Peripheral vascular system

Salome Khazhalia MD. PHD candidate 2024

Anatomy and Physiology
 INTIMA
• a single continuous lining of endothelial cells
with remarkable metabolic properties.
• Intact endothelium synthesizes regulators of
thrombosis such as prostacyclin, plasminogen
activator, and heparin-like molecules.
• It produces prothrombotic molecules such as
von Willebrand factor and plasminogen
activator inhibitor. vasoconstrictors like
endothelin and angiotensin-converting
enzyme, and vasodilators such as nitric oxide
and prostacyclin.
• Atheroma formation begins in the intima,
where circulating lipoproteins, especially
low-density lipoproteins inserted
 Media
• The media is composed of smooth
muscle cells that dilate and constrict
to accommodate blood pressure and
flow.
 Arterial Branching
• The aorta and its immediate branches are
large highly elastic arteries such as the
common carotid and iliac arteries.
• These arteries course into medium-sized
muscular arteries such as the coronary
and renal arteries
• Medium-sized arteries divide into small
arteries less than 2 mm in diameter and
even smaller arterioles with diameters
from 20 to 100 µm
• . From the arterioles, blood flows into the
vast network of capillaries, each the
diameter of a single red blood cell, only 7
to 8 µm across. Capillaries have an
Arterial Pulses
• The brachial artery at the bend
of the elbow just medial to the
biceps tendon

• ■ The radial artery on the lateral

flexor surface

• ■ The ulnar artery on the medial

flexor surface
 Pulses in the Abdomen
• In the abdomen
Celiac trunk: esophagus, stomach,
proximal duodenum, liver, gallbladder,
pancreas, spleen (foregut)
■ Superior mesenteric artery: small
intestine—jejunum, ileum, cecum;
large intestine—ascending and
transverse colon, right splenic flexure
(midgut)
■ Inferior mesenteric artery: large
intestine—descending and sigmoid
colon,rectum
 Pulses in the Legs

• ■ The femoral artery just below the

inguinal ligament
• ■ The popliteal artery, an extension of
the femoral artery that passes
medially behind the knee
• ■ The dorsalis pedis (DP) artery on the
dorsum of the foot just lateral to the
extensor tendon of the big toe
• ■ The posterior tibial (PT) artery lies
behind the medial malleolus of the
ankle. An interconnecting arch
between its two chief arterial
branches protects circulation to the
 Veins
• The great saphenous vein, which
originates on the dorsum of the foot,
passes just anterior to the medial
malleolus, continues up the medial
aspect of the leg, and joins the femoral
vein of the deep venous system below
the inguinal ligament
• ■ The small saphenous vein, which
begins on the lateral side of the foot,
passes upward along the posterior calf,
and joins the deep venous system in
the popliteal fossa.
• Bridging or perforating veins connect
the superficial system with the deep
 The Lymphatic System

• Lymph nodes are round, oval, or bean-

shaped structures that vary in size
according to their location. Some
lymph nodes, such as the preauricular
nodes, if palpable at all, are typically
very small.
• The inguinal nodes, by contrast, are
relatively larger—often 1 cm in
diameter and occasionally 2 cm in an
adult.
• Only the superficial lymph nodes are
accessible to physical examination.
These include the cervical nodes the
axillary nodes and nodes in the arms
 Lymph nodes of the arm.
• Epitrochlear lymph nodes are located
on the medial surface of the arm
approximately 3 cm above the elbow.
• from 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
the epitrochlear nodes.
• Lymphatics from the rest of the arm
drain primarily into the axillary nodes.
 Superficial inguinal lymph nodes
• . The superficial inguinal nodes include
two groups.
• The horizontal group lies in a chain high
in the anterior thigh below the inguinal
ligament. It drains the superficial
portions of the lower abdomen and
buttock, the external genitalia (but not
the testes), the anal canal and perianal
area, and the lower vagina.
• The vertical group clusters near the
upper part of the saphenous vein and
drains a corresponding region of the
leg.
Common or Concerning Symptoms

