VASCULAR
ARTERIAL VASCULAR DISEASE!
History: Peripheral vascular disease most common in LL but also occurs in upper limb, GIT, cerebral and renal vessels.!
!
RF: smoking, hypercholesterolaemia (F/H), HTN, DM and thrombophilia!
CLINICAL FEATURES - LIMBS!
Classic symptom of PVD in lower limb = intermittent claudication; pain in muscle due to ischaemia, brought on by
exercise and relieved by rest!
- Cramping in nature!
- Most common calf (superficial femoral artery disease) or buttock (aorto-iliac disease)!
- Can vary with temperature, worsening in cold!
- More severe going uphill!
- Differential diagnosis: spinal claudication (pain at rest, relieved by leaning forwards - may improve going uphill) and
venous claudication (pain ‘bursting’ and taking longer to go at rest)!
- Sudden deterioration: urgent assessment required !
More severe disease: rest pain!
- Constant pain, typically in feet, occurs at night when in bed (due to reduced cardiac output, thus reduced BP and
peripheral vasodilation; all 3 —> decreased blood supply)!
- Relieved: hanging leg out of bed/ walking; gravity increased BF; hanging leg out of bed - cools it, decreases
metabolism and thus requires less blood flow!
- Eventually gangrene (tissue necrosis) may supervene!
!
- Males with aorto-iliac disease may complain of buttock claudication and impotence (Leriche’s syndrome)!
CLINICAL FEATURES - OTHER SYSTEMS!
History to look for symptoms of other areas of vascular system:!
- Cardiac: MI, angina?!
- GIT: Upper to central abdominal cramping, with pain 20mins after large meal = mesenteric angina!
- Renal: Renal HTN!
- Cerebrovascular!
- Carotid (anterior circulation): strokes, TIAs, transient blindness i.e. amaurosis fugax!
- Vertebral (posterior circulation): dizziness, drop attacks, bilateral blindness, diplopia, vertigo, problems with
! stance/gait, !
EXAMINATION!
Examine patient in warm room !
Inspection: !
- Colour of limb: Ischaemic: white as marble (acute ischaemia)/ varying degrees of pallor, purple/blue cyanosis or red
shiny appearance (chronic ischaemia).!
- Scars from previous vascular procedures!
- Male ischaemic leg typically hairless!
- Buerger’s Angle: angle to which leg must be raised before coming white (vascular angle)!
- Normally, leg can be raised to 90’ and toes stay pink. Severe ischaemia; reduced to 15’ (causes pallor)!
- Following elevation, limb placed in dependent position; in presence of severe ischaemia, purple/red colour as foot is
reperfused. !
- Normal limb: veins full even when patient horizontal; ischaemic foot, veins collapsed and look like pale blue gutters
in subcutaneous tissue; guttering of the veins!
- Inspect pressure areas (heel, tips of toes, ball of foot, 5th MT head) for signs of trophic changes, ulceration, gangrene !
- Inspect between toes!
Palpation!
- Skin temperature!
- Capillary refilling time: pinch nail/pulp of toe/finger for 2s and observe how long it takes blanched area to return to
pink; normal digits immediate; delay >ws indicates ischaemic digit. !
- Palpate and record all pulses (normal, weak or absent)!
Auscultation: listen along course of major arteries for bruit (neck, abdomen, groin)!
- Measure BP in both arms: exclude subclavian disease!
- Ankle Brachial Presure Index (ABPI) measured in lowe limb; gives idea of severity of peripheral vascular disease!
!
VASCULATURE 1
ARTERIAL VASCULAR DISEASE!
History: Peripheral vascular disease most common in LL but also occurs in upper limb, GIT, cerebral and renal vessels.!
!
RF: smoking, hypercholesterolaemia (F/H), HTN, DM and thrombophilia!
CLINICAL FEATURES - LIMBS!
Classic symptom of PVD in lower limb = intermittent claudication; pain in muscle due to ischaemia, brought on by
exercise and relieved by rest!
- Cramping in nature!
- Most common calf (superficial femoral artery disease) or buttock (aorto-iliac disease)!
- Can vary with temperature, worsening in cold!
- More severe going uphill!
- Differential diagnosis: spinal claudication (pain at rest, relieved by leaning forwards - may improve going uphill) and
venous claudication (pain ‘bursting’ and taking longer to go at rest)!
- Sudden deterioration: urgent assessment required !
More severe disease: rest pain!
- Constant pain, typically in feet, occurs at night when in bed (due to reduced cardiac output, thus reduced BP and
peripheral vasodilation; all 3 —> decreased blood supply)!
- Relieved: hanging leg out of bed/ walking; gravity increased BF; hanging leg out of bed - cools it, decreases
metabolism and thus requires less blood flow!
- Eventually gangrene (tissue necrosis) may supervene!
!
- Males with aorto-iliac disease may complain of buttock claudication and impotence (Leriche’s syndrome)!
CLINICAL FEATURES - OTHER SYSTEMS!
History to look for symptoms of other areas of vascular system:!
- Cardiac: MI, angina?!
- GIT: Upper to central abdominal cramping, with pain 20mins after large meal = mesenteric angina!
- Renal: Renal HTN!
- Cerebrovascular!
- Carotid (anterior circulation): strokes, TIAs, transient blindness i.e. amaurosis fugax!
- Vertebral (posterior circulation): dizziness, drop attacks, bilateral blindness, diplopia, vertigo, problems with
! stance/gait, !
EXAMINATION!
Examine patient in warm room !
Inspection: !
- Colour of limb: Ischaemic: white as marble (acute ischaemia)/ varying degrees of pallor, purple/blue cyanosis or red
shiny appearance (chronic ischaemia).!
- Scars from previous vascular procedures!
- Male ischaemic leg typically hairless!
- Buerger’s Angle: angle to which leg must be raised before coming white (vascular angle)!
- Normally, leg can be raised to 90’ and toes stay pink. Severe ischaemia; reduced to 15’ (causes pallor)!
- Following elevation, limb placed in dependent position; in presence of severe ischaemia, purple/red colour as foot is
reperfused. !
- Normal limb: veins full even when patient horizontal; ischaemic foot, veins collapsed and look like pale blue gutters
in subcutaneous tissue; guttering of the veins!
- Inspect pressure areas (heel, tips of toes, ball of foot, 5th MT head) for signs of trophic changes, ulceration, gangrene !
- Inspect between toes!
Palpation!
- Skin temperature!
- Capillary refilling time: pinch nail/pulp of toe/finger for 2s and observe how long it takes blanched area to return to
pink; normal digits immediate; delay >ws indicates ischaemic digit. !
- Palpate and record all pulses (normal, weak or absent)!
Auscultation: listen along course of major arteries for bruit (neck, abdomen, groin)!
- Measure BP in both arms: exclude subclavian disease!
- Ankle Brachial Presure Index (ABPI) measured in lowe limb; gives idea of severity of peripheral vascular disease!
!
VASCULATURE 1
