Examination of vessels

Examination of
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…)
Underdiagnosed and undertreated
Not modifiable: age, gender (male), family
Intermittent claudication (claudere – to limp) – lower
extremity (dysbasia intermittens)
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
Palpation of pulses:
Upper extremity: brachial, ulnar and radial
Lower extremity: femoral, popliteal, posterior
tibial, doralis pedis
Pulse abnormality: proximal occlusion/stenosis
Auscultation of accessible arteries for bruits
(accelerated blood flow velocity and flow
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
Screening instrument
• Segmental blood pressure measurements
• Qualitative sound alteration
Triphasic→ monophasic Doppler sound (arterial
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
• 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
blood pressure
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
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)
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,
Physical findings – depends on
the location: hypertension,
(asymmetric blood pressure),
pulse deficit, aortic
regurgitation, acute coronary
syndrome, mesenteric
ishemia, limb ischemia
Special arterial syndromes
Thrombangiitis obliterans (TAO)
Thrombangiitis obliterans – Winiwater-Bürger
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
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,
Venous diseases
Venous diseases
Chronic venous disorders:
Chronic venous disease – chronic venous insufficiency
Particular venous disorders
Venous aneurysms
Venous tumors
Pelvic congestion syndrome
Compression syndromes (v. cava superior and inferior syndrome, left iliac compression
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
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
Transfascial (perforating
veins): connection.
Insufficiency of these parts
leads venous hypertension,
edema and dysfunction of
Pathomechanism of CVD
Venous hypertension (>30/90/ Hgmm):
Superficial veins
Deep veins
Valve insufficiency≈90%
Perforating veins
Deep vein obstruction≈10%
Insufficiency of epifascial veins
Insufficiency of deep veins
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:
Gender (female)
Pregnancy/OAC, hormon
Type of work (vertical)
Tobacco use
Sedentary lifestyle
Deep vein thrombosis
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 )
No visible or palpable signs of venous disease
teleangiectasias or reticular veins
varicose veins
changes in the skin and subcutaneous tissue secondary to CVI
(pigmentation, eczema, lipodermatosclerosis, atrophie blanche)
5. healed venous ulcer
6. active venous ulcer
Reticular veins
Corona phlebectatica
Perforating vein – blow out
Varicose veins
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
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
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
• 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
• 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,
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