• ● Abdominal, flank, or back pain

• ● Pain or weakness in the arms or legs
• ● Intermittent claudication
• ● Cold, numbness, pallor in the legs; hair loss
• ● Swelling in calves, legs, or feet
• ● Color change in fingertips or toes in cold weather
• ● Swelling with redness or tenderness
 Peripheral Arterial Disease.
• PAD refers to stenotic, • Peripheral Arterial Disease “Warning Signs”
occlusive, and aneurysmal • ● Fatigue, aching, numbness, or pain that
disease of the abdominal limits walking or exertion in the legs; if
aorta, its mesenteric and present, identify the location. Ask also about
renal branches, and the erectile dysfunction.
arteries of the lower
extremities, exclusive of the • ● Any poorly healing or nonhealing wounds
coronary arteries. of the legs or feet
• ● Any pain present when at rest in the lower
leg or foot and changes when standing or
supine
• ● Abdominal pain after meals and associated
“food fear” and weight loss
• ● Any first-degree relatives with an AAA
 Health Promotion and Counseling: Evidence and
Recommendations
• ● Screening for lower-extremity peripheral artery disease
• ● The ankle–brachial index
• ● Screening for renal artery disease
• ● Screening for abdominal aortic aneurysm
Screening for Lower-Extremity Peripheral Artery Disease

• Prevalence increases with age, ranging from around 5% at

ages 40 to 49 years to 15% to 20% in persons aged 80 years
and older.
• Cardiovascular risk factors, particularly smoking and diabetes,
increase risk for PAD.
• 40% to 60% of PAD patients have coexisting coronary artery
disease and/or cerebral artery disease,
• Only a minority of PAD patients have classic claudication
(exertional calf pain relieved by rest), and many are
asymptomatic.
 The Ankle–Brachial Index
• The ABI is the ratio of blood pressure measurements in the foot and
arm; values <0.9 are considered abnormal
• Association (ACCF/AHA) practice guidelines recommend measuring
ABI in those at risk,(Age ≥65 years , Age ≥50 years with a history of
diabetes or smoking , Leg symptoms with exertion , Nonhealing
wounds) in order to offer therapeutic interventions to reduce the risk
of cardiovascular events.
• sensitivity of an abnormal ABI is low (15% to 20%), the specificity is
99%
• 1. Patient should rest supine in a warm room for at least 10 min before testing.
• 2. Place blood pressure cuffs on both arms and ankles as illustrated, then apply
ultrasound gel over brachial, dorsalis pedis, and posterior tibial arteries.
• 3. Measure systolic pressures in the arms ■ Use vascular Doppler to locate
brachial pulse ■ Inflate cuff 20 mm Hg above last audible pulse ■ Deflate cuff
slowly and record pressure at which pulse becomes audible ■ Obtain 2
measures in each arm and record the average as the brachial pressure in that
arm 4. Measure systolic pressures in ankles ■ Use vascular Doppler to locate
dorsalis pedis pulse ■ Inflate cuff 20 mm Hg above last audible pulse ■ Deflate
cuff slowly and record pressure at which pulse becomes audible ■ Obtain 2
measures in each ankle and record the average as the dorsalis pedis pressure in
that leg ■ Repeat above steps for posterior tibial arteries
• Inflate cuff 20 mm Hg above last audible
pulse
• ■ Deflate cuff slowly and record pressure at
which pulse becomes audible
• ■ Obtain 2 measures in each arm and record
the average as the brachial pressure in that
arm
• 4. Measure systolic pressures in ankles , Use
vascular Doppler to locate dorsalis pedis
pulse.
• Inflate cuff 20 mm Hg above last audible
pulse
• ■ Deflate cuff slowly and record pressure at
which pulse becomes audible
• ■ Obtain 2 measures in each ankle and
record the average as the dorsalis pedis
pressure in that leg
• ■ Repeat above steps for posterior tibial
arteries
Interpretation of Ankle–Brachial Index
• >0.90 (with a range of 0.90 to 1.30) = Normal lower extremity blood
• 0.89 -0.60 = Mid PAD
• 0.59 -0.40 = Moderate PAD
• <0.39- severe PAD
 Screening for Renal Artery Disease.

