The Peripheral Vascular
System
Anatomy and Physiology - Arteries
• Arterial pulses are palpable when artery lies close to body surface
• Arms – Two/Three Locations
– Brachial: above bend elbow
– Radial: flexor surface wrist laterally
– Ulnar: overlying tissues frequently obscure
• Legs – Four Locations
– Femoral: below inguinal ligament
– Popliteal: behind knee
– Dorsalis pedis: dorsum foot; lateral extensor tendon
– Posterior tibial: behind medial malleolus ankle
Anatomy and Physiology - Veins
• Deep Veins
– Carry ~ 90% venous return from lower extremities
• Superficial Veins: subcutaneous
• Communicating Veins
– Connect superficial (saphenous) system with deep
system
• Deep, superficial and communicating veins have
one-way valves
– Allow venous blood to flow from superficial to deep
system toward heart, but not in opposite direction
Anatomy and Physiology – Lymphatic
System
• Extensive vascular network that drains lymph
from bodily tissue and returns it to venous
circulation
• Lymph nodes
– Round, oval or bean-shaped structures
– Vary in size according to location
• Important role in body’s immune system
– Cells in lymph nodes engulf cellular
debris/bacteria and produce antibodies
• Only superficial lymph nodes accessible to
physical examination
Health History
• Common or Concerning Symptoms
– Pain in arms/legs
– Intermittent claudication
– Cold, numbness, pallor in legs, hair loss
– Color change in fingertips or toes in cold weather
– Swelling in calves, legs or feet
– Swelling with redness or tenderness
Health History
• Arterial Peripheral Vascular Disease Legs
– Intermittent claudication
• Ask patients “Have you ever had any pain/cramping in legs when
walking or with exercise?”; “Does pain get better with rest?”
• Arterial spasm Fingers/Toes
– Ask patients “Do your fingertips/toes ever change color in cold
weather or when you handle cold objects?”
• Venous peripheral vascular disease
– Swelling of feet and legs
• Ask about ulcers on lower legs, often near the ankles
Health Promotion and Counseling
• Most patients with peripheral arterial disease
(PAD) have no symptoms or non-specific
symptoms
– Triad of exercise-induced calf pain that causes
stopping of exercise and relief of pain in 10
minutes present in only 10% affected patients
• Screen for subclinical PAD
• Aggressive risk factor intervention
Health Promotion and Counseling
• Risk factors for Peripheral Arterial Disease
– Current/past tobacco use
– Hyperlipidemia
– Diabetes mellitus
– CAD
– Hypertension
– Cerebrovascular disease
Ankle-Brachial Index (ABI)
• Detects stenosis of 50% or more in major vessels
of legs
• Measure systolic blood pressure (with Doppler
ultrasonography) in each arm and in dorsalis
pedis and posterior tibial pulses
• Calculate reading for right and left
– Divide arm pressure by ankle pressure
• ABI 0.90-1.30: normal
ABI 0.41-.90: mild to moderate disease
ABI 0.00-0.40: severe disease with critical stenosis
Techniques of Examination
• Important Areas of Examination
– Arms
• Size, symmetry, skin color
• Radial pulse, brachial pulse
• Epitrochlear lymph nodes
– Legs
• Size, symmetry, skin color
• Femoral pulse and inguinal lymph nodes
• Popliteal, dorsalis pedis and posterior tibial pulses
• Peripheral edema
Techniques of Examination - Arms
• Inspect both arms from fingertips to
shoulders
• Note:
– Size, symmetry and any swelling
– Venous pattern
– Color of skin and nail beds; texture of skin
• Palpate radial pulse
– Use pads of fingers on flexor surface of wrist
– Partially flex patient’s wrist
– Compare pulse in both arms
Techniques of Examination - Arms
• Palpate Brachial Pulse
– Flex elbow slightly
– Palpate artery medial to biceps tendon in
antecubital crease
• Epitrochlear nodes
– Flex elbow 90°
– Support forearm
– Feel in groove between biceps and triceps muscle,
3 cm above medial epicondyle
Palpate the Brachial artery
Techniques of Examination - Legs
• Patient should lay down, draped so external
genitalia covered and legs fully exposed
• MUST remove stockings or socks
• Inspect both legs from groin and buttocks to feet
• Note:
–
–
–
–
Size, symmetry and any swelling
Venous pattern/venous enlargement
Pigmentation, rashes, scars or ulcers
Color and texture of skin, color of nail beds, distribution
of hair on lower legs, feet and toes
Techniques of Examination - Legs
• Palpate superficial inguinal nodes
– Horizontal/Vertical groups
– Note size, consistency and discreteness and
tenderness
– Nontender, discrete nodes up to 1-2cm are
palpable in normal people
Palpate for the superficial inguinal nodes
• Horizontal group: below the inguinal legement
• Vertical group: near the upper part of the saphenous vein
Techniques of Examination –
Palpate Pulses
•
•
•
•
Femoral Pulse
– Press deeply below inguinal ligament
– Midway between anterior superior iliac spine and symphysis pubis
Popliteal Pulse
– Flex knee some, leg relaxed
– Place fingertips of both hands to meet midline behind knee and press deeply
into popliteal fossa
Dorsalis Pedis Pulse
– Feel dorsum of foot, lateral to extensor tendon of great toe
Posterior tibial pulse
– Curve fingers behind, slightly below medial malleolus of ankle
Palpate the popliteal pulse
• In the tissue behind the knee
Palpate the popliteal pulse
palpate the dorsalis pedis pulse
• Dorsum of the foot, just lateral to the extensor
tendon of the big toe.
