Peripheral Vascular System Overview and Examination Techniques

Palpable arterial pulses of the Upper Limb

a. Brachial pulse

b. Radial pulse

c. Ulnar pulse

Palpable arterial pulses of the Lower Limb

a. Femoral

b. Popliteal

c. Posterior tibial

d. Dorsalis pedis

6 P's of arterial pathologies

1. Pallor (Pale; dt arterial occlusion)

2. Polar (Cold; dt arterial occlusion)

3. Pulselessness (Diminished; dt arterial occlusion)

4. Paraesthesia ('Pins & Needles'; dt arterial occlusion)

5. Pain (Works with paraesthesia)

6. Paralysis (dt necrosis of tissue or gangrene)

Venous system made up of:

1. Deep veins (90% of venous return)

2. Superficial veins (Great and small saphenous)

3. Anastomotic veins (connect the saphenous veins)

4. Perforating/ communicating veins (connect deep to superficial veins)

Lymphatic system

Vascular network that drains lymph fluid from the body tissues and returns it to venous circulation

Upper limb palpable nodes

Epitrochlear

Axillary

Lower limb palpable nodes

Inguinal nodes - vertical and horizontal

Pitting oedema

• Soft and usually bilateral

• Pitting after 2 seconds over bony

prominences

• Skin thickening, ulceration and

pigmentation depends on cause

• Causes include: Dependency,

immobilisation, heart failure, nephrotic syndrome, liver cirrhosis, chronic venous insufficiency, hypoalbuminemia, medications.

Non-pitting oedema

• Most common is lymphoedema

• Soft in early stages

• Thickening of skin

• Ulceration is rare

• No pigmentation

• Unilateral or bilateral

• Due to obstructed lymph channels by tumours, fibrosis, inflammation and surgical intervention

Atherosclerosis

Hardening of arteries due to plaque causing decreased blood flow

Clot = Atheroma

Predominantly in the legs - intermittent claudication

Buergers disease

When an atheroma breaks off and results in thrombus (i.e. decreased blood flow and necrosis)

Form of vasculitis

A.K.A Thromboangitis obliterans

Sxs:

Pain (IC)

Numbness

Paraesthesia

Predisposition to stroke or MI

Risk factors:

Smoking

Rx:

Amputation

Deep vein thrombosis

Blood clot in a deep vein

Sxs:

Pain

Swelling

Warmth + Redness (dt inflammation)

Occurs mostly in leg (calf)

Cx's:

Surgery

Pregnancy

Trauma

Hormones

Refer to doppler ultrasound

Rx:

Anticoagulant

Thrombophlebitis

Formation of a clot in a vein resulting in inflammation

Sxs - Same as DVT

Risk factors - Same as DVT

Difference from DVT = Different vein; saphenous veins

Self limiting

Raynaud's disease

Vasospasm of blood vessels which will prevent blood flow leading to colour changes in the extremities, nose, and ears

3 phases:

1. Whiteness - pallor dt ischaemia

2. Blueness - P.cyanosis dt vasodilation

3. Rubor - Normal flow

Primary Raynaud's disease:

Dt cold exposure and emotional stress

Secondary Raynaud's disease:

Dt pre-existing condition (RA)

Varicose veins

Tortuous appearance of superficial veins

Occurs in lower limbs dt gravity - i.e. valves work harder

Valves damaged ->swelling ->discoloration (blue/purple) ->surrounding skin becomes darker dt venous insufficiency

Cx's:

Pregnancy

Medication

Long standing periods

Spider veins - same process but smaller vessels walls are affected bcoz they have no valves

Compartment syndrome

Increased pressure within fascial compartments of extremities.

Dt:

Muscular damage

Trauma

Surgery

Mechanism:

Muscles get inflammed, swell, enlarge, and compress N's and V's (i.e. poor circulation)

Fascia can no longer expand & becomes red, warm, and painful

Rx:

Surgical fascial decompression

Lymphangitis

Inflammation of lymphatic vessels

Red appearance (red streaks)

Sxs (local):

Pain

Redness

Warmth

Swelling

Sxs (systemic):

Fever

L. node enlargement

Cx:

Bac/Fungal infection (streptococcus)

Staphylococcus

Dermatological, not vascular

Bacterial infection of the skin

Types of ulcers

1. Pressure ulcer

2. Arterial insufficiency ulcer

3. Venous insufficiency ulcer

4. Neuropathic ulcer

Chronic Arterial Insufficiency

Arterial occlusion; tissue ischaemia

Combination of:

Atherosclerosis & Beurgers disease

chronic venous insufficiency

Venous hypertension

Combination of:

DVT & Varicose veins

Venous stasis:

Pitting oedema

Pruritis

Brown pigmentation of skin

Lipodermatosclerosis

Ulceration

Where do ulcerations most commonly occur and what are their characteristics

Dorsum of the foot - smaller, painful, deeper, dry, well delineated

Risk factors:

Obesity

T2DM

Htn

Genetics

Pulse grading

0 = Absent

+1 = Diminished

+2 = Normal

+3 = Increased

+4 = Bounding

Capillary refill

Time for color to return after pressure.

Allens Test

Assesses arterial supply to the hand.

Special tests for lower extremities

1. Beurgers test

2. Trendelenburg's test

3. Varicose vein mapping

Special investigations

1. Dopper ultrasound

2. Angiogram

3. Venogram

4. D-dimer (blood test)

5. Biopsy

Refferals

1. Vascular surgeon

2. Phlebologist

3. Endocrinologist