VASCULAR DISEASES

1. DR P S SUDHAKAR

2. I. Age and sex :-
 old age - Atherosclerosis is obviously a
disease, It affects men more
often than women.
 Men between 20 and 40 years of age--
Buerger's disease
(Thromboangiitis obliterans)
 Young women-
Raynaud's disease
 Middle age-
Diabetic arteriopathy

3. 2. Limbs affected:
 Lower limbs-
Buerger's disease and
atherosclerotic gangrene
 upper limbs –
Raynaud's disease mainly
affects the upper limbs
 A patient who presents with superficial
gangrene of the finger, the following causes
should specially be considered :
 Ray:naud's disease,
 the cervical rib,
 scalenus anticus syndrome,
 Morvan's disease - painless whitlow in
syringomyelia.

4. 3. Bilateral or unilateral:
Bilateral- Buerger's disease and
Raynaud's disease
Unilateral- Atherosclerotic gangrene may
be unilateral to start with but
often ends as a bilateral
disease.
Gangrene due embolism is
mostly unilateral.
Diabetic
gangrene may be unilateral or
bilateral.

5. 4. Mode of onset-
Buerger's disease and Raynaud's
disease occur spontaneously and
gradually.
Embolic gangrene starts suddenly
and the patient feels severe pain
radiating down the course of the
artery.
Diabetic gangrene may start from
slight trauma such as caused by
careless paring of the toe nail or
mild infection

6. 5. Pain
Note its site, character, radiation, whether it
increases in walking or exercise, whether it
disappears when the exercise stops and
whether it becomes worse on application of
warmth.
When circulation of the limb is impaired, two
types of pain are noticed :
(1) Intermittent claudication.
(2) Rest pain.

7. INTERMITTENT CLAUDICATION :-
CLAUDUCATION : A condition in which
cramping pain in the leg
is induced by exercise,
typically caused by
obstruction of the
arteries.
INTERMITTENT CLAUDICATION
Refers to an aching pain
in your legs when you
walk or exercise that goes
away when you rest. The
pain may affect you.

8. The pain may affect :
1. calf
2. hip
3. thigh
4. buttock
5. arch of foot
 lt is a pain in the muscles, usually calf and it
is described by the patient as a cramp.
 The site of the pain depends on the level of
arterial occlusion
Pain in the foot in Buerger's disease in
which the arterial occlusion is mostly in
the lower tibial or plantar arteries;

9. ◦ Pain in the calf in case of arterial occlusion
in femoro-popliteal junction which is very
common.
◦ in the thigh when the occlusion is at
the opening of the superficial
femoral artery
◦ Pain in the buttock in case of occlusion
in the bifurcation of the common
iliac artery or the aorta.

10. BOYD'S CLASSIFICATION :-
Grade 1:
 The patient often complains that after
walking a distance, called the 'claudication
distance , the pain starts.
 Sometimes if the patient continues to walk
the metabolites increase the muscles blood
flow and sweep away the P-substances
produced by exercise and pain disappears.

11.  Grade II
More often the pain continues and
the patient can still walk with effort.
 Grade III
But mostly the pain compels the
patient to take rest

12. REST PAIN :
 This pain is continuous and aching in nature.
 This pain seems to be due to ischaemic
changes in the somatic nerves.
 It is the cry of the dying nerves.
 The pain is worse at night, gets aggravated
by elevation of the leg above the level of the
heart and is relieved by hanging the leg
below the level of the heart.
 It usually affects the most distal part first that
means the tip of the toes.
 The painful part becomes very sensitive and
any movement or pressure causes an acute
exacerbation.

13. 6. Effect, of heat and cold :-
 Application of warmth will increase the
symptoms of arterial occlusion.
 Raynaud's phenomenon i.e. intermittent
attack of pallor or cyanosis is often seen in
Raynaud's disease and sometimes in
Buerger's disease.

14.  In Raynaud's disease a number of attacks can
be seen:-
Each attack is comprised of 3 stages viz.
(i) Local Syncope
(ii) Local asphyxia
(iii) Local recovery,

15. Local Syncope :
 In which the affected digits become cold and
white with tingling and numbness.
 These changes are due to spasm of the
digital arteries.

16. Local asphyxia
 In which the white digits turn blue with
burning sensation.
 This change is due to slowing of circulation
and accumulation of reduced haemoglobin.

17. Local recovery
 In which the bluish discolouration gradually
disappears and the digits regain normal
colour due to release of spasm of digital
arteries.
 Such attacks are repeated, till in the end
patches of superficial ulceration and
gangrene appear at the finger tips, which is
known as local gangrene.

18. 7. Paraeasthesia
 When the muscle pain begins, the patient
often feels numbness, pins and needles and
other types of paraesthesia in the skin of the
foot.
 This is due to shunting of blood from the skin
to muscle.

