1. PERIPHERAL VASCULAR DISEASES DR. Mohamed Seyam PhD. PT. Assistant Professor Of Physical Therapy For Cardiovascular /Respiratory Disorder

2. Structure of Blood Vessels Composed of three layers (tunics)  Tunica intima – composed of simple squamous epithelium  Tunica media – sheets of smooth muscle Contraction – vasoconstriction Relaxation – vasodilatation  Tunica externa – composed of connective tissue  -Lumen

3. Types of Arteries Elastic arteries – the largest arteries Diameters range from 2.5 cm to 1 cm Includes the aorta and its major branches Sometimes called conducting arteries High elastin content

4. Muscular (distributing) arteries Lie distal to elastic arteries Diameters range from 1 cm to 0.3 mm Includes most named arteries Tunica media is thick Unique features Internal and external elastic lamina Arterioles Smallest arteries Diameters range from 0.3 mm to 10 µm Larger arterioles possess all three tunics

5. Capillaries Diameter from 8–10 µm Red blood cells pass through single file Site-specific functions of capillaries Lungs – oxygen enters blood, carbon dioxide leaves Small intestines – receive digested nutrients Endocrine glands – pick up hormones Kidneys – removal of nitrogenous wastes

6. Veins Conduct blood from capillaries toward the heart Blood pressure is much lower than in arteries Smallest veins – called venules Diameters from 8 – 100 µm Smallest venules – called postcapillary venules Venules join to form veins Tunica externa is the thickest tunic in veins

7. Vascular Anastomoses Vessels interconnect to form vascular anastomoses Organs receive blood from more than one arterial source Neighboring arteries form arterial anastomoses Provide collateral channels Veins anastomose more frequently than arteries Vasa Vasorum Vasa vasorum vessels of vessels Nourish outer region of large vessels

8. 1- Aneurysm An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel or An aneurysm is a localized dilatation of the weaken medial layer wall of a large and medium sized arteries, such as the aorta and cerebral arteries. It may produce no symptoms (small than 5 cm), may cause problems through pressing on adjacent structures or may become occluded with thrombus or rupture, with potential devastating effects. As an aneurysm increases in size, the risk of rupture increases. A ruptured aneurysm can lead to bleeding and subsequent hypovolemic shock, leading to death. Aneurysms are a result of a weakened blood vessel wall, and can be a result of a hereditary condition or an acquired disease.

9. Aneurysms can be classified by their location: - Arterial and venous. - The heart. -The aorta, including: -Thoracic aortic aneurysms -Abdominal aortic aneurysms. -The brain, cerebral aneurysms -The legs, the popliteal arteries. - The kidney, renal artery aneurysm. - Capillaries, capillary aneurysms.

10. Classifications True And False Aneurysms  A true aneurysm is one that involves all three layers of the wall of an artery (intima, media and adventitia).  True aneurysms include atherosclerotic, syphilitic, and congenital aneurysms, as well as ventricular aneurysms.  A false aneurysm, or pseudo-aneurysm, is a collection of blood leaking completely out of an artery or vein, but confined next to the vessel by the surrounding tissue.  This blood-filled cavity will eventually either thrombose (clot) enough to seal the leak, or rupture out of the surrounding tissue.

11. Causes of aneurysm 1- Atherosclerosis 2- Trauma such as, penetrating, acute blunt (Having a dull edge or not having a sharp edge ), constricted trauma (. To make smaller or narrower by squeezing 3- Infections such as syphilis, Tuberculosis, causing Rasmussen's aneurysms and brain infections, causing infectious intracranial aneurysms 4- Arteritis such as polyarteritis nodosa (PAN) Polyarteritis nodosa is an autoimmune disease that affects arteries. 5- Congenital defects. 6- Copper deficiency affecting elastin, results in vessel wall thinning.

