Diseases of the blood vessels

[jamesmayur]

Structure
8.1 Anatomy
8.2 Investigations in arterial disease
8.3 Diseases of arteries
8.3.1 Arteriosclerosis
8.3.2 Atherosclerosis
8.3.3 Aneurysm
8.3.4 Thromboangiitis obliterans (Buerger’s disease)
8.3.5 Raynaud disease
8.4 Arterial surgery
8.5 Diseases of veins


8.1 Anatomy

Structure of blood and lymph vessels

Arteries have three coats:

1. Tunica adventitia - An outer coat composed «•/ mainly of fibrous tissue which prevents over distension.

2. Tunica media - A middle coat composed of muscle and elastic tissue. In the large arteries this coat is mainly elastic but in the smaller arteries it is mainly muscular to control the lumen.

3.Tunica intima - An inner coat composed of epithelial cells providing a smooth lining which helps to prevent clotting.

Veins also have three coats. These are similar to the arteries but there is much less muscle and elastic tissue in veins. The tunica media, therefore, is thin. The tunica intima is reduplicated at intervals to form valves which aid venous return by allowing the blood to flow in one direction only, i.e. towards the heart. Valves are numerous in the veins of the lower limbs.

Lymph vessels

These consist of a thin layer of endothelium similar to blood capillaries but much more permeable. This allows the drainage of tissue fluid which cannot be re-absorbed directly into the bloodstre3m either because there is an excess amount or there are particles that are too large to enter the blood capillaries.




Structure of the arterial system

The arterial system begins on the left side of the heart with the ascending aorta. The aorta continues as an arch and then descends through the thoracic and abdominal cavities before dividing into common iliac arteries. Each common iliac artery divides into an internal iliac artery which supplies the pelvis and an external iliac artery which continues as the femoral artery to the lower limb. The femora! artery continues as the popliteal artery which divides into anterior and posterior tibial arteries. The anterior tibial artery continues as the dorsalis pedis artery and the posterior tibial artery divides into medial and lateral plantar arteries before ending in the foot as a series of arches.

From the arch of the aorta, the brachiocephalic trunk on the right side gives off the subclavian and common carotid arteries but on the left side these arteries are given off directly from the arch. The subclavian artery continues as the axillary and then brachial arteries before dividing into radial and ulnar arteries which end in the hand in a series of arches.

The common carotid artery divides into an external carotid artery supplying the head and neck and the internal carotid artery which supplies the brain through the cerebral arteries. The brain is also supplied by the vertebral artery. Both vertebral arteries (from the subclavian arteries) join to form the basilar artery which forms an anastomosis with the cerebral arteries.

Structure of the venous system

This is divided into two main sets of veins, deep and superficial.

Deep veins

These accompany the arteries. The smaller arteries, for example brachial and tibial, each have two sets of veins - venae commitantes - accompanying them but the larger arteries have a large single vein, usually of the same name (for example popliteal and axillary), following the same course. In the lower part of the body the common iliac veins unite to form the inferior vena cava and in the upper part of the body the subclavian veins and the internal jugular veins unite to form the brachiocephalic veins which in turn form the superior vena cava. The two venae cavae drain into the right atrium of the heart.

Superficial veins

In the lower limb there are two main veins:

1. The great (long) saphenous vein - This begins as a continuation of the medial marginal veins of the foot, passes up in front of the medial mallE0lus, behind the media! tibial and femoral condyles, up the medial side of the thigh to pass through the saphenous opening and ends in the femoral vein in the femoral triangle.

2. The small (short) saphenous vein - This begins as a continuation of the lateral marginal vein of the foot, then passes behind the lateral mallE0lus up the lateral border of the tendo calcaneus. It pierces the deep fascia, passes between the two heads of gastrocnemius and ends in the popliteal vein in the popliteal fossa.

In the upper limb there are two main veins:

1. The cephalic vein - This begins on the lateral side of the dorsal venous network of the hand and passes on to the anterior aspect of the lateral side of the forearm. In front of the elbow joint it passes between biceps and brachioradialis, up the lateral border of biceps and then passes between deltoid and pectoralis major. In the infraclavicular fossa it pierces the clavipectoral fascia, crosses the axillary artery and ends in the axillary vein.

2. The basilic vein - This begins on the medial side of the dorsal venous network of the hand and passes up the posterior aspect of the medial side of the forearm. Just below the.elbow it passes anteriorly up the front of the elbow between biceps and pronator teres and along the medial border of biceps. It becomes deep at the middle of the upper arm and ascends along the medial side of the brachial artery to the lower border of the teres major where it continues as the axillary vein.

