Disorders of the Peripheral Vascular System

Arterial (Non-Cardiac) and Venous

Objectives

• Describe peripheral vascular disorders• Name 8 common peripheral vascular disorders• Explain the pathophysiology of peripheral

vascular disorders.• Describe nursing interventions in caring for

clients with peripheral vascular disorders.

Assessment of Arterial and Venous Circulation

• Pulse – may be decreased r/t poor blood flow• Appearance – may be discolored, shiny, scaly• Temperature – may be cool or abnormally warm• Capillary refill – poor blood flow = >3sec• Hardness – hard = chronic stasis, risk of ulceration• Edema – pitting may indicate acute edema• Sensation – pain or numbness and tingling

Arterial Diseases (Non-Cardiac)

Peripheral Arterial Disease

PAD Risk Factors• P.A.D. is caused by the build-up of fatty deposits (plaque) and cholesterol

in the arteries outside the heart.

The First Tool to Establish the PAD Diagnosis:A Standardized Physical Examination

Pulse intensity should be assessed and should be recorded numerically as follows:

– 0, absent– 1, diminished– 2, normal

– 3, bounding– 4, Cannot be

obliterated

Use of a standardexamination should

facilitate clinicalcommunication

Ankle Brachial Index

• A technique in which a hand held doppler is used to measure the ratio of ankle systolic BP to the highest brachial blood pressure

• Normal = 0.91-1.30• Mild PAD = 0.71-0.90• Moderate PAD = 0.41-0.70• Severe PAD = < 0.40

http://www.nhlbi.nih.gov/health/dci/Diseases/pad/pad_diagnosis.html

ABI Procedure

Using the ABI: An ExampleNormal = >0.90

ABI=ankle-brachial index; DP=dorsalis pedis; PT=posterior tibial; SBP=systolic blood pressure.

Right ABI80/160=0.50

Brachial SBP160 mm Hg

PT SBP 120 mm Hg

DP SBP 80 mm Hg

Brachial SBP150 mm Hg

PT SBP 40 mm HgDP SBP 80 mm Hg

Left ABI120/160=0.75

Highest brachial SBP

Highest of PT or DP SBP

aABA

Interpreting the Ankle-Brachial Index

Adapted from Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192. Figure 6.

Exercise ABI Testing: Treadmill

• Indicated when the ABI is normal or borderline but symptoms are consistent with claudication*.

• If the ABI results fall post-exercise - supports a PAD diagnosis;

• May “unmask” PAD, if resting ABI is normal.

*Claudication = tissue ischemia

.

Magnetic Resonance Angiography (MRA)

• MRA has virtually replaced contrast arteriography for PAD diagnosis

• Excellent arterial picture

Computed Tomographic Angiography (CTA)

• Requires iodinated contrast

• Requires ionizing radiation

• Produces an excellent arterial picture

Symptoms of Peripheral Artery Disease

• Terms: – Claudication: the process of activity ischemia LE

pain in affected extremity; usually subsides with rest

– Intermittent Claudication = a weakness of the legs accompanied by cramping pains in the calves caused by poor circulation of blood muscles.

Symptoms of Peripheral Artery Disease

Asymptomatic: Without obvious symptomatic complaint (but usually has an ABI of <.90)

Classic claudication: Lower extremity symptoms confined to the muscles with a consistent (reproducible) onset with exercise and relief with rest

“Atypical” leg pain: Lower extremity discomfort (foot, toe, or leg pain) that is exertional but that does not consistently resolve with rest

Signs and Symptoms of Peripheral Artery Disease

Critical limb lschemia: Pain at rest, non-healing wound (8-12 weeks), or gangrene

Acute limb ischemia (Arteriosclerosis Obliterans): The five “P”s, defined by the clinical symptoms and signs that suggest potential limb jeopardy:

- Pain- Pulselessness- Pallor- Paresthesias- Paralysis - (& polar sensation (coldness), as a sixth “P”).

http://images.google.com/imgres?imgurl=http://medicine.ucsd.edu/Clinicalimg/Skin-Gangrene-DIC.jpg&imgrefurl=http://medicine.ucsd.edu/Clinicalimg/Skin-Gangrene-DIC.html&h=709&w=1054&sz=801&hl=en&start=11&tbnid=zNwt7JAWDFZ-cM:&tbnh=101&tbnw=150&prev=/images?q=gangrene&svnum=10&hl=en&lr=

