Vascular Assessment

Normal Physiology of the Cardiovascular System (CVS)

Heart contracts approximately every 0.8s Divided into 2 phases Cardiac output is about 5 litres Myocardium has the ability to contract without nerve impulses. Myogenicity.

 The most important of these is the sinoatrial (SA) node, situated in the right atrium. Essential that the heart can alter its activity according to demands placed upon it.

 Sympathetic nerve acts on the heart via beta-receptors. Increasing stoke volume and heart rate. Parasympatheic (vagus) nerve slows heart rate

 Overall purpose of all vessels is to deliver blood with its nutrients etc and to remove waste products.

Capillary Function
Exchange of substances Pressure drop Capacitance vessels

Arterial, Venous and Capillary Structure

Assessment of the Lower Limb.

In order to maintain tissue integrity and viability, it is essential that blood flow to the lower limbs is maintained and regulated

 It is important that the Podiatrist is aware of what to look for in a healthy vascular system, and is clear regarding what constitutes normal and abnormal in relation to blood supply

Beginning the assessment

Initially, you will have made sure you have collected information regarding patient details, including medical and surgical history, current and previous medication, and also an indication of any relevant family history, such as ischaemic heart disease, hypertension, diabetes, stroke, etc.

 What indications would encourage you to perform a vascular assessment on your patient? A good approach to vascular assessment is to follow a simple structure, so that no aspect is missed,

 One thing often forgotten when carrying out any clinical examination is that you should use the information collected to make a diagnosis. Without this, your examination is meaningless. Additionally, should you become involved in litigation, the lack of a diagnosis may impair your defence as it could be implied that you were unable to interpret the results of your tests.

 A further point to note about assessment is that no single test result or observation should be used to formulate your diagnosis. Instead, you should be able to combine the results of all observations to come up with a working diagnosis, on which you then base your management plan, or your referral to another health professional.

Arterial Insufficiency
Pain Pallor Pulselessness Paraesthesia Paralysis Perishing cold.

Causes
Thrombosis, Embolus, Aneurysms, Oedema Transient ischaemia Chronic ischaemia

 Arterial in-sufficiency is usually associated with pain Site Nature Duration Aggravating Factors

 This stage can be recognised by mottling, muscle tenderness, motor or sensory deficit and necrosis.

 Intermittent claudication Night cramps Rest pain

Observations.
Skin may appear Pink White Blue Red Dusky pink.

Tissue Viability
A poor blood supply will mean that the skin and other soft tissues will be receiving inadequate nourishment

Clinical Tests
Temperature gradient Sub-papillary plexus filling time (CRT) Buergers test Allens test

Pedal Pulses

Posterior Tibial

Dorsalis Pedis

Peroneal

Anterior Tibial

Doppler Ultrasound
Allows pulses to be heard more clearly Sound waves bounce of objects (usually red blood cells) Can also be fed to a printer

ABPI
This was first described by Yao in the 1960s Calculated by recording the systolic pressure at the brachial artery and at the posterior tibial artery (ankle), using the following method;

Lay patient flat for 10 mins Measure systolic brachial pressures (L+R) Measure systolic pressures in PT Measure systolic pressure in DP Divide the highest pressure on left foot with highest overall brachial pressure

Venous Insufficiency
Arises in the superficial and/or deep veins Affects the return of blood to the heart Pooling of blood in the ankles Exacerbated by gravity More evident around the malleoli

Past History
Venous problems? DVT Pregnancy? Varicose veins Familial Telangiectases around the medial malleoli can indicate poor drainage Mottled cyanosis to lower third of limb

Symptoms
Varicose related pain Ankle oedema Alleviated by elevation Varicosities- especially on standing Unilateral PVD Bilateral - CHF

Temperature
In venous insufficiency the skin often feels warm, which suggests that the arterial supply is satisfactory. However, it should be borne in mind recent thrombosis may result in inflam-mation of the veins (phlebitis) due to the presence of the thrombosis

Varicose Veins
Presence of these may be due to valvular incompetence in the superficial division of the venous system in isolation, or in combination with venous hypertension created by back-pressure due to an obstruction in the veins.

Tissue Viability
Poor venous return results in the accumulation of waste products and therefore the viability of the surrounding skin is affected lipodermatosclerosis may develop

Oedema
Associated with venous problems Hydrostatic pressure causes leakage into the tissues

Leg Shape
Patients with chronic venous ulceration and oedema may develop characteristic 'champagne legs', also known as 'inverted bottle legs', and this is characteristic of lipodermatosclerosis.

Pulling all the information together.

Once the vascular assessment is complete, the next step is to decide on a management plan suitable for the patient. It should also be remembered that the results of the assessment may indicate that it is better to refer the patient to a specialist for further investigation.