1. Which area of sterile protective clothing is not considered sterile even before coming in contact with a nonsterile object?
a. front of gown above waist level
b. front of gown below waist level
c. sleeves
d. gloves

2. Arterial, Venous (and Lymphatic) Systems
Their Significance in Chronic Lower Extremity Wounds

4. Pain occurring when an extremity is elevated indicates:
Arterial disease
Venous disease
Lymphatic disease

5. When describing the benefits of your exercise program to your patient (to educate and also to improve compliance), you tell her that regeneration of the affected part of her circulatory system is possible.
Which part of the circulatory system would have been impaired for this to be true?

6. Arterial system
Venous system
Lymphatic system

7. The arterial system contains what percentage of total body blood volume?
30%
50%
90%

8. The venous system is: Low volume, low pressure
High volume, low pressure
Low volume, high pressure
High volume, high pressure

10. “. . .it is best to think of a wound not as a disease, but rather as a manifestation of disease.”
Joe McCulloch

11. In order to manage wounds effectively, it is essential to appreciate the underlying cause.

12. A Brief Review of Structure and Function of Vascular Structures
Part I
A Brief Review of Structure and Function of Vascular Structures

13. Overview of 3 Circulatory Systems
Arterial
Venous
Lymphatic

14. 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 adventitia – collagen fibers plus blood vessels & nerves (outer)

15. Variations in Vessel Walls
The common theme of the three layers varies widely, depending on type, size, and location of the artery, vein, or lymph vessel.

16. 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

17. 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

18. Arterial Pressure normal systolic pressure< 140 mm Hg
arterial capillary pressure 25 mm Hg
high pressure/low volume system

19. Arteries of the
Anterior Leg

20. Arteries of the
Posterior Leg

21. Venous System Removes interstitial fluid from tissues
Returns deoxygenated blood to right atrium
Contains 70% of blood volume

22. 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

23. Venous Pressure - wide variation (10-90 mm Hg)
- low pressure/high volume
- blood conveyed back to heart by:
muscle pump
respiratory “pump” (vacuum?)
valves

24. ? Questions ? What 3 “factors” return venous blood to the heart?
Bonus: What is one more factor not included in this program?
What forms venous valves?

25. Superficial Veins, Posterior Leg

26. Superficial Veins, Anterior Leg

27. 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

28. 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

29. Pressures in Lymphatics
Very low pressure
Lymph moved centrally by valves*, negative pressure in chest, muscle pump (like veins)
*Lymphangion: lymph vessel segments with valves at either end—a “lymph pump”

30. Thoracic and Right
Lymphatic Ducts

31. Normal: Equilibrium Between. . .
Arterial Capillary
Venous Capillary
Initial Lymph Vessel
Interstitial Tissue

32. Capillary Bed
capillaries allow diffusion of O2 and nutrients to tissues, AND
CO2 and other waste products diffuse out of tissues, WHILE
- Open-ended lymphatics move comparatively small amounts of fluid from the capillary bed, but handle large cells

33. Review: Equilibrium at the Capillary Bed
Adequate Arterial Supply
Functional Venous Return Structures
Patent Lymphatic Structures
Normal Interstitial “Space”

34. Vascular Diseases Producing Wounds in the Lower Extremity
Part II
Vascular Diseases Producing Wounds in the Lower Extremity

35. Classifications of Wounds in Lower Extremity
Arterial
Venous
Mixed

36. Basis for Wounds of Arterial Origin
Arteriosclerosis – “hardening of arteries”
-calcification of arteries of all sizes
- loss of elasticity of arterial walls
Atherosclerosis – fibrous “plaque”
- thickening of inner coat (intima)
- fatty degeneration of middle layer (media)

37. Events Producing Wounds of Arterial Origin
Diminished arterial flow
Thrombus or microembolus formation
Blockage - most often at bifurcations
Tissue hypoxia and cell death

38. Appearance of Limb in Arterial Disease – Trophic Changes
Pale, cool skin
Abnormal toenail growth
Hair absent
Muscle atrophy
Edema

