PVD | Batch 2022

Peripheral Vascul Diseases

CONTENTS
Arterial system
Contents Artery: Carries oxygenated blood (exception for the pulmonary
vein that also carries oxygenated blood) away from the heart

Peripheral Vascular System

Arterial System
Are muscular, elastic, and tubular extension of the heart

Venous System Proximal Arteries: characteristics of these are elastic and have
Lymphatic System more increased pressure

Arterial Diseases
Distal Arteries: characteristics of these are muscular and have
more decreased pressure

Artery ➡ Arterioles ➡ Capillaries (are thin in nature and is the

Peripheral vascular system “exchange vessel”)

Arterioles — smallest arteries

Fx: Mainly for transportation of O2, proteins, and nutrients

- transports blood from artery to capillaries

Consists of 3 Systems:
- Thicker than veins

Arterial System
- Strong enough to hold HIGH blood pressure

Venous System
- Movement of blood is dependent on heart function

Lymphatic System
- Can change diameter when sympathetic division of
Blood Vessel: is the framework of the PVS; hollow tubes that ANS is activated (vasodilation/vasoconstriction)

conducts blood thru the tissues of the body

- NO VALVES

Layers of the Blood Vessel:

1) TUNICA INTIMA
Aka “Tunica Interna”

Innermost layer of the blood vessel

Nutrients comes from the blood ow itself

4 Layers of the Tunica Intima:

Basement Membrane
Internal Elastic Membrane — layer b/n intima
and media
Types:

Connective Tissue
1. Elastic Arteries

Endothelium: Only layer present in all blood - largest arteries

vessels

- First to receive blood coming from the heart

- Strong to hold high pressure of blood

2) TUNICA MEDIA
- Vessels proximal to heart = High Pressure

Middle layer of the blood vessel

2. Muscular Arteries

Composed of a smooth mm (basta smooth mm,

kaya nya mag contract)

- Medium-sized and small arteries

Artery: where we can nd the bulk of the tunica

- Small muscular arteries — responsible for the vasoconstriction
media
& vasodilation

- Vessels that are distal from the heart = Low pressure

3) TUNICA ADVENTITIA 3. A

Aka “Tunica Externa”

Outermost layer
Venous system
Composed of elastic and collagenous ber

Veins: Carries deoxygenated blood towards the heart

Veins: where the bulk of the tunica adventitia is

Aka “Capacitance Vessel”

found
Possesses valves

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 PVD | Batch 2022

Carries 60% to 64% blood volume

3 types of veins
Collects blood from capillaries

Nutrients exchange
3T e o v s
Medium Veins — collects and transports blood from small
veins to large veins
Superficial veins Loc: Underneath the skin

Large Veins — collects and transports blood rom medium veins 2 Great Super cial Veins in the LE:

back to the heart

Portal Veins — veins that carry blood to other organs except Greater Saphenous Vein
the heart (e.g., Hepatic portal vein)
Runs on the medial aspect of the leg and
Valves — veins that have a diameter of >2 cm
thigh to join the femoral vein

- prevent back ow of blood

- Uni-directional ow to the heart

Lesser Saphenous Vein

- 3-layered; does not need muscular or elastic Run behind the lateral malleolus to the
because of low blood pressure
posterior leg to join the popliteal vein
- Thinner than arteries, might collapse/break under
stress
Perforating vein Aka “Communicating V”

- Any movement of the body that pulls the veins, Connects the super cial vein to the deep vein
assists the blood to return to the heart (skeletal
deep vein Large veins that already follows the structure of
muscle contraction); e.g., ambulation

an artery (DeLisa)

Types of Vessels:

Pulmonary Veins — carries oxygenated blood from lungs to heart

Lymphatic system
Systemic Veins — carries deoxygenated blood from tissues and
Protects the body from infections and other diseases via the
other organs to heart

immune response

Deep Veins — located along muscles and bones

Facilitates movement of uid back and forth from bloodstream to
Perforating/Communicating/Connecting Veins — connects interstitium (remove excess uid, blood wastes)

super cial to deep veins

Not Located in: CNS and Cornea of eye

Super cial Veins — found at the surface of the skin

Lymph uid is rst absorbed in: Capillary level to Small vessels

2 Great Veins:
called Pre-Collectors to Larger vessels called Collectors

1. Great Saphenous Vein

Contains lymph vessels/ lymphatics, lymph uid, lymph tissue and
2. Lesser Saphenous Vein
organs (spleen, lymph nodes, tonsils, thymus, thoracic duct)