Options in Limb Revascularization

• Endovascular reconstruction options– Percutaneous transluminal angioplasty (PTA)– Stents

• Surgical reconstruction options– Endarterectomy– Embolectomy– Aortoiliac/aortofemoral reconstruction– Femoropopliteal bypass (above knee and

below knee)– Femorotibial bypass

Critical Limb Ischemia – Nursing Interventions

• Assessment: 5- P’s• Maximize tissue perfusion– Treat pain– Reduce risk factors– Positioning

• Reposition at least every 2 hours• Avoid crossing legs• Legs in dependent position if tolerated by patient• Keep linens off extremity by using foot cradle

– Avoidance of vasoconstrictors• ETOH, nicotine, stress, cold

Post-op Surgical Revascularization: Nurse Management

• Monitor VS• Assess 5 P’s• Check peripheral pulses (doppler) frequently• Check operative site for bleeding or infection• Measure abdomen for increasing size• If symptoms of bleeding or rupture occurs,

immediate intervention needed

Thromboangiitis Obliterans(Buerger’s Disease)

• Disorder of unknown cause where the small and medium-sized arteries become inflamed and thrombotic

• Affects primarily the feet and hands

Strong correlation with smoking: The classic Buerger’s Disease patient is a young male (e.g., 20–40 years old) who is a heavy cigarette smoker. • Confirmed by angiogram

Signs and Symptoms of Beurger’s Disease

• Extremely painful, especially in non-diabetics with normal sensation

• Claudication: Pain induced by insufficient blood flow during exercise

• Most common in the Orient, Southeast Asia, India and the Middle East

• Decreased perfusion– Cold, pale, skin– Ulcers, necrosis of skin

• Sensitivity to cold

Medical Management

• Focus is on preventing progression of the disease by modifying risk factors

• In many cases quitting smoking will cure the disease

• Surgical intervention may be necessary in cases of advanced necrosis

• Surgical interruption of nerve pathways may be performed (rarely) in cases involving extreme pain

Raynaud’s Disease

• Intermittent arterial spasms causing ischemia to the periphery

• Usually precipitated by cold or emotional stimuli

• Cause is unknown• May be associated with other autoimmune

conditions

Signs and Symptoms of Raynaud’s Disease

• Chronically cold hands and feet

• Pallor• Numbness• Cyanosis of nailbeds• Pain

Raynaud’s Disease

Medical Management

• Diagnosed by cold stimulation test– Skin temperature changes are recorded after

submersion in ice bath• Submerge patient’s hand in an ice water bath for 20

seconds and record ongoing temperatures• Skin temperature changes are recorded by a thermistor

attached to each finger

Medical Management

• Medications used to treat– Calcium channel blockers• Relax smooth muscles of the arterioles

– Relaxation and stress management– For extreme pain, surgical intervention may

interrupt nerve pathways

Raynaud’s Patient Teaching

• Avoid temperature extremes

• Avoid vasoconstricting agents

• Wear mittens/gloves and warm socks for any exposure to cold– Weather– Fridge/freezer or frozen foods

Arterial Aneurysm

• True Aneurysm– Focal dilation within an artery. – Differentiated from pseudoaneurysm because the

dilated area of the vessel contains all three layers. – Common Etiologies:• Atherosclerosis• Congenital or genetic predisposition (Marfan’s)• Trauma to vessel wall (usually causes pseudoaneurysm)

Arterial Aneurysm

• Marfan Syndrome– A connective tissue multisytemic disorder– Characterized by skeletal changes, long limbs, joint

laxity, cardiovascular defects (aortic aneurysm, mitral valve prolapse), mutation in the fibrin-1 gene.

