2. Peripheral Vascular Disease
Arterial and Venous Disorders
Marion Technical College
NUR 1021

3. Peripheral vascular disease (PVD)
Disorders that change natural flow of blood through the arteries and veins of the peripheral circulation
Affects legs much more frequently than the arm
Some patients have both arterial and venous disease
Typically appears in patients ages

4. Peripheral vascular disease (PVD) – cont.
Cost of the disease is very high
Is expected to increase as baby boomers age and obesity in the United States continues to be a major health problem.

5. Physiologic Effects If diminished blood flow to tissues
Tissue integrity is challenged if demands exceed supply of oxygen & nutrients
Ischemia & eventual death of tissue if inadequate blood flow

6. Damaged Arteries
Obstructions from atherosclerotic plaque, thrombus or embolus
Damaged also from
Chemical/mechanical trauma, infections, inflammation, vasospastic disorders & congenital malformations

7. Acute or Gradual Changes
Sudden arterial occlusion
Profound & irreversible tissue ischemia & death
Gradual occlusion
Collateral circulation may develop
Tissue adapts gradually to ↓ blood flow
Less risk of sudden tissue death

8. Veins Carry deoxygenated blood to heart Normal venous pressure
Higher than arterial pressure, and lower in the right atrium than in the feet.
This allow veins to channel blood from extremities to heart.

9. Damaged Veins
Damaged by a thrombus, incompetent valves, decreased pumping action of surrounding muscles
Result - increased venous pressure
If the pressure in peripheral veins in greater than the pressure in tissues, where is the fluid going to go?
(Hint: Think about hydrostatic pressures)

10. Venous Diseases
Lead to pooling of blood in extremities, resulting in edema
Edematous tissue- cannot get adequate nutrition
Tissues are susceptible to breakdown, injury & infection
Venous diseases : DVT, varicose veins & venous stasis ulcers

11. Arterial Vessels More Often Affected
Peripheral arterial disease (PAD) may affect
Aortoiliac artery
Femoral artery
Popliteal artery
Tibial artery
Peroneal artery

12. Geriatric Considerations
Arteries become thicker – the intimal layer may become fibrotic & vessels stiffen
Results in increasing peripheral vascular resistance
May lead to ↑ work load of the left ventricle & possible heart failure

13. Risk factors for Peripheral Arterial Disease & Atherosclerosis
Diabetes
Hyperlipidemia
Hypertension
Nicotine use
High homocysteine levels
Familial/genetics
Increasing age
Female gender

14. Which Risk Factors for atheroslcerosis are non- modifiable?
Familial/genetics
Increasing age
Female gender

15. Assessment of Vascular System
Physical assessment:
Skin – changes occur from inadequate blood flow
Cool, pale extremities- increases with elevation
Rubor- reddish, blue color in dependent position
Severe peripheral arterial damage
Occurs from vessels that cannot constrict & remain dilated

16. Assessment of Vascular System (cont.)
Dry, shiny, taut skin
Loss of hair on extremity
Nails thickened & ridged
Edema
Gangrene after prolonged tissue necrosis

17. Assessment of Vascular System (cont.)
Classic symptom of PAD—intermittent claudication
Ischemic muscle ache or pain that is precipitated by a constant level of exercise
Resolves within 10 minutes or less with rest
Reproducible

18. Chronic arterial occlusion
Hallmark symptom: Intermittent claudication
Resting pain when occlusion severe
Elevating leg increases pain
Dependent position relieves pain

19. Assessment of Vascular System (cont.)
Pain in forefoot at rest – REST pain
Severe arterial insufficiency
Relief – put extremity in dependent position → improves perfusion
Often occurs at night
Pulses
Diminished or absent pedal, popliteal, or femoral pulses
Use a Doppler if unable to palpate pulses

20. Assessment of Vascular System (cont.)
Paresthesia
Shooting or burning pain in extremity
Present near ulcerated areas
Produces loss of pressure and deep pain sensations
Injuries often go unnoticed by patient