Thinner than veins, might collapse under stress

Capillaries
Under normal condition, lymph ow is not directly related to gravity

- interface/connects arterial system to venous system

Under abnormal condition, lymph ow is directly related to gravity
- Exchange vessel to blood cells, gases, nutrients uid
—> pooling of uid —> edema
- Thinnest blood vessel, might collapse easily under stress
Lymphatics: Carries lymph uid back to the bloodstream

- Blood ows very slowly There is (-) lymphatic uid in the CNS and cornea

Lymph Nodes: Abundant in:

Cervical Area

Axillary Area

Inguinal Area

(+) macrophages present in the lymph nodes — w/c lters

the uid from foreign invaders

Assessment/examination

History Taking
Pain

DM

Hypertension

Hyperlipidemia

Smoking hx

Surgery

Ulcers

Exercise

Diet and Alcohol Intake

Prolonged bed rest/ ight

Claudication

Hx of edema

Occupation

Inspection
Skin color

Hair distribution

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Nails (e.g., digital clubbing)

AtheroSCLEROSIS OBLITERANS (ASO)
Atrophy

Wound/Ulcers

Edema

Gait abnormalities

Palpation
Monitor Distal Pulse

There is in ammation w/ (+) occlusion of the artery a ecting

medium to large arteries (common in the LE)

Goodmna & Fuller: Arteriosclerosis in which proliferation of the

intima has caused complete obliteration of the lumen of the artery

Aka: Arteriosclerosis Obliterans, Atherosclerotic Occlusive Disease,

Chronic Occlusive Arterial Disease, Obliterative Arteriosclerosis,
and PAD

MC arterial occlusive disease

Is a progressive disease that causes ischemic ulcers of the legs and
feet and is most often seen in older clients w/ DM

P i r v u d a

Arterial Diseases Etiologic and Risk Factors

Atherosclerosis Obliterans (ASO)
PAD is more prevalent in women

Thromboangitis Obliterans (TAO)

Individuals w/ PAD are more likely to have CHD and
cerebrovascular disease than those w/out PAD

Raynaud’s Phenomenon

Venous Diseases
Risk Factors:
Varicose Veins

Atherosclerosis

Super cial Vein Thrombosis (DVT)

Cigarette smoking

Deep Vein Thrombosis (DVT)

DM or impaired glucose tolerance

Chronic Venous Insu ciency (CVI)

Male > Female

Lymphatic Diseases
Hypertension

Lymphadenopathy

Low levels of HDL cholesterol

Lymphedema
High levels of triglycerides

Apolipoprotein B

Lp(a)

Homocysteine

Fibrinogen

Blood viscosity

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Pathogenesis Medical Management

Arterial narrowing or obstruction that occurs as a result of the Client hx

atherosclerotic process reduces blood ow to to the limbs during Clinical examination

exercise or at rest
ABI

Muscular reactivity
Segmental Limb pressures

Prostacyclin and Nitric Oxide usually activate vascular Pulse Volume Recordings

relaxation

Duplex Ultrasonography

Arteriography w/ contrast or w/ MRI

Early Warning Signs:

(+) Intermittent Claudication

Drugs:

Antiplatelet:

Clinical Manifestations Antitrhombin:

Goodman & Fuller:

Antiplatelet:

Claudication symptoms appear when the diameter of the vessel Statins:

narrow by 50%
Aspirin
Elevated foot develops increased pallor

Venous lling delayed following foot elevation

Dependent rubor: Redness of distal limb

Surgical Intervention
- Is indicated if blood ow is compromised enough to produce
Gangrene: Death of tissue
symptoms of ischemic pain at rest

Acute Ischemia:

Pain

Bypass Graft

Pallor

Angioplastic Treatment

Paresthesia

Endovascular and Open Surgical Tx: Recomended for limb salvage

Paralysis
in patients w/ critical limb ischemia

Pulselessness

Silent Ischemia: Arteries become. Signi cantly blocked w/out

symptoms developing
Prevention and Tx
Sense of weakness or tiredness
Risk factor reduction and lifestyle measures

The distance a person can walk before the onset of pain indicates Smoking cessation

the degree of circulatory inadequacy (e.g., 2 blocks of more is mild; Dietary management to decrease cholesterol and dat

1 block is moderate; 0.5 block or less is severe)

