Arterial & Venous Insufficiencies Flashcards
What is an arterial insufficiency wound?
a wound that results from a lack of blood flow
occurs when there is some sort of trauma to an already ischemic limb
What is the etiology of arterial insufficiency?
- trauma
- acute embolism
- diabetes mellitus
- RA
- Thromboangitis (Buerger’s disease)
What is the difference between arteriosclerosis and atherosclerosis?
Arterio: thickening/hardening of arteries
Athero: narrowing of arteries (plaque build up)
What is Intermittent Claudication and how does it occur?
Activity-specific discomfort due to local ischemia
- pain normally stops w/in 1-5 minutes of rest
- about 50% stenosis to occur
- pain is described as cramping, burning, fatigue
- usually Iliofemoral artery obstruction or Infrapopliteal artery obstruction
What is ischemic rest pain?
- more significant arterial disease
- burning pain exacerbated with elevation and relieved by dependency position
- increasing tissue O2 demand can fatally upset the balance b/w O2 supply and tissue demand which causes an ulcer
What is the chain of events for an AI ulcer?
Arterial insufficiency -> intermittent claudication -> ischemic rest pain -> ulcer
What is gangrene?
- when O2 supply does NOT equal demand = cell death
- lack of perfusion to tissues which leads to dead tissue
usually tips of fingers/toes
What is better: dry or wet gangrene?
DRY is better
- wet = signs of infection
What are contributing factors to arterial disease?
Diabetes*
- calcification
- microvascular disease
- hyperglycemia (impairs all phases of healing & decreases infection fighting ability)
- A1c level
*causes all of the above to occur
What is the pain of arterial wounds?
- severe unless masked via neuropathy
- increases with elevation
What is the position of arterial wounds?
- primarily LE
- distal toes
- dorsal foot
- areas of trauma
What is the presentation of arterial wounds?
- regular appearance
- may conform to precipitating trauma
- pale granulation tissue (if present)
- black eschar (dead tissue over wound)
- gangrene
- little to no drainage
What is the periwound & extrinsic tissue like around arterial wounds?
- thin, shiny, anhydrous (dry)
- loss of hair growth
- thickened, yellow nails
- pale, dusky or cyanotic skin
- dependent rubor
- unusual edema (could indicate VI or CHF)
How are the pulses in arterial wounds?
- decreased or absent pedal pulses
How is the temperature of arterial wounds?
- cool/decreased
What are the characteristics of arterial insufficient wounds?
- begin small and shallow
- round and regular or conform to trauma
- any granulation tissue will be pale or grey
- necrotic tissue desiccated with black eschar
- minimal or no wound drainage, even with infection
How can PT’s test for AI?
- Pulses
- Doppler ultrasound
- ABI
- Rubor of Dependency
- Capillary Refill
- Venous Filling Time
Why would you do a doppler ultrasound test?
- decreased or absent pulses
- helpful in assessing arterial patency
supine position
Why would you do an ABI?
SHOULD BE FIRST LINE OF TESTING
- decreased/absent pulses
- signs/symptoms of AI
- history of PVD
What do the values of the ABI mean?
1.1-1.3: vessel calcification (too high)
.9-1.1: normal
.7-.9: mild to moderate arterial insufficiency
.5-.7: moderate arterial insufficiency; intermittent claudication
<.5: severe arterial insufficiency; rest pain; NO COMPRESSION
<.3: rest pain and gangrene
What are some reasons to do a rubor of dependency test?
- unable to tolerate ABI, ABI >1.1, diabetes, or vessel calcification
What does Rubor of Dependency do?
- indirectly assesses LE arterial blood flow
blood pools in the foot
How do you perform a Rubor of Dependency?
1) elevate LE 60 degrees for 1 minute
2) note foot color (on sole of the foot): little or no color change is normal
3) Return leg to surface and note time to return to normal color: normal is 15-20 seconds
How do you interpret the results of a Rubor of Dependency test?
Pallor after __ sec of elevation:
- 45-60: mild AI
- 30-45: moderate AI
- w/in 25: severe AI
Why would you do a capillary refill test?
- digital ulcer
- abnormal doppler ultrasound or ABI
done AFTER putting on compression bandaging for venous ulcers
- reliable indicator of surface arterial blood
- normal refill time is <3 seconds
Why would you do a venous filling time test?
- unable to tolerate ABI, ABI >1.1, diabetes or vessel calcification
- suspected concomitant VI
- prolonged time is predictive of arterial insufficiency
How do you perform a venous filling time test and how are the results interpreted?
1) patient in supine, note superficial veins on dorsal foot
2) elevate limb to 60 degrees for 1 minute
3) lower limb to dependent position, note time for veins to refill
Results:
<5 secs: VI
5-15 secs: normal
>20 secs: AI
What are some medical tests for blood flow?
- plethysmography
- duplex scanning
- transcutaneous oxygen monitoring (TCOM)
- Toe pressures
- Arteriography (dye scan)
What are some medical interventions for AI?
