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Peripheral Vascular

DiseaseGUNAWAN TOHIR

FK UMP PALEMBANG

2012

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Peripheral Vascular Disorders Ischemia-lack of blood

supply to meet the

needs of the tissue.

Causes of Ischemia

vasoconstriction

occlusion of lumen of

the artery due to:

Atherosclerosis (fatty

deposits)

Thrombosis/bloodclot/embolism

s/s = coldness, pallor,

or rubor (redness),

cyanosis (blueness) pain, changes in skin or

nails

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PRIMARY SITESOF

INVOLVEMENT

Femoral & Popliteal

arteries: 80-90%

Tibial & Peroneal

arteries: 40-50%

Aorta & Iliac arteries:

30%

Harrisons Principles of

Int Med

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PVD

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DOPPLER

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Peripheral Arterial Occlusive

Disease (830) Pathophysiology: Narrowing and sclerosis of large

arteries (femoral, iliac, popliteal) especially atbifurcations due to plaque formation

Risk factors: smoking, obesity, sedentary lifestyle,HTN, DM, hyperlipidemia, Fa hx

S/S: see previous slide. May also have bruit overfemoral or popliteal : doppler area

Dx Tests: US, exercise testing (822), pulsevolumes, angiography (823), Trendelenberg test (seeAssessment text)

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Peripheral Vascular Diseases Arterial Manifestations:

Diminished or absent pulses

Smooth, shiny, dry skin, nohair

No edema

Round, regularly shapedpainful ulcers on distal foot,toes or webs of toes

Dependent rubor

Pallor and pain when legselevated

Intermittent claudication

Brittle, thick nails

Venous Manifestations:

Normal pulses

Brown patches ofdiscoloration on lower legs

Dependent edema

Irregularly shaped, usuallypainless ulcers on lower legsand ankles

Dependent cyanosis and

pain Pain relief when legs

elevated

No intermittent claudication

Normal nails

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Physical Assessment of PVD Arterial disease:

acutepain,intermittent

claudication (pain

increases with exercise,relieved with rest), hair

loss distant with

occulusion, thick brittle

nails

Parasthesia, pallor

when limb elevated,

rubor when limb

dependent(down), skintemp cold,

dimished/weak/or

absent pulses, no

edema, but ulcers in

distal areas, foot, toes,

ankles, calves

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Physical Assessment of PVD

Venous disease

little or no pain, some

tenderness along

inflamed vein,

no hair loss, skin color

brawny(reddish-

brown),cyanotic if

dependent position

Veins may be visible,

warm skin temperature,

edema typically

present, pulses normaland present/palpable,

no changes in hair or

nails, little skin

breakdown (ulcers)

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Risk Factors-PVD

Being a man over age

50 yr. of age

cigarette smoking hypertension, high

cholesterol

heart disease and

diabetes

inability of the kidneys

to filter out waste

products

And maintain fluid

balance

no/little exercise obesity

wearing tight

obstructive

garments/girdles,elastic top

socks/garters

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HOW DOES AN INTERMITTENT

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HOW DOES AN INTERMITTENT

CLAUDICATION PATIENT PRESENT

CLINICALLY?

Leg pain caused and reproduced by a certain degree

of exertion

Relieved by rest

Not affected by body position Atherosclerotic lesions usually found in arterial

segment one level above affected muscle group

Calf claudication more commonly due to disease in

femoral arteries and less commonly due to diseasein popliteal or proximal tibial or peroneal arteries;

Hip/Thigh/Buttock claudication due to aortoiliac

disease

Am J Cardiol 2001; 87 (suppl): 3D-13D

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DIFFERENTIAL DIAGNOSISCALF

Venous occlusion

Tight bursting pain /

dull ache that worsens

on standing and resolveswith leg elevation

Positional pain relief

Chronic compartment

syndromeTight bursting pain


Nerve root compression


HIP/THIGH/BUTTOCK Arthritis

Persistent pain, brought

on by variable amounts

of exercise

Associated symptoms inother joints

Spinal cord compression

History of back pain

Symptoms while

standing

Positional pain reliefFOOT

Arthritis

Buerger disease

(thromboangitis obliterans)


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DIAGNOSIS History taking

Careful examination of leg

Pulse evaluation

Ankle-brachial index (ABI):

SBP in ankle (dorsalis pedis and posterior tibial

arteries)