Pain control

Occlusive disease of the femoral & popliteal arteriesL Occurs at Daily physical training and exercise therapy — to improve
the point at which the super cial femoral artery passes thru the collateralization and function

adductor magnus tendon into the popliteal space

marked by intermittent claudication of the calf and foot that

may radiate to the ipsilateral popliteal region and lower
Thromboangitis obliterans (TAO)
thigh

Occlusive disease of the tibial & common peroneal arteries:

Arterial Ulcers: May develop as a result of ischemia,

located over bony prominence on the toes or feet (e.g.,
metatarsalsal heads, heels, lateral malleoli)

Skin is shiny and atrophic, and ssures and cracks are

common

Pain at rest indicates severe involvement, w/c may mimic DVT, but
relief from the occlusive disease can sometimes be obtained by
dangling the uncovered leg over the edge of the bed. — This
dependent position would increase symptoms of DVT, w/c is
treated by leg elevation

Late Stage of the Dx:

(+) Gangrene: black tissue can be seen

Patient affectations

Non- DM Patient Most common a ected arteries:

Abdominal Aorta

Common Iliac Artery

Femoral Artery

DM Patients Most common a ected arteries:

In ammation of the arteries w/ (+) occlusion in the small a.

Femoral A.

Aka “Buergers Disease”, “Disease of a young make smoker”

Tibial A.
UE > LE

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Begins to from the Distal segment to Proximal segment —

Ascending pattern

Raynaud’s phenomenon

Superficial vein thrombosis (svt)

Abnormal vasoconstriction re ex a ecting the small a.

Precipitating/Aggravating Factors:

Cold
Aka “Super cial Vein Thrombophlebitis”

Emotional Stress
In ammation w/ (+) clot formation a ecting super cial veins
Cyclic Color Pattern: (“French Flag Sign”)
(saphenous vein)

Pallor (Pale):
Varcosities: Most serious complication

Cyanosis (Blue):

Rubor (Red):
Signs & Symptoms
Pain along the course of the saphenous vein

V o d a
UE VT
Varicose veins
(+) Dull pain and local tenderness in the region of the involved vein

Distention, swollen super cial veins

Super cial induration ( rm or hard cord)

A ected: (+) valves; ⬆ pressure in the LE d/t:

(+) Rubor

prolonged standing
Iatrogenic SCT: Secondary to prolonged IV catheter use

Obesity

Pregnancy

Crossed-legs

Signs & symptoms

Aching

Heavy leg

Appearance of spider vein

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Deep vein thrombosis (DVT) Abdominal, thoracic, pelvic, hip, or knee surgical
procedures

Neurologic or other conditions leading to paresis or

paralysis

Prolonged immobilization

Cancer

CHF

Pathogenesis
Any trauma to the endothelium of the vein wall exposes
subendothelial tissues to platelets and clotting factors in the venous
blood, initiating thrombosis.

Platelets adhering to the vein wall attract the deposition of brin,

leukocytes, and erythrocytes, forming a thrombus that may remain
attached to the vessel wall.

Clinical Manifestations
In the early stages, 1/2 of the people w/ DVT are asymptomatic
for any signs or symptoms in the e ected extremity

LE (> 90%) > UE

PE: may be the 1st clinical manifestation of deep thrombosis

Lower Vein thrombosis

Client may report a dull ache, a tight feeling, or pain in the calf,
often misdiagnosed as some other cause of leg pain

DVT is proximal, above the trifurcation of the popliteal vein (80% of

DVT cases)

In ammation w/ (+) clot formation a ecting the deep vein

(+) Leg or calf swelling

Virchow’s Triad:
Pain or tenderness

Hypercoagubility Dilation of super cial veins

Intimal wall damage (+) Pitting edema

Venous stasis (+) warmed leg on a ected side

(+) Homan’s Test:

(+) cyanotic skin (if venous obstruction is severe)

1) Supine

2) Squeeze the calf

Upper vein thrombosis

3) Passively dorsi ex the foot

4) (+) Pain
10% of all DVT cases

Anti-coagulant Medications:
Subclavian vein, axillary vein or both w/ occurrences less often
Heparin: IV route
a ecting the internal jugular and brachial vein

Warfarin: Oral route

Secondary UE DVT: Usually associated w/ infection, a systemic
Immobilize patient while administering these medications to illness (e.g., malignancy), the use of an indwelling peripherally
prevent Pulmonary Embolism.
inserted canal catheter (PICC) lines or central venous catheters
(CVCs), malignancy, or less often, hemodialysis

