Peripheral Vascular Disease

Definition: (Sulivan p.651)

PVD is a generic term use to describe any disorder that interferes with
arterial or venous blood flow of the extremities. These diseases can affect the
arterial, venous, or lymphatic circulatory system which can cause disturbance in the
circulation of the extremities. This usually leads to various acute or chronic medical
conditions such as ischemia, or infarction of the limb most commonly the lower
extremity

Related Anatomy and Pathophysiology: (Tortora and snell p.737-741)

Blood Vessels:
1. Arteries
 Transport blood from heart and distribute it to the various tissues of
the body by means of their branches.
 Carries Oxygenated Blood
 more elastic near the heart while more muscular ones reside
peripherally

Arterioles – the smallest arteries, less than 0.1 mm in diameter

3 Layers in Arteries:
a. Tunica Intima or Interna
 Contains endothelium, abasement membrane and a layer of elastic
tissue called internal elastic lamina.
 It is closest to the lumen. Which is the hollow center through which
blood flows
 inner most layer

Includes:
1. Endothelial cell lines the lumen of all arteries normally from a
barrier that controls the entry of substance from the blood into
artery wall.
2. Internal elastic lamina a perforated tube of elastic tissue that
eliminates the outer portion of intima
3. Basal lamina an underlying meshwork of loose connective tissue
that attaches to the endothelial cells.

b. Tunica Media
 the meddle coat and usually the thickest layer
 it consists of elastic fibers and smooth muscle fibers that extend
circularly around the lumen, much like a ring encircles the finger
 It is also has external elastic lamina composed of elastic tissue.
 Middle layer
Composed of:
1. Smooth Muscle cell – appears to be the major connective tissue
forming the cell of the artery wall producing
 collagen, elastic fibers and
proteoglycans

2. Elastic Tissue – prominent in aorta pulmonary arteries and other

elastic arteries.

c. Tunica Adventitia or Externa

 The outer coat and composed mainly of elastic and collagen fibers
 Outermost layer
 Composed mainly of collagen fibers

Normal Blood Flow:

1. Laminar or Stream – blood flow that is at steady rate through a long smooth
vessel, with each layer of blood remaining same distance from the wall.
2. Turbulent Flow – blood flowing in all directions in the vessel continually mixing
within the vessel.

Vasoconstriction
 it is a decrease in the diameter of a lumen of blood vessel because of the
sympathetic neurons of the autonomic nervous system that are distributed
to the smooth muscle of the tunica media an increase in sympathetic
stimulation typically stimulates the smooth muscle to contract, squeezing the
vessel wall and narrowing the lumen.

Vasodilation
 the resulting ↑ in lumen diameter
 it is contrast to vasoconstriction, smooth (M) fibers relax when sympathetic
stimulation ↓ or when certain chemicals such as nitric oxide, hydrogen, and
lactic acid are present.

Types of Arteries
I. Elastic Arteries
 Largest diameter arteries (greater than 1cm) because the tunica media
contains a high proportion of elastic fibers.
 Their internal elastic lamina is incomplete and their external elastic lamina
is thin
 The elastic fibers function as P° reservoir because as blood is ejected from
the heart into elastic arteries, their wal stretch to accommodate the surge
of blood, storing mechanical energy for a short time. Then the elastic
fibers recoil and convert and stored energy into kinetic energy causing
blood to flow

II. Muscular Arteries

 Medium-sized arteries ranging in diameter from 0.1 to 10mm
 Their tunica media contains more smooth (M) and fewer elastic fibers
than elastic fibers
 They are capable of greater vasoconstriction and vasodilation to adjust
the rate of blood flow
 They have thin internal elastic lamina and a prominent external elastic
lamina
 They are also called Distributing Arteries because they distribute blood
to various parts of the body

2. Vein
 vessels that transport blood back to the heart are thin walled tubes
containing bicuspid valves
 Serves as capacitance vessels and maintain unidirectional flow
 Carries unoxygenated blood from the capillaries to the heart

a. Venules
 It is the smallest vein
b. Tributaries
 smaller veins that unite to form larger veins, which commonly join
with one another to form venous plexuses