Structure of the lymphatic system

This is a network of lymph vessels and nodes (glands) which is responsible for draining tissue fluid from the tissue spaces and returning it to the venous network near the heart.

The lymph vessels accompany blood vessels and are found in the skin, subcutanE0us tissue, muscle, fascia, viscera and intestines. Along the course of the vessels are situated lymph nodes. Lymph, therefore, passes along lymph vessels through a series of nodes before entering the venous circulation.

In the upper limb lymph flows through vessels to the axillary lymph nodes from where it passes to the subclavian trunks.

In the lower limb lymph flow passes through popliteal and inguinal nodes to iliac nodes and then to the lumbar trunk.

The lumbar trunk and the left subclavian trunk drain into the thoracic duct which is the main vessel of the lymphatic system. The right subclavian trunk drains into the right lymphatic duct. Both these vessels end by draining into the junction of the jugular and subclavian veins.

8.2 Investigations in arterial disease

1. Chest X-ray and ECG to determine the state of the blood supply to the heart and lungs.

2. Blood glucose values and urine analysis to determine the presence of diabetes mellitus.

3. Blood tests are used to determine the presence of fat which can increase the blood viscosity which in turn inhibits blood flow. Haemoglobin count is taken for evidence of anaemia which exacerbates arterial disease. Polycythaemia, clotting and platelet abnormalities should also be investigated.

4. Arteriography - Radio-opaque fluid is injected into the arteries and this outlines the vessels. The lower limb arteries are investigated through a lumbar aortogram or a femoral arteriogram and carotid and cerebral arteries are investigated through a carotid arteriogram. The state, lumen and course of the arteries can be detected.

5. Ultrasound scanning - This can be used to detect abnormalities in the size and position of vessels, e.g. aneurysms. As a non-invasive procedure it is safer and less distressing for the patient than other procedures.

6. Arterial pulse - Palpation or auscultation of arterial pulses provides a guide to the level of the occlusion. Complete occlusion results in absent pulses distally, and partial occlusion may result in a weakened pulse. Increased pulsation with a murmur is due to an aneurysm.

7. Skin changes - Charts may be made of the distribution of loss of sensation and of skin temperature. These can be used to determine the extent and progress of the disease as it affects the skin.

8. Doppler tests - Ultrasound is used to detect the rate of blood flow in an artery. When the sound wave is reflected there is a change in frequency which is a function of the blood flow rate. Flow patterns vary with the degree of occlusion.

9. Radio-isotopes - These can be used to measure blood flow by means of a Geiger counter.

10. Pressure changes - These can be measured by inserting a needle into the vessel and reading the level on a manometer or by measuring the pressure with a sphygmomanometer cuff placed round the leg and the Doppler flow probe.

11. Exercise tolerance - This is tested by the patient stepping up and down two steps at a set rate or on a treadmill which gives a standardized test. The number of steps without pain or discomfort gives an indication of the patient’s exercise tolerance.

12. Thermography - This is a non-invasive technique which gives a picture of the skin temperature variation of the whole limb.

8.3 Diseases of arteries

8.3.1 Arteriosclerosis

This is a degenerative process during which elastic tissue is replaced by fibrous tissue and the tunica media becomes thickened. It is part of the normal ageing process.

Pathology

Degenerative changes begin in the tunica media of medium-sized arteries with destruction of muscle and elastic tissue. These changes spread later to affect the tunica intima. Calcium is deposited in the tunica media replacing the degenerated tissues.

There is therefore loss of elasticity which leads to increased peripheral resistance and raised blood pressure.

8.3.2 Atherosclerosis

This is the most common occlusive arterial disease and is characterized by an abnormal mass of lipid material (atheroma) in the intima layer of an artery. Atherosclerosis and arteriosclerosis may exist independently but frequently occur together.

Aetiology

Atherosclerosis becomes increasingly common with age. The majority of patients are aged over 50 and the disease is rarely found in pE0ple aged under 30. Males are affected more than females.

Vessels affected are the aorta, large arteries and some medium-sized vessels particularly the cerebral, renal, femoral and coronary arteries. The smaller arteries are not so commonly affected. When the disease is found in one vessel other arteries are likely to be affected and it may well be widespread. A number of factors are known to predispose to the condition.

These are:

1. Diet - A diet rich in animal fat raises the serum cholesterol level. This occurs in the affluent societies of North America and Europe and not in the underdeveloped countries.

2. Hyperlipidaemia - A high level of Hpids in the bloodstream.

3. Diabetes - This is associated with arteries being narrower than normal.

4. Cigarette smoking - When nicotine is absorbed into the bloodstream it causes vasoconstriction of the small peripheral vessels.

