Session 11.1

Question 1

How does blood flow through the venous system?

Answer 1

From superficial veins through perforating veins into deep veins

NB: the calf muscle pump contraction generates pressure to push blood in the deep vein back to the heart

Question 2

What are the deep veins of the leg??

Answer 2

• external Iliac vein
• Femoral vein
• popliteal vein
• calf veins

Question 3

What are the superficial veins of the leg?

Answer 3

• the long saphenous vein (tributaries in front of the medial malleolus)
• the short saphenous vein (lateral side of calf down past the lateral malleolus)

Question 4

Where does the short saphenous vein rejoin the deep veins?

Answer 4

At the popliteal vein

Question 5

Where does the long saphenous vein join the deep veins?

Answer 5

The femoral vein

Question 6

What are varicose veins and whats the pathophysiology?

Answer 6

Varicose veins are tortuous, twisted or lengthened veins

The vein wall is inherently weak in these veins, which leads to dilation and separation of valve cusps so they become incompetent.

NB: The aren’t dangerous in themselves

Question 7

What are the symptoms of varicose veins?

Answer 7

Symptoms must be along the vein itself

• heaviness
• tension
• aching
• itching

Question 8

What are the complications of varicose veins?

Answer 8

From the vein itself

• haemorrhage
• thrombophlebitis (inflammation of vein due to thrombosis) occurs due to low blood velocity. Produces an inflammatory response, including pain. You can see the outline of the vein.

From venous hypertension

• oedema
• skin pigmentation e.g haemosiderin staining as red cells leak out, macrophages ingest RBC, iron in blood is oxidised from ferrous to ferric = can see rust under skin.
• varicose eczema
• lipodermatosclerosis - skin is hard and yellow bits on surface.
• venous ulceration. Smelly, difficult to heal and painful.

Question 9

Why would varicose veins bleed in the shower?

Answer 9

Standing up = pressure is increased in veins and warm showers = vasodilation.

Lie patient down and elevate legs above heart = bleeding will stop

Question 10

How do you get venous hypertension?

Answer 10

As a result of calf muscle pump failure

Question 11

Why do you get calf muscle pump failure?

Answer 11

• deep vein incompetence
• failure of calf muscle contraction: immobility, obesity, reduced hip, knee and/or ankle movement
• volume overload

Question 12

What’s a retrograde circuit in the calf muscle pump?

Answer 12

Go through valve the wrong way instead of flowing normal from superficial to deep
Calf muscle pump becomes over full with blood

Question 13

What’s Virchow’s triad?

Answer 13

Helps explain the pathophysiology of thrombosis 
Is
- changes in lining of vessel wall
- changes in flow of blood
- changes in constituents of blood

Question 14

How do you get arterial thrombosis?

Answer 14

From virchows triad
- changes in the lining of the vessel wall

E.g due to atheroma

Question 15

How do you get venous thrombosis?

Answer 15

From virchows triad
- changes in flow of blood

Stasis leads to venous thrombosis

Question 16

Why does stasis lead to venous thrombosis?

Answer 16

Usually stasis and another factor e.g surgery, the pill, dehydration and cancer etc.

Question 17

What is the constitution of an arterial thrombosis in response to bleeding?

Answer 17

Involves platelets so are platelet rich

Question 18

What’s the difference between venous bleeding and arterial bleeding?

Answer 18

Venous

• dark, oozing.
• involves intrinsic pathways. Overcome with anti- coagulant agent.

Arterial

• spurting.
• platelets then intrinsic and extrinsic pathways.
• aspirins work against platelets so use if you want to stop arterial thrombosis.

Question 19

What do venous thrombi mainly consist of and what does this lead to?

Answer 19

Fibrin, formed from fibrinogen

Produces an inflammatory response (rubor, tumor, dolor, calor, reduced function).

Question 20

What are the signs and symptoms of a DVT?

Answer 20

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 21

How is DVT linked to surgery??

Answer 21

• immobility prior to surgery
• no calf muscle pump during surgery
• immobility after surgery
• surgery is trauma

Dvt can lead to pulmonary embolism

Question 22

What’s a collateral circulation?

Answer 22

The alternate circulation around a blocked artery or vein via another path, such as nearby minor vessels.

Development takes weeks or months. Provided you’ve got stenosis beforehand, can form pathologically.

Common around joints e.g elbow and joints.

Question 23

What’s acute limb ischaemia?

Answer 23

Poor blood supply to limb occurs quickly so no time for collateral circulation to form.
Commonest cause - embolism (from heart or abdominal aortic aneurysm) and trauma.

Sudden onset.

If not reversed within 6 hours cannot be recovered and if not amputated the patient will die (hyperkalaemia due to dead tissue releasing intracellular potassium).

Question 24

What Are the symptoms of acute ischaemia?

Answer 24

The 6 P’s

• pain
• paralysis
• paraesthesia (pins and needles)
• pallor
• perishing cold
• pulseless

Limb goes pale to being synoptic, then goes blue due to reduced haemoglobin then go red after 6 hours.

Question 25

What’s chronic arterial disease?

Answer 25

• intermittent claudication (= stable angina)

- critical ischaemia with rest pain (like unstable angina) and ulceration/gangrene (like an MI)

Question 26

What’s claudication?

Answer 26

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

Often will stop when they stop walking

Question 27

Where is the femoral pulse felt?

Answer 27

The mid inguinal point

Question 28

Where can the dorsal is pedis pulse be felt?

Answer 28

Lateral to the extensor hallucis longus tendon

Question 29

What is rest pain in the foot and what will it progestin to if untreated?

Answer 29

Pain in the foot that comes on when patient goes to bed and is relieved by hanging the foot out of bed
Ischaemia is severe that muscles, foot skin and bone are ischaemic at rest

This can lead to gangrene (dry= lack of blood supply and wet = due to infection) or ulceration (a break in the continuity of the epithelium)