The document provides an overview of peripheral vascular diseases, detailing the structure and function of arteries and veins, and discussing arterial and venous insufficiencies. It highlights risk factors, comparisons of arterial and venous disorders, and specific conditions such as arteriosclerosis obliterans and Raynaud's phenomenon. Additionally, it covers the examination and assessment techniques for diagnosing these vascular issues.

1. Peripheral Vascular
Diseases

2. Arteries
 are thick-walled vessels that transport 02
and blood via
the aorta from the heart to the tissues
3 Layers of Arteries
1. inner layer of endothelium (intima)
2. middle layer of connective tissue, smooth muscle and elastic
fibers (media)
3.outer layer of connective tissue (adventitia)
 have smooth muscles that contracts & relaxes to respond
changes in blood volume.

3. Veins
 are thin-walled vessels that transport deoxygenated blood
from the capillaries back to the right side of the heart
3 Layers – intima, media, adventitia
 there is little smooth muscle &
connective tissue  makes
the veins more distensible 
they accumulate large volumes of blood
 Major veins, particularly in the lower
extremities, have one-way valves
---allow blood flow against gravity
 Valves allow blood to be pumped back
to the heart but prevent it from
draining back into the periphery

4. Peripheral Vascular Diseases
 charac. by a reduction in blood flow and hence 02 through the
peripheral vessels
 when the need of the tissues for 02 exceeds the supply, areas of
ischemia and necrosis will develop
Factors that can contribute to the development of peripheral
vascular disorders :
 atherosclerotic changes
 thrombus formation
 embolization
  coagulability of blood
 hypertension
 inflammatory process/infection

5. Arterial Insufficiency
 there is a deceased blood flow toward the tissues, producing
ischemia
 pulses one usually diminished or absent
 sharp, stabbing pain occurs because of the ischemia,
particularly with activity
 there is interference with nutrients and 02
arriving to the
tissues, leading to ischemic ulcers and changes in the skin.
Venous Insufficiency
 there is deceased return of blood from the tissues to the heart
 leads to venous congestion and stasis of blood
 pulses are present
 lead to edema, skin changes and stasis ulcers

6. Comparison of characteristics of Arterial & Venous Disorders
Arterial Disease Venous Disease
Skin cool or cold, hairless,
dry, shiny, pallor on
elevation, rubor on
dangling
warm, though,
thickened,
mottled, pigmented
areas
Pain sharp, stabbing,
worsens w/ activity and
walking, lowering feet
may relieve pain
aching, cramping,
activity and walking
sometimes help,
elevating the feet
relieves pain
Ulcers severely painful, pale,
gray base, found on
heel, toes, dorsum of
foot
moderately painful, pink
base, found on medial
aspect of the ankle
Pulse often absent or
diminished
usually present
Edema infrequent frequent, esp. at the
end of the day and in
areas of ulceration

7. Risk Factors
1. Age (elderly) – blood vessels become less elastic, become
thin walled and calcified –  PVR –  BP
2. Sex (male)
3. Cigarette smoking
– nicotine causes vasoconstriction and spasm of the arteries – 
circulation to the extremities
– C02 inhaled in cigarette smoke reduces 02 transport to tissues
4. Hypertension – cause elastic tissues to be replaced by fibrous
collagen tissue  arterial wall become less distensible 
resistance to blood flow   BP
5. Hyperlipedimia – atherosclerotic plaque
6. Obesity – places added burden on the heart & blood vessels
– excess fat contribute to  venous congestion

8. 7. Lack of physical activity
– Physical activity – promotes muscle contraction 
 venous return to the heart
– aids in development of collateral circulation
8. Emotional stress – stimulates sympathetic N.S. - peripheral
vasoconstriction   BP
9. Diabetes mellitus – changes in glucose & fat metabolism
promote the atherosclerotic process
10. Family history of arthrosclerosis
Risk Factors (cont.)