21. Complications Atrophy of the skin and underlying muscles
Delayed healing
Wound infection
Tissue necrosis
Arterial ulcers

22. Complications→Serious Outcome
Nonhealing arterial ulcers and gangrene are the most serious complications
May result in amputation if blood flow is not adequately restored or if severe infection occurs

23. NCLEX Challenge:
The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. What did the nurse most likely assess in this patient?
1. rubor with extremity elevation
2. normal hair distribution bilaterally over lower extremities
3. peripheral pulses present bilaterally
4. complaints of leg pain upon rest

24. Diagnostic Studies
Continuous wave (CW) doppler study- use of a handheld device to “hear” the pulses
Provides specific information for calculation of ABI

25. Diagnostic Studies
ABI (ankle-brachial index) – ratio of ankle systolic blood pressure to the arm systolic blood pressure
Ankle-brachial index <0.70 in PAD
With increasing arterial narrowing:
There is a progressive decrease in systolic pressure distal to the involved sites

26. Continuous-wave Doppler ultrasound
Detects blood flow, combined with computation of ankle or arm pressures
This diagnostic technique helps characterize the nature of peripheral vascular disease

27. Diagnostic Studies
CT: cross sectional images of soft tissue & volume changes
If patient has renal disease, patient should be hydrated (IV or oral) 12 hrs before procedure
Monitor urinary output post procedure
Evaluate for iodine or shellfish allergies
Premedicate -steroids & histamine blockers

28. Diagnostic Studies Angiography
Injection of radiopaque contrast into arterial system for visualization of vessels
Can identify location of stenosis or aneurysm
Collateral circulation identified
Teach patient that sense of warmth felt with injection of dye
Be alert for severe allergic reaction
Monitor injection site- bleeding or hematoma

29. Diagnostic Studies Magnetic Resonance Angiography
MRI with special scanner to locate blood vessels
Can rotate image for multiple views
Contraindicated:
Metal implants
Older tattoos (metal materials)
Prepare patient for banging/popping sounds
Panic button- if feeling claustrophobic

30. Diagnostic Studies Contrast Phlebography (Venography)
Radiopaque contrast injected into veins
Unfilled vein – location of a thrombus
Monitor injection site - bleeding or hematoma
Lymphoscintography
radioactive colloid injected into 2nd digit space
Provides serial images of lymphatic system

31. Are we having fun yet?

32. Something that makes this all happen….Arterial Disorders
Arteriosclerosis and atherosclerosis
Peripheral arterial occlusive disease
Upper extremity arterial occlusive disease
Aortoiliac disease
Aneurysms (thoracic, abdominal, other)
Dissecting aorta
Arterial embolism and arterial thrombosis
Raynaud’s phenomenon

33. Arteriosclerosis “Hardening of the arteries” Diffuse disease process
Muscle fibers & endothelial lining of walls of small arteries & arterioles thicken
Results in loss of elasticity, calcification of arterial walls

34. Atherosclerosis Atheromas or plaques Creates risk for thrombosis
Result of cholesterol, lipids & cellular debris in inner layers of large and medium-sized arteries
Result→ decreased blood flow from narrowing of lumen→ eventual development of collateral circulation
Creates risk for thrombosis
Vulnerable areas- regions where arteries bifurcate

35. C-reactive protein (CRP)
Sensitive marker of cardiovascular inflammation-systemically and locally
Slight increases in serum CRP levels
Associated with an increased risk of damage in the vasculature
Especially if these increases are accompanied by other risk factors such increasing age, HTN or positive family history of cardiovascular disease

36. Signs/Symptoms
Not usually present until artery narrowed by 60% or more
Early red flags include pain or changed appearance or sensation in foot or leg
Intermittent claudication
Resting causes pain to subside

