PERIPHERAL

VASCULAR DISEASES

PRESENTED BY,
A.SURUTHI,
MPT-1st YEAR,
MTPG&RIHS.
 PERIPHERAL VASCULAR DISEASES
Peripheral vascular diseases can affect the arterial, venous, or
lymphatic circulatory systems.
Characterized by reduction in blood flow and hence oxygen through the
peripheral vessels.
When the need of the tissues for oxygen exceeds the supply, areas of
ischemia and necrosis will develop.
FACTORS CONTRIBUTE TO DEVELOPMENT OF PERIPHERAL
VASCULAR DISORDERS:
• Atherosclerotic changes
• Thrombus formation
• Embolization
• Increased coagulability of blood
• Hypertension
• Inflammatory process/ infection
ARTERIAL INSUFFICIENCY:
 Decreased blood flow towards the tissues producing ischemia
 Interference with nutrients and oxygen arriving to the tissues, leading to
ischemic ulcers and changes in that skin.
 RISK FACTORS:
a) Cigarette Smoking
b) Diabetes
c) High-fat Diet
d) Hypertension
Treatment Modality -Vasotrain 447
Artassist

VENOUS INSUFFICIENCY:
 Decreased return of blood from the tissues to the heart.
 Leads to venous congestion and stasis of blood.
 Family history is the major risk factor.
 TYPES OF ARTERIAL DISORDERS
ACUTE ARTERIAL OCCLUSIVE DISEASE
a. Arterial Thrombosis And Embolism
 A sudden cessation of blood flow ta an extremity is the most common
presentation of acute arterial occlusive disease.
Acute loss of blood flow to peripheral arteries may be caused by thrombus,
embolism, or trauma to an artery.
Most common location of arterial embolus: femoral-popliteal bifurcation
Symptoms include abrupt onset of pain, pallor, diminished or absent pulses,
paresthesias.
THROMBUS EMBOLUS
CHRONIC ARTERIAL INSUFFICIENCY
a. Atherosclerosis:
* Characterized by nodular deposits of fatty material that can line the wall
of artery.
* Ischemia tissue necrosis gangrene
* Arteriosclerotic obliterans-hardening of arteries. Inability to expand
and constrict with changing pressures, the vessels may rupture.
* Intermittent claudication-most common
* Rest pain
* Diminished or absent pulses, pallor of the skin, trophic changes.
B. Thromboangitis Obliterans:
* Also known as Buerger’s disease. Characterized by recurring
inflammation of the intermediate and small arteries and veins of the
lower and upper extremities.men[20-35years]
* Chronic disease, occurs predominantly in individuals who smoke
heavily.Affects small vessels of the extremities beginning distally and
moving proximally.
* Vasoconstriction ischemia necrosis ulceration
CLINICAL FEATURES
 Intermittent claudication(arches of foot)
 Digital rest pain
 Diminished or absent pulses
 extremities are red and cyanotic
 Paresthesia of hand and feet
 Swelling in feet and hand
 Open sores on fingers and toes
DIAGNOSIS
* Ankle-brachial index
* Photoplethesymography
* Rubor dependancy test
* Modified Allen’s test
MEDICAL MANAGEMENT
* Anti-nicotine replacement drug
* Anti-platelet drug
* Vasodilator[cilastozal]
* Anti-histamine
* Patient education
SURGICAL MANAGEMENT
* Sympathectomy
PHYSIOTHERAPY MANAGEMENT
a. Buerger’s exercise
b. Aerobic exercise-walking
c. Skin ulcer- laser, ultraviolet radiation, infrared radiation, proper skin care
d. Increase circulation- iontophoresis
RAYNAUD’S DISEASE:
* Caused by vasospasm, most often affecting the arterioles and small arteries
of the fingers or toes.
* Usually bilateral( affecting both arms and feet) and symmetric
* During arterial spasm- sluggish blood flow causes pallor, coldness,
numbness, cutaneous cyanosis and pain.
* Following the spasm- the involved areas becomes intensely reddened with
tingling and throbbing sensations
* With longstanding or prolonged cases-ulceration can develop on the
fingertips and toes
CLASSIFICATION
a. PRIMARY RAYNAUD’S MEDICAL MANAGEMENT
* Family history * Vasodilator
* Living area climate * Calcium channel blockers
b. SECONDARY RAYNAUD’S * Alpha blockers
* Working with vibratory machinery
* Emotional distress
* Exposure to chemicals such as
PVC, silica
* Smoking
* autoimmune disease
DIAGNOSIS
* Cold stimulation test
* Nailfold capillaroscopy
SURGICAL MANAGEMENT
* Sympathectomy
* Ray amputation
PHYSIOTHERAPY MANAGEMENT
Patient education
Stress management-relaxation exercises, environmental
modification, music therapy
Regular graded aerobic conditioning program
Prevent skin ulceration-proper nail care, proper shoe selection
and fit, avoid restrictive clothing, avoid exposure to extremes of
temperature
Prevent or minimize joint contracture-repetitive, active ROM
and gentle stretching exercises
Wound management-electrical stimulation, UVR, IRR, ultrasound
therapy
EVALUATION OF ARTERIAL DISORDERS:
Rubor of dependancy test
Treadmill test for claudication
Air plethysmography
Arteriography
Doppler ultrasonography
GENERAL TREATMENT GOALS PLAN OF CARE
ACUTE Decrease ischemia by restoration Medical: bed rest; complete systemic
ARTERIAL or improvement of blood flow anticoagulant therapy
DISEASE Physical: postioning of the patient in
bed with head end slightly raised
Surgery: Thrombo-embolectomy and
Reconstructive arterial or bypass
graft, endarterectomy.

