The Peripheral Vascular System Anatomy and Physiology Arteries

Arteries contain 3 concentric layers of tissue:

- the intima - the media - the adventitia The intima

The endothelium of the intima has metabolic properties, it synthetizes:

- regulators of thrombosis (i.e. prostacyclin, plasminogen activator and heparinlike molecules)

- prothrombotic molecules (i.e. plasminogen activator inhibitor)

- modulates blood flow and vascular reactivity (vasoconstrictors like endothelin - vasodilators like prostacyclin)

It also regulates:

• Immune and inflammatory reactions through elaboration of:

- interleukins - adhesion molecules - histocompatibility antigens The media and adventitia

• The media is composed of SMOOTH MUSCLE CELL that dilate and constrict to accommodate blood pressure flow

• Small arterioles called the VASA VASORUM perfuse the media

• The adventitia is composed of connective tissue containing nerve fibers and the vasa vasorum

Arteria pulses palpable in the arms:

- The brachial artery

- The radial artery

- The ulnar artery

Pulses palpable in the leg:

- The femoral artery

- The popliteal artery

- The dorsalis pedis artery

- The posterior tibial artery Veins

Veins are thin-walled and highly distensible

The venous intima consists of NONTHROMBOGENIC ENDOTHELIUM

Protruding into the lumen are VALVES the promote unidirectional venous return

The media contains elastic tissue and smooth muscle that change vein caliber in response to venous pressure

Veins from the arm, upper trunk and head and neck drains into the SUPERIOR VENA CAVA

Veins from the legs and lower trunk drain upward into the INFERIOR VENA CAVA

The superficial vein of the leg include:

- The great saphenous vein

- The small saphenous vein The lymphatic system

• Drains lymph fluid from body tissue and returns it to the venous circulation

• Lymph fluid is filtered through lymph nodes (only superficial ones are accessible to physical examination)

• Vascular and immune function Lymphatics of upper limb

• EPITROCHLEAR NODES drain from the ulnar surface of the foreharm and hand

• AXILLARY NODES drain the rest of the arm Lymphatics of lower limb

The SUPERFICIAL INGUINAL NODES include 2 groups:

• The horizontal group (below the inguinal ligament)

• The vertical group (near the upper part of the saphenous vein)

The horizontal group The vertical group drains drains: a corresponding region of the leg - superficial portion of the lower abdomen and buttock - external genitalia (not the testes) - anal canal - perianal area and the lower vagina

Lymphatics of lower limb

Lymphatics from the portion of the leg drained by the small saphenous vein join the deep system at the popliteal space Peripheral vascular disorders Common or concerning symptoms Abdominal, flank, or back pain Pain in the arms or legs Intermittent claudication Cold, numbness, pallor in the legs; hair loss Swelling in calves, legs, or feet Color change in fingertips or toes in cold weather Swelling with redness or tenderness Peripheral arterial disease

• Peripheral arterial disease (PAD) is a common manifestation of atherosclerosis affecting 12% to 29% of community populations

• Prevalence increases with age and presence of cardiovascular risk factors Risk factors for lower extremity PAD Age 50, or younger if diabetes or atherosclerosis risk factor of smoking, dyslipidemia, hypertension, or hyperhomocysteinemia Age 50 to 69 and history of smoking or diabetes

Age 70 or older

Leg symptoms with exertion or ischemic rest pain

Abnormal lower pulses

Known atherosclerotic coronary, carotid, or renal artery disease PAD warning signs

Fatigue, aching, nubness or pain that limits walking or exertion in the legs; in case identify the location

Any poorly healing or nonhealing wounds of legs or feet

Any pain present when at rest in the lower leg or foot and changes when standing or supine

Abdominal pain after meals and associated “food fear” and weight loss (suggest intestinal ischemia of the celiac or superior or inferior mesenteric arteries) Any first-degree relatives with an abdominal aortic aneurysm (prevalence is of 15% to 28%)

SYMPTOM LOCATION suggests the site of arterial ischemia:

• Buttock, hip: aortoiliac • Erectile dysfunction: iliac- pudendal • Thigh: common femoral or aortoiliac • Upper calf: superficial femoral • Lower calf: popliteal • Foot: tibial or peroneal

Abdominal Aortic Aneurysm (AAA)

