1. Vascular Medicine for medical students
Zsolt Pécsvárady
Pécs

2. Basic considerations:
ARTERIES:
Atherosclerosis is the 1st major cause of the morbidity
and mortality in the western societies. ( 50% or more
from all diseases ) Must find as early as possible.
Atherosclerosis alter the whole vascular system of the
body. The symptoms and signs of the disease
depend on the localisations of the organs involed ( heart,
brain, kidney, GI tract, extremities ), but we have to
check the disease in all locations.
Because of the symmetry of our body, bilateral simultaneous
palpation or auscultation is a great help in the diagnosis.
Nearly 80 % of the diagnosis is available from medical
history and physical examination.

3. Medical history: symptoms
Not enough blood supply
- early stages: during activity ( reversible )
- advance stage: end organ failure ( irreversible )

4. Periferal arterial disease – PAD –
Main symptom is intermittant claudication ( IC )
Latin word claudico = to limp
90 % of patients, IC is due to stenosis or occlusion
of the arteries supplying the lower extremities
Bruit at the place of stenosis
( between % stenosis only )

5. Rose criteria as tool for intermittent claudication 1
Rose criteria as tool for intermittent claudication 1. Do you get pain in either leg on walking? Yes No
2. Does this pain ever begin when you are standing still or sitting? Yes No
3. In what part of your leg do you feel it? Pain includes calf/calves Pain does not
include calf/calves ( If calves not mentioned, ask: Anywhere else?)
4. Do you get it if you walk uphill or hurry? Yes No Never hurries or walks uphill
5. Do you get it if you walk at an ordinary pace on the level? Yes No
6. Does the pain ever disappear while you are walking? Yes No
7. What do you do if you get it when you are walking? Stop or slow down Carry on
8. What happens to it if you stand still? Relieved Not relieved
9. How soon? min. or less More than 10 min.

6. Sign and symptoms of PAD
Exercional leg pain and relief with rest
Cool or cold feet to palpation
Nocturnal and rest pain relieved with dependency
Absent pulses
Blanching or pallor on elevation
Delay venous filling after elevation
Dependent rubor
Atrophy of subcutaneous fatty tissue
Shiny skin
Loss of hair on foot and toes
Thickened nails, often with fungal infections
Gangrene or nonhealing ulcer

7. Palpation
Auscultation
Blood Pressure
measurement

8. Phsysical examination: palpation
Pulse: absent = 0
diminished = 1
normal = 2
Congenital absence of pedal pulses:
1000 children (age: 1-10 yr ) without PAD:
12% missing of Art. D.P.
500 youngsters (age: 0-19 yr) without PAD:
8.7% missing Art. D.P.
0.2% misssing Art. T.P.
But:
Leng & Fowkes, J Clin Epid.1992;45:1101
Ludbrook et al, BMJ, 1962:1:1724

9. Functional test ( 1 ): Treadmill test to evaluate
the claudication distance
Standard slope: 12 %
Standard speed: 3,2 km/h

10. Functional test ( 2 ): Ratchow test

11. Functional tests ( 3 ) : Allen test
Pressing radial / ulnar
artery and ischemisation

12. Functional test ( 4 ) : Adson test ( Thoracic Outlet Syndr )
art. radialis
art. subclavia

13. CW Doppler measurement
a. D.P.

14. ABI = Ankle-brachial index
BP lower extremities *
ABI =
BP upper extremities**
* The higher between aDP or aTP
in one leg
** The higher between the two arms
Normal: –1.30
Mild to moderate: 0.70–0.90
Moderate to severe: 0.40–0.69
Severe: <0.40
Non compressable >1.30

15. Segmental blood pressure measurement w / CW Doppler
a. T.P.
a. D.P.

16. Segmental BP
measurement

17. Bi-directionalis Doppler
pulse wave analysis

18. Periferal arterial disease Ed. Coffmann, Eberhardt Humana Press 2003

19. ABI and mortality rate independent predictor for CV risk
100
ABI >0.85 80
survival (%) 60
ABI 0.40–0.85 40
ABI <0.40 20 2 4 6 8 10
years
McKenna M, et al. Atherosclerosis. 1991;87:

20. Duplex ultrasound 2D presentation Doppler measurement Indications
– structure of blood vessel wall, IMT, plaque analysis
Doppler measurement
haemodinamique changes
degree of stenosis ( speed of flow)
Indications
stenosis, occlusion, aneurysma, pseudoaneurysma, AV-fistula, controll after operation or PTA ( percutan transluminal angioplasty )

21. Intima Media Thickness

23. Angiography
Invasive but
gold standard

24. 3D CT, MRI near future

25. Comparison of non-invazive screening technics in earlyPAD
Method
Cost
Specificity
Senzitivity
ABI + 95
Carotis IMT
81-100
85-86
EBT
+++ 59 89
MRI
+++++ 83
100
N.Wong et al 2002 Meta-analysis