9. Arteriosclerosis Obliterans
 is a disorder in which there is an arteriosclerotic narrowing
or obstruction of the inner & middle layer of the artery
 most common cause of arterial obstructive disease in the
extremities
 the lower extremities are involved more than upper
extremities
 common site of disease – femoral artery, iliac arteries,
popliteal arteries
 in a diabetic, the disease becomes more progressive, affects
the smaller arteries and often involves vessels below the
knee

10. Thromboangitis Obliterans ( Buerger’s
Disease)
 characterized by acute inflammatory lesions and occlusive
thrombosis of the arteries & veins
 has a very strong assoc. with cigarette smoking
 commonly occurs in male – bet. 20-40 y.o
 may involve the arteries of the upper extremities (wrists)
 usually affect the lower leg. toes, feet

11. Thromboangitis Obliterans

12. Raynaud’s phenomenon
 refers to intermittent episodes during which small arteries or
arterioles of L and R arm constrict (spasm) causing changes in skin
color and temperature
 generally unilateral and may affect only 1 or 2 fingers
 may occur after trauma, neurogenic lesions, occlusive arterial
disease, connective tissues disease
 charac. by reduction of blood flow to the fingers manifested by
cutaneous vessel constriction and resulting in blanching (pallor)
Raynauds’ Disease
 unknown etiology, may be due to immunologic abnormalities
 common in women 20-40 y.o
 maybe stimulated by emotional stress, hypersensitivity to cold,
alteration in sympathetic innervation

13. Raynauds’ Disease

14. Aneurysm
 is a localized or diffuse enlargement of an artery at some point
along its course
 can occur when the vessel becomes weakened from trauma,
congenital vascular disease, infection or atherosclerosis
Pathophysiology
 enlargement of a segment of an artery  the tunica media
(middle layer composed of smooth muscle & elastic tissue) is
damaged  progressive dilation, degeneration  risk of rupture
 * most common site is the aorta
 may develop in any blood vessel

15. Arterial Embolism
 blood clots floating in the circulating arterial blood.
 the embolus is frequently a fragment of arterioscherotic plaque
loosened from the aorta
 emboli will tend to lodge in femoral or popliteal arteries, blood flow
is impaired and ischemia develops
Clinical manifestations:
 S/Sx depends on the size of the embolus, the presence of collateral
circulation and if it is close to a major organ
 abrupt onset of severe pain from the sudden cessation of
circulation
 muscular weakness and burning, aching pain occur
 distal pulses are absent and extremity becomes cold, numb and pale
 symptoms of shock may develop if the embolus blocks a large artery

16.  Venous disease

17. Venous Anatomy
 Superficial, deep, and perforating /
communicating veins
 One-way valves prevent pooling of blood in
legs
 Muscle contractions help facilitate blood
return to heart
 Flows superficial deep veins

18. Chronic Venous Disease /
Insufficiency
 Chronic Venous Disease =
arise from venous valve
incompetence resulting in
retrograde blood venous
blood flow, lasting for an
abnormal duration and with
associated signs /
symptoms
 Chronic Venous
Insufficiency = represents
more advanced state of
above, including edema,
skin changes, and
ulcerations

19. Clinical Signs/Sx of Venous
Disease
Symptoms Signs
 Limb discomfort (tiredness,
heaviness)
 LE pain (generalized
achiness or localized) or
swelling
– Worse w/ standing
– Improves w/ elevation or
walking
 Paresthesias (tingling,
burning)
 Tightness in legs
 Skin irritation/itching or
discoloration / redness
 Bleeding
 Muscle cramps
 Generalized fatigue
 Evidence of dilated veins,
including telangiectasias,
reticular veins, and
varicose veins
 Leg oedema
– Can be unilateral in early
stages
– Often localized only to
legs/feet
 Skin changes
 Ulcers
 Haemorrhaging
 Superficial
thrombophlebitis

20. Varicose Veins
 Dilated,
elongated,
tortuous
subcutaneous veins
≥3 mm in diameter
 Incompetent
venous valves

21. Varicose Veins
 Prevalence
– Generally F > M, 10-30% of general pop’n,
increases w/ age
 Risk Factors:
– Age, family hx, female, obesity, sedentary
lifestyle, prolonged standing, smoking,
trauma to LE, prior venous thrombus (deep
or superficial), pregnancy / high estrogen
states, lax ligaments (flat feet, hernias),
AV fistulas

22. Varicose Veins
Primary Secondary
 Varicose veins caused
by venous insufficiency
due to venous wall
weakness
 Example: due to age or
pregnancy
 Varicose veins caused
by venous insufficiency
due to venous damage
from other etiology
 Example: deep vein
thrombosis or leg
injury

23. Common Sites Of Venous, Arterial And
Neuropathic Ulceration
Image courtesy of Mr. Nikolas Kosanovic M.D, General Surgery, Rural Clinical School, University of Melbourne

