Pathologies of the CVS system

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Popliteal Aneurysm

Definition:

A pathological dilation of the popliteal artery due to a weakness or defect in the arterial wall or predisposed by injury.
Causes:

The popliteal artery, a continuation of the femoral artery is common side of peripheral aneurysms.

Peripheral aneurisms are more common in males especially over the age of 55. It is often predisposed by atherosclerotic changes to the vessels, other vascular or collagen disease. In some cases (20%) the patient may also have a history of abdominal aortic aneurism.

Examination: 

If the popliteal aneurism is large it may be visible as a mass in the popliteal fossa. Palpating the popliteal fossa may reveal a pulsating artery which is abnormally pulsatile. More accurate diagnostic methods include duplex ultrasonography, A non pulsating popliteal mass may be a Baker's cyst or inflamed knee bursa.

Varicose Veins

Definition: Stretched, tortuous or distended veins, usually in lower extremities.
Causes: Varicose veins are formed due to valve incompetence secondary to an inherent weakness in the vein wall causing dilation and separation of venous valve cusps. Risk factors include: older age, parity, obesity

EXAMINATION:

With patient standing and both legs fully exposed, observe limbs for swelling, skin colouration and prominent veins. If veins are tortuous and dilated they are varicose. Determination of whether the veins affected are the long or short saphenous vein system. Observe both legs carefully for any signs of swelling, varicose eczema or pigmentation changes.  With patient standing, palpate veins and subcutaneous tissues on both legs. Check for tenderness, thickening of tissues or pitting oedema. Check cough impulse at both popliteal and femoral saphenous junctions; a strong impulse indicates incompetence. (Ref GPNotebook)

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Elevated Jugular Venous Pressure (JVP)

Definition: Evaluating the pressure in the venous system as the blood is returned to the right side of the heart before it is sent into the pulmonary circulation.

 

Test procedure: The patient lies supine and at 45 degrees. The internal jugular vein is visualised as it ascends the side of the neck between the two heads of the sternocleidomastoid muscle. If the jugular vein appears to be distended attempt to measure the height of the distension as a vertical column of blood in relation to the sternal angle.

 

Test findings: A normal jugular venous pressure should not exceed 3-4 cm above the sternal angle. Higher readings may signify right-sided heart failure, constrictive pericarditis, pleural effusion, obstructed vena cava and other pathologies of the heart and lungs

 

Considerations: To help you visualise the jugular vein observe the patient's neck when lying complete flat on the couch. Alternatively placing pressure over the liver (hepatojugular reflux) increases venous return and causes temporary jugular vein distension. Do not mistake the external jugular for the internal. The external jugular vein may appear engorged even in physiological states.

Deep Vein Thrombosis (DVT)

 

DEFINITION: Formation of a blood clot in a vein, in the lower extremities, which partially or completely impedes blood flow. DVT is a medical emergency. Thrombus dislodgement may precipitate pulmonary embolus.

 

CAUSES: Risk factors to look for in the case history include: immobility, trauma, familial thrombophilia, COP/HRT, pregnancy, dehydration, increased age, obesity, male sex, previous DVT, heart failure, cancer, vasculitis.

 

EXAMINATION: DVT can be asymptomatic but typical presentation is unilateral tightness or pain in the lower limb (usually calf) exacerbated by walking or standing. Visual examination and palpation of the affected leg may reveal: oedema (can be pitting), changes in cutaneous colouration (redness or cyanosis) and warmth. Superficial veins can also be engorged. If venous engorgement persists with limb elevation above 45 degrees this is suggestive of DVT.  Homans’ sign is not recommended for diagnosis of DVT as it is insensitive or nonspecific and may, theoretically dislodge the clot.

 

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Abdominal Aortic Aneurysm (AAA)

DEFINITION: Localized dilation or bulge in the abdominal aorta. Risk of rupture is related to the degree of dilation.

 

CAUSES: The cause of AAA is degradation of the layers of the aorta, with inflammatory infiltrates in both the intima and tunica media. The major risk factors include: atherosclerosis, smoking, male sex, increasing age (aneurysms are uncommon in under 60s), familial, infection and trauma.

 

EXAMINATION: Most patients are asymptomatic with visible or palpable pulsatile lower abdominal swelling. First observe the abdomen at eye-level looking for swelling pulsations.  Palpation at the level of the umbilicus may reveal enlargement of the aorta with expansile pulsations (A solid mass adjacent to the aorta will be pulsatile but not expansile). Detection of bruits is not confirmatory of AAA. Patient may also present with peripheral emboli in the toes (‘blue toe syndrome’). Confirmation of diagnosis and aneurysm size is by ultrasound. The major risk is dissection which typically presents with sudden, severe back, abdominal or inguinal pain with hypotension and possible syncope. It is a medical emergency.

Splinter haemorrhages

DEFINITION: Asymptomatic subungal capillary bleeding along longitudinal ridges.

 

CAUSES:  Most often due to trauma and local dermatological disease. Can be due to systemic causes including thrombotic illness, such as endocarditis and vasculitis.

 

EXAMINATION: Visual examination of the nail bed of both hands reveals painless longitudinal haemorrhage. Local traumatic cause - more distal? If systemic embolic disease is suspected examine patients’ hands and feet for other peripheral stigmata of endocarditis (viz. Osler’s nodes (painful septic emboli on finger pads and palms) and Janeway lesions (painless macular lesions on palms and soles).

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