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PERIPHERAL VASCULAR DISEASES

ARTERIAL DISEASE
acute
Acute Embolism
Acute Thrombosis
Vasospastic disease
chronic
Atheriosclerosis Obliterans
Thromboangiitis Obliterans
Diabetic Angiopathy

VENOUS DISEASE
acute
Thrombophlebitis
Phlebothrombosis
Thromboembolism
Deep Vein Thrombosis
chronic
Varicose Vein
Chronic Venous Insufficiency

LYMPHATIC DISEASE
Lymphedema


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ACUTE EMBOLISM


  - the most common encountered form of acute arterial disease.
  - Thrombus in the heart is the most common source (from MI or 
      valvular diseases)
  - Acute onset of excruciating pain with weakness and numbness
  - Requires emergency embolectomy or anticoagulation

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ACUTE THROMBOSIS


  - usually occurs in area with previously existing atherosclerotic 
     lesion
  - most common site is the lower end of the femoral artery
  - involves larger arterial vessels than embolism so causes greater
     damage

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VASOSPASTIC DISEASE

  a. Raynaud’s phenomenon 
         – refers to episodic digital vasospam 
      in response to cold exposure or emotional stress. 
         - The vasosconstriction results in pallor and numbness which
      persists for the duration of the cold stimulus. This is followed 
      by cyanosis and later by reactive hyperemia and rubor. The
      condition is present secondary to certain underlying diseases
      like Connective tissue diseases, PVD’s, primary pulmonary 
      hypertension and occult carcinoma or secondary to drugs like 
      Beta blockers and oral contraceptives or those with prolonged
      exposure to vibration.

  b. Raynaud’s disease
         - is the primary idiopathic form of cold hypersensitivity and 
      primarily affects young, healthy women (60-90%)
         - heredity may play a role because of its association with
      migraine and hypertension.
    
  Criteria for the Dx of Raynaud’s disease:
    a. episodes of reynaud’s phenomenon
    b. bilateral involvement
    c. absence of gangtene
    d. no underlying disease
    e. history of symptoms for at least 2 years

  Specific theories for the etiology of Raynaud’s disease
    a. abnormal sympathetic activity
    b. abnormal digital vessels
    c. abnormal immunologic process

  Diagnostic tests
    a. Ice water immersion test
    b. Serial digital pulp temperature measurement
	
  Treatment
    a. vasodilator
    b. warm mittens
    c. temperature biofeedback
    d. avoid cold exposure
    e. avoid stress or relaxation tech is indicated
    f. avoid smoking

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ARTERIOSCLEROTIS OBLITERANS


  - also called Chronic arterial disease, Obliterative arteriosclerosis   
      or Arteriosclerosis occlusive disease
  - involves the large and medium sized arteries particularly of the
      LE and the occlusive lesion is called an atheromatous (lipid
      cholesterol, macrophages, and proliferating smooth muscle cells)
      that obstruct the lumen and impair blood flow.\
  - the most commonly affected arterial segment is between the 
      superficial femoral and popliteal artery (located in the Hunter’
      canal)
  - predominant in men between ages 50-70

  - risk in women after menopause approaches that of men
	
  Risk factor
   a hyperlipidemia
   b.hypertension
   c.smoking
   d.DM
   e.Obesity
   f. Hyperuricemia
   g.Sedentary lifestyle
   h.(+) family history

  S/Sx
   a. intermitted claudication vs Pseudoclaudication
* as the disease progresses, the pain may be present at rest
   b. pain, pallor, paresthesia, pulselessness, and paresis
   c. (+) signs of rubor of dependency
   d. skin color and pigmentation changes
   e. foot is cold to touch
   f. trophic changes – thin skip, dry and scaly skin, hairless
   g.late stages – tissue nocrosis and ulceration

  DDx
a. spinal stenosis			e. plantar neuroma
b. Arthiritis of hip and knee		f. herniated IV disc
c. Peripheral neuropathy		g. tarsal tunnel syndrome
d. Popliteal artery entrapment   	h. McArdle’s disease

  Laboratory Tests:
   a. Inpedance plethysmography
   b. Doppler ultrasound
   c. Arteriography
   d. Transcutaneous measurement of 02 tension
   e. Duplex scanninh
   f. Pneumatic cuff ankle-brachial index/ratio (ABI)

    Normal	        >0.9 / 1		
    Mild		0.7 – 0.9
    Moderate	        0.4 – 0.6
    severe              <0.4
 
  Treatment:
   a. Patient’s education, risk factor modification, daily foot 
       care and skin exam, smoking cessation, caloric restriction.
   b. Treat underlying DM, hypertension, DM, heart disease,
       hyperuricemia
   c. Edema control and local wound care
   d. Shoes and protective foot devices
   e. Elevating head of bed 6-8 inches
   f.  Analgesic and vasodilators
   g. Therapeutic exercise – conditioning, aerobic to increase	
       threshold
   h. Orthotics – AFO or patellar tendon bearing orthosis (decrease 
       PF activity and help in push off)
   i. Surgery – in severe cases
            - sympathectomy or endarterectomy
   j. Elevate the head than leg
   k Rubor of dependency
   l. Antiamputation drugs
            - aspilet – dev. platelet aggrevation

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THROMBOANGIITIS OBLITERANS


- second most common form of chronic occlusive arterial disease
- predominant in young male smokers (Nicotine is a potent vasocontrictor) 
   characterized by segmental, (thrombosing inflammation of the 
   intermediate and small arteries of the extremities. The disease begins
   distally then progress proximally.
- Etiology is unknown but it has high relationship with cigarette 
   smoking. Possible hypersensitivity to tobacco products and the
   role of cell mediated immune reaction causing vascular damage.
- Clinical manifestations, laboratory tests, and management the same as
   ASO


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DIABETIC ANGIOPATHY

- DM produces both microangipathy and atherosclerotic vascular
   changes.
- The accompanying neuropathy aggravates the skin and tissue
   injury and delay the healing process.
- The elevated blood glucose level affects the lipid and protein
   metabolism and results in accelerated atherosclerosis.