5. Hypertension - This may accelerate vascular disease.

6. Other factors - These may be obesity, lack of exercise, high alcohol intake.

Pathology

1. Lipid material is deposited on the tunica intima.

2. Fibrin is laid down over the lipid material causing patches of raised areas on the intima.

3. Thrombocytes tend to become caught on these areas and this leads to thrombus formation.

4. These lesions gradually increase in size whilst the underlying intima becomes softened and the areas become ulcerated.

5. This ulceration leads to inflammation which spreads to the other arterial walls and neighbouring veins.

6. As thrombus formation continues, the lumen of the affected vessel becomes occluded. A collateral circulation may become established and this can be adequate to supply the needs of the tissues.

Clinical features

These depend on the site of the affected artery. Coronary artery disease causes angina and leads to ischaemia of the cardiac muscle. Cerebral artery disease causes ischaemia of the brain and clinical features depend on the area of the brain affected. Vertebral artery disease may cause dizziness, faintness or impaired vision.

The iliac, femoral and popliteal arteries are commonly affected, and the clinical features are as follows:

1. Intermittent claudication.

2. Rest pain.

3. Cold limbs.

4. Sensory changes.

5. Skin changes.

6. Loss of pulses.

Intermittent claudication

The patient complains of severe cramp-like pain, commonly in the calf muscles, which develops during exercise, particularly walking. At first, the pain ceases when the exercise stops but as the disease progresses the pain is provoked by less exercise and takes longer to subside. It is due to the circulation being inadequate to meet the demands of the working muscles. Other muscles affected may be the glutei, quadriceps, and anterior tibialis.

Rest pain

This is a severe burning pain in the foot or toes which occurs most commonly at night. The patient is frequently wakened by the pain which may be relieved to a certain extent by the leg being suspended over the side of the bed.

Cold limbs

The toes and feet feel cold both to touch and to the patient.

Sensory changes

Pins and needles, tingling or complete anaesthesia may be present especially in the hands or feet and is increased by exercise.

Skin changes

Owing to ischaemia there may be dryness, scaling, brittle nails and loss of hair. The skin may have a white, shiny appearance or be discoloured with a delay in the return of colour after blanching.

Gangrenous changes resulting in death of tissue may be present in the toes or heels and trophic ulcers may be formed on the skin.


Loss of pulses

There may be partial or complete loss of one or more peripheral pulses depending on the severity of the condition and the site of the occlusion.

Complications

Aneurysm - especially in the arch of the aorta.

Rupture of an artery from a trivial cause such as a slight blow or injury or a sudden rise in blood pressure.

Treatment

Medical

Advice is given to stop smoking, avoid cold, wear warm loose clothing, keep the skin clean and free from infection or pressure, avoid using hot water bottles, avoid sitting with the legs crossed, avoid wearing tight shoes, socks, garters or belts. Shoes should be inspected for stones or nails and trauma of all kinds to the legs avoided. It may be necessary to use padding to keep the heels off the bed and blocks to keep the pressure of the sheets off the feet.

Analgesics are prescribed to relieve pain. Anticoagulants may be given to patients with diffuse occlusive disease.

Diet should be low in animal fat and cholesterol and patients suffering from obesity must start a reducing diet.

Regular exercise is important, and the patient should undertake to walk a stated distance each day.

Physiotherapy

This is usually given postoperatively and will be considered with surgery later. Some patients on medical treatment may be referred for physiotherapy. This may mean teaching the patient a good walking pattern and monitoring a walking programme - teaching the patient how to chart the intensity of pain on a scale of 0-10, to record the distance walked and the time taken for the pain to settle with rest.

Buerger’s exercises may be indicated. This is a pattern of positions designed to encourage the development of a collateral circulation in the legs. The procedure is as follows:

1. The patient lies supine with the legs supported in elevation (at an angle of 45° to the horizontal) until the skin blanches - about 2 minutes.

2. The patient sits up with the legs dependent until the skin color is bright red (3 minutes)

3. The patient lies with the legs horizontal until the skin colour returns to normal (5 minutes)

This pattern of positions is repeated four or five times for three times daily. Improvement is determined by decreasing times required for the changes in skin color. Trophic skin ulcers may be treated following principles similar to those for venous ulcers.

8.3.3 Aneurysm

An aneurysm is a dilatation of the wall of an artery forming a sac in communication with that vessel. A true aneurysm is a dilatation of one or more layers of its wall caused mainly by atherosclerosis and sometimes by syphilis or acute infections. The weakened arterial wall produces a sacular or fusiform dilatation with resultant thinning of all coats. Most commonly affected vessels are the aorta and popliteal arteries. Since atherosclerosis occurs most commonly in men over 60 years of age the incidence of aneurysms is greatest in this age group.

