Vascular disorders Flashcards
Peripheral Artery Disease
Involves thickening of the artery walls and progressive narrowing of arteries of upper and lower extremeties
*usually sypmtomatic in ppl 60-80; but may appear earlier if you have diabetes
*higher prevelence in blacks
risks a/w PAD
literally all the other CVD
Higher risk of mortality –> strokes and HF
Etiology/Pathophysiology of PAD
-Atherosclerosis is leading cause in majority of cases (affects coronary, carotid, and lower extremeties)
-gradual thickening of the intima and media due to cholesterol and lipid deposits
-exact cause unknown; inflammation and endothelial injury play a major role
Risk factors that increase chances of getting PAD
tobacco
atherosclerosis
diabetes
htn
high cholesterol
older than 60
symptoms occur when arteries are 60-75% blocked
Potential arteries in lower extremeties that may be affected by PAD
iliac
femoral
ppopliteal
tibial
peroneal
Manifestations of PAD:
Claudication
Paresthesia
Reduced blood flow
Pain at rest
Critical limb ischemia
Lower extremety PAD manifestation: classic
Classic
-intermittent claudication
*ishemic muscle pain caused by constant level of exercise –> build up of lactic acid from anaerobic metabolism
*resolves w/in 10 mins or less with rest
*reproducible
Lower extremety PAD manifestation: paresthesia
Paresthesia
-numbness r tingling in toes or feet from nerve tissue ischemia
-neuropathy causes shooting or burning pain
-loss of pressure and deep pain sensations from low blood flow
-injuries often go unnoticed
LE PAD manifestations: Reduced blood flow to limb
-thin shiny and taut skin
-loss of hair on lower legs
-diminished or absent pedal, popliteal, or femoral pulses
-pallor of foot with leg elevation
-reactive hyperemia of foot with dependent position
LE PAD manifestation: pain at rest
-progressive disease
-occurs in feet or toes
-aggravated by limb elevation
-occurs from insufficient blood flow to distal tissues
-occurs more often at night
-pain relief by gravity
LE PAD manifestsation: Critical Limb Ischemia
characterized by:
-chronic ischemic rest pain lasting for 2+ weeks
-nonhealing arterial leg ulcers or gangrene
-more likely in diabetics or those w/ HF or stroke history
Complications of LE PAD
-atrophy of skin and underlying muscles
-delayed healing
-wound infection
-tissue necrosis
-arterial ulcers over bony prominences
Arterial ulcers
super serious if they don’t heal and develop gangrene
-collateral circulation may prevent gangrene
-might resulr in amputation if bloodflow isn’t restored and severe infection occurs
-amputation is indicated when there’s uncontrolled pain and spreading infection
Diagnostic studies for LE PAD
Doppler ultrasound
-segmental BP taken along leg when supine –> drop of 30+ = PAD
Duplex imaging
-bidirectional, color Doppler
Ankle brachial index (ABI)
-divide ankle SBP by higher brachial SBP
-old ppl and those w/ DM might have artifically elevated ones
Angiography and magnetic resonance angiography
Interprofesional care of IE PAD: Risk factor modification
REDUCE CVD RISKS
BP control
-reduce sodium; DASH diet
Tobacco cessation
Keep Hgb A1C < 7% if diabetic
Aggressive treatment of hyperlipidemia w/ diet and statins
Drug therapy for LE PAD
ACE inhibitors
Antiplatelet agents
Drugs for claudication
LE PAD drugs: ACE-i
Reduce PAD symptoms
e.g. Ramipril (Altace)
-decreases CV morbidity/mortality
-increases peripheral blood flow
-increases ABI
-increases walking distance
LE PAD drugs: antiplatelet agents
Aspirin and/or Clopidrogrel (plavix)
-reduce CVD risk
*don’t use anticoagulants
LE PAD drugs for claudication
Cilostazol (pletal)
-inhibits platelet aggregation
-increases vasodilation
-NOT FOR HF PATIENTS
Pentoxifylline (Trental)
-improves flexibility of RBCs and WBCs
-decreases fibrinogen concentration, platelet adhesiveness, and blood viscosity
LE PAD Exercise therapy
most effective for intermittent claudication
-30-45 mins 3x a week
-more important in women bc they decline faster
-increases survival rate
LE PAD nutritional care
keep BMI <25 (BUT ALSO FUCK THAT)
Waist circumference under 40 in men and 35 in women
3-5% weight loss yields reduced triglycerides, glucose, A1C, and decreased risk of DMII
Recommend reduced calories and salt for obese or overweight persons
LE PAD alternative/complementary therapie
Consult with HCP before taking dietary or herbal supplements esp if taking NSAIDs or anticoagulants
Interactions pose bleeding risk
How to treat leg with CLI: drugs and procedures
Revascularization via bypass surgery using autogenous vein
Percutaneous transluminal angioplasty
IV prostanoids (not FDA approved though)
Decrease CVD risk w/ statins, antiplatelet ACE-i, and B-blockers
How to treat LE PAD patient with CLI: conservative treatment
-protect from trauma
-decrease ischemic pain
-prevent/control infection
-improve arterial perfusion
*spinal cord stimulation can help with pain
*growth factors and gene therapy can help promote angiogenesis
Catheter based procedures for LE PAD
(similar to angiography)
-insert catheter into femoral artery for all of them
-done in cath lab, not OR
-antiplatelets given postprocedure to prevent restenosis
Includes
PTA
Atherectomy
Cryoplasty
Percutaneous transluminal angioplasty
-catheter has balloon tip
-balloon is inflated dilating the vessel by compressing atherosclerotic intimal lining
-stent is placed to hold artery open
*stent coated with drug to limit growth of new tisue in treated area
Atherectomy
removal of plaque
-performed using a cutting dic, laser, or rotating diamond tip
Cryoplasty
combo of PTA and cold therapy
-balloon filled with liquid NO that changes to gas
-gas expands and cools to 14 F
-limits restenosis by reducing smooth muscle cell activity
Peripheral artery bypass surgery
Use umbilical vein or composite sequential bypass graft
PTA with stenting can also be used along with bypass
Other surgical options for LE PAD
Endