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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
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Vascular Disease Arterial Venous Lymphatic Atherosclerosis Aneurysms
Thrombophlebitis Venous insufficiency Lymphatic Lymphedema
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Vascular Surgery Surgical and interventional techniques for treatment of vascular pathology Medical management Open vascular surgery Endovascular techniques
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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
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Why choose Vascular Surgery as Career?
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Vascular Disease Majority of vascular disease in the U.S. caused by two processes Atherosclerosis Thrombophlebitis
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Vascular Disease Risk factors for atherosclerosis Diabetes mellitus
Hyperlipidemia Hypertension Smoking Genetics
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Vascular Disease Risk factors for thrombophlebitis Virchow’s triad
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Vascular Exam What Do You Need?
Stethoscope Doppler Blood pressure cuff
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Vital Signs Temperature Height Weight Blood pressure Both arms
Heart rate & rhythm Respiratory rate
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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+
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Thrill Palpable vibration present with turbulent blood flow
May indicate arterial stenosis May be noted in the presence of arteriovenous fistula
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Bruit Audible ‘blowing sound’ heard over an area of turbulent flow
May indicate arterial stenosis
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Vascular Exam General observation Scars Muscle wasting Hair Skin color
Wounds Absent digits Capillary refill (normal < 2 seconds)
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta
Femoral Popliteal Dorsalis pedis Posterior tibial
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta
Femoral Popliteal Dorsalis pedis Posterior tibial Palpate one carotid artery at a time
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate the subclavian artery just above the clavicle
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Neck Listen for bruits Feel for masses/thrills
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Neck Listen for bruits Feel for masses/thrills
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Neck Listen for bruits Feel for masses/thrills
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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
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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
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta
Femoral Popliteal Dorsalis pedis Posterior tibial Radial and ulnar arteries connect via the palmar arches
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Allen’s Test Tests arterial blood flow to the hand
Important assessment prior to radial arterial puncture or line placement
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Allen’s Test Elevate hand and make a fist for 30 seconds
Compress both radial and ulnar arteries Open hand
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Allen’s Test Release pressure on ulnar artery
Hand should regain color within 5 seconds Normal Allen’s Test implies patent ulnar artery
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate aorta between two hands to estimate diameter
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Pulse Exam Palpate aorta between two hands to estimate diameter
Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial
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Abdomen Listen for bruits Feel for masses/thrills
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Abdomen Listen for bruits Feel for masses/thrills
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Abdomen Listen for bruits Feel for masses/thrills
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Abdomen Mohammed Al-Omran, M.D., and Badr Aljabri, M.D. N ENGL J MED 2009; 360:2004
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Open vs endo
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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
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Femoral artery lies two fingerbreadths lateral to pubic tubercle
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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
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial External rotation of hip facilitates palpation in obese patients
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Pulse Exam Carotid Listen for femoral bruit Subclavian Brachial Radial
Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Listen for femoral bruit
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta Femoral Popliteal Dorsalis pedis Posterior tibial Palpate popliteal artery with fingertips of both hands
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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
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Pulse Exam Carotid Subclavian Brachial Radial Ulnar Abdominal aorta
Femoral Popliteal Dorsalis pedis Posterior tibial Palpate posterior tibial artery just posterior to medial malleolus
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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
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Extremities Acute arterial insufficiency The 6 p’s Pain Pallor
Pulselessness Poikilothermia Paresthesias Paralysis
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Extremities Arterial insufficiency Gangrene
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Extremities Arterial insufficiency Foot ulceration
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Extremities Arterial insufficiency Trophic changes Shiny skin
Hair loss Thickened toenails
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Extremities Arterial insufficiency Note any previous amputations
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Extremities Vasospasm Color changes
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Doppler Ultrasound Exam
If arteries are not palpable, use doppler to detect flow
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Doppler Ultrasound Exam
Ultrasound signals reflected from moving blood cells represented by audible signal Triphasic Biphasic Monophasic
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Doppler Ultrasound Exam
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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)
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Ankle-Brachial Index Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg
Left Brachial 170 mmHg DP 70 mmHg PT 90 mmHg
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Ankle-Brachial Index Right Brachial 180 mmHg DP 60 mmHg PT 40 mmHg
Left Brachial 170 mmHg DP 70 mmHg PT 90 mmHg
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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
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Ankle-Brachial Index >1.29 Unreliable, non-compressible Normal Mild arterial insufficiency Moderate arterial insufficiency <0.40 Severe arterial insufficiency
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Ankle-Brachial Index ABI is not a useful measure if tibial arteries are non-compressible due to calcification Diabetes ESRD
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Foot xray with arteial calcium
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Ankle-Brachial Index Toe-Brachial Index (TBI)
More accurate if tibial vessels calcified Normal=
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Ankle-Brachial Index Useful to document change from baseline after revascularization Bypass Angioplasty/stent Change in ABI of > 0.15 is considered significant
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Extremities Venous insufficiency Acute Chronic
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Extremities Acute deep venous thrombosis
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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
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Extremities Acute superficial thrombophlebitis
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Extremities Chronic Venous insufficiency Edema Hyperpigmentation
Ulceration
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Extremities Varicose veins Examine patient in standing position
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Extremities Trendelenberg test Tests for venous valvular incompetence
Patient supine, leg elevated Compress proximal thigh or proximal calf with tourniquet Patient stands
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Extremities Trendelenberg test Step 1
Look at varicose veins for rapid filling If rapid filling, incompetent perforator or communicating veins present
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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
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Ulcers Arterial Venous Neuropathic Painful May be painful Painless
Do not bleed May bleed Toes/foot Calf/ankle Metatarsal head
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Extremities Lymphatic insufficiency
Painless, non-pitting swelling of toes, foot and leg
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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
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Patient Centered Medicine - Year 2
The Vascular System Thank you QUESTIONS?
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Video References Video 1 Video 2
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