PERIPHERAL

VASCULAR
DISEASE
PERIPHERAL VASCULAR
DISEASE (PVD)
• Disorders that change natural flow of blood through the
arteries and veins of the peripheral circulation
• Affects legs much more frequently than the arm
• Some patients have both arterial and venous disease

• Typically appears in patients ages 60 -80

PERIPHERAL VASCULAR
DISEASE (PVD) – CONT.
• Cost of the disease is very
high
• Is expected to increase as
baby boomers age and
obesity in the United
States continues to be a
major health problem.
PHYSIOLOGIC EFFECTS

• If diminished blood flow to tissues

• Tissue integrity is challenged if demands exceed supply of oxygen &
nutrients

• Ischemia & eventual death of tissue if inadequate blood flow

DAMAGED ARTERIES

• Obstructions from atherosclerotic plaque, thrombus or

embolus

• Damaged also from

• Chemical/mechanical trauma, infections, inflammation, vasospastic
disorders & congenital malformations
ACUTE OR GRADUAL CHANGES

• Sudden arterial occlusion

• Profound & irreversible tissue ischemia & death

• Gradual occlusion
• Collateral circulation may develop
• Tissue adapts gradually to ↓ blood flow
• Less risk of sudden tissue death
VEINS

• Carry deoxygenated blood to heart

• Normal venous pressure
• Higher than arterial pressure, and lower in the right atrium than in the
feet.

• This allow veins to channel blood from extremities to heart.

DAMAGED VEINS

• Damaged by a thrombus, incompetent valves,

decreased pumping action of surrounding
muscles
• Result - increased venous pressure
• If the pressure in peripheral veins in greater
than the pressure in tissues, where is the fluid
going to go?

• (Hint: Think about hydrostatic pressures)

VENOUS DISEASES

• Lead to pooling of blood in extremities, resulting in edema

• Edematous tissue- cannot get adequate nutrition
• Tissues are susceptible to breakdown, injury & infection

• Venous diseases : DVT, varicose veins & venous stasis

ulcers
ARTERIAL VESSELS MORE
OFTEN AFFECTED
• Peripheral arterial disease
(PAD) may affect
• Aortoiliac artery
• Femoral artery
• Popliteal artery
• Tibial artery
• Peroneal artery
GERIATRIC CONSIDERATIONS

• Arteries become thicker – the intimal layer may become

fibrotic & vessels stiffen

• Results in increasing peripheral vascular resistance

• May lead to ↑ work load of the left ventricle & possible heart failure
 RISK FACTORS FOR PERIPHERAL
ARTERIAL DISEASE & ATHEROSCLEROSIS

• Diabetes • Familial/genetics
• Increasing age
• Hyperlipidemia
• Female gender
• Hypertension
• Nicotine use
• High homocysteine
levels
WHICH RISK FACTORS FOR
ATHEROSLCEROSIS ARE NON-
MODIFIABLE?
• Familial/genetics
• Increasing age
• Female gender
 ASSESSMENT OF VASCULAR
• PhysicalSYSTEM
assessment:
• Skin – changes occur from inadequate blood
flow
• Cool, pale extremities- increases with
elevation
• Rubor- reddish, blue color in dependent
position
• Severe peripheral arterial damage
• Occurs from vessels that cannot
constrict & remain dilated
ASSESSMENT OF VASCULAR SYSTEM
(CONT.)

• Dry, shiny, taut skin

• Loss of hair on extremity
• Nails thickened & ridged
• Edema
• Gangrene after prolonged tissue necrosis
 ASSESSMENT OF VASCULAR SYSTEM
(CONT.)
• Classic symptom of PAD—intermittent claudication

• Ischemic muscle ache or pain that is

precipitated by a constant level of exercise
• Resolves within 10 minutes or less with rest
• Reproducible
CHRONIC ARTERIAL OCCLUSION

• Hallmark symptom: Intermittent claudication

• Resting pain when occlusion severe

• Elevating leg increases pain
• Dependent position relieves pain
 ASSESSMENT OF VASCULAR SYSTEM
(CONT.)
• Pain in forefoot at rest – REST pain
• Severe arterial insufficiency
• Relief – put extremity in dependent position → improves perfusion
• Often occurs at night

• Pulses
• Diminished or absent pedal, popliteal, or femoral pulses
• Use a Doppler if unable to palpate pulses
ASSESSMENT OF VASCULAR SYSTEM
(CONT.)