A dissecting aneurysm is formed by a split in the tunica media producing an inner and outer wall with blood passing through two channels.

A false aneurysm results from an accident to an artery due to trauma or surgery. Blood escapes from the damaged vessel and forms a haematoma adjacent to the arterial wall.

Clinical features

Many aneurysms are asymptomatic and may be diagnosed on examination for another condition. When symptoms do occur they are usually caused by pressure on neighbouring structures and depend upon which artery is implicated. The following may occur:

1. Ischaemia, gangrene in the foot (popliteal artery).

2. Lumbar backache or central abdominal pain (abdominal aorta).

3. Pulsating mass in the abdominal cavity (abdominal aorta).

4. Difficulty in swallowing due to esophageal pressure (thoracic aorta).

5. Paraplegia due to pressure on nerve roots or spinal cord (aorta).

If untreated, aneurysms may rupture and this can be life threatening in that the patient may bleed to death.

Treatment

Resection of the aneurysm and replacement with a prosthetic graft or a by-pass graft.

8.3.4 Thromboangiitis obliterans (Buerger’s disease)

Aetiology

This is a disease of unknown aetiology which is precipitated by cigarette smoking. Cessation of smoking improves the outcome of the disease. It affects males between the ages of 20 and 40. There does not appear to be any marked racial bias although originally it was thought to be more common,in Jews. The arteries of the upper limb and viscera are affected as well as those in the legs but v the distal arteries of one leg are usually affected first unlike atherosclerosis where the larger proximal arteries are initially affected.

Pathology

Lymphocytes invade the arterial wall. The wall becomes inflamed and clots form which obstruct the lumen of the artery. Ultimately, the vessel may degenerate and fibrous tissue formation further reduces the lumen. The process is slowly progressive and extends to the collateral vessels.

Clinical features

These are mainly in the legs. There is rest pain and the feet are cold, sweating and often have fungal infections. On elevation, the foot becomes pale and on dependency red. The two principal symptoms are intermittent claudication and gangren. As the digital arteries are affected the toes may be completely ischaemic but the foot has a good blood supply and the foot pulses are present. (In atherosclerosis the gangrene is the result of proximal arterial disease and the pulses are absent.) The pain associated with the onset of gangrene is severe and may prevent sleep.

Treatment

Smoking is forbidden because : causes vasoconstriction. Drugs may be prescribed in the form of analgesics and vasodilators. Skin hygiene is essential to prevent wound infection.

Physiotherapy

The aim is to improve the circulation to increase the blood supply to the affected limbs thus delaying the onset of gangrene. Buerger’s exercises may be given to assist the establishment of a collateral circulation. In the early stages of the disease the patient is encouraged to exercise without producing the pain.

Surgery

1. Upper thoracic or lumbar sympathectomy to relax arterial muscle and increase the vessel lumen thereby improving the blood supply to the extremities.

2. Amputation, initially of gangrenous toes, may be performed but amputation higher up the limb is usually necessary later due to the progressive nature of the disease. Reconstructive surgery of the arteries is difficult because the smaller distal vessels are affected.

8.3.5 Raynaud disease

This is a vasomotor disorder characterized by intermittent spasm of the digital arterioles.

Aetiology

The disease occurs in women more than men and between the ages of adolescence and middle age. The hands are primarily affected, usually bilaterally, and the feet may also be affected. Exposure to cold precipitates the disease and in some cases emotional disturbances have similar effects.

Pathology

Spasm of the digital arterioles reduces blood flow to the skin of the fingers which become white and numb. When the spasm wears off the blood returns to the fingers. Initially the fingers are blue because the blood quickly loses its oxygen to the ischaemic tissues but then they become red, swollen and painful as the blood fills all the dilated arterioles. As the disease progresses there may be permanent spasm resulting in necrosis of the fingers or toes.

Clinical features

The attacks are intermittent, affecting both hands. On exposure to cold, the fingers feel numb and appear white and shiny. On rewarming they become pink with a burning sensation. Severe cases show ulceration and atrophy of the fingers. The wrist and ankle pulses can be palpated. Similar features are present in other vascular disorders such as Buerger’s disease and atherosclerosis as well as in cervical rib. These are known as secondary Raynaud’s phenomena.

