Vascular Physiology 3
• Upper and lower extremity arterial
conditions other than atherosclerosis.
Upper extremity ischemia
Emboli
• Heart most likely source of non-atherosclerotic
emboli. 10-20% of all cardiac emboli lodge in
upper extremity. 70% of all upper ext emboli
come from heart.
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Thrombus
Tumor
Valvular lesions
Fairly common
Raynaud’s Disease
(Cold sensitivity)
• Female- most frequent 18-30 years
• Abnormal vasoconstriction of extremities
upon exposure to cold or emotional stress.
• Intermittent attacks of pallor, cyanosis,then
rubor of digits (usually upper), bilateral or
symetrical, normal radial and ulnar pulse.
• No evidence of obstructive disease.
• Fairly common
Raynaud’s Disease cont.
• Treatment
– Warmth, gloves, socks, avoid cold
– Vasodilators
Raynaud’s Phenomenon
(cold sensitivity)
• Intermittent pallor, cyanosis, redness,normal.
Repeats.
• Response to cold or emotion.
• Numbness, tingling, burning may occur.
• Secondary to such conditions as occlusive arterial
disease, systemic scleroderma, thoracic outlet
syndrome, pulmonary hypertension, myxedema or
trauma.
• Fairly common
Raynaud’s Phenomenon cont.
• Vascular Lab to look for underlying cause
of vasoconstriction.
• Vascular Lab to document vasospasm.
Arterial/Venous fistulae
• Surgically constructed for hemodialysis
– Cimino-Brescia: end to end or side to side anastomosis
between the radial artery and cephalic vein at wrist.
– Prosthetic graft (PTFE)
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Loop between brachial art and antecubital vein
Straight between radial art at wrist and antecubital vein
Straight between brachial artery and subclavian vein
Common
Buerger’s Disease
• Thromboangiitis Obliterans (fairly
uncommon)
– Men <40yrs
– 99% smoke
– Affects small and medium arteries, can affect
veins also.
– Inflammation leading to formation of thrombi
– Tissue necrosis develops early because of poor
collaterals in end arteries of fingers and toes.
Trauma
• Dissection, thrombosing, Arterial/venous
fistulae.
• Acute ischemia
• Can happen to upper or lower ext.
• Fairly common
Thoracic Outlet Syndrome
• Compression of nerve, artery, or vein in the
thoracic outlet area.
• Area of 1st rib, clavicle, and scalene muscle.
• A “cervical rib” with or without a fibrous
band may be present.
• Uncommon
Types of Thoracic Outlet
Syndrome.
True neurogenic: Wasting of muscles of hand
and hand weakness, with positive
electromyography.
Vascular Thoracic Outlet: an arterial or
venous lesion is present on angiography.
Duplex and photocell exam is helpful and
most likely ordered before angio.
Thoracic Outlet Types cont.
• Disputed Thoracic Outlet.
– Weakness, parathesia, pain of hand, arm,
shoulder girdle, chest wall, and headache.
– Eletromyographic test normal.
– Hand wasting is never found.
– Patients do not progress to true neurogenic or
vascular thoracic outlet.
Tumor
• Muscular masses can be present in the
upper extremity. Some are vascular and
cause bruit.
• Masses can compress artery or vein.
• Uncommon
Rheumatic/Autoimmune
Diseases
Giant Cell Arteritis: Temporal arteritis and
Takayasu’s
Can cause arm claudication or Raynaud’s
phenomenon. Uncommon
Radiation arteritis
• Inflammation of subclavian and axillary
arteries resulting from radiation treatment.
• Uncommon but is seen
Fibromuscular dysplasia
• Systemic disorder, smooth muscle
hyperplasia, and general disorganization of
the arterial wall.
• Can cause arm claudication. Uncommon
Summary upper
• Common causes for upper art conditions
– Emboli
– Cold sensitivity (vasospasm in Raynaud’s)
– A-v grafts
Upper summary cont.
• Somewhat common
– Buerger’s Disease (men more than women)
– Trauma
Upper summary cont.
• Uncommon upper ischemia causes
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Thoracic outlet
Tumor
Rheumatic/Autoimmune disease
Radiation arteritis
Fibromuscular dysplasia
Non-atherosclerotic Lower
Extremity arterial conditions
• Account for much less lower extremity
ischemia than upper extremity ischemia.
Emboli
• Causes acute ischemia/ medical emergency
• Most non-atherosclerotic emboli come from
the heart
• Entire lower extremity can be involved,
most occlude lower leg, foot or toes.