19. 8. History of superficial phlebitis:
 This is characterized by swelling, redness and
minor pain in the affected part.
 It occurs in high proportion of cases of
Buerger's disease.

20. 9. Involvement of other arteries:-
 Enquiry must be made if there is complain of
fainting,
 Transient black out,
 Chest pain,
 Weakness or paraesthesia in the upper limbs,
 Blurred vision,
 Abdominal pain to exclude occlusive arterial
disease anywhere in the body.

21. 10. Impotence
Due to failure in erection is not uncommon
symptom in case of bilateral internal iliac
artery occlusion.

22. 11. PAST HISTORY.
 The patient with arterial occlusion may give a
history of previous cardiac attacks or embolic
syndromes.
 The patient may be diabetic.
 There may be a history of exposure to cold
(Frost Bite) etc.

23. 12 Personal History.
Excessive smoking has been in criminated as
causing thromboangiitis obliterans and
worsening atherosclerotic disease.

24. 13. Family History.
It is amazing to know that arterial disease
particularly atherosclerosis is often familial
and if you practice the habit of asking if other
members of the family are affected with the
same disease or not, you will find quite a few
are or were suffering from this disease.

25. PHYSICAL EXAMINATION

26.  Considerable constitutional distrubances may
be observed in severe acute ischaemia from
embolus and in gas gangrene.
 There may be lowering of the blood pressure
and increase in the pulse rate in both these
conditions.
 In chronic ischaemia there is not much
constitutional disturbances.

27. A. INSPECTION
l. Change of colour is the most noticeable
feature of an ischaemic limb.
To detect minor change in the colour the
clinician should put the affected limb and
its fellow side by side.
 Sudden arterial obstruction:
Marked pallor is a remarkable
feature in case of embolism or in
spasm of the arterioles in Raynaud's
disease.

28.  Congestion and purple-blue cyanosed
appearance
Are the characteristic features of
severe ischemia.
As soon as the limb is elevated it
becomes pallor.

29. While examining a case of arterial insufficiency,
one must know the signs of ischemia
These are :
1. thinning of the skin,
2. Diminished growth of hair
3. loss of subcutaneous fat, shininess,
4. Trophic changes in the nails which become
brittle and show transverse ridges
5. Minor ulceration in the pressure areas such
as heel, malleoli, ball of the foot, tips of the
toes etc.

33.  This test must be carried out in broad day
light.
 The patient lies on his back on the examining
table.
 The patient is asked to raise his legs one
after the other keeping the knees straight.
The legs of a normal individual remain pink
even if they are raised to 90°.

34.  But in case of an ischemic limb elevation to a
certain degree will cause marked pallor and
the veins will be empty and 'guttered '.

35. Buerger's angle
 The angle (between the limb and the
horizontal plane) at which such pallor
appears is called ·'Buerger's angle' or the
'Vascular angle'.
A vascular angle of less than 30° indicates
severe ischemia.

36. If the feet do not become pallor and occlusive
arterial disease is suspected the following
addition may be performed.
The elevated legs are supported by the
examiner, while the patient flexes and
extends his ankles and toes to the point of
fatigue.
If there is occlusive arterial disease the sole of
the foot assumes cadaveric pallor and the
veins on the dorsum of the foot become
empty and guttered.

37.  The feet are now lowered so that the patient
adopts sitting posture.
 Within 2 or 3 minutes a cyanotic hue spreads
over the affected foot, whereas no change will
be observed in case of healthy limb.
This is due to cyanotic congestion.

38.  After elevating the legs, the patien t is asked
to sit up and hang his legs down by the side
of the table.
 A normal leg will remain pink as it was during
elevated position.
But an ischemic leg will first become pallor
when elevated and gradually become pink in
horizontal position.

39.  This change of color takes place slowly and is
called 'the capillary filling time' .
 In severe ischemia it takes about 20 to 30
seconds to become pink.
 Then the ischemic limb again changes color
and becomes purple-red quickly.
This is due to the filling of the dilated skin
capillaries with deoxygenated blood.

40.  After keeping the limb elevated for a while if
it is then laid flat on the bed, there will be
normal refilling of the veins within 5 seconds.
But in ischemic limb it will be delayed.
 If a normal limb is raised to about 90° there
will be gradual collapse or 'guttering of the
veins'.
But in ischemic limb the veins are seen
collapsed either in the horizontal position or
as soon as it is lifted to even 10° above the
horizontal level.

41. Extent and color of the gangrenous area.
1. This is important to ascertain the level of
arterial occlusion.
2. ln gas gangrene, besides the typical odour
of sulphurated hydrogen, the muscles also
change their colour to brick-red, green or
even black according to the stage of the
disease.

