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

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Vascular physiology 3
Vascular Physiology 3

  • Upper and lower extremity arterial conditions other than atherosclerosis.


  • 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

Raynaud s disease cold sensitivity
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

Raynaud s disease cont
Raynaud’s Disease cont.

  • Treatment

    • Warmth, gloves, socks, avoid cold

    • Vasodilators

Raynaud s phenomenon cold sensitivity
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

Raynaud s phenomenon cont
Raynaud’s Phenomenon cont.

  • Vascular Lab to look for underlying cause of vasoconstriction.

  • Vascular Lab to document vasospasm.

Arterial venous fistulae
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

Buerger s disease
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.


  • Dissection, thrombosing, Arterial/venous fistulae.

  • Acute ischemia

  • Can happen to upper or lower ext.

  • Fairly common

Thoracic outlet syndrome
Thoracic Outlet Syndrome

  • Compression of nerve, artery, or vein in the thoracic outlet area.

  • Area of 1st rib, clavicle, and scalene muscle.

  • A “cervical rib” with or without a fibrous band may be present.

  • Uncommon

Types of thoracic outlet syndrome
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.

Thoracic outlet types cont
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.


  • Muscular masses can be present in the upper extremity. Some are vascular and cause bruit.

  • Masses can compress artery or vein.

  • Uncommon

Rheumatic autoimmune diseases
Rheumatic/Autoimmune Diseases

Giant Cell Arteritis: Temporal arteritis and Takayasu’s

Can cause arm claudication or Raynaud’s phenomenon. Uncommon

Radiation arteritis
Radiation arteritis

  • Inflammation of subclavian and axillary arteries resulting from radiation treatment.

  • Uncommon but is seen

Fibromuscular dysplasia
Fibromuscular dysplasia

  • Systemic disorder, smooth muscle hyperplasia, and general disorganization of the arterial wall.

  • Can cause arm claudication. Uncommon

Summary upper
Summary upper

  • Common causes for upper art conditions

    • Emboli

    • Cold sensitivity (vasospasm in Raynaud’s)

    • A-v grafts

Upper summary cont
Upper summary cont.

  • Somewhat common

    • Buerger’s Disease (men more than women)

    • Trauma

Upper summary cont1
Upper summary cont.

  • Uncommon upper ischemia causes

    • Thoracic outlet

    • Tumor

    • Rheumatic/Autoimmune disease

    • Radiation arteritis

    • Fibromuscular dysplasia

Non atherosclerotic lower extremity arterial conditions
Non-atherosclerotic Lower Extremity arterial conditions

  • Account for much less lower extremity ischemia than upper extremity ischemia.


  • 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


  • Mostly traumatic

  • Infection is most serious complication

  • Can be painful

  • Rarely causes ischemia

  • Occurs more in lower extremity than upper

Popliteal artery entrapment
Popliteal Artery entrapment

  • Popliteal artery compression by medial head of gastrocnemius muscle.

  • Young patients

  • With exercise the gastrocnemius muscle contraction compresses artery.

  • Uncommon


  • Dissection, thrombosing, Arterial/venous fistulae.

  • Acute ischemia

  • Can happen to upper or lower ext.

  • Fairly common

Arterial venous fistulas
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

Raynaud s disease
Raynaud’s Disease

  • Affects upper extremities more significantly than lower.

  • Vasospasm without underlying occlusive or systemic cause.

  • Uncommon in lower


  • 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.

Buerger s disease1
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.

Advential cyst
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


  • Heparin induced thrombosis

  • Antithrombin III deficiency

  • Abnormal fibrinolytic system

  • Abnormal platelet aggregation

  • Uncommon

Hematologic disease
Hematologic disease

  • Polycythemia Vera

  • Thrombocytosis

  • Dysproteinemias.

  • Sudden onset, usually affects digits

  • Hematology consult for therapy

  • Uncommon

Summary of lower extremity arterial complications
Summary of Lower extremity arterial complications

  • Common

    • Emboli

    • Pseudoaneurysm (Lower ext arterial injury, does not usually cause ischemia)

Summary lower cont
Summary lower cont.

  • Fairly common

    • Popliteal artery entrapment

    • Trauma

    • Arterial – venous fistula

Summary lower ext arterial
Summary Lower ext arterial

  • Uncommon in Lower ext ischemia

    • Raynaud’s disease or phenomena

    • Arteritis

    • Buerger’S Disease

    • Advential cyst

    • Hypercoagulability

    • Hematologic disease

References vas phy 3
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, 4th Ed., Hallett, Brewster, Rasmussen pgs 238-247

References vas phy 3 cont
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 4th Ed, Bernstein, Mosby, 1993.

  • Slide 12 Vascular Diagnosis 4th Ed., Bernstein, Mosby, 1993 pg 631

Refer vas phy 3 cont
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 4th, Hallett, pg37.

  • Slide 21 Cardiology Clinics, August 1991,pgs 501

Reference vas phy 3 cont
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.