1. Examination of
vascular disorder
A.P DR. MIN OO
(SURGERY)

2. Outline
2
 Introduction
 Learning objectives
 Peripheral occlusive arterial disease
 Venous disorder
 Applied anotomy & pathophysiology for arterial supply
& venous drainage of lower limb
 Video show for examination peripheral vascular disease
 Video show for examination of varicose vein
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3. Introduction
3
Arterial
 Peripheral occlusive arterial disease (POAD) is
predominantly affects the lower limbs.
 It may be acute or chronic
 Acute limb ischaemia is surgical emergency
 Chronic limb ischaemia may be complication of
diabetes or Burger`s disease
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4. Introduction
4
Venous
 Congenital anormalies
( Klippel Trenaunay syndrome)
 Inflammation ( thrombophlenitis)
 Thrombosis & its sequalae
 Acute thrombosis DVT( deep vein thrombosis)
 Varicose vein (V.V)
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5. Learning objectives
5
 To apply the basic science knowledge of anatomy &
pathophysiology in clinical examination
 To know the clinical features of Peripheral Occlusive
Arterial Disease(POAD) (acute & chronic ischaemic
limbs) and deep vein thrombosis (DVT) & varicose
veins(V.V)
 To able to examine and apprehend the physical signs
of the patient with POAD & V.V
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6. Peripheral occlusive arterial disease (POAD)
6
 Peripheral occlusive arterial disease (POAD) is
caused by
a) atherosclerosis, thrombosis , embolism,
b) vascular trauma,
c) complications of DM
d) Burger`s disease
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7. Peripheral occlusive arterial disease (POAD)
7
 Male> female
 Risk factors are ???
Cigarette smoking
Hypertension
Hyperlipidaemia
Diabetes mellitus
 Critical ischaemia when reduction of blood flow leads to
tissue viability can not sustained.
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8. Clinical features (POAD)
8
Chronic ischaemia ???
 Intermittent claudication in - calf( femoral),
- thigh (iliac), buttock ( aortic )
 Cold peripheries
 Prolonged capillary refill time
 Rest pain, especially at night
 Venous guttering
 Absent pulses
 Arterial ulcer
 Gangrene over pressure point
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9. Clinical features (POAD)
9
Acute ischaemia ??? ( 6 P & 2 M)
 Pain
 pallor
 Pulselessness
 Paraesthesia
 Paralysis
 Perishing cold
 Pistol-shot onset
 Mottling ( late sign)
 Muscle rigidity ( late sign)
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10. Deep vein thrombosis(DVT)
10
Epidemiology
 DVT is very common in surgical patients
 Affect 10-30 % of all general surgical patients over 40 years
who undergo a major operation
 PE is a common cause of sudden death in hospital patients
( 0.5-3 % of patients die from P.E)
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11. Deep vein thrombosis(DVT)
11
 Ilio femoral thrombous Migratrion of thrombus to the
lungs ( P.E) pulmonary embolism  fatal
 Destruction of valves in deep venous system  chronic
venous hypertension  post-phlebitis limb(PPL)
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12. Deep vein thrombosis(DVT)
12
Aetiology
Risk factors ???
 Increasing age >40 years
 Immobilization
 Obesity
 Malignancy
 Inflammatory bowel disease
 Anti coagulant protein deficiency (e.g. antithrombin III, protein C,
protein S)
 Trauma
 Sepsis
 Heart disease
 Pregnancy/ oestrogen
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13. Deep vein thrombosis(DVT)
13
Virchow`s triad ???
 Stasis
 Endothelial injury
 hypercoagulopathy
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14. Deep vein thrombosis(DVT)
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Pathology
 Aggregation of platelets in the valve pokets
 Activation of clotting cascade producing fibrin
 Fibrin production overwhelms the natural anti-coagulating
(fibrinolytic ) system
 Natural H/O  resolve / PE/ CVH(PPL)
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15. Deep vein thrombosis(DVT)
15
Clinical features
DVT
 Asymptomatic
 Calf tenderness
 Ankle edema
 Mild pyrexia
P.E ???
 Substernal chest pain
 Dyspnoea
 Circulatory arrest
 Pleuritic chest pain
 haemoptysis
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16. Deep vein thrombosis(DVT)
16
Clinical features
PPL
 H/O of DVT
 Aching limb
 Leg swelling
 Venous eczema
 Venous ulceration
 Inverted bottle-shape leg
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17. Arterial Anatomy
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18. Arterial Anatomy
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19. Arterial Anatomy
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20. Venous anatomy
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 Superficial
 Deep
 perforator
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21. 21
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22. Saphenofemoral
junction
22
Great saphenous vein
dorsal venous arch
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23. 23
Popliteal
vein
Saphenopoplite
al junction
Short saphenous vein
dorsal venous arch
( lateral side of foot)
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24. Perforating vein
24
 Blood from superficial veins enters the deep veins at
the saphenopopliteal and saphenofemoral junctions
 In the calf and thigh there are a number of valved
perforating veins
 It penetrates the deep fascia at an obligue angle 
compressed when muscles contract during walking
(Calf m/s pump )
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25. Perforating vein
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 The most important are the direct perforating
veins of the medial calf and the mid-thigh
1. mid thigh perforators ( Dodd )  Hunter’s
canal ( adductor hiatus )
2. Lower leg perforators ( Cockett )  I, II & III
I  5cm
II  10cm above medial malleous
III  15cm
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26. 26
Dodd’s perforator
Boyd’s perforator
III (15 cm)
II (10 cm) Cockett’s perforators
I (5 cm)
May or Kuster
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27. Deep veins
27
 The deep veins of the lower limb arise from 3 pairs of venae
commitantes  anterior and posterior tibial and peroneal
veins
 ant tibial vein  from dorsal venous arch
 post and peroneal vein  from plantar arch
 These veins intercommunicate and join in the popliteal fossa
 form the popliteal vein  passes up through the adductor
canal becomes the femoral vein in the thigh
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28. 28
 Deep (profunda) femoral veins drain from thigh
muscles  terminate in femoral vein
 Femoral vein passes deep to the inguinal lig. 
external iliac vein common iliac vein  IVC
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29. Deep femoral vein
29
Femoral vein
Popliteal
vein
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30. 30
Video show for PVD & V.V
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31. THANK YOU FOR YOUR
ATTENTION
31
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