Peripheral venous and arterial disease Flashcards
Lower limb venous system divided into
Superficial and Deep veins
Where are deep veins and superficial veins located?
Superficial: Within subcutaneous tissue
Deep: Underneath deep fascia with major arteries
Movement of blood veins
Superficial to deep veins
Deep veins lower limb (9)
Common iliac –> external iliac –> common femoral (branches into deep and superficial femoral) –> popliteal –> anterior/posterior tibial and peroneal
Superficial veins lower limb
Femoral vein –> long saphenous vein (anteromedial) (always in front of medial malleolus)
Popliteal vein –> short saphenous vein (posterolateral)
Bridges between deep and sueprficial veins
Femoral vein (gives rise to long saphenous) Popliteal vein (gives rise to short saphenous)
Name the calf muscle pump muscles and describe what they do
Gastrocnemius and Soleus
Soleus and gastrocnemius muscles in the leg push the blood against gravity back towards heart
What is the calf muscle pump also known as?
AKA ‘the peripheral heart’
How is calf muscle pump assisted?
- Valves open = blood pushed into deep veins = valves close to prevent retrograde movement of blood (back flow of blood = perforating valves open again and blood fills the deep vein from the superficial vein, through the perforating vein
What occurs during exercise to venous pressure in the foot?
Venous pressure in the foot is reduced
When standing still, pressure increases
What is the most common cause of peripheral vascular disease?
Atheroma
What do you see in the early part of peripheral venous disease?
Varicose veins
What are varicose veins?
Veins that have become twisted and tortuous due to the valves being ineffective
What is a common site for varicose veins?
- Saphenous veins
- They are superficial so you can see them on the surface
Describe how varicose veins occur
- Starts with WALL OF VEINS WEAKEN
- Then varicosities develop
- And valve cusps separate causing valves to become incompetent
- The flow through the veins becomes slowed = stasis and pooling or even reversed
How do varicose veins affect blood flow?
Valves ineffective, slow or even reversed blood movement (blood pooling and stasis)
Do varicose veins usually cause problems?
- Don’t normally cause problems in own right but they can present symptomatically
Shape of varicose veins
Tortuous and twisted
Symptomatic presentation peripheral venous disease (9)
- Heaviness
- Aching
- Muscle cramps
- Throbbing
- Leg cramps
- Pain
- Ankle swelling
- Varicose eczema
- Haemorrhage- bleeding from damaged veins
Along the affected vein
Risk factors peripheral venous disease (5)
Age Family history FEMALE Number of births If your occupation involves long periods of standing
Complications of peripheral venous disease
- Superficial vein thrombophlebitis (inflammation from clot in vein) - painful erythematous follows varicose veins
- Increased risk of DEEP vein thrombosis
What is chronic venous insufficiency? (3)
- More advanced disease
- Reflux and/or obstruction causing venous hypertension
- (50% people develop it within 10 years of a DVT)
Complications chronic venous insufficiency (4)
Lipodermatosclerosis (inflammation and thickening of subcutaneous fat)
Haemosiderin staining (brawny oedema)
Venous ulceration
Venous Eczema
Why does do you get haemosiderin staining in chronic venous insufficiency? (4)
- Increase in hydrostatic pressure in post-capillary venules
- Leaking of RBC
- Haem oxidsed by macrophages (haemosiderin forms)
- Rusty looking leg
Describe venous eczema (6)
- Chronic
- Itchy
- Red
- Swollen
- Tight
- Can lead to Lipodermatosclerosis
What can venous eczema lead to? (2)
- Lipodermatosclerosis (inflammation and thickening of subcutaneous fat)
- Hard to the touch compared to other fatty tissues above or below
Where do ulcers usually form?
Around hard nodular areas (eg medial malleolus)
Describe venous ulceration (6)
- Chronic
- Painful
- Often develop around hard nodular areas like medial malleolus
- Result of venous hypertension
- Very distressing and challenging to treat
- Treat ulcer and the cause
Why does calf muscle pump fail?
Because calf muscles aren’t being used properly to cause plantar flexion at the ankle joint during walking
Immobile people at risk
Which people are at risk of calf muscle pump failure? (4)
- Injured/immobile patients
- Elderly (May shuffle or be immobile)
- Parkinsons patients who end up shuffling instead of walking properly (No plantar flexion)
What occurs during calf muscle pump failure? (4)
- Deep vein incompetence - retrograde flow - system overwhelmed - Superficial vein incompetence - blood moves from deep to superficial veins instead of superficial to deep - Calf muscle pump overflows - Leads to venous hypertension
Treatment venous hypertension/calf muscle pump failure?
