VASCULAR DISEASES

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Aneurysms

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 Aneurysm

Atherosclerotic

wall weakening in
complicated
lesion

abdominal aorta

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4
 Aortic Aneurysm

Abdominal Aortic Thoracic Aortic Aneurysm

Aneurysm (AAA) (front view)
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 Aortic Aneurysm

A sac or dilation formed at a weak point

Abnormal localized permanent
dilatation of a blood vessel

One or all three layers may be involved

May rupture and lead to death

Sometimes classified by gross
appearance as fusiform or saccular

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Characteristics of Aneurysms

False aneurysm
Blood escapes into
connective tissue,
outside of arterial
wall

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Characteristics of Aneurysms
Fusiform aneurysm
Symmetric,
spindle-shaped
expansion
Involves entire
circumference

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Characteristics of Aneurysms

Saccular aneurysm
Out-pouching on
one side only

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Characteristics of Aneurysms

Dissecting aneurysm
Separation of
arterial wall layers
that fills with
blood

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 Thoracic Aortic Aneurysm

Occurs most
frequently in men,
50 – 70 yrs of age

Etiology –
atherosclerosis,
hypertension,
infection

1/3 die from
rupture

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 Thoracic Aortic Aneurysm

Vasculitis, syphilis, traumatic (automobile
accidents), collagen vascular disease
(Marfan's syndrome), smoking


S/S depend on size and rate of growth


Substernal pain, dyspnea, neck or back pain

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 Assessment Findings with
Thoracic Aneurysm

May be asymptomatic

Chest pain

Dyspnea, hoarseness or dysphagia

Distended neck veins and edema of
head and arms

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 Thoracic Aortic Aneurysm

Imaging
 Must be differentiated from other diagnoses (lung

neoplasm, mediastinal masses).

 CT scan and MRI very sensitive to assess.


Treatment
 Controlling HTN and Beta Blockers may slow

growth.
 Surgery is for patients that have symptoms, >5cm,

or rapidly expanding size.

 Morbidity and Mortality higher than with AAA

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 Diagnostic Studies


Chest xray

Transesophageal
echocardiogram

CT scan

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 Management of Thoracic
Aneurysm

Control underlying hypertension

Surgical repair
 Resection of aneurysm and

replacement with graft

 Repair with endovascular graft

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 Thoracic Aneurysm Repair

Depends on type and location

Cardiopulmonary bypass required

Thoracotomy or median sternotomy
incision

Graft goes over the aneurysm

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Grafts

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 Abdominal Aortic Aneurysm
(AAA)

Occurs more frequently in Caucasians,
more in men and elderly clients

Etiology – atherosclerosis,
hypertension, trauma, infection,
congenital abnormalities in vessels,
genetic predisposition

Most are infrarenal
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 Assessment Findings with AAA

Approximately 60% of clients are
asymptomatic

Pulsatile mass in the upper and middle
abdomen

Abdominal or low back pain

Bruit may be heard

Diminished femoral and distal pulses

Patchy mottling of feet and toes

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 Abdominal Aortic Aneurysms

Imaging
 Abdominal U/S for screening and

monitoring progression
 Abdominal CT scan to specifically

measure size and its relationship

with the renal arteries

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 Diagnostic Tests with AAA


Abdominal
ultrasound

CT scan, MRI

The aortic abdominal aneurysm has an intramural

thrombus, and its size is approximately 6.7 cm in
diameter. The true lumen of the aorta is indicated
by the arrowheads.

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 Management of AAA

If small, monitor every 6 months

Keep BP down

Preoperatively
 Cardiac evaluation must be done
 Cardiac interventions may need to be done before repair of
aneurysm

Treatment
 For >5cm surgical intervention with graft replacement
 If symptomatic surgical treatment must be immediate regardless of
size
 Stent grafts are treatment
 Inserted through common femoral arteries

 Less than 2 hours, minimal blood loss

 May need more complicated repair depending on patient condition

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 Abdominal Aortic Aneurysms

Complications
 Myocardial infarction, bleeding, limb

ischemia, bowel infarction, renal

insufficiency, stroke
 Graft infection and graft fistulas can occur

 Endoleak

 Some patients will develop another

aneurysm in another location

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 Endovascular Repair

For high risk surgery patients

Before aneurysm reaches diameter for
elective surgery

Inserted through femoral artery

Decreased length of stay in hospital

Still need monitoring for complications

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“Endovascular” Aortic Aneurysm Repair

Pre-repair Post-repair
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 Popliteal and Femoral

Popliteal make up approximately 85% of
peripheral artery aneurysms

Symptoms due to arterial thrombosis, peripheral
embolus, compression of adjacent structures

U/S used for diagnosis and measurement

Surgery – >2cm if asymptomatic and for all
symptomatic regardless of size

Femoral
 Pulsatile groin masses

 Same problems as popliteal

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www.memorialcare.com

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www.azheart.com
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 Atherosclerosis

Occurs from vascular damage, involved
in coronary and cerebral vascular disease

 Stable plaque
 Unstable plaque

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 Peripheral Vascular Diseases

Arterial Manifestations:
 Diminished or absent pulses
 Smooth, shiny, dry skin, no
hair
 No edema
 Round, regularly shaped
painful ulcers on distal foot,
toes or webs of toes
 Dependent rubor
 Pallor and pain when legs
elevated
 Intermittent claudication
 Brittle, thick nails

Venous Manifestations:
 Normal pulses
 Brown patches of
discoloration on lower legs
 Dependent edema
 Irregularly shaped, usually
painless ulcers on lower legs
and ankles
 Dependent cyanosis and
pain
 Pain relief when legs
elevated
 No intermittent claudication
 Normal nails
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 PAD Risk Factors
(same as for atherosclerosis)

Modifiable Non- Modifiable


Cigarette smoking 
Personal or family

Obesity history

Diabetes Mellitus 
Heart disease

Physical Inactivity 
History of stroke

High Cholesterol 
Age

High Blood 
Male
Pressure

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 PVD

Disorders that interfere with natural flow
of blood through peripheral circulation

Patients can have arterial and venous
disease

Chronic condition

Systemic manifestation of atherosclerosis

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 Obstructions

Inflow
 located above the inguinal ligament

 may not cause significant damage


Outflow
 below superficial femoral artery

 typically cause significant damage

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 Assessment

Intermittent claudication – pain with
ambulation that stops with rest

Inflow disease – discomfort in
buttocks, lower back and thighs

Outflow disease – burning or cramping
in ankles, feet, toes and calves, resting
pain

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Peripheral Vascular Disease

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 Patient Assessment

Blood pressure checks in both arms

Palpate pulses and compare with opposite
side

Capillary filling time

Inspect extremities for edema, discoloration,
loss of hair, temperature differences, ulcers

Observe for intermittent claudication with
ambulation

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 Stages of PAD

Stage I
 Asymptomatic

 No claudication

 Pedal pulses affected


Stage II
 Claudication

 Pain or burning with exercise but relieved with

rest
 Symptoms reproducible by exercise

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 Stages of PAD

Stage III
 Resting Pain

 Awakens patient at night

 Numbness or burning quality

 Relieved with extremity in dependent position


Stage IV
 Necrosis/Gangrene

 Gangrenous odor

 Ulcers and necrotic tissue

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 Diagnostic Exams

Systolic blood pressure readings

Exercise tolerance testing

Plethysmography
 Non-invasive technique for measuring the

amount of blood flow present or passing

through, an organ or other part of the body
 Used to diagnose deep vein thrombosis

and arterial occlusive disease

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 Treatment
Non-surgical

Exercise

Patient positioning

Medication

Angioplasty

Arthrectomy – non-surgical procedure to
open blocked coronary arteries or vein
grafts by using a device on the end of a
catheter to cut or shave away
atherosclerotic plaque
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Arthrectomy

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 Treatment

Surgical

Bypass (inflow and outflow)
 Aortoiliac and aortofemoral bypass

 Axillofemoral bypass

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Graft Bypass

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 Acute Peripheral Arterial Occlusion

Embolus is most common cause

Affects both upper and lower extremities

History of recent MI or a-fib

Severe pain even resting

Temperature cool, mottled and no pulse

Immediate intervention needed to prevent loss of
extremity

Treatment – thrombectomy

Must observe extremity for improvement of
condition also for complications

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 Acute Arterial Occlusive Disease
(arterial embolism)

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 P’s – pain, pallor, pulselessness, paresthesia, paralysis,

poikilothermia – inability to control temp

 ABI (ankle-brachial index) <1

 U/S

 MRI

 Angiography

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 Diagnostic Findings With
Arterial Occlusive Disease

Decreased Ankle-Brachial Index (ABI)

0.50 to 0.95 indicates mild to moderate
insufficiency

0.25 or less indicates severe
Ankle pressure = ABI (normally 1.0)
Brachial pressure

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 Management of Arterial Embolism

Medical
 Anticoagulants - heparin bolus then 1000

U/hr
 Thrombolytics


Surgical (depends on occlusion time)
 Embolectomy

 Bypass

 Angioplasty with stent placement

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 Buerger’s Disease
(thromboangiitis obliterans)

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
 U/S
 Angiography
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 Management of Buerger’s 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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Thromboangiitis Obliterans
(Buerger’s disease)

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Thromboangiitis Obliterans
(Buerger’s disease)

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 Varicose Veins

Dilated, tortuous superficial veins of the lower
extremities

May be superficial or deep

Symptomatic or asymptomatic – Symptoms do not
always correspond to the number and size of
varicosities

Female, family history, prolonged sitting or
standing

Dull aching feeling after long periods of standing

Complications include ulceration, stasis
dermatitis, superficial venous thrombosis and
thrombophlebitis
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 Varicose Veins

Treatment includes compression stockings worn all
day and removed at night

Periodic elevation of legs and exercise are
recommended

Encourage walking and weight loss

Surgery is for patients that have persistent, disabling
pain, ulceration, superficial thrombophlebitis

Sclerotherapy can be used for small varicosities
 More than one treatment may be needed


This is chronic disease and requires continued
stockings, rest and exercise

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 Clinical Manifestations of
Varicose Veins

Swollen, dilated,
tortuous veins

Dull aching

Muscle cramps

Increased muscle
fatigue

Ankle edema

Diagnosis – duplex
ultrasound

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 Other Venous Disorders

Venous Thrombosis
 Thrombus formation in a vein

 May be deep (DVT) or superficial


Thrombophlebitis
 Inflammation of a vein along with

thrombus formation

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 Venous Thromboembolism

Thrombus- a blood clot in a blood
vessel

Embolism- a clot that travels and
blocks a vessel

DVT (deep vein thrombosis) – serious
because it can cause a pulmonary
embolism

DVT most common in legs but can
occur in the upper extremities also

Thrombus formation is associated with
Virchow’s Triad
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VIRCHOW’S TRIAD

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 Virchow’s Triad

Venous stasis
 due to reduced

blood flow

Injury to the intimal
lining
 creates site for clot

formation

Hypercoagulability
 increased tendency

to clot

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 Clinical Manifestations of
Superficial Venous Thrombosis

Pain

Tenderness

Redness

Warmth

Palpable cord

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 Complications Of Venous
Thrombosis

Pulmonary embolus

Chronic venous insufficiency

Venous stasis ulcers

Chronic edema

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 Medical Management Of
Superficial Thrombophlebitis

Elevation of extremity

Warm compresses to area

Analgesics and possibly NSAIDS

Possibly antibiotics

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Preventative Measures For Venous
Thrombosis and Thrombophlebitis

Active or passive leg exercises

Intermittent pneumatic compression
devices

Compression stockings

Encourage post-op deep breathing

Avoid using pillows under knees

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Sequential Compression Device

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http://faculty.valencia.cc.fl.u
s
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 Clinical Manifestations Of DVT

Swelling or edema of involved extremity

Tenderness

Homan’s sign

Signs of pulmonary embolus
 Chest pain
 Hemoptysis
 Dyspnea
 Apprehension
 Hypotension
 Cardiac arrest

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DVT Filter

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 Chronic Venous Insufficiency

Results from faulty venous valves
which allow reflux of blood

Venous pressure increases and venous
stasis occurs. Edema also occurs.

Small veins rupture and RBCs escape
into surrounding tissues.