37. Prevention Heart Healthy Diet
reduce fat intake, use unsaturated fats, decrease cholesterol intake
Medications – Statins to reduce cholesterol
Control hypertension with medications
Often need 2-3 types of HTN medications
Eliminate nicotine

38. Management Modify risk factors Exercise program Eliminate nicotine
Correct HTN
Exercise program
Eliminate nicotine
Medication- reduce blood lipids
Low cholesterol diet
Surgical graft procedures
Femoral/popliteal bypass- improves outflow

39. Radiologic Interventions
Angioplasty/percutaneous transluminal angioplasty (PTA)
Widens area & flattens plaque against wall of artery
Stents - prevent recollapse & reocclusion
Complications from procedure
Hematoma, bleeding
Distal embolization, intimal damage artery

40. Stents Small metal mesh tubes

41. I am PRR-fectly ready for whatever comes next

42. Peripheral Arterial Occlusive Disease
A form of arteriosclerosis involving occlusion of arteries, most commonly in the lower extremities; may be acute or chronic
Femoral popliteal area -most commonly affected in nondiabetic patients
Patient with diabetes mellitus tends to develop PAD in the arteries below the knee

43. Arterial thrombosis & Arterial embolism
Arterial embolism - sudden arterial occlusion caused by emboli
Results in acute ischemia of affected body parts
Most stem from thrombus formation in heart chambers
Arteriosclerotic conditions may predispose patients to emboli formation

44. Embolization of Thrombi…
If thrombi originates in left side of heart
Can obstruct artery of the lower extremity (iliofemoral, popliteal, tibial)
If originate in right side of the heart
Travel to lungs → pulmonary embolus
Noncardiac sources of emboli
Aneurysms
Ulcerated atherosclerotic plaque
Recent endovascular procedures
Venous thrombi
Rarely, arteritis

45. Clinical signs/symptoms
6” “P’s”of acute arterial ischemia
Pain- as PAD progresses- continuous pain at rest
Pallor (pale)- occurs with leg elevation
Pulselessness
Paresthesia
Paralysis
Poikilothermia (cool)
The physical appearance of the limb provides important information about blood flow. The skin becomes thin, shiny, and taut, and hair loss occurs on the lower legs. Diminished or absent pedal, popliteal, or femoral pulses are present. Pallor (blanching of the foot) develops in response to leg elevation (elevation pallor). Conversely, reactive hyperemia (redness of the foot) develops when the limb is in a dependent position (dependent rubor).
As PAD progresses and involves multiple arterial segments, continuous pain develops at rest. Rest pain most often occurs in the forefoot or toes and is aggravated by limb elevation. Rest pain occurs when there is insufficient blood flow to meet basic metabolic requirements of the distal tissues. Rest pain occurs more often at night because cardiac output tends to drop during sleep and the limbs are at the level of the heart. Patients often try to achieve partial pain relief by dangling the leg over the side of the bed or sleeping in a chair to allow gravity to maximize blood flow.

46. Clinical signs/symptoms(cont)
Toenails thick, skin shiny & dry; sparse hair on leg
100% blockage= acute arterial occlusion
Immediate intervention or necrosis of tissue in a few hours
Chronic rest pain, ulceration, or gangrene = critical limb ischemia

47. Goal : Keep affected limb viable
Anticoagulant therapy
Continuous IV unfractionated heparin (UH)
Prevent thrombus enlargement & inhibits further embolization
In patients undergoing embolectomy, UH should be followed by long-term anticoagulation with warfarin

48. Interventional Techniques
To restore blood flow - embolus/thrombus is removed ASAP
Options include
percutaneous catheter-directed thrombolytic therapy
percutaneous mechanical thrombectomy with or without thrombolytic therapy
surgical thrombectomy or surgical bypass

49. Extraction of an embolus
Use of balloon-tipped embolectomy catheter
Deflated balloon-tipped catheter - advanced past the embolus, inflated, and then gently withdrawn, carrying the embolic material with it

