PAD: Risk Factors
� HTN
� Hyperlipidemia
� LDL women < 135 men < 150
� HDL > 40
� Total triglycerides
� Total cholesterol
� DM
� Cigarette smoking
� Obesity
� Familial disposition
� Advancing age
� Pt w/ PAD also has increased risk for chronic angina, MI, & stroke
PAD: Physical Assessment/CM
� Intermittent claudication
� Often one of 1st sx
� Reproducible pain - walking creates pain (burning, cramping) in calf which stops at rest & returns when walking picks up again (at about same distance)
� Usually what gets pt to Dr
� As disease progresse
The 4 Stages in PAD
Stage I: Asymptomatic
� No claudication is present
� Bruit or aneurysm may be present
� Pedal pulses decreased or absent
Stage II: Claudication
� Muscle pain, burning, cramping, occurs w/ exercise
� relieved w/ rest
� Sx are reproducible w/ exercise
Stage
Sx of Inflow/Outflow disease
� Pain in lower back, buttocks, & thighs
� Mild: discomfort (not severe) after walking 2 blocks; relieved by rest
� Moderate: Pain after walking 1 or 2 blocks; eases w/ rest most of time
� Severe: severe pain after walking < a block & may include rest pai
Sx of PAD:
� Loss of hair on lower legs
� Diminished or absent pedal, popliteal, or femoral pulses (peripheral pulses)
� Posterial tibial - best measure of arterial function b/c pedal pulse not palpable in some ppl
� Compare strength of pulses bilaterally
� Dry, sca
PAD: Imaging assessment: Arteriography of the lower extremities: Definition, risks
� Done if stent placement planned
� To determine amt of occlusion b/4 peripheral bypass surgery
� Injection of contrast medium
� Risks include:
� Hemorrhage
� Thrombosis
� Embolus
� Death
PAD: Imaging assessment: Doppler probe: Describe.
� Noninvasive & Inexpensive
� Obtain segmental SBP of LE at thigh, calf, & ankle
� Normal BP readings in thigh & calf are higher than in UE
� So when PAD is present, they may be lower than brachial pressure
� To evaluate severity of inflow disease, BP tak
PAD: Exercise tolerance testing: describe
� Can be done on treadmill or w/ drugs
� Provides info about claudication w/out rest pain
� Take pulse vol recording b/4 starting, then again when Sx appear (or 5 min after they appear)
� If PAD present:
� ? in ankle pressure of 40-60mmHg for 20-30sec in
PAD: Plethysmography: describe
� Provides graphs or tracings of arterial flow in limb
� Waveform flattened=occlusion present
� The flatter it is, the greater the occlusion
PAD: Interventions: Nonsurgical management: Exercise & Positioning
� Helps develop collateral circulation
� Should not exercise if have severe rest pain, venous ulcers, or gangrene present.
� Start exercise gradually (walk until claudication, rest, & continue) & ? gradually
� Some pts have swelling & b/c swelling prevent
PAD: Interventions: Nonsurgical management: Promoting Vasodilation
� Provide warmth b/c vasoconstriction ? arterial flow
� Prevent long periods of exposure to cold
� Wear socks or insulated shoes at all times
� Never apply direct heat b/c sensitivity may be ? & may cause injury
� Drink adeq fluids to reduce bld viscosity
If a patient has both arterial and venous disease, what does that mean for interventions?
We must consider them separately.
PAD: Interventions: Nonsurgical management: Drug Therapy
�Hemorheologic agent: Pentoxifylline (Trental)
� ? flexibility of red blood cells
� ? blood viscosity by
� Inhibits platelet aggregation &
� ? fibrinogen thus
� ? bld flow in extremities
� Many pt report limited improvement
�Antiplatelet agents- Aspirin (
PAD: Interventions: Nonsurgical management: Percutaneous Transluminal Angioplasty (PTA)
� Non-surgical, but invasive method
� Balloon catheter dilates artery
� Advanced into or above occluded artery
� Opens vessel & improves arterial flow
� Stents may be placed
� Candidate for stents are pt w/ stenosis of common or external iliac 1arteries
�
PAD: Interventions: Nonsurgical management: Laser-assisted angioplasty
� Invasive
� Laser probe advanced through cannula
� Heat from laser vaporizes plaque
� Balloon catheter may be inserted
� Usually done w/ smaller occlusions in distal superficial femoral, proximal popliteal, & common iliac arteries.
