Arterial diseases and Examination of Arterial system By Dr.

Mohammad Nauman FRCS

Common terminology used in arterial disease

Claudication
intermittent

Ischaemia
Acute chronic

Critical ischemia gangrene

Common disease processes of arterial disease

Thrombosis Embolism Atherosclerosis Arteritis (angiitis) Endartritis obliterans (buergers disease) Arterial spasm Aneurysm Arterio-venous fistula Traumatic arterial injury

Gangrene
It is the death of the tissues with superadded putrefaction Points to note in established Gangrene Extent & colour Gas gangrene Gas, crepitus, odour of hydrogen sulphide Muscle colour Brick red green black Type of gangrene Dry Parts become mummified Wet Putrifaction as In diabetic gangrene Line of demarcation Line between living & dead Limb above the gangrenous area congested, oedematous, pale Black patches indicate skip lesion

Arterial walls

Aneurysms

Mesenteric ischemia

Arteriovenous fistula
Athroma removal

Gangrene
Gangrene of fingers Raynaud, cervical rib, scalene anticus syndrome, Morvans disease painless syringomyelia Uinlateral / Bilateral Atherosclerosis Unilateral first Bilateral Buergers & Raynauds disease Bilateral

Embolic Gangrene Unilateral-- mostly Diabetic Unilateral / bilateral

History
Age & Sex > men than women Old age Atherosclerosis Young men 20-40 years Buergers disease Young women Raynauds disease Middle age Diabetic arteriopathy Limb affected Lower limb Buergers disease Upper limb Raynaud disease Mode of Onset Gradual & spontaneous Buerger, Raynaud Sudden Embolic Trauma or infection Diabetic Gangrene

symptoms
Pain
Two types Claudication

Intermittent pain ClaudioLimp Pain in calf on walking accumulation of P Substance Rest pain Continuous aching pain Cry of dying nerves Pain worse at night, on elevation Pain relieved hanging down below heart level

Site of pain Depends on level of obstruction Foot Tibial / planter aretries Buergers disease Calf Occlusion Femoral-Popliteal Junction Thigh Superficial femoral artery Buttock Occlusion at bifurcation Iliac artery/Aorta Claudication distance Distance walked when pain starts

symptoms
Effects of cold and warmth warmth increases symptoms Raynaud Local syncope digits become cold & white + Tingling & numbness spasm of arteries Local asphyxia digits become blue with burning sensation slow circulation + accumulation of reduced Hb Local recovery release of spasm normal colour

Paraesthesia Tingling, numbness, pins and needles in foot-blood is shunted from skin to muscles Superficial phlebitis Swelling, redness, pain Buergers disease Involvement of other arteries Take H/O Fainting, transient blackouts (cranial), chest pain, (angina, heart), weakness, paraesthesia in upper limb, blurred vision, (ophthalmic), abdominal pain (mesenteric), Impotence abdominal aorta Bilateral Iliac artery occlusion

Physical Examination

Inspection
Colour change Marked pallor
sudden occlusion Embolism, Raynaud disease

Purple blue cyanosed

Severe ischaemia, pregangrene stage Elevation of limb leads to Pallor.

Signs of Ischaemia Thinning of skin, Diminished hair growth Loss of subcutaneous fat, Shininess Brittle nails with transverse ridges Minor ulcers in pressure areas ``heel, malleoli, ball of foot, tips of toes

Buergers Test Broad day light Patient lying on his back Normal Raise straight legs to 900 colour of skin remains pink Ischaemic limb Marked pallor on elevation Veins collapsed and guttered Angle between limb and horizontal plane Buergers Angle Pallor at Angle < 300 Severe ischaemia Legs elevated (doctor hold limbs) Ankle Exercised till fatigue Pallor at Heel indicates Occlusive disease Feet now lowered to sitting posture in 2-3 min. Cyanosed

Ischaemia (cond)
Capillary filling time Elevated pallor leg when becomes pink on bringing down the time taken is called Capillary filling time Severe ischaemia Takes 2030 sec. Again limb changes colour to purplered due to skin filling with deoxygenated blood Venous filling Normal
Elevated limb when put down 5 sec. Veins fill within

Ischaemic limb take more time

Palpation
Skin temperature With back of fingers Compare with other limb Capillary filling Press the nail see blanching Venous refilling Two finger test venous filling poor in ischaemic limb Harveys sign Cross leg test shows oscillatory movements of knee due to popliteal artery pulsations Movements absent in blocked artery

Examination of vessels
Dorsalis pedis aretry Just lateral to tendon Extensor hallucis longus

Posterior tibial Mid way between med. Malleolus & Tendo Achillis

Ant.tibail artery Midway between malleioli anteriorly tendon Exten. hallucis longus

lateral to

Popletial artery Knee 400 flexion to relax the fossa Palpate in upper part of popletial fossa

Femoral Feel at mid point ( Ant.sup. Iliac spine & Symphysis pubis)

Radial & ulnar Felt at wrist,

Brachial artery Medial to biceps tendon

Auscultation
Listen along the course of major artery systolic bruit due to turbulence of blood flow renal artery stenosis Continuous machinery murmur arteriovenous fistula Check BP in both arms

Reactive hyperaemia Inflate sphygmomanometer above 250mmHg & then release Hyperaemia in 1-2 sec in normal limb Delayed in arterial occlusive disease

Neurological examination
Sensation lost in gangrenous area Border line of gangrene skin is hyperaesthetic

Ulcers exclude/ find underlying cause Hemiplegia, transvesre myelitis, syringomyelia, tabes dorsalis Adsons test Positive in cervical rib, scalene syndrome patient sits on stool Turn face to other side Radial pulse obliterated due to compression Examination of LN

The End