Peripheral Vascular

Disease
Alternative Names:

 Peripheral vascular disease; PVD; Peripheral

arterial disease; PAD; Arteriosclerosis
obliterans
Definition:

 Arteriosclerosisof the extremities is a

disease of the blood vessels characterized by
narrowing and hardening of the arteries that
supply the legs and feet. This causes a
decrease in blood flow that can injure nerves
and other tissues.
Causes, incidence, and risk factors:

 Arteriosclerosis , or "hardening of the arteries,"

commonly shows its effects first in the legs and feet.
The narrowing of the arteries may progress to total
closure (occlusion) of the vessel. The vessel walls
become less elastic and cannot dilate to allow
greater blood flow when needed (such as during
exercise). Calcium deposits in the walls of the
arteries contribute to the narrowing and stiffness.
The effects of these deposits may be seen on
ordinary X-rays.
 This is a common disorder, usually affecting
men over 50 years old. People are at higher
risk if they have a personal or family history
of coronary artery disease (heart disease) or
cerebrovascular disease (stroke), diabetes ,
smoking, hypertension (high blood pressure),
or kidney disease involving hemodialysis .
Pathophysiology:
Lab Findings:
 Routine blood tests generally are indicated in the
evaluation of patients with suspected serious
compromise of vascular flow to an extremity. CBC,
BUN, creatinine, and electrolytes studies help
evaluate factors that might lead to worsening of
peripheral perfusion. Risk factors for the
development of vascular disease (lipid profile,
coagulation tests) also can be evaluated, although
not necessarily in the ED setting.
 An ECG may be obtained to look for evidence of
dysrhythmia, chamber enlargement, or MI.
Imaging studies:
 Doppler ultrasound studies are
useful as primary noninvasive
studies to determine flow
status.
 Magnetic resonance imaging
(MRI) Plaques are imaged
easily, as is the difference
between vessel wall and
flowing blood.
Other Tests:
 The ankle-brachial index (ABI) is a
useful test to compare pressures in
the lower extremity to the upper
extremity. Blood pressure normally
is slightly higher in the lower
extremities than in the upper
extremities. Comparison to the
contralateral side may suggest the
degree of ischemia.
 Transcutaneous oximetry affords
assessment of impaired flow
secondary to both microvascular
and macrovascular disruption. Its
use is increasing, especially in the
realm of wound care and patients
with diabetes.
Medical Surgical Management

 Vascular Surgical Procedure

 a. Inflow procedure- Provide blood supply from the
Aorta.
 b. Outflow procedure- Provide blood supply to vessels
below the femoral artery.
Surgical Treatment
 arterial bypass
 Peripheral arterial bypass
surgery is required for
atherosclerotic lesions in
the arteries of the leg. This
surgery involves using a
vein graft (saphenous vein),
taken from the same leg,
and suturing the vein into
the artery to bypass the
blockage. While the patient
is anesthetized using
general or spinal
anesthesia, an incision is
made in the inside of the
leg from the groin to below
the knee.
  endarterectomy

Endarterectomy is a
surgical procedure
removing plaque material
from the lining of an
artery.
  patch graft angioplasty
 Patch angioplasty is
used to repair a partial
disruption of a vessel
wall or longitudinal
incision, where simple
suture would result in
narrowing of the vessel.
 amputation
Nursing Interventions

 1. Lower the extremity below the level of the heart.

 2. Encourage moderate amount of walking or
graded extremity exercise.
 3. Encourage active postural exercise (Buerger
Allen Exercise).
 4. Discourage standing still or sitting for a long
period of time.
 5. Maintain warm temperature and avoid chilling.
 6. Discourage nicotine use.
 7. Counsel patient about stress management.
 8. Encourage the avoidance of constrictive clothing
and accessory.
 9. Encourage avoidance of leg crossing.
 10. Administer vasodilator medication and
adrenergic blocking agents as prescribed.
 11. Instruct patient ways to avoid trauma.
 12. Encourage patient to wear protective shoes and
padding for pressure area.
 13. Encourage meticulous hygiene.
 14. Caution patient to avoid scratching or vigorous
rubbing.
 15. Promote good nutrition.
Management: Exercise

 Efficacy
 Walking improves claudication distance
 Exercise types
 Walking (standard walking or on a treadmill)
 Stair stepping
 Time for Exercise
 Start: 3-5 times per week for 30 minutes per time
 Increase by 5 minutes until 50 minutes/session
 Continue program for at least 6 months
 Speed and grade selection
 Intensity that provokes claudication at 3-5 minutes
 Continue to increase intensity as ability improves
 claudication should occur at every session
 Intermittent walking technique
 Walk until moderate to near maximal claudication pain
 Rest briefly at severe claudication symptoms
 Rest in sitting or standing position
 Restart walking when claudication symptoms tolerable
Management: Medications
 Antiplatelet Medications
 First-Line agents
 Aspirin
 Second-Line (alternatives if Aspirin intollerant)
 Ticlopidine (Ticlid)
 Clopidogrel (Plavix)
 Phosphodiesterase inhibitor medications
 Cilostazol (Pletal)
 Significant benefits in claudication distance
 Preferred agent over Pentoxifylline
 Higher frequency of adverse effects
 Contraindicated in Congestive Heart Failure
 Pentoxifylline (Trental)
 Only small benefits in claudication distance
 Consider 3 month trial before assessing benefits