Davies Vascular: Chapter 3, Testing Considerations, Patient History, Mechanisms of Disease, and Physical Examination

Claudication

Pain in muscles occurring during exercise but subsiding with rest.

Arterial Spasm, Atherosclerosis, Arteriosclerosis, or Occlusion

True claudication results from inadequate blood supply to the exercising muscle , which may be caused by what 4 things?

Aortoiliac Disease

Bilateral buttock claudication strongly suggests what?

Iliofemoral Disease

Unilateral buttock claudication strongly suggest what?

Nerve or Musculoskeletal Involvement

Differential diagnoses for pseudo claudication can be what two things?

Distal External Iliac / Common Femoral Disease

Thigh claudication strongly suggests what?

Femoral / Popliteal Disease

Calf claudication strongly suggests what?

Ischemic Rest Pain

A severe symptom of diminished blood flow to the most distal portion of the extremity.

Occurs mainly at rest.

Symptoms occur in the *forefoot, heel, and toes*

Necrosis

Tissue death due to a deficient or absent blood supply.

Necrosis

Most severe symptom of arterial insufficiency.

Claudication, Ischemic Rest Pain, Tissue Necrosis

Three symptoms of chronic occlusive disease are?

Acute Arterial Occlusion

Symptoms include; *pain,pallor,pulselessness,paresthesia,paralysis,polar, and purplish skin color*

May result from thrombus,embolism, or trauma.

Considered an emergency situation due to the inability of the arteries to form collaterals

Pain,Pallor,Pulselessness,Paresthesia, Paralysis,Polar,Purplish Feet

What are the 7 symptomatic p's associated with acute arterial occlusion?

Pallor

Skin paleness

Cyanosis

Bluish discoloration of the skin

Rubor

Dark red coloration of the skin

Paresthesia

Burning/Itching/Numbing/Tiggling sensation of the skin

Raynauds Phenomenon

A condition that exists when symptoms of intermittent ischemia of the finger or toes occur in response to cold exposure as well as emotional stress.

Diabetes,Hypertension,Hyperlipidemia,Smoking, Advanced Age, Family History and Gender( GF HAS HD)

Name the 7 risk factors that can contribute to vascular disease?

Diabetes Mellitus

The most common form of diabetes

Diabetic

Atherosclerosis is more common and occurs at a younger age with what type of patient?

Diabetic

What type of patients have a higher incidence of occlusive disease of the distal popliteal and tibial arteries?

Diabetic

What type of patient will develop medial calcification in the lower extremeties?

Diabetic

In what type of patient will there be a higher incidence of gangrenous changes and amputations of the extremities?

Diabetic

In what type of patient will there be a poor sensation as a result of neuropathy leading to increased trauma?

Systemic Hypertension

Associated with a greater incidence of coronary atherosclerosis.

Increases an individuals susceptibility to peripheral and cerebrovascular involvement.

Hyperlipidemia

Risk factor closely associated with the development of atherosclerosis because fat is insoluble in water.

Smoking

Risk factor of vascular disease in which chemicals irritate the endothelial lining of the arteries and cause vasoconstriction.

Atherosclerosis

*The most common arterial pathology*

Applied to a number of pathologic conditions in which there is thickening,hardening,and loss of elasticity of the walls of the arteries.

*Changes occur in the tunica intima and media*

At The Origins/Bifurcation of a Vessel

In a very broad sense, atherosclerosis most often occurs where on a vessel?

Leriche Syndrome

Caused by *obstruction of the terminal aorta*

Occurs in *males*

Symptoms include *fatigue in the hips,thighs,or calves during exercise, absence of pulsation in the femoral arteries, impotence, and coldness/pallor of the lower limbs*

Embolism

Obstruction of a blood vessel by a foreign substance or blood clot.

May be gas,liquid,or solid.

Plaque or Thombus

Most frequent cause of embolism.

Distally Until it Lodges in a Small Vessel

Embolisms can be caused by plaque or thrombus which travel in which direction?

Collateral

Emboli's often improve as a result of blood flow from what type of vessel?

Blue Toe Syndrome (Cyanosis)

Typically caused by an embolism, but can also be caused by ulcerated and or atherosclerotic lesions, the inflammatory process of arteritis, and some angiographic procedures.

True,Dissecting, and Pseudo

What are the three pathology related aneurysms?

True Aneurysm

A dilation of all three layers of the arterial wall.

False Aneurysm

Type of aneurysm that does not contain all arterial wall layers.

Infrarenal Aorta

The most common location for arterial aneurysms

Common Femoral or Popliteal Artery

Patients with one aneurysm have a higher chance of having a second aneurysm that can be located in what two areas?

Popliteal Arteries

In what arteries are aneurysms typically located bilaterally ?

Aneurysms

Possible causes of this include poor arterial nutrition, congenital defects , infection, atherosclerosis, trauma

Focal, Fusiform,Saccular,and Concentric

What are the 4 shapes an aneurysm can take?

Fusiform Aneurysm

A diffuse, circumferential or dilatation of an arterial segment.

Saccular Aneurysm

A localized outpouching of an artery resulting from wall thinning and stretching.

Rupture and Embolization

What are two complications that can result from an aneurysm?

Wall Dilatation + Lower PSV at the Walls = Stagnancy in Diastole

Explain why aneurysmal formation has the ability to form a thrombus?

Dissecting Aneurysm

Occurs when a small tear of the intima allow blood to form a cavity between two wall layers.

Weakening of the Media and an Intimal Tear.

What two conditions must be met for a dissecting aneurysm to form?

Thoracic Aorta

The most common location of a dissecting aneurysm

Pseudoaneurysm

Essentially a pulsating hematoma.

Results in the main arterial wall following the insertion of a catheter.

There must be communication from the main artery to the pulsatile structure (a neck).