50. What is catheter-directed intraarterial thrombolytic therapy ?
Use tPA [alteplase] for patients with short-term (less than 14 days) thromboembolic disease
Percutaneous catheter-inserted into femoral artery & threaded to site of clot
Thrombolytic drug is infused
Thrombolytic agents work by directly dissolving the clot over a period of 24 to 48 hours
Catheter may act as a mechanical thrombectomy device- designed to remove or fragment the thrombus

51. Revascularization Approaches
Patient with chronic rest pain, ulceration, or gangrene has critical limb ischemia
Critical limb ischemia often leads to amputation within 6 months if untreated
Percutaneous transluminal balloon angioplasty for non-surgical approach
Atherotomy – use of cutting device or laser to remove plaques

52. Revascularization Approaches
Surgery -indicated in patients with long areas of stenosis or severely calcified arteries
Common surgical approach
Peripheral artery bypass →improves blood flow beyond a stenotic or occluded artery
Use a vein graft or a synthetic graft

53. A, Femoral-popliteal bypass graft around an occluded superficial femoral artery
B, Femoral-posterior tibial bypass graft around occluded superficial femoral, popliteal, and proximal tibial arteries

54. Revascularization Approaches
Endarterectomy
Opening the artery and removing the obstructing plaque
Followed by a patch graft angioplasty
Sewing a patch to the opening to widen the lumen

55. NCLEX Challenge:
The nurse recognizes which client is at greatest risk for developing intimal injury leading to atherosclerosis?
a. A client with diabetes who also smokes one pack of cigarettes daily
b. A client with decreased low-density lipoprotein (LDL) and increased high-density lipoprotein (HDL) levels
c. A client with inherited hypolipidemia
d. A client with a sedentary lifestyle A
Atherosclerosis can be caused by mechanical and/or chemical injury. Individuals with diabetes often have premature, severe atherosclerosis from elevated LDL levels and intimal injury from hyperglycemia. Cigarette smoking releases toxins into the bloodstream, further contributing to intimal injury.

56. Amputation - least desirable end-stage surgical option
May be required if extensive tissue necrosis
If infectious gangrene or osteomyelitis develops
Indicated if all major arteries in the limb are occluded
Every effort made to preserve as much of limb as possible to optimize rehabilitation

57. Postoperative Nursing Care
Main goal -maintain adequate circulation
Check pulses frequently and compare with unaffected extremity
Notify physician immediately if decrease/loss
Monitor color & temp. of extremity
Assess sensation & movement of extremity
Can elevate leg to reduce edema
Avoid knee flex position; no crossing legs
Turn & reposition frequently
Monitor fluid balance

58. Ambulatory and Home Care
Management of risk factors
Importance of meticulous foot care
Importance of gradual physical activity after surgery
Avoid crossing legs
Daily inspection of the feet
Comfortable well-fitting shoes with rounded toes and soft insoles

59. Nursing Management for PAD Nursing Diagnoses
Ineffective tissue perfusion (peripheral)
Impaired skin integrity
Activity intolerance
Ineffective therapeutic regimen management

60. Nursing Management Planning
Overall goals for patient with PAD
Adequate tissue perfusion
Relief of pain
Increased exercise tolerance
Intact, healthy skin on extremities

61. Collaborative Care - PAD Exercise Therapy
Exercise improves oxygen extraction in the legs and skeletal metabolism
Walking is the most effective exercise for individuals with claudication
30 to 60 minutes daily
use pain as a guide
Bedrest → leg ulcers, cellulitis, gangrene, or acute thrombotic occlusions

62. Collaborative Care Nutritional Therapy
Dietary cholesterol <200 mg/day
Decreased intake of saturated fat
Soy products can be used in place of animal protein