3. Capillaries
 microscopic vessel that connects the arterioles to venules
 they range in diameter from 4-10micrometer
 known as Exchange Vessels because their prime function is to
exchange of nutrients and wastes between the blood and tissue
cells through the interstitial fluid
a. Microcirculation
 the flow of blood from arteriole to venules through capillaries

Types of Capillaries
1. Continuous Capillaries
 In which the plasma membrane of endothelial cells from a continuous
tube that is interrupted only by intercellular clefts, which are gasps
between neighboring endothelial cells
 Found in skeletal (M), smooth (M), connective tissue and lungs

2. Fenestrated Capillaries
 the plasma membrane of endothelial cells in these capillaries have
many fenestrations, it is small pores ranging from 70-100mm in
diameter
 found in the kidneys, villi of small intestines, choroid plexuses of the
ventricles of the brain and some endocrine glands

3. Sinusoids
 Are wider and more winding than other capillaries
 Their endothelial cells may have usually large fenestrations
 In addition to having an incomplete or absent basement membrane,
sinusoids have very large intercellular clefts
  Found in liver, bone marrow, spleen and some endocrine glands

Epidemiology (Sullivan, 10th edition, pp. 651)

between 10-25% of LE are caused by arterial disease

incidence of arterial disease and LE ulceration is significantly lower than that

for venous disease and ulceration

arterial wounds more frequently lead to loss of limb and death

incidence of venous ulceration is much higher than arterial ulceration

incidence of CVI increases with age

Classification Peripheral Vascular disease:

1. Arterial Dysfunction
a. Acute arterial disease
1. Arterial thrombosis
2. Arterial embolism
3. Vasopastic Disease or Raynaud’s Disease

b. Chronic arterial disease

1. Arteriosclerosis Obliterans (ASO) or Chronic Arteriosclerosis
2. Thromboangitis Obliterans (TAO) or Buerger’s Disease

2. Venous Dysfunction
a. Acute Venous Disease
1. Phlebitis or thrombophlebitis
2. Phlebothrombosis
3. Venous Thrombosis
4. Thromboembolism

b. Chronic Venous Disease

1. Chronic Venous insufficiency
2. Varicose Veins

3. Lymphatic Disorder
a. Primary lymph edema
b. Secondary lymph edema

I. Arterial Dysfunction

Types of Arterial Disorder:

A. Acute Arterial Disease
  may be caused by a thrombus (blood clot), embolism (a detached
intravascular solid, liquid or gaseous mass carried by blood to a site distal
to its point of origin) or a trauma to an artery
 result in absent or diminished pulses and complete or partial interruption
of circulation to an extremity
 Severity of the problem depends on the site of the occlusion, the
availability of collateral circulation and extent to which the thrombus is
propagated

Classical Signs and Symptoms of Acute Arterial Disease (De Lisa p.795)
 Pain
 Pallor
 Pulselessness
 Paresthesia
 Paralysis
 Polar

1. Arterial thrombosis
 Occurs less frequent
 Usually occurs in the area of previously existing atherosclerotic lesion.
When the lumen narrows in the presence of an atherosclerotic lesion,
the blood flow becomes turbulent and this motion shows its passage
through the area and permits platelet to collect. The platelet
aggregation plus significant amount of fibrin leads to thrombus
development.
 Result in severe ischemia if it occurs in aortic bifurcation.
 Most common form atheroma
Atheroma – are arterial lesions of unknown etiology characterized by
deposition of lipid in the intimal layer following
endothelial damage, laying down of connective tissue
and smooth muscle proliferation
- In systemic circulation affect large arteries
- In coronary and cerebral circulation medium
size arteries
 Arterial wall disease – most important cause of arterial thrombosis

2. Arterial Embolism
 Most common acute arterial disease
 Result from dislodging of a preexisting thrombus (most common from
the heart)
  Most common in arterial segment between the Femoral and popliteal
artery (hunter’s canal)

