Vascular System - Pedro Schestatskypedroschestatsky.com.br/_files/material/49/534b0451ddad2.pdf · Vascular System CHAPTER14 ... arteries, the veins, the capillary bed that connects

The Peripheral Vascular System

C H A P T E R

The Peripheral Vascular System 1414

C H A P T E R 1 4 ! T H E P E R I P H E R A L V A S C U L A R S Y S T E M 441

Brachial artery

Ulnar artery

Arterial arches

Radial artery

ANATOMY AND PHYSIOLOGY

This chapter focuses on circulationto the arms and legs. It includes thearteries, the veins, the capillary bedthat connects them, and the lym-phatic system with its lymph nodes.

Arteries

Arterial pulses are palpable when anartery lies close to the body surface.In the arms, there are two or some-times three such locations. Pulsa-tions of the brachial artery can befelt in and above the bend of theelbow, just medial to the biceps ten-don and muscle. The brachial arterydivides into the radial and ulnar ar-teries. Radial artery pulsations canbe felt on the flexor surface of thewrist laterally. Medially, pulsationsof the ulnar artery may be palpable,but overlying tissues frequently ob-scure them.

The radial and ulnar arteries are in-terconnected by two vascular archeswithin the hand. Circulation to thehand and fingers is thereby doublyprotected against possible arterialocclusion.

In the legs, arterial pulsations canusually be felt in four places. Thoseof the femoral artery are palpablebelow the inguinal ligament, mid-way between the anterior superioriliac spine and the symphysis pubis.The femoral artery travels down-ward deep within the thigh, passesmedially behind the femur, and be-comes the popliteal artery. Poplitealpulsations can be felt in the tissuesbehind the knee. Below the knee,the popliteal artery divides into twobranches, both of which continueto the foot. There the anterior branchbecomes the dorsalis pedis artery. Itspulsations are palpable on the dor-sum of the foot just lateral to theextensor tendon of the big toe. Theposterior branch, the posterior tib-ial artery, can be felt as it passes be-hind the medial malleolus of theankle.

Like the hand, the foot is protectedby an interconnecting arch betweenits two chief arterial branches.

Veins

The veins from the arms, together with those from the upper trunk and thehead and neck, drain into the superior vena cava and on into the rightatrium. Veins from the legs and the lower trunk drain upward into the in-ferior vena cava. Because the leg veins are especially susceptible to dysfunc-tion, they warrant special attention.

The deep veins of the legs carry about 90% of the venous return from thelower extremities. They are well supported by surrounding tissues.


442 B A T E S ’ G U I D E T O P H Y S I C A L E X A M I N A T I O N A N D H I S T O R Y T A K I N G

Anterior superioriliac spine

Inguinal ligament

Femoral artery

Symphysis pubis

Popliteal artery

Arterial arch

Posterior tibial artery

Dorsalis pedis artery

In contrast, the superficial veins are located subcutaneously, and are sup-ported relatively poorly. The superficial veins include (1) the great saphe-nous vein, which originates on the dorsum of the foot, passes just in frontof the medial malleolus, and then continues up the medial aspect of the legto join the deep venous system (the femoral vein) below the inguinal lig-ament; and (2) the small saphenous vein, which begins at the side of thefoot and passes upward along the back of the leg to join the deep systemin the popliteal space. Anastomotic veins connect the two saphenous veinssuperficially and, when dilated, are readily visible. In addition, communi-cating (or perforating) veins connect the saphenous system with the deepvenous system.

Deep, superficial, and communicating veins all have one-way valves. Theseallow venous blood to flow from the superficial to the deep system and to-ward the heart, but not in the opposite directions. Muscular activity con-tributes importantly to venous blood flow. As calf muscles contract in walk-ing, for example, blood is squeezed upward against gravity, and competentvalves keep it from falling back again.



Femoral vein

Great saphenousvein

Small saphenousvein

Femoral vein

Communicatingvein

Small saphenousvein

Great saphenousvein

The Lymphatic System and Lymph Nodes

The lymphatic system comprises an extensive vascular network that drainsfluid, called lymph, from bodily tissues and returns it to the venous circu-lation. The system starts peripherally as blind lymphatic capillaries, andcontinues centrally as thin vascular vessels and then collecting ducts thatfinally empty into major veins at the root of the neck. The lymph trans-ported in these channels is filtered through lymph nodes that are inter-posed along the way.

Lymph nodes are round, oval, or bean-shaped structures that vary in sizeaccording to their location. Some lymph nodes, such as the preauriculars,if palpable at all, are typically very small. The inguinal nodes, in contrast,are relatively larger—often 1 cm in diameter and occasionally even 2 cm inan adult.

In addition to its vascular functions, the lymphatic system plays an impor-tant role in the body’s immune system. Cells within the lymph nodes engulfcellular debris and bacteria and produce antibodies.

Only the superficial lymph nodes are accessible to physical examination.These include the cervical nodes (p. 133), the axillary nodes (p. 300), andnodes in the arms and legs.



Infraclavicularnode

Centralaxillary nodes

Lateralaxillarynodes

Epitrochlearnodes



Femoralvein

Greatsaphenousvein

Verticalgroup

Femoralartery

Horizontalgroup

Recall that the axillary lymph nodes drain most of the arm. Lymphaticsfrom the ulnar surface of the forearm and hand, the little and ring fingers,and the adjacent surface of the middle finger, however, drain first into theepitrochlear nodes. These are located on the medial surface of the arm about3 cm above the elbow. Lymphatics from the rest of the arm drain mostlyinto the axillary nodes. A few may go directly to the infraclaviculars.

The lymphatics of the lower limb,following the venous supply, consistof both deep and superficial systems.Only the superficial nodes are pal-pable. The superficial inguinal nodesinclude two groups. The horizontalgroup lies in a chain high in the ante-rior thigh below the inguinal liga-ment. It drains the superficial portionsof the lower abdomen and buttock,the external genitalia (but not thetestes), the anal canal and perianalarea, and the lower vagina.

The vertical group clusters near theupper part of the saphenous vein anddrains a corresponding region of theleg. In contrast, lymphatics from theportion of leg drained by the smallsaphenous vein (the heel and outeraspect of the foot) join the deep sys-tem at the level of the popliteal space.Lesions in this area, therefore, arenot usually associated with palpableinguinal lymph nodes.

Fluid Exchange and the Capillary Bed

Blood circulates from arteries to veins through the capillary bed. Here fluidsdiffuse across the capillary membrane, maintaining a dynamic equilibrium be-tween the vascular and interstitial spaces. Blood pressure (hydrostatic pressure)within the capillary bed, especially near the arteriolar end, forces fluid out intothe tissue spaces. In effecting this movement, it is aided by the relatively weakosmotic attraction of proteins within the tissues (interstitial colloid oncoticpressure) and is opposed by the hydrostatic pressure of the tissues.

As blood continues through the capillary bed toward the venous end itshydrostatic pressure falls, and another force gains dominance. This is the col-loid oncotic pressure of plasma proteins, which pulls fluid back into the vasculartree. Net flow of fluid, which was directed outward on the arteriolar side ofthe capillary bed, reverses itself and turns inward on the venous side. Lym-phatic capillaries, which also play an important role in this equilibrium, removeexcessive fluid, including protein, from the interstitial space.

THE HEALTH HISTORY


See Table 14-1, Painful PeripheralVascular Disorders and Their Mimics, pp. 460–461.

Lymphatic dysfunction or disturbances in hydrostatic or osmotic forces canall disrupt this equilibrium. The most common clinical result is the increasedinterstitial fluid known as edema (see Table 14-4, Some Peripheral Causesof Edema, p. 464).

Changes With Aging

Aging itself brings relatively few clinically important changes to the peripheralvascular system. Although arterial and venous disorders, especially athero-sclerosis, do afflict older people more frequently, they probably cannot beconsidered part of the aging process. Age lengthens the arteries, makes themtortuous, and typically stiffens their walls, but these changes develop with orwithout atherosclerosis and therefore lack diagnostic specificity. Loss of arte-rial pulsations is not a part of normal aging, however, and demands carefulevaluation. Skin may get thin and dry with age, nails may grow more slowly,and hair on the legs often becomes scant. Because these changes are com-mon, they are not specific for arterial insufficiency, although they are classi-cally associated with it.

Common or Concerning Symptoms

! Pain in the arms or legs! Intermittent claudication! Cold, numbness, pallor in the legs, hair loss! Color change in fingertips or toes in cold weather! Swelling in calves, legs, or feet! Swelling with redness or tenderness

THE HEALTH HISTORY

To assess possible peripheral vascular disease, begin by asking patients aboutany pain in the arms and legs. Be aware that pain in the extremities may arisefrom the skin, the peripheral vascular system, the musculoskeletal system, orthe nervous system. In addition, visceral pain may be referred to the ex-

Interstitial space

Artery

Capillary bed

Lymphatic vessel

Vein

EXAMPLES OF ABNORMALITIES

tremities, like the pain of myocardial infarction that radiates to the left armor cervical arthritis that radiates to the shoulder.

To elicit symptoms of arterial peripheral vascular disease in the legs, in-quire about intermittent claudication, which is exercise-induced pain thatis absent at rest, makes the patient stop exertion, and remits within about10 minutes. Ask “Have you ever had any pain or cramping in your legs whenyou walk or exercise?” and “How far can you walk without stopping to rest?”Also, “Does the pain get better with rest?” These questions clarify whatmakes the patient stop and how quickly the pain is relieved. Ask also aboutcoldness, numbness, or pallor in the legs or feet or loss of hair over the ante-rior tibial surfaces.

Many patients with arterial peripheral vascular disease have few symptoms,so it is important to identify background risk factors. Assess the patient’s his-tory of tobacco abuse. Ask if the patient has had hypertension, diabetes, orhyperlipidemia. Further, is there any history of myocardial infarction orstroke? Such patients warrant further evaluation, even if without symptomsin the extremities (see p. 448).

To elicit symptoms of arterial spasm in the fingers or toes, ask “Do yourfingertips ever change color in cold weather or when you handle cold ob-jects?” . . . “What color changes do you notice?” . . . “What about your toes?”

There may be symptoms of venous peripheral vascular disease, such asswelling of the feet and legs. Ask about any ulcers on the lower legs, often thenear ankles.

The redness, swelling, and tenderness of local inflammation are seen insome vascular disorders and in other conditions that mimic them. In con-trast, relatively brief leg cramps that commonly occur at night in other-wise healthy people do not indicate a circulatory problem, and cold handsand feet are so common in healthy people that they have relatively littlepredictive value.

THE HEALTH HISTORY


Atherosclerosis can cause sympto-matic limb ischemia with exertion;distinguish this from spinal stenosis,which produces leg pain with exertion that may be reduced byleaning forward (stretching thespinal cord in the narrowed verte-bral canal) and less readily relievedby rest.

Hair loss over the anterior tibiae indecreased arterial perfusion. “Dry”or brown-black ulcers from gan-grene may ensue.

