Module 2: Vascular Disorders Flashcards
Peripheral Artery Disease (PAD)
Involves thickening of the artery walls and
progressive narrowing of arteries of upper and lower extremities
Symptomatic age 50 to 70; earlier with diabetes
In United States, 8.5 million over age 40 have PAD
* prevalence with blacks
Strongly related to other CVD
Higher risk of mortality, CVD mortality, major
coronary events and stroke
Etiology and Pathophysiology of PAD
Atherosclerosis is leading cause in majority of
cases
Gradual thickening of the intima and media due
to cholesterol and lipid deposits
Exact cause unknown; inflammation and
endothelial injury play a major role
Symptoms occur when vessels are 60-75%
blocked
Risk Factors for PAD
Risk factors:
Tobacco use
Diabetes
HTN
High cholesterol
Age greater than 60
Multiple risk factors increase the risk of PAD
Atherosclerosis often affects coronary, carotid, and lower extremity arteries
Clinical Manifestations of PAD
Classic symptom of PAD—intermittent claudication
Ischemic muscle pain that is caused by a constant
level of exercise
* Build up of lactic acid from anaerobic metabolism
Resolves within 10 minutes or less with rest
Reproducible
Occurs in as many as 1/3 of patients with PAD
Paresthesia
Numbness or tingling in the toes or feet from nerve tissue ischemia
Neuropathy causes severe shooting or burning pain
Produces loss of pressure and deep pain sensations from reduced blood flow
Injuries often go unnoticed by patient
Reduced blood flow to limb
Thin, shiny, and taut skin
Loss of hair on the lower legs
Diminished or absent pedal, popliteal, or femoral
pulses
Elevation pallor
* Pallor of foot with leg elevation
Dependent rubor
* Reactive hyperemia of foot with dependent position
Pain at rest
Progressive disease
Occurs in feet or toes most often
Aggravated by limb elevation
Occurs from insufficient blood flow to distal tissues
Occurs more often at night
Pain relief by gravity
Critical Limb Ischemia (CLI)
-Characterized by
Chronic ischemic rest pain lasting more than 2 weeks
Nonhealing arterial leg ulcers or gangrene
- At increased risk
Diabetes
HF
History of stroke
Complications of PAD
Prolonged ischemia leads to:
Atrophy of skin and underlying muscles
Delayed healing
Wound infection
Tissue necrosis
Arterial ulcers over bony prominences
Most serious: Nonhealing arterial ulcers and
gangrene
Collateral circulation may prevent gangrene
May result in amputation
If adequate blood flow is not restored and if severe infection occurs
Indicated with uncontrolled pain and spreading
infection
PAD Diagnostic Studies
Doppler ultrasound
Segmental blood pressure
Duplex imaging
Bidirectional, color Doppler
Ankle-brachial index (ABI)
Done using a hand-held Doppler
Calculated by dividing the ankle systolic BP (SBP) by the higher of the brachial SBPs
Falsely elevated results can be seen in older patients or those with diabetes
Nutrition Therapy for PAD
BMI <25 kg/m2
Waist circumference is less than 40 in for men
and less than 35 in for women
3% to 5% weight loss yields reduced
triglycerides, glucose, A1C, and decreased risk
of type 2 diabetes
Recommend reduced calories and salt for obese
or overweight persons
Leg with Critical Limb Ischemia
Revascularization via bypass surgery using
autogenous vein
-This surgical procedure involves using a vein from the patient’s body (autogenous vein) to create a bypass around the blocked artery in the leg.
The vein is grafted above and below the blocked area, allowing blood to flow around the obstruction.
Percutaneous transluminal angioplasty (PTA)
-PTA is a less invasive procedure where a small balloon at the tip of a catheter is inserted into the blocked artery.
-Once in place, the balloon is inflated to open the artery, improving blood flow. Stents may also be placed to keep the artery open.
IV prostanoids (iloprost [Ventavis])
-Iloprost is a type of medication known as a prostanoid, which can help improve blood flow and reduce symptoms.
-While it’s used for CLI, it’s important to note that Iloprost (Ventavis) is not FDA-approved specifically for this condition. It is primarily approved for pulmonary arterial hypertension.
Continue to decrease CVD risk: statins, antiplatelet, ACE inhibitor, and beta-blocker
Managing overall cardiovascular risk is crucial in the treatment of CLI. This includes medications like:
Statins: To lower cholesterol levels and stabilize plaque in the arteries.
Antiplatelet Agents: Such as aspirin or clopidogrel, to prevent blood clots.
