Peripheral Arterial And Venous Disease

Question 1

Lower limb venous anatomy

Answer 1

Lower limb venous system divided into superficial and deep veins

Deep veins underneath the deep fascia with the major arteries

Superficial veins located in the subcutaneous tissue - 2 - the long saphenous vein and the short saphenous vein

Movement of blood from superficial to deep veins

Question 2

Calf muscle pump - the peripheral heart

Answer 2

Soleus and gastrocnemius muscles contribute to pushing blood against gravity back towards the heart

In veins valves open to allow for blood to be pushed through to deep veins,

Question 3

Peripheral venous disease

Answer 3

Varicose veins – valves ineffective (or become damaged) and blood movement is slow or even reversed

Saphenous veins are common site of pathology

Walls of veins weaken, this leads to varicosities developing and valve cusps separate

Question 4

Symptom development for peripheral venous disease and complications

Answer 4

Patients describe heaviness and aching, muscle cramps and throbbing with Thin itchy skin along the affected vein(s)

Could be due to -
Haemorrhage
Varicose eczema
Superficial vein thrombophlebitis - (inflammatory processes resulting in clot in vein that is very superficial)
Presents with painful erythematous, which follows varicose veins and increases the risk of DVT

Chronic venous insufficiency - There could be reflux of blood or obstruction of valve, this leads to -
venous hypertension,
oedema
lipodermatosclerosis (inflammation and thickening of fat layer under the skin)
venous ulceration
(As cant get the blood back up to the heart)

Question 5

Venous eczema and ulceration

Answer 5

Chronic, itchy red and swollen tight and can lead to lipodermatosclerosis – hard to the touch c.f. other fatty tissues

Chronic, painful, often develop around hard nodular areas like medial malleolus - Result of venous hypertension

This development of chronic venous insufficiency occurs in ~ 50% of DVT patients

Question 6

Venous hypertension and calf muscle pump failure

Answer 6

Why does the calf muscle pump fail?
Need to be using calf muscles properly – the role of these muscles is extensors of the foot, therfore plantar flexion of the ankle joint during walking is required so that you are “using” them properly

Deep vein incompetence leads to retrograde flow - can go both ways - and the valve becomes overwhelmed

Superficial vein incompetence -

Question 7

Thrombosis

Answer 7

Arterial and venous thrombus precipitated by different pathophysiology

Arterial thrombosis - by far most common cause is atheroma
It’s platelet rich - activated – aggregate – plug hole

Venous thrombosis - comes about via stasis and usually another factor - trauma, COCP, dehydration, chemotherapy inflammatory conditions, pregnancy - Low flow and little platelet component, fibrin rich

Question 8

Deep vein thrombosis

Answer 8

Clotting of blood in a deep vein – commonly calf - due to impaired venous return and hypercoagulability

Inflammatory response produced following thrombosis - pain, swelling, redness

Ambulatory and post surgery patients – signs vary in severity and frequency - Calf tenderness, warmth, distended and visible superficial veins, oedema present with Pyrexia with no other obvious cause and asymmetry between legs

Differential diagnoses – soft tissue trauma, cellulitis, lymphatic obstruction… - Do the Wells’ score – a pre test probability as part of diagnosis

DVT, surgery and “economy class syndrome” Stasis is present – no calf muscle pump - due to inactivity or inability to use, can occur before surgery and after surgery

Trauma – prothrombotic state following malignancy or pregnancy

Reason why its key to promote mobility soon after surgery

Prophylaxis (tailored towards movement) vastly

Question 9

Peripheral arterial disease

Answer 9

The body is Physiologicaly designed to limit incidence of acute ischaemia – when we flex or bend a joint do we not lose blood flow?
E.g. if we flex a joint we may restrict blood supply to a certain area so helpful to have lots of different vessels going to similar areas
Adaptive response to stenosis of a major vessel over a period of months or years, is angiogenesis of new vessels - however if occlusion is rapid then no time to form these vessels

Acute (within minutes or days) limb ischaemia
Occlusion occurs acutely – minutes to days – no collateral circulation can develop in this time

Caused by Trauma and embolism - atrial fibrillation, popliteal artery aneurysm, sudden rupture of atherosclerotic plaque

Leg ischaemia 6 “Ps”
Pain - initially, Pallor, Perishing with cold, Pulseless, Paraesthesia, Paralysis or reduced power
* may be subtle –compare both limbs

Referral to vascular surgical unit immediately – extent of threat of limb survival dictates action –

Question 10

Pathology of claudication

Answer 10

By far the most common presentation is atheroma
—> ATS of superficial femoral artery

Present with calf claudication due to occlusion of blood - if untreated it becomes critical ischaemia

Where the stenosis (narrowing of vessels) is identified will dictate where the claudication presents and which pulses can be palpated

Check to feel 4 pulses
Femoral pulse - felt at the mid inguinal point
Popliteal pulse - deep in popliteal fossa
Posterior tibial pulse - just behind the medial malleolus
Dorsalis pedis pulse - just lateral to extensor hallucis longus tendon

Question 11

Doppler ultrasonography

Answer 11

Sonogram using ultra sound and the Doppler effect to measure real- time flow and velocity

Useful for recording flow and velocity of blood

- in the heart as part of echocardiogram – heart failure, valve disease etc.
- in distal vessels – legs when diagnosing peripheral arterial disease