Peripheral Vascular Disease

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Peripheral Vascular Disease. Arterial/Venous: Acute/Chronic. Peripheral Vascular Disease. A term used to describe a group of diseases that involve pathophysiological changes in the peripheral arteries (i.e., excluding the coronary arteries) or veins resulting in blood flow disturbances. - PowerPoint PPT Presentation

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  • Peripheral Vascular DiseaseArterial/Venous: Acute/Chronic

  • Peripheral Vascular DiseaseA term used to describe a group of diseases that involve pathophysiological changes in the peripheral arteries (i.e., excluding the coronary arteries) or veins resulting in blood flow disturbances.

  • Lymphatic disorders (also considered a form of PVD)Lymphatic system (ducts and nodes)

    plays a role in filtering foreign particlesprovides the only means by which interstitial proteins can return to the venous system (if blocked, obstructed [or *removed], edema may develop with risk of infection)

  • Raynauds Diseasecharacterized by bilateral intermittent arteriolar vasoconstriction/vasospasm in the hands and feet, often precipitated by emotional factors, cold, tobacco, causing color (white to blue to red) and temperature changes as well as burning pain in affected digits

    is usually associated with underlying systemic disease (e.g., autoimmune disorders)

    unlike other acute arterial disorders Raynauds is, with proper management (e.g., avoidance of triggers), essentially benign and self-limiting

  • ManagementThought to be vasospasm resulting from an exaggerated response to SNS stimulationcalcium channel blockers (i.e. nifedipine (Adalat), diltiazem *Cardizem) may be used)Preventionavoid/manage stressavoid exposure to cold/cold H20avoid nicotine, caffeine, drugs that elicit a vasoconstrictive effectsafety precautions

  • Acute Arterial Insufficiency(Acute Arterial Occlusion)usually involves complete blockage, is of sudden onset, and constitutes an emergency situation (muscle necrosis within 2-3 hours)

    etiologies include:arterial compressionthrombosis/embolismarterial injury/damage

    Risk factorsnonmodifiable; modifiable

    Risk factors:AgeGender (male)Family historyModifiable risk factors:HypertensionDiabetesHyperlipidemiaSmokingObesity

  • ThrombosisThe formation of a blood clot within a blood vesselCan occur in the arterial or venous systemsLeads to obstruction of a blood vessel in the circulatory systemCan lead to ischemia and infarction, and even deathCan also lead to embolismClot within a vessel breaks free and travels through body (embolizes)Thromboembolism is combination of a thrombosis and embolus

  • Why does this happen?Hemostasis

    Formation of blood clot formation at the site of vessel injury

    Carefully regulated systemInvolves platelets and coagulation factors

    Lack of coagulation factors bleeding

    Overactive coagulation cascade thrombosis

  • Arterial thrombosis (ie. ischemic limb)

  • What are the features of an acute ischemic limb?REMEMBER THE 6 PS:

    PAIN

    PALLOR

    PULSELESNESS

    PERISHING COLD (POIKILOTHERMIA)

    PARASTHESIAS

    PARALYSIS

    excruciating paincolor pale or cyanoticmay be pulseless skin cool to touch loss of sensation/ position senseloss of movement

  • Chronic Arterial Insufficiency(Peripheral Arterial Disease)primarily caused by atherosclerosis, disrupting the balance between arterial oxygen supply and demand

    risk factors same as for CAD, with diabetes, HTN, and smoking as particularly high risk factors (see Table 40-3 Collaborative Care: Peripheral Arterial Disease

  • Peripheral Arterial DiseaseThickening of artery wallsProgressive narrowing of the arteries of the upper and lower extremitiesresulting in tissue perfusion and ischemia in the area distal to the obstructionmay be acute or chronic

  • Risk FactorsTypical Patient:Smoker (2.5-3x)Diabetic (3-4x)HypertensionHx of Hypercholesterolemia/AF/IHD/CVA

  • Patients at riskBased in part upon the above observations, the 2005 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on PAD, which were produced in collaboration with major vascular medicine, vascular surgery, and interventional radiology societies, identified the following groups at risk for lower extremity PAD

    Risk Factors:Atherosclerosis (same as RFs for CAD and CVD)Smoking (2.5-3x)Diabetes 3-4xHypertension, increased age >50, male and family historyRARE: homocysteinuria

  • Peripheral Arterial Diseaseone limb is usually affected more than the other, therefore always compare bilaterallylower limbs more susceptible than the upper limbsmost common locations for stenosis are the aortoiliac bifurcation and the femoral bifurcationnearly half of the clients with arterial PVD have associated CAD

  • Clinical Manifestationsintermittent claudication (pain in calf, thigh, or buttock depending on the location of the blockage)rest pain in forefoot especially at night (advanced disease) capillary refillelevational pallordependent ruborpins & needles sensation (paresthesia, due to ischemia)affected limb cool to touch

