1. Vascular Physiology 3 Upper and lower extremity arterial conditions other than atherosclerosis.

2. Upper extremity ischemia

3. Emboli Heart most likely source of non-atherosclerotic emboli. 10-20% of all cardiac emboli lodge in upper extremity. 70% of all upper ext emboli come from heart. –Thrombus –Tumor –Valvular lesions –Fairly common

4. Raynaud’s Disease (Cold sensitivity) Female- most frequent 18-30 years Abnormal vasoconstriction of extremities upon exposure to cold or emotional stress. Intermittent attacks of pallor, cyanosis,then rubor of digits (usually upper), bilateral or symetrical, normal radial and ulnar pulse. No evidence of obstructive disease. Fairly common

5. Raynaud’s Disease cont. Treatment –Warmth, gloves, socks, avoid cold –Vasodilators

6. Raynaud’s Phenomenon (cold sensitivity) Intermittent pallor, cyanosis, redness,normal. Repeats. Response to cold or emotion. Numbness, tingling, burning may occur. Secondary to such conditions as occlusive arterial disease, systemic scleroderma, thoracic outlet syndrome, pulmonary hypertension, myxedema or trauma. Fairly common

7. Raynaud’s Phenomenon cont. Vascular Lab to look for underlying cause of vasoconstriction. Vascular Lab to document vasospasm.

8. Arterial/Venous fistulae Surgically constructed for hemodialysis –Cimino-Brescia: end to end or side to side anastomosis between the radial artery and cephalic vein at wrist. –Prosthetic graft (PTFE) Loop between brachial art and antecubital vein Straight between radial art at wrist and antecubital vein Straight between brachial artery and subclavian vein Common

9. Buerger’s Disease Thromboangiitis Obliterans (fairly uncommon) –Men <40yrs –99% smoke –Affects small and medium arteries, can affect veins also. –Inflammation leading to formation of thrombi –Tissue necrosis develops early because of poor collaterals in end arteries of fingers and toes.

10. Trauma Dissection, thrombosing, Arterial/venous fistulae. Acute ischemia Can happen to upper or lower ext. Fairly common

11. Thoracic Outlet Syndrome Compression of nerve, artery, or vein in the thoracic outlet area. Area of 1 st rib, clavicle, and scalene muscle. A “cervical rib” with or without a fibrous band may be present. Uncommon

12. Types of Thoracic Outlet Syndrome. True neurogenic: Wasting of muscles of hand and hand weakness, with positive electromyography. Vascular Thoracic Outlet: an arterial or venous lesion is present on angiography. Duplex and photocell exam is helpful and most likely ordered before angio.

13. Thoracic Outlet Types cont. Disputed Thoracic Outlet. –Weakness, parathesia, pain of hand, arm, shoulder girdle, chest wall, and headache. –Eletromyographic test normal. –Hand wasting is never found. –Patients do not progress to true neurogenic or vascular thoracic outlet.

14. Tumor Muscular masses can be present in the upper extremity. Some are vascular and cause bruit. Masses can compress artery or vein. Uncommon

15. Rheumatic/Autoimmune Diseases Giant Cell Arteritis: Temporal arteritis and Takayasu’s Can cause arm claudication or Raynaud’s phenomenon. Uncommon

16. Radiation arteritis Inflammation of subclavian and axillary arteries resulting from radiation treatment. Uncommon but is seen

17. Fibromuscular dysplasia Systemic disorder, smooth muscle hyperplasia, and general disorganization of the arterial wall. Can cause arm claudication. Uncommon

18. Summary upper Common causes for upper art conditions –Emboli –Cold sensitivity (vasospasm in Raynaud’s) –A-v grafts

19. Upper summary cont. Somewhat common –Buerger’s Disease (men more than women) –Trauma

20. Upper summary cont. Uncommon upper ischemia causes –Thoracic outlet –Tumor –Rheumatic/Autoimmune disease –Radiation arteritis –Fibromuscular dysplasia

21. Non-atherosclerotic Lower Extremity arterial conditions Account for much less lower extremity ischemia than upper extremity ischemia.

