PERIPHERAL VASCULAR SYSTEM

ANATOMY OF ARTERIES

• Major Arteries:

  • Right common carotid

  • Brachiocephalic

  • Lateral thoracic

  • Occipital

  • Internal carotid

  • External carotid

  • Left common carotid

  • Left subclavian

  • Arch of aorta

  • Pulmonary

  • Left coronary

  • Right coronary

  • Axillary

  • Brachial

  • Superior mesenteric

  • Abdominal aorta

  • Common iliac

  • Aorta

  • Celiac

  • Splenic

  • Internal iliac

  • External iliac

  • Deep medial circumflex femoral

  • Deep femoral

  • Femoral

  • Popliteal

  • Renal

  • Inferior mesenteric

  • Radial

  • Ulnar

  • Palmar arch (Deep, Superficial, Digital)

  • Anterior tibial

  • Peroneal

  • Posterior tibial

  • Arcuate

  • Dorsal metatarsal

  • Dorsal pedis

ANATOMY OF VEINS

• Major Veins:

  • Angular

  • Anterior facial

  • Right brachiocephalic

  • Right subclavian

  • Superior vena cava

  • Pulmonary

  • Right coronary

  • Inferior vena cava

  • Hepatic

  • Portal

  • Renal

  • Superior sagittal sinus

  • Straight sinus

  • Cervical plexus

  • External jugular

  • Internal jugular

  • Left brachiocephalic

  • Left subclavian

  • Cephalic

  • Axillary

  • Left coronary

  • Basilic

  • Long thoracic

  • Splenic

  • Median basilic

  • Superior mesenteric

  • Common iliac

  • External iliac

  • Femoral

  • Great saphenous

  • Popliteal

  • Peroneal

  • Posterior tibial

  • Anterior tibial

  • Dorsal venous arch

  • Volar digital

STRUCTURE OF ARTERIES AND VEINS

• Components:

  • Arteries:

  • Endothelium (tunica intima)

  • Elastic membrane (thinner in veins)

  • Smooth muscle layer (tunica media, thinner in veins)

  • Connective tissue (tunica adventitia)

  • Veins: Similar structure with differences noted above related to wall thickness

GREAT VESSELS

• Includes:

  • Right common carotid artery

  • Superior vena cava

  • Right subclavian artery

  • Right pulmonary artery

  • Aortic valve

  • Tricuspid valve

  • Inferior vena cava

  • Brachiocephalic artery

  • Left common carotid artery

  • Left subclavian artery

  • Arch of aorta

  • Left pulmonary artery

  • Pulmonic valve

  • Mitral valve

  • Aorta

CIRCULATION PATHWAY

• Right Lung: Blood flows from

  • Superior vena cava

  • Pulmonary artery -> Lungs

  • Pulmonary veins -> Left atrium

  • Inferior vena cava

• Upper/Systemic Circulation:

  • Aorta

  • Involves liver circulation, intestinal circulation, lower systemic capillaries

HEALTH HISTORY - ADDITIONAL QUESTIONS

• Relevant to Peripheral Vascular Health:

  • Leg pain? (intermittent claudication): lower perfusion causes muscle pain

  • Discoloration?: hands? feet? paleness?

  • Visible veins/varicosities?

  • Ulcerations? (skin breakdown)

  • Edema?

SPECIFIC CONDITIONS DISCUSSED

• Raynaud's:

  • Genetic disorder

  • loss of color in the fingertip or earlobe, especially in the cold

• Arterial Embolic Disease:

  • clots in extremities

  • can lead to symptoms such as severe pain, pallor, and, in some cases, tissue necrosis if blood flow is not restored quickly.

• Venous Stasis:

  • bad values lead to blood pooling in areas

• Deep Vein Thrombosis (DVT):

  • Signs & Symptoms: Pain in area, warmth, erythema, swelling

  • Prevention methods:

  • Use of Sequential Compression Devices (SCDs)

  • Thrombo-Embolic Deterrent stockings (TEDs): compression stockings

  • Ambulation/movement

  • Avoid crossed legs ( can restrict circulation)

  • Avoid IVs in feet (reduce trauma) 

INSPECTION OF PERIPHERAL PERFUSION

• Parameters to Assess:

  • Color

  • Clubbing

  • Edema

  • Varicose veins (palpable)

  • Ulcerations (skin breakdown)

  • Hair distribution (related to perfusion)

  • Jugular venous distension (JVD)

JUGULAR VENOUS PRESSURE ASSESSMENT

• JVD indication: Increased pressure in right atrium

  • Indicates increased pressure in right atrium 

  • Assess at a 45-degree angle, turn head away, look at jugular vein

  • CHF may increase JVD

PALPATION TECHNIQUES

• Evaluate:

  • Skin temperature & texture

    • Always compare right and left

    • norm = symmetrical

  • Capillary refill time (CRT)

    • Pressure applied to nail bed until it turns white, then time how long blood returns to tissue

    • <2 sec = rapid

    • >2 sec = delayed

  • Arterial pulses:

  • 
    

LOCATION OF PULSES

• Assess pulses at:

  • Carotid

  • Brachial

  • Radial

  • Femoral

  • Popliteal

  • Pedal (Dorsalis Pedis): behind ankle

  • Posterior Tibial: inside ankle

CHARACTERISTICS OF PULSES

• Important Characteristics to document:

  • Rate

  • Rhythm

    • regular or irregular

  • Symmetry

  • Amplitude:

    • Bounding = 4+

    • Full, Increased = 3+

    • Expected = 2+

    • Diminished = 1+

    • Absent = 0

EDEMA GRADING

• Scale for grading edema severity:

  • 1+ = 2 mm (trace)

  • 2+ = 4 mm (mild)

  • 3+ = 6 mm (moderate)

  • 4+ = 8 mm (severe)

• Note if edema is pitting (sign of chronic)

SPECIAL TECHNIQUES FOR ASSESSMENT

• Homan's Sign: Assess for leg discomfort

  • The patient lies on their back with their knee extended. The examiner passively dorsiflexes (bends upward) the patient's foot while squeezing the calf muscle

• Allen Test: ulnar perfusion

  • cut off circulation to ulnar/radius then retore blood flow to ulnar

AUSCULTATION**

• Assessment of Arterial Pulses:

  • Listen for bruits (turbulent flow sounds) at critical sites using a stethoscope

  • A normal finding is no bruits

  • Use bell of the stethoscope at temporal & carotid sites

ASSESSING FOR BRUITS

• Assess for temporal bruits

• Assess for carotid bruits

BLOOD PRESSURE ASSESSMENT

• Assess blood pressure in both arms

• Determine methods to assess for orthostatic hypotension

SUMMARY OF KEY LEARNINGS

• Patient's history includes cardiovascular and peripheral vascular assessments

• Know sites for arterial pulses

• Evaluate blood pressure in both arms (preferably in one position)