Arterial Aneurysm– Risk (higher with smoking and hypertension)• Rupture• Dissection• Thromboembolism

– Common Locations• Abdominal Aorta• Ascending Aorta (Aortopathy, also associated with

bicuspid aortic valve)• Popliteal• Cerebral Aneurysms (increased risk of SAH)

Types of Arterial Aneurysms

• Fusiform

• Saccular

• Dissecting or Pseudo- aneurysm

Arterial Aneurysm

• Signs and Symptoms– Dependent on location of aneurysm– Pulsating mass may be felt in superficial arteries– Symptoms may be due to:• Local mass effect/compression of other structures• Hoarsness, low urine output, GERD

– Rupture• Low BP, Pain

– Thromboembolism

Aneurysm Rupture

• Aortic aneurysm ruptures present with severe chest, back, or abdominal pain (depending on location) and are often fatal

• Cerebral aneurysm ruptures present with “worst headache of life” and subarachnoid hemorrhage (SAH). Also may have stroke symptoms

Medical Management

• Control of HTN is essential to reduce the risk of rupture– Beta blockers are especially preferred due to

slowing of heart rate and the rate of rise of blood pressure

• Surgical intervention to repair aneurysm varies depending on type and location of aneurysm

Nursing Care

• Nursing management of pre-operative aneurysm pt. focuses on controlling HTN (with medication) and monitoring for s/s of rupture– Pallor, weakness, tachycardia, hypotension, sudden onset

abdominal, chest, back or groin pain; abd. pulsating mass

• Post-operative management focuses on maintaining effective tissue perfusion

• Teaching includes prevention and management of atherosclerosis and HTN– Risk Factor Reduction

Venous Disorders

Venous Insufficiency• Blood regurgitates through the valves in the veins

and then “leaks” into the tissue, causing edema• Chronic venous insufficiency can cause an area of the

skin to turn darker and become dry and scaly• Eventually chronic edema (stretching) can lead to

ulcerations of the skin

Normal Blood Flow

Venous Stasis

Venous Stasis Ulcer

Venous Stasis Ulcers

• Occur from chronic deep vein insufficiency and,

• Stasis of blood in the venous system of the legs

• A leg ulcer = an open, necrotic lesion – Results when an inadequate supply of oxygen-rich

blood and nutrients reaches the tissue cell death, tissue sloughing, and skin impairment

Venous Stasis Ulcers

• Signs and Symptoms:– Most significant sign is the ulceration– Skin will be darkened around ulcerated area– Varying degrees of pain– If diabetic, may not have any pain– Edema– Pedal pulses often present

Venous Stasis Ulcers

• Medical Management– Focus on wound healing• The wound will not heal if the skin continues to

be stretched• Use TED hose or ACE wrap and elevate the legs

whenever possible– Treatment of infection if needed– Nutrition with adequate protein

Venous Stasis Ulcers

• Medical Management cont.– Debridement of necrotic tissue if needed– Unna’s paste boot– Protective boot that can be left on for 1-2 weeks• (next slide)

Unna’s Boot is a medicated bandage that provides gradient compression therapy for controlling venous ulcers, venous insufficiencies, and other minor orthopedic problems. The bandage is permeated with zinc oxide and calamine to comfort the skin. Unna’s Boot is commonly used for active patients who are not confined to a wheelchair or bed. Unna’s Boot comes in the form of a non-raveling gauze that will mold evenly to the applied limb. Once applied, the bandage forms a semi-rigid cast that provides high working pressure and a lower resting pressure. This is ideal for patients who actively walk around and would like to preform normal daily activities. The 100% cotton base reduces wastage and the calamine prevents skin irritation. Depending on the amount of drainage from the ulcer, Unna’s Boot is usually kept in place for 3-7 days. A self-adherent wrap can also be wrapped around Unna’s Boot for extra support.

Varicose Veins

Varicose Veins

• Tortuous dilated vein with incompetent valves• Usually in lower extremities• Higher incidence in women aged 40-60• Risk: family tendency, congenital

abnormalities, pregnancy, obesity, constrictive clothing, and prolonged standing

Varicose Veins

• Pathophysiology– Incompetent valves Veins lose elasticity– Relatively weak vessel walls (compared to arteries)

Unable to support the increased pressure of the blood within the vessel Vein dilates as blood in it flows backward