• Paresthesia
• Shooting or burning pain in extremity
• Present near ulcerated areas
• Produces loss of pressure and deep pain sensations
• Injuries often go unnoticed by patient
COMPLICATIONS

• Atrophy of the skin and underlying muscles

• Delayed healing
• Wound infection
• Tissue necrosis
• Arterial ulcers
COMPLICATIONS→SERIOUS
OUTCOME
• Nonhealing arterial ulcers and gangrene are the most
serious complications

• May result in amputation if blood flow is not adequately

restored or if severe infection occurs
• NCLEX Challenge:

• The nurse suspects that a patient is experiencing

the effects of peripheral atherosclerosis. What
did the nurse most likely assess in this patient?

• 1. rubor with extremity elevation

• 2. normal hair distribution bilaterally over lower
extremities
• 3. peripheral pulses present bilaterally
• 4. complaints of leg pain upon rest
DIAGNOSTIC STUDIES

• Continuous wave (CW) doppler study- use of a handheld

device to “hear” the pulses
• Provides specific information for calculation of ABI
DIAGNOSTIC STUDIES

• ABI (ankle-brachial index) – ratio of ankle systolic blood

pressure to the arm systolic blood pressure
• Ankle-brachial index <0.70 in PAD

• With increasing arterial narrowing:

• There is a progressive decrease in systolic pressure distal to the
involved sites
• Continuous-wave Doppler ultrasound
• Detects blood flow, combined with computation of ankle or
arm pressures
• This diagnostic technique helps characterize the nature of
peripheral vascular disease
DIAGNOSTIC STUDIES

• CT: cross sectional images of soft tissue & volume changes

• If patient has renal disease, patient should be hydrated (IV or oral) 12
hrs before procedure
• Monitor urinary output post procedure
• Evaluate for iodine or shellfish allergies
• Premedicate -steroids & histamine blockers
 DIAGNOSTIC STUDIES
• Angiography
• Injection of radiopaque contrast into arterial system for visualization of vessels
• Can identify location of stenosis or aneurysm
• Collateral circulation identified
• Teach patient that sense of warmth felt with injection of dye
• Be alert for severe allergic reaction
• Monitor injection site- bleeding or hematoma
 DIAGNOSTIC STUDIES
• Magnetic Resonance Angiography
• MRI with special scanner to locate blood vessels
• Can rotate image for multiple views
• Contraindicated:
• Metal implants
• Older tattoos (metal materials)
• Prepare patient for banging/popping sounds
• Panic button- if feeling claustrophobic
DIAGNOSTIC STUDIES

• Contrast Phlebography (Venography)

• Radiopaque contrast injected into veins
• Unfilled vein – location of a thrombus
• Monitor injection site - bleeding or hematoma

• Lymphoscintography
• radioactive colloid injected into 2nd digit space
• Provides serial images of lymphatic system
ARE WE HAVING FUN YET?
SOMETHING THAT MAKES THIS ALL
HAPPEN….ARTERIAL DISORDERS

• Arteriosclerosis and atherosclerosis

• Peripheral arterial occlusive disease
• Upper extremity arterial occlusive disease
• Aortoiliac disease
• Aneurysms (thoracic, abdominal, other)
• Dissecting aorta
• Arterial embolism and arterial thrombosis
• Raynaud’s phenomenon
ARTERIOSCLEROSIS

• “Hardening of the arteries”

• Diffuse disease process
• Muscle fibers & endothelial lining of walls of small arteries &
arterioles thicken
• Results in loss of elasticity, calcification of arterial walls
ATHEROSCLEROSIS

• Atheromas or plaques
• Result of cholesterol,
lipids & cellular debris in
inner layers of large and
medium-sized arteries
• Result→ decreased blood
flow from narrowing of
lumen→ eventual
development of collateral • Creates risk for
circulation thrombosis
• Vulnerable areas- regions
where arteries bifurcate
C-REACTIVE PROTEIN (CRP)

• Sensitive marker of cardiovascular inflammation-

systemically and locally
• Slight increases in serum CRP levels
• Associated with an increased risk of damage in the vasculature
• Especially if these increases are accompanied by other risk factors
such increasing age, HTN or positive family history of
cardiovascular disease
SIGNS/SYMPTOMS

• Not usually present until artery narrowed by 60% or more

• Early red flags include pain or changed appearance or
sensation in foot or leg
• Intermittent claudication
• Resting causes pain to subside
 PREVENTION
• Heart Healthy Diet
• reduce fat intake, use unsaturated fats, decrease cholesterol intake