12. Physical therapy treatment Take all medications as recommended by your physician. The goals of your program should be to increase your endurance level, joint range of motion and ability to perform activities of daily living. Choose activities that are comfortable and well-tolerated, such as walking, swimming, or low-intensity sports such as bowling. Start slowly and emphasize duration over intensity. Gradually progress to exercising 15 to 20 minutes, Three or more days per week. All exercise training, whether aerobic or resistance, should be performed at moderate to-low intensity

14. 2- Varicose Veins Varicose veins are enlarged any veins, but the veins most commonly affected are those in legs and feet. That's because standing upright increases the pressure in the veins of lower body. Varicose veins are dilated, elongated, and tortuous superficial veins of the lower extremities that look blue in the lower limb They are produced by incompetent valves and increased intraluminal pressure.

16. Etiology 1- Primary varicose veins. Primary varicose veins result from hereditary weakness of the vein wall and valves. 2- Secondary varicose veins. It is a sequel to deep venous thrombosis resulting from a) Dilation of collateral veins. b) Damage to valves of deep veins.

17. Pathophysiology 1- Increase venous pressure in the upright posture 2- The vein increases both in length and diameter so that tortuousities develop and varicosity extends progressively throughout the length of the affected vein. 3- Dilatation of the affected veins, causes separation of the valve cusps (valve incompetent).. 4- Valves incompetent of deep veins, leads to chronic venous stasis 5- loss of elastic tissue, muscle atrophy of the media layer and hypertrophy of the outer layer 6- In primary varicose veins, the incompetence tends to progress downward in the saphenous main channel and in its tributaries. 7- In secondary varicose veins, which arise because of deep vein insufficiency, the incompetence tends to progress upward from incompetent perforating veins in the lower one third of the leg.

18. Symptoms 1- Symptoms vary in degree. No symptoms in less sever cases (superficial varicose veins), and often concerned about the cosmetic appearance of the legs. 2- Aching in the legs, aggravated by standing, and improved by walking and elevation elevation of lower limb. 3- Fatigue, pain in the legs with difficulty in walking. 4- The legs feel heavy and occasionally mild ankle edema develops 5- Superficial venous thrombosis may be a recurring problem and rarely varicosity ruptures and bleeds.

19. Complications 1- Bleeding following rupture of vein. 2- Venous ulcer due to devitalized skin. 3- Superficial venous thrombosis. 4- Edema, particularly of the foot and ankle. 5- Pigmentation: black to brown due to hemosiderin from RBCs breakdown, 6- Dermatitis is an inflammation of the skin. 7-Cellulitis is a diffuse inflammation of connective tissue, caused by bacteria, with severe inflammation of dermal and subcutaneous layers of the skin.

20. Management 1. Assessment 2. Conservative. 3. Surgical 4. Physical therapy.

21. 2- Conservative a) Avoid : - prolonged standing, sitting, obesity, constricting garments. b) Avoid Shower or bathe in the evening. c) Apply well—fitted below the knee support stockings (20 - 40 mm Hg) before ambulating in the morning or exercising. d) Above the knee heavy support stockings generally are not necessary, since the majority of symptoms from varicose veins occur below the knee where venous pressure is highest. e) Elevate the feet 10-15 minutes, 3-4 times daily f) Avoid trauma to varicose veins.

22. 3- Surgical and Nonsurgical Nonsurgical management Sclerotherapy : This is not recommended, it Is the injection of ta sclerosing agent (chemical irritant) into the varicose vein which makes them shrink Radiofrequency treatment. Radiofrequency energy (instead of laser energy) is used inside a vein to scar and close it off. It can be used to close off a large varicose vein in the leg.

23. phlebectomy is a treatment for superficial varicose veins. The procedure involves the removal of the varicose veins through small 2–3 mm incisions in the skin overlying the veins. The procedure may be performed in hospital or outpatient settings. The procedure may be performed with tumescent local anesthesia, such as with lidocaine. Complications are uncommon, but include paresthesia, bruising, and hematoma. Graded compression stockings are usually worn for 1–2 weeks after the procedure. Patients usually return to normal light activity immediately after the procedure. This procedure is often used as an adjunct to endovenous laser treatment or other endovenous ablations of the greater saphenous vein

24. 4- Physical therapy management Aims 1- Assist venous return 2- Avoid venous stasis and its complications Methods 1. Positioning 2. Bandaging 3. Pneumatic compression therapy 4. Electromagnetic therapy 5. exercise