pem fisik arteri vena

8/12/2019 Pem Fisik Arteri Vena

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Arterial, Venous

(and Lymphatic) Systems

Their Significance in Chronic Lower

Extremity Wounds


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Pain occurring when an extremity

is elevated indicates:A. Arterial disease

B. Venous disease

C. Lymphatic disease


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When describing the benefits of your exercise

program to your patient (to educate and also

to improve compliance), you tell her thatregeneration of the affected part of her

circulatory system is possible.

Which part of the circulatory system wouldhave been impaired for this to be true?


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A. Arterial system

B. Venous system

C. Lymphatic system


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The arterial system contains what

percentage of total body blood volume?A. 30%

B. 50%

C. 90%


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. . .it is best to think of a wound

not as a disease, but rather as a

manifestation of disease.Joe McCulloch


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In order to manage wounds

effectively, it is essential to

appreciate the underlying cause.


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Part I

A Brief Review of

Structure and Function ofVascular Structures


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Overview of 3 Circulatory

Systems

Arterial

Venous

Lymphatic


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Common Vessel Wall Layers or

Coats (Tunics) Tunica intima - endothelial cells and basement

membrane; uniformly smooth in all structures;(inner)

Tunica media - smooth muscle and elastic tissue

(middle)

Tunica adventitiacollagen fibers plus bloodvessels & nerves (outer)


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Arterial System

Conveys oxygenated blood to tissues

Responds to sympathetic and humoral

stimuli that maintain blood pressure

Shunts blood from nonworking to working

organs

Contains 30% of blood volume


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Artery Characteristics

Aorta to arteriole

Media: thick layers of muscular and elastic

tissue

Diameter responds to left ventricular

pressure

Lie on flexor side of major joints


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Arterial Pressure

- normal systolic pressure< 140 mm Hg

- arterial capillary pressure 25 mm Hg

- high pressure/low volume system


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Arteries of theAnterior Leg


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Arteries of thePosterior Leg


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Venous System

Removes interstitial fluid from tissues

Returns deoxygenated blood to right atrium

Contains 70% of blood volume


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Vein Characteristics

Large, medium, and small

Superficial, deep, and perforating veins

Valves in medium and large veins formed

by folds in intima

Two large, major veins usually accompany

each major artery on flexor side of joints


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Venous Pressure

- wide variation (10-90 mm Hg)

- low pressure/high volume

- blood conveyed back to heart by:

muscle pump

respiratory pump (vacuum?)

valves


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Superficial Veins,

Posterior Leg


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Superficial Veins,

Anterior Leg


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Lymphatic System

removes interstitial fluid and large cells that

cannot pass into capillary or venule

has immunologic and phagocytic functions

controls tone of precapillary arterioles


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Characteristics of Lymphatics

Very thin walls

Many semilunar, paired valves in larger

vessels

No major direct link to artery or vein except

the thoracic and right lymphatic ducts


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Pressures in Lymphatics

Very low pressure

Lymph moved centrally by valves*,negative pressure in chest, muscle pump(like veins)

*Lymphangion: lymph vessel segmentswith valves at either enda lymph pump


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Thoracic and Right

Lymphatic Ducts


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Capillary Bed

- capillaries allow diffusion of O2and

nutrients to tissues, AND

- CO2 and other waste products diffuse out oftissues, WHILE

- Open-ended lymphatics move

comparatively small amounts of fluid fromthe capillary bed, but handle large cells


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Review: Equilibrium at the

Capillary Bed Adequate Arterial

Supply

Functional VenousReturn Structures

Patent Lymphatic

Structures

Normal Interstitial

Space


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Part II

Vascular Diseases Producing

Wounds in the LowerExtremity


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Classifications of Wounds in

Lower Extremity Arterial

Venous

Mixed


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Basis for Wounds of Arterial

Origin Arteriosclerosishardening of arteries

-calcification of arteries of all sizes

- loss of elasticity of arterial walls

Atherosclerosisfibrous plaque

- thickening of inner coat (intima)

- fatty degeneration of middle layer (media)


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Events Producing Wounds of

Arterial Origin

Diminished arterial flow

Thrombus or microembolus formation

Blockage - most often at bifurcations

Tissue hypoxia and cell death


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Appearance of Limb in Arterial

DiseaseTrophic Changes Pale, cool skin

Abnormal toenail growth

Hair absent

Muscle atrophy

Edema


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Trophic Skin Changes in Arterial

Disease


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Arterial Diseases associated with

Wound Development Arteriosclerosis obliterans

Other Examples

- Diabetes

- Vasculitis (RA)

- Sickle Cell Disease

Thromboangiitis obliterans*


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Arteriosclerosis obliterans

Disease of large and medium sized arteries

Associated with:

High blood pressure

Hyperlipidemia

Arterial occlusion particularly at bifurcations


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Necrosis of Toe in



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Heel Ulcer in Arteriosclerosis

Obliterans


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Other Examples: Arterial

Diabeteshyperglycemiasticky bloodadds to development of atherosclerosis

Vasculitisinflammation blocks bloodflow

Sickle Cell Diseaseclumps of misshapenred cells occlude small arteries


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Thromboangiitis obliterans

Also called Buergers Disease

Affects adults under age 40

*Veins also involved

Unlike arteriosclerosis obliterans, may

affect hands

Primary cause: cigarette smoking!


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Thromboangiitis obliterans -

early


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Thromboangiitis obliterans - late


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Rubor of Dependency in



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Etiology of Venous Stasis

Wounds, continued Arteriovenous fistula theory (1947)

Fibrin cuff theory (1982)

Leukocyte activation (1988)

ALL mostly discredited as causes of ulcers. . .


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Venous Thrombosis


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Varicose Veins


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Varicose Veins


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Venous Stasis Ulcer


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Importance of the Calf Pump

Normal Edema Present


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Appearance of Limb in Venous

Insufficiency (Early) Stasis dermatitis

Erythema

weeping blebs or vesicles

edema


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Stasis Dermatitis - Early


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Appearance of Limb in Venous

Insufficiency (Late)

Induration of subcutaneous tissue

Brawny (brownish) discoloration:Hemosiderin iron-containing pigment

Edema

Ulceration usually around medial malleolus


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Stasis Dermatitis (Late)


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Questions. . .

1. Your venous stasis wound patient asks

specifically:

a. why she developed varicose veinsb. why her lower calf is discolored.

You would explain that. . .


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Noninvasive Tests of Venous

Sufficiency

Doppler ultrasound

Plethysmography

Percussion test #

Brodie-Trendelenburg test #

Venous filling time #


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Venous Filling Time


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Tests for Deep Venous

Thrombosis (DVT)

- cuff test #

- test for Homans sign #


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Combined Pathologies

Arterial and venous disease may coexist

Venous disease can contribute to lymphaticdysfunction, and vice-versa


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How is Lymphedema different

from Edema? Edema: tissue fluid accumulated in the

interstitial spaces secondary to many causes

Lymphedema: protein rich fluid that

accumulates in the tissue secondary to

lymphatic blockage


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Lymphedema itself not usually

associated with wounds A complete discussion of lymphedema will

be addressed in the oncology section of this

course.


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Combined Pathologies

Thorough examination

Teamwork

Patient education

General rule: treat most threatening aspect

first (usually arterial insufficiency)


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The End!

pem fisik arteri vena

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