Only about 10% of affected pa-tients have the classic symptoms ofexertional calf pain relieved by rest.

Digital ischemic changes ofblanching, followed by cyanosis,then rubor with cold exposure and rewarming in Raynaud’s phenomenon or disease

Hyperpigmentation, edema, andpossible cyanosis, especially whenlegs are dependent, in venous stasisulcers

Inflammation in cellulitis, superficialthrombophlebitis, and erythema nodosum

Etiology of common leg crampsand “restless legs” not well under-stood. Leg cramps sometimes fromdiuretic use with hypokalemia


HEALTH PROMOTION AND COUNSELING


*Hirsh AT, Criqui MH, Treat-Jacobson D, et al: Peripheral Arterial Disease: Detection, Awareness,and Treatment in Primary Care. JAMA 286 (11):1317–1324, 2001; Hiatt WR: Medical Treatment of Peripheral Arterial Disease and Claudication. NEJM 344 (21):1608–1620, 2001.


Important Topics for Health Promotion and Counseling

! Detection of peripheral arterial disease (PAD)! Risk factors for PAD! Screening for PAD: the ankle–brachial index (ABI)

Peripheral arterial disease (PAD) generally refers to atherosclerotic occlusionof arteries in the lower extremities. The femoral and popliteal arteries are in-volved most commonly, followed by the tibial and peroneal arteries. PADaffects from 12% to 25% of community populations; however, recent stud-ies* have shown that despite significant associations with cardiovascular andcerebrovascular disease, PAD often is underdiagnosed in office practices.Most patients with PAD have either no symptoms or a range of nonspecificleg symptoms, such as aching, cramping, numbness, or fatigue. The classictriad for vascular claudication, exercise-induced calf pain that causes stop-ping of exercise and results in relief of pain in 10 minutes or less, may bepresent in only about 10% of affected patients.*

Patients with current or past tobacco use, diabetes, hypertension, hyper-lipidemia, or cardiovascular or cerebrovascular disease are at increased riskof atherosclerotic PAD. Such patients should be screened for subclinical PADand targeted for aggressive risk factor intervention. For screening, cliniciansshould consider use of the ankle–brachial index (ABI), a highly accurate testfor detecting 50% or greater stenoses of 50% or more in major vessels of thelegs. The ABI is readily performed by clinicians or office staff, and consists ofmeasuring the systolic blood pressure with Doppler ultrasonography in eacharm and in the dorsalis pedis and posterior tibial pulses. The ABI is calcu-lated on both the right and left by dividing the higher right ankle pressureby the higher right arm pressure, and the higher left ankle pressure by thehigher left arm pressure. ABI values are as follows: 0.90–1.30 is considerednormal; 0.41–0.90—mild to moderate peripheral arterial disease, usuallywith symptoms of claudication; and 0.00–0.40—severe peripheral vasculardisease with critical leg ischemia.

The severity of peripheral vascular disease closely parallels the risk of myo-cardial infarction, ischemic stroke, and death from vascular causes. Patientswith ABIs in the lowest category have a 20% to 25% annual risk of death.*A wide range of interventions is available to reduce both onset and progres-



Suggests atherosclerotic peripheralarterial disease

Preview: Recording the Physical Examination—The Peripheral Vascular System

Note that initially you may use sentences to describe your findings; lateryou will use phrases. The style below contains phrases appropriate formost write-ups. Unfamiliar terms are explained in the next section, Techniques of Examination. Recall that the written description of lymphnodes appears after the Head and Neck section (see p.143). Likewise, assessment of the carotid pulse is recorded in the Cardiovascular section(see p. 265).

“Extremities are warm and without edema. No varicosities or stasischanges. Calves are supple and nontender. No femoral or abdominalbruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric.”

OR

“Extremities are pale below the midcalf, with notable hair loss. Rubornoted when legs dependent but no edema or ulceration. Bilateral femoralbruits; no abdominal bruits heard. Brachial and radial pulses 2+; femoral,popliteal, DP and PT pulses 1+.” (Alternatively, pulses can be recorded asbelow.)

Dorsalis PosteriorRadial Brachial Femoral Popliteal Pedis Tibial

RT 2+ 2+ 1+ 1+ 1+ 1+LT 2+ 2+ 1+ 1+ 1+ 1+

sion of subclinical PAD, including meticulous foot care and well-fittingshoes, tobacco cessation, treatment of hyperlipidemia, optimal control andtreatment of diabetes and hypertension, use of antiplatelet agents, and, ifneeded, surgical revascularization.

(Students should consult specialty texts for less common forms of vascularocclusion from arterial or venous thrombosis or endarteritis from infection,inflammation, or autoimmune disease.)


TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES


Lymphedema of arm and handmay follow axillary node dissectionand radiation therapy.

Prominent veins in an edematousarm suggest venous obstruction.

(Source of photo above: Marks R: SkinDisease in Old Age. Philadelphia, JBLippincott, 1987)

In Raynaud’s disease, wrist pulsesare typically normal but spasm ofmore distal arteries causes episodes

Important Areas of Examination

The Arms! Size, symmetry, skin color! Radial pulse, brachial pulse! Epitrochlear lymph nodes

TECHNIQUES OF EXAMINATION

Assessment of the peripheral vascular system relies primarily on inspection ofthe arms and legs, palpation of the pulses, and a search for edema. See Chap-ter 3 for a method of integrating these techniques into your examination of thelimbs. Additional techniques may be useful when you suspect an abnormality.