• AAA is defined as an infrarenal aortic diameter ≥ 3cm

• It s found in over 50% of older male smokers

• Rupture and mortality increases when the aortic diameter extends 5.5cm

• Palpation is useful when the diameter reaches ≥ 4cm

Risk factors of AAA

Smoking

Age 65 or older

Family history

Coronary artery disease

PAD

Hypertension

Hyperlipidemia Painful peripheral vascular disorders

Intermittent Atherosclerosis claudication (ateriosclerosis obliterans) Rest pain Acute Arterial Arterial Disorders Occlusion

Raynaud’s Disease and Phenomenon Painful peripheral vascular disorders

Superficial Thrombophlebitis

Deep Venous Venous Disorders Thrombosis (DVT)

Chronic Venous Insufficiency (deep) Painful peripheral vascular disorders

Thromboangiitis Obliterans (Buerger’s Disease)

Compartment Syndrome

Acute Lymphangitis Techniques of peripheral arterial examination Important areas of examination

The arms The abdomen The legs Size, symmetry, skin Aortic width Size, symmetry, skin color color

Redial pulse, brachial Pulsatile mass Femoral pulse and pulse inguinal lymph nodes Epitrochlear lymph Popliteal, dorsalis pedis nodes and posterior tibial pulses Peripheral edema Key components of peripheral arterial examination Measure blood pressure in both arms

Palpate carotid upstoke, ausculatate for bruits

Auscultate for aortic, renal and femoral bruits; palpate aorta and determine maximanl diameter

Palpate brachial, radial, ulnar, femoral, popliteal, dorsalis pedis, and posterior arteries

Inspect ankles and feet color, temperature, skin integrity; note any ulcerations; check for hair loss, trophic skin changes, hypertrophic nails Arms

Inspect both arms, notice:

• Size, symmetry and any swelling

• Venous pattern

• Color and texture of the skin and the color of the nails beds

• Palpate the RADIAL PULSE

If you suspect arterial insufficiency feel for the BRACHIAL PULSE • Feel for one or more EPITROCHLEAR NODES If a node is present note its size, consistency and tenderness

Epitrochlear nodes are difficult or impossible to identify in most normally healthy people Abdomen

Listen for the AORTIC, RENAL AND FEMORAL BRUITS • Palpate and estimate the width of the abdominal aorta in the epigastric area (especially in older adults due to higher risk of AAA)

• Assess for a pulsatile mass

Legs

Inspect both legs. Notice:

• Size, symmetry and any swelling • Venous pattern and nay venous enlargement • Any pigmentation, rashes, scars or ulcers • Color and texture of the skin, the color of the nails beds, and the distribution of hair

Palpate the SUPERFICIAL INGUINAL NODES: • Note their size, consistency and tenderness • Nontender discrete inguinal nodes up to 1-2cm in diameter are frequently palpable in normal people

The peripheral arteries

• The FEMORAL PULSE

• The POPLITEAL PULSE The peripheral arteries

• The DORSALIS PEDIS PULSE

• The POSTERIOR TIBIAL PULSE The peripheral veins

• Note the color of the skin • Look for edema • Check for pitting edema (depression caused by pressure from your thumb for at least 2 sec)

If EDEMA is present look for possible causes in the peripheral vascualr system:

• recent deep venous thrombosis (DVT), • chronic venous insufficiency from previous deep DVT or incompetence of the venous valves, • lymphedema

Try to identify any venous tenderness that may accompany DVT (may have no demonstrable signs)

Ask the pt to stand and inspect the saphenous system for varicosities Special Techniques Evaluating the arterial supply to the hand

• Ulnar, radial and brachial pulse

• The Allen test

Postural color changes of chronic arterial insufficiency

If pain or diminished pulses suggest arterial insufficiency look for postural color changes:

• Raise both legs until maximal pallor of the feet (within 1min) • Ask the pz to sit up (legs dangling down)

Note the time required for:

- Return of pinkness (about 10 sec) - Filling veins of feet and ankles (about 15 sec)

Mapping varicose veins

Transmit pressure waves along the blood- filled veins with pt standing Evaluating the competency of venous valves

Assess the vascular competency in communicating veins and saphenous system:

Pt supine, elevate legs about 90°

Occlude the great saphenous vein in the upper tigh by manual compression (enough to occlude the vein but not the deeper vessels)

Ask the pt to stand

While keeping the vein occluded watch for venous filling in the leg

Normally the saphenous vein fills from below (about 35 sec)

Rapid filling of superficial veins (while the saphenous is occluded) indicate incompetent valves in communicating veins

After the pt stands for 20 sec release the compression and look for sudden additional venous filling

Normally there is none (competent valves block retrogade flow)