Anatomy and Structures of

Blood Vessel
 ext. il. a.
com Fem. a.
prof Fem. a.
sup Fem. a.

popl. a.

ant. tib. a.
post. tib. a.

feb. a.
post. tib. a.

Dor. ped. a.
 Anatomy and Structures of Blood Vessels

Arteries Arterioles Capillaries

Tunica Externa + - -

few SMF
Tunica Media
++ + -

++ + +
Tunica Intima
basement-
membrane

Three layers of the a vessel wall

Physiology and Charactheristics of Blood Flow

Laminar flow

Pressure Pressure

Velocity Velocity

Effects of Stenosis Plaque on Flow Pattern, Velocity and Pressure

 Blood Pressure Changes in
Systemic Circulation

150 150
PRESSURE (mmHg)

100 100

50 STENONIS
50

ARTERIES ARTERIOLES VEINS ARTERIES ARTERIOLES VEINS

& CAPILLARIES & CAPILLARIES

Normal Stenosis
 Other characterities of blood flow

1.Flow that is low resistance is continous (monophasic)

2. Flow that is hight resistance is pulsatile (tri or biphasic)
3. Diastolic flow reversal is :
- Normally in peripheral arteries
- Disappears in distal to a stenosis
- Can also disappears in proximal to significant stenosis
4. Vasoconstriction causes an increase in pulsatility in small-
medium size arteries on the contrary vasodilation causes in
pulsatility
5. Total blood flow may be normal in an extremity at rest in even
when theres is a sygnificant stenosis
PATHOLOGY

 Arterio venous fistula

 Aneurysms :
- Fusiform
- Saccular
- Pseudo aneurysm
 Extractment of popliteal artery by the gastrocnemius muscle
 Compartment syndrome
 Chronic occlusive lower etremity arterial disease
- Atherosclerosis obliterans (ASO)
- Thromboangiitis obliterans (TAO)
 Acute oclusive lower extrimity arterial disease
Diagnostic Examinations
 Segmental pressure examination
 Plethysmography – pulse volume recording (PVR)
 PVR/segmental pressure examination
 Treadmill / reactive hyperamia testing
 Trans cutaneus oximetry
 Extractment of the popliteal artery by gastrocnemius
muscle test
 Duplex Color Examination
 Angiography examinations :
- contrast
- magnetic resonance (MRA)
 Magnetic resonance Imaging (MRI)
 Computerized X-ray Tomography (CT)
 Jenis-jenis pemeriksaan
NON INVASIF
• Trans Cranial Doppler (TCD)
• Duplex Sonography Carotis
• Duplex Sonography Ekstremitas atas
• Duplex Sonography Femoralis
• Duplex Sonography Renalis
• Duplex Sonography Abdominalis
• Flow Mediated Dilatation (FMD)
• Pletismography
• Rheography
• Laser fluximetri
INVASIF
• Aortografi
• Venografi
 TINDAKAN
NON INVASIF
• Laser Vena
INVASIF
• Stent Vaskuler
• Trombolitik
BEDAH
• Embolektomy
• By Pass Vaskuler
Prosedur Dan Persiapan Pemeriksaan Non
Invasif Vaskuler
1. Pemeriksaan Trans Cranial Doppler.
2. Pemeriksaan Carotis.
3. Pemeriksaan Visceral Abdomen (arteri
renalis).
4. Pemeriksaan Tungkai dan Lengan :
FMD, Duplex extremitas atas, femoralis,
pletismography, dan laser fluximetri.
 Trans Cranial Doppler (TCD)
• Pemeriksaan TCD bertujuan untuk
menilai aliran pembuluh darah arteri di
otak.
• Indikasi:
– Stroke
– Vertigo
– Migraine
– Pusing yang
berkepanjangan
 Prosedur pemeriksaan TCD
• Pasien diberitahu tujuan
pemeriksaan
• Posisi pasien saat
pemeriksaan adalah duduk,
kecuali pada pasien tertentu
bisa dengan posisi berbaring
• Transduser alat TCD akan
diletakkan pada pelipis,
tengkuk kanan dan kiri
pasien.
• Lama pemeriksaan berkisar
antara 30 – 60 menit
(tergantung kelainan yang
ditemukan).
 Duplex Sonography Carotis
• Pemeriksaan ini bertujuan untuk menilai
struktur anatomi pembuluh darah beserta
aliran darah dari jantung menuju ke otak.
• Indikasi:
– Stroke
– Pusing berkepanjangan
– Hipertensi
– Hiperkolesterolemia
 Prosedur Pemeriksaan Duplex
Sonography Carotis