Treatment

Medical

Advice is given to avoid cold extremities by wearing thick, loose-fitting gloves, woollen socks and furlined boots. Also the hands should not be immersed in cold water. Working and living conditions should be in a warm atmosphere. Smoking must be stopped because nicotine in the blood causes vasoconstriction of the blood vessels, especially the small peripheral ones.

Vasodilator drugs have been tried but have limited success because the normal vessels tend to dilate rather than the diseased vessels.

Physiotherapy

Active exercises may be given to increase the flow of the general circulation.

Contrast baths may help. The patient is instructed to place the hands or feet in a hot bath for 3 minutes and then a cool bath for 1 minute. This can help to accelerate the rate of blood flow in the peripheral vessels.

Connective tissue massage may provide a symptomatic improvement in the condition. The sacral and lumbar basic area should be treated first and then the extremities. This reduces tension in the back and the patient often feels the extremities becoming warmer. A course of connective tissue massage is often of benefit prior to the advent of winter.

Surgery

Sympathectomy - In the dorsal region for the hands and in the lumbar region for the feet. The vasoconstrictor action of the sympathetic system on the blood vessels is released resulting in vasodilatation. The effect tends to wear off after a few months although some permanent benefit can be obtained. Again the operation should be performed at the beginning of winter.

8.4 Arterial surgery

This involves reconstruction of arteries.

Indications

Arteriosclerosis, thrombosis, aneurysm, congenital abnormalities, trauma.

Types of operation

1. Sympathectomy.
2. Direct suture.
3. Embolectomy.
4. Endarterectomy.
5. Arterial grafts.

When arterial surgery has failed or it is not possible to revascularize a limb, amputation is the only treatment.

Sympathectomy

This involves removal of the sympathetic nerve supply to a part of the body causing selective vasodilatation (increased activity of sympathetic system causes vasoconstriction).

A sympathectomy produces a local increase in blood supply to skin but its effect is not permanent. (Vasodilator drugs have a general effect.) The sympathetic system does not affect muscle arterial circulation and it is of no benefit in the treatment of intermittent claudication.

Direct suture

This is the rejoining of an artery after a part is removed.


Embolectomy

This is direct removal of an embolus through an opening in the artery. A Fogarty catheter with a balloon at the end is passed beyond the embolus. The balloon is then inflated and the catheter is withdrawn, removing the embolus and clearing the vessel.

Endarterectomy

This is the removal of an atheromatous occlusion by stripping it out together with the tunica interna and part of the media.

Arterial grafts

A graft may be used to replace an aneurysm or obstructed segment of an artery in larger arterie:. A graft may also be used to construct a bypass round an obstructed artery. A bypass will be successful provided there is no significant arterial disease proximal or distal to the bypass.

For a general artery bypass the next suitable material is a saphenous vein which has a thick muscular wall and can withstand arterial pressure. As the vein has valves to aid venous blood flow the vein used for grafting must be reversed so that arterial blood flow is not obstructed. The cephalic vein in the arm can also be used.

A number of synthetic materials have been tried for grafting but the most commonly used is Dacron (terylene) which is inert, flexible and strong. Dacron grafts remain patent in aortic or iliac regions, and it is the material of choice because saphenous veins are not wide enough. It does, however, show a tendency to thrombose when used in the femoral or popliteal arteries and is used only when a saphenous vein graft is not possible or has failed.

An arterial bypass graft is described by the proximal and distal anastomoses, for example:

1. A femoro-popliteal graft is from the femoral artery to the popliteal artery.

2. An aorto-bifemoral graft is from the aorta to both femoral arteries (a trouser graft).

3. A femoro-femoral graft is from one femoral artery to the other (cross-over graft) and is used when one iliac artery is healthy and the other diseased.

4. An axillo-femoral graft is from the axillary artery to the femoral artery and is used to revascularize the lower limb when the aorta is blocked.

Complications of surgery

These can be general as in any major surgery or local around the site of operation.

General

Circulatory complications are more likely to arise in arterial surgery than in other forms of major surgery because of the nature of the disease, the site of surgery and the age of patient:

1. Coronary thrombosis or cerebrovascular accident- If a thrombosis dislodges it may block one of the blood vessels supplying the heart or the brain.

2. Deep vein thrombosis - A thrombosis may form in the deep veins particularly of the calf due to sluggish venous circulation and increased release of thromboplastin at the operation site which may be near veins.

3. Respiratory complications - Secretions may accumulate because the patients are often smokers. The operation may take a number of hours and the patients may have limited respiratory function.

A pulmonary embolus may result from deep vein thrombosis.

Local

1. Infection - This is more likely to arise with a Dacron graft because it has no natural antibodies. Infection leads to breakdown of the anastomosis and leakage of blood into the neighbouring tissues.