63. Collaborative Care Complementary/Alternative Therapies
Ginkgo biloba
Effective in increasing walking distance for patients with intermittent claudication
Folate, vitamin B6, cobalamin (B12)
Lowers homocysteine levels
Homocysteine is a common amino acid (one of the building blocks that make up proteins) found in the blood and is acquired mostly from eating meat. High levels of homocysteine are related to the early development of heart and blood vessel disease. In fact, an elevated level is considered an independent risk factor for heart disease. High homocysteine is associated with low levels of vitamin B6, B12, and folate and renal disease. Research has shown, however, that reducing your homocysteine levels with vitamins does not reduce the risk of heart disease.
Doctors aren't sure how or even if homocysteine increases the risk of heart and blood vessel disease, but there appears to be a link between high homocysteine levels and damage to the arteries, leading to atherosclerosis (hardening of the arteries) and the formation of blood clots.

64. Collaborative Care Care of Leg with Critical Limb Ischemia
Protect from trauma
Reduce vasospasm
Prevent/control infection
Maximize arterial perfusion

65. Interventions: Promote vasodilation and prevent compression
Arterial dilation -may not be possible if artery is severely sclerosed or damaged
Teaching:
Warmth promotes arterial flow and cold causes vasoconstriction
Nicotine causes vasospasm
Emotional upsets cause vasoconstriction
Avoid constricting clothing
Place extremity below level of heart

66. Foot care guidelines - Same as diabetic foot care
Prevent foot injury and blisters
Treat any injury or blister immediately
Use neutral soaps & body lotions- prevent skin drying
Pat skin dry – avoid vigorous rubbing
Stockings or socks -clean and dry
Soak fingernails and toenails before trimming
Trim nails straight across – may need podiatrist
Don’t cut corns and calluses

67. NCLEX Challenge
A client who has returned to the unit after arterial revascularization states that pain similar to that before the procedure is felt in the affected limb. Which is the nurse’s best action?
a. Notifying the surgeon
b. Elevating the extremity
c. Administering pain medication
d. Placing a warm blanket on the operative limb
ANS: A
The surgeon should be notified if the client has an increase in ischemic pain because this signals graft occlusion. This is a surgical emergency and the nurse must recognize this as a sign of graft occlusion. Elevating the extremity would further compromise blood flow. Covering the extremity or administering pain addresses only the clinical manifestations, not the cause, of the compromised blood flow.

68. Collaborative Care Drug Therapy
Antiplatelet agents
Aspirin
Ticlopidine (Ticlid)
Clopidogrel (Plavix)
Antiplatelet agents such as aspirin or clopidogrel (Plavix) prevent the formation of thromboemboli, which can lead to myocardial infarction and stroke.
Aspirin has been shown to reduce the risk of cardiovascular events (e.g., myocardial infarction, stroke, and cardiovascular death) in patients with vascular disease; however, adverse events associated with aspirin use include gastrointestinal upset or bleeding.
Statins improve endothelial function in patients with PAD; however, there is conflicting research regarding whether or not statins decrease claudication symptoms in patients or improve pain-free walking time in patients with PAD

69. Collaborative Care Drug Therapy (Cont’d)
ACE inhibitors
Ramipril (Altacel)
↓ Cardiovascular morbidity
↓ Mortality
↑ Peripheral blood flow
↑ABI
↑ Walking distance

70. Collaborative Care Drug Therapy (Cont’d)
Drugs prescribed for treatment of intermittent claudication
Pentoxifylline (Trental)
↑ Erythrocyte flexibility
↓ Blood viscosity
Cilostazol (Pletal)
↑ Vasodilation
↑ Walking distance
Pentoxifylline increases erythrocyte flexibility, lowers blood fibrinogen concentrations, and inhibits neutrophil adhesion and activation.
Cilostazol, a phosphodiesterase III inhibitor, is a vasodilator that inhibits platelet aggregation

71. NCLEX Challenge:
In reviewing the menu selections of a client who is ordered a low-cholesterol diet, the nurse questions which selection?
a. Oatmeal
b. Eggs
c. Banana
d. Wheat toast