• Pasien diberitahu tujuan

pemeriksaan.
• Posisi pasien saat pemeriksaan
adalah berbaring dengan posisi
kepala ekstensi.
• Transduser alat duplex sonography
carotis akan diletakkan pada leher
kanan dan kiri pasien.
• Lama pemeriksaan berkisar antara
20 – 30 menit (tergantung
kelainan yang ditemukan).
 Duplex Sonography Visceral
(arteri renalis)
• Pemeriksaan ini bertujuan untuk menilai
struktur dan fungsi arteri renalis kanan-kiri.
• Indikasi:
– Hypertensi lama yang tidak turun dengan obat
 Prosedur Pemeriksaan Duplex
Sonography Visceral (arteri Renalis)
• Pasien diberitahu tujuan
pemeriksaan.
• Posisi pasien saat
pemeriksaan adalah
berbaring.
• Transduser alat duplex
sonography renalis akan
diletakkan pada bagian
pinggang belakang kanan dan
kiri pasien.
• Lama pemeriksaan berkisar
antara 30 – 60 menit
(tergantung kelainan yang
ditemukan).
 Duplex Sonography Flow Mediated
Dilatation (FMD)
• Pemeriksaan ini bertujuan untuk menilai
fungsi endotel dan elastisitas pembuluh darah
arteri baik di jantung maupun di luar jantung.
• Indikasi:
– Pasien Coroner
– Pasien tidak memungkinkan melakukan treadmill
test.
 Prosedur Pemeriksaan Duplex
Sonography FMD
• Pasien diberitahu tujuan
pemeriksaan.
• Posisi pasien saat pemeriksaan
adalah berbaring.
• Pasang manset tensi ± 3 Cm
dibawah siku.
• Kembangkan manset sampai 200
mmHg.
• Lakukan pemeriksaan pada arteri
brachialis.
• Lama pemeriksaan berkisar antara
15 – 30 menit (tergantung kelainan
yang ditemukan).
 Duplex Sonography Femoralis
• Pemeriksaan ini bertujuan untuk menilai
struktur anatomi pembuluh darah arteri dan
vena dari jantung menuju ke kaki dan kembali
ke jantung.
• Indikasi:
– Claudicatio pada tungkai
– Oedema pada tungkai
– Nyeri pada tungkai
 Prosedur Pemeriksaan Duplex
Sonography Femoralis
• Pasien diberitahu tujuan
pemeriksaan.
• Posisi pasien saat
pemeriksaan adalah
berbaring setengah duduk.
• Transduser alat duplex
sonography femoralis akan
diletakkan pada tungkai kanan
dan kiri pasien.
• Lama pemeriksaan berkisar
antara 30 – 45 menit
(tergantung kelainan yang
ditemukan).
 Doppler Pletismography
• Pemeriksaan ini bertujuan untuk menilai ankle-
brachial-index (A-B-I) pembuluh darah arteri
extremitas atas dan extremitas bawah.
• Menilai tekanan perifer ujung kaki atau TOE
PRESSURE
• Indikasi:
– Claudicatio pada extremitas bawah.
– Oedema tungkai disertai nyeri extremitas bawah.
– Pada pasien yang menderita luka akibat D.M.
 Prosedur Pemeriksaan Doppler
Pletismography
• Pasien diberitahu tujuan pemeriksaan.
• Posisi pasien saat pemeriksaan adalah berbaring.
• Lakukan pemeriksaan pada arteri brachialis kanan kiri, arteri
Tibialis posterior kanan kiri . kemudian untuk mengetahui
hasilnya dilakukan pembagian antara tekanan di arteri tibialis
posterior dengan arteri brachialis.
• Lakukan pemeriksaan tekanan perifer pada jari kaki dengan
memasang manset pada ibu jari.
• Ukur tekanan di daerah tersebut.
• Normal tekanan diatas 50 mmHg.
Posisi pasien pada pemeriksaan
Pletismography
 Laser Fluximetri
• Pemeriksaan ini bertujuan untuk mengetahui
perfusi mikrosirkulasi jaringan kulit.
• Indikasi:
– Pasien dengan keluhan kesemutan di daerah extremitas
bawah.
– Gangrene pada diabetes untuk mengetahui tingkat
pengobatan.
– Batas amputasi pada pasien diabetes yang akan dilakukan
amputasi.
Prosedur Pemeriksaan Laser Fluximetri
• Pasien diberitahu tujuan pemeriksaan.
• Posisi pasien saat pemeriksaan adalah berbaring.
• Pasang elektrode pada daerah yang akan diperiksa :
1. Tidak ada gangrene/luka elektrode diletakan kaki paling distal
(dorsum pedis).
2. Ada gangrene/luka elektrode diletakan 1-2 Cm diatas luka.
• Hasil :
– Tidak normal : TcpO2 < 20 mmHg.
– Normal : TcpO2 > 40 mmHg.
Pemeriksaan Laser Fluximetri
Lanser P, Integrated Approach of
cardiovaskular medicine, Diagnsotic of
vaskular disease,principle and technology,
Springer-Verlag Berlin heiderberg 1997,pp
345-346
All aspect of Vascular Medicine