39. Trophic Skin Changes in Arterial Disease

40. Arterial Diseases associated with Wound Development
Arteriosclerosis obliterans
Other Examples
- Diabetes
- Vasculitis (RA)
Sickle Cell Disease
Thromboangiitis obliterans*

41. Arteriosclerosis obliterans
Disease of large and medium sized arteries
Associated with:
High blood pressure
Hyperlipidemia
Arterial occlusion particularly at bifurcations

42. Necrosis of Toe in Arteriosclerosis obliterans

43. Heel Ulcer in Arteriosclerosis Obliterans

44. Other Examples: Arterial
Diabetes – hyperglycemia—”sticky blood” adds to development of atherosclerosis
Vasculitis – inflammation blocks blood flow
Sickle Cell Disease – clumps of misshapen red cells occlude small arteries

45. Thromboangiitis obliterans
Also called Buerger’s Disease
Affects adults under age 40
*Veins also involved
Unlike arteriosclerosis obliterans, may affect hands
Primary cause: cigarette smoking!

46. Thromboangiitis obliterans - early

47. Thromboangiitis obliterans - late

48. Noninvasive Tests of Arterial Sufficiency
Doppler ultrasound
Skin temperature
Arterial perfusion
Pulses #
Capillary refill test #
Venous filling time #
Rubor of dependency #

49. Rubor of Dependency in Arteriosclerosis obliterans

50. Pathology of Wounds associated with Venous Diseases
Venous thrombosis (thrombophlebitis)
Deep vein (DVT)
Superficial vein
Venous Stasis
Venous obstruction
Varicose veins
Ulceration

51. Etiology of Venous Stasis Wounds
Old theory: venous congestion (1917)
insufficient oxygenation of tissues
WRONG !!!
Tissues have been shown to be adequately oxygenated.

52. Etiology of Venous Stasis Wounds, continued
Arteriovenous fistula theory (1947)
Fibrin cuff theory (1982)
Leukocyte activation (1988)
ALL mostly discredited as causes of ulcers. . .

54. Question ???
True or False
Your patient was once told that the reason she developed ulcers at the ankles was that the swelling in her legs prevented adequate oxygen from reaching the tissues.
How would you respond?

55. Present Theory of Etiology of Venous Stasis Wounds
High pressure causes extravasation of macromolecules (e.g. fibrinogen) and red blood cells into dermal interstitium.
Degradation of these molecules and cells attracts leukocytes, macrophages, mast cells (inflammation).
Inflammation leads to tissue injury (breakdown) and wound development.

57. Venous Thrombosis

58. Varicose Veins

59. Varicose Veins

60. Venous Stasis Ulcer

61. Importance of the “Calf Pump”
Normal Edema Present

62. Appearance of Limb in Venous Insufficiency (Early)
Stasis dermatitis
Erythema
weeping blebs or vesicles
edema

63. Stasis Dermatitis - Early

64. Appearance of Limb in Venous Insufficiency (Late)
Induration of subcutaneous tissue
Brawny (brownish) discoloration: “Hemosiderin” iron-containing pigment
Edema
Ulceration usually around medial malleolus

65. Stasis Dermatitis (Late)

66. Questions. . . 1. Your venous stasis wound patient asks specifically:
why she developed varicose veins
why her lower calf is discolored.
You would explain that. . .

67. Noninvasive Tests of Venous Sufficiency
Doppler ultrasound
Plethysmography
Percussion test #
Brodie-Trendelenburg test #
Venous filling time #

68. Venous Filling Time

69. Tests for Deep Venous Thrombosis (DVT)
- cuff test #
- test for Homan’s sign #

70. Combined Pathologies Arterial and venous disease may coexist
Venous disease can contribute to lymphatic dysfunction, and vice-versa

71. 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

72. Lymphedema itself not usually associated with wounds
A complete discussion of lymphedema will be addressed in the oncology section of this course.

73. Combined Pathologies Thorough examination Teamwork Patient education
General rule: treat most threatening aspect first (usually arterial insufficiency)

74. The End!