Arterial, Venous

(and Lymphatic) Systems

Their Significance in Chronic Lower
Extremity Wounds

Pain occurring when an extremity
is elevated indicates:
A. Arterial disease
B. Venous disease
C. Lymphatic disease
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?
A. Arterial system
B. Venous system
C. Lymphatic system

The arterial system contains what
percentage of total body blood volume?
A. 30%
B. 50%
C. 90%
The venous system is:
A. Low volume, low pressure
B. High volume, low pressure
C. Low volume, high pressure
D. High volume, high pressure
. . .it is best to think of a wound
not as a disease, but rather as a
manifestation of disease.
Joe McCulloch
In order to manage wounds
effectively, it is essential to
appreciate the underlying cause.
Part I
A Brief Review of
Structure and Function of
Vascular Structures
Overview of 3 Circulatory
Systems
Arterial

Venous

Lymphatic


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)

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.
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
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
Arterial Pressure
- normal systolic pressure< 140 mm Hg

- arterial capillary pressure 25 mm Hg

- high pressure/low volume system

Arteries of the
Anterior Leg
Arteries of the
Posterior Leg
Venous System
Removes interstitial fluid from tissues

Returns deoxygenated blood to right atrium

Contains 70% of blood volume
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
Venous Pressure
- wide variation (10-90 mm Hg)
- low pressure/high volume
- blood conveyed back to heart by:
muscle pump
respiratory pump (vacuum?)
valves
? Questions ?
What 3 factors return venous blood to the
heart?

What forms venous valves?
Superficial Veins,
Posterior Leg
Superficial Veins,
Anterior Leg
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
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

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 enda lymph pump

Thoracic and Right
Lymphatic Ducts
Normal: Equilibrium Between. . .
Arterial Capillary

Venous Capillary

Initial Lymph Vessel

Interstitial Tissue

Capillary Bed
- capillaries allow diffusion of O
2
and
nutrients to tissues, AND
- CO
2
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

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



Part II
Vascular Diseases Producing
Wounds in the Lower
Extremity
Classifications of Wounds in
Lower Extremity
Arterial
Venous
Mixed

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)

Events Producing Wounds of
Arterial Origin

Diminished arterial flow
Thrombus or microembolus formation
Blockage - most often at bifurcations
Tissue hypoxia and cell death
Appearance of Limb in Arterial
Disease Trophic Changes
Pale, cool skin
Abnormal toenail growth
Hair absent
Muscle atrophy
Edema
Trophic Skin Changes in Arterial
Disease
Arterial Diseases associated with
Wound Development
Arteriosclerosis obliterans
Other Examples
- Diabetes
- Vasculitis (RA)
- Sickle Cell Disease
Thromboangiitis obliterans*


Arteriosclerosis obliterans
Disease of large and medium sized arteries
Associated with:
High blood pressure
Hyperlipidemia
Arterial occlusion particularly at bifurcations
Necrosis of Toe in
Arteriosclerosis obliterans
Heel Ulcer in Arteriosclerosis
Obliterans
Other Examples: Arterial
Diabetes hyperglycemiasticky blood
adds to development of atherosclerosis

Vasculitis inflammation blocks blood
flow

Sickle Cell Disease clumps of misshapen
red cells occlude small arteries
Thromboangiitis obliterans

Also called Buergers Disease
Affects adults under age 40
*Veins also involved
Unlike arteriosclerosis obliterans, may
affect hands
Primary cause: cigarette smoking!

Thromboangiitis obliterans -
early
Thromboangiitis obliterans - late
Noninvasive Tests of Arterial
Sufficiency
Doppler ultrasound
Skin temperature
Arterial perfusion
Pulses #
Capillary refill test #
Venous filling time #
Rubor of dependency #
Rubor of Dependency in
Arteriosclerosis obliterans
Pathology of Wounds associated
with Venous Diseases
Venous thrombosis (thrombophlebitis)
Deep vein (DVT)
Superficial vein
Venous Stasis
Venous obstruction
Varicose veins
Ulceration
Etiology of Venous Stasis
Wounds
Old theory: venous congestion (1917)
insufficient oxygenation of tissues

WRONG !!!
Tissues have been shown to be adequately
oxygenated.
Etiology of Venous Stasis
Wounds, continued
Arteriovenous fistula theory (1947)

Fibrin cuff theory (1982)

Leukocyte activation (1988)

ALL mostly discredited as causes of ulcers. . .

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?
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.
Venous Thrombosis
Varicose Veins
Varicose Veins
Venous Stasis Ulcer
Importance of the Calf Pump
Normal Edema Present
Appearance of Limb in Venous
Insufficiency (Early)
Stasis dermatitis
Erythema
weeping blebs or vesicles
edema

Stasis Dermatitis - Early
Appearance of Limb in Venous
Insufficiency (Late)

Induration of subcutaneous tissue
Brawny (brownish) discoloration:
Hemosiderin iron-containing pigment
Edema
Ulceration usually around medial malleolus

Stasis Dermatitis (Late)
Questions. . .
1. Your venous stasis wound patient asks
specifically:
a. why she developed varicose veins
b. why her lower calf is discolored.

You would explain that. . .
Noninvasive Tests of Venous
Sufficiency

Doppler ultrasound
Plethysmography
Percussion test #
Brodie-Trendelenburg test #
Venous filling time #

Venous Filling Time
Tests for Deep Venous
Thrombosis (DVT)

- cuff test #

- test for Homans sign #


Combined Pathologies
Arterial and venous disease may coexist

Venous disease can contribute to lymphatic
dysfunction, and vice-versa

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
Lymphedema itself not usually
associated with wounds
A complete discussion of lymphedema will
be addressed in the oncology section of this
course.
Combined Pathologies
Thorough examination
Teamwork
Patient education
General rule: treat most threatening aspect
first (usually arterial insufficiency)

The End!