ST.

LOUIS REVIEW CENTER

ARTERIAL AND VENOUS PROBLEMS • Effect: Blood backs up in the systemic circulation,
leading to increased venous pressure and systemic
1. Arterial Problem: Peripheral Arterial Disease (PAD)
congestion.
• Affects arteries, reducing blood flow to the • Symptoms:
extremities (legs, arms, feet).
o Swelling (edema) in legs and feet
• Leads to ischemia, pain, ulcers, and potential o Jugular vein distension
gangrene if untreated. o Ascites (fluid buildup in the abdomen)
2. Venous Problem: Chronic Venous Insufficiency PERIPHERAL ARTERIAL DISEASE
(CVI)
• Affects veins, primarily in the legs and feet. • condition characterized by narrowing or blockage
• Causes swelling, varicose veins, skin changes, of the arteries, primarily in the legs, due to
and venous ulcers due to poor blood return to atherosclerosis (plaque buildup).
the heart.
PATHOPHYSIOLOGY OF PERIPHERAL ARTERIAL DISEASE
NORMAL PULMONARY CIRCULATION PATHWAY (PAD)

1. Deoxygenated blood from the body returns to the • Peripheral Arterial Disease (PAD) is caused by
right atrium via the superior and inferior vena cava. atherosclerosis, leading to progressive narrowing
2. Blood flows into the right ventricle through the and hardening of arteries in the lower extremities.
tricuspid valve. • This reduces blood flow, depriving tissues of oxygen
3. The right ventricle pumps blood through the and nutrients. If left untreated, it can progress to
pulmonary valve into the pulmonary artery. critical limb ischemia (CLI) or gangrene.
4. The pulmonary artery branches into the right and
left pulmonary arteries, carrying blood to the lungs. 1. Reduced Blood Flow → Ischemia (Oxygen
5. In the lung capillaries, gas exchange occurs: Deficiency)
o CO₂ is expelled. • Atherosclerotic plaques build up in the arteries,
o O₂ is absorbed into the blood. narrowing the lumen and reducing blood supply
6. Oxygenated blood returns to the left atrium via the to the legs and feet.
pulmonary veins. • The affected muscles and tissues become
7. Blood then flows into the left ventricle and is hypoxic (low oxygen levels), especially during
pumped out to the body via the aorta. physical activity, leading to intermittent
claudication (pain during exertion).
NORMAL HEART ACTIVITY
2. Anaerobic Metabolism (Due to Oxygen Deficiency)
• When the heart contracts, oxygenated blood is • When oxygen supply is insufficient, cells shift from
pumped into the arteries and delivered to the aerobic metabolism (which requires oxygen) to
body. anaerobic metabolism (which does not).
• Deoxygenated blood returns to the heart via the • Anaerobic metabolism is less efficient,
veins, where it is sent to the lungs for oxygenation. producing less ATP (energy) and generating
lactic acid as a byproduct.
Blood Pressure Differences:
3. Lactic Acid Accumulation → Pain & Inflammation
• Arterial pressure → Higher (pushes blood • Lactic acid and other metabolic byproducts
downward). lower pH in the tissues, irritating nerve endings
• Venous pressure → Lower (blood flows upward, and triggering pain (claudication).
returning to the heart). • Inflammation develops as the body tries to
repair damaged tissues, leading to:
HEART FAILURE TYPES & EFFECTS o Redness and swelling
Left-Sided Heart Failure o Increased oxidative stress
o Further blood vessel damage
• Cause: The heart cannot effectively pump
4. Prolonged Ischemia → Tissue Necrosis & Gangrene
oxygenated blood to the body.
• If blood flow remains critically low, the affected
• Effect: Blood accumulates in the lungs, causing
tissues do not receive enough oxygen or
pulmonary congestion (fluid buildup in the lungs).
nutrients, leading to cell death (necrosis).
• Symptoms:
• Types of tissue damage:
o Shortness of breath
o Reversible: Intermittent claudication (pain
o Coughing/wheezing
with activity, relieved by rest)
o Pulmonary edema
o Irreversible: Critical limb ischemia (CLI) –
Right-Sided Heart Failure Persistent pain at rest, non-healing ulcers,
and eventual gangrene (dead, blackened
• Cause: The heart cannot effectively return tissue).
deoxygenated blood to the lungs.
5. Gangrene (Final Stage of Severe PAD)

