A.P DR. MIN OO(SURGERY)

Examination of vascular disorder

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Outline

Introduction

Learning objectives

Peripheral occlusive arterial disease

Venous disorder

Applied anotomy & pathophysiology for arterial supply

& venous drainage of lower limb

Video show for examination peripheral vascular

disease

Video show for examination of varicose vein

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Introduction

Arterial

Peripheral occlusive arterial disease (POAD) is

predominantly affects the lower limbs.

It may be acute or chronic

Acute limb ischaemia is surgical emergency

Chronic limb ischaemia may be complication

of diabetes or Burger`s disease

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Venous

Congenital anormalies

( Klippel Trenaunay syndrome)

Inflammation ( thrombophlenitis)

Thrombosis & its sequalae

Acute thrombosis DVT( deep vein thrombosis)

Varicose vein (V.V)

Introduction

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Learning objectives

To apply the basic science knowledge of anatomy & pathophysiology in clinical examination

To know the clinical features of Peripheral Occlusive Arterial Disease(POAD) (acute & chronic ischaemic limbs) and deep vein thrombosis (DVT) & varicose veins(V.V)

To able to examine and apprehend the physical signs of the patient with POAD & V.V

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Peripheral occlusive arterial disease (POAD)

Peripheral occlusive arterial disease (POAD) is caused by

a) atherosclerosis, thrombosis , embolism,

b) vascular trauma,

c) complications of DM

d) Burger`s disease

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Peripheral occlusive arterial disease (POAD)

Male> female

Risk factors are ???

Cigarette smoking

Hypertension

Hyperlipidaemia

Diabetes mellitus

Critical ischaemia when reduction of blood flow leads

to tissue viability can not sustained.

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Clinical features (POAD)

Chronic ischaemia ???

Intermittent claudication in - calf( femoral),

- thigh (iliac), buttock ( aortic )

Cold peripheries

Prolonged capillary refill time

Rest pain, especially at night

Venous guttering

Absent pulses

Arterial ulcer

Gangrene over pressure point

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Acute ischaemia ??? ( 6 P & 2 M)Pain pallorPulselessnessParaesthesiaParalysisPerishing coldPistol-shot onsetMottling ( late sign)Muscle rigidity ( late sign)

Clinical features (POAD)

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Epidemiology

DVT is very common in surgical patients

Affect 10-30 % of all general surgical patients over

40 years who undergo a major operation

PE is a common cause of sudden death in hospital

patients ( 0.5-3 % of patients die from P.E)

Deep vein thrombosis(DVT)

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Deep vein thrombosis(DVT)

Ilio femoral thrombous Migratrion of thrombus

to the lungs ( P.E) pulmonary embolism fatal

Destruction of valves in deep venous system

chronic venous hypertension post-phlebitis

limb(PPL)

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Aetiology Risk factors ??? Increasing age >40 years ImmobilizationObesityMalignancy Inflammatory bowel diseaseAnti coagulant protein deficiency (e.g. antithrombin III,

protein C, protein S)TraumaSepsisHeart diseasePregnancy/ oestrogen

Deep vein thrombosis(DVT)

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Virchow`s triad ???

Stasis

Endothelial injury

hypercoagulopathy

Deep vein thrombosis(DVT)

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Pathology

Aggregation of platelets in the valve pokets

Activation of clotting cascade producing fibrin

Fibrin production overwhelms the natural anti-

coagulating (fibrinolytic ) system

Natural H/O resolve / PE/ CVH(PPL)

Deep vein thrombosis(DVT)

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Clinical featuresDVTAsymptomaticCalf tendernessAnkle edemaMild pyrexia

P.E ???Substernal chest painDyspnoeaCirculatory arrestPleuritic chest painhaemoptysis

Deep vein thrombosis(DVT)

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Clinical featuresPPL H/O of DVT

Aching limb

Leg swelling

Venous eczema

Venous ulceration

Inverted bottle-shape leg

Deep vein thrombosis(DVT)

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Arterial Anatomy

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Arterial Anatomy

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Arterial Anatomy

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Venous anatomy

Superficial

Deep

perforator

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Saphenofemoral junction

Great saphenous vein

dorsal venous arch

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Popliteal veinSaphenopopliteal junction

Short saphenous vein

dorsal venous arch( lateral side of foot)

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Perforating vein

Blood from superficial veins enters the deep veins

at the saphenopopliteal and saphenofemoral

junctions

In the calf and thigh there are a number of valved

perforating veins

It penetrates the deep fascia at an obligue angle

compressed when muscles contract during walking

(Calf m/s pump )

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The most important are the direct perforating veins of the medial calf and the mid-thigh1. mid thigh perforators ( Dodd ) Hunter’s

canal ( adductor hiatus )2. Lower leg perforators ( Cockett ) I, II & III

I 5cmII 10cm above medial malleousIII 15cm

Perforating vein

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Dodd’s perforator

Boyd’s perforator Cockett’s perforators

May or Kuster

I (5 cm)II (10 cm)

III (15 cm)

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Deep veins

The deep veins of the lower limb arise from 3 pairs of venae commitantes anterior and posterior tibial and peroneal veins

ant tibial vein from dorsal venous arch post and peroneal vein from plantar arch

These veins intercommunicate and join in the popliteal fossa form the popliteal vein passes up through the adductor canal becomes the femoral vein in the thigh

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Deep (profunda) femoral veins drain from thigh muscles terminate in femoral vein

Femoral vein passes deep to the inguinal lig. external iliac vein common iliac vein IVC

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Femoral vein

Popliteal vein

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Video show for PVD & V.V

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THANK YOU FOR YOUR ATTENTION