___________________________________

SBP in upper arm (brachial artery)


NEJM 2001; 344: 1608-1621

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Ankle-Brachial Index Values and

Clinical Classification

Clinical Presentation Ankle-Brachial Index

Normal > 0.90

Claudication 0.50-0.90

Rest pain 0.21-0.49

Tissue loss < 0.20


NEJM 2001; 344: 1608-1621

Values >1.25 falsely elevated; commonly seen in diabetics

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The history and physical examination

(pulse evaluation and careful

examination of the leg) are usually

sufficient to establish the diagnosis

P i itif

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Diagnostik Buerger nilai positif

Kriteria +1 +2

Usia onset 30-40 tahun

Klaudikasio intermiten kaki Ada riwayat Ada saat pemeriksaan

Ekstremitas atas asimptomatik Simptomatik

Tromboflebitis superficial migrans Ada riwayat Ada saat pemeriksaan

Fenomena Raynaud Ada riwayat Ada saat pemeriksaan

Angiografi, biopsi Khas untuk salah satu Khas untuk keduanya

Poin positif

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Nilai negatif

Kriteria -1 -2

Usia onset 45-50 tahun >50 tahun

Jenis kelamin, kebiasaan merokok wanita Tidak merokok

lokasi 1 ekstremitas Tidak ada ekstremitas yang terlibat

Hilangnya pulsasi brakial Femoral

Artiosklerosis, DM, hipertensi,

hiperlipidemi

Terdiagnosis dalam 5-10 tahun kemudian Terdiagnosis dalam 2-5 tahun kemudian

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Interpretasi

Interpretasi dari total poin-poin tersebut antara

lain

0-1 diagnosisBuergers disease tersingkirkan 2-3 tersangka, probabilitas rendah

4-5 probabilitas sedang

6 probabilitas tinggi, diagnosis dapatdipastikan

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Raynauds & Buergers DZ

Raynauds-periodic

constriction ofarteries

that supply extremities,

mostly hands and feet

arteriospastic (pulses

never absent) spaz-out!

Freq. Young women s/s usually precipitated

by

Exposure to cold,

emotional upset,

tobacco usage.

3-color changes,

vasoconstrictive pallor-

cyanosis-ruboror

hyperemia cold, numbness,

pain,tingling,swelling

lasts minutes-hrs.

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Continued: Raynauds disease

Pallor-cyanosis

(especially fingers)-

painful-aching pain-

client learns warmth

relieves pain-go inside

warm, or placed in

warm water-which

relieves vasopsasms-

blood rushes to the

extremity

Ulcers/gangrene &

pain may appear at

fingertips with

chronicity

TX-prevent chilling,

avoid risk factors, no

ETOH,tobacco, weargloves, heat,

vasodilators, avoid

stress

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Buergers dz (arterial/venous)

thromboangitis obliterans

Inflamm. Of bld

vessels (arteries/veins)

and formations of clots

(thrombus)

usually lower

extremities

association: tobaccousage,men 25-40yrs

S/S- my foot fell

asleep,foot always

cold,

cyanosis,redness/

mottled-purplish-red of

the foot/leg, pain,

phlebitis may occur,

ulcers,gangrene,

changes skin/nails if

circl. is impaired

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Acute Arterial Occlusive Disease

(arterial embolism-840)

Pathophysiology: blood clots from arteries, left

ventricle, or trauma suddenly break loose and

become free flowing, lodge in bifurcations, causing

obstruction distally with acute and sudden symptoms

Assessment: +6 Ps (pain, pallor, pulselessness,

paresthesia, paralysis, poikilothermia), ABI

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Management of Arterial

Embolism

Medical:

Anticoagulants-heparin bolus then 1000U/hr

Thrombolytics

Surgical (depends on occlusion time): Embolectomy (840)

Bypass

Angioplasty with stent placement

Nursing:

Administer and monitor anticoag or thrombolytic tx

If surgery, then monitor for postop angioplasty and stentplacement, bypass, or embolectomy (similar to bypass

except no ICU and hospital time is less).

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Buergers Disease

(thromboangiitis obliterans-834)

Pathophysiology: obstructive and inflammatory

disease of small and medium sized arteries and

veins. Believed to be autoimmune. Has

exacerbations and remissions. Smoking is very high

risk factor.