Arms

Inspect both arms from the fingertips to the shoulders. Note:

! Their size, symmetry, and any swelling

! The venous pattern

! The color of the skin and nail beds and the texture of the skin

Palpate the radial pulse with the padsof your fingers on the flexor surfaceof the wrist laterally. Partially flexingthe patient’s wrist may help you feelthis pulse. Compare the pulses inboth arms.

The Legs! Size, symmetry, skin color! Femoral pulse and inguinal

lymph nodes! Popliteal, dorsalis pedis, and

posterior tibial pulses! Peripheral edema


There are several systems for grading the amplitude of the arterial pulses.One system is to use a scale of 0 to 4, as below; however, you should checkto see what scale is used in your institution.



of sharply demarcated pallor of thefingers (see Table 14-1, Painful Peripheral Vascular Disorders andTheir Mimics, pp. 460–461).

Note that if an artery is widely di-lated, it is aneurysmal.

Bounding carotid, radial, andfemoral pulses in aortic insuffi-ciency; asymmetric diminishedpulses in arterial occlusion fromatherosclerosis or embolism

An enlarged epitrochlear nodemay be secondary to a lesion in its drainage area or may be associated with generalized lymphadenopathy.

4+ Bounding3+ Increased2+ Brisk, expected1+ Diminished, weaker than expected0 Absent, unable to palpate

If you suspect arterial insufficiency,feel for the brachial pulse. Flex thepatient’s elbow slightly, and with thethumb of your opposite hand palpatethe artery just medial to the bicepstendon at the antecubital crease. Thebrachial artery can also be felt higherin the arm in the groove between thebiceps and triceps muscles.

Feel for one or more epitrochlearnodes. With the patient’s elbow flexedto about 90° and the forearm sup-ported by your hand, reach aroundbehind the arm and feel in the groovebetween the biceps and triceps mus-cles, about 3 cm above the medialepicondyle. If a node is present, noteits size, consistency, and tenderness.

Epitrochlear nodes are difficult orimpossible to identify in most nor-mal people.

Legs

The patient should be lying down and draped so that the external genitaliaare covered and the legs fully exposed. A good examination is impossiblethrough stockings or socks!

Medial aspect of left arm

Right hand of examinerMedial epicondyle of humerus

Inspect both legs from the groin and buttocks to the feet. Note:

! Their size, symmetry, and anyswelling

! The venous pattern and anyvenous enlargement

! Any pigmentation, rashes,scars, or ulcers

! The color and texture of theskin, the color of the nailbeds, and the distribution ofhair on the lower legs, feet,and toes.

Palpate the superficial inguinalnodes, including both the hori-zontal and the vertical groups.Note their size, consistency, anddiscreteness, and note any ten-derness. Nontender, discrete in-guinal nodes up to 1 cm or even2 cm in diameter are frequentlypalpable in normal people.

Palpate the pulses in order to assess the arterial circulation.

! The femoral pulse. Press deeply, below the inguinal ligament and aboutmidway between the anterior superior iliac spine and the symphysis pubis.As in deep abdominal palpation, the use of two hands, one on top of theother, may facilitate this examination, especially in obese patients.



Verticalgroup

Greatsaphenousvein

Femoral vein

Femoral arteryHorizontalgroup

See Table 14-2, Chronic Insuffi-ciency of Arteries and Veins (p. 462).

See Table 14-3, Common Ulcers ofthe Feet and Ankles (p. 463).

Lymphadenopathy refers to enlarge-ment of the nodes, with or withouttenderness. Try to distinguish be-tween local and generalized lym-phadenopathy, respectively, byfinding either (1) a causative lesionin the drainage area, or (2) enlargednodes in at least two other non-contiguous lymph node regions.

A diminished or absent pulse indi-cates partial or complete occlusionproximally; for example, at theaortic or iliac level, all pulses distalto the occlusion are typically affected. Chronic arterial occlusion,usually from atherosclerosis,causes intermittent claudication,(pp. 460–461), postural colorchanges (p. 458), and trophicchanges in the skin (p. 462)

An exaggerated, widened femoralpulse suggests a femoral aneurysm,a pathologic dilatation of the artery.


! The popliteal pulse. The patient’s knee should be somewhat flexed, the legrelaxed. Place the fingertips of both hands so that they just meet in themidline behind the knee and press them deeply into the popliteal fossa.The popliteal pulse is often more difficult to find than other pulses. It isdeeper and feels more diffuse.



An exaggerated, widened poplitealpulse suggests an aneurysm of thepopliteal artery. Neither poplitealnor femoral aneurysms are com-mon. They are usually due to atherosclerosis, and occur primarilyin men over age 50.

Atherosclerosis (arteriosclerosisobliterans) most commonly ob-structs arterial circulation in thethigh. The femoral pulse is thennormal, the popliteal decreased or absent.

If you cannot feel the popliteal pulse with this approach, try with the patientprone. Flex the patient’s knee to about 90°, let the lower leg relax againstyour shoulder or upper arm, and press your two thumbs deeply into thepopliteal fossa.

! The dorsalis pedis pulse. Feel thedorsum of the foot (not the ankle)just lateral to the extensor tendonof the great toe. If you cannot feela pulse, explore the dorsum of thefoot more laterally.

! The posterior tibial pulse. Curveyour fingers behind and slightlybelow the medial malleolus of theankle. (This pulse may be hard tofeel in a fat or edematous ankle.)