� May get heparin duri
PAD: Interventions: Nonsurgical management: Atherectomy
� Rotablator (high speed rotary metal burr) scrapes plaque w/o damaging vessel wall
� Results in fine particle destruction & blockage removal
PAD: Surgical Management: Arterial revascularization
� Arterial revascularization is most common surgical procedure to ? arterial bld flow in affected limb
� Usually indicated for severe rest pain or claudication whose ADLs are severely affected or may lose limb
PAD: Surgical Management: Arterial revascularization: Graft materials used
� Synthetic materials like polytetrafluoroethylene (PTFE), GORE-TEX, or Dacron used when pts own veins not usable
� Adeq patency above knee, but not satisfactory in infrapopliteal outflow vessels
� Autogenous (pt's own) veins may not be long enough for ve
PAD: Surgical Management: Inflow Procedures
involve bypassing occlusion above superficial femoral arteries (SFAs)
� Incl aortoiliac, aortofemoral, & axillofemoral bypasses
� More successful, w/ less chance of reocclusion or postop ischemia
PAD: Surgical Management: Outflow Procedures
involve bypassing occlusion at or below superficial femoral arteries
� Incl femoropopliteal, & femorotibial bypasses
� Less successful in relieving ischemic pain & reocclude more often than inflow
� Preferred graft material is pts saphenous vein (best), o
PAD: Post-op: Assessment: Graft occlusion, pain, infection
� Monitor patency of graft by checking extremity q 15 min for 1 hr, then q 1 hr for
� Color, temp, & pulse intensity
� Some localized warmth, redness, & edema is expected initially
� Some throbbing pain is expected, but ischemic pain is red flag
� one of
PAD: Post-op: Treatment of graft occlusion and when it is most likely to happen
Reocclusion first 24hrs most likely.
� Notify the surgeon immediately
� Emergency thrombectomy - removal of clot
� Most common Tx for acute graft occlusion
� Done bedside
� Very successful w/ synthetic grafts, but not autogenous vein grafts which may requ
PAD: Post-op: HTN may cause what? In regards to respiratory interventions, what should the patient be doing post-op? Diet? Contraindications? Compartment syndrome?
� HTN may indicate hypovolemia which ? risk for clotting/occlusion
� Cough & Deep Breath q 1-2 hr & incentive spirometry
� NPO for up to 24 hr post-surgery (less if didn't involve aorta or abd wall) & bedrest for 18-24 hr
� Bending of hip & knee contraind
PAD: Community Based Care
� Management at home requires a team approach
� Don't raise legs above heart unless they also have a venous disorder (venous stasis)
� Instruct patients on methods to promote vasodilation
� Provide teaching on methods to prevent ulcers & injury
� Incision
Acute Peripheral Arterial Occlusion (APAO): Describe disease and manifestations
� Onset is sudden & dramatic (unlike chronic PAD)
� Embolus is most common cause
� Most commonly originate in heart
� Often follows MI w/in a week or w/in several weeks of a-fib
� More common in LE
� Severe pain below the level of the occlusion even at re
APAO: What is usually the first intervention?
� Unfractured heparin administered to prevent further clot formation (bolus up to 10,000 units)
Why is thrombolytic therapy not recommended for APAO pt? What may be used instead? Monitor for what?
b/c bleeding risks outweigh benefits
� Local intraarterial thrombolytic therapy w/ t-PA or Activase or ReoPro
� Monitor for Sx of bleeding, bruising, hematoma
� Platelet counts at 3, 6, 12 hr post infusion
� If platelets drop <100,000 adjust or d/c infusi
Describe thrombectomy or embolectomy. Postop: what should you monitor for?
� Dr makes arteriotomy (surg opening into artery) under local anesthesia ? removes embolus w/ catheter ? may use patch graft to close
� Post op monitor extremities for:
� Improvement in
� Color
� Temp
� Pulse
� Monitor other extremities for Sx of new obst
Buerger's Disease: Describe
� Thromboangiitis obliterans
� relatively uncommon occlusive disease
� limited to medium & small arteries & veins
� Distal upper & lower limbs mostly
� Larger arteries get involved in late stages
� Veins less commonly involved
Buerger's Disease: Who is it most often found in? Intervention? First CM? other CMs?
� Often identified w/ tobacco smoking & young, adult men
� If stop smoking, disease will go away!