- Risk factor management: cholesterol, BP, diabetes
- Prescription drugs: for pain and circulation
- Sympathetic block: eliminates CNS control of vasoconstriction (stays dilated)
What are some surgical interventions for AI?
- debridement
- revascularization
- percutaneous balloon angioplasty
- amputation
What determines prognosis of AI wounds?
- size and depth: superficial/smaller heal faster
- local tissue perfusion: ABI >.5, toe pressure > 30mmHG not great
What are some ways PT’s can help manage AI wounds?
- coordinate care with patients, caregivers, and other disciplines
- address etiology and modifiable risk factors
- limb protection ed: from trauma, chemicals, heat/cold, open wounds
What are some things to consider when it comes to local wound care in AI wounds?
- protect surrounding skin: moisturize dry skin, reduce friction, provide padding to ischemic tissue
- address wound bed: choose appropriate dressing, debride necrotic tissue if appropriate
- maximize circulation: avoid compression, choose footwear to accommodate bandages and decrease stress on tissues
- educate patient/caregiver
What are some precautions in treating AI wounds?
- avoid compression and compression dressings (decreases BF)
- PT has limited value in patients with low ABI w/o revascularization
- reassess POC if wound doesn’t progress w/in 2-6wks
- avoid sharp debridement of dry, eschar-covered, uninfected ulcers in patients w/ low ABI
- gangrenous tissue must be removed surgically
When would you refer a patient for further testing with AI?
- invalid ABI (cant compress arteries)
- wounds that fail to progress
- suspected infection
- exposed capsule or bone
What are some things PT’s can do with patients with AI?
- gait-training and mobility
- aerobic conditioning
- resistive exercise
- stretching and positioning (avoid excessive hip & knee flexion)
What are some modalities and physical agents for AI?
- therapeutic heat
- E-stim
- hyperbaric O2 chamber
- negative pressure wound therapy
What are some footwear options for those with AI?
Temporary:
- cast shoes
- rocker bottoms
- enclosed shoe
Permanent:
- extra depth toe box
- adequate length
- soft/flexible
- specialized if needed via orthotist
What is venous insufficiency?
- condition where the veins, particulary in the LE, have difficulties sending blood back to the heart
- Prevalence is up to 35%
- 30% VI ulcers need 6+ months to heal
- 91% of venous ulcers can heal with conservative management
often also have AI
How does blood return back to the heart?
- calf muscle pump
- respiratory pump
- valves
What is the main etiology for VI?
- sustained venous hypertension
What are some common causes of venous HTN?
Vein dysfunction:
- incompetent superficial and perforating veins
- bicuspid valves fail to close
- valve damage
Calf muscle pump failure
or combo of both
What vein, if reflux occurs, increases odds of a VI ulcer by 7x?
Great saphenous vein
- incompetence occurs in 25-50% of VI ulcers
most VI appears to be caused by reflux
What are the two theories for the mechanism by which venous hypertension causes tissue damage?
White blood cell theory:
- congestion & distension is caused by venous hypertension
- this causes WBC’s to come to area increasing pressure
- WBC’s become trapped & start inflammatory response
- ulcer forms from hypoxia
Fibrin cuff theory:
- distension causes leaking veins & causes fibrinogen to leak out causing edema
- fibrinogen forms to fibrin & attaches to capillary walls forming a cuff (prevents O2 & nutrient exchange)
- causes an ulcer
What are some risk factors for VI ulcer development?
- vein dysfunction
- valve damage
- calf muscle failure: calf weakness/paralysis, decreased DF, prolonged standing, incompetent valves
- trauma
- previous VI ulcer
- advanced age
- obesity
- diabetes
How is diabetes a risk factor for VI ulcer development?
- increased risk of microvascular disease and impaired immune response
- impairs all 3 phases of wound healing
- more sustained hyperglycemia, greater adverse affect on wound healing
What is the pain of a VI ulcer?
- mild to moderate unless masked by neuropathy
- decreases with elevation/compression
What is the position of a VI ulcer?
- medial malleolus
- medial leg
- areas of trauma
What is the presentation of a VI ulcer?
- irregular shape
- fibrous, glossy coating
- red, ruddy wound bed
- copious drainage
What does the periwound & extrinsic tissue look like with VI ulcers?
- edema
- dermatitis and cellulitis
- hemosiderin staining
- lipodermatosclerosis
What are the pulses like with VI ulcers?
- normal or decreased due to edema or concomitant AI
What is the temperature of a VI ulcer?
- normal to mild warmth
What are some tests for VI?
- clinical assessment for DVT
- ABI
- Trendelenburg test
- doppler
- venous filling time
- circumferential measurements
Why would you do a clinical assessment for DVT?
- lower leg ulcer
- lower leg edema
- suspected DVT
scoring a 3 or higher means hold treatment and consult physician
How do you do the Trendelenburg test and why would you do it?