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• Gangrene occurs when necrotic tissue 3. Ischemia → Lactic acid production → Pain and
becomes infected or undergoes further inflammation
decomposition due to bacterial invasion. 4. Persistent ischemia → Tissue necrosis → Gangrene
• Types:
Predisposing Factors
o Dry gangrene: Lack of circulation causes
tissue to shrink, darken, and dry out. • Leading cause: Smoking (nicotine)/vaping
o Wet gangrene: Bacterial infection leads to ✓ Nicotine increases blood viscosity and causes
swelling, pus formation, and foul odor vasoconstriction
(medical emergency). • Other risk factors:
o Gas gangrene: Caused by Clostridium
bacteria, producing gas and toxins that ✓ Viscous blood (due to conditions like Diabetes
rapidly destroy tissues. Mellitus, Dehydration, High cholesterol, High
calcium levels)
6. Systemic Complications of PAD
• Increased risk of cardiovascular disease: PAD is ✓ Virchow’s Triad (SHE – increases clot formation
a systemic disease, meaning the same risk):
atherosclerotic process affects the coronary
1. Stasis (slow blood flow due to immobility,
arteries (heart attack risk) and carotid arteries
obesity, pregnancy)
(stroke risk).
• Chronic inflammation and oxidative stress 2. Hypercoagulability (excessive clotting due
further worsen endothelial function, to smoking, dehydration, estrogen therapy,
accelerating disease progression. calcium supplements)

Summary Flowchart of PAD Pathophysiology 3. Endothelial injury (damage to blood vessels

due to trauma, hypertension, or constrictive
1. Atherosclerosis → Arterial Narrowing clothing)
2. Reduced Blood Flow → Ischemia Clinical Manifestations
3. Anaerobic Metabolism → Lactic Acid Buildup • Cold extremities
4. Lactic Acid + Ischemia → Pain & Inflammation • Poor wound healing → Increased risk of
gangrene/infection
5. Prolonged Ischemia → Tissue Necrosis • Decreased pulse quality (Peripheral pulse
grading: Normal = +2)
6. Necrosis + Infection → Gangrene • Pulse deficit (Difference between apical and
TYPES OF VASCULAR DISORDERS peripheral pulse)
• Dry ulcers
VASO-OCCLUSIVE DISORDERS • Muscle wasting/atrophy
• Hair loss (especially in lower extremities)
Vaso-occlusive disorders occur when blood flow is • Cardinal Sign (Pathognomonic Feature):
physically obstructed due to factors like blood clots, Intermittent Claudication
swelling, or plaque buildup, leading to: • “Pain in the legs while walking”
• Ischemia (lack of oxygen supply) ✓ Worsens with activity → Relieved with rest
• Pain and inflammation ✓ Pain is on and off (but still present even at
• Organ damage and tissue necrosis rest)

BUERGER’S DISEASE (THROMBOANGIITIS OBLITERANS) Watch out for: Superficial veins being partially affected
(small, shallow clots)
A rare, non-atherosclerotic inflammatory disorder that
affects the small and medium arteries and veins, causing DIAGNOSTIC TESTS
blood clot formation, arterial swelling, and obstruction.
• Arteriogram (iodine contrast dye) – to visualize
Mnemonic: The Five B’s of Buerger’s Disease arterial blockages
• Watch for iodine/seafood allergies (IgE-mediated
o Buerger’s Disease
reaction)
o Blockage (Bara) in arteries
• Doppler Ultrasound (Duplex Scan) – to assess blood
o Blood clot formation
flow
o Baba (affects lower extremities: toes, ankles, feet,
• Clotting parameters – to evaluate blood
legs)
coagulation levels
o Boys (most common in males, especially smokers)
MANAGEMENT & TREATMENT
PATHOPHYSIOLOGY
1. Address Underlying Causes
1. Blood clot formation (thrombi) in arteries → Arterial
• Encourage smoking cessation
swelling → Obstruction
• Hydration to reduce blood viscosity
2. Blockage in peripheral arteries/arterioles → Tissue
ischemia • Oxygen therapy to improve circulation