� Continued smoking causes occlusion in more proximal vessels
� Intermittent claudication (muscle pain caused by inadequate bld supply)of arch of foot is oft
Buerger's Disease: Interventions
� Preventing progression of disease
� Avoiding vasoconstriction
� Complete abstinence of tobacco
� Avoid extreme cold
� Promoting vasodilation
� Drug therapy: nifedipine (Procardia)
� Relieving pain
� Managing ulceration & gangrene
� Overall, tx similar t
Raynaud's Phenomenon: Describe disease, CM, possible cause
� Caused by vasospasm of arterioles & arteries of upper & lower extremities
� Usually pt is > 30 yo (disease occurs 17 - 50 yo)
� Can occur in either gender (disease more common in women)
� Occurs unilaterally (Raynaud's disease occurs bilaterally)
� Term
Raynaud's Phenomenon: Drug therapy, lumbar sympathetomy
Procardia, Cyclospasmol, & Dibenzyline
� All cause vasodilation & SE of facial flushing, HA, hypotension, dizziness
� Lumbar sympathectomy
� Surgeon cuts sympathetic nerve fibers that cause vasoconstriction in legs
� Effective for foot Sx
� If done on UE,
PVD: Venous Thromboembolism: Describe disease processes
� One of the greatest challenges for medical world
� Includes both thrombus & embolism complications
� Thrombus-blood clot
� Embolus-something that travels through the blood stream
� Thrombophlebitis
� Thrombus associated w/ inflammation
� Mostly occurs i
PVD: Venous Thromboembolism: Thrombus formation associated with? Incidences that promote DVT?
Virchow's triad:
1.Stasis of blood flow
2.Endothelial injury
3.Hypercoagulability
� Ulcerative colitis
� Heart failure
� Immobility (bedrest, sit for long periods - long flights, sitting at desk)
� Highest incidence occurs in pts who have undergone:
� Hip
PVD: Venous Thromboembolism: Health Promotion and Maintenance
� Avoid oral contraceptives
� Drink adequate fluids
� Exercise during long periods of rest
� Compression stockings
� Pt education
� Sequential compression devices (SCD's)
PVD: DVT: assessment: classic s/s
May or may not be symptomatic.
Can occur in arm r/t IV or compression injury by rib.
� Calf or groin pain & tenderness
� Compare painful site to other limb
� Sudden onset of unilateral swelling of leg
� Positive Homan's sign - not advised
� Pain in calf w
PVD: DVT: Assessment: Physical exam findings adequate for dx:
� Venous duplex ultrasonography - preferred diagnostic test
� Accuracy depends on skills of test giver
� Doppler flow studies
� Accuracy depends on skills of test giver
� More sensitive to proximal than distal DVT
� Impedance Plethysmography
� Assesses ve
PVD: DVT: Nursing Dx, Focus of management
� Risk for Ineffective Tissue Perfusion
� Acute Pain
� Prevent further complications like PE
� Prevent further thrombus formation
� Prevent an increase in thrombus size
PVD: DVT: Nonsurgical management: Preventative therapy, rest
� Avoid oral contraceptives.
� Drink adequate fluids to avoid dehydration.
� Exercise legs during long periods of bedrest or sitting.
� Patient education
� Leg exercises
� Early ambulation
� Adequate hydration
� Graduated compression stockings (not as com
PVD: DVT: Nonsurgical Management: Drug therapy: Anticoagulant therapy
DOC for existing & at-risk DVT
� Tx for at-risk ppl to prevent DVT:
� Low dose SC heparin
� LMWH: enoxaparin (Lovenox)
� Drug of choice post orthopedic surg
� Selective factor Xa inhibitors: fondaparinux (Arixtra)
� Warfarin
PVD: DVT: Nonsurgical Management: Conventional Tx for DVT? UFH (Unfractionated Heparin Therapy)?
IV unfractionated hep therapy followed by oral warfarin
Unfractionated Heparin Therapy (UFH)
� Inhibits clotting factors (except VII & XIII)
� At high doses inhibits nearly all
� Prevents formation of other clots
� Prevents enlargement of existing clot
�
PVD: DVT: Nonsurgical Management: Drug Therapy: Assess for s/s of? Monitor HIT for? White clot syndrome?
� Assess for s/s of bleeding -incl pain & LOC changes, bld in stool
� Monitor for HIT (heparin induced thrombocytopenia)
� Watch for severe platelet reduction 6-14 days after Tx starts
� Notify Dr & d/c if platelet <150,000
� White clot syndrome - platele
PVD: DVT: Nonsurgical Management: Drug Therapy: LMWH (Low Molecular weight heparin)?
� Inhibit thrombus formation
� Given SC
� Enoxaparin (Lovenox), dalteparin (Fragmin), ardeparin (Normiflo)
� Danaparoid (Orgaran)- classified as LMWH but is heparinoid
� Longer half life & more predictable response than UFH
� May be used at home
� Candida
PVD: DVT: Nonsurgical Management: Drug Therapy: Warfarin?
� Works in liver
� If getting continuous UFH, add warfarin at least 5 days later
� Can start after first dose of LMWH
� Inhibits synthesis of 4 Vit K clotting factors
� Takes 3-4 days to exert therapeutic anticoagulation
� Monitor PT &/or INR
� INR should
PVD: DVT: Alternatives to heparin?