Palpate the posterior tibial pulse
• Behind the medial malleoulus of the ankle.
Grading Amplitude of Arterial Pulses
•
•
•
•
•
4+
3+
2+
1+
0
Bounding
Increased
Brisk, expected
Diminished, weaker than expected
Absent, unable to palpate
Techniques of Examination - Edema
• Compare one foot and leg with the other
– Note relative size and prominence of veins, tendons
and bones
• Check for pitting edema
– Press firmly with thumb for 5 seconds over dorsum
each foot, behind medial malleolus and shins
– Look for pitting (depression caused by pressure
from thumb)
• Severity of edema graded on four-point scale
(slight to very marked)
Grade edema
• May be graded by measuring the depth of pitting in
centimeters, or by weight change, or the time pitting
remains after releasing the pressure.
• Grade edema on this scale
– 1+: Mild pitting, slight indentation, no perceptible
swelling of the leg
– 2+: Moderate pitting, indentation subsides rapidly
– 3+: Deep pitting, indentation remains for a short
time, leg looks swollen
– 4+: Very deep pitting, indentation last a long time, leg
is very swollen
If you suspect edema:
• Measure the legs:
– The forefoot
– The smallest possible circumference above the
ankle
– The largest possible circumference at the calf
– The mid-thigh, a measured distance above the
patella with the knee extended
– A difference of more than 1 cm just above the
ankle or 2cm at the calf is unusual in normal
people and suggests edema.
Techniques of Examination - Edema
• If edema present, look for causes
– Recent deep venous thrombosis
– Chronic venous insufficiency
– Lymphedema
• Note color of skin
– Local area of redness
– Brownish areas near ankles
– Ulcers and where
– Thickness of skin
Special Techniques
• Evaluate arterial supply of the hand if you suspect
arterial insufficiency
– Check radial, brachial and ulnar pulses
– Perform Allen test
• If suspect chronic arterial insufficiency
(pain/diminished pulses), check for postural color
changes
• Evaluate competency of venous valves
– Assess retrograde filling (Trendelenburg) test
Allen test
•
•
•
•
•
•
Tight fist
Compress
Open hand
Pale palm
Release pressure
Normally:
– Flushed
Within 3 – 5 seconds.
Postural color changes of Chronic Arterial
Insufficiency:
• Raise the patient’s both legs up to 60 degrees
• Postural color change; pale color develops; within a
minute
• Ask the patient to sit-up with legs dangling down
• Compare the two legs, note the time required for:
– Return of the pinkness; normally within 10s.
– Filling of the veins; normally within 15s
– Unusual rubor (dusky redness) after 1 min
Assessment of Peripheral Vascular System
• Postural colour changes of Chronic Arterial Insufficiency
– Normally color return within 10 sec
– Veins refill within 15 sec
60 cm
Mapping Varicose veins
• You can map out the course and connection of varicose
veins by transmitting pressure waves along the bloodfilled veins.
• With the patient standing, place your palpating fingers
gently on a vein, and with your other hand below it,
compress the vein sharply.
• Feel for the pressure wave transmitted to the fingers of
your upper hand.
• A palpable pressure wave indicates that the two parts of
the vein are connected.
Mapping Varicose veins
Feel for pressure wave
15-20
cm
Evaluating the competency of venous valves
• By the retrograde filling
(Trendelenburg)test.
• Assess the competency in
both the communicating
veins and the saphenous
system.
 When the patient
In supine position, elevate
one leg about 90 to empty it
of venous blood.
Evaluating the competency of venous valves
• Occlude the great saphenous vein in the upper thigh by manual
compression.
• Ask the patient to stand
• While you keep the vein occluded, watch for venous filling in the leg
• Normally the saphenous vein fills from below; normally it takes 35
seconds.