Signs of graft breakdown:

(a) Excessive loss of blood from redivac drain.
(b) Swelling at operation site.

2. Haemorrhage - This results from immediate leakage at the suture line.

3. Graft obstruction - This may arise due to thrombosis formation from slowing of the blood flow or irritation of the arterial wall.

Signs of graft obstruction: The following signs may be present distal to the operation site:

(a) Diminished or lost pulses.
(b) Limb feels and/or appears cold.
(c) Pain and numbness.
(d) Colour becomes mottled, pale.

4. Peripheral neuropathy - Peripheral nerves may be damaged resulting in weakness of the muscles supplied by the damaged nerve.

Management

Preoperatively

All patients except those for acute emergency surgery, bleeding aneurysms or sudden total blockage of a main artery will be admitted before surgery. Investigations are carried out on the arterial and respiratory systems (see above). Drug therapy is reviewed, e.g. antibiotics and anticoagulants (heparin or warfarin).

Physiotherapy

This involves an explanation to the patient of the treatment and teaching the postoperative exercises to prevent complications.

Respiratory care

1. The patient is strongly advised to give up or at least reduce smoking.

2. Expansion breathing exercises and breathing control are taught.

3. Effective coughing or huffing is practised with the patient shown how to support the wound particularly if there is an abdominal incision.

4. More vigorous treatment may be required if lung infection is present.

Circulatory care

The importance of foot exercises must be explained and the patient practises them except where there is evidence of gangrene in the foot. General deep breathing is also taught so that the diaphragmatic movement will aid venous return.

Postoperatively

The patient may spend 24 hours in the intensive care unit, particularly for aortic grafts.

The patient wears antiembolitic stockings and lies supine with a bed cradle to allow the feet to move freely. This also enables observation of skin colour and arterial pulses. The lower limbs should be flat and not supported on a pillow.

A redivac drain remains in situ until drainage is minimal.

Physiotherapy

Breathing exercises

These are given when the patient recovers consciousness to the basal areas of the lungs combined with huffing to encourage expectoration with minimum effort by the patient. Thoracic incisions must be supported by the patient with the help of the therapist.

Foot exercises

These are given immediately to prevent deep vein thrombosis.

Active toe and ankle movements of both legs, particularly full-range dorsi- and plantar flexion are encouraged with all levels of graft. The patient must do the exercises vigorously every hour.

The therapist should note the skin temperature and colour of the lower limbs for signs of postoperative complications. The temperature chart should be read daily because a raised temperature is indicative of infection in the chest, urine or wound. Pain and swelling in the calf is indicative of deep vein thrombosis.

Blood-stained sputum, together with chest pain, should be reported in case a pulmonary embolus is developing. All arterial surgery has the same basic physiotherapy but following an embolectomy or endarterectomy the patient can move aft joints of the lower limbs and is discharged after a few days.

Following arterial grafts no undue strain must be put on the graft and kinking must be avoided. The joints over which the graft passes must not be bent, e.g. avoid knee movements in femoral popliteal grafts and hip movements in ilio-femoral grafts.

The patient begins walking in 2-3 days following a femoral popliteal graft and knee movements are gradually encouraged. With more proximal grafts the patient must be encouraged to stand straight. The walking pattern is corrected daily and the distance is gradually increased before discharge in 7-10 days. The patient should walk up and down stairs.

In surgery where an arm vein has been used for grafting all movement of the upper limb joints should be encouraged postoperatively. Patients do not normally require physiotherapy after discharge from hospital.

Advice to patients

1. Avoid restrictive clothing which may interfere with the circulation, e.g. tight belts or bands.

2. Stop smoking or reduce it as much as possible.

3. Avoid positions which cause pressure on the graft, e.g. knee flexion beyond 90°, sitting back on heels, or crossing one leg over the other in femoral popliteal grafts.

4. Avoid prolonged standing (but if this is unavoidable then practise marking time). However, a daily walk should be encouraged.

5. Avoid exposure to excessive cold and take care with application of heat, e.g. hot-water bottles.

6. A gradual return to normal function and increasing the amount of physical activity is to be encouraged.

8.5 Diseases of veins

Superficial venous thrombosis (phlebitis or thrombophlebitis)

This is an inflammation of the inner walls of superficial veins mainly of lower limb.

Causes

1. Trauma to the vessel wall from a drip needle or pressure externally due to tight garments or position of limb.

2. Circulating toxins from septic wounds.

3. Association with deep venous thrombosis.

Pathology

Irritation produced changes in the tunica intima, causing a thrombus to form. The thrombus becomes attached to the vein wall and rarely produces an embolus.