Tips on feeling difficult pulses: (1) Position your own body and examininghand comfortably; awkward positions decrease your tactile sensitivity. (2) Place your hand properly and linger there, varying the pressure of yourfingers to pick up a weak pulsation. If unsuccessful, then explore the area de-liberately. (3) Do not confuse the patient’s pulse with your own pulsatingfingertips. If you are unsure, count your own heart rate and compare it withthe patient’s. The rates are usually different. Your carotid pulse is convenientfor this comparison.

Note the temperature of the feet and legs with the backs of your fingers. Com-pare one side with the other. Bilateral coldness is most often due to a coldenvironment or anxiety.



The dorsalis pedis artery may becongenitally absent or may branchhigher in the ankle. Search for apulse more laterally.

Decreased or absent foot pulses (assuming a warm environ-ment) with normal femoral and popliteal pulses suggest occlusive disease in the lowerpopliteal artery or its branches—a pattern often associated with diabetes mellitus.

Sudden arterial occlusion, as by em-bolism or thrombosis, causes painand numbness or tingling. The limbdistal to the occlusion becomescold, pale, and pulseless. Emergencytreatment is required. If collateralcirculation is good, only numbnessand coolness may result.

Coldness, especially when uni-lateral or associated with othersigns, suggests arterial insuffi-ciency from inadequate arterialcirculation.

EXAMPLES OF ABNORMALITIESTECHNIQUES OF EXAMINATION


Look for edema. Compare one foot and leg with the other, noting their rel-ative size and the prominence of veins, tendons, and bones.

Check for pitting edema. Press firmly but gently with your thumb for at least5 seconds (1) over the dorsum of each foot, (2) behind each medial malle-olus, and (3) over the shins. Look for pitting—a depression caused by pres-sure from your thumb. Normally there is none. The severity of edema isgraded on a four-point scale, from slight to very marked.

Edema causes swelling that mayobscure the veins, tendons, andbony prominences.

See Table 14-4, Some PeripheralCauses of Edema (p. 464).

Shown below is 3+ pitting edema.

If you suspect edema, measurement of the legs may help you to identify it andto follow its course. With a flexible tape, measure (1) the forefoot, (2) thesmallest possible circumference above the ankle, (3) the largest circumfer-ence at the calf, and (4) the midthigh a measured distance above the patellawith the knee extended. Compare one side with the other. A difference ofmore than 1 cm just above the ankle or 2 cm at the calf is unusual in normalpeople and suggests edema.

If edema is present, look for possible causes in the peripheral vascular sys-tem. These include (1) recent deep venous thrombosis, (2) chronic venousinsufficiency due to previous deep venous thrombosis or to incompetenceof the venous valves, and (3) lymphedema. Note the extent of the swelling.How far up the leg does it go?

Is the swelling unilateral or bilateral? Are the veins unusually prominent?

Try to identify any venous tenderness that may accompany deep venousthrombosis. Palpate the groin just medial to the femoral pulse for tender-ness of the femoral vein. Next, with the patient’s leg flexed at the knee andrelaxed, palpate the calf. With your fingerpads, gently compress the calf mus-cles against the tibia, and search for any tenderness or cords. Deep venousthrombosis, however, may have no demonstrable signs, and diagnosis oftendepends on high clinical suspicion and other testing.

Note the color of the skin.

! Is there a local area of redness? If so, note its temperature, and gently tryto feel the firm cord of a thrombosed vein in the area. The calf is mostoften involved.

! Are there brownish areas near the ankles?

! Note any ulcers in the skin. Where are they?

! Feel the thickness of the skin.

Ask the patient to stand, and inspect the saphenous system for varicosities. Thestanding posture allows any varicosities to fill with blood and makes themvisible. You can easily miss them when the patient is in a supine position.Feel for any varicosities, noting any signs of thrombophlebitis.



Conditions such as muscular atrophy can also cause differentcircumferences in the legs.

In deep venous thrombosis, the extent of edema suggests the location of the occlusion: the calfwhen the lower leg or the ankle isswollen, the iliofemoral veins whenthe entire leg is swollen.

Venous distention suggests a venouscause of edema.

A painful, pale swollen leg, togetherwith tenderness in the groin overthe femoral vein, suggests deepiliofemoral thrombosis. Approxi-mately half of patients with deepvenous thrombosis in the calf havetenderness and cords deep in thecalf. Calf tenderness is nonspecific,however, and may be presentwithout thrombosis.

Local swelling, redness, warmth,and a subcutaneous cord suggestsuperficial thrombophlebitis.

A brownish color or ulcers justabove the ankle suggest chronicvenous insufficiency.

Thickened brawny skin occurs in lymphedema and advanced venous insufficiency.

Varicose veins are dilated and tor-tuous. Their walls may feel some-what thickened. Many varicoseveins can be seen in the leg on p. 459.

Release your pressure over the ulnar artery. If the ulnar artery is patent, thepalm flushes within about 3 to 5 seconds.

Patency of the radial artery may betested by releasing the radial arterywhile still compressing the ulnar.


Special Techniques

Evaluating the Arterial Supplyto the Hand. If you suspect arte-rial insufficiency in the arm or hand,try to feel the ulnar pulse as well asthe radial and brachial pulses. Feelfor it deeply on the flexor surface ofthe wrist medially. Partially flexingthe patient’s wrist may help you. Thepulse of a normal ulnar artery, how-ever, may not be palpable.

The Allen test gives further information. This test is also useful to assure thepatency of the ulnar artery before puncturing the radial artery for blood sam-ples. The patient should rest with hands in lap, palms up.

Ask the patient to make a tight fist with one hand; then compress both ra-dial and ulnar arteries firmly between your thumbs and fingers. Next, askthe patient to open the hand into a relaxed, slightly flexed position. Thepalm is pale.