• After the patient stands for 20 seconds, release the compression and
look for sudden additional venous filling; normally there is none and
slow filling continues.
• When both steps of this test are normal the response is termed
negative-negative.
•
Chronic Insufficiency of Arteries and Veins
Arterial
insufficiency
Venous
insufficiency
Pain
Intermittent claudication,
progress to pain at rest
Often painful
Mechanism
Tissue ischemia
Venous hypertension
Pulses
Decreased or absent
Normal, may difficult to feel
through edema
Color
Pale, especially on
elevation, dusky red on
dependency
Normal, or cyanotic
ondependency, petechia
and then brown
pigmentation
Temperature
Cool
Normal
Chronic Insufficiency of Arteries and Veins
Arterial
insufficiency
Venous
insufficiency
Pain
Intermittent claudication,
progress to pain at rest
Often painful
Mechanism
Tissue ischemia
Venous hypertension
Pulses
Decreased or absent
Normal, may difficult to feel
through edema
Color
Pale, especially on
elevation, dusky red on
dependency
Normal, or cyanotic
ondependency, petechia
and then brown
pigmentation
Temperature
Cool
Normal
Arterial insufficiency
Venous Insufficiency
Recording Your Findings
• Initially you may use sentences; later you will
use phrases
• Examples:
– “Extremities are warm and without edema. No
varicosities or stasis changes. Calves are supple
and nontender. No femoral or abdominal bruits.”
Doppler Ultrasonic Stethoscope
• Doppler Ultrasonic Stethoscope
– To detect weak thready pulse
– Apply light pressure, place the device 45 degree
angle, use gel
Ankle-Brachial Index (ABI):
• Is a noninvasive way to
determine the extent of
peripheral vascular
disease.
• Take the higher ankle
systolic BP and divide it
by the higher brachial
systolic BP (Right and
left)
Ankle-Brachial Index (ABI):
– Normal ABI is 0.90 - 1.30 because ankle
pressure is slightly higher than brachial
– <.89 - >0.60 : mild PAD
– <.59 - >0.40: moderate PAD
– <.39: severe PAD
Doppler Ultrasonography
• Doppler Ultrasonography
– Each arm
– Dorsalis pedis
– Posterior tibial
• Doppler Ultrasonography:
– Definition: Doppler ultrasonography is a non-invasive diagnostic
procedure that changes sound waves into an image that can be
viewed on a monitor.
– Purpose: Doppler ultrasonography can detect the direction,
velocity, and turbulence of blood flow. It is frequently used to
detect problems with heart valves or to measure blood flow
through the arteries.
– The test is widely used because it is noninvasive, uses no x rays,
and gives excellent images. It is harmless, painless, and widely
available.
• Preparation: There is no special preparation needed for
this test. The ultrasound technician may apply a clear gel
to the skin in order to help the transducer more freely
over the body.
• Aftercare: No aftercare is necessary.
• Normal results: A Doppler ultrasonography test showing
no restricted blood flow is a normal finding.
• Abnormal results: Disrupted or obstructed blood flow
through the neck arteries may indicate the person is a
risk of having a stroke. (Narrowed arterial flow in the legs
does not necessarily indicate a risk of stroke.)
Arteriograms & Arteriography
•
Description
.It is invasive procedure involves visualization of arteries, the
most common site for an arteriogram is the femoral artery.
. Arterial catheters are positioned with a guide wire that is
used to advance the catheter to a special location in the
arterial tree.
. Because the arterial catheter is radiopaque, movement of
catheter is noted with fluoroscopy.
Arteriograms & Arteriography
. After correct placement is obtained, dye is injected into
the catheter to outline a portion of the artery. In this
way the circulation in the lower extremity can be
visualized.
. The catheter can be threaded via the femoral artery into
the abdominal aorta to the level of the renal arteries for
renal arteriogram.
. Other sites for arteriography include brachial artery &
carotid artery
Arteriograms & Arteriography
• Purposes
1.
Observe blood flow
2.
Detect any lesion
3.
Diagnosed of kidney or liver lesion
4.
Introduction of chemotherapeutic drugs
5.
Introduction of drugs to stop bleeding
6.
Remove atherosclerotic plaques
Arteriograms & Arteriography
- Client preparation;
. Before
.. NPO 6- 8 hrs
.. Consent form
.. Body weight to determine dose of dye
.. Shaving the area
. After
.. Pressure dressing should not be removed
.. Stay supine 4 -6 hrs because of fear from bleeding
.. Ice bag may apply to puncture site
.. V/S Q 15 min 1st hr then Q2-4 hrs
.. Observe pulses distal to arterial puncture