24.  Arterial symptoms produced by exercise
and relieved by resting even standing
 Venous symptoms worsened by standing
and improved by exercise and leg elevation
24
Similarities and
Differences

25.  In the arterial system, treatment is
aimed at opening and restoring blood flow
 In the venous system, treatment is aimed
at obstructing and eliminating
dysfunctional blood vessels
25
Treatment Differences

26. Peripheral Vascular
system examination

27. Assessment
 Anatomy
 History / clinical presentation
 Aetiology or Causes / Risk Factors
 Examination – special tests

28. Peripheral vascular tree -
Anatomy

29. History / Clinical
Presentation
 Full History
 Claudication – Site?
 Rest Pain !!!!!
 Ulceration? Chronic Wounds / poor
healing
 Bleeding / itching / skin changes /
swelling / cellulitis
 Skin / sensation changes

30. RISK FACTORS
SMOKING! (even a few
cigarettes/day)
Diabetes (esp poorly controlled)
Dyslipidaemia
Hypertension
Family Hx (CVS/PVD/dyslipidaemias)
Age
Ethnicity
Obesity
(Vasculitides – active inflammation, hyperhomocysteinaemias)

31. Arterial System

32. Inspection
 REMEMBER inspection can give clues to causes
also
 General inspection including hands and face
Look closer at legs –
 Skin changes / Hair changes / Colour changes
 Ulcers / Wounds
 Scars

33. Palpation
 SUPINE – expose abdomen and legs
Feel –
Start distally – temperature / scars (compare L Vs R)
Tibial shaft for oedema (pitting or non) – note upper
level (severity)
scrotum /abdominal wall maybe involved
unilateral disease – DVT or compression of large veins
by node/tumour
Non pitting – lymphatic diseases / hypothyroidism

34. Palpation (and auscultation)
 Feel PULSES (and auscultate each for bruits)
DP / Post Tib / Pop / Femoral
Abdo– MUST complete exam by assessing Abdominal
Aorta, bruits and assess for sacral oedema…
Full abdo exam: ascites (severe CF), tender liver-
capsule/veins, splenomegaly, full CVS exam

35. PULSES POPLITEAL
Relax the fossa
Use both hands to feel behind fat pad – almost like
bimanual palp

36. PULSES ANT tibial /
D.PEDIS / POST TIB

39. Buerger’s test
“Any hip pain if I lift your leg up straight…?”
Angles ?
<20 severe

41. SPECIAL TESTS - ABPI
 Ratio BP lower limb to BP Upper limb
 Indicates - Severity of PVD
 BP ankle – systolic DP or post Tib
 BP arm – highest of left or right Brachial
systolic
 ABPI = BP ankle / BP arm

43. ABPI – interpretation
 >1.2 – suggests calcification of vessels (age)
 1.2-1.0 – Normal Range
 0.9 – 1.0 – Acceptable (borderline abnormal)
No referral needed
 0.8-0.9 – mild disease (manage risk factors)
 0.5 – 0.8 - moderate disease (routine referral)
(mixed ulcers – bandage with care)
 <0.5 – severe disease (URGENT referral) (no
compression bandaging!!!)

44. Remember – acute ischaemia
 Painful
 Pale
 Pulseless
 ‘Perishingly’ cold
 Paraesthetic
 ?paralysed

45. Venous System

46. Venous system
 Position – this time STANDING
 Remainder the same – Inspect /
Palpate /
 Special tests

47. Examination
Inspect WHOLE leg – long saph / short saph regions
If unilateral swelling –measure circumference
(Use bony landmark as point of reference)
Palpate – hard veins = Thrombosis, Tenderness =
phlebitis
Cough Impulse test: saphenofemoral valve (thrill –
incompetence)
Trendelenburg – incompetence of saphenofemoral valve
(POSITIVE)
If veins still fill up – incompetence lower - Perthes
Test

48. Varicose veins

49. Trendelenberg tests

51. Special tests - Trendelenburg

52. Perthes test
Same as Trendelenburg – but on standing release small vol
blood into veins
Ask patient to pump calves (stand up and down on tip toes)
Veins become less tense if perforators have competent valves
More tense if incompetence
Note Pt will feel pain when veins fill up!!!!
So BE VIGILANT and ready to STOP IMMEDIATELY

56.  Do systematically

57. Thank you!