42. Type
Of the gangrene should be noted -
whether dry i.e. the part becomes mummified
or wet and putrefying as seen in diabetic
gangrene.

43. Line of demarcation
 Is often seen between the dead gangrenous
part and the normal living limb.
 In gangrene due to all the conditions this line
of demarcation is poorly marked except in
AINHUM.
 In this condition there is a linear deeping
groove al the base of the Iittle or the fourth
toe, which is the pathognomon.ic feature.

44.  lt is always advisable to observe the limb
above the gangrenous area.
 This may be congested, edematous or pale,
which indicates the possibility of later
involvement of this area.
 There may be black patches, which indicate
'skip lesions'.

45. PALPATION

46.  The temperature is best felt with the back of
the fingers.
 It is always essential to compare the two
limbs and to feel the whole of the affected
limb to find out the zone where the
temperature changes from the normal warm
temperature to cold skin of the ischemic site.
 It is wiser to feel for the temperature rather
than to assess the temperature by looking at
the color of the limb.
The purplish red and congested limb may be
very cold.

47.  The tip of the nail or the pulp of a toe or a
finger is pressed for a few seconds and the
pressure is released.
 The time taken for the blanched area to turn
pink after the pressure has been released is a
crude indication of capillary blood flow.
This time will be definitely longer in case of
ischemic limb.

48.  The two index fingers are placed side by side on
a vein.
 The fingers are now pressed firmly and the finger
nearer the heart is moved proximally keeping the
steady pressure on the vein so as to empty the
short length of the vein between the two fingers.
 The distal finger is now released.
 This will allow venous refilling to be observed.
This is poor in ischemic limb and is increased in
arteriovenous fistula.
This is known as Harvey's sign.

49.  This is performed to detect popliteal pulsation.
 The patient is asked to sit with the legs crossed
one above the other so that the popliteal fossa of
one leg will lie against the knee of the other leg.
 The patient's attention is diverted by taking
history.
 The crossed leg will show oscillatory movements
of the foot which occur synchronously with the
pulse of the popliteal artery.
If the popliteal artery is blocked, this oscillatory
movement will be absent.

50.  To provoke the arteriospasm in case of
Raynaud's disease the patient is asked to put
her hand into ice-cold water.
 This will initiate the attack and the hand
becomes white.
 The patient is then asked to dip her hand in
warm water.
The hand will become blue due to cyanotic
congestion.

51.  This test is performed when thoracic outlet
syndrome is suspected.
 The patient is asked to abduct his shoulders
to 90 degrees and at the same time the upper
limbs are externally rotated fully.
 Now the patient is instructed to open and
close the hands for a period of 5 minutes.
A normal individual can perform this without
any difficulty.

52.  Whereas the patient with thoracic outlet
syndrome will complain of fatigue and pain in
forearm muscles, paraesthesia of the forearm
and tingling and numbness sensation in the
fingers.
 Majority of these patients fail to complete this
test due to pain and distress and they drop
their arms.
 If this test is performed in case of cervical
disc syndrome patient will feel pain in the
neck and shoulders, though little distress is
felt in the forearm and hand.

53.  Allen’s test to know the patency of radial and
ulnar arteries :— The patient is asked to
clench his fist tightly.
 The surgeon presses on the radial and ulnar
arteries at the wrist.
 After 1minute the patient is asked to open
the fist.
 The palm appears white.
 Now pressure on the radial artery is removed
and the change in colour of the hand is
noted.

54. If the radial artery is blocked the colour
remains white, but if it is patent the palm
assumes normal colour.
 Now the pressure on the ulnar artery is
removed.
 Now the test is repeated and the pressure on
the ulnar artery is first removed keeping
pressure on the radial artery.
 If the ulnar artery is blocked the hand
remains white, but if it is patent the palm
assumes normal colour.

55.  This is performed when arteriovenous fistula
is suspected.
 A pressure on the artery proximal to the
fistula will cause reduction in size of swelling,
disappearance of bruit, fall in pulse rate and
the pulse pressure returns to normal.

56.  Patient's radial pulse is felt.
 The patient throws shoulders backwards and
downwards as an exaggerated military
position.
 This will compress the subclavian artery
between the clavicle and the first rib leading
to reduction or disappearance of the radial
pulse.
 Simultaneously a subclavian bruit may be
heard.

57.  Patient's radial pulse is again monitored.
 The affected arm is now passively
hyperabducted.
 This will cause reduction or disappearance of
the radial pulse due to compression by the
pectoralis minor tendon in pectoralis minor
syndrome.
 An axillary bruit may be heard near the
position where pectoralis minor tendon
crosses the axillary artery.

58.  By feeling the gangrenous area one can
assess the type of gangrene.
 In case of dry gangrene the part will be hard
and shrivelled, whereas in case of wet
gangrene the part will be oedematous with or
without crepitation.