1. No category

Examination of
vessels
Peripheral arterial disease
Chronic arterial diseases:
•
Atherosclerotic peripheral arterial disease
•
Thrombangiitis obliterans
•
Subclavian stenosis-subclavian steal syndrome-dyspraxia
•
Thoracic outlet syndrome (TOS)
•
Coarctatio aortae
•
Leriche syndrome
•
Takayashu arteriitis
•
Fibromusculare dysplasia
•
Popliteal entrapment syndrome
Acut arterial diseases:
•
Acut limb ischemia
•
Aortic dissection
Peripheral arterial disease (PAD)
Disorder, that obstructs the blood supply to the
lower and upper extremities most commonly
caused by atherosclerosis.
Other causes: thrombosis, embolism, vasculitis,
fibromuscular dysplasia, entrapment
Peripheral vascular disease: PAD + venous +
lymphatic + atherosclerosis of other arteries
(carotid, renal…)
Epidemiology
Underdiagnosed and undertreated
Not modifiable: age, gender (male), family
Symptoms
1.
Intermittent claudication (claudere – to limp) – lower
extremity (dysbasia intermittens)
2.
Dyspraxia intermittens – upper extremity
Pain, cramp or fatigue in the affected muscles with exercise,
resolved with rest –imbalance between need and supply
because of arterial stenosis (like stable angina!)
•
Buttock, thigh, hip – aorta, iliac arteries
•
Calf – femoral, popliteal
•
Ankle, pedal – tibial, peroneal
Distance, speed, incline precipitate the claudication.
Symptoms – critical limb ischaemia
• Pain and/or paraesthesia at rest: worsens
on leg elevation, improves with leg
dependency (effect of gravity on
perfusion pressure)
• Skin fissuring, ulceration, necrosis
(apical, pretibial)
Typical position: sit on the edge of the bed
Physical findings - inspection
• Pallor: precipitation with leg elevation and
dorsi/plantarflexion (Ratschcow).
• Dependent rubor and venous distension (dilated
small vessels and transcapillary leakage)
• Muscle atrophy
• Hair loss
• Thickened and brittle toenails
• Smooth and shiny skin
• Subcutaneous fat atrophy
Severe limb ischaemia: cool skin, petechiae, cyanosis,
dependent rubor and oedema, fissure, ulcer,
gangrene with pale base
Blue toe syndrome
Physical findings
1.
Palpation of pulses:
•
Upper extremity: brachial, ulnar and radial
•
Lower extremity: femoral, popliteal, posterior
tibial, doralis pedis
Pulse abnormality: proximal occlusion/stenosis
2.
Auscultation of accessible arteries for bruits
(accelerated blood flow velocity and flow
disturbance):
•
Supra/infraclavicular fossa: subclavian stenosis
•
Back leftside: coarctation
•
Abdominal: renal, iliacal
•
Groin: iliofemoral
CW Doppler method
Measurement of blood flow velocity.
Pulsatile (arterial - normally triphasic) or phasic (venous - breathing)
velocity signals sound coded.
Unidirectional and bidirectional CW Dopplers (pocket or hand held
Dopplers)
Screening instrument
• Segmental blood pressure measurements
• Qualitative sound alteration
Triphasic→ monophasic Doppler sound (arterial
stenosis/occlusion)
Absence of venous sounds→ thrombosis
CW Doppler
Ankle/brachial index (screening test)
The ratio of systolic blood pressure measured over posterior
tibial artery or dorsalis pedis (the higher) and the brachial
artery.
• Normal value: 1-1,3
• <0,9 – more than 50% stenosis over the measurement point
(sensitivity and specificity≈95%)
• <0,5 – critical limb ischemia
• >1,3 – Mönckeberg sclerosis (calcified vessel cannot be
compressed)
Segmental
blood pressure
measurement
Color Doppler (duplex, triplex scan)
Arteries (morphology and function)
Deep veins (DVI)
Anatomy, valve function,
Superficial veins
stenosis, reflux
Perforating veins
Other noninvasive methods:
CT or MR angiography
MRA
CTA
Invasive method: angiography
2D projection of arterial tree
Acute limb ischemia
Thrombotic or embolic occlusion of arteries on the extremities,
which suddenly reduce the blood flow.
• Thrombosis: atherosclerotic arterial disease, slow evolution of
symptoms (within 2 weeks)
• Embolism: commonly without atherosclerosis, thrombotic sources
in the heart, occlusion in the branching points, sudden onset of
symptoms one segment distally from the occlusion
• Rarely: dissection, trauma
Symptoms (5 Ps)
Pain
Pulselessness
Pallor
Paresthesia
Paralysis
Aortic dissection
Dissection of the aortic wall
layers after the formation of
intimal tear causing a true
and a false lumen.