• Onset of hypertension at age ≤30 years

• Onset of severe hypertension at age ≥55 years
• Accelerated (sudden and persistent worsening of previously controlled
hypertension), resistant (not controlled with three drugs), or malignant
hypertension (evidence of acute end-organ damage)
• New worsening of renal function or worsening function after use of an
angiotensin-converting enzyme inhibitor or an angiotensin-receptor
blocking agent
• An unexplained small kidney or size discrepancy of >1.5 cm between the
two kidneys
• Sudden unexplained pulmonary edema, especially in the setting of
worsening renal function
 Screening for Abdominal Aortic Aneurysm
• AAA is defined as an infrarenal aortic diameter ≥3 cm
• Because symptoms are uncommon and screening can reduce AAA-related
mortality by about 50% over 13 to 15 years.
• the USPSTF makes a grade B recommendation for one-time ultrasound
screening of men aged 65 to 75 years who have smoked more than 100
cigarettes in a lifetime.
 Techniques of Examination
• Key Components of the Peripheral Arterial Examination
• ● Measure the blood pressure in both arms
• Palpate the carotid upstroke, auscultate for bruits
• ● Auscultate for aortic, renal, and femoral bruits; palpate the aorta and
assess its maximal diameter
• ● Palpate the pulses of the brachial, radial, ulnar, femoral, popliteal, DP,
and PT arteries.
• ●Inspect the ankles and feet for color, temperature, and skin integrity;
note any ulcerations; inspect for hair loss, trophic skin changes,
hypertrophic nails.
 Radial and brachial artery palpation

• If you suspect arterial insufficiency,

palpate the brachial pulse. Flex the
patient’s elbow slightly, and palpate
the artery just medial to the biceps
tendon at the antecubital crease The
brachial pulse can also be palpated
higher in the arm in the groove
between the biceps and triceps
muscles. Palpate one or more
epitrochlear nod
 Epitrochlear nodes palpation

• patient’s elbow flexed to about

90º and the forearm supported
by your hand, reach around
behind the arm and feel in the
groove between the biceps and
triceps muscles,
• Epitrochlear nodes are difficult
to identify in most healthy
people.
 Legs
• Their size, symmetry, and any swelling or edema
• The venous pattern and any venous enlargement
• Any pigmentation, rashes, scars, or ulcers
• The color and texture of the skin, the color of the nail beds, and the
distribution of hair
• Inspect the color of the skin.
• Inspect the saphenous system for varicosities
Palpation: The Peripheral Pulses.
Popliteal pulse
• The patient’s knee should be
somewhat flexed, with the leg relaxed.
• Place the fingertips of both hands so
in the midline behind the knee and
press them deeply into the popliteal
fossa
• The popliteal pulse is more difficult to
find than other pulses. It is deeper and
feels more diffuse.
• If you cannot palpate the popliteal
pulse with this approach, try with the
patient prone.
 DP, PT

• The DP pulse. Palpate the dorsum of

the foot , just lateral to the extensor
tendon of the great toe
• The PT pulse. Curve your fingers
behind and slightly below the
medial malleolus of the ankle
• This pulse may be hard to feel in a
fat or edematous ankle
The Peripheral Veins: Swelling and Edema.

• If swelling or edema is present,

palpate for pitting edema.
• Press firmly but gently with your
thumb for at least 2 seconds
over the dorsum of each foot,
behind each medial malleolus,
and over the shins
• The severity of edema is graded
on a four-point scale, from slight
to very marked.
 Special Techniques
• Evaluating Arterial Perfusion of the
Hand.
• The Allen test compares patency of
the ulnar and radial arteries.
• Ask the patient to make a tight fist
with one hand; then compress both
radial and ulnar arteries firmly
between your thumbs and fingers
 Allen test

• Next, ask the patient to open the

hand into a relaxed, slightly flexed
position The palm is pale.
• Release your pressure over the ulnar
artery. If the ulnar artery is patent,
the palm flushes within about 3 to 5
seconds
• Test patency of the radial artery by
releasing the radial artery while still
compressing the ulnar artery
Postural Color Changes of Chronic Arterial Insufficiency

