clinical skills: peripheral vascular system (part one)

detection of peripheral artery disease (PAD)

what is careful assessment of the peripheral vascular system essential for?

12% (8 million Americans)

what percentage of the population has peripheral artery disease (PAD)?

coronary artery disease (CAD)

if a patient has peripheral artery disease (PAD), what are they more likely to have?

1/2

PAD is silent in what fraction of those affected?

age

what does the prevalence of PAD increase with?

7%

what percentage of ppl ages 60-69 have PAD?

23%

what percentage of ppl ages 80 and older have PAD?

cardiovascular morbidity and mortality

detection of PAD is important because it is a marker for...

MI, stroke

the risk of death from ___ and ___ triples with PAD

intima, media, adventia

what are the three concentric layers of arteries?

tunica intima

what layer of arteries surrounds the lumen of blood vessels?

regulators of thrombosis like plasminogen activator and heparinlike molecules

what does tunica intima synthesize?

prothrombotic molecules

tunica intima makes ___ like Von Willebrand factor and plasminogen activator inhibitor

angiotensin-converting enzyme, nitric oxide and prostacyclin

tunica intima modulates blood flow through synthesis of vasoconstrictors like ___ and vasodilators like ___ and ___

interleukins

how does tunica intima regulate immune and inflammatory reactions?

tunica media

what layer of arteries is made of smooth muscle that dilates and constricts to accommodate blood pressure and flow?

connective tissue containing nerve fibers

what is adventitia?

fatty streak

endothelial injury permits entry of LDL cholesterol and circulating mononuclear cells into the vessel wall, where they form what?

fibrous plaque

attachment of platelets and proliferation of smooth muscle cells within an arterial lesion leads to production of what?

emboli

a fibrous plaque may encroach on the arterial lumen or rupture to occlude the vessel and provide a source of what?

brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial

list the palpable arteries

muscle contraction

what is venous return aided by?

90%

what percentage of returning blood do deep femoral veins carry?

deep femoral vv

which veins in the legs are well supported by tissue?

subcutaneous, poor support

describe superficial veins (of legs)

great saphenous, small saphenous, and communicating vv

list superficial veins of leg

lymphatics

what is the vascular network that drains lymphatic fluid?

immune system

the lymph nodes are part of what system?

trap foreign substances (debris, bacteria) and produce antibodies

what is the function of lymph nodes?

person and location

what does the size of lymph nodes vary by?

pain in legs during exertion that is relieved by rest within 10 minutes

what is intermittent claudication?

-fatigue, aching, numbness, or pain that limits walking or exertion in legs

-erectile dysfunction

-poorly healing or nonhealing wounds of LE

-pain present at rest and changes w standing or supine

-abd pain after meals, weight loss, food fear

-first degree relative w H/O AAA

what are the warning signs of PAD?

intestinal ischemia of celiac or superior or inferior mesenteric aa

PAD warning signs: abd pain after meals, weight loss, and food fear suggests what?

15-28%

PAD warning signs: first degree relative w H/O AAA increases risk by what percentage?

central (lymph nodes)

what lymph nodes are palpable?

pectoral, lateral, and subscapular (lymph nodes)

what lymph nodes are seldom palpable?

into the axilla

where do all of the lymphatics of the breast drain?

near brachial a

where is the epitrochlear node located?

ulnar side of arm, 3rd, 4th, and 5th digits

what does the epitrochlear lymph node drain?

epigastrium, upper quadrants, and costovertebral areas

for a HTN pt where should you auscultate for renal a stenosis?

DVT (f)

what could tenderness in the femoral v be?

DVT (c)

cord and tenderness in the calf can be a sign of what?

below inguinal ligament and high in anterior thigh

where are the horizontal group of inguinal lymph nodes located?

horizontal group

which group of inguinal lymph nodes drains the superficial lower abd, buttocks, external genitalia (not testes), anal canal, perineum, and lower vagina?

near upper great saphenous v

where are the vertical group of inguinal lymph nodes located?

vertical group

what group of inguinal lymph nodes drains the dorsum of the foot and medial aspect of leg?

vertical

which group is not typically associated with palpable inguinal lymph nodes?

3+

what is the rating for a pulse that is bounding (aneurysmal)?

2+

what is the rating for a pulse that is brisk, normal?