• Heparin, thrombolytic therapy,
embolectomy
• Common
Pseudoaneurysm
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Mostly traumatic
Infection is most serious complication
Can be painful
Rarely causes ischemia
Occurs more in lower extremity than upper
Popliteal Artery entrapment
• Popliteal artery compression by medial head
of gastrocnemius muscle.
• Young patients
• With exercise the gastrocnemius muscle
contraction compresses artery.
• Uncommon
Trauma
• Dissection, thrombosing, Arterial/venous
fistulae.
• Acute ischemia
• Can happen to upper or lower ext.
• Fairly common
Arterial-Venous Fistulas
• Can be surgically created in lower ext for
hemodyalisis. Occurs less frequently than in
upper. Complications: aneurysm,
pseudoaneurysm, infection, graft occlusion.
• Fairly common (more often in arms)
• Traumatic:
– Artery and venous connection due to trauma
– Infection is most serious complication over ischemia
– Can be painful
Raynaud’s Disease
• Affects upper extremities more significantly
than lower.
• Vasospasm without underlying occlusive or
systemic cause.
• Uncommon in lower
Arteritis
• All types of arteritis affects upper
extremities much more frequently than
lower. (Takayasu’s, Giant Cell Arteritis,
Polyarteritis or periarteritis.
• Uncommon to see these listed as cause for
lower extremity ischemia, but is possible.
Buerger’s Disease
• Thromboangiitis Obliterans: described as rarely a
cause, and accounting for less than 1% of lower
extremity vascular disease.
• Young, male, smokers, digit ischemia
• Sudden onset
• Claudication of foot and arch rather than legs.
• Associated superficial thrombophlebitis
• Less likely to cause lower ext ischemia than upper
extremity ischemia.
Advential Cyst
• Cyst of advential layer of arterial wall,
causing stenosis or occlusion by
thrombosing.
• Can cause claudication
• Can be surgically drained or bypassed.
• Can reoccur
• Uncommon
Hypercoagulability
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Heparin induced thrombosis
Antithrombin III deficiency
Abnormal fibrinolytic system
Abnormal platelet aggregation
Uncommon
Hematologic disease
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Polycythemia Vera
Thrombocytosis
Dysproteinemias.
Sudden onset, usually affects digits
Hematology consult for therapy
Uncommon
Summary of Lower extremity
arterial complications
• Common
– Emboli
– Pseudoaneurysm (Lower ext arterial injury,
does not usually cause ischemia)
Summary lower cont.
• Fairly common
– Popliteal artery entrapment
– Trauma
– Arterial – venous fistula
Summary Lower ext arterial
• Uncommon in Lower ext ischemia
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Raynaud’s disease or phenomena
Arteritis
Buerger’S Disease
Advential cyst
Hypercoagulability
Hematologic disease
References Vas Phy 3
• Slides 1,2,3,4,5 Taber’s cyclopedic Medical
Dictionary, Davis 1985
• Slide 5 Intro to Vascular Ultrasonography,
Zwiebel, Saunders, 2000, Pg258
• Slides 6,7,8 Intro to Vascular Ultrasonography,
Zwieber, pgs 259-260. & Handbook of Patient
Care in Vascular Disease, 4th Ed., Hallett,
Brewster, Rasmussen pgs 238-247
References Vas Phy 3 cont
• Slide 9 Intro to Vascular Ultrasonography,
Zwiebel, 2000, pg 259. & Cardiology Clinics,
PVD in The Elderly, Breslin Ed., August 1991,
pgs 559-560.
• Slides 10,11 Intro to Vascular Ultrasonography,
Zwiebel, 2000, pgs 259-261. & Vascular
Diagnosis 4th Ed, Bernstein, Mosby, 1993.
• Slide 12 Vascular Diagnosis 4th Ed., Bernstein,
Mosby, 1993 pg 631
Refer Vas Phy 3 cont.
• Slides 13,14,15 Cardiology Clinics, August 1991
pgs547-552. & Vascular Diagnosis, Bernstein, pg
631
• Slides 16,17 Intro to Vascular Ultrasonography,
Zweibel, 2000 Pg 260.
• Slide 20 Handbook of Patient Care in Vascular
Disease 4th, Hallett, pg37.
• Slide 21 Cardiology Clinics, August 1991,pgs 501
Reference Vas Phy 3 cont.
• Slide 22 Intro to Vascular Ultrasonography,
Zweibel, 2000, pg205. & Cardiology Clinics,
August 1991 pgs 559-560
• Slide 23,26 Cardiology Clinics, August 1991,
pg501.
• Slide 27 Cardiology Clinics, August 1991, pgs
501-502/
• Slide 29 Cardiology Clinics, August 1991, 497513.