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Figure 15-16 Close-up of a necrobiosis lipoidica diabeticorum lesion.

Figure 15-16 Close-up of a necrobiosis lipoidica diabeticorum lesion.

Figure 15-17 Deep vein thrombosis, left leg.

Table 15-2 Precipitating Factors in Thromboembolism

Factor

Cause

Stasis

Arrhythmia Heart failure

Immobilization Obesity

Varicose veins Dehydration

Blood vessel injury

Trauma Fracture

Increased coagulability

Neoplasm

Oral contraceptives

Pregnancy

Polycythemia

Previous thromboembolism

Secondary to venous thrombosis, inflammation around the vein may result. Erythema, warmth, and fever then occur, and thrombophlebitis is present. In many cases, the examiner can palpate this tender, indurated vein in the groin or medial thigh. This is commonly referred to as a cord.

Deep vein thrombophlebitis is associated with symptomatic pulmonary embolism in approximately 10% of patients. If the embolus is large, main pulmonary artery obstruction may occur, which can result in death. It is estimated that an additional 45% of patients with thrombophlebitis have asymptomatic pulmonary emboli.

Several factors that are important in precipitating thromboembolism are outlined in Table 15-2.

An important and common peripheral vascular condition is Raynaud's disease or phenomenon. Classically, this condition is associated with three color changes of the distal fingers or toes: white (pallor), blue (cyanosis), and red (rubor). These color changes are related to arterio-spasm and decreased blood supply (pallor), increased peripheral extraction of oxygen (cyanosis), and return of blood supply (rubor). The patient may experience pain or numbness of the involved area as a result of the causes of pallor and cyanosis. During the hyperemic or rubor stage, the patient may complain of burning paresthesias. Between episodes, there may be no symptoms or signs of the condition.

Raynaud's disease, which is primary or idiopathic, must be differentiated from Raynaud's phenomenon, which is secondary. Table 15-3 lists some of the different characteristics of these conditions.

Gangrene is necrosis of the deep tissues resulting from a decreased blood supply. Features of the main vascular diseases causing gangrene of the lower extremities are summarized in Table 15-4.

Table 15-3 Differential Diagnosis of Raynaud's Disease and Raynaud's Phenomenon

Feature Raynaud's Disease Raynaud's Phenomenon

Table 15-3 Differential Diagnosis of Raynaud's Disease and Raynaud's Phenomenon

Feature Raynaud's Disease Raynaud's Phenomenon

Sex	Female	Female
Bilaterality	Present (often symmetric)	± (asymmetric)
Precipitated by cold	Common	Increases symptoms
Ischemic changes	Rare	Common
Gangrene	Rare	More common
Disease association*	No	Yes

*Such as scleroderma, systemic lupus erythematosus, dermatomyositis, or rheumatoid arthritis.

*Such as scleroderma, systemic lupus erythematosus, dermatomyositis, or rheumatoid arthritis.

Table 15-4 Differential Diagnosis of the Main Vascular Diseases Causing Gangrene

Feature Diabetes Atherosclerosis Thromboangiitis Obliterans Raynaud's Disease Arterial Embolism

Age	Any	Older than 60 years	Younger than 40 years	Younger than 40 years	Any
Sex	Either	Either	Male	Female	Either
Onset	Gradual	Gradual	Gradual	Gradual	Sudden
Pain	Moderate	Moderate	Severe	Moderate	Often severe
Distal pulses	May be absent	May be absent	May be absent	Present	Absent*

*Affected artery does not have pulsation.

Useful Vocabulary
Listed here are the specific roots that are important for understanding the terminology related to vascular disease.
Root	Pertaining to	Example	Definition
angi(o)-	blood vessel	angiography	Radiographic visualization of blood vessels
embol(o)-	wedge; stopper	embolism	Sudden blocking of a vessel by a clot
phleb(o)-	veins	phlebotomy	Incision into a vein for blood removal
thrombo-	clot	thromboembolism Obstruction of a blood vessel by a clot that has broken loose from its site of formation
varico-	twisted; swollen	varicose	Unnaturally swollen and twisted

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