Protect the limb Protect from trauma. pressure on

skin must be reduced by special
mattress.
CHRONIC Improve exercise tolerance Regular graded aerobic exercise
ARTERIAL program of walking or bicycling
DISEASE
Improve vasodilation Iontophoresis

Relieve pain at rest Sleep with leg in dependant position

over the edge of bed or with head end
of bed slightly elevated.

Prevent joint contractures and Active or mild resistance ROM

muscle atrophy, if patient exercises to extremities.
confined to bed

Prevent skin ulceration Proper education on care and

protection of skin
Proper shoe selection and fit
Avoid use of support hose

Promote healing of skin ulcer Electrical stimulation

Oxygen therapy
WEEK EXERCISES INTENSITY AMBULATION
1-3 Isometrics- 15 reps, 2-3 times Half a mile or just
quadriceps, daily prior to point of
hamstrings sets claudication[1-2
AROM-ankle times a day]
pumps, heel slides,
heel and toe raises
in sitting.

4-6 AROM and 20 reps, 2-3 times 1 mile or to point of

resistive excercises- daily claudication
standing toe raises,
SLR, wall squats.

7-10 Continue resistive 20 reps, 3 times 1+ miles or

exercises with daily distance as
increase resistance tolerated
as tolerated.
VENOUS DRAINAGE SYSTEM
 VENOUS DISORDERS
THROMBOPHLEBITIS:
* An acute inflammatory condition with occlusion of a superficial or
deep vein by a thrombus.
VIRCHOW’S TRIAD:

* Causes include trauma, surgery or prolonged inactivity.

* Superficial venous thrombosis-The affected vein might be near the
surface of your skin- Red, hard cord just under the surface of your
skin that's tender to the touch- saphenous vein
* Deep venous thrombosis- deep within a muscle- leg may become
swollen, tender and painful- Femoral, popliteal veins
 DEEP VEIN THROMBOSIS
Formation of blood clot in one of the deep veins of the body, usually in
the legs.
Tends to occur at the bifurcation of deep vein, site of turbulent blood
flow.
Virchow’s triad
Risk factors:
General: age, immobilization for longer period, pregnancy and
postpartum period, post-operative period, long plane or car
trips(>4hrs)
Medical: previous DVT, iatrogenic-central venous catheters, stroke,
SLE, sepsis, ulcerative colitis, nephrotic syndrome, protein c deficiency,
obesity
Drugs: oral contraceptive pills
Clinical presentation:
Calf pain or tenderness
swelling with pitting edema
increased skin temperature,
cyanosis with severe obstruction,
poor or even absent distal pulses.
Homan’s sign
 pratt’s sign,
moses’ sign
DIAGNOSIS:
* D-dimer test
* Duplex ultrasonography
* MRI studies
* CT venography
Prevention:
 Avoid smoking
 well-balanced diet
 maintaining healthy weight.
 Travelling: occassional short walks, wear elastic compression stockings,
ankle pumps
 Mechanical prophylaxis :graduated compression stockings (GCS),
intermittent pneumatic compression (IPC) and venous foot pumps to
improve blood flow in the deep veins of the leg.
 Early mobilisation, ambulation and exercises involving ankle dorsiflexion
are encouraged to further minimize venous stasis.
Treatment:
 Warfarin
 Subcutaneous Unfractionated Heparin (UFH)
 Low-molecular-weight Heparins (LMWH)
 VARICOSE VEINS
* Abnormally dilated veins with incompetent valves, occuring most often in
the lower extremities.
* Usually affected: women(30-50years)
* Usually affects the saphenous vein and its branches.
RISK FACTORS:
• Genetic,
• Age,
• Gender,
• Pregnancy
• Overweight and obesity.
CAUSES:
* Congenital absent or defective venous valves,
* Incompetent venous valves,
* Elevation of venous pressure,
* Infections and
* Trauma.
Features:
 enlarged veins that are visible on skin,
 mild swelling of ankle and feet,
throbbing or cramping in legs,
itchy legs, feeling of heaviness of legs,
 night time cramps, spider veins, skin discoloration.
CLINICAL SIGNS:
Brodie-trendlenberg test,
 perthe’s test,
modified perthe’s test,
pratt’s test.
Prevention:- Bicycling or Bicycle Legs
Lunges
To reduce the risk of developing
varicose veins: Rocking Your Feet
* Get plenty of exercise, for Knee bends with ankle flexion
example, walking. Swimming
* Maintain a healthy weight. Wearing compression
* Avoid standing still for too long. stockings
* Do not sit with the legs crossed. SURGERY:
* Sit or sleep with your feet raised High end ligation and stripping
on a pillow.
Endovenous laser ablation
MANAGEMENT:
low-impact exercises:
Walking or Running
Leg Lifts
 LYMPHEDEMA
* Excessive accumulation of extravascular and extracellular fluid in
tissue spaces. caused by disturbance of water and protein balance
across the capillary membrane.
FEATURES:
* Painless swelling of distal extremity
* Heaviness of extremity
* Paresthesia of hand and foot
* Tautness of skin
* Skin breakdown
* Peau d’ orange apperance
* Cellulitis
EVALUATION:
* Girth measurement
* Volumetric measurement of extremity
* Stemmer’s sign
* Lymphangiography
GENERAL TREATMENT PLAN OF CARE
GOALS

Reduce lymphedema  Intermittent mechanical compression device

 Positioning of extremity
 Manual lymphatic drainage
 Isometric and isotonic exercises to distal
muscles

Prevent further edema  Elastic support stocking or sleeve

 Regular elevation of extremity
 Avoidance of increased loads on lymphatics:
a. Dependant limb positioning
b. Local heat application
c. Hot environments

Prevent infections and cellulitis  Frequent applications of moisturizers to skin

 Use of antibiotics