Assessment: pain and instep claudication, intense

rubor, absence of distal pulses (pedal, radial, ulnar),paresthesias; segmental limb blood pressures, US,

angiography

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Management of Buergers

Disease

Medical/Surgical:

Pain meds

Stop smoking

Treatment of infection and gangrene Sympathectomy (removal of sympathetic ganglia or

branches-causes permanent vasodilation

Amputation

Nursing: Support stopping smoking

Administer pain meds

Education regarding protection extremities from cold and

trauma.

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Raynauds Disease (841)

Pathophysiology: arterial spasms of small

cutaneous vessels of fingers and toes. May

have too many alpha 2 receptors leading tovasoconstriction and not enough beta

receptors. Aggravated by cold and stress.

Assessment: classic tri-color symptoms-pallor, cyanosis, rubor, pain, and paresthesia.

Bilateral and symmetric.

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Management of Raynauds

Disease

Medical/Surgical:

Avoiding cold, stress, nicotine

Ca++ channel blockers (particularly nifedipine) especially

for acute vasospasm sympathectomy

Nursing:

Avoid stress, take stress mgmt classes

Avoid cold and trauma Teach about nifedipine (can cause orthostatic

hypotension)

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Hypertension (855)

Definitions and Etiology:

SBP > 140 and DBP > 90 at least 3 times.

Affects 20-25% of population. 90-95% have primary or

essential HTN (unknown etiology). Other 5-10% havesecondary, meaning there is a disease process causing it(i.e., thyrotoxicosis, renal artery stenosis,

pheochromocytoma). Hypertensive crisis-DBP > 120.Malignant HTN-rises rapidly. White coat HTN-

increased BP when patient goes to MD. Risk factors are similar to CAD

Classifications p. 855, Table 32-1

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Assessment of HTN

S/S:

Usually absent unless

severe or advanced

If symptoms theyinclude HA, blurred

vision, dizziness,

nosebleeds

BP > 140/90

S4 gallop rhythm

Dx Tests:

BP readings

CBC, UA, lytes, lipids,

glucose, renal and liverfunctions

ECG

CXR

Echo

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TX-management of Buergers Disease

No tobacco , avoid

factors cause

vasoconstriction

Avoid becoming chilled,wear warm socks, boots,

gloves, warm water

baths

Avoid prolongedstanding- job changes?

Nursing?

Avoid injury/infection

exercising to stimulatecirculation, however, aslong as it doesnt cause

pain

Buerger-Allen exercises-

Do not keep legselevated-ischemia

vasodilators/anti-

coagulants may help

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Buerger-Allen exercises Elevate feet/legs till feet

blanch(whitish), thenlowering them till turnred, then resting legs/feet

in a horizontal position.

Client performs exerciseslying in bed or on sofa.

Dr. tells client how often

to perform them

The client is instructed to

watch the changes in

color blanching indicates

inadequate blood.Supply-maintaining this

position could harm

tissues (death)

May instead walk, foot

exercises help too

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Varicose Veins-dilated tortuous

veins, with incompetent valves

Competent Valves

allow bld. To return to

the heart and prevent

back-flow

Risk factors: obesity,

standing in 1 place too

long, pregnancy constriction and or

pressure on the legs

Generally, bld collects

Saphenous Vein,

Superficial Veins

dilated and distended,dark blue

purplish swellings

c/o legs tired/heavyfeeling, cramping pain

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TX & Management of Varicosities

TX: ligation/stripping-

may use surgical or

more likely lasar tx.

Zap- them

DX- Doppler studies

Injection

sclerotherapy- old tx Prevention-Best Tx

Avoid sitting/standing

for long periods of time

maintain ideal body

weight

avoid injury to legs

no crossing legs

no constrictiveclothing/hosiery

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Continued Tx: Varicosities

Elastic stockings long-

(TED) hose- removed

once q 8hr. X 30min.

Check skin

Promote circulation

Taught to apply hose

while lying in bed w/legs elevated

Change position

frequently

Keep legs elevated at

rest, to promote venous

return back to the heart

Avoid infections, wear

comfortable but

supportive shoes

Maintain weight

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Disorders of veins-most common is thrombophlebitis-

formation of a thrombus (clot)in association with

inflammation of vein

Classified as either

superficial or deep

65% IV therapy-

superficial; 5% of

surgical patients-deep,

especially bedrest, long

abdominal surgery, hip,

anything causes venousstasis

Worry clot-travels or

emboli to lung, heart,

brain

Etiology- 3 things

In 1846, VirchowsTriad: formation of clot

1.venous stasis/pooling2.damage of endothelium

or inner lining of vein 3. hypercoagulabilty of

blood-

are your clients high risk

to any of these? Prolonged bedrest,

obesity,varicose veins,hip/knee replacements,Oral contraceptives.

