Peripheral Arterial and Venous Disease

Question 1

What is the role of the deep fascia in the leg?

Answer 1

The deep fascia surounds the calf muscle. This means that when the muscles contract, the pressure rises which allows venous flow to go up.

Question 2

What are the key deep veins in the leg?

Answer 2

• External iliac vein
• Femoral vein
• Popliteal vein

Question 3

What are the key superficial veins in the leg?

Answer 3

Long saphenous vein (drains into femoral triangle)

Short saphenous vein (drains into popliteal fossa)

Question 4

Where is the long saphenous vein?

Answer 4

This is the one constant vein.

ALWAYS infront of the medial malleolus.

It is important as can use it to get fluid into venous system.

Question 5

What are the roles of valves?

Answer 5

Prevent backflow.

Question 6

How is venous blood returned to heart?

Answer 6

Blood flows from superficial to deep.
Deep via calf muscle pump pushes blood back to the heart

Question 7

What are varicose veins?

Answer 7

Varicose veins are tortuous, twisted or lengthened veins.

Question 8

Where are common sites of varicose veins?

Answer 8

Long saphenous

Short saphenous

Question 9

What causes varicose veins?

Answer 9

The vein wall is inherently weak in varicose veins,
which leads to dilatation and separation of valve
cusps**so that they become**incompetent

Question 10

What are the symptoms of varicose veins?

Answer 10

• Heaviness
• Tenson
• Aching
• Itching

Only attribute it if along the vein itself.

Question 11

What are the complications if a patient has venous hypertension in the lower limb?

Answer 11

From the vein itself

• Haemorrhage
• Thrombophlebitis

From venous hypertension

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

Question 12

How do you stop bleeding from varicose veins?

Answer 12

Lie the patient down and elivate the leg.

(Bleeding from varicose veins usually occurs in the shows as the patient is standing (gravity) and hot (venodilation)

Question 13

What is thrombophlebitis?

Answer 13

Low blood velosity which results in thrombosis.

Venous thrombosis produces an inflammatory response, including PAIN (bad pain)

Question 14

What is haemosiderin staining?

Answer 14

Oxidising iron in blood from ferrous to ferric.

So, see rust under the skin.

Question 15

Varicose eczema

Answer 15

• Lower limb
• Very itchy

Question 16

What is Lipodermatosclerosis?

Answer 16

Thickening of the fat in the skin,

Can lead to venous ulceration

Question 17

Venous ulceration

Answer 17

It is venous hypertension that leads to venous ulceration.

Venous hypertension is a result of calf muscle pump failure.

Question 18

What are the causes of calf muscle pump failure?

Answer 18

• ‘Failure; of calf muscle contraction - immobility, obesity, reduced hip, knee and/or ankle movement
• Deep vein incompetence
• Volume overload - superficial vein incompetence (as blood goes through the valve the wrong way and into calf muscle pump. So, overfilling of calf muscle pump)

Question 19

What is Virchow’s triad?

Answer 19

Thrombosis occurs when there is:

• Changes in the lining of the vessel wall
• Changes in the flow of blood
• Changes in the constituents of blood

Question 20

What is the most common cause of arterial thrombosis?

Answer 20

Changing in the lining of the vessel wall

Question 21

What is the most common cause of venous thrombosis?

Answer 21

Changes in blood flow - Stasis leads to venous thrombosis

Question 22

Why does stasis lead to venous thrombosis?

Answer 22

In reality it is usually stasis plus another ‘provocateur’ – surgery
(trauma), oral contraceptive pill, dehydration, cancer.

Arterial thrombosis in response to bleeding involves platelets, extrinsic and then intrinsic pathways. Arterial thrombi are platelet rich

Question 23

Venous bleeding

Answer 23

Venous thrombosis does not involve platelets in
a major way, initially the intrinsic pathway is
involved and then the extrinsic. Venous thrombi
are fibrin rich.

Low flow initiates Venous thrombosis

Question 24

What does DVT produce?

Answer 24

Most commonly begins in the deep calf veins.

Produced an inflammatory response.

• Calor
• Dolor
• Functio laesa
• Rubor
• Tumor

Question 25

What are the clinical features (signs and symptoms) of a DVT?

Answer 25

Symptoms * Pain, cannot walk * Swelling * Blue-red skin discolouration Signs * Calf tenderness * Muscle induration * Skin warmth * Skin discolouration * Distended, warm superficial veins * Oedema * Pyrexia

Question 26

Why is there an association between surgery and DVT?

Answer 26

* Immobility prior to surgery * No calf muscle pump during surgery * Immobility after surgery * Surgery is trauma. The body's response trauma includes a 'prothrombotic state' The dreaded, often fatal consequence of DVT is pulmonary embolism.

Question 27

Where in the body is collateral circulation common?

Answer 27

Particularly common across joints * Elbow * Knee * Shoulder * Hip * ect...

Question 28

When does collateral circulation develop?

Answer 28

Collateral circulation develops in response to a stenosis. This can take weeks or months but, it means if the vessel gets blocked, the patient may not notice anything.

Question 29

How does acute limb ischaemia occur?

Answer 29

* The limb goes from a normal blood supply to greatly impaired blood supply over a period of minutes. No chance for for collateral vessel development (takes weeks / months) * Commonest cause are embolism (from heart or abdominal aortic aneurysm) and trauma * Sudden onset * 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)

Question 30

What are the signs / symptoms of acute ischaemia?

Answer 30

6 P's * Pain * Paralysis * Paraesthesia * Pallor * Perishingly cold * Pulseless

Question 31

What is the colour of a leg in acute peripheral ischaemia?

Answer 31

1. White 2. Blue 3. Fixed mottled

Question 32

What are the types of peripheral arterial disease?

Answer 32

* Intermittent claudication (equivalent to stable angina) * Critical ischaemia * Rest pain (equivalent to unstable angina) * Ulceration/gangrene (equivalent to myocardial infarction)

Question 33

What is the definition of claudication?

Answer 33

Pain in the muscles of the lower limb excited by walking / exercise. The calf muscle are most frequently affected, although more proximal muscles may be affected. Pain relieved rapidly by stopping exercise for a few mitures even whilst standing up.

Question 34

What are the relevent arterials in leg?

Answer 34

Question 35

Aortoiliac occlusion

Answer 35

* Bilateral buttock, thigh and calf claudication * Absent lower limb pulses * Rare

Question 36

Common Illiac occlusion

Answer 36

* Right buttock, thigh and calf claudication * Absent right lower limb pulses * Not so common

Question 37

Common femoral (or external iliac) occlusion)

Answer 37

* Right thigh and calf claudication * Absent right lower limb pulses * Not so common

Question 38

Suoerficial femoral artery occlusion

Answer 38

MOST COMMON * Right calf claudication * Femoral pulse present, absent popliteal and pedal pulss * By far the most common finding in patients with claudication

Question 39

Critical ischaemia

Answer 39

**_Limb viabiltiy is threatened_** * Rest pain (Equivalent to unstable angina) * Ulceration / gangrene (Equivalent to MI)

Question 40

What is rest pain?

Answer 40

* Pain in the FOOT that comes on when the patient goes to bed and is relieved by hanging the foot out of the bed * The ischaemia is so severe that at rest the foot skin, muscles, bones are ischaemic at rest. This means that there is not enough oxygen to provide for the cells basic metabolic requirements. * If left untreated will lead to: * Dry gangrene (mummification) * Wet gangrene * Ulceration Can save the leg in 95% of patients that present with rest pain.