• Medications – Statins to reduce cholesterol

• Control hypertension with medications
• Often need 2-3 types of HTN medications

• Eliminate nicotine
MANAGEMENT

• Modify risk factors

• Correct HTN
• Exercise program
• Eliminate nicotine
• Medication- reduce blood lipids
• Low cholesterol diet
• Surgical graft procedures
• Femoral/popliteal bypass- improves outflow
 RADIOLOGIC INTERVENTIONS

• Angioplasty/percutaneous transluminal angioplasty

(PTA)
• Widens area & flattens plaque against wall of artery
• Stents - prevent recollapse & reocclusion

• Complications from procedure

• Hematoma, bleeding
• Distal embolization, intimal damage artery
 STENTS
SMALL METAL MESH TUBES
I AM PRR-FECTLY READY FOR
WHATEVER COMES NEXT
 PERIPHERAL ARTERIAL OCCLUSIVE
DISEASE
• A form of arteriosclerosis involving occlusion of arteries, most commonly
in the lower extremities; may be acute or chronic
• Femoral popliteal area -most commonly affected in nondiabetic patients

• Patient with diabetes mellitus tends to develop PAD in the arteries below the knee
ARTERIAL THROMBOSIS &
ARTERIAL EMBOLISM
• Arterial embolism - sudden arterial occlusion caused by emboli
• Results in acute ischemia of affected body parts
• Most stem from thrombus formation in heart chambers

• Arteriosclerotic conditions may predispose patients to emboli

formation
 EMBOLIZATION OF THROMBI…
• Noncardiac sources of emboli
• Aneurysms
• Ulcerated atherosclerotic plaque
• Recent endovascular procedures
• Venous thrombi
• Rarely, arteritis
• If thrombi originates in left side of
heart
• Can obstruct artery of the lower
extremity (iliofemoral, popliteal, tibial)
• If originate in right side of the heart
• Travel to lungs → pulmonary embolus
CLINICAL SIGNS/SYMPTOMS

• 6” “P’s”of acute arterial ischemia

– Pain- as PAD progresses- continuous pain at rest
– Pallor (pale)- occurs with leg elevation
– Pulselessness
– Paresthesia
– Paralysis
– Poikilothermia (cool)
CLINICAL
SIGNS/SYMPTOMS(CONT)
• Toenails thick, skin shiny & dry; sparse hair on leg
• 100% blockage= acute arterial occlusion
• Immediate intervention or necrosis of tissue in a few hours

• Chronic rest pain, ulceration, or gangrene = critical limb

ischemia
GOAL : KEEP AFFECTED LIMB
VIABLE
• Anticoagulant therapy
• Continuous IV unfractionated heparin (UH)
• Prevent thrombus enlargement & inhibits further embolization
• In patients undergoing embolectomy, UH should be followed
by long-term anticoagulation with warfarin
INTERVENTIONAL TECHNIQUES

• To restore blood flow - embolus/thrombus is removed

ASAP
• Options include
• percutaneous catheter-directed thrombolytic therapy
• percutaneous mechanical thrombectomy with or without thrombolytic
therapy
• surgical thrombectomy or surgical bypass
EXTRACTION OF AN EMBOLUS

• Use of balloon-tipped embolectomy

catheter
• Deflated balloon-tipped catheter -
advanced past the embolus, inflated,
and then gently withdrawn, carrying
the embolic material with it
WHAT IS CATHETER-DIRECTED
INTRAARTERIAL THROMBOLYTIC
THERAPY ?
• Use tPA [alteplase] for patients with short-term (less than
14 days) thromboembolic disease
• Percutaneous catheter-inserted into femoral artery &
threaded to site of clot
• Thrombolytic drug is infused
• Thrombolytic agents work by directly dissolving the
clot over a period of 24 to 48 hours
• Catheter may act as a mechanical thrombectomy
device- designed to remove or fragment the thrombus
REVASCULARIZATION
APPROACHES
• Patient with chronic rest pain, ulceration, or gangrene has
critical limb ischemia
• Critical limb ischemia often leads to amputation within 6 months if
untreated

• Percutaneous transluminal balloon angioplasty for non-

surgical approach
• Atherotomy – use of cutting device or laser to remove
plaques
REVASCULARIZATION
APPROACHES
• Surgery -indicated in patients with long areas of stenosis or
severely calcified arteries
• Common surgical approach
• Peripheral artery bypass →improves blood flow beyond a
stenotic or occluded artery
• Use a vein graft or a synthetic graft
A, Femoral-popliteal bypass graft around an occluded
superficial femoral artery

B, Femoral-posterior tibial bypass graft around

occluded superficial femoral, popliteal, and proximal
tibial arteries
REVASCULARIZATION
APPROACHES
• Endarterectomy
• Opening the artery and removing the obstructing plaque
• Followed by a patch graft angioplasty
• Sewing a patch to the opening to widen the lumen
NCLEX CHALLENGE:

• The nurse recognizes which client is at greatest risk for

developing intimal injury leading to atherosclerosis?