ACE Inhibitors: To lower blood pressure and reduce strain on the heart.
Beta-Blockers: Also to manage blood pressure and reduce the heart’s workload.
Conservative treatment
-Conservative treatment refers to non-surgical approaches that focus on managing symptoms and preventing complications, especially in conditions where surgery might not be immediately necessary, feasible, or the patient’s preference.
Protect from trauma
This involves safeguarding the affected area (like a limb) from injury or excessive pressure, which can worsen the condition. For example, using protective footwear and avoiding activities that might lead to cuts, bruises, or other injuries.
Decrease ischemic pain
Pain management is crucial, particularly for conditions that cause ischemic pain (pain resulting from reduced blood flow). This can include medications like analgesics, and in some cases, specific drugs that help improve blood flow and reduce pain.
Prevent/control infection
Keeping the affected area clean and monitoring for signs of infection is important. In cases where the skin integrity is compromised, such as ulcers or wounds, appropriate wound care and possibly antibiotics may be needed to prevent or treat infections.
Improve arterial perfusion – healing is unlikely
Enhancing blood flow to the affected area is crucial, as healing is unlikely without adequate perfusion. This can be achieved through lifestyle changes (like smoking cessation and exercise), medications (such as vasodilators or antiplatelet drugs), and in some cases, specific therapies designed to improve circulation without increasing blood flow
Spinal cord stimulation - pain
In cases where pain is difficult to manage with conventional methods, spinal cord stimulation, a procedure where electrical impulses are used to relieve pain, can be an option.
Angiogenesis—new blood vessel growth
This involves therapeutic approaches to encourage the formation of new blood vessels in areas with poor circulation. While still an area of active research, certain treatments and medications can promote angiogenesis, potentially improving blood flow in ischemic tissues.
Interventional Radiology Procedures
Catheter Based Procedures
Catheterization Lab instead of OR
Pre and postprocedure nursing care—same as for
diagnostic angiography
Special catheter inserted in femoral artery in all of the following procedures
Antiplatelet agents given postprocedure to reduce risk of restenosis (clopidogrel or low dose ASA)
Interventional Radiology Procedures
Catheter Based Procedures
Percutaneous transluminal angioplasty (PTA)
Catheter has a balloon at the tip
Balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining
Stent is placed to hold artery open
* Stent coated with drug (paclitaxel) to limit growth of new tissue in treated area
Interventional Radiology Procedures
Catheter Based Procedures
Atherectomy
Removal of obstructing plaque
Performed using a cutting disc, laser, or rotating
diamond tip
Interventional Radiology Procedures
Catheter Based Procedures
Cryoplasty
Combines PTA and cold therapy
Balloon filled with liquid nitrous oxide that changes to
a gas; the gas expands and cools to 14° F (−10° C)
Limits restenosis by reducing smooth muscle cell
activity
Interprofessional Care
Surgical Therapy
Peripheral Artery Bypass Surgery
-with autogenous vein or synthetic graft to bypass blood around the lesion
Human umbilical vein or composite sequential bypass graft may be used
PTA with stenting may also be used in combination with bypass surgery
Femoral-popliteal Bypass Grafts (picture)
Interprofessional Care
Surgical Therapy
-Endarterectomy
-Patch graft angioplasty
-Amputation
Other surgical options:
Endarterectomy—open artery and remove plaque
Patch graft angioplasty—open artery, remove plaque and sew patch to widen the lumen
Amputation—considered if necrosis, gangrene, or
osteomyelitis develop
* As much of the limb as possible is preserved to improve rehabilitation potential
Nursing Care for PAD
Health promotion
Identification of at-risk patients
Diet modification
Proper care of feet
Avoidance of injuries
Regular follow-up care
Acute care
In recovery area, after surgery or radiologic
intervention, frequently monitor
* Skin color and temperature
* Capillary refill
* Presence of peripheral pulses distal to the operative site
Notify HCP immediately with any changes
* Sensation and movement of extremity
* Pain management
Acute care—after leaves recovery
Continued circulatory assessment
Monitor for potential complications
* Report: Increased pain, loss of pulses, pallor or
cyanosis, numbness or tingling
Avoid knee-flexed positions
Turn and position frequently, OOB, ambulate; avoid prolonged sitting