Clinical features

There is a localized, reddened, warm area with hard, cord-like swelling along the course of the affected superficial vein. Pain may be present at rest and is aggravated by movement of the limb. As the condition resolves the skin becomes pigmented (brown) along the course of the vein.

Treatment

1. Firm elastic bandaging or stockings from the toes -”To beyond the upper limit of the affected area.
2 Drug therapy:

(a) Antibiotics in cases of infective phlebitis.
(b) Analgesics to relieve pain.
(c) Anti-inflammatory, e.g. indomethacin to reduce the inflammation.

3. Exercise - The patients should be encouraged to carry out foot exercises with the legs elevated and to remain ambulant to maintain venous circulation. In severe cases the patient may be confined to bed for a short period.

4. It is important that the physiotherapist recognizes the condition in a patient so that treatment can be instigated and physiotherapy modified if necessary.

Deep venous thrombosis (DVT)

This is blocking of a deep vein by the formation of a thrombus - most commonly in the lower limb.

Predisposing factors

1. Venous stasis due to a paralysed or immobile limb, prolonged bed rest or during surgery.

2. Injury to the vessel wall - during surgery or trauma.

3. Increased coagulability of the blood. An increase in the number of platelets is common after surgery or childbirth.

4. Middle-aged to elderly patients, particularly those who are obese.

5. Drugs - notably the contraceptive pill.

6. A previous history of DVT or pE0ple with vascular or blood disorders.

Pathology

Damage to the intima causes platelets to be deposited on the vein wall. Venous stasis increases the accumulation of platelets which adds to the size of the thrombus resulting in occlusion of the vessel lumen. There is further extension of the thrombus (propagated thrombus) along the vessel to the next junction with a vein. A portion may break off giving rise to a pulmonary embolus or the thrombus may become organized and firmly attached to the venous wall. Gradually it is recanalized and the circulation is re-established but the valves are often destroyed leaving chronic venous insufficiency. This is a particular disadvantage in the lower limb.

Clinical features

1. Aching or cramp-like pain at site of thrombus
2. Tenderness on deep palpation over the area.
3. Oedema around the joint distal to the area. .
4. May be symptomless.
5. Unexplained systemic features, e.g. mild pyrexia, pleuritic pain, tachycardia in a patient recovering from surgery.
6. Severe pulmonary embolus giving signs extreme distress, breathlessness and shock may
be the first indication of DVT.
7. Increased pain in the calf on passive dorsiflexion of the foot (Homans’ sign) is suggestive of DVT in lower leg.

Treatment

Prevention is better than cure and early diagnosis is important for effective treament.

Diagnosis

Phlebography is used for establishing the diagnosis in doubtful cases.

A Doppler probe can assess venous flow. If a distal vein is blocked no flow will occur in a proximal vein, e.g. thrombosis in calf results in no flow in the femoral vein.

Prevention (lower limb DVT)

1. Inpatients confined to bed with a cradle under the bedclothes and the bed end elevated 15-22 cm.

2. TED (anti-embolitic) stockings should be worn by all patients who are confined to bed postoperatively.

3. General breathing exercises and active movements of the hips, knees and particularly foot and ankle for patients on prolonged bed rest.

4. Early ambulation and not sitting with the legs dependent is important.

5. Passive movements of a paralysed limb.

6. Any risk factors should be minimized, e.g. stop the contraceptive pill before planned surgery.

7. Anticoagulant therapy, e.g. low-dose heparin may be given prE0peratively in high-risk cases or dextran during surgery.

Treatment

1. Bed rest with a cradle and the end of the bed elevated until all the local signs subside - maybe up to 7 days. This helps the thrombus to adhere to the venous wall.

2. Foot and leg exercises while in bed and a gradual increase in mobility. The patient must walk and not stand or sit with the legs dependent and must wear support on the legs at all times even in bed.

3. Anticoagulant therapy. This is begun immediately with heparin given intravenously (heparin inhibits the conversion of prothrombin to thrombin).

Oral anticoagulants are then started, e.g. warfarin which slows down the formation of vitamin K necessary in the formation of thrombin. This may be continued for up to 6 months to reduce the risk of further DVT.

Pulmonary Embolism

This is a complication of deep venous thrombosis. If a thrombus breaks off in a deep vein it travels in the venous system to the right side of the heart where it enters the pulmonary artery and passes into the pulmonary circulation where it blocks a vessel, the lumen of which is too narrow to let it pass through. The factors that predispose to a deep vein thrombosis also predispose to a pulmonary embolism.