Arterial occlusive disease is muchless common in the arms than inthe legs. Absent or diminishedpulses at the wrist in acute embolicocclusion and in Buerger’s disease,or thromboangiitis obliterans.

Extending the hand fully maycause pallor and a falsely positivetest.

Persisting pallor indicates occlusionof the ulnar artery or its distalbranches.

Postural Color Changes ofChronic Arterial Insufficiency.If pain or diminished pulses suggestarterial insufficiency, look for pos-tural color changes. Raise both legs,as shown at the right, to about 60° until maximal pallor of the feet develops—usually within a minute.In light-skinned persons, either main-tenance of normal color, as seen inthis right foot, or slight pallor isnormal.

Then ask the patient to sit up withlegs dangling down. Compare bothfeet, noting the time required for:

! Return of pinkness to the skin, nor-mally about 10 seconds or less

! Filling of the veins of the feet andankles, normally about 15 seconds.

This right foot has normal color andthe veins on the foot have filled.These normal responses suggest anadequate circulation.

Look for any unusual rubor (dusky redness) to replace the pallor of the de-pendent foot. Rubor may take a minute or more to appear.

Normal responses accompanied by diminished arterial pulses suggest that agood collateral circulation has developed around an arterial occlusion.

Color changes may be difficult to see in darker-skinned persons. Inspectthe soles of the feet for these changes, and use tangential lighting to seethe veins.



The foot below is still pale and theveins are just starting to fill—signsof arterial insufficiency.

Persisting rubor on dependencysuggests arterial insufficiency (seep. 462). When veins are incompe-tent, dependent rubor and thetiming of color return and venousfilling are not reliable tests of arte-rial insufficiency.

Marked pallor on elevation sug-gests arterial insufficiency.

(Source of foot photos: Kappert A, Winsor T: Diagnosis of Peripheral Vascular Disease. Philadelphia, FADavis, 1972).


Mapping Varicose Veins. Youcan map out the course and connec-tions of varicose veins by transmit-ting pressure waves along the blood-filled veins. With the patient standing,place your palpating fingers gentlyon a vein and, with your other handbelow it, compress the vein sharply.Feel for a pressure wave transmittedto the fingers of your upper hand.A palpable pressure wave indicatesthat the two parts of the vein areconnected.

A wave may also be transmitteddownward, but not as easily.

Evaluating the Competency of Venous Valves. By the retrogradefilling (Trendelenburg) test, you can assess the valvular competency in boththe communicating veins and the saphenous system. Start with the patientsupine. Elevate one leg to about 90° to empty it of venous blood.

Next, occlude the great saphenous vein in the upper thigh by manual com-pression, using enough pressure to occlude this vein but not the deeper ves-sels. Ask the patient to stand. While you keep the vein occluded, watch forvenous filling in the leg. Normally the saphenous vein fills from below,taking about 35 seconds as blood flows through the capillary bed into thevenous system.

After the patient has stood for 20 seconds, release the compression and lookfor any sudden additional venous filling. Normally there is none: competentvalves in the saphenous vein block retrograde flow. Slow venous filling continues.

When both steps of this test are normal, the response is termed negative–negative. Negative–positive and positive–negative responses may also occur.



Rapid filling of the superficialveins while the saphenous vein isoccluded indicates incompetentvalves in the communicating veins.Blood flows quickly in a retrogradedirection from the deep to thesaphenous system.

Sudden additional filling of super-ficial veins after release of compres-sion indicates incompetent valvesin the saphenous vein.

When both steps are abnormal,the test is positive–positive.

Feel for apressure wave

Compress sharply

TABLE 14-1 ! Painful Peripheral Vascular Disorders and Their Mimics



Problem Process Location of Pain

Arterial DisordersAtherosclerosis(arteriosclerosis obliterans)! Intermittent claudication

! Rest pain

Acute Arterial Occlusion

Raynaud’s Disease and Phenomenon

Venous DisordersSuperficial Thrombophlebitis

Deep Venous Thrombosis

Chronic Venous Insufficiency (deep)ThromboangiitisObliterans (Buerger’sdisease)

Acute Lymphangitis

Mimics*Acute Cellulitis

Erythema Nodosum

Episodic muscular ischemia induced by exercise,due to obstruction of large or middle-sized arteriesby atherosclerosis

Ischemia even at rest

Embolism or thrombosis, possibly superimposedon arteriosclerosis obliterans

Raynaud’s disease: Episodic spasm of the smallarteries and arterioles; no vascular occlusion.Raynaud’s phenomenon: Syndrome is secondary toother conditions such as collagen vascular disease,arterial occlusion, trauma, drugs

Clot formation and acute inflammation in asuperficial vein

Clot formation in a deep vein

Chronic venous engorgement secondary to venousocclusion or incompetency of venous valves

Inflammatory and thrombotic occlusions of smallarteries and also of veins, occurring in smokers

Acute bacterial infection (usually streptococcal)spreading up the lymphatic channels from a portalof entry such as an injured area or an ulcer

Acute bacterial infection of the skin andsubcutaneous tissues

Subcutaneous inflammatory lesions associated witha variety of systemic conditions such as pregnancy,sarcoidosis, tuberculosis, and streptococcal infections

Usually the calf, but also may be in thebuttock, hip, thigh, or foot, depending onthe level of obstruction

Distal pain, in the toes or forefoot

Distal pain, usually involving the foot and leg

Distal portions of one or more fingers.Pain is usually not prominent unlessfingertip ulcers develop. Numbness andtingling are common.

