Ppt12

Chapter 12
The Peripheral Vascular System
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy and Physiology - Arteries
• Arteries must respond to the variations that cardiac systole and diastole
generate in cardiac output
• Anatomy and size vary according to their distance from the heart
• Arterial pulses are palpable when artery lies close to body surface
– Arms
o Brachial: at bend of elbow just medial to biceps tendon
o Radial: lateral flexor surface at wrist
o Ulnar: medial flexor surface (overlying tissues may obscure)
– Legs
o Femoral: below inguinal ligament
o Popliteal: passes medially behind the femur; palpable behind knee
o Dorsalis pedis: dorsum of foot; lateral to extensor tendon of big
toe
o Posterior tibial: behind medial malleolus of ankle

Anatomy and Physiology - Veins
• Veins are thin-walled and highly distensible
• Deep veins
– Carry ~90% venous return from lower extremities and are
well-supported by surrounding tissues
• Superficial veins
– Subcutaneous with poor tissue support
o Include great saphenous and small saphenous veins
o Anastomotic veins connect two saphenous veins
o Perforating veins connect superficial (saphenous) system
with deep system
• Deep, superficial, and perforating veins have one-way valves
– Propel blood toward heart, preventing pooling, venous
stasis, and backward flow

Anatomy and Physiology –
Lymphatic System
• Extensive vascular network that drains lymph from
body tissues and returns it to venous circulation
• Lymph nodes
– Round, oval, or bean-shaped structures
– Vary in size according to location
• Important role in body’s immune system
– Cells in lymph nodes engulf cellular debris/bacteria
and produce antibodies
• Only superficial lymph nodes accessible to physical
examination

Health History
• Common or concerning symptoms
– Pain in arms/legs
– Intermittent claudication
– Cold, numbness, pallor in legs, hair loss
– Swelling in calves, legs, or feet
– Color change in fingertips or toes in cold weather
– Swelling with redness or tenderness

Health History (cont.)
• Peripheral arterial disease (PAD)
– Intermittent claudication
o Ask patients, “Have you ever had any pain or
cramping in the legs when walking or with
exercise?” “Does the pain get better with rest?”
• Arterial spasm: fingers and toes
– Ask patients, “Do your fingertips or toes ever
change color in cold weather or when you handle
cold objects?”
• Venous peripheral vascular disease
– Swelling of feet and legs
o Ask about ulcers on lower legs, often near ankles

Health Promotion and Counseling
• Most patients with peripheral arterial disease (PAD)
have no symptoms or non-specific symptoms
– Triad of exercise-induced calf pain that causes
patient to stop exercise and experience relief of
pain in 10 minutes is present in only 10% of
affected patients
• Screen for subclinical PAD
• Aggressive risk factor intervention

Ankle-Brachial Index (ABI)
• Detects stenosis of 50% or more in major vessels
of legs
• Measure systolic blood pressure (with Doppler
ultrasonography) in each arm and in pedal pulses
• Calculate reading for right and left
– Divide arm pressure by ankle pressure
• ABI 0.90-1.30: normal
ABI 0.41-.90: mild to moderate disease
ABI 0.00-0.40: severe disease with critical stenosis

Techniques of Examination
• Important areas of examination
– Arms
o Size, symmetry, skin color
o Radial pulse, brachial pulse
o Epitrochlear lymph nodes
– Legs
o Size, symmetry, skin color
o Femoral pulse and inguinal lymph nodes
o Popliteal, dorsalis pedis, and posterior tibial pulses
o Peripheral edema

Techniques of Examination - Arms
• Inspect both arms from fingertips to shoulders
– Note the following:
o Size, symmetry, and any swelling
o Venous pattern
o Color of skin and nail beds; texture of skin
• Palpate radial pulse
– Use finger pads on flexor surface of wrist
– Partially flex patient’s wrist
– Compare pulse in both arms

Techniques of Examination – Arms (cont.)
• Palpate brachial pulse
– Flex elbow slightly
– Palpate artery medial to biceps tendon in
antecubital crease
• Epitrochlear nodes
– Flex elbow 90°
– Support forearm
– Feel in groove between biceps and triceps
muscle, 3 cm above medial epicondyle

Techniques of Examination - Legs
• Patient should lay down, draped so external genitalia
is covered and legs are fully exposed
• MUST remove patient’s stockings or socks
• Inspect both legs from groin and buttocks to feet
• Note the following:
– Size, symmetry, and any swelling
– Venous pattern/venous enlargement
– Pigmentation, rashes, scars, or ulcers
– Color and texture of skin, color of nail beds,
distribution of hair on lower legs, feet, and toes

Techniques of Examination – Legs (cont.)
• Palpate superficial inguinal nodes
– Horizontal/vertical groups
– Note size, consistency, and discreteness and
tenderness
– Nontender, discrete nodes up to 1-2 cm are
palpable in normal people

Techniques of Examination –
Palpate Pulses
• Femoral pulse
– Press deeply below inguinal ligament, midway between
anterior superior iliac spine and symphysis pubis
• Popliteal pulse
– Flex knee some, leg relaxed
– Place fingertips of both hands to meet midline behind knee
and press deeply into popliteal fossa
• Dorsalis pedis pulse
– Feel dorsum of foot, lateral to extensor tendon of great toe
• Posterior tibial pulse
– Curve fingers behind and slightly below medial malleolus of
ankle

Grading Amplitude of Arterial Pulses
• 3+ Bounding
• 2+ Brisk, expected (normal)
• 1+ Diminished, weaker than expected
• 0 Absent, unable to palpate

Techniques of Examination - Edema
• Compare one foot and leg with the other
– Note relative size and prominence of veins,
tendons, and bones
• Check for pitting edema
– Press firmly with thumb for 5 seconds over
dorsum of each foot, behind medial malleolus
and shins
• Severity of edema graded on four-point scale
(slight to very marked)

Techniques of Examination – Edema
(cont.)
• If edema is present, look for causes
– Recent deep venous thrombosis
– Chronic venous insufficiency
– Lymphedema
• Note color of skin
– Local area of redness
– Brownish areas near ankles
– Ulcers and where
– Thickness of skin

Special Techniques
• Evaluate arterial supply of the hand if you suspect
arterial insufficiency
– Check radial, brachial, and ulnar pulses
– Perform Allen test
• If chronic arterial insufficiency is suspected (pain/
diminished pulses), check for postural color
changes
• Evaluate competency of venous valves
– Assess retrograde filling (Trendelenburg) test

Question
A patient you are seeing complains of a sore on his lower
leg that does not seem to get better. Based on
examination findings, you suspect venous insufficiency.
Which of the clinical findings below would suggest venous
insufficiency as the cause of his problem?
a. Leg discomfort is exacerbated by dependency
b. Hyperpigmentation is present around the lower calf
area
c. Ulceration is present on the medial side of the ankle
d. Affected leg feels warm to the touch
e. All the above

Answer
e. All the above
• Leg discomfort is exacerbated by dependency
• Hyperpigmentation is present around the lower
calf area
• Ulceration is present on the medial side of the
ankle
• Affected leg feels warm to the touch

Question
A patient you are seeing complains of severe pain in
her right foot. Based on examination findings, you
suspect arterial insufficiency. Which of the clinical
findings below would suggest arterial insufficiency as
the cause of her problem?
a. Brisk posterior tibial and dorsalis pedis pulses
b. Pallor of the foot upon elevation
c. Pitting edema of the lower leg
d. Warmth of the right foot

Answer
b. Pallor of the foot upon elevation
• Decreased posterior tribal and dorsalis pedis
pulses
• No edema of the lower leg
• Cool right foot

Ppt12

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