The Vascular System Carlos F. Bechara, MD MS RPVI FACS Patient Centered Medicine - Year 2 The Vascular System Carlos F. Bechara, MD MS RPVI FACS Associate Professor, Department of Surgery Program Director, Vascular Surgery Fellowship Division of Vascular Surgery and Endovascular Therapy Loyola University Hospital/Stritch School of Medicine Carlos.bechara@lumc.edu

Vascular Disease Arterial Venous Lymphatic Atherosclerosis Aneurysms Thrombophlebitis Venous insufficiency Lymphatic Lymphedema

Vascular Surgery Surgical and interventional techniques for treatment of vascular pathology Medical management Open vascular surgery Endovascular techniques

Vascular Surgery 5+2 track 0+5 track (50 programs) 5-year general surgery residency 2-year vascular surgery fellowship 0+5 track (50 programs) 5-year vascular surgery residency 2 years core surgery, 3 years vascular surgery

Why choose Vascular Surgery as Career?

Vascular Disease Majority of vascular disease in the U.S. caused by two processes Atherosclerosis Thrombophlebitis

Vascular Disease Risk factors for atherosclerosis Diabetes mellitus Hyperlipidemia Hypertension Smoking Genetics

Vascular Disease Risk factors for thrombophlebitis Virchow’s triad

Vascular Exam What Do You Need? Stethoscope Doppler Blood pressure cuff

Vital Signs Temperature Height Weight Blood pressure Both arms Heart rate & rhythm Respiratory rate

Pulse Exam Grading the pulses 0 non-palpable 1+ weak 2+ normal 3+ increased 4+ bounding/aneurysmal dop non-palpable, but signal dopplerable 2+ 2+ 1+ 1+ 2+ 2+, B 2+ 2+ 2+ 2+ 2+ 4+ 2+ 2+ 2+ 2+

Thrill Palpable vibration present with turbulent blood flow May indicate arterial stenosis May be noted in the presence of arteriovenous fistula

Bruit Audible ‘blowing sound’ heard over an area of turbulent flow May indicate arterial stenosis

Vascular Exam General observation Scars Muscle wasting Hair Skin color Wounds Absent digits Capillary refill (normal < 2 seconds)

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate one carotid artery at a time

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate the subclavian artery just above the clavicle

Neck Listen for bruits Feel for masses/thrills

Neck Listen for bruits Feel for masses/thrills

Neck Listen for bruits Feel for masses/thrills

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate brachial artery against humerus in the distal upper arm

Pulse Exam Carotid Palpate radial and ulnar arteries at the wrist Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate radial and ulnar arteries at the wrist R U

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Radial and ulnar arteries connect via the palmar arches

Allen’s Test Tests arterial blood flow to the hand Important assessment prior to radial arterial puncture or line placement

Allen’s Test Elevate hand and make a fist for 30 seconds Compress both radial and ulnar arteries Open hand

Allen’s Test Release pressure on ulnar artery Hand should regain color within 5 seconds Normal Allen’s Test implies patent ulnar artery

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate aorta between two hands to estimate diameter

Pulse Exam Palpate aorta between two hands to estimate diameter Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial

Abdomen Listen for bruits Feel for masses/thrills

Abdomen Listen for bruits Feel for masses/thrills

Abdomen Listen for bruits Feel for masses/thrills

Abdomen Mohammed Al-Omran, M.D., and Badr Aljabri, M.D. N ENGL J MED 2009; 360:2004

Open vs endo

Pulse Exam Carotid Lateral to medial: Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Lateral to medial: Nerve Artery Vein Lymphatics

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Femoral artery lies two fingerbreadths lateral to pubic tubercle

Pulse Exam Carotid Palpate femoral artery just below inguinal ligament Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate femoral artery just below inguinal ligament

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial External rotation of hip facilitates palpation in obese patients

Pulse Exam Carotid Listen for femoral bruit Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Listen for femoral bruit