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Thrombophlebitis- superficial or

deep (DVT)?

Superficial

palpable, firm, cordlike

vein, surrounding vein,

warm, reddened,

tender, edema maybe

IV therapy-arms

varicose veins-legs

Deep- DVT

no s/s in 50% of casesor unilateral leg

edema/swelling, pain,warm skin, mildtemp, cyanosis

possibly, Positive

Homans sign: painupon dorsiflexion offoot - but not always

present in all cases

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Dx- thrombophlebitis-Various ( venogram, non-invasive doppler

studies, coagulation studies PT,PTT,platelet ct., bleeding time,

INR, arteriogram, Lung scan if emboli?

Conservative tx:

bedrest with leg

elevated until

tenderness is reduced

about 5-7 days. Warm

moist heat (K-pad)

may be used to relievepain and inflammation

Dont massage legs

Pain control/anti-

inflammatory drugs

If edema- TED hose or

ace (elastic) wraps

Anti-coagulants like

Heparin Drip- IV-

(DVTs only) bleedingand safety precautions

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Cont. TX/Management

thrombophlebitis

Pharmacological Tx-

aimed to prevent clots,

dont dissolve them

(Heparin/Lovenox-SQ/Coumadin-po.)

Heparin/Lovenox-SQ-

lw. Abdomen 2 inchesaway umbilicus

Dont rub with alcohol

pad after shot, use 5/8

inch needle

SQ- no more than 1cc

ever injected into tissue

or one site, if more

needed use divideddoses.

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Cont. general guidelines

thrombophlebitis/DVTs

Measurement- of bothlegs/calves

Heparin/Coumadin

Coumadin is startedwhile on Heparin-IV;Monitor PT, (A)PTT,INR-

antidote coumadin is

Vit.K Heparin-Protamine

sulfate antidote

Avoid aspirin while on

anti-coagulants like

Heparin/Coumadin

Nurse recognize high riskpatients for

thrombophlebitis,

bedrest, age, dehydration,

oral contraceptives,steroids, IV drug use

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Continued:

thrombophlebitis/DVTs

If on

Heparin/Coumadin- s/s

bleeding gums, urine,

stool, any orifice,bruising, epistaxsis,

petehiae, no foley, no

rectal temp, no IM

injections

Always check lab

values PT- & INR for

Coumadin

(A)PTT & INR-

Heparin (IV)

5000 u Heparin SQ

considered low doseprophylaxsis/mainten

ance dosage

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Cont. DVT-thrombophlebitis

Elastic stocking (TED)

hose-properly

measured, fitted, and

evenly applied -stockings compress

superficial veins &

prevent venous stasis-

or pnuematic

alternating

compression boots

Prevent pressure under

the knee avoid

pillows/knee gatches

on bed)

No pressure on

popliteal space

Avoid OC withrecurrent

thrombophlebitis

rest/exercise/fluids

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More general guidelines

Avoid prolongsitting-pressure underknee

Elderly, heart dz,infection, dehydrationmost proned tothrombophlebitis

Avoid prolong sittingcar/airplane/bus ride

Or sitting in front of TV

long period of time

(Sedentary lifestyle)

Change positionsfrequently and exercise

legs at intervals is

necessary

Avoid standing longperiod of time too!

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Lab values for Coumadin/Heparin Coumadin/warfarin :

Check the PT (pro-thrombin time)

Want the PT about 1.5-

2.0 times control value(normal for adults=10-13sec)

INR you want a targetlevel for coumadin or

warfarin therapy between(2.0-3.0) for mostconditions like DVT, hipsurgery etc.

INR is more reliable test

PTT or APTT (partialthromboplastin time oractivated partialthromboplastin time)

Used in Heparin therapy& also INR too!

PTT control=60-70 sec;and APTT=20-35 sec.

Want 1.5-2.5 times

control value in secondsfor optimal anticoagulanttherapy

Most cases: INR level tobe within (2-3)

PVD K2

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