration.

Question 28

Give 5 signs of DVT

Answer 28

``` Calf tenderness. Muscle induration. Skin warmth. Skin discolouration. Distended, warm superficial veins. Oedema. Pyrexia. ```

Question 29

Why is there an association between surgery and DVT?

Answer 29

Immobility prior to and after surgery. No calf muscle pump during surgery. Surgery is trauma, body responds with prothrombotic state.

Question 30

What is a fatal consequence of DVT??

Answer 30

PE

Question 31

What happens in acute limb ischaemia? What does this lead do?

Answer 31

No chance for collateral development was limb does from normal to greatly impaired blood supply in period of minutes. Therefore if not reversed within 6 hours the limb cannot be recovered and if not amputated the patient will die (hyperkalaemia due to dead tissue releasing intracellular potassium leading to cardiac asystole).

Question 32

What are the 2 commonest causes of acute limb ischaemia?

Answer 32

Embolism (from heart of AAA). | Trauma.

Question 33

Name 4 signs/symptoms of acute ischaemia

Answer 33

Pain, paralysis, paraesthesia, pallor leading to patchy cyanosis (blanching) and then fixed mottling (nonblanching), perishing cold, pulseless.

Question 34

What are the 2 main signs/symptoms seen with chronic peripheral arterial disease?

Answer 34

Intermittent claudication - of calf muscles usually, pain relieved rapidly by stopping exercise for a few minutes, even whilst standing up. Leads to: Critical ischaemia - rest pain, leads to: ulceration/gangrene.

Question 35

What is the definition of claudication?

Answer 35

Pain in the muscles of the lower limb elicited by walking/exercise.

Question 36

Where is the femoral pulse felt?

Answer 36

Common femoral artery at mid-inguinal point (midway between pubic symphysis and anterior superior iliac spine)

Question 37

What 2 pulses can be felt in the foot (pedal pulses)? Where is each found?

Answer 37

Dorsalis pedis artery - anterior foot, lateral to extensor hallucis longus tendon. Posterior tibial artery - posterior to medial malleolus.

Question 38

What symptoms are seen in aortoiliac occlusion? Why is it rare?

Answer 38

Bilateral buttock, thick and calf claudication, absent lower limb pulses. Rare as usually chronic and collaterals develop.

Question 39

What symptoms are seen in common iliac occlusion? How common is it?

Answer 39

One-sided buttock, thigh and calf claudication. Absent one-sided lower limb pulses. Not very common.

Question 40

What symptoms are seen in common femoral occlusion? How common is it?

Answer 40

One-sided thigh and calf claudication, absent right lower limb pulses. Not very common.

Question 41

What symptoms are seen in superficial femoral artery occlusion? How common is it?

Answer 41

One-sided calf claudication. Femoral pulse present, absent popliteal and pedal pulses. Commonest finding in patients with claudication.

Question 42

What is rest pain?

Answer 42

Occurs in critical ischaemia. Pain in the good that comes on when the patient goes to bed. Relieved by hanging foot out of bed. Ischaemia is so severe that not enough oxygen to provide for the cells basic metabolic requirements.

Question 43

What does rest pain progress to if left untreated?

Answer 43

Gangrene and ulceration