11. Peripheral arterial & venous disease

Question 1

Outline the structure of venous anatomy within the lower limb.

Answer 1

Divided into superficial and deep veins, perforating veins travel from superficial to deep.

Question 2

What are the deep veins of the lower limb?

Answer 2

External iliac, Femoral, Popliteal vein

Question 3

What are the superficial veins of the lower limb?

Answer 3

Long and short saphenous

Question 4

What is the one vein that remains constant in the body, despite anatomical variation?

Answer 4

Long saphenous vein runs anterior to the medial malleolus.

Question 5

How does the calf muscle pump aid venous flow?

Answer 5

When the calf muscle contracts, the pressure rises due to the deep fascia compartmentalisation, propelling the venous blood towards the heart.

Question 6

What is the doppler test?

Answer 6

Ultrasound test which uses high frequency sound waves to assess blood flow in a vessel.

Question 7

What is the pathophysiology of varicose veins?

Answer 7

Vein wall is inherently weak, leading to dilatation and separation of valve cusps, making them incompetent.

Question 8

What are symptoms associated with varicose veins?

Answer 8

Heaviness, tension, aching, itching

* along the vein itself*

Question 9

What are the complications of varicose veins ( the veins themselves)?

Answer 9

Vein haemorrhage, thrombophlebitis

Question 10

What are the complications of varicose veins as a result of venous hypertension?

Answer 10

Oedema
Skin pigmentation
Varicose eczema 
Venous ulceration
Lipodermatosclerosis

Question 11

When do varicose veins usually haemorrhage and cause bleeding?

Answer 11

Shower - warm heat causes vasodilation and standing up increases pressure at the feet.
- Lie down and lift leg.

Question 12

What is thrombophlebitis?

Answer 12

Inflammation and swelling in the veins due to a clot. Inflammatory response initiated!

Question 13

What symptoms are associated with thrombophlebitis?

Answer 13

Pain

Haemosiderin staining due to increased capillary permeability

Question 14

What leads to venous ulceration?

Answer 14

Calf muscle pump failure leads to venous hypertension which leads to venous ulceration.

Question 15

What are some causes of calf muscle pump failure?

Answer 15

• Lack of contraction - immobility, obesity
• Deep vein incompetence
• Volume overload - superficial vein incompetence

Question 16

How can valve incompetence lead to venous ulceration??

Answer 16

If valve incompetent, blood will return back down superficial vein and back into the calf muscle pump, causing dilation and venous hypertension which can lead to venous ulceration.
= retrograde circuit

Question 17

Which of virchow’s triad occurs in arteries?

Answer 17

Changes in the lining of the vessel wall

Question 18

Which of virchow’s triad is common in veins and leads to thombosis?

Answer 18

Changes in blood flow - stasis + another factor leads to venous thrombosis

Question 19

What can cause venous stasis?

Answer 19

Trauma - surgery
Oral contraceptive pill
Dehydration
Cancer

Question 20

How do arterial thrombi differ to venous thrombi?

Answer 20

Arteries spurt when they bleed, so thrombi are platelet reach.
Thrombi do not spurt, thrombi are fibrin rich.

Question 21

What pathways are needed to cause arterial and venous thrombosis?

Answer 21

Venous - intrinisic, then extrinisic.

Arterial - platelets, extrinsic and then intrinsic.

Question 22

How does the body respond to DVT?

Answer 22

Inflammatory response:

Calor,dolor,rubor, tumor, loss of function

Question 23

What are the symptoms of DVT?

Answer 23

Pain, cannot walk
Swelling
Blue-red skin discolouration

Question 24

What are the signs of DVT?

Answer 24

Calf tenderness
Skin warmth
Skin discolouration 
Distended, warm superficial veins 
Oedema
Pyrexia

Question 25

Why is surgery considered a significant risk factor for DVT?

Answer 25

• Immobility prior and following to surgery
• No calf muscle pump during surgery
• Surgery = trauma, prothrombotic state

Question 26

What is a fatal consequence of DVT?

Answer 26

PE

Question 27

Explain why a complete arterial occlusion may present without consequences?

Answer 27

If chronic development of an atheroma, body develops collateral circulation which bypasses the stenosis.

Question 28

What is acute limb ischaemia?

Answer 28

Limb goes from a normal blood supply to greatly impaired within minutes - no time for collateral vessel development.
Patient will die of hyperkalaemia if not amputated.

Question 29

What are the commonest causes of acute limb ischaemia?

Answer 29

Embolism, trauma

Question 30

What are the 6 symptoms/signs of acute limb ischaemia?

Answer 30

6 P's:
Pain
Pallor
Paralysis
Paraesthesia
Perishing cold
Pulseless

Question 31

How might the appearance of a leg with acute limb ischaemia present and progress?

Answer 31

Initially pale, develops blanching patches before fixed, mottling which is non-blanching.

Question 32

How might chronic peripheral arterial disease present?

Answer 32

Intermittent claudication

Question 33

Which artery in the lower limb is most commonly diseased?

Answer 33

Superficial femoral artery

Question 34

Where can arterial pulses be palpated in the lower limb?

Answer 34

Femoral pulse - MIPA
Popliteal pulse - deep
Pedal pulse - dorsalis pedis artery

Question 35

What pulses will be present if the superficial femoral artery is occluded?

Answer 35

Femoral pulse present

Popliteal & pedal pulses absent

Question 36

How do the symptoms of critical arterial ischaemia differ from chronic?

Answer 36

REST PAIN - pain in the foot that continues when the patient goes to bed.
Relieved by hanging the foot out of the bed.

Question 37

What are 3 reasons why the pain is worse when lying in bed?

Answer 37

1. No gravity effect
2. Decreased CO
3. Higher O2 demand - warmer

Question 38

What can critical arterial ischaemia lead to?

Answer 38

Gangrene

Ulceration (anterior tibia most common)