  • Peripheral Arterial Diseaseweakened or diminished pulseschronic trophic changes thin, shiny, dry or scaling skin with hair loss thick, yellow, & brittle toenailsmuscle atrophyulceration (*arterial), gangrene possiblebruitErectile dysfunction (e.g., aortoiliac disease)*please note the differing characteristics of arterial and venous ulceration in course text (Table 40-2)

  • Pictures

  • ULCERassociated with claudication + signs of ischaemiaoccur on dorsum of foot + anterior skin pulses, cold to touch, hairless skinPainful, punched out edge

  • Diagnosishistory (symptoms & presence of risk factors)physical exam (signs)doppler assessment of peripheral pulses ankle/brachial index [ABI] (normal is ~1)see p. 1015 treadmill (exercise testing)angiography (necessary before any surgery)

  • ABI Clinical Correlation >0.9 Normal Limb0.5-0.9Intermittent Claudication
  • What does the ABI mean?

  • Take the highest measurement in both limbs low ABI is also predictive of an increased risk of all-cause and cardiovascular mortality and of the development of coronary artery calcification

    95% sensitive in detecting angiogram positive disease and around 99% specific in identifying supposedly healthy subjects

  • Goals of managementreduce progression of the diseasepromote arterial blood flowpromote vasodilationprevent vascular compressionpain reliefattain/maintain tissue integritypromote adherence

  • Managementrisk reduction/reduce disease progressionsmoking cessationweight reductionexercise (e.g., walking), unless contraindicatedreduction of blood lipid levelsdiet (e.g., cholesterol, saturated fats and TFAs, fiber) and, in some cases, pharmacologic intervention (e.g., antilipidemeic drugs) blood glucose and blood pressure controlantiplatelet meds

  • promote arterial blood flowkeep lower extremities below the level of the heart (e.g., reverse trendelenburg position)encourage, or assist with, walking or graded isometric exercise to increase collateral circulation (*if not contraindicated)avoid prolonged standing or sitting in one positionpharmacologic therapyInhibit platelet aggregation

  • promote vasodilation and prevent vascular compressionapply external warmth (e.g., socks, warm bath, or warm drink), promoting tissue perfusionNEVER APPLY DIRECT HEAT AS IT MAY CAUSE A BURNprevent exposure to cold and chillingavoid crossing legs/constrictive clothing and accessoriessmoking cessationminimize stressful situations

  • pain reliefanalgesics (opioids)maintain tissue integrityprevent infection/injury/traumameticulous foot care well-balanced diet that includes adequate protein attain and maintain ideal weight Promote self carepatient/client education

  • Surgical/Radiological ManagementManagement depends on the etiology and may include:embolectomyrevascularizationanticoagulationfibrinolytic agentsamputation Prevention bestknow those at risk and monitor them closely

  • percutaneous transluminal angioplasty (PTA) with stent insertion (e.g., isolated lesion)endarterectomy (e.g., carotid artery)thrombolytic therapy (acute emboli/arterial graft occlusion)arterial bypass (vascular) grafting (e.g., femoral-popliteal graft using saphenous vein)followed by anticoagulation/antiplateletsamputation (in presence of gangrene)

  • Femoropopliteal Bypass (Fem-Pop Bypass) for Peripheral Arterial Disease

  • Venous DisordersAcute Venous Disorderssuperficial thrombophlebitisthrombophlebitis/deep vein thrombosis (DVT)/PE

    Chronic Venous Disordersvaricose veinschronic venous insufficiency

  • Venous thromboembolismDeep vein thrombosisPulmonary embolism

  • Venous thromboembolismDeep venous thrombosisBlood clot in the proximal veins of the legLess commonly in the armsSymptoms include:Pain (never massage)Swelling (calf circumference)RednessWarmthPE could be first manifestation!Above affecting one limb (unilateral)! Most common in lower extremities

  • most common in the lower extremities50% may be asymptomaticunilateral swelling distal to the site (elevated venous pressure from venous pooling pushes fluid into interstitial spaces creating edema) *[may need to measure circumference]*pain on dorsiflexion (Homans sign) is present in less than 1/3 and is no longer considered a valid sign for DVTtenderness to palpation of calf (never massage!)redness or warmth of the legdilated (prominent) veinslow-grade feverunfortunately, pulmonary embolism may be the first clinical manifestation for some

  • Venous thromboembolismPulmonary embolismBlood clot (from DVT) breaks offTravels to lungCan lead to infarctSymptoms:Chest painShortness of breathLightheadedness (low BP)SyncopeHemoptysisCan be life threatening!

  • Pulmonary embolismUntreated PEMortality rate of ~30%1Most die within hours of diagnosisTreated PEProspective NEJM study looked at 399 patients with newly diagnosed PE94% received conv