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate popliteal artery with fingertips of both hands

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate dorsalis pedis artery between 1st and 2nd extensor tendons

Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate posterior tibial artery just posterior to medial malleolus

Extremities Chronic arterial insufficiency Buerger’s test Elevate leg > 45 degrees x 1 minute Observe for foot pallor Allow patient to sit with feet dangling Observe for foot rubor

Extremities Acute arterial insufficiency The 6 p’s Pain Pallor Pulselessness Poikilothermia Paresthesias Paralysis

Extremities Arterial insufficiency Gangrene

Extremities Arterial insufficiency Foot ulceration

Extremities Arterial insufficiency Trophic changes Shiny skin Hair loss Thickened toenails

Extremities Arterial insufficiency Note any previous amputations

Extremities Vasospasm Color changes

Doppler Ultrasound Exam If arteries are not palpable, use doppler to detect flow

Doppler Ultrasound Exam Ultrasound signals reflected from moving blood cells represented by audible signal Triphasic Biphasic Monophasic

Doppler Ultrasound Exam

Ankle-Brachial Index ABI = Systolic pressure at ankle Systolic pressure in arm Normal = 1.0 Use highest ankle pressure (DP or PT) Use highest arm pressure (right or left)

Ankle-Brachial Index Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg Left Brachial 170 mmHg DP 70 mmHg PT 90 mmHg

Ankle-Brachial Index Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg Left Brachial 170 mmHg DP 70 mmHg PT 90 mmHg

Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg ABI 60/180= 0.3 Ankle-Brachial Index Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg ABI 60/180= 0.3 Left Brachial 170 mmHg DP 70 mmHg PT 90 mmHg ABI 90/180= 0.5

Ankle-Brachial Index >1.29 Unreliable, non-compressible 0.95-1.29 Normal 0.81-0.94 Mild arterial insufficiency 0.41-0.80 Moderate arterial insufficiency <0.40 Severe arterial insufficiency

Ankle-Brachial Index ABI is not a useful measure if tibial arteries are non-compressible due to calcification Diabetes ESRD

Foot xray with arteial calcium

Ankle-Brachial Index Toe-Brachial Index (TBI) More accurate if tibial vessels calcified Normal= 0.6-0.75

Ankle-Brachial Index Useful to document change from baseline after revascularization Bypass Angioplasty/stent Change in ABI of > 0.15 is considered significant

Extremities Venous insufficiency Acute Chronic

Extremities Acute deep venous thrombosis

Extremities Deep venous thrombosis Homan’s sign Edema Calf pain with passive dorsiflexion of foot at ankle Present in 30% of patients with DVT and 20% of patients without DVT Edema Skin discoloration Congested foot veins

Extremities Acute superficial thrombophlebitis

Extremities Chronic Venous insufficiency Edema Hyperpigmentation Ulceration

Extremities Varicose veins Examine patient in standing position

Extremities Trendelenberg test Tests for venous valvular incompetence Patient supine, leg elevated Compress proximal thigh or proximal calf with tourniquet Patient stands

Extremities Trendelenberg test Step 1 Look at varicose veins for rapid filling If rapid filling, incompetent perforator or communicating veins present

Extremities Trendelenberg test Step 2 Release tourniquet Look at varicose veins for filling If normal valve at compression site, vein slowly fills from distally If incompetent valve at compression site, vein rapidly fills from above when compression is released

Ulcers Arterial Venous Neuropathic Painful May be painful Painless Do not bleed May bleed Toes/foot Calf/ankle Metatarsal head

Extremities Lymphatic insufficiency Painless, non-pitting swelling of toes, foot and leg

Summary History plays a large role in understanding physical exam findings Thorough physical exam can detect vascular disease before complications arise A change in the exam is important in monitoring vascular disease

Patient Centered Medicine - Year 2 The Vascular System Thank you QUESTIONS?

Video References Video 1 Video 2