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2. Medications • Bilateral & Symmetrical effects
• Thrombolytics (Clot Busters): • Specific time-related symptoms:
✓ T-PA (Tissue Plasminogen Activator) • During cold exposure:
✓ Streptokinase ✓ White phase (Pallor) → Numbness and
• Anticoagulants (Prevents New Clots): paresthesia
✓ Heparin, Warfarin ("-parin" drugs) ✓ Blue phase (Cyanosis) → Blood remains trapped
• Vasodilators: Improve blood flow by relaxing due to continued vasoconstriction
blood vessels ✓ Red phase (Hyperemia) → Sudden vasodilation
• Analgesics: Pain management causes flushing and throbbing pain
• Watch out for: Orthostatic Hypotension
3. Surgical Interventions (Postural/Positional Hypotension)
• Cardinal Sign: Progressive color shifting in
• Thrombectomy (removal of the clot)
fingers/toes (Raynaud’s Phenomenon)
• Debridement (removal of dead tissue)
✓ White (Vasoconstriction – Blood moves from
• Amputation (if gangrene spreads)
peripheral to central circulation)
4. Proper Positioning ✓ Blue (Severe vasoconstriction – Blood remains
trapped in peripheral tissues)
• Position the affected limb BELOW the heart level ✓ Red (Sudden vasodilation – Blood rushes back to
to improve blood flow peripheral tissues)
• Avoid elevation (it worsens the condition)
• Best position: High Fowler’s DIAGNOSTIC TESTS
• Avoid: Trendelenburg, Lithotomy, or Dangling
• Arteriogram – Checks arterial blood flow
• Kidney Function Test (KFT) – Ensures kidneys can
5. Key Medications to Watch For
safely handle contrast dye
• Aspirin – Can cause injury
• Doppler Ultrasound (Duplex Scan) – Assesses blood
• Anticoagulants – Used to prevent blood
circulation
thickening (high viscosity)
• Ice Water Test – Induces vasospasm for observation
VASO-SPASTIC DISORDERS
MANAGEMENT: "VAWACS"
• temporary narrowing of blood vessels due to
• Vasodilators (for White & Blue phases;
excessive contraction of the vascular smooth
contraindicated in Red phase due to hypotension
muscle.
risk)
• Reduces blood flow but is reversible once the spasm
✓ Alpha-Adrenergic Blockers (Peripheral Acting
resolves.
Vasodilators) – "Zosin" drugs
RAYNAUD’S DISEASE • Avoid Stress – Relaxation Exercises
• Warm Clothing – Protect extremities from cold
• Raynaud’s disease is a vaso-spastic arterial disorder exposure
characterized by sudden vasospasm (narrowing) of • Avoid Injuries – Reduced blood supply increases
peripheral arteries and arterioles, leading to: infection risk
✓ Tissue ischemia (lack of oxygen supply) • Caution: Fall Risk – Patients may experience sudden
✓ Lactic acid buildup → Pain and inflammation dizziness due to hypotension
✓ Lower risk of tissue necrosis (compared to vaso- • Steroids – For autoimmune-related Raynaud’s
occlusive disorders like Buerger’s disease) disease
• Common in: Females • Stop Smoking – Reduces vasospasms
• Most affected sites: Fingers and toes (most sensitive • Positioning: Below the level of the heart (avoid
to temperature changes) elevation)
• Oxygen Administration – Improves circulation
PREDISPOSING FACTORS
PERIPHERAL VENOUS DISORDERS
• Leading cause: Cold exposure
• Other risk factors: • (Deoxygenated Blood Retention in Peripheral Veins)
✓ Stress
✓ Smoking/Vaping PATHOPHYSIOLOGY
✓ Autoimmune diseases affecting connective Impaired venous return to the heart → Blood cannot
tissues (causing vasculitis):
move upward through peripheral veins → Regurgitation
o Systemic Lupus Erythematosus (SLE) & backflow → Venous distention (dilation of veins) →
o Rheumatoid Arthritis (RA) Deoxygenated blood retention → Swelling &
o Scleroderma complications
CLINICAL MANIFESTATIONS
COMMON VENOUS CONDITIONS (SERIOUS)
• Ischemic pain and inflammation
VARICOSE VEINS (VARICOSITY)
• Poor wound healing → Increased risk of infection
• Pulse deficit (difference between apical and • Key Features: (+) Distention (+) Retention
peripheral pulse) • Cause:

