PCCR Peripheral Vascular System

arterial, venous, lymphatic system

what comprises the peripheral vascular system?

intima

single continuous lining of epithelial cells

regulates immune/inflammatory rxns, moderates vasoconstriction and vasodilation, location where plaque forms

functions of intima

media

smooth muscle cells with elastic properties

media

surrounded by internal and external laminae

adventitia

connective tissue outer layer

advenitia

contains nerve fibers and vasa vasorum

chronic inflammation of vascular endothelial cells resulting plaque formation

what is atherosclerosis?

vessel injury

what is plaque formation initiated by?

changes in cardiac output during systole and diastole

what do arteries respond to?

large, medium, small, arterioles, capillaries

order of arterial branching

brachial, radial, ulnar, vascular arches in hand

upper extremity arterial pulses

bend of elbow, medial to biceps tendon

location of brachial artery

lateral flexor surface, bt radial styloid and flexor carpi radialis tendon

location of radial artery

medial flexor surface, bt flexor carpi ulnaris and flexor digitorum superficialis

location of ulnar artery

epigastrium

where can you palpate aortic pulsations?

femoral, popliteal, posterior tibial , dorsalis pedis

lower extremity arterial pulses

below inguinal ligament, midway bt the anterior superior iliac spine and pubic symphysis

location of femoral pulse

popliteal fossa

location of popliteal pulse

behind medial malleolus

Location of posterior tibial pulse

dorsum of foot, lateral to extensor tendon of great toe

location of dorsalis pedis

bounding

3+ pulse

brisk, normal

2+ pulse

diminished, weaker than expected

1+ pulse

absent

0 pulse

small weak pulse

large, bounding pulse

diminished pulse pressure, slow upstroke, prolonged peak

what is a small, weak pulse?

decreases SV, increased PVR

what is a small weak pulse caused by?

increased pulse pressure, rapid rise and fall with brief peak

what is a large, bounding pulse?

increased SV, decreased PVR, increased vascular stiffness/resistance

what are the causes of a large, bounding pulse?

bisferiens pulse

Pulsus alternans

increased arterial pulse with double systolic peak

what is a bisfiens pulse?

HOCM, AR, AR+AS

what are the causes of a bisferiens pulse?

regular, but force of pulse alternates bt weak and strong

what is pulsus alternans?

severe left ventricular dysfunction

what is pulsus alternans indicative of?

bigeminal pulse

pulsus paradoxus

normal beat alternating with premature contraction with varying amplitude dt diminish stroke volume of premature contraction

what is a bigeminal pulse?

greater than normal drop in systolic pressure during inspiration, varying amplitude with respirations

what is pulsus paradoxus?

pericardial tamponade, constrictive pericarditis, obstructive pulmonary disease

what is pulsus paradoxus found in?

thin walled, holds 2/3 of circulating blood, unidirectional valves

characteristics of veins

capillaries, venules, superficial and deep veins to either the portal vein of venas cavas

venous blood flow

abdominal viscera, inferior vena cava after hepatic veins

what does the portal vein drain and empty into?

inferior vena cava

LE drained into:

superior vena cava

UE drained into:

deep veins

carries 90% of venous blood from lower extremity

deep veins

well supported by surrounding tissue

backflow, pooling, venous stasis

unidirectional valves prevent:

caudally

contraction of the calf muscle pumps blood:

superficial veins

poorly supported by surrounding tissue:

great and small saphenous veins

superficial veins of LE

dorsum of foot, anterior to MM, medially up leg, joins femoral vein of deep venous system below inguinal ligament

great saphenous vein

lateral foot, superiourly along posterior calf, joins deep venous system in popliteal fossa

small saphenous vein

extensive vascular network that drains lymph from body tissues and returns it to venous circulation

what is the lymphatic system?

porous endothelium

what is the lymphatic system comprised of?

tissue fluid, cellular debris, plasma proteins, cells

what does the lymphatic system collect?

networks of lymphatic capillaries in EC space that collect tissue fluid, cellular debris, plasma proteins, and cells

what are lymphatic plexuses?

lymphatic plexuses, vascular channels, collecting ducts, veins in neck

what is the pathway of the lymphatic system?

right side of head, neck, thorax, right upper limb

what does the right lymphatic duct drain fluid from?

right jugular vein and right subclavian vein

what does the right lymphatic duct empty into?

rest of the body

what does the thoracic duct drain fluid from?

left internal jugular vein and left subclavian vein

what does the thoracic duct empty into?

round, oval, bean shaped structures that vary in size based on location

what are lymph nodes?

engulf cellular debris and bacteria and produce antibodies

what is the function of lymph nodes?

ulnar surface of forearm and hand, 3/4 fingers, adjacent surface of middle finger

what do the epitrochlear lymph nodes drain?

rest of the upper extremity

what do the axillary lymph nodes drain?

infraclavicular node

where does some lymph fluid go directly to?

anterior thigh below inguinal ligament

where is the horizontal group of inguinal LN located?

superficial lower abdomen and buttocks, external genitals, but not the testes, anal canal, perianal area, lower vagina

what does the horizontal group of inguinal LN drain?

dorsum of foot, medial aspect of leg

what does the vertical group of inguinal LN drain?

small saphenous vein and joins deep system in the popliteal space

where is the heel, outer aspect of the foot, and posterior calf follow?

filtered fluid returned to circulation as lymph

what is transcapillary exchange?

hydrostatic pressure

what is the arteriolar end dominated by?

forces fluid into tissue spaces

what does hydrostatic pressure do?

colloid osmotic pressure of plasma proteins

what is the venous end dominated by?

pulls fluid back into vascular tree

what does colloid osmotic pressure do?

increased interstitial fluid or edema

what does lymph dysfunction or disturbances in hydrostatic or osmotic forces can disrupt the equilibrium cause?

increased plasma volume from sodium retention, altered capillary dynamics, inadequate removal of filtered lymph fluid, obstructions, increased capillary permeability

what are the causes of lymph dysfunction that can lead to edema?

Extracellular fluid that become clinically apparent as swelling

what is edema?

Edema that is compressible or lessens with external pressure

what is pitting edema?

Edema caused by obstructive lymph drainage, usually not compressible

what is lymphedema?

barely detectable when pressing skin

1+ pitting edema

slight indentation, 15 sec to rebound

2+ pitting edema

deeper indentation, 30 sec to rebound

3+ pitting edema

>30 to rebound

4+ pitting edema

Enlarged lymph nodes with or without tenderness

what is lymphadenopathy?

Causative lesion in drainage area causing focal enlargement

what is local lymphadenopathy?

Enlarged nodes in at least three non-contiguous lymph regions

what is generalized lymphadenopathy?

pain/swelling, coldness, numbness, pallor, discoloration of legs, hair loss, ab/flank/back pain, claudication, leg cramps, sensitivity to cold, ulceration

ROS peripheral vascular system

cold or pale extremity

red flag peripheral vascular system

acute arterial occlusion

what is a cold or pale extremity a concern for?

pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis

SS PAD

pain that limits walking, ED, unhealing wounds, ab pain after eating, first degree relatives with AAA

warning signs of PAD

buttocks or hip

location of pain for aortoiliac

ED

location of pain for aortoiliac-pudental

thigh

location of pain for common femoral or aortoiliac

upper calf

location of pain for superficial femoral

lower calf

location of pain for popliteal