• Raise both legs to about 90º for up to 2

minutes until there is maximal pallor of the
feet.
• Then ask the patient to sit up with legs
dangling down. Compare both feet, noting the
time required for: Return of pinkness to the
skin, normally about 10 seconds or less .
• Gravity aids blood flow and colour returns in
the ischaemic leg. The skin at first becomes
blue, as blood is deoxygenated in its passage
through the ischaemic tissue, and then red,
due to reactive hyperaemia from post-hypoxic
vasodilatation.
Evaluating the Competency of Venous Valves.
• Use the retrograde filling (Trendelenburg) test ■
With the patient supine, elevate one leg to about
90º to empty it of venous blood.
• ■ Occlude the great saphenous vein in the upper
thigh by manual compression, using enough
pressure to occlude this vein but not the deeper
vessels.
• ■ Ask the patient to stand. While you keep the
vein occluded, watch for venous filling in the leg.
Normally, the saphenous vein fills from below,
taking about 35 seconds as blood flows through
the capillary bed into the venous system.
• ■ After the patient stands for 20 seconds, release
the compression and look for sudden additional
venous filling. Normally, slow filling continues
because competent valves in the saphenous vein
block retrograde flow.
 Recording the Physical Examination—The Peripheral Vascular System

• “Extremities are warm and without edema. No varicosities or stasis

changes. Calves are supple and nontender. No femoral or abdominal
bruits. 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. Rubor noted when legs
dependent but no edema or ulceration. Bilateral femoral bruits; no
abdominal bruits heard. Brachial and radial pulses 2+; femoral, popliteal,
DP and PT pulses 1+.” (Alternatively, pulses can be recorded as below.)
 Types of Peripheral Edema
• Pitting Edema Edema is a soft, bilateral palpable swelling from
increased interstitial fluid volume and retention of salt and water,
demonstrated by pitting after 1 to 2 seconds of thumb pressure on
the anterior tibiae and feet. Pitting edema occurs in several
conditions: when legs are dependent from prolonged standing or
sitting, which leads to increased hydrostatic pressure in the veins and
capillaries; heart failure leading to decreased cardiac output;
nephrotic syndrome, cirrhosis, or malnutrition leading to low albumin
and decreased intravascular colloid oncotic pressure; and with
selected medications.
 Types of Peripheral Edema
• Pitting Edema Edema is a soft, bilateral
palpable swelling from increased
interstitial fluid volume and retention of
salt and water, demonstrated by pitting
after 1 to 2 seconds of thumb pressure
on the anterior tibiae and feet.
 Chronic Venous Insufficiency
• Edema is soft, with pitting on
pressure, and occasionally
bilateral. Look for brawny
changes and skin thickening,
especially near the ankle.
Ulceration, brownish
pigmentation, and edema in the
feet are common. It arises from
chronic obstruction and
incompetent valves in the deep
venous system.
Lymphedema
• Edema is initially soft and pitting, then
becomes indurated, hard, and
nonpitting.
• Skin is markedly thickened; ulceration is
rare.
• There is no pigmentation.
• Edema often occurs bilaterally in the feet
and toes.
• Lymphedema arises from interstitial
accumulation of protein-rich fluid when
lymph channels are infiltrated or
obstructed by tumor, fibrosis, or
inflammation, or disrupted by axillary
node dissection and or radiation.
 clinical case
• A 27-year-old male patient, non-smoker, presented to the
Rheumatology Department with a 3-week history of painful
erythematous lesions on both shins. He also mentioned low-grade
fever (up to 37.5°C), fatigue and arthralgia. He did not have any
significant past and family medical history. There was no history of a
similar episode in the past. There were no symptoms of cough or
weight loss . He did not take any medications.
 Clinical case
• Physical examination revealed multiple rounded purplish nodules located
bilaterally on the extensor surface of the lower extremities.
• Tarsal joints were swollen and tender.
• Additionally, the patient was afebrile, in a good general condition .
• Laboratory investigations revealed an elevated C-reactive protein – CRP (119.82
mg/l, normal 5.0 mg/l) and erythrocyte sedimentation rate – ESR (74 mm/h;
normal 0–10 mm/h).
• Urine and blood culture results were negative.
• Throat swab revealed growth of normal flora.
• His chest X-ray revealed bihilar lymphadenopathy.
Lower extremity
CT