Ligation (tie off) and vein stripping (tying/removing)
- This improves ulceration
Arterial thrombus vs venous thrombus
Different pathophysiology
Arterial:
- Most common cause is atheroma
- Platelet rich, they are activated and aggregate to form a plaque
Venous:
- stasis + another factor( ie anything = that causes hypercoagulative state?) (pregnancy, the pill, trauma, dehydration, chemo - )
- low flow and little plates component FIBRIN RICH
Virchows traid
Hypercoagulable state
Vessel wall damage
Flow problem (stasis)
What is deep vein thrombosis?
Clotting of blood in a deep vein which impaires venous return
Deep vein thrombosis common site
Calf
Describe the inflammatory response produced following thrombosis (3)
- Pain
- Swelling (asymmetrical)
- Redness
Signs DVT (7)
Variable in severity and frequency: - Calf tenderness - Warmth - Redness - Distended and visible superficial veins - Swollen leg (oedema) - Pyrexia with no other obvious - Asymmetry
How to test suspected DVT
Wells score (assess risk) - pre-test probability can help form part of diagnosis
A score of 2+ is a risk
Other diagnoses with similar signs of DVT (differential diagnoses)
Lymphatic obstruction
Soft tissue trauma
Cellulitis
Causes DVT (7)
Stasis because no calf muscle pump Pre/Post surgery Immobility Trauma - prothrombotic state following: Malignancy Pregnancy
Decrease risk of DVT (4)
- Promote mobility soon after surgery
- Prophylaxis (anticoagulants post surgery)
- Gradient stockings
- Physical activity
FATAL consequence of DVT
Pulmonary embolism
What is the body’s way of reducing acute ischaemia risk when we flex joint?
Form collateral circulation (alternative routes to same destination)
What is an adaptive response to stenosis of a major vessel over a period of months or years?
Form collateral circulation (alternative routes to same destination)
What is acute limb ischaemia?
Occlusion occurs in minutes/days
No time for collateral circulation to form
Causes of acute limb ischaemia (3)
Trauma and embolism e.g.:
Atrial fibrillation
Popliteal artery aneurysm
Sudden rupture of atherosclerotic plaque
Signs and symptoms of acute limb ischaemia (6)
The 6P's Pain Pallor Perishingly cold Pulseless Paraesthesia Paralysis also increased capillary refill time *may be subtle - compare both limbs
Actions after ischaemia (7)
- Immediate referral to vascular surgery unit
- extent of threat of limb survival dictates action
- image first then either:
- Angioplasty (surgical repair or unblocking of a BV)
- Thrombectomy
- Intra-arterial thrombolysis or
- Amputation
If revascularisation is possible after acute limb ischaemia, what may be a complication?
Compartment syndrome
What is chronic peripheral arterial disease similar to?
Coronary artery disease
Describe Chronic peripheral arterial disease (3)
- Intermittent claudication of the lower limb (cramping pain in calf muscle upon exercise)
- Caused by atherosclerosis
- Pain relieved by rest
Management chronic peripheral arterial disease (claudication) (5)
Exercise Smoking cessation Anti-platelet drugs Angioplasty Bypass graft
What device do you use in Diagnosing peripheral vascular disease?
Ankle-Brachial Pressure Index
divide ankle systolic by brachial systolic, if <0.8 BAD
Describe the use of an ABPI (3)
- part of early diagnostics for peripheral artery disease
- divide ankle systolic by brachial systolic
- ABPI <0.8 suggests presence of PAD
Untreated claudication becomes…
critical ischaemia
Pathology of claudication
- Mild, moderate and severe claudication
- Then rest pain, ulcer, gangrene (when critical)
ischaemia) - Most common presentation is Atheroma –> atherosclerosis of femoral artery
- Present with calf claudication
- Untreated becomes critical ischaemia (then you could get serious ulcers and gangrene)
Critical limb ischaemia presentation
Progression of peripheral vascular disease REST PAIN (blood supply is so poor get pain when resting)
(hanging foot out of bed relieves pain)
(Strong pain relive needed at this stage)
What can critical limb ishcaemia lead to?
Ulceration and gangrene
How to identify location of occlusion is?
Which pulses can and cannot be palpated
4 diff. lower limb pulses that you can palpate and their locations?
1. Femoral pulse (mid inguinal point = midway between ASIS and pubic symphysis) 2. Popliteal pulse (deep in popliteal fossa) 3.Dorsalis Pedis pulse (lateral to extensor hallucis longus tendon) 4. Posterior tibial pulse (behind medial malleolus)
What scan is used in Diagnosing peripheral arterial disease?
Describe it’s uses
Doppler ultrasonography (estimates flow and velocity of blood)
Useful for measuring flow and velocity of blood - the sounds of blood movement are computed into flow and velocity and can be used to see whether there are any occlusions in the vessels
Velocity increases through stenosis then becomes turbulent
Changing frequency doppler effect
Higher frequency waves (high pitch) if blood moving towards (more bunched up)
Lower frequency (lower pitch) waves if moving away (waves spread out)
Doppler effect definition
Apparent change in frequency of a wave caused by relative motion between source of wave and observer
