VASCULAR DISORDERS

Muthuukaruppan M.

Thromboangiitis Obliterans
Nonatherosclerotic vascular disease, characterized by minimal presence of atheromas, segmental vascular inflammation, vasoocclusive phenomenon involving small & medium sized arteries & veins of upper & lower extremities. Associated with tobacco use and exposure is the cause for initiation and progression. Disease mechanism is unclear, an immunologic phenomenon that leads to vasodysfunction and inflammatory thrombi.

 Increased cellular sensitivity to types I & III collagen, have serum anti-endothelial cell antibody titers and have impaired peripheral vasculature endothelium-dependent vasorelaxation. Common in India, Bangladesh, Korea, Japan and in few races in Israel. Common in males between 20 45 years. Diagnostic criteria are: younger than 45yrs, current history of tobacco use, presence of distal extremity ischemia (claudication, pain at rest, ischemic ulcers or gangrene), exclusion of autoimmune disease and source of emboli.

 70-80% patients present with Buerger disease with distal ischemic rest pain and/or ischemic ulcerations on the toes, feet or fingers. Involvement of large arteries are unusual Claudication of feet, legs, hands or arms and sensitivity to cold. Paresthesias of feet and hands and impaired distal pulses. Foot infections are common in later stages Arteries of extremities are common but rarely proximal arteries are also seen.

 Allens test is used to check the integrity of blood refill in the arteries. Arteriography / angiography are done. Absolute discontinuation of tobacco is the only proven strategy. Intravenous iloprost an prostaglandin analogue Thrombolytic therapy is being under experimentation. Use of protective garments, treatment against infections, avoidance of cold environments and drugs that lead to vasoconstriction.

Raynauds disease
Recurrent vasospasm of the fingers and toes in response to stress or cold exposure. Raynauds phenomenon was described to be episodic, symmetric, vasospasm with pallor, cyanosis and sense of fullness or tautness which may be painful. Raynauds phenomenon is classified as primary and secondary. Primary presents with vasospasm alone with no association with another illness.

 Secondary Raynauds phenomenon presents with vasospasm associated with another illness mostly autoimmune disease. Young female patients with Raynauds phenomenon alone for more than 2 years are at low risk than older patients and males with Raynauds phenomenon. Associated with autoimmune diseases like progressive systemic sclerosis (Scleroderma,95%) and mixed connective disorders. Hyper-activation of the sympathetic nervous system causing vasoconstriction of the peripheral blood vessels, leading to tissue hypoxia.

 Presents with pain within the affected extremities, pallor and sensations of cold and numbness. Episodic and when the episode subsides or area is warmed, the blood flow returns and accompanied by swelling, tingling and pain. Deficiency of a vasodilatory mediators, nitric oxide, endothelin-1 a potent vasoconstrictor found to be circulating in high levels and some have identified that habituation to stressful stimuli is reduced. Related to occupations such as jackhammers, industrial exposure to PVC, solvents like xylene, acetone and chlorinated solvents.

 Warming of local body part, cessation of nicotine reduces the symptoms. Calcium channel blockers and prostacyclin analogue are preferred. Cervical & digital sympathectomy are surgical approaches. Goals of Physiotherapy are to maintain independence of function, lung function, ROM and muscle power. Flexibility exercises, breathing control, stretching, hydrotherapy with cautious temperature and thermotherapy before exercises are beneficial.

Deep Vein Thrmobosis

Venous thromboembolism is a presentation of DVT Development of venous thrombosis may be due to venous stasis, activation of blood coagulation and vein damage. Frequent causes for venous stasis are immobilization or central venous obstruction. Other causes may be due to reduced blood flow from increased blood viscosity, anatomic variants and mechanical injury to vein.

 Common risk factors for DVT are presence of acute infectious disease, older than 75yrs, cancer, history of prior DVT, pregnancy and postpartum period, long plane or car trips > 4hrs, stroke, SCI, CHF, Burns, obesity, polycythemia, thrombocytosis, surgery and immobilization more than 3 days. Pain, limb edema, tenderness and fullness in skin texture, whereas cyanosis and ischemia is rare. Primary management objectives are to prevent pulmonary embolism and prevent or minimize developing post thrombotic syndrome. Anti-coagulant therapy and thrombolytics is the main stay.

 Prevention is the primary management of DVT, with the known risk factors active limb movement, early immobilization, pneumatic compression devices and compression garments are encouraged. Post DVT physical therapy is contraindicated or ensued with caution. Active movements are preferred than any passive mobilization.

Varicose Veins
Veins that have become enlarged and tortuous. Veins while losing the elasticity or valve functions become varicose and enlarge. Most common in the superficial veins of the legs when forced to high pressures in long standing. Varicose veins can be painful and heavy after exercise or at night. Appearance of spider veins, ankle swelling in evening and brownish yellow skin discolouration near the affected veins.

 Venous dermatitis or eczema, cramps develop. Minor injuries may bleed more than normal and may present with restless leg syndrome. Stages: 1. No visible or palpable signs of venous disease 2. Telangectasia or reticular veins 3. Varicose veins 4. Edema 5. Skin changes: pigmentation, eczema 6. Skin changes: lipodermatosclerosis 7. 5 and 6 but with healed ulcers 8. Skin changes with active ulcers

 More common in women, factors are pregnancy, obesity, menopause, aging, prolonged standing, leg injury and abdominal straining. Management: Elevating limbs are for temporary symptomatic relief. Compression stockings, intermittent pneumatic compression devices. Pharmacologic management with antiinflammatory and flavonoids. Endovenous thermal ablation, sclerotherapy Phlebectomy and vein ligation

 Physiotherapy management involves prevention and symptomatic management. Avoiding long standing and compression garments. Pain relief and edema management are the realms of physiotherapy.

References
1. Elizabeth Dean(2005), Donna Frownfelter, Cardiovascular & pulmonary physical therapy, (4th ed.), Mosby 2. Jennifer Pryor, Barbara A. Webber (2005), Physiotherapy for respiratory and cardiac problems, (2nd ed.), Churchill Livingstone 3. Stuart B. porter (2003), Tidys Physiotherapy, (14th ed.), Churchill Livingstone. 4. Alexandra Hough (2001), Physiotherapy in respiratory care, (3rd ed.), Nelson Thornes.

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