3. Vasospastic disease (Braddom p.1361)

 Includes such process as livedo reticularis or cutis marmorata (a bluish
or purplish discoloration of the skin seen constantly or upon exposure
to cold) acrocyanosis (symmetric mottled cyanosis of the hands and
feet accentuated by cold and emotion)
 Arterial spasm that occurs appears to be localized in small arteries and
arterioles.
a. Raynaud’s disease (Kisner p.826)
 Aka Primary Raynaud’s Syndrome
 Often in women than men
 An acute arterial disease caused by an abnormality of the
sympathetic nervous system with recurrent attacks of
vasospasm of peripheral arteries affecting distal
extremities especially in the small arteries of the hand
precipitated by exposure to cold or emotional stress
manifested by:
1) Changes in skin color (pallor [blanching]) of the
fingertips and nail beds.
2) Cyanosis and pain
3) sensory loss (numbness)
4) Sensitivity to cold of the digits
- Symptoms relieved slowly by warmth

b. Idiopathic Raynaud’s disease/Raynaud’s Syndrome

 Raynaud’s Phenomenon – it is a secondary complication
and associated with other disease:
- Scleroderma
- Systemic lupus erythematosus
 - Systemic sclerosis
- Vasculitis
 Similar to raynaud’s disease but there is presence of
pathology of blood vessel wall.
B. Chronic arterial disease

1. Arteriosclerosis Obliterans (ASO) or Chronic Arteriosclerosis

(Sullivan ,10th Edition, pp.651)
 A peripheral manifestation of atherosclerosis characterized by
intermittent claudication, rest pain, trophic changes
 This is the arterial disease most likely lead to ulceration
 Most common form of chronic occlusive affecting the LE
 Involves large and medium sized arteries
 Common in elderly men patients than women
 A.k.a. chronic arterial disease, peripheral arterial occlusive,
atherosclerotic occlusive
 Intermittent claudication one of the earliest symptom (De Lisa)
- Muscle cramping type of pain due to prolonged
walking that is caused by chronic arterial insufficiency.

- Weakness
- Fatigue
- Numbness
- Paresthesia
- Can be relieved by rest
- Pain at rest as the disease progress
Reversible risk factors:
- Smoking – most common
- Hyperlipidemia (mean plasma cholesterol is >50mg/dl higher
that in control
- Hypertension
- Diabetes
- Obesity

Intermittent Claudication VS Pseudoclaudication (Magee p.576)

Basis Intermittent Claudication Pseudoclaudication
Etiology Vascular insufficiency Compression of lumbo
Relief with change in None Present
position
Distance tolerated Little variability per Considerable variability
individual
Character of pain Deep, cramping pain Neuropathic with
 paresthesia
Neurologic deficits Absent Present
Seen in LE arterosclerosis Spinal Stenosis

2. Thromboangitis Obliterans (TAO/Buerger’s Disease) (Braddom

p. 1359, Kisner p.826)
 2nd most common of occlusive arterial disease
 Affects the small and medium size arteries
 Initially occurs in the small arteries of the feet and hands and
progresses proximally and results in vasoconstriction, decrease arterial
circulation to the extremities, ischemia and eventualnecrosis and
ulceration of soft tissue
 Occurs predominantly in young male smokers (usually 25-40 yrs. Old)
 Involves inflammatory reaction of arteries to nicotine
Nicotine – is also a very potent vasoconstrictor and is responsible for
more immediate decrease of temperature.
 Cessation of smoking arrest the disease
 Clinical findings: Cold distal extremity
 Lesions usually distal to knees or elbows
Clinical manifestations:
a) The first symptoms is usually intermittent claudication, often of the
instep initially and of the calf with further progression of the disease
b) Upper extremity involvement and cold sensitivity are seen frequently
c) Ischemic rest pain in the digits Is often associated with ulceration and
gangrene
d) If Px comtinue to smoke even with the presence of disease, minor and
then major amputations are required to remove the gangrenous tissue.