• a. A client with diabetes who also smokes one pack of

cigarettes daily
• b. A client with decreased low-density lipoprotein (LDL)
and increased high-density lipoprotein (HDL) levels
• c. A client with inherited hypolipidemia
• d. A client with a sedentary lifestyle
AMPUTATION - LEAST DESIRABLE END-
STAGE SURGICAL OPTION

• May be required if extensive tissue necrosis

• If infectious gangrene or osteomyelitis develops
• Indicated if all major arteries in the limb are occluded
• Every effort made to preserve as much of limb as possible to optimize
rehabilitation
POSTOPERATIVE NURSING CARE

• Main goal -maintain adequate circulation

• Check pulses frequently and compare with unaffected extremity
– Notify physician immediately if decrease/loss
– Monitor color & temp. of extremity
– Assess sensation & movement of extremity
– Can elevate leg to reduce edema
– Avoid knee flex position; no crossing legs
– Turn & reposition frequently
– Monitor fluid balance
 AMBULATORY AND HOME CARE
• Management of risk factors
• Importance of meticulous foot care
• Importance of gradual physical activity after surgery
• Avoid crossing legs
• Daily inspection of the feet
• Comfortable well-fitting shoes with rounded toes and soft insoles
NURSING MANAGEMENT FOR PAD
NURSING DIAGNOSES
• Ineffective tissue perfusion (peripheral)
• Impaired skin integrity
• Activity intolerance
• Ineffective therapeutic regimen management
NURSING MANAGEMENT
PLANNING
• Overall goals for patient with PAD
• Adequate tissue perfusion
• Relief of pain
• Increased exercise tolerance
• Intact, healthy skin on extremities
COLLABORATIVE CARE - PAD
EXERCISE THERAPY
• Exercise improves oxygen extraction in the legs and
skeletal metabolism
• Walking is the most effective exercise for individuals with
claudication
• 30 to 60 minutes daily
• use pain as a guide

• Bedrest → leg ulcers, cellulitis, gangrene, or acute

thrombotic occlusions
COLLABORATIVE CARE
NUTRITIONAL THERAPY
• Dietary cholesterol <200 mg/day
• Decreased intake of saturated fat
• Soy products can be used in place of animal protein
COLLABORATIVE CARE
COMPLEMENTARY/ALTERNA
TIVE THERAPIES
• Ginkgo biloba
• Effective in increasing walking distance for patients with intermittent
claudication

• Folate, vitamin B6, cobalamin (B12)

• Lowers homocysteine levels
 COLLABORATIVE CARE
CARE OF LEG WITH CRITICAL LIMB
ISCHEMIA

• Protect from trauma

• Reduce vasospasm
• Prevent/control infection
• Maximize arterial perfusion
 INTERVENTIONS:
PROMOTE VASODILATION AND
PREVENT COMPRESSION
• Arterial dilation -may not be possible if artery is severely
sclerosed or damaged
• Teaching:
• Warmth promotes arterial flow and cold causes vasoconstriction
• Nicotine causes vasospasm
• Emotional upsets cause vasoconstriction
• Avoid constricting clothing
• Place extremity below level of heart
FOOT CARE GUIDELINES -
SAME AS DIABETIC FOOT
CARE
• Prevent foot • Stockings or socks -clean
and dry
injury and • Soak fingernails and toenails
blisters before trimming
• Trim nails straight across –
• Treat any injury or may need podiatrist
blister immediately • Don’t cut corns and calluses
• Use neutral
soaps & body
lotions- prevent
skin drying
• Pat skin dry –
avoid vigorous
rubbing
NCLEX CHALLENGE