Pain in a local area along the course of asuperficial vein, most often in thesaphenous system

Pain, if present, is usually in the calf, butthe process more often is painless.

Diffuse aching of the leg(s)

! Intermittent claudication, particularly inthe arch of the foot

! Rest pain in the fingers or toes

An arm or a leg

Arms, legs, or elsewhere

Anterior surfaces of both lower legs

* Mistaken primarily for acute superficial thrombophlebitis.



Factors ThatTiming Aggravate Factors That Relieve Associated Manifestations

Fairly brief; pain usuallyforces the patient to rest.

Persistent, often worse atnight

Sudden onset; associatedsymptoms may occurwithout pain.

Relatively brief (minutes)but recurrent

An acute episode lastingdays or longer

Often hard to determinebecause of lack ofsymptoms

Chronic, increasing as theday wears on! Fairly brief but recurrent! Chronic, persistent, may

be worse at night



Pain associated with a seriesof lesions over several weeks

Exercise such as walking

Elevation of the feet, as in bed

Exposure to cold,emotional upset

Prolonged standing

! Exercise

Rest usually stops the painin 1–3 min.

Sitting with legs dependent

Warm environment

Elevation of the leg(s)

! Rest! Permanent cessation of

smoking helps both kindsof pain (but patientsseldom stop)

Local fatigue, numbness, diminishedpulses, often signs of arterialinsufficiency (see p. 462)

Numbness, tingling, trophic signs andcolor changes of arterial insufficiency(see p. 462)

Coldness, numbness, weakness,absent distal pulses

Color changes in the distal fingers:severe pallor (essential for thediagnosis) followed by cyanosis andthen redness

Local redness, swelling, tenderness, a palpable cord, possibly fever

Possibly swelling of the foot and calfand local calf tenderness; oftennothing

Chronic edema, pigmentation,possibly ulceration (see pp. 462, 463)

Distal coldness, sweating, numbness,and cyanosis; ulceration and gangreneat the tips of fingers or toes;migratory thrombophlebitis

Red streak(s) on the skin, withtenderness, enlarged, tender lymphnodes, and fever

A local area of diffuse swelling,redness, and tenderness withenlarged, tender lymph nodes andfever; no palpable cord

Raised, red, tender swellings recurringin crops; often malaise, joint pains,and fever

TABLE 14-2 ! Chronic Insufficiency of Arteries and Veins


TABL

E 14

-2!

Chr

onic

Insu

ffici

ency

of

Art

erie

s an

d Ve

ins

Chr

onic

Art

eria

l Ins

uffic

ienc

y (A

dvan

ced)

Chr

onic

Ven

ous

Insu

ffici

ency

(Ad

vanc

ed)

Pain

Puls

esC

olor

Tem

pera

ture

Edem

a

Skin

Cha

nges

Ulc

erat

ion

Gan

gren

e

Inte

rmitt

ent c

laud

icat

ion,

pro

gres

sing

to p

ain

at re

st

Dec

reas

ed o

r abs

ent

Pale

, esp

ecia

lly o

n el

evat

ion;

dus

ky re

d on

dep

ende

ncy

Coo

l

Abs

ent o

r mild

; may

dev

elop

as t

he p

atie

nt tr

ies t

o re

lieve

rest

pain

by

low

erin

g th

e le

g

Tro

phic

cha

nges

: thi

n, sh

iny,

atr

ophi

c sk

in; l

oss o

f hai

r ove

r the

foot

and

toes

; nai

ls th

icke

ned

and

ridge

d

If p

rese

nt, i

nvol

ves t

oes o

r poi

nts o

f tra

uma

on fe

et

May

dev

elop

Non

e to

an

achi

ng p

ain

on d

epen

denc

y

Nor

mal

, tho

ugh

may

be

diffi

cult

to fe

el th

roug

h ed

ema

Nor

mal

, or c

yano

tic o

n de

pend

ency

. Pet

echi

ae a

nd th

enbr

own

pigm

enta

tion

appe

ar w

ith c

hron

icity

.

Nor

mal

Pres

ent,

ofte

n m

arke

d

Ofte

n br

own

pigm

enta

tion

arou

nd th

e an

kle,

stas

isde

rmat

itis,

and

poss

ible

thic

keni

ng o

f the

skin

and

nar

row

ing

of th

e le

g as

scar

ring

deve

lops

If p

rese

nt, d

evel

ops a

t sid

es o

f ank

le, e

spec

ially

med

ially

Doe

s not

dev

elop

(Sou

rces

of p

hoto

s: A

rter

ial I

nsuf

ficie

ncy—

Kap

pert

A, W

inso

r T: D

iagn

osis

of P

erip

hera

l Vas

cula

r Dise

ase.

Phi

lade

lphi

a, F

A D

avis,

197

2; V

enou

s Ins

uffic

ienc

y—M

arks

R: S

kin

Dise

ase

in O

ld A

ge. P

hila

delp

hia,

JB

Lip

pinc

ott,

1987

)

TABLE 14-3 ! Common Ulcers of the Feet and Ankles


TABL

E 14

-3!