OTHERS: (Robbins p.556-576)

A. Arteriosclerosis – intimal smooth muscle proliferation, elastic tissue
proliferation and eventually replacement by hyalinized fibrous
connective tissue

B. Takayasu’s Disease (Pulseless Disease; Primary Aortic Arteritis)

 An idiopathic inflammatory condition of the aorta and its branches
 Affect intima and adventitia
 Affect young adults

C. Monckeberq’s medial Sclerosis

 Condition characterized by isolated rings of calcification in the
tunica media with normal intina
 Affects elderly

Test and measurements of arterial sufficiency (Kisner p.827)

- Palpation and comparison of pulses in the involved and uninvolved upper and
lower extremities
- Skin temperature
 - Skin integrity and pigmentation
- Test for reactive hyperemia (rubor dependence)
- Claudation time
- Ultrasonography, Doppler measurement of blood flow, transcutaneous
oximetry
- Magnetic resonance angiography
- Arteriography

II. VENOUS DYSFUNCTION:

1. Phlebitis or thrombophlebitis (Tortora p.759)
 Vein wall inflamed causing damage to the endothelial lining or which
platelets are deposited leading to thrombus formation
 Usually seen in a male under 45y/o
 Greater Saphenous vein Is usually involved
 Inflammation of a vein involving clot formation
 Superficial thrombophlebitis occurs in veins under the skin especially in
the calf (Tortora, 5th Edition, pp 759)

Clinical signs and symptoms:

a) Dull pain in the region of the involved vein
b) Redness and tenderness along the course of the vein
c) Subcutaneous venous distention
d) Palpable end
e) Warmth
f) (-) edema of the extremities
g) (-) deep calf tenderness
h) Swelling of the extremity
i) Inflammation and discoloration of the extremity
j) Rapid pulse

Risk Factors:
a) Immobility
b) Obesity
c) Age of Px (risk increase with age)
d) Orthopedic injuries
e) Postoperative Px
f) Congestive heart failure
g) Malignancy
h) Use of oral contraceptives
i) Pregnancy

2. Phlebothrombosis
 Most important complication following surgery
 Most common on the left side
 Refers to thrombosis of deep venous system, not accompanied by
immediate signs or symptoms of inflammation (usually the Calf)
 Superficial veins are usually involved
 3. Deep Venous Thrombosis (Braddom p.798 -799)
 Partial or complete occlusion of a vein by a thrombus with a secondary
inflammation reaction in the wall of the vein
 F>M
 Adult>children
 Frequently involves the deep veins of the lower extremity and the pelvis

Predisposing Factor:
a) Major general surgery
b) Total hip replacement
c) Prolonged bed rest
d) Cardiac failure or stroke
e) Use of oral contraceptives drugs
f) Cigarette smoking
g) Cancer particularly adenocarcinoma of the pancreas ,prostate, breast
and

Complications:
a) Pulmonary embolism with acute respiratory failure
b) Venous valvular damage resulting to postphlebitis state
c) Chronic pulmonary hypertension secondary to repeated pulmonary
emboli
d) Increase incidence of future deep venous thrombosis

4. Thromboembolism
 A venus thrombi that becomes dislodge forms an emboli which can travel
to the right side of the heart and reach the lungs.

Clinical Signs and symptoms:

a) Pain
b) SOB
c) Tachycardia

Predisposing Factors
a) Immobilization
b) Hypercoagulability
c) Local vessel trauma

B. Chronic Venous Disease

Signs and Symptoms:
a) Pain
b) Heaviness
c) Edema
d) Varicosities
e) Subcutaneous fibrosis
f) Skin pigmentation
g) Dermatitis
 h) Ulceration

1. Chronic venous insufficiency (Sullivan p.652, De Lisa p.800-801)

 One of the most frequently seen vascular problem

Clinical manifestation:
a) Dilated veins
b) Leg pain
c) Progressive edema of the involved extremity
d) Cutaneous changes e.g stasis dermatitis
e) Thin,shiny,atrophic,cyanotic skin.
f) Brownish discoloration
g) Thick and fibrous subcutaneous tissue
h) Ulceration – in later age

Etiology:
a) High venous pressure
b) Capillary dilation
c) Problems in the pumping action of the calf muscle

2. Varicose Veins (Tortora, 10th Edition,pp.702 Sullivan,5th Edition,pp.644)

 predominantly develops in the LE especially the greater saphenous vein

consists of abnormal dilated ,elongated and tortuous alterations basic
valvular incompetence that exist secondary to defective valves or weakness
of the vein walls

 When a leaky venous valves can cause veins to become dilated and twisted
in appearance. Happens when the walls of veins weaken or are enlarged ,the
valves cannot function properly and blood pools in the veins ,eventually the
veins become dilated.