� Bivalirudin (Angiomax) & lepirudin (Refludan)
� Highly-selective direct thrombin inhibitors
� Watch for bleeding
PVD: DVT: Thrombolytic Therapy
� Effective in dissolving clots
� Greatest adv is prevof valvular damage & venous insufficiency
� Prevents new clots during first 24 hrs
� Most serious complication is intracerebral bleeding
� Watch for bleeding Sx, incl LOC change
� Must be started w/in
DVT: Surgical Management- Treatment, reason for treatment, post-op assessment:
� Surgical tx is rarely necessary, unless its massive & doesn't respond to other Tx, & thrombus is only 1-2 days old
� Thrombectomy - most common
� Inferior vena caval interruption (IVC)
� For pt who can't tolerate anticoagulant therapy & recurrent DVT or
DVT: Community based care: Education
� Educate on hazards of anticoagulant therapy
� Avoid smoking
� Avoid oral contraceptives
� Avoid contact sports esp if on anticoagulant
� Medical alert bracelet (anticoagulant)
� Inform dentist & other HCP's
� Avoid alcohol
� Plenty of fluids
� Avoid sit
DVT: Warfarin therapy: foods and drugs that interfere:
� Eat only a little (b/c of Vit K): broccoli, cauliflower, spinach, kale, green leafy, brussels sprouts, cabbage, liver
� Avoid if possible: allopurinol, NSAIDs, APAP, Vit E, antihistamines, cholesterol-reducing drugs, antibiotics, bc pills, antidepressan
PVD: Venous Insufficiency: Describe disease process and causes
� Result of prolonged venous HTN, stretching veins & damaging valves
� May develop venous stasis ulcers (severe cases), swelling, cellulitis
� Standing or sitting long periods of time
� Obesity
� Thrombophlebitis
PVD: Venous Insufficiency: Assessment:
� Edema in both legs
� Stasis dermatitis-reddish brown discoloration along ankles, up to calf
�Stasis ulcers may form
� Result from edema or minor injury to limb
� Usually on medial malleolus (inner ankle) w/ irregular borders
� Very difficult to heal, re
PVD: Venous Insufficiency: Assessment: Tx focus. Why isn't surgery done?
? edema & promote venous return
� Wear elastic compression stockings
� Elevate legs above level of the heart at least 20 min 4-5 times daily (note: above the heart for venous disorders, below the heart for arterial disorders)
� Debridement of ulcers (chem
PVD: Venous Insufficiency: Community Based Care
� Avoid standing still if possible
� Elevate legs when sitting
� Avoid crossing legs (ankles ok for short periods)
� Avoid tight girdles, pants, narrow banded knee high socks
� Manage weight
� Apply stockings b/4 getting out of bed (don't push down)
Varicose veins: Describe disease, symptoms, group it's common in:
�Distended, protruding veins that appear darkened & tortuous
� r/t incompetent (defective) valves
�Other Sx: pain or feeling of fullness in LE
�Common in 30 yo or older & common in occupations that require standing for long periods (nursing, teaching)
� A
Varicose Veins: What test is used? Describe it. Collaborative management interventions?
� Trendelenburg test: supine in trendelenburg & then sit up: if veins fill from distal end its normal, if have varicosities will fill from proximal end
� Elastic stockings - preferred Tx
� Elevation of extremities- preferred Tx
� Sclerotherapy - solution
PVD: Phlebitis: Describe the disease, cause, management, complications
� Inflammation of superficial veins
� Often caused by IV therapy
� Management�warm, moist soaks (dilate & promote circulation) & elastic stocking to dilate vein & promote circulation
� Complications - tissue necrosis, infection, or pulmonary embolus
PVD: Vascular trauma: causes, management, types. What is the most important intervention?
�Causes:
� Punctures
� Lacerations
� Transections
� Most important: maintain airway, control bleeding, restore bld flow
� Assess for circulatory, sensory, or motor impairment
� Method of repair varies depending on injury
� If deep vessels injured, impairm
Define and describe PVD and PAD
Typically refers to disease in arteries but also includes veins
Disorder that alter natural flow of bld thru arteries & veins of peripheral circulation
� Results in partial or total arterial occlusion
� Affects legs more often than arms
� Deprives the LE
Define different classification of PAD obstructions
� based on arteries involved & relationship to inguinal ligament
� Inflow obstructions are located above inguinal ligament
� Involve distal end of aorta & common, internal, & external iliac arteries
� Gradual inflow occlusions may not cause tissue damage