S11) The Peripheral Arterial and Venous Systems Flashcards
Describe the role of the calf muscles in blood circulation in the limbs
- The veins in the lower limb have valves which permit unidirectional blood flow
- When the calf muscles contract (soleus and gastrocnemius), the deep veins are compressed and blood flows upwards towards heart
Briefly describe the role of perforating veins in the lower limb
- When the muscles relax, blood is “sucked” into the deep veins via the perforating veins from the superficial veins
- The valves in the perforating veins only allow unidirectional blood flow
Describe the pathology of the perforating veins of the lower limb
Varicosities result when the valves in the perforating veins become incompetent or diseased
What are varicose veins?
Varicose veins are tortuous, twisted, or lengthened veins
ineffective blood flow
most common site are saphenous veins
walls of veins weaken = disrupt valves
pooling of blood and blood flows backwards (retrograde)
Describe the pathophysiology of varicose veins
The vein wall is inherently weak in varicose veins, which leads to dilatation and separation of valve cusps so that they become incompetent
What are the symptoms of varicose veins?
Occur along the vein itself (trunk varices):
- Heaviness
- Tension
- Aching
- Itching
What are the 5 complications of varicose veins resulting from venous hypertension due to calf muscle pump failure?
- Oedema
- Skin pigmentation
- Varicose eczema
- Lipodermatosclerosis
- Venous ulceration
What are the complications of varicose veins resulting from the vein itself?
- Haemorrhage
- Thrombophlebitis
What is thrombophlebitis?
Thrombophlebitis is an inflammatory process that causes a venous thrombosis to form, commonly in the legs:
- Superficial thrombophlebitis
- Deep vein thrombosis
What are the causes of calf muscle pump failure?
- Failure of calf muscle contraction – immobility, obesity, reduced movement
- Deep vein incompetence
- Superficial vein incompetence (volume overload)
What is the pathophysiology of thrombosis?
Virchow’s triad:
- Changes in the lining of the vessel wall
- Changes in the flow of blood
- Changes in the constituents of blood
In terms of Virchow’s triad, what is the most important factor in the pathophysiology of arterial thrombosis?
Changes in the lining of the vessel wall
In terms of Virchow’s triad, what is the most important factor in the pathophysiology of venous thrombosis?
Changes in the flow of blood
stasis
chemo
inflammatory conditions
platelet rich
Does stasis lead to thrombosis?
Stasis + another provocateur (trauma, oral contraceptive pill, dehydration, cancer)
Distinguish between arterial and venous thrombosis in response to bleeding
- Arterial thrombosis in response to bleeding involves vasoconstriction, platelets, extrinsic and then intrinsic pathways, hence arterial thrombi are platelet rich and caused by atheroma
- Venous thrombosis in response to bleeding involves venoconstriction, intrinsic then extrinsic pathways, hence, venous thrombi are fibrin rich
What is a deep vein thrombosis?
- A deep vein thrombosis is the formation of a thrombus within a deep vein, most commonly the deep calf veins
- It produces an inflammatory response - you will see lots of swelling (calor, dolor, rubor, tumor, functio laesa)
can be fatal if missed
What are the symptoms of DVT?
- Pain (cannot walk)
- Swelling
- Blue-red skin discolouration
What are the signs of DVT?
- Calf tenderness
- Skin warmth & discolouration
- Distended, warm superficial veins
- Oedema
- Pyrexia
What is the association between surgery and DVT?
- Immobility prior to surgery
- No calf muscle pump during surgery
- Immobility after surgery
- Surgery is trauma (body’s response → prothrombotic state)
What is the fatal consequence of DVT?
Pulmonary embolism
What is peripheral arterial disease?
Peripheral arterial disease is a common condition, in which a build-up of fatty deposits in the arteries restricts blood supply to leg muscles
alternative routes exist so blood can still pass and limit acute ischemia eg collateral circulation
What are the two types of peripheral arterial disease?