Pathology

A large embolus causes complete occlusion of the pulmonary artery causing blockage of the blood flow from the right ventricle, usually resulting in death. Smaller emboli cause occlusion of pulmonary circulation to a segment of a lung.

Clinical features

Large embolus

1. Sudden collapse.
2. Severe retrosternal pain and shock.
3. Dyspnoea and distension of neck veins.
4. Reduced air entry and scattered wheeze.

Smaller embolus

1. Sudden onset of severe chest pain.
2. Dyspnoea.
3. Haemoptysis and pleuritic pain.


Treatment

1. Drugs: anticoagulants. Streptokinase - dissolves thrombus.

2. Surgery - pulmonary embolectomy.

3. Bed rest with the end of the bed elevated. Patient is allowed up when all symptoms have disappeared.

It is important that the physiotherapist can recognize the signs of a pulmonary embolus so that treatment can be instigated early. Physiotherapy in the form of active exercises to the lower limb and early ambulation are important preventative measures.

Varicose veins

Varicose veins are dilated, lengthened and tortuous with incompetent valves. Superficial varicose veins can be seen through the skin.

Aetiology

Age - any age, but commonest 40-50 years.
Sex - Female more than male.

Predisposing factors

1. Compression of pelvic veins during pregnancy.
2. Occupation necessitating constant standing, e.g. shop assistant.

3. Tight corsets or garters.
4. Heredity may be a factor.
5. Secondary to deep venous thrombosis.
6. Basic weakness of vein wall.

Pathology

The vein wall dilates at weak areas and the valves become incompetent. Normally as the calf muscles contract there is pressure on the deep veins which forces the blood proximally. This pressure is not transmitted to the superficial veins because of the valves in communicating veins. When these valves become incompetent the pressure pushes the blood into the superficial veins which dilate and lengthen. A vicious circle is set up, the ineffectual valves permitting regurgitation and the increased amount of blood thus left in the veins still further dilating them and making the valves more incompetent.

During standing the force of gravity tends to keep the blood in the lower parts of the body, aggravating the condition.

There is loss of elastic tissue, muscle atrophy of the media layer and hypertrophy of the outer layer.

Clinical features

1. Superficial veins appear as tortuous ’knotted’ structures.

2. May be only cosmetically troublesome or the ^patient may complain of pain, aching and fatigue

in the legs with difficulty in walking.

3. Cramp in calf muscles, especially at night.

4. Calf muscles weaken, lose their pumping action and support for the veins accentuating the venous changes.

5. Skin of leg may be pigmented, indurated and show signs of ulceration.

6. There is congestion and oedema of the ankles due to the dilated veins and the abnormally high pressure in the capillaries which results in increased exudation of lymph.

Complications

1. Bleeding following rupture of vein.
2. Venous ulcer due to devitalized skin.
3. Superficial venous thrombosis.
4. Oedma, particularly of the foot and ankle.


Treatment

1. Conservative.
2. Surgical.

Conservative

The aim of treatment is to improve venous return:

1. Elastic support which increases efficiency of calf muscles as a pump. This may be elastic stockings or elastic bandages which may be more effective.

2. Encourage walking but avoid standing especially for long periods.

3. Elevation of lower legs for 10 minutes three times a day and sleep with end of bed raised.

4. Injection of sclerosant solution into the vein followed by firm bandaging of the leg for 6 weeks. The sclerosant produces inflammation in the vein causing its lumen to be obliterated so that no blood can pass through.

Physiotherapy - The patient is encouraged to practise foot and ankle exercises in elevation and instructed to walk 1-2 miles a day, in support stockings if necessary, to keep blood flowing through the deep veins. The correct pattern of walking must be emphasized.

Surgical

This is carried out when the patient is in severe pain or is in an occupation which involves prolonged standing. The aim is to remove as many dilated veins as possible and ligate others.

Physiotherapy

Post-operatively the legs are bandaged and elevated to promote blood flow in the deep veins. When resting, the knee should be straight but the patient must practise leg exercises hourly as soon as possible. For example: foot and ankle ’pumping’ exercises, hip and knee flexion and extension, quadriceps and gluteal contractions.

First day post-operatively - The patient is helped out of bed and walking is commenced with the legs well bandaged. The patient is encouraged to move the ankle and knee joints together with the correct ’push off’ with even timing and stride length patterns.

Second day post-operatively - The distance walked is progressed (avoid standing still) and a flight of stairs attempted.

The patient is discharged within 48 hours with clear instructions on the wearing of support stockings for several weeks and the continuation of the exercises at home.
Physiotherapy may also be given for any venous ulcers or oedema.