Arteritis

Inflammation of the arterial wall often resulting in thrombosis of the vessel.

Includes Takayasu, Temporal and Poly.

Buerger's Disease (Thromboangitis Obliterans)

The most common type of arteritis?

Buerger's Disease

Associated with *heavy smoking*

Primarily in *men < 40 yrs*

*Occlusions of the distal arteries (toes and fingers)*

Rest pain and ischemic ulcerations.

Inflammation of the arterial wall.

Superficial Thrombophlebitis is a secondary result.

Patchy areas of ulcerations or gangrene.

May be associated with atherosclerotic occlusive disease of the larger arteries.

Most often associated with collagen vascular syndrome such as rheumatoid arthritis or lupus.

Coarctation of The Aorta

A congenital narrowing or *stricture of the thoracic aorta*

Clinical findings = *hypertension due to decreased kidney perfusion* or *manifestation of lower extremity ischemia* (decreased pulses and segmental pressures)

Dissection

*Media is weakened and the intima develops a tear* in which blood leaks into a false lumen between the intima and media.

Flow velocities differ in each lumen.

Can affect the aorta and peripheral arteries.

Thin membrane that divides the arterial lumen into two compartments.

*Usually starts from the thoracic aorta* but can extend to the iliac.

*May occur due to hypertension or severe chest trauma*

Complications include stenosis/occlusion of the main artery or it's branches, and rupture.

Primary Raynauds Disease

Intermittent digital ischemia caused by digital arterial spasm.

Common in young women.

May be hereditary.

Usually bilateral.

Patient presents with long term history of symptoms without progression.

Benign condition.

Secondary Raynauds or Obstructive Raynauds Syndrome

Consists of normal *vasoconstrictive responses of the arterioles superimposed on a fixed arterial obstruction*

Ischemia is constantly present.

May be the first manifestation of a collagen disorder, *Buerger's disease*, or an anatomic abnormality.

Entrapment of the Popliteal Artery

Thought to be caused by compression of the popliteal artery by the medial head of the gastrocnemius muscle or fibrous bands.

Found in young men.

Bilateral.

Entrapment of the Popliteal Artery

Most written about entrapment syndrome.

Collagen Vascular Disorder

Occurs when problems with the immune system affect collagen, which contributes to the structures of tendons, bones, and connective tissue.

Examples include temporal arteritis and scleroderma.

Scleroderma

Rare, progressive disorder that involves hardening and tightening of the skin and connective tissue.

Raynauds Phenomenon

Localized scleroderma affects only the skin, and the first signs of the disease may be the presence of what disease?

Ehlers-Danlos Syndrome

A group of inherited disorders affecting connective tissue such as *skin,joints,and blood vessel walls*

The vascular form of this can be more severe and can cause the walls of the blood vessels to rupture.

May be preceded by aneurysm or dissection.

Livedo Reticularis

A vascular condition characterized by a *purplish discoloration of the skin*

More often on legs.

*Net-like appearance*

Possibly aggravated by cold

Causes no symptoms and does not need treatment.

Necrobiosis Lipodica

A disorder of collagen degeneration with thickening of blood vessel walls, *fat deposition*, and granulomatous response.

Patients present with *shiny red-brown patches on the skin that enlarge over time*

More common in *women*

*Occurs early in diabetic patients*

Cause is unknown.

Possible causes include diabetic microangiopathy, vasculitis, trauma, and inflammatory changes.

Vasculitis

Inflammation of the blood vessels causing changes such as thickening, weakening, scarring, and narrowing in the blood vessel walls.

Giant Cell Arteritis

*Inflammation of the cranial arteries* especially the temples.

Polyarteritis

*Inflammation of the medium sized arteries* in various parts of the body.

May include a rash and skin ulcers.

Takayasu's Arteritis

*Inflammation of the larger arteries* in the body.

Pallor

Skin change resulting from a deficient blood supply

Rubor

A dark reddish discoloration of the skin.

*Suggests damaged, dilated vessels or vessels dilated as a result of reactive hyperemia or infection*

Cyanosis

A bluish discoloration of the skin and mucuous membranes.

Occurs when there is a *concentration of deoxygenated hemoglobin*

Livedo Reticularis

*Purple patches on the skin of the dorsum of the foot*

Results from dilated capillary and venule filling.

Warm

Upon physical examination, the patients skin should be what temperature

Arterial Ulcerations

*Results from arterial insufficiency*

*Deep and regular in shape*

*Often located on the feet/toes*

Painful.

Important to obtain information about the length of time this has been present.

Loss of Hair on the Extremities, Scaly Shiny Skin, Thickened Toenails

Name three trophic changes that can occur due to decreased circulation.

Decreased Arterial Perfusion

Capillary refill time > 3 seconds indicates what?

Pallor

Elevating the extremity with impaired circulation produces what due to poor arterial perfusion?

Dependant Rubor

Coloration that is caused by the *large amount of blood flowing into small vasodilated superficial arteries*?

0-4

Grading pulses occurs on a scale of?

Fistula, Poststenotic Turbulence, or Patent Dialysis graft

A palpable vibration or thrill over a pulse site may indicate what three things?

Thumb

When palpating a pulse, the examiner should not use what finger?

Aorta, Femoral, Popliteal, Dorsalis Pedis, and Posterior Tibial Arteries

Palpable pulses include what arteries?

Bruits

Abnormal, low frequency *sounds* heard on auscultation.

Caused by significant stenosis that sets up a vibratory response in the tissue distal to the stenosis.

Graded on a scale of 1-3.

Sites include abdominal aorta, carotid, femoral, popliteal arteries

Makes it disappear

A severe stenosis, with a > 90% diameter reduction, does what to a bruit?

Decrease

Poor cardiac output can do what to a bruit?