72. Buerger’s Disease (Thromboangiitis obliterans)
Inflammatory changes in both arteries and veins
Results in destruction of small and medium vessels
Usually affects lower extremities but can also be seen in upper extremity vessels

73. Etiology
Affects male cigarette smokers between ages 20 and 40, small incidence in females
Long history of tobacco use
Do not have other CVD risk factors (hypertension, hyperlipidemia, DM)

74. Pathophysiology Inflammatory process damages the blood vessel wall
Lymphocytes and giant cells infiltrate the vessel wall with fibroblast proliferation
Ultimately, thrombosis and fibrosis occur in the vessel, causing tissue ischemia.

75. Signs and Symptoms Pulses decreased/absent
Symptoms- may be confused with PAD or autoimmune disorders as scleroderma
High rate of periodontitis & presence of Phorphyromonas gingivalis (periodontal pathogen) in occluded blood vessels
Suggests possible bacterial cause
Pulses decreased/absent

76. May progress to painful ulceration
Pain – cramps in feet (esp. arches) or legs after exercise (intermittent claudication) - relieved by rest
Rest pain, burning/sensitivity to cold may be early symptoms
May progress to painful ulceration
Amputation rate if patient continues tobacco use is almost 3 times greater than for those who do not

77. Management
Same as that for nursing care of patient with arterial peripheral disease
Complete cessation of tobacco use in any form
Use of nicotine replacement products is contraindicated
Patients have a choice between tobacco and their affected limbs, but not both

78. Treatment
Antibiotics -treat any infected ulcers & analgesics to manage ischemic pain
Sympathectomy & implantation of a spinal cord stimulator
Improves distal blood flow & reducing pain
Neither alters the inflammatory process.
Amputation- if ulceration & gangrene
A variety of novel drug therapies to treat Buerger's disease have been studied but the results have been marginal. One therapy with modest effectiveness in Europe has been IV iloprost (a prostaglandin analog). Another promising area of research is the intramuscular gene transfer of vascular growth factors. Surgical options include sympathectomy (transection of a nerve, ganglion, and/or plexus of the sympathetic nervous system), implantation of a spinal cord stimulator, and bypass surgery. Sympathectomy and implantation of a spinal cord stimulator are useful in improving distal blood flow and reducing pain, but neither alters the inflammatory process. Bypass surgery typically is not an option due to the involvement of smaller, distal vessels but may be used in selected patients with severe ischemia.

79. Raynaud’s Phenomenon
Characterized by vasospasm of the arterioles and arteries of the upper and lower extremities, usually unilaterally
Raynaud's disease occurs bilaterally

80. Difference in Disorders
Primary or idiopathic Raynaud’s (Raynaud’s disease) occurs in absence of underlying disease.
Secondary Raynaud’s (Raynaud’s syndrome) –
Associated with an underlying disease
Usually a connective tissue disorder- systemic lupus erythematosus, rheumatoid arthritis, or scleroderma

81. Clinical Manifestations
Classic clinical picture -- Raynaud’s
Pallor brought on by sudden vasoconstriction.
Skin then becomes bluish (cyanotic) -of pooling of deoxygenated blood during vasospasm
As a result of exaggerated reflow (hyperemia) due to vasodilation, a red color (rubor) is produced when oxygenated blood returns to the digits after the vasospasm stops

82. Color Changes –Raynaud’s
Characteristic sequence of color change of Raynaud’s phenomenon
White, blue, and red
Numbness, tingling, and burning pain occur as the color changes
Manifestations tend to be bilateral and symmetric and may involve toes and fingers

83. Management
Avoiding stimuli (e.g., cold, tobacco) that provoke vasoconstriction
Is a primary factor in controlling Raynaud’s phenomenon
Calcium channel blockers (nifedipine [Procardia], amlodipine [Norvasc])
May be effective in relieving symptoms
Wear gloves when outside; avoid touching cold items as steering wheel

84. If I got this ---you can too!!