Symptoms: severe, sudden back
pain, syncope, heart failure,
hemiplegia
Physical findings – depends on
the location: hypertension,
pseudohypotension
(asymmetric blood pressure),
pulse deficit, aortic
regurgitation, acute coronary
syndrome, mesenteric
ishemia, limb ischemia
Special arterial syndromes
Thrombangiitis obliterans (TAO)
Thrombangiitis obliterans – Winiwater-Bürger
disease
Young male with tobacco use (rare disease,
common in Asia)
Vasculitis, thrombosis of medium sized arteries,
veins on the upper and lower extremities
Clincal presentation: rest pain, ulceration,
migratory thrombophlebitis, Raynaud syndrome
Popliteal entrapment syndrome
Young, typically athletic person (rare disease)
Cause: anatomic variation in the insertion of the
medial head of the gatrocnemius muscle or
popliteal muscle – compression of popliteal
artery during exercise
Clinical presentation: intermittent claudication,
popliteal aneurysm, thrombosis
Physical findings and diagnostic tests are normal
at rest!
Fibromuscular dysplasia
Young caucasian woman (rare)
It typically affects the carotid, renal and iliac arteries.
Clinical presentation: intermittent claudication, critical limb
ischemia, hypertension, neurological symptoms
Leriche syndrome
Chronic atherosclerotic occlusion of the infrarenal aorta.
Typically in middle aged male
Clinical presentation: symmetrical bilateral claudication, impotency
Aortic coarctation
Stenosis of the end of aortic arch (opposite the ductus
arteriosus Botalli - congenital)
Young male with upper extremity hypertension, lower
extremity hypotension (difference more than 10 mmHg),
symmetrical intermittent claudication. Interscapular systolic
murmur.
Takayasu arteritis – aortic arch disease
Vasculitis of aortic arch and primary branches.
Female under 40 in Asia.
Clinical presentation: depends on the location. Intermittent
dyspraxia, TIA, stroke, angina, renal insufficiency with
fever and other signs of chronic inflammation.
Subclavian artery stenosis
Commonly atherosclerotic origin with ipsylateral
low blood pressure, pulselessness and
intermittent dyspraxia. Systolic bruit over infraand supraclavicular fossa
Special form - subclavian steal syndrome:
reversal flow in ipsylateral vertebral artery
shunted to the upper extremity.
Vertebrobasilar symptoms provoked by arm
exertion: dizziness, diplopia, dysarthria, vertigo,
syncope
Venous diseases
Venous diseases
Chronic venous disorders:
•
Chronic venous disease – chronic venous insufficiency
Primary
Secondary
•
Particular venous disorders
Venous aneurysms
Venous tumors
Pelvic congestion syndrome
Compression syndromes (v. cava superior and inferior syndrome, left iliac compression
syndrome)
Congenital venous malformations
Agenesis, hypoplasia, valvular dysplasia
Arteriovenous fistulae
Acute venous diseases:
•
Deep vein thrombosis (DVT) – Venous thromboembolism (VTE)
•
Superficial thrombophlebitis (STP)- superficial vein thrombosis
•
Acute venous trauma – variceal bleeding
Definitions
Chronic venous disease (CVD) – chronic
venous insufficiency (CVI): symptoms caused
by valve insufficiency and/or venous
obstruction in peripheral venous system
(epifascial, subfascial or transfascial).
• Primary: most common form.
• Secundary: post-thrombotic syndrome, EhlersDanlos syndrome…
Venous anatomy
• Subfascial (deep veins)
system, high pressure
compartment: muscle pump
(m. soleus, gastrocnemius).
Epifascial (superficial veins),
low pressure compartment:
flow only after muscle
relaxation.
Transfascial (perforating
veins): connection.
Insufficiency of these parts
leads venous hypertension,
edema and dysfunction of
microcirculation.
Pathomechanism of CVD
Venous hypertension (>30/90/ Hgmm):
Superficial veins
Deep veins
Valve insufficiency≈90%
Perforating veins
Deep vein obstruction≈10%
Combination
Insufficiency of epifascial veins
Insufficiency of deep veins
Epidemiology
Prevalence (lifestyle dependent):
Developing countries:
New-Guinea: males – 5%, females - 0,1%
Cook-Islands: males - 2,1%, females - 4%
Western coutries:
USA: males – 15%, females - 27,7% (2003. Criqui et al.)
Croatia: males – 18,9%, females 34,6% (2000. Kontosic et al.)
Venous ulcers: cost of treatment 2 billon dollars/year (2%)
Mortality low
quality of life low
Epidemiology II.
