Peripheral Vascular Disease -function: transportation, O2, proteins, nutrients - 3 systems I. Arterial System II. Venous System III. Lymphatic System - the framework of the peripheral vascular system – BV Layers of the BV 1. Tunica Intima -AKA Tunica Interna - Innermost Layer - Layers: Basement Membrane Connective Tissue Endothelium (Only layer present in all BV) 2. Tunica Media - Middle Layer of the BV - Composed of a smooth mm. - Bulk Tunica Media (Artery) 3. Tunica Adventitia -Tunica externa -outermost layer of the BV - Composed of elastic, collagenous fiber - Bulk (Veins) I. Arterial System - Artery - Oxygenated Blood – away from the heart - muscular, elastic and tubular extension of the heart - Proximal – inc. in pressure – therefore they are elastic - Distal - dec. in pressure – Muscular - Artery – Arterioles – Capillaries (thin in nature) “exchange vessel” II. Venous System - Veins - Deoxygenated Blood - towards the heart - (+) valves - carries 60 – 64% of Blood volume - AKA Capacitance Vessel 3 Types of Vein 1. Superficial Veins - Underneath the skin - 2 great S.V. in the LE - Great Saphenous V. – runs on the medial aspect of the leg and thigh to join c the Femoral V. - Lesser Saphenous Vein - runs behind the Lat. Malleolus to the post. Leg to join the popliteal V. 2. Perforating Vein AKA Communicating Vein - connects the SV to the Deep Vein 3. Deep Vein - Large veins that already follows the structure of an artery III. Lymphatic System - Lymphatics – carries fluid back to the blood steam - (-) CNS, Corneas - Lymph Nodes – Cervical, Axillary, Inguinal - (+) Macrophages PVD I. Arterial Dse 1. Atherosclerosis Obliterans - inflammation & occlusion affecting medium to large arteries - MC: on LE>UE - early warning signs: (+) int. claudication - late stage: (+) Gangrene - MC in non-DM patient: Abdominal Aorta, Common Iliac Artery, Femoral A. - MC in DM: Femoral Artery, Tibial Artery - If Q in Board exam – Femoral A. Always 2. Thromboangitis Obliterans - inflammation and occlusion affecting small A. - MC UE>LE - AKA Buerger’s Dse - Dse. of a young male smoker - Distal ➜ proximal / Ascending Pattern 3. Raynaud’s Phenomenon - abnormal vasoconstriction reflex affecting small A. - Precipitating Factors: Exposure to cold, Emotional Stress - Cyclic Color Pattern – Pallor, Cyanosis, Rubor (French Flag Sign) II. Venous Diseases 4. Chronic Venous Insufficiency - inc. pressure in the deep veins - MC form of Venous Diseases Stages I: Edema & Pigmentation II: Edema, Pigmentation, Varicosities & Dermatitis III: Ulceration: MC manifestation of CVI III. Lymphatic Diseases 1. Lymphadenopathy - Enlargement of the lymph nodes c or without tenderness - Dse of the Lymph nodes 1. Varicose Veins - distended, swollen superficial veins - MC affected: (+) Valves – inc. pressure in LE - Prolonged Standing, Obesity, Pregnancy, Cross legs - S/Sx: Aching, heavy leg, appearance of spider vein 2. Superficial Vein Thrombosis (Superficial Vein Thrombophlebitis) - inflammation and clot formation affecting SV - MC affected: Saphenous Vein - most serious complication: Varicosities - S/Sx: Pain along the course of the saphenous Vein 3. Deep Vein Thrombosis - Inflammation & clot formation affecting the deep vein - Virchow’s Triad H – Hypercoagulability I - Intimal Wall damage V - Venous Stasis - (+) Homan’s Test - Anti-coagulant Heparin - IV Warfarin – Oral pt. should be immobilized - MC complication of DVT is Pulmonary Embolus - Best prevention: Early Mob. 2. Lymphedema - Excessive accumulation of fluids in the tissue Primary Lymphedema – Hereditary – genetic risk 25% - Best initial exercise: Brisk walking - Milroy’s Dse – edema after birth - Lymphedema Praecox – edema present <35 yo - Lymphedema Tarda – Edema >35 yo Secondary Lymphedema - surgery, malignancy, infection, tumor Pulse Temperature Ulceration AI Dec. / Absent Cold L. Malleolus, Ant. Tibia Pain Painful Pale on Elevation Dusky red on dependency (+) Gangrene (+) Rest pain VI Normal Normal M. Malleolus, Medial aspect of leg & thigh Painless Pain (According to Sulli) Relief of pain from leg elevation (+) Edema (+) Pigmentation (+) Varicosities (+) Dermatitis Special Test 1. Claudication Time - Arterial Insufficiency - Treadmill - measure the time or distance where the pain is felt 2. Stemmers Test - Lymphedema - Pinch Skin at the base of the 2nd toe - Able Lift of skin = (-) Edema, (-) Stemmers - Unable to lift = (+) Edema, (+) Stemmers 3. ABI – Ankle Brachial Index - Arterial Insufficiency - Doppler Ultrasound - UE: Loc of Doppler – Brachial Pulse / Radial Answer Brachial - Cuff Brachium - LE: Loc. Doppler – Dorsalis Pedis / Post. Tib. Answer Dorsalis - Cuff Calf Area - LE / UE - Interpretation > 1.20 falsely elevation: DM 1.19 – 0.95 Normal 0.94 – 0.75 – mild art. Dse + int. Claudication 0.74 – 0.50 – mod art dse + rest pain <0.50 Severe art. Dse