- used to identify incompetence and differentiate b/w which veins
1) supine, leg in 45 degrees elevation for 1 minute
2) note venous distension
3) Tourniquet to distal thigh
4) stand upright and note time for superficial venous distension
5) repeat w/o tourniquet
How do you interpret the results of the Trendelenburg test?
Tourniquet on: <20 sec = deep or perforator vein incompetence
Tourniquet off: <10 sec = superficial vein incompetence
What do circumferential measurements do?
- objectively measure the size of limbs with edema
- determines effectiveness of compression and therapies
What are some medical tests for VI ulcer?
- duplex ultrasonography
- venography
- doppler studies
What are some management risk factors for VI ulcers?
- cardiovascular disease
- obesity
- diabetes
What are some pharmacological interventions?
- fibrinolytics (improves healing)
- topical agents (antimicrobial, steroids)
- systemic antibiotics
What are some surgical options for VI?
Vein surgery:
- ligation (tie off veins around ulcer)
- stripping (recession of varicosities)
- sclerotherapy
- SEPS procedure (subfascial endoscopic interruption of perforation veins)
- PAPS (percutaneous ablation of perforating veins)
- stents
What is the prognosis of VI ulcers?
- average time is 8 weeks
- smaller ulcers = 5-7 weeks
- larger ulcers = 10-16 weeks
30-60% will heal within 3 months if treated with compression
check ABI and refer if not healing w/in 4 weeks
How can PT help in the management of VI ulcers?
- educate about etiology
- inform risk factors for re-ulceration
- edema control: positioning, exercise, compression
- educate on guidelines
What are some guidelines for those with VI ulcers?
- control swelling
- protect your feet and legs
- live healthy
- call a clinical if notice wound is getting bigger, draining more, smells, have increased swelling/pain, or detect a new wound
What are some precautions in treatment of VI ulcers?
- concomitant arterial disease (cannot compress if have AI)
- allergic reactions (topicals and antibiotics)
- inappropriate whirlpool use
When would you refer a patient with VI for further testing?
- patients scoring 3 or more on DVT prediction
- ulcer fail to progress
- suspected infection
- bone scan/X-rays if exposed capsule or bone
- atypical presentation of VI
What is important when caring for a VI ulcer?
Protect surrounding skin
Address wound bed
- treat needs of the wound
- use periwound skin sealants
- choose absorptive
Enhance venous return
- compression
- edema prevention
What are some interventions that can be done with those with VI ulcers?
ROM and strengthening exercises
- target ankle PF/DF
Aerobic exercise
Gait and mobility training
- positive influence on calf muscle/respiratory pumps weight loss, and blood sugar control
What is compression therapy used for?
- VI ulcers
- lymphedema ulcers
What are some benefits of compression therapy?
- enhances calf muscle pump
- improves venous return
- decreases peripheral edema
- reduces venous distension
- increases tissue O2
- protects limb from trauma
What are some common ways to compress?
- paste bandage
- short-stretch bandage
- multilayer compression bandage system
What are some contraindications for compression?
ABI
- .5-.69 = cautious use of LOW compression
- <.5 = NO COMPRESSION
Acute infection
Pulmonary edema
Uncontrolled/severe CHF
Active DVT
What is a paste bandage?
Gauze impregnated w/ zinc oxide, calamine, glycerin, and gelatin that hardens to a semi-rigid support
- worn for 1 week
- pt must be ambulatory
What are some disadvantages of a paste bandage?
- inability to shower
- odor
- clinicians must apply and remove
What is a short stretch compression wrap and what are some disadvantages?
High working pressure, low resting pressure
- ambulatory & non-ambulatory patients
Disadvantages:
- prone to slippage
- pt’s must be able to re-apply
What does a long stretch compression wrap do?
High resting pressure, low working pressure
- very elastic
What do the different layers of a compression wrap do?
Inner layer:
- absorbs excess drainage
- provides padding
Middle layer:
- absorbs drainage
Outer 1-2 layers:
- increases pressure
stays better than short stretch
What is a Circaid wrap?
- removeable semi-rigid orthotic compression device
- rows of nonelastic velcro straps provide sustained compression
- easy to apply but expensive
daily wear required
What are tubular bandages and the disadvantages?
- off the shelf
- allow for graduated compression
Disadvantages:
- generic shapes & sizes do not accommodate all patients
- bandages lose shape & compression in a short time
What are compression garments?
- used for long term management for edema reduction and control venous hypertension
- require circumferential and limb length measurements
- usually require donning aids
- wear 24/7 except while sleeping and bathing
What are the indications for class 0-4 of compression garments?
0: Non ambulatory patients (<20mmHg)
1: mild VI, VI w/ mild AI (20-30 mmHg)
2: moderate VI (30-40 mmHg)
3: severe VI (40-50 mmHg)
4: severe VI rarely required (>50 mmHg)
What is most important when it comes to adherence to compression?
Education:
- closed but underlying pathology remains (must continue to wear compression garments)
- provide rationale for not wanting to go through healing an ulcer again
- risk of discontinuing compression (could get another ulcer and edema)
- veins are damaged and we CANNOT fix them damaged forever