1+

what is the rating for a pulse that is diminished and weaker than expected (common in elderly)?

0

what is the rating for a pulse that is absent or unable to palpate?

phlebitis

what is the medical term for inflammation of a vein?

venous tenderness, cords, heat/erythema

what are signs of phlebitis?

press for 5 seconds over a boney surface

how can you note pitting edema?

indentation takes >30 seconds to rebound

what is a pitting grade of 4+?

indentation takes 30 seconds to rebound

what is a pitting grade of 3+?

slight indentation takes 15 seconds to rebound

what is a pitting grade of 2+?

barely detectable indentation

what is a pitting grade of 1+?

venous insufficiency

what is failure of the veins to adequately circulate the blood, especially from the lower extremities?

lymphedema

what is swelling in an arm or leg caused by lymphatic system blockage?

orthostatic edema

what kind of edema is caused by prolonged sitting or standing or ill-fitting shoes?

venous insufficiency, lymphedema, CHF, nephrotic syndrome, cirrhosis, malnutrition, drugs, orthostatic edema

what is the etiology of edema?

increased interstitial fluid

what is swelling in edema due to?

arterial supply to the hand, patency of ulnar a before puncturing the radial a for blood samples

what is the allen test used to evaluate (2)?

color return in 3-5 seconds

describe a positive allen test

color fails to return, ulnar a supply to hand is not sufficient so radial a cannot be safely pricked

describe a negative allen test and what it means

rest hand in lap w palm up, pt clenches fist, compress radial and ulnar aa, pt relaxes hand, note pallor, release ulnar, note color return, repeat releasing radial a

describe how to perform allen test

PAD (ABI)

what does the ankle brachial index (ABI) confirm the diagnosis of?

ankle brachial index (ABI)

what test compares BP in UE and LE?

ankle systolic BP/brachial systolic BP

describe the calculation of ankle brachial index

if calcified aa

when is ankle brachial index (ABI) less sensitive?

claudication or CV risk factors

the ankle brachial index should be used in patients with what?

noncompressible

what does range of >1.30 indicate for ABI?

normal

what does a range of 0.91-1.30 indicate for ABI?

mild-to-moderate PAD

what does a range of 0.41-0.90 indicate for ABI?

severe PAD

what does a range of 0.00-0.40 indicate for ABI?

no pain

what is normal Homan's sign?

calf pain

what is abnormal Homan's sign?

can dislodge a clot

why is the exam for Homan's sign cautioned?

plaque buildup, arteriosclerosis obliterans, atheroscleorsis, occlusive disease

list types of PAD

diabetes, smoking hx, dyslipidemia, HTN, hyperhomocysteinemia

what are risk factors for PAD in pts under 50 yo?

increases

when homocysteine increases what happens to thrombosis risk?

70 yo and older

what ages increase risk for PAD?

50%

what percentage of PAD is symptomatic?

other vascular disease

if PAD is present, what is likely?

rest pain (ischemia even at rest)

if untreated what will intermittent claudication process to?

decreased or absent distal pulses, pallor especially with elevation, dependent rubor (flushed skin), cool temp, +/- edema, trophic changes, wounds that do not heal, muscle atrophy if severe, prolonged capillary refill

list signs of PAD

prolonged, +4-5 seconds

what capillary refill is consistent with PAD?

varicose veins

what are superficial vv that are dilated and tortuous?

familial, long periods of increased venous pressure, secondary to thrombophlebitis

what is epidemiology of varicose vv?

maybe none or fatigue, ache, heaviness

what are symptoms of varicose vv?

dilated veins, +/- tissue changes

what are signs of varicose vv?

saphenous system

what does superficial thrombophlebitis usually involve?

superficial vein

where does a clot form in superficial thrombophlebitis?

sudden inflammation and dull pain

what are symptoms of superficial thrombophlebitis?

local redness, pain, mild edema, palpable cord

what are signs of superficial thrombophlebitis?

spontaneous, pooled blood (pregnancy, post partum, varicose vv), secondary to trauma

what are causes of superficial thrombophlebitis?

rare

pulmonary embolism secondary to superficial thrombophlebitis is...

no

is anticoagulation therapy needed for superficial thrombophlebitis?

deep system is affected too

superficial thrombophlebitis is usually benign and brief unless...