🫀 Arteries & Peripheral Arterial Disease (PAD)

🔹 General Function

• The heart pumps freshly oxygenated blood through arteries to all body tissues.
• Arteries supply oxygen and essential nutrients to tissues.

🔹 Arteries Accessible to Examination

• Temporal & Carotid arteries – located in the head and neck.
• Arteries in the Arm
• Brachial → bifurcates into ulnar & radial arteries.
• Arteries in the Leg
• Femoral
• Popliteal
• Anterior tibial → dorsalis pedis
• Posterior tibial → plantar arteries

🔹 Peripheral Arterial Disease (PAD)

• Peripheral arterial disease (PAD) is a condition where the arteries that carry blood to the limbs, such as the legs and arms, become narrowed or blocked. This reduces blood flow and oxygen delivery to the affected areas. 

• So, it refers to noncoronary arterial disease.
• Leads to reduced blood flow, which may cause:
• Claudication (leg pain while walking)
• Weak/absent pulses in legs or feet
• Delayed wound healing (Watch out if the patient has also Diabetes)

Arteries in the Arm

Vessels in the Leg

🩸 Veins

The course of the veins generally parallels that of the arteries, but the body contains more veins, and they usually lie closer to the skin surface. Their main function is to drain deoxygenated blood and waste products from tissues and return them to the heart. Because veins can stretch and hold large volumes of blood, they are often called capacitance vessels.

🔎 Veins Accessible to Examination

• Jugular veins in the neck
• Leg veins divided into three groups:
• Deep veins: femoral and popliteal
• Superficial veins: great and small saphenous
• Perforator veins: connecting channels that join superficial and deep systems

⚙️ Mechanisms for Venous Return

Unlike arteries, veins work under a low-pressure system. To keep blood moving toward the heart, they rely on three key mechanisms:

• Contracting skeletal muscles compress veins and push blood upward.
• Pressure gradient from breathing helps move blood as the chest expands and contracts.
• Intraluminal valves act as one-way doors that stop blood from flowing backward. When these valves become incompetent, blood begins to pool in the veins. This results in dilated, twisted vessels known as varicose veins.

In the legs, these mechanisms form the calf pump, often called the peripheral heart, where calf muscle contraction and venous valves work together to overcome gravity.

🧍‍♀️ Pregnant Woman

• During pregnancy, hormonal changes lead to vasodilation, which lowers blood pressure.
• There could be dependent edema, varicosities in the legs and vulva, and the development of hemorrhoids. This is because the enlarging uterus compresses the iliac veins and the inferior vena cava. This obstruction of venous return can

👵 Aging Adult

-arteriosclerosis

-intermittent claudication

-risk of DVT and pulmonary embolism

-loss of lymphatic tissue

Notes: Intermittent claudication is a condition where leg pain occurs during exercise and subsides with rest. It is caused by a narrowing or blockage of the arteries in the legs, reducing blood flow to the muscles. 

📌 Quick Summary

• AHA: PAD is considered a CAD risk equivalent → screening & treatment required.
• Genetics: Multiple genes + environment; no single biomarker.
• Environmental factors: Smoking, diabetes, HTN, high cholesterol, obesity.
• Disparities: PAD disproportionately affects non-Hispanic Blacks.
• Screening: Ankle-Brachial Index (ABI) is the main noninvasive tool; wider access is needed.

Extra Notes:

Dependent edema is a condition where excess fluid accumulates in the lower extremities, such as the ankles, feet, and calves, due to gravity. 

📝 Subjective Data in Peripheral Vascular Assessment

When assessing subjective data, it is essential to explore patient-reported symptoms and histories that may indicate peripheral vascular disease.

🦵 Leg Pain or Cramps

Quick Summary – Questions.

• Leg pain or cramps?
• PQRSTU (Questions)
• Precipitating activity (walking, exercise)
• Recent activity changes
• Effect on Activities of Daily Living (ADLs)
• Comorbid conditions

🩹 Skin Changes (Arms and Legs)

Quick Summary – Questions.

• Color or temperature changes
• Appearance (dryness, thinness, shiny skin)
• Support hose use or prior treatment
• Presence and location of sores/ulcers (painful or not)
• Swelling and associated symptoms
• Factors that relieve or worsen symptoms

💊 Ask the patient about Medications they consume:

• Prescription (Rx) medications
• Over-the-counter (OTC) therapies
• Supplements

🚬 Smoking History

Smoking is one of the most significant risk factors for peripheral vascular disease. Patients should be asked about their pack-per-day (PPD) history, duration of smoking, and whether they have attempted or are currently undergoing cessation therapy.