• A client who has returned to the unit after arterial

revascularization states that pain similar to that before
the procedure is felt in the affected limb. Which is the
nurse’s best action?
• a. Notifying the surgeon
• b. Elevating the extremity
• c. Administering pain medication
• d. Placing a warm blanket on the operative limb
COLLABORATIVE CARE
DRUG THERAPY
• Antiplatelet agents
• Aspirin
• Ticlopidine (Ticlid)
• Clopidogrel (Plavix)
COLLABORATIVE CARE
DRUG THERAPY (CONT’D)
• ACE inhibitors
• Ramipril (Altacel)
• ↓ Cardiovascular morbidity
• ↓ Mortality
• ↑ Peripheral blood flow
• ↑ABI
• ↑ Walking distance
COLLABORATIVE CARE
DRUG THERAPY (CONT’D)
• Drugs prescribed for treatment of intermittent claudication
• Pentoxifylline (Trental)
• ↑ Erythrocyte flexibility
• ↓ Blood viscosity
• Cilostazol (Pletal)
• ↑ Vasodilation
• ↑ Walking distance
NCLEX CHALLENGE:

• In reviewing the menu selections of a client who is

ordered a low-cholesterol diet, the nurse questions
which selection?

• a. Oatmeal
• b. Eggs
• c. Banana
• d. Wheat toast
 BUERGER’S DISEASE (THROMBOANGIITIS
OBLITERANS)

• Inflammatory changes in both arteries and veins

• Results in destruction of small and medium vessels
• Usually affects lower extremities but can also be seen in upper extremity
vessels
 ETIOLOGY

• Affects male cigarette smokers between ages 20 and 40, small incidence in
females

• Long history of tobacco use

• Do not have other CVD risk factors (hypertension, hyperlipidemia, DM)
PATHOPHYSIOLOGY

• Inflammatory process damages the blood vessel wall

• Lymphocytes and giant cells infiltrate the vessel wall with
fibroblast proliferation
• Ultimately, thrombosis and fibrosis occur in the vessel,
causing tissue ischemia.
 SIGNS AND SYMPTOMS
• Symptoms- may be confused with PAD or
autoimmune disorders as scleroderma

• High rate of periodontitis & presence of

Phorphyromonas gingivalis (periodontal pathogen) in
occluded blood vessels
• Suggests possible bacterial cause

• Pulses decreased/absent
• Pain – cramps in feet (esp. arches) or legs after exercise
(intermittent claudication) - relieved by rest
• Rest pain, burning/sensitivity to cold may be early symptoms

• May progress to painful ulceration

• Amputation rate if patient continues tobacco use is almost 3 times greater than
for those who do not
MANAGEMENT

• Same as that for nursing care of patient with arterial

peripheral disease
• Complete cessation of tobacco use in any form
• Use of nicotine replacement products is contraindicated
• Patients have a choice between tobacco and their affected limbs, but
not both
TREATMENT

• Antibiotics -treat any infected ulcers & analgesics to

manage ischemic pain
• Sympathectomy & implantation of a spinal cord stimulator
• Improves distal blood flow & reducing pain
• Neither alters the inflammatory process.

• Amputation- if ulceration & gangrene

 RAYNAUD’S PHENOMENON
• Characterized by vasospasm of the arterioles and arteries of the upper and
lower extremities, usually unilaterally

• Raynaud's disease occurs bilaterally

DIFFERENCE IN DISORDERS

• Primary or idiopathic Raynaud’s (Raynaud’s disease) occurs

in absence of underlying disease.
• Secondary Raynaud’s (Raynaud’s syndrome) –
• Associated with an underlying disease
• Usually a connective tissue disorder- systemic lupus
erythematosus, rheumatoid arthritis, or scleroderma
 CLINICAL MANIFESTATIONS
• Classic clinical picture -- Raynaud’s
• Pallor brought on by sudden vasoconstriction.
• Skin then becomes bluish (cyanotic) -of pooling of deoxygenated blood during vasospasm
• As a result of exaggerated reflow (hyperemia) due to vasodilation, a red color (rubor) is
produced when oxygenated blood returns to the digits after the vasospasm stops
COLOR CHANGES –RAYNAUD’S

• Characteristic sequence of color change of Raynaud’s

phenomenon
• White, blue, and red
• Numbness, tingling, and burning pain occur as the color
changes
• Manifestations tend to be bilateral and symmetric and may
involve toes and fingers
 MANAGEMENT
• Avoiding stimuli (e.g., cold, tobacco) that provoke vasoconstriction
• Is a primary factor in controlling Raynaud’s phenomenon
• Calcium channel blockers (nifedipine [Procardia], amlodipine [Norvasc])
• May be effective in relieving symptoms

• Wear gloves when outside; avoid touching cold items as steering wheel
IF I GOT THIS ---YOU CAN TOO!!