Brown discoloration of tissues occurs

Stasis ulcers develop

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 Clinical Manifestations Of
Chronic Venous Insufficiency

Swollen limb

Dry, itchy, coarse,
leathery skin

Reddish brown skin on
lower extremity above
ankles

Stasis ulcers above
ankles

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 Leg Ulcers

75% result from chronic venous
insufficiency and 20% from PAD

Appear as an open, inflamed sore

Eschar may be present

Venous ulcers usually present above the
malleolus

Arterial ulcers usually occur on or between
toes

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 Venous Leg Ulcer

Take long time to treat and heal

Venous insufficiency

Stasis dermatitis

Stasis ulcer

Over the malleolus (more medial than
lateral)

If not controlled they can lose extremity

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80
 Arterial Ulcers

Claudication after walking short distance

Pain at ulcer site

Between or top of toes

Cold feet

Decreased or absent pulses

Possible gangrene

Atrophy of skin

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 Treatment of Stasis Ulcer
(Venous or Arterial)

Wound culture

Oral antibiotics if infection present

Debridement of nonviable tissue
 Surgical debridement
 Enzymatic debridement
 Wet to dry dressings
 Calcium algenate dressings

Keep ulcer clean and moist while healing
 Hydrocolloid dressing
 Unna boot

Improve nutrition

Hyperbaric oxygen therapy (HBO)

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 Aspirin

Inhibits platelet aggregation
 Reduces ability of blood to clot


Contraindications
 Allergy, GI bleed, bleeding disorder,

children <18 with viral infection


Report
 Signs of bleeding, petechiae, ecchymoses,

bleeding gums, black or bloody stools

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 Heparin

Inhibits formation of new clots

Does not dissolve existing clot but prevents its extension

Contraindications
 Active bleeding, hemophilia, thrombocytopenia,

suspected intracranial hemorrhage


Monitor
 H/H, platelets (prior and regular intervals), PTT


PROTECT FROM INJURY

Avoid IM injections

Report
 Drop in BP, bleeding


ANTIDOTE
 Protamine sulfate 1% sol (heparin antagonist)

86
 Lovenox (low molecular
weight heparin)

Anticoagulant

Prevention of DVT

Treatment of DVT, PTE, Acute Coronary Syndrome

Contraindication
 GI bleed, active bleeding, bleeding disorder,

thrombocytopenia

Monitor
 H/H, platelets


Report
 Signs of bleeding, drop in platelet count

87
 Coumadin (warfarin sodium)

Prevents new clots from forming

Treatment of A-Fib

Prophylactic if prosthetic heart valve

Contraindications
 Hemophilia, active bleeding, esophageal varices, severe

hepatic disease

Antidote
 Holding one or more doses, Vit K, blood transfusion may

be needed

Monitor
 PT, INR

Report
 Bleeding (nose, mouth, gums, urine, stool)

Take at the same time each day

Maintain consistency in diet with Vit K foods (broccoli,
cabbage, lettuce, green tea, spinach, tomatoes)
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 Plavix

Antiplatelet

Irreversible on platelets

Contraindications
 Intracranial hemorrhage, active bleeding


Education
 Discontinue one week before having

surgery

Monitor
 Signs of bleeding, platelet count

89
 Tissue Plasminogen Activator

Thrombolytic

For CVA patients within *3* hour time frame from
onset of s/s

Contraindications
 Active internal bleeding, recent surgery or

trauma, bleeding disorder, use of oral

anticoagulants, uncontrolled HTN

Monitor
 Bleeding, neuro checks, cardiac rhythm


Education
 IM contraindicated, no invasive procedures,

quiet and on bed rest during administration

90
 Trental (pentoxifylline)

Decreases blood viscosity and improves
blood flow
 Results in reducing tissue hypoxia,

decreased pain and paresthesias


Contraindications
 Intracranial bleed


Monitor
 Relief from pain and cramping, improved

walking tolerance
91
 Vit K

Antidote for overdose of Coumadin

Contraindication
 Severe liver disease


Monitor
 Patient, PT/INR, Bleeding


IV route for emergencies only

92
 Protamine Sulfate

Antidote for heparin overdose

Used after stopping heparin

Contraindication- hypersensitivity to
fish

Monitor- patient and vital signs

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