Clinical Signs and Symptoms

 dull aching, heaviness or a feeling of fatigue brought about by period of

standing(most common complaint)

 cramps often at night(relieved with leg elevations)

 itching from associated eczematoid dermatitis

 brownish pigmentation and thinning of skin above the ankle

Complications:

 edema and ulceration of the skin of the distal leg may develop

 chronic stasis dermatitis with fungal and bacterial infection

 thrombophlebitis
  local trauma or prolonged sitting can lead to superficial venous thrombosis

Test and measures of venous sufficiency (kisner p.832)

- Girth measurement of upper and lower extremities

- Percussion test
- Homan’s sign
- Response to compression of the limb with a blood pressure cuff
- Doppler ultrasonography
- Venous duplex screening/scanning
- Venography

3. Lymphatic Disorder (Sullivan,10th Edition,pp.653)

Lymphedema
an excessive accumulation of fluids in tissue spaces which result in swelling of
the extremity or body part secondary to malformation or obstruction of
lymphatic channels from trauma, infection ,radiation or surgery

it is a chronic d/o characterized by an abnormal accumulation of lymph fluid in

the tissues of one or more body regions

can develop within a few weeks of insult or as long as 30years

Clinical Stages:

I. Edema easily pits in response to P° and is reduce in response to elevation.

There’s no evidence of thickened spongy fibrosis on exam

II. Edema does not easily pit with P° and does not reduce with elevation.
Some degree of fibrosis maybe present.

III. Edema is irreversible with fibrosis and sclerosis of the skin and
subcutaneous tissue

CLASSIFICATION:
I. Primary Lymphedema
is caused by a condition that is congenital or hereditary; lymph nodes r lymph
vessels formation is abnoamal
a. Hereditary (Milroy's Disease)
transmitted as an autosomal dominant trait
enlargement of an extremity at birth with firm, non-pitting edema
childs developmental activities are not impaired

b. Congenital
no past family Hx of lymph edema

c. Lymphedema Praecox
mostly affects females in their 2nd-3rd decade without apparent etiology
soft and non-pitting edema followed by firm non-pitting edema

d. Lymphedema Tarda
non-pitting and firm edema with common recurrent infection over 35 y/o

II. Secondary Lymphedema

is caused by an injury to one or more components of lymphatic system: some
portion of lymphatic system has been blocked, dissected, fibrosed or
otherwise damaged or altered.(Sullivan,10th Edition,pp.654)
more prevalent than Primary Lymphedema
most common cause is surgery and/or radiation therapy as part of breast CA
treatment

Clinical Presentation: (Sullivan, 10th edition, pp.654)

swelling distal to or adjacent to the area where system function has been
impaired
swelling usually not relieved by elevation
dermal abnormalities
loss of mobility and Rom
impaired wound healing
fibrotic changes of the dermis
early stage: pitting edema
late stage: non-pitting edema
numbness and tingling
feeling of fatigue, heaviness, P°, or tightness in the affected area
discomfort varying from mild to intense
Test for Intermittent Claudication
stoop test
bicycle test
treadmill test

Management:
A. For Arterial Insufficiency
 anti-platelet therapy
 vasodilator drugs
 beta blockers
 blood flow enhancing agents
 anti-oxidants
Rehabilitation Management:
 general self care measures
 exercises
 angioplasty
 surgical revascularization
 intermittent pneumatic compression
 chelation therapy
B. For Venous Insufficiency
 anti-coagulants
 heparin
 low molecular weight heparin
 warfarin
 thrombolitic agent

Rehabilitation Management:
 compression
 exercise
Surgery:
 Sclerotherapy
 Subfascial Endoscopic Perforator Vein Surgery
 Deep Vein Reconstruction
C. Lymphatic Disease
 Diuretic agents
 Anti-biotic therapy
 Benzopyrones
Rehabilitation Management:
 Skin care
 Specialized massage
 Compression
Compression bandage
Compression Garments
 Elevation
 Exercise
 Gasopneumatic compression therapy

Surgery
 Excisional Debulking
 Reconstruction of Lymphatics