Risk factors:
Age
Family
Gender (female)
Pregnancy/OAC, hormon
replacemant
Type of work (vertical)
Obesity
Tobacco use
Hypertension
Sedentary lifestyle
Operation/injury
Deep vein thrombosis
Obstipation
Symptoms
Impression of swelling (edema, constriction induced by
socks, difficulties in putting shoes)
Pain along varicose pathway, on ulcer, or diffuse calf pain
Pruritus in association with stasis dermatitis
Heavy legs (premenstrual, heat waves, alcohol)
Restless legs (intolerance to heat in the bed)
Night cramps
Symptoms worsen: at the end of the day, during the hot
season, progestogens
No response to analgesics
Clinical signs
• Teleangiectasias < 1mm
• Reticular veins – 1-3 mm
• Varicose veins > 3 mm (accessory or truncal)
• Corona phlebectatica paraplantaris
• Edema (pitting) – increases throughout the day, can be
prevented by physical exercise, compression, or venoactive drugs
• Trophic changes:
Eczema, pigmentation, stasis dermatitis (reversible)
Lipodermatosclerosis , atrophie blanche (irreversible)
• Healed ulcer
• Active ulcer: medial malleolar or supramalleolar venous ulcer
CVI classification
Clinical ( C )
0.
1.
2.
3.
4.
No visible or palpable signs of venous disease
teleangiectasias or reticular veins
varicose veins
edema
changes in the skin and subcutaneous tissue secondary to CVI
(pigmentation, eczema, lipodermatosclerosis, atrophie blanche)
5. healed venous ulcer
6. active venous ulcer
Symptomatic/asymptomatic
Teleangiectasias
Reticular veins
Corona phlebectatica
paraplantaris
Perforating vein – blow out
Varicose veins
Edema
Ulcus venosum
Phlebological tests
• Tap sign (Schwartz’s test)
• Cough test
• Trendelenburg test
• Perthes test
• Linton test
Recidive varicosity after crossectomy
After subclavian vein trombosis
Vena cava inferior syndrome
Superficial vein thrombosis –
thrombophlebitis (STP)
Partial or complete occlusion of a superficial vein
by a thrombus.
STP is characterised by severe local inflammation.
• >90%: varicophlebitis (part of CVI)
• <10%: coagulopathy, cancer, pregnancy,
Bürger disease, Behcet disease….
Clinical presentation
• A band of swelling along the path of the vein
• Induration (thrombus)
• Erythema (perivenous reaction)
• Local rise in temperature
• Severe pain
Color Duplex ultrasound: exclusion of deep vein
involvement!
Deep vein thrombosis
Main symptoms:
• Pain (increasing with weight-bearing,
strethcing the foot at the first steps).
• Edema, which may be already present, or
develop progressively during the day
• Lividity or cyanosis
Physical findings
Examination in the dorsal decubitus position with slightly flexed
knees (20°)
• Skin colour (lividity, cyanosis), temperature, dilated collateral
veins (pretibial – Pratt veins) , calf tension, presence of edema.
• Perimeter: measurement with standard distance to the patella
• Homan‘s sign – pain on passive dorsiflexion of the foot
• Payr sign – muscle pain on vigorous palpation of the plantar
muscles with thumbs
• Meyer sign: muscle pain after pretibial pressure
• Laubry sign: pain along the affected vein during coughing
• Löwenberg test: pain of extremity distal to the inflated cuff<120
mmHg
B-mode compression sonography, Duplex US, or as „gold standard”
ascending phlebography
Compression ultrasound
Special forms
• Paget-Von Schrötter syndrome: deep vein thrombosis of
subclavian vein (effort thrombosis), recently in
thrombophylias
• Phlegmasia alba dolens: pale discolouring of the limb
secondary to cutaneous arterial vasospasm (massive
subtotally iliofemoral thrombosis)
• Phlegmasia cerulea dolens: severe cyanosis and edema
with totally obstruction of ipsylateral venous system with
pulselessness
• Cockett syndrome: iliac vein compression complicated with
iliac vein thrombosis (descending thrombosis)
•
Traveller’s DVT (economy class syndrome): after long
seated journey (at least 5 hours) within 4 weeks
Diseases of microcirculation
Related to:
•
Small vessel function (Raynaud phenomenon)
•
Capillary density, cross sectional area
(diabetes, systemic sclerosis)
•
Blood and/or plasma viscosity
(myeloproliferative diseases, MM,
cryoglobulinemia…)
Raynaud phenomenon
Painful discoloration of the fingers and/or the toes after
exposure to changes of temperature or emotional events
because of vasospasm.
Three phase (bi- and monophasic also): white
(oligemia/vascular syncope) – blue (oxigen↓/asphyxia) –
red (reactive flushing)
Prevalence≈5%, typically young woman
Diagnosis: clinically, typical signs and symptoms
To exclude the secondary forms: rheumatologic diseases,
drugs, hypothyreoidism, hematologic, neoplastic diseases,
frost bite, vibration, TOS….
Capillary microscopy and laser doppler