Vascular System Flashcards
injury to vascular endothelial cells
provokes thrombus formation, atheromas, and the vascular lesions of hypertension
Atheroma
begins in the intima as lipid-filled foam cells and then becomes fatty streaks
Complex atheromas
thickened asymmetric plaques that narrow the lumen, reducing blood flow, and weaken the underlying media. They have a soft lipid core and a fibrous cap of smooth muscle cells and a collagen-rich matrix. Plaque rupture may precede thrombosis
Accumulation of interstitial fluid termed edema
due to lymphatic dysfunction or disturbances in hydrostatic or osmotic forces that disturb the equilibrium of the fluid exchange in the capillary bed
An expanding hematoma from abdominal aortic aneurysm (AAA)
may cause symptoms by compressing the bowel, aortic branch arteries, or the ulcers
Peripheral arterial disease (PAD)
stenotic, occlusive, and aneurysmal disease of the aorta, its visceral arterial branches, and the arteries of the lower extremities, exclusive of the coronary arteries
Atherosclerotic PAD
Symptomatic limb ischemia with exertion.
Intermittent claudication
any pain or cramping in the legs during exertion that is relieved by rest within 10 minutes
Neurogenic claudication
pain with walking or prolonged standing, radiating from the spinal area into the buttocks, thighs,lower legs, or feet
Spinal stenosis (Likelihood ratio 7.4 of neurogenic claudication)
If the pain from neurogenic claudication is relieved by sitting
Likelihood ratio over 6 of neurogenic claudication
If the pain from neurogenic claudication is relieved by bending forward or if bilateral buttock or leg pain is present
Hair loss over the anterior tibiae
due to decreased arterial perfusion
Dry or brown-black ulcers
due to gangrene
PAD “warning signs”
- fatigue, aching, numbness, or pain that limits walking or exertion in the legs; if present, ID the location. Ask also about erectile dysfunction 2. any poorly healing or non-healing wounds of the legs or feet 3. any pain present when at rest in the lower leg or foot and changes when standing or supine 4. abdominal pain after meals and associated “food fear” and weight loss 5. Any first-degree relatives with an abdominal aortic aneurysm
Symptom location suggests the site of arterial ischemia
- buttock, hip - aortoiliac 2. erectile dysfunction - illiac-pudendal 3. thigh - common femoral or aortoiliac 4. upper calf - superficial femoral 5. lower calf - popliteal 6. foot - tibial or peroneal
Abdominal pain, “food fear,” and weight loss
suggests intestinal ischemia of the celiac or superior or inferior mesenteric arteries
lymphedema of the arm and hand
may follow axillary node dissection and radiation therapy
Prominent veins in an edematous arm
suggest venous obstruction
Raynaud’s disease
wrist pulses are typically normal, but spasm of more distal arteries causes episodes of sharply demarcated pallor of the fingers
if an artery is widely dilated
aneurysmal
bounding carotid, radial and femoral pulses
aortic insufficiency
arterial occlusion from atherosclerosis or embolism
asymmetric diminished pulses
enlarged epitrochlear node
local or distal infection, or generalized lymphadenopathy
an inguinal mass suspicious for an incarcerated hernia
often diagnosed as AAA at surgery
warmth and redness over calf
cellulitis
Lymphadenopathy
enlargement of the nodes, with or without tenderness
Distinguish between local and generalized lymphadenopathy
local - finding either a causative lesion in the drainage area; generalized - enlarged nodes in at least two other noncontiguous lymph node regions
A diminished or absent pulse
makes partial or complete proximal occlusion 10 times more likely
If the occlusion is at the aortic or iliac level
all pulses distal to the occlusion are typically affected
Chronic arterial occlusion, usually from atherosclerosis
causes intermittent claudication, postural color changes, and trophic changes in the skin
an exaggerated, widened femoral pulse
femoral aneurysm, a pathologic dilation of the artery
an exaggerated, widened popliteal pulse
aneurysm of the popliteal artery
Popliteal and femoral aneurysms
not common, but they are usually caused by arteriosclerosis and occur primarily in men older than 50 years
Atherosclerosis (arteriosclerosis obliterans)
most commonly obstructs arterial circulation in the thigh. The femoral pulse is normal, the popliteal decreased or absent
dorsalis pedis artery
may be congenitally absent or may branch higher in the ankle. search for a pulse more laterally
What does the absent pedal pulses with normal femoral and popliteal pulses indicate?
atherosclerotic disease in the lower popliteal artery or its branches 14 times more likely, seen in diabetes mellitus
What does sudden arterial occlusion from embolism or thrombosis cause?
causes pain and numbness or tingling. The limb distal to the occlusion becomes cold, pale, and pulseless. Emergency treatment is required
What does coldness, especially when unilateral or associated with other signs suggest?
suggests inadequate arterial perfusion
What does the edema cause?
causes swelling that may obscure the vein, tendons, and bony prominences
What does calf asymmetry increase the likelihood of?
DVT. Also consider muscle tear or trauma, Baker’s cyst (posterior knee) and muscular atrophy
In DVT, the location of edema suggests the location of the occlusion:
the popliteal vein when the lower leg or the ankle is swollen; the iliofemoral veins when the entire leg is swollen
What does venous distention suggest?
a venous cause of edema
When is the bilateral edema present?
in heart failure, cirrhosis, and nephrotic syndrome
What does a painful, pale swollen leg, together with tenderness in the groin over the femoral vein, suggest?
deep iliofemoral thrombosis
What is the risk of pulmonary embolism in proximal vein thrombosis?
50%. Only half of patients with DVT in the calf half tenderness and cords deep in the calves. Absence of calf tenderness does not rule out thrombosis
Superficial thrombophelbitis
local swelling, redness, warmth, and a subcutaneous cord. It is an emerging risk factor for DVT
Chronic venous insufficiency
brownish discoloration or ulcers just above the malleolus
What does thickened brawny skin suggest?
lymphedema and advanced venous insufficiency
Varicose veins
dilated and tortuous. Their walls may feel somewhat thickened.
What do both Buerger’s disease or thromboangiitis obliterans have in common?
Absent or diminished pulses at the wrist. Arterial occlusive disease is much less common in the arms than in the legs.
Allen test
It is useful to ensure the patency of the ulnar artery before puncturing the radial artery for blood samples.
What does extending the hand fully may cause in Allen test?
a falsely positive Allen test
What does persisting pallor indicate in Allen test?
occlusion of the ulnar artery or its distal branches
What does marked pallor on elevation of both legs suggest?
arterial insufficiency
When patient sits up with legs dangling down after having to raise the legs for a minute, if the left foot is still pale and the veins are just starting to fill,
it is a sign of arterial insufficiency
When patient sits up with legs dangling down after having to raise the legs for a minute, if there is persisting unusual rubor to replace the pallor of the dependent foot,
it is a sign of arterial insufficiency. When veins are incompetent, dependent rubor and the timing of color return and venous filling are not reliable tests of arterial insufficiency
Retrograde filling (Trendelenburg) test
assess the valvular competency in both the communicating veins and saphenous system
What does rapid filling of the superficial veins while the saphenous vein is occluded indicate?
incompetent valves in the communicating veins. Blood flows quickly in a retrograde direction from the deep to the saphenous system
What does sudden additional filling of superficial veins after release of compression indicate?
incompetent valves in the saphenous vein