Early Mobilization: Best prevention for DVT

Other Symptoms:

Numbness

Goodman & Fuller:

Heaviness

Vein thrombosis: is a partial occlusion (mural thrombus) or

complete occlusion (occlusive thrombus) of a vein by a thrombus Redness or warmth of the arm

(clot) w/ secondary in ammatory reaction in the wall of the vein Dilated veins

(thrombophlebitis).
Low-grade fever

Venous Thrombus: Is an intravascular collection of brin network, Chills and malaise

platelets, erythrocytes, and leukocytes, the end result of the Bruising or discoloration of the area of proximal to the
activation of the clotting cascade w/ the potential to produce thrombosis

signi cant morbidity and mortality.

Swelling

Venous Thromboembolism (VTE): DVT + PE

Decreased neck and shoulder motion

DVT is classi ed as distal if it is below the knee and proximal if it is

Severe thrombosis can cause superior vena cava syndrome

located in the popliteal vein or above.

Edema of the face and arm

Femoral or Iliac veins: where DVT most commonly occurs

Vertigo and dyspnea

Incidence, Etiology, and Risk Factors

VTE is MC reason for hospital readmission and death after total hip
Medical management
and total knee arthroplasty
Early mobilization for low-risk individuals

Highest incidence of DVT occurs with:

Prophylactic use of anticoagulants for moderate to high-risk
individuals

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Acute DVT: Mobilization and compression stockings reduce the

P m &s n yl h m
risk of posttrhombotic syndrome

Routine use of knee elastic stockings in all post-operative clients

Secondary lymphedema Lymphedema Secondary to:

Pneumatic pressure devices with on/o cycles applied for the rst Surgery

few hours after major surgery to mimic calf pump

Malignancy

Ankle pumping

Infection

E ective in increasing average peak venous velocity ( ow)

Tumor
from the lower extremity with DF of the ankle by >200% —
reducing DVT while immobilized

Diagnosis

Chronic venous insufficiency (cvi)

⬆ pressure in the deep veins

Most common form of venous diseases

S g o c

Stage 1 Edema

(+) Pigmentation

stage 2 Edema

(+) Pigmentation

(+) Varicosities

(+) Dermatitis/ Skin Eczema

stage 3 (+) Ulceration — MC manifestation of CVI

Arterial insufficiency v.s. Venous
insufficiency

L p i d a A V

Lymphadenopathy Pulse ⬇ /absent pulse Normal pulse

Enlargement of the lymph nodes w/ or w/out tenderness

Temperature Cold Warm/normal
Disease of the lymph nodes

Ulceration Lateral Malleolus

Medial malleolus

Anterior TIbia Medial aspect of the leg/

thigh

Pain Painful
Painless

(Pale on elevation)
(Relief of pain upon leg
Dusky red on elevation)
dependency

Others (+) Gangrene

(+) Edema

(+) Rest pain (+) Brown spots/

pigmentation

(+) varicosities

(+) Dermatitis

Lymphedema
Excessive accumulation of uids in the tissue
S c t s
P m &s n yl h m

Primary Lymphedema: <25% genetic risk; Brisk Walking: Best exercises

Milroy’s disease Edema after birth

Lymphedema praecox Edema present <35 y.o.

Lymphedema tardy Edema present >35y.o.

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Claudication Time Given to patients w/ arterial insu ciency Ankle Brachial For arterial insu ciency

Use of treadmill
Index (ABI) Use of doppler ultrasound
Measure the time and distance where the pain
is felt
FOR UE:
Exercise may be given to the point of pain, not DUS: Brachial Pulse & Radial Pulse

beyond the pain

Cu : brachium

For LE:
DUS: Dorsalis Pedis Pulse & Posterior Tibial
Pulse

Cu : Calk area

Stemmer’s Test For lymphedema

Pinch o skin at the base of 2nd toe

(+) Lift of skin = (-) edema and stemmer’s test

(-) Lift of skin = (+) edema and stemmer’s test

>1.20: Falsely elevated (common in DM patients)

1.19 - 0.95: Normal

0.94 - 0.75: Mild arterial disease; (+) intermittent

claudication

0.74 - 0.50: Moderate arterial disease; (+) rest pain

<0.50: Severe arterial de ciency; for amputation

To solve:

Divide diastolic blood pressure to systolic blood

pressure

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