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✓ Weak or incompetent valves in peripheral veins • Dioxels (promote vascular health & protect
→ Blood regurgitates (flows backward) instead veins)
of moving one way → Retention of blood & fluids • Analgesics (pain relief)
→ Vein distention & tortuosity • Diuretics (reduce swelling by removing excess
✓ Increased venous pressure → Vein walls weaken fluid)
→ Rupture → Bleeding ✓ Loop Diuretics:
o Furosemide (Lasix), Bumetanide
Spider Veins (Early Stage of Varicose Veins) (Bumex), Torsemide (Demadex),
• Key Features: (-) Distention (+) Retention Ethacrynic Acid
• Small, visible veins without significant bulging o Effective for 6 hours
o WOF: Hypokalemia, Photosensitivity,
PREDISPOSING FACTORS Ototoxicity

• Leading cause: Aging (valve wear & tear) PROCEDURES & SURGICAL OPTIONS
• Other risk factors:
• Compression Stockings (Thigh-Length) – Improves
✓ Prolonged standing/sitting
circulation
✓ Sedentary lifestyle
• Laser Surgery/Ablation – Minimally invasive
✓ Obesity/Pregnancy
treatment
✓ Smoking & Alcohol consumption
• Radiofrequency Ablation – Uses heat to close off
✓ Trauma
damaged veins
✓ Genetic predisposition/Congenital conditions
• Sclerotherapy – Effective for spider veins (injection
✓ Oral contraceptives (OCP) – Estrogen
therapy)
✓ Constrictive clothing
• Surgical Procedures: Vein Stripping & Ligation –
CLINICAL MANIFESTATIONS Removal of affected veins

• Warm skin, tender to touch

• Pain (due to increased venous pressure – PVP)
• Skin discoloration (bluish-purple/blue-red)
• Peripheral edema (localized swelling)
✓ Generalized edema (Anasarca) occurs only if
heart, liver, or kidney failure is present
• Enlarged affected veins (distended, tortuous
appearance)
• Common site: Lower extremities
• Wet ulcers (due to venous stasis)
• Decreased pulse quality/grading

COMPLICATIONS

• Blood clot formation → Risk of:

✓ Deep Vein Thrombosis (DVT)
✓ Thrombophlebitis (inflammation of veins due to
clot formation)

DIAGNOSTIC TESTS

• Venogram (to assess vein structure & function)

• Doppler Ultrasound (Duplex scan – evaluates blood
flow)
• Clotting & Bleeding Parameters
• Assessment
✓ Comprehensive Physical Assessment (Head-to-
Toe Examination)

MANAGEMENT

• Treat underlying conditions/factors

• Positioning:
✓ Elevate the affected limb above heart level
✓ Worsens with dependent positioning
• Diet: Low Sodium (to reduce fluid retention)
• Medications
• Anticoagulants (prevent clot formation)
• Antiplatelets (prevent platelet aggregation)
• Thrombolytics (clot busters)

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