- Acute limb ischaemia
- Chronic limb ischaemia
Describe the pathophysiology of acute limb ischaemia
- The limb goes from a normal blood supply to greatly impaired blood supply over a period of minutes (sudden onset)
- No chance for collateral vessel development (weeks/months)
What are the commonest causes of acute limb ischaemia?
- Embolism (from heart / abdominal aortic aneurysm)
- Trauma
What are the 6 signs & symptoms of acute limb ischaemia?
- Pain
- Paralysis
- Paraesthesia (numbing)
- Pallor
- Pulselessness
- Perishing cold
What are the consequences of acute limb ischaemia?
- If not reversed within 6 hours the limb cannot be recovered (angioplasty/thrombectomy)
- If not amputated the patient will die (hyperkalemia)
What are the clinical features of chronic peripheral arterial disease?
- Intermittent claudication (equivalent to stable angina)
- Rest pain (equivalent to unstable angina)
- Ulceration/gangrene (equivalent to myocardial infarction)
What is claudication?
Chronic peripheral arterial disease
Claudication is a cramping pain in the muscles of the lower limb elicited by walking / exercise (similar to angina)
- most common presentation is atheroma
- last image can lead to ischemia and cause loss of limbs
managment:
exericise
antiplatelet drugs
Where can you feel the femoral pulse?
The femoral pulse can be palpated at the mid-inguinal point
Where can you feel the popliteal pulse?
Popliteal pulse is palpated deep in the popliteal fossa (difficult to feel)
Where can you feel the dorsalis pedis pulse?
Dorsalis pedis pulse can be palpated just lateral to extensor hallucis longus tendon
Where can you feel the posterior tibial pulse?
The posterior tibial pulse can be palpated posterior to the medial malleolus
Describe normal lower limb circulation
- No symptoms
- Full set of lower limb pulses
Describe aortoiliac occlusion
- Bilateral buttock, thigh and calf claudication
- Absent lower limb pulses
- Rare
Describe common iliac occlusion (unilateral)
- Right buttock, thigh and calf claudication
- Absent right lower limb pulses
- Not so common
Describe common femoral occlusion (unilateral)
- Right thigh and calf claudication
- Absent right lower limb pulses
- Not so common
Describe superficial femoral artery occlusion (unilateral)
- Right calf claudication
- Femoral pulse present, absent popliteal and pedal pulses
- Commonest finding in patients with claudication
What is rest pain?
critical lim ischaemia
- Rest pain is pain in the foot that comes on when the patient goes to bed and is relieved by hanging the foot out of the bed (help blood move to bottom)
- The ischaemia is so severe that at rest the foot skin, muscles, bones are ischaemic at rest, if left untreated then will progress to gangrene/ulceration
What are the clinical features of critical ischaemia?
- Rest pain (equivalent to unstable angina)
- Ulceration/gangrene (equivalent to myocardial infarction)
lower limb venous anatomy
- superficial (skin) and deep veins (within muscle)
- blood travels from superficial vessels to deep vessels then to right side of the heart
*superficial femoral vein is a DEEP vein*
long saphenous vein
very important anatomical site
can be used to place IV into
risk factors of varicose veins
- female
- standing up a lot in occupation
- number of births
age
development of chronic venous insufficiency
- more advanced version of varicose veins
= venous hypertension
- lipodermatosclerosis ( inflammation and thickening of the skin)
- haemosiderin staining
- venous ulceration
venouse eczema and ulceration
ulcer - damage to the venous system so blood cant travel through and heal
- very difficult to treat (must treat whole venous system and gain structure back
can ligate veins to prevent retrograde flow
reasons people may not walk properly / deep vein conditions
- immobility
- parkinsons (not using calf muscle and not using plantar flexion)
risk factors of DVT
immobility // stasis
trauma
pregnancy
= good to promote mobility after surgery, keep doing plantar flexion and moving calf muscles
Ankle - brachia; pressure index
measure blood pressure in the arm (brachial artery) and leg (tibial artery )and if the blood pressure isnt even then it shows lower limb arteriole disease
doppler ultrasonography
sonogram using ultrasound measures flow of blood
heart failure and valve disease