• Arterial systems

• Microcirculation

• Vein

• Limphatic Sistems
 Natural History Of Vascular Disease
Early Intervention Late Intervention
Natural History

Risk Factor modification

Primary Prevention
Endovascular
100%
Intervention\surgery

Angiogenesis/
Quality of Life (%)

Vasculogenesis

Early Diagnosis
& Treatment
CLINICAL HORIZON

Pharmacological
therapy

Secondary
prevention &
rehabilitation

0 30-40 Death
AGE (YEAR)
What is Peripheral Arterial Disease?
• Arteries to lower extremities
become stenosed or
occluded usually by
atherosclerosis

• Mainly in large and medium

calibre arteries

• Most commonly at
bifurcations
PAD - ATHEROSCLEROTIC
ATHEROSCLEROSIS
History
1) The vascular laboratory must answer three basic question :
– Are the symptoms doe to vascular disease
– How extensive is ?
– Where is the disease located with the affected ??

2) Questions to ask the patients

– Do you get pain (at rest/at exercise/at night) ?
– How far can you get ?
– Where exactly in your leg ?
– Is it the both of legs / in one the leg worse ?
– How long hove you had this sore/ulcer?
– Do you feel pains/needles / tingling ?
– Do you have Diabetes, Hypertension, high cholesterol?
– Do you smoke?
 Locations of PAD Lesions

• The primary sites 20% of cases are

proximal
for atheromatous aortoiliac lesions

lesions in PAOD
60% of cases are
superficial
femoral lesions

20% of cases are

distal lesions of
the arteries of the
leg or foot, rarely
isolated
(frequently
upstream
iliofemoral
lesions)
 Who is at Risk from PAD?
Pathological conditions

• Hypertension +++
Major risk factor at cerebral level

• Dyslipidemia +++
Major risk factor at coronary level

• Diabetes mellitus ++
Major risk factor for arteries of the
legs

• Obesity +

• Blood hyperviscosity, coagulation

abnormalities
 Who is at Risk from PAD?
Lifestyle

• Smoking +++
Major risk factor for atherosclerosis
of the leg and coronary arteries

• Unbalanced diet (fats)

• Sedentary lifestyle

• Stress?
 Who is at Risk from PAD?