22. Emboli Causes acute ischemia/ medical emergency Most non-atherosclerotic emboli come from the heart Entire lower extremity can be involved, most occlude lower leg, foot or toes. Heparin, thrombolytic therapy, embolectomy Common

23. Pseudoaneurysm Mostly traumatic Infection is most serious complication Can be painful Rarely causes ischemia Occurs more in lower extremity than upper

24. Popliteal Artery entrapment Popliteal artery compression by medial head of gastrocnemius muscle. Young patients With exercise the gastrocnemius muscle contraction compresses artery. Uncommon

25. Trauma Dissection, thrombosing, Arterial/venous fistulae. Acute ischemia Can happen to upper or lower ext. Fairly common

26. Arterial-Venous Fistulas Can be surgically created in lower ext for hemodyalisis. Occurs less frequently than in upper. Complications: aneurysm, pseudoaneurysm, infection, graft occlusion. Fairly common (more often in arms) Traumatic: –Artery and venous connection due to trauma –Infection is most serious complication over ischemia – Can be painful

27. Raynaud’s Disease Affects upper extremities more significantly than lower. Vasospasm without underlying occlusive or systemic cause. Uncommon in lower

28. Arteritis All types of arteritis affects upper extremities much more frequently than lower. (Takayasu’s, Giant Cell Arteritis, Polyarteritis or periarteritis. Uncommon to see these listed as cause for lower extremity ischemia, but is possible.

29. Buerger’s Disease Thromboangiitis Obliterans: described as rarely a cause, and accounting for less than 1% of lower extremity vascular disease. Young, male, smokers, digit ischemia Sudden onset Claudication of foot and arch rather than legs. Associated superficial thrombophlebitis Less likely to cause lower ext ischemia than upper extremity ischemia.

30. Advential Cyst Cyst of advential layer of arterial wall, causing stenosis or occlusion by thrombosing. Can cause claudication Can be surgically drained or bypassed. Can reoccur Uncommon

31. Hypercoagulability Heparin induced thrombosis Antithrombin III deficiency Abnormal fibrinolytic system Abnormal platelet aggregation Uncommon

32. Hematologic disease Polycythemia Vera Thrombocytosis Dysproteinemias. Sudden onset, usually affects digits Hematology consult for therapy Uncommon

33. Summary of Lower extremity arterial complications Common –Emboli –Pseudoaneurysm (Lower ext arterial injury, does not usually cause ischemia)

34. Summary lower cont. Fairly common –Popliteal artery entrapment –Trauma –Arterial – venous fistula

35. Summary Lower ext arterial Uncommon in Lower ext ischemia –Raynaud’s disease or phenomena –Arteritis –Buerger’S Disease –Advential cyst –Hypercoagulability –Hematologic disease

36. References Vas Phy 3 Slides 1,2,3,4,5 Taber’s cyclopedic Medical Dictionary, Davis 1985 Slide 5 Intro to Vascular Ultrasonography, Zwiebel, Saunders, 2000, Pg258 Slides 6,7,8 Intro to Vascular Ultrasonography, Zwieber, pgs 259-260. & Handbook of Patient Care in Vascular Disease, 4 th Ed., Hallett, Brewster, Rasmussen pgs 238-247

37. References Vas Phy 3 cont Slide 9 Intro to Vascular Ultrasonography, Zwiebel, 2000, pg 259. & Cardiology Clinics, PVD in The Elderly, Breslin Ed., August 1991, pgs 559-560. Slides 10,11 Intro to Vascular Ultrasonography, Zwiebel, 2000, pgs 259-261. & Vascular Diagnosis 4 th Ed, Bernstein, Mosby, 1993. Slide 12 Vascular Diagnosis 4 th Ed., Bernstein, Mosby, 1993 pg 631

38. Refer Vas Phy 3 cont. Slides 13,14,15 Cardiology Clinics, August 1991 pgs547-552. & Vascular Diagnosis, Bernstein, pg 631 Slides 16,17 Intro to Vascular Ultrasonography, Zweibel, 2000 Pg 260. Slide 20 Handbook of Patient Care in Vascular Disease 4 th, Hallett, pg37. Slide 21 Cardiology Clinics, August 1991,pgs 501

39. Reference Vas Phy 3 cont. Slide 22 Intro to Vascular Ultrasonography, Zweibel, 2000, pg205. & Cardiology Clinics, August 1991 pgs 559-560 Slide 23,26 Cardiology Clinics, August 1991, pg501. Slide 27 Cardiology Clinics, August 1991, pgs 501-502/ Slide 29 Cardiology Clinics, August 1991, 497- 513.