Graduated compression stockings
Ambulatory care
Management of risk factors
* Smoking cessation
Long-term antiplatelet/ASA therapy
Supervised exercise training after revascularization
Importance of meticulous foot care
Daily inspection of the feet
Comfortable shoes with rounded toes and soft
insoles; shoes lightly laced
Show how to check skin temperature, capillary refill, and palpate pulses
Patient and caregiver teaching
Acute Arterial Ischemic Disorders
Etiology and pathophysiology
Sudden interruption in arterial blood supply to a
tissue, organ, or extremity
If untreated, can result in tissue death
Causes: embolism, thrombosis, or trauma
Most frequent: embolization of thrombus from the
heart related to: infective endocarditis, mitral valve
disease, atrial fibrillation, cardiomyopathies, and
prosthetic heart valves
Noncardiac causes: aneurysms, ulcerated
atherosclerotic plaque, endovascular procedures,
and venous thrombi
Thrombi from left side of heart may dislodge and
travel anywhere in systemic circulation
Most block an artery in the leg
Sudden local thrombosis may occur at site of
atherosclerotic plaque
Predisposing factors: hypovolemia, hyperviscosity,
and hypercoagulability
Traumatic injury to an extremity may cause
partial or complete blockage
Acute arterial occlusion may occur with arterial
dissection of the carotid artery or aorta or
procedure-related injury
Acute Arterial Ischemic Disorders
6Ps
Pain
Pallor
Pulselessness
Paresthesia
Paralysis (late sign)
Poikilothermia
- Adaptation of limb to environmental temperature (cool)
Immediate intervention needed to avoid ischemia,
necrosis, and gangrene – can occur within hours
Acute Arterial Ischemic Disorders
Treatment
Early diagnosis and treatment
Anticoagulant—IV unfractionated heparin
Restore blood flow—remove thrombus
Surgical thrombectomy
Percutaneous catheter-directed thrombolytic therapy
Percutaneous mechanical thrombectomy with or
without thrombolytic therapy
Surgical bypass
Percutaneous catheter-directed thrombolytic therapy with alteplase or urokinase preferred if arterial
ischemia is less than 14 days old
* Thrombolytic dissolves clot over 24 to 48 hours
* Requires close monitoring or catheter position and
bleeding at insertion site
Surgical revascularization—trauma or arterial
blockage
Amputation—ischemic rest pain and tissue loss
Long-term anticoagulation recommended if risk for further embolization exists
Thromboangiitis Obliterans
Buerger’s Disease
Nonatherosclerotic, segmental, recurrent
inflammatory disorder of the small and medium
arteries and veins of the arms and legs
Most common in men younger than 45 years old with history of tobacco and/or marijuana use without other CVD risk factors
Thromboangiitis Obliterans
Buerger’s Disease
Phases
Acute phase
Inflammatory thrombus blocks vessel
Chronic phase
Thrombosis and fibrosis causes ischemia
Symptoms
Intermittent claudication of feet, hands, or arms; rest pain, ischemic ulcerations, changes in color and
temperature, paresthesia, superficial vein thrombosis and cold sensitivity
Thromboangiitis Obliterans
Buerger’s Disease
Diagnosis + Treatment
No specific lab or diagnostic tests
Based on history and symptoms and exclusion of
other disorders
Treatment: no smoking tobacco or marijuana; no
nicotine replacements
Conservative:
Avoid cold exposure; walking program, antibiotics for ulcers, analgesia for pain, avoid trauma
IV iloprost—promotes vasodilation
Surgeries
Lumbar sympathectomy
Spinal cord stimulator
Microsurgical flap and omental transfer
Bypass surgery
Amputation
Stem cell therapy
Raynaud’s Phenomenon
-Episodic, vasospastic disorder of small cutaneous
arteries; fingers and toes most commonly involved
More common in women, age 15 to 40 years
Pathogenesis—abnormalities in vascular,
intravascular, and neuronal mechanisms that cause
vasodilation
May occur alone (primary) or with other diseases
Contributing factors
Use of vibrating machinery
Work in cold environments
Exposure to heavy metals
High homocysteine levels
Diagnosis: persistent symptoms for at least 2 years
Characteristic change in color of fingers, toes, ears,
and nose
White, blue, and red
Also: coldness, numbness followed by throbbing,
aching pain, tingling, and swelling
Several minutes to hours
Prolonged, frequent attacks causes thick skin, brittle nails, punctate lesions and gangrenous ulcers
Triggers: cold exposure, emotional upset, tobacco
use and caffeine
Raynaud’s Nursing Care
Patient education: prevent episodes
* Avoid temperature extremes; wear appropriate clothing
* No tobacco products; avoid caffeine
* No vasoconstrictor drugs
* Stress management
Immerse hands in warm water to help decrease
vasospasm