• Further evaluation with high

resolution chest computed
tomography confirmed the
lymphadenopathy and also
demonstrated thickened
bronchial walls of both lungs and
nodular lesions
Erythema nodosum

• Painful raised, bilateral erythematous

lesions from inflammation of
subcutaneous fat tissue, seen in
systemic conditions such as pregnancy,
sarcoidosis, tuberculosis, streptococcal
infections, inflammatory bowel disease,
drugs (oral contraceptives)
• Anterior pretibial surfaces of both lower
legs; can also appear on extensor arms,
buttocks, and thighs
 Clinical case
• An 11-year-old girl was admitted to clinic with a history of bluish
discoloration of the fingers of both hands for the past 1½ months.
Initially, discoloration was in the index, middle, and ring finger of
distal phalanx of both hands in a patchy manner, which gradually
progressed to involve the entire distal phalanx and other fingers of
both the hands and was associated with pain.
• she experienced deepening of discoloration after exposure to cold
environment and also had a history of difficulty in holding a pen while
writing
 Past history
• Her past history and birth history were not significant. She had not
achieved menarche.
• Her maternal grandfather died because of myocardial infarction,
maternal grandmother is a diagnosed case of rheumatoid arthritis, and
her mother also has history of joint pain and swelling.
• On examination, her vitals were stable with oxygen
saturation of at room air.
• All the peripheral pulses were well felt and blood
pressure was within normal limit for age.
• There were no signs of vitamin deficiency,
petechiae/purpura, malar rash, joint swelling, and
cafe-au lait spots.
• There were no signs suggestive of scleroderma,
Sjogren's syndrome, or lupus erythematosus.
• Systemic examination and ophthalmic examination
were normal.
• Local examination revealed cold palms and bluish
discoloration of the distal phalanges of all digits, and
minimal discoloration of toes of both feet this
discoloration were more marked on exposure to cold
Clinical case
• hemoglobin 11.1 gm%, white blood cell
count 11,100/mm3,
• tuberculin test being negative.
• Her liver, kidney, and thyroid functions
were within normal limit.
• Coagulation profile, lipid profile, and D-
dimer assay were normal with, Australia
antigen, hepatitis C as well as HIV
serology were all negative.
• Antinuclear antibody (ANA) titer was
1:100 by indirect immunofluorescence
assay, but anti-dsDNA antibody,
phospholipid antibody, anti-Smith
antibody, and rheumatoid factor
were negative.
 Clinical case

• A well-developed, 30-year-old White male presented to the primary

care office complaining that his cough and dyspnea was not
improving and that his symptoms were worse. The adolescent had
been seen 3 days prior at an urgent care center for cough and fever.
He was diagnosed with pneumonia and prescribed azithromycin.
• Review of the adolescent's health history during the office visit
showed that his family were negative for any major illness.
• The past history , patient had 2 spontaneus abortion and was
diagnosed with antiphospholipid andtibody syndrome.
 Vital sighns
• BP- 110/82 mmHg; HR- 130/min, RR- 29/min; SaO2- 87% on RA,
increased to 95% w/ 2L of O2. Exam: No heart murmurs, bilateral lung
crackles at bases, JVD was difficult to assess due to the patient’s
obesity, no lower extremity edema noted Lab Results: Normal CBC,
Creatinine- 0.9 mg/dl, BNP- 180 pg/mL, Ddimer- 1900 ng/mL,
troponin- 4.77 ng/lL, CKMB 15.8, CPK-184 U/L Blood gas analysis: Ph
7.18, PaCO2 31 mmHg, PaO2 55 mmHg
Lower extremities
ECG
• On initial examination, the patient
had tachycardia, bilateral visible
supra-clavicular pulsations, severe
pallor, and systolic murmur in the
pulmonary area radiating all over
the precordium. The patient was
hemodynamically stable. The ECG
showed sinus tachycardia and an
"S1Q3T3" pattern
ECHOCARDIPGRPHY
CT scan