Com

mon

Ulc

ers

of t

he F

eet

and

Ank

les

Art

eria

l Ins

uffic

ienc

yC

hron

ic V

enou

s In

suffi

cien

cyN

euro

path

ic U

lcer

Loca

tion

Skin

Aro

und

the

Ulc

erPa

in

Ass

ocia

ted

Gan

gren

eA

ssoc

iate

dSi

gns

Toe

s, fe

et, o

r pos

sibly

in a

reas

of

trau

ma

(e.g

., th

e sh

in)

No

callu

s or e

xces

s of p

igm

ent;

may

be a

trop

hic

Ofte

n se

vere

, unl

ess n

euro

path

ym

asks

it

May

be

pres

ent

Dec

reas

ed p

ulse

s, tr

ophi

c ch

ange

s,pa

llor o

f the

foot

on

elev

atio

n, d

usky

rubo

r on

depe

nden

cy

Inne

r or s

omet

imes

out

er a

nkle

Pigm

ente

d, so

met

imes

fibr

otic

Not

seve

re

Abs

ent

Ede

ma,

pig

men

tatio

n, st

asis

derm

atiti

s, an

d po

ssib

ly c

yano

sis o

fth

e fo

ot o

n de

pend

ency

Pres

sure

poi

nts i

n ar

eas w

ithdi

min

ished

sens

atio

n, a

s in

diab

etic

poly

neur

opat

hy

Cal

lous

ed

Abs

ent (

and

ther

efor

e th

e ul

cer m

aygo

unn

otic

ed)

In u

ncom

plic

ated

neu

ropa

thic

ulc

er,

abse

nt

Dec

reas

ed se

nsat

ion,

abs

ent a

nkle

jerk

s

(Sou

rce

of p

hoto

s: M

arks

R: S

kin

Dise

ase

in O

ld A

ge. P

hila

delp

hia,

JB

Lip

pinc

ott,

1987

)

TABLE 14-4 ! Some Peripheral Causes of Edema


TABL

E 14

-4!

Som

e Pe

riph

eral

Cau

ses

of E

dem

a

Abo

ut o

ne t

hird

of t

otal

bod

y w

ater

is e

xtra

cellu

lar,

or o

utsid

e th

e bo

dy’s

cel

ls.A

bout

25%

of e

xtra

cellu

lar fl

uid

is pl

asm

a an

d th

e re

mai

nder

is in

ters

titia

l flui

d. A

tth

e ar

terio

lar e

nd o

f the

cap

illar

ies,

hydr

osta

tic p

ressu

rein

the

bloo

d ve

ssel

s and

the

collo

id o

ncot

ic p

ressu

rein

the

inte

rstit

ium

cau

se fl

uid

to m

ove

into

the

tiss

ues;

atth

e ve

nous

end

of t

he c

apill

arie

s and

in th

e ly

mph

atic

s, hy

dros

tatic

pre

ssur

e in

the

inte

rstit

ium

and

the

collo

id o

ncot

ic p

ress

ure

of p

lasm

a pr

otei

ns c

ause

flui

d to

re-

turn

to th

e va

scul

ar c

ompa

rtm

ent.

A n

umbe

r of c

linic

al c

ondi

tions

disr

upt t

his b

al-

ance

, res

ultin

g in

ede

ma,

or a

clin

ical

ly e

vide

nt a

ccum

ulat

ion

of in

ters

titia

l flui

d.N

ot d

epic

ted

belo

w is

cap

illar

y le

ak sy

ndro

me,

whe

re p

rote

in le

aks i

nto

the

inte

r-st

itial

spac

e, se

en in

bur

ns, a

ngio

edem

a, sn

ake

bite

s, an

d al

lerg

ic re

actio

ns.

Chr

onic

Ven

ous

Pitt

ing

Edem

aIn

suffi

cien

cyLy

mph

edem

a

Nat

ure

of E

dem

a

Skin

Thi

cken

ing

Ulc

erat

ion

Pigm

enta

tion

Edem

a of

Foo

tBi

late

ralit

yEx

ampl

es/

Mec

hani

sms

Soft,

pits

on

pres

sure

Abs

ent

Abs

ent

Abs

ent

Pres

ent

Alw

ays

!In

ters

titia

l flui

d fro

m: l

egs d

epen

dent

from

pro

long

ed st

andi

ng o

r sitt

ing

"!

hydr

osta

tic p

ress

ure

in v

eins

, cap

illar

ies;

cong

estiv

e he

art f

ailu

re "

#ca

rdia

cou

tput

, !hy

dros

tatic

pre

ssur

e in

vei

ns,

capi

llarie

s; ne

phro

tic sy

ndro

me,

cirr

hosis

,m

alnu

triti

on "

low

alb

umin

, #in

tra-

vasc

ular

col

loid

onc

otic

pre

ssur

e; d

rugs

Soft,

pits

on

pres

sure

; lat

er m

ay b

ecom

ebr

awny

(ha

rd)

May

be

pres

ent,

espe

cial

ly n

ear a

nkle

Com

mon

Com

mon

Ofte

n pr

esen

t

Occ

asio

nally

Chr

onic

obs

truc

tion

or v

alvu

lar

inco

mpe

tenc

e of

the

deep

vei

ns

Soft

in e

arly

stag

es, t

hen

beco

mes

indu

rate

d, h

ard,

non

pitt

ing

Bec

omes

mar

ked

Rar

e

Abs

ent

Pres

ent,

incl

udin

g to

es

Ofte

n

Lym

ph c

hann

els o

bstr

ucte

d by

tum

or,

fibro

sis, i

nflam

mat

ion;

also

from

axi

llary

node

diss

ectio

n, ra

diat

ion

Pitt

ing

Sw

olle

n fo

otA

dvan

ced

Pitt

ing

Pig

men

t

Ulc

er

No

pitti

ng

Ski

n th

ick F

oot s

wol

len

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Vascular System - Pedro Schestatskypedroschestatsky.com.br/_files/material/49/534b0451ddad2.pdf · Vascular System CHAPTER14 ... arteries, the veins, the capillary bed that connects