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THROMBOPHLEBITIS

- refers to the inflammation of a vein causing damage to the endothelial 
  lining on which platelets are deposited. S/SX include bursting pain, 
  swelling, tenderness, inflammation and skin discoloration. The blood 
  clot is short and well anchored and embolism is rare.


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PHLEBOTHROMBOSIS

- refers to thrombosis of the deep venous system not accompanied by signs 
  of inflammation. It is caused by stasis of blood and the patient presents 
  with tenderness on squeezing the calfs, (+) Homan sign, edema diatal to 
  the point of obstruction. The blood clot is long and poorly anchored 
  usually propagated and embolism is common and may be massive, the 
  involved site is usually the calf veins.



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THROMBOEMBOLISM

– a venous thrombi that becomes dislodged and travel to the right side 
  of the heart and reach the lungs (pulmonary embolism). Patient 
  complains of  sudden onset of dyspnea, tachypnea, tachycardia and 
  cyanosis and could lead to death if not adequately treated by 
  anticoagulation.





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DEEP VEIN THROMBOSIS

- partial or complete occlusion of a vein by a thrombus with secondary 
  inflammatory reaction in the wall of the vein. Predisposing factors 
  include immobility, major surgery, hip replacement, stroke or heart 
  failure, use of oral contraceptives, erderly people, and cancer patients.
  S/Sx include unilateral leg pain, swelling, warmth, tenderness, fever, 
  (+) Homan sign.







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VARICOSE VEIN

- dilated, tortuous, elongated superficial veins in the lower extremity
  particularly in the long saphenous veins. Females 4x more affected
  because it is affected by hormonal factors

S/Sx:
- dilated, tortuous veins, brownish pigmentation, congestion and 
  edema, dull, aching pain with leg fatigue and heaviness.
- Leg cramps and itching

Diagnosis:
- inspection and Doppler flow meter

Treatment:
1. vein ligation/vein stripping	       5. topical and oral throbolytic	
2. thrombolectomy		       6. elastic stocking
3. sclerotherapy		       7. elevation and massage
4. intermittent		               8. ankle pump
                                       9. Laser surgery
	
Types:

a. Primary varicose veins
- hereditary, more common in females, often with (+) family history
- the primaryabnormality is connective tissue laxity and later with 
  valvular incompetence
- obesity and old age (loss tissue elasticity) are also predisposing 
  factors

b. Secondary varicose veins
- due to high venous pressure in the superficial venous systems
- due to obstruction and valvular incompetence in the deep venous 
  system
- pregnancy
- increased intraabdominal pressure
- jobs requiring prolonged standing
- AV fistula
- oral contraceptive
- aging


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CHRONIC VENOUS INSUFFICIENCY


- high pressure in deep vein due to valvular insufficiency
- in the most frequently seen vascular problem in PT clinic and more 
  prevalent than arterial disease
- the defect is in the venous valves which causes a decrease in venous 
  flow resulting to distal pooling of blood. It is usually the result of 
  congenital or acquired valvular incompetence and, less frequently, 
  obstruction of the veins, although it can occur after DVT and valve 
  destruction (post-phlebitic syndrome)
- the primary problem is increase pressure in the deep venous system 
  secondary to incompetence valves.

- Common Precipatating Conditions:
a. varicose veins		   d. deep venous valve insufficiency
b. deep vein obstruction	   e. prolonged leg dependency
c. congestive heart failure	   f. muscle weakness/immobility

- S/SX 
    - edema
    - varicosities 
    - dermatitis
    - subcutaneous fibrosis 
    - skin pigmentation
    - skin ulceration
    - pain throughout the leg
    - leg heaviness with nighttime relief

- Management

           STAGE			           TREATMENT
Stage I		
         a. edema		       a. gradient elastic stocking 
                                           20-30mmHg
         b. skin pigmentation          b. skin care-moisteurizing

Stage II	
         a. edema		       a. elastic stocking
         b. skin pigmentation	       b. skin care
         c. dermatitis                 c. topical steroids
         d. varicosities               d. surgical consultation, 
                                          elevation, massage

Stage III	
        a. edema		       a. elastic stocking
        b. skin pigmentation	       b. skin care
        c. dermatitis		       c. antiseptic solution
        d. varicosities	               d. elevation/massage/surgery
        e. ulceration		       e. bio-occlusive dressing, 
                                                 external compression boots


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LYMPHEDEMA


- swelling of the extremity or other body parts secondary to 
  malformation or obstruction of the lymphatic channel
	
classification

1. Primary Lymphedema
    a. Hereditary lymphedema – autosomal dominant, Milroy’s 
                                              disease
    b. Congenital

Congenital and Hereditary Lymphedema
     - enlargement of extremities at birth
     - firm, non pitting edema
     - child’s development and activities are not impaired

Conditions associated with Congenital Lymphedema
1. Tuner’s syndrome	4. Congenital absence of nails
2. Noonan syndrome	5. Distichiasis
3. Fabry’s disease      6. Pleural effusion

    c. Lymphedema praecox – 2nd and 3rd decade, females
    d. Lymphedema tarda – after age of 35 years

Praecox and Tarda
    - occurs without apparent etiology
    - firm and non pitting edema later
    - no pain or ulceration
    - recurrent infections are common

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