Non-modifiable factors

• Age +++

• Male sex ++

• Genetic factors
 Peripheral Arterial
Disease
Fontaine Classification:

Stage I Asymptomatic:
atherosclerosis developing

Stage II Stable claudicants, pain on exercise, skin

discolouration.

Stage III Rest pain.

Stage IV Trophic changes: ulcers, necrosis

and gangrene.
Stage II: Intermittent Claudication
Stage III: Rest Pain
Stage IV: Serious Trophic Disorders
 Prevalence of Peripheral
Arterial Disease in Population CoCaLis

Aged 55-74 Years

Intermittent Claudication 5% 1 in 20

Critical Limb Ischaemia 0.2% 1 in 500

(during lifetime)

Amputation 0.05% 1 in 2000

 CoCaLis

DANGER

Claudication is a manifestation of
multivessel disease of the
heart, brain and legs.
Physical examination
 Look at the skin for any abnnormalities & whithin the
skin feels cool, hot or warm to the touch
 Feel for pulses in the arteries (grade ?? /location)
 Feel for the lymph nodes, thrill, and mass
 For both of the legs

 Inspeksi
 Palpasi
 Auskultasi
 Diagnosis - Physical
Assessment

• Inspection of limbs

• Palpation of pulses – may be decreased in

volume or absent

• Auscultation – to detect bruits in carotid,

aorta, femoral vessels
 Palpation and Auscultation

Palpation Auscultation
Normal No Bruit
++
Mild Stenosis Soft Bruit
++
Significant Stenosis Harsh Bruit
+/-
Critical Stenosis Soft Bruit
-/+
Occlusion No Bruit
-
 Common Characteristics

• Skin colour – pallor, cyanosis, mottling,

dependent rubor
• Capillary refill - slower
• Skin temperature - cooler
• Sensation – decreased with parasthesia and
tingling
• Atrophic changes – foot hair loss, nail
thickening, shiny skin
• Ulcerated lesions – toes, heel, dorsum of foot
Segmental Pressure Examination

• Procedures of examinations :
- The patient must be supine position
- For every 1cm the limb is above the heart, the pressure
decreases by 0.74 mmHg
- The width of the cuff is :
- 20% - 25% greater than the width of the limb
- 40% greater than the circcumference of the limb
- At least 20 mmHg post the disappearance a Doppler –
detected pulse
- The first flow of blood is the peak systolic pressure
Diagnostic Prosedures and Analysis

A. Segmental pressure examination

– Pressure gradient and difference between two adjacent :
• From the arm to the ankle
• From the arm to the TOE
• From the arm to the upper thigh
• From the upper thigh to the lower thigh
• From the lower thigh to the calf
• From the calf to the ankle
• Any comparison between the right and the left
• Compare with previous studies
Measurement areas and arteries for measurement
in the lower extremity
Differential Diagnosis Of Intermittent
claudication

 Lower extremity arterial diseases

 Chronic compartment syndrome
 Venous claudication
 Nerve Root compression
 Hip arthritis
 Spinal cord compresion
 Aneurysms variable
shapes and types

A: Fusiform infrarenal aortic aneurysm. B: Tortuous elongated aortic aneurysm with the sac
shifted to the left of the midline. C: Saccular aortic aneurysm. D: Infrarenal aortic aneurysm
extending into the iliac arteries. E. Suprarenal aortic aneurysm involving the renal arteries. F:
Dissecting aortic aneurysm with a tear between the intima and media allowing blood into the
subintimal space. G: Dissecting aortic aneurysm in which the intima or media has fully dissected,
creating a false flow lumen. H: Double aneurysm of the aorta producing a ‘dumb-bell
appearance’. I: False aneurysm of the common femoral artery following arterial puncture. (TL,
true lumen; FL, false lumen.)