Varicose Veins

• Signs and Symptoms:– Vary according to area of varicosity– May appear as darkened areas on the surface of

the skin– May experience dull aches, fatigue, cramping,

heaviness of legs– May shows sign of venous stasis

Varicose Veins

• Data Collection:– Subjective• Assessment of risk factors– Family hx, pregnancy

• Aches, cramping, fatigue, heaviness, pain

– Objective• Inspecting for varicosities• Inspecting for ulcerations

Data Collection

• Trendelenburg’s test: Evaluates the filling time of veins to assess for incompetent valves• Pt. lies down with the affected leg raised to allow for

venous emptying• A tourniquet is applied above the knee• Pt. stands• The direction and filling time of the veins are recorded

before and after the tourniquet is removedWhen the veins fill rapidly from a backward blood flow, the

veins are determined to be incompetent

Varicose Veins

• Medical Management:– TED hose– Rest and leg elevation– Sclerotherapy may be used for cosmetic purposes– Vein ligation and stripping may be used in severe

cases

Varicose Veins

• Nursing Interventions:– Analgesics for discomfort– Regular exercise– Leg elevate 6-10 inches on small stool if tendency

to get varicose veins– Frequent position changes not standing in one

spot for extended time

Varicose Veins

Nursing Interventions: cont.– Teach about applying support hose after legs have

been elevated for an extended time (10-15 minutes)

– Do not fold or roll hose down– Smooth hose and avoid wrinkles– Remove hose daily, wash, dry, elevate legs above

the heart when in bed or feet when sitting

Thrombophlebitis

Definitions

• Phlebitis: Inflammation in the wall of a vein without clot formation

• Thrombophlebitis: formation of a clot in a vessel, typically a superficial vein, with associated inflammation

• Thrombosis: formation of a clot in a vessel• Thrombus: a formed clot that remains at the site

where it formed • Embolus: the thrombus moves distally to another

anatomic location

Superficial Thrombophlebitis

• Inflammation of a vein and formation of a thrombus

• Women may be more susceptible• Risk factors include– Venous stasis– Hypercoagulability– Trauma to blood vessel wall

Thrombophlebitis (superficial)

• Signs and Symptoms:– Pain, edema in affected area– Red streak over a vein– Erythema, warmth, and tenderness along course

of the vein– Circumference of calf or thigh may increase

Thrombophlebitis (superficial)

• Subjective: – c/o pain in affected extremity– Note hx. of venous disorders

• Objective: inspect the extremity for:– Color– Temperature– Leg circumferences– Upper body venous congestion

Thrombophlebitis

• Medical Management:– Superficial thrombophlebitis• Moist heat to improve circulation• Elevation of legs to improve venous return• NSAIDs

Deep Vein Thrombosis

• Deep vein thrombosis (DVT) occurs in larger, deep veins and can be threatening to life and limb

• Mortality primarily due to risk of pulmonary embolism

DVT Signs and Symptoms

• Warm, tender, unilateral edema• May not have symptoms• Unilateral leg pain, tightness, discomfort• Positive Homan’s sign– Pain with dorsiflexion of the foot– Only appears in 10% of patients

Diagnostics for Deep Vein Thrombosis

• Ultrasound duplex scan is most widely used

• D-dimer blood test – normally undetectable; level is ↑ once a clot is in the process of being broken down

Prevention of DVT

• Early ambulation in the hospital• Low molecular weight heparin or

subcutaneous heparin– Lovenox 30 mg – 40 mg SubQ Daily– Heparin 5,000- 10000 units SubQ Q12 hr

• TED hose• Pneumatic compression stockings or boots

DVT Assessment• Subjective/Objective:– Ask client about recent injury– Is the affected area tender to touch– History of clots– Check for chest pain, dyspnea, tachycardia or

hemoptysis– Assess skin for redness, tenderness, hardness or

warmth, and Homan’s sign– Measure both legs at baseline

Treatment of DVT

• Anticoagulation with IV heparin or SubQ Lovenox (1 mg/Kg) until PT/INR is therapeutic on coumadin

• Long-term anticoagulation with coumadin (or other newer meds on the market)

• In patients who cannot be anticoagulated, consider Inferior Vena Cava (IVC) Filter to prevent Pulmonary Embolus (PE)

Complications of DVT

• Pulmonary embolus– Most likely cause of death in DVT– Sudden severe pleuritic chest pain, dyspnea,

tachypnea– Treatment• Anticoagulation• Fibrinolytic therapy for large, hemodynamically

significant PE• IVC Filter to prevent recurrent PE in patients who

cannot be anticoagulated• Surgical Thrombectomy

DVT Nursing Management

• Bed rest and elevation of the leg• Do not massage leg• Prevention is best way to treat• NURSE: Monitor vitals, IV sites, measure

circumference of affected leg, assess for s/s of embolization

• Assess for signs of bleeding if on anticoagulants• Remove elastic support or pneumatic compression

daily for hygiene.