Quick Summary – Smoking

• Pack-per-day (PPD) history
• Duration of smoking
• Use of cessation therapy

🧾 Objective Data – Peripheral Vascular System

🛠 Preparation

Equipment Needed:

• Paper tape measure
• Tourniquet or blood pressure cuff
• Stethoscope
• Doppler ultrasonic probe

✋ Inspect and Palpate the Arms

The arms are examined for color, nail bed appearance, skin temperature, texture, and turgor, as well as the presence of lesions, edema, or clubbing.

• Clubbing: detect early changes using the profile sign.
• Capillary refill: note if it is brisk or sluggish.
• Radial pulse: graded on a 0–3+ scale (0 = absent, 2+ = normal, 3+ = bounding).
• Ulnar and brachial pulses: not usually assessed in routine exams.

🦵 Inspect and Palpate the Legs

The legs should be uncovered while keeping genitalia draped.

• If asymmetry is observed, measure the circumference at the same level on both legs.
• Document skin discoloration, ulcers, or gangrene, noting size and location.
• Palpate for temperature and pulses with bilateral comparison.
• Assess neurovascular status with a monofilament test.
• Check for presence of hair (patchy hair can be a symptom of Peripheral Artery Disease or DVT)

Key Lower Extremity Pulses:

• Femoral artery: below inguinal ligament, midway between pubis and iliac spine.
• Popliteal pulse: felt with fingers curled into the popliteal fossa.
• Posterior tibial: behind the medial malleolus in the groove near the Achilles tendon.
• Dorsalis pedis: just lateral and parallel to the tendon of the big toe.

Edema Assessment:

• Press firmly over tibia or medial malleolus for 5 seconds.
• Grade pitting edema:
• 1+ mild, slight indentation
• 2+ moderate, subsides quickly
• 3+ deep, remains, leg swollen
• 4+ very deep, lasts long, gross swelling
• Note: ankle circumference is more reliable; always follow institutional standards.

Color Change Test:

• Raise legs for 30 seconds → arterial contribution only.
• Sit with legs down → note time for color return (<10 sec normal) and venous filling.
• Assess strength and sensation in lower legs.

🎧 Doppler Ultrasonic Probe

Used to detect weak peripheral pulses, measure low blood pressure, or assess lower extremity circulation.

• Position supine, legs rotated outward.
• Apply coupling gel; place transducer at 90° with light pressure.
• Identify pulses by swishing, whooshing sound.

👶👵 Developmental Competence

• Pregnant Women: expect diffuse bilateral pitting edema, especially in third trimester; varicose veins common.
• Older Adults: dorsalis pedis and posterior tibial pulses may be harder to find; trophic arterial changes such as thin shiny skin, thick ridged nails, and hair loss on lower legs.

👣 Health Promotion & Foot Care

• Inspect feet regularly for breakdown or abnormalities.
• Exercise to improve circulation; avoid prolonged sitting.
• Wear well-fitting shoes indoors and outdoors.
• Lubricate feet to prevent dryness and cracking.
• Recommend patients to use a mirror if necessary to check the the the sole or plantar surface.

🚨 Abnormal Findings

• Pulse contours: weak (1+), bounding (3+), water-hammer, bigeminus, alternans, paradoxus, bisferiens.
• Arms: Raynaud phenomenon, lymphedema.
• Legs: arterial ulcers, venous (stasis) ulcers, neuropathic ulcers.
• Peripheral vascular disease: varicose veins, DVT, aneurysms, occlusions.

Pain Profiles:

• Arterial disease → oxygen deficit symptoms.
• Venous disease → metabolic waste buildup.
• Always note location, character, onset, duration, aggravating/relieving factors, and risk factors.

✅ Summary Checklist

• Inspect arms (color, size, lesions)
• Palpate radial & brachial pulses, check epitrochlear node
• Inspect legs (color, size, lesions, trophic changes)
• Palpate temperature, inguinal nodes, and pulses (femoral, popliteal, posterior tibial, dorsalis pedis)
• Test sensation with monofilament

📝 Peripheral Vascular System – Professor’s Notes

• DVT (Deep Vein Thrombosis) → expect swelling, pain, edema, warmth; patient often avoids moving the extremity due to discomfort.
• Ulcers/Lesions → wounds that do not heal, commonly in arterial disease (ischemic ulcers), venous disease (stasis ulcers), or in diabetes.
• Pitting Edema → press over tibia or ankle; grade 1+ to 4+ depending on depth and duration.
• Neurovascular Test → check strength and sensation. Example: patient closes eyes and describes what is felt when you touch or apply pressure.
• Pregnancy → dependent edema common, especially in the third trimester; varicose veins may also develop.
• Diabetic Foot Care → loss of sensation (neuropathy) → high risk for ulcers.
• Wear comfortable shoes, avoid walking barefoot.
• Inspect feet daily; use a mirror to check bottoms of feet.
• Varicosities → common in people who stand for long periods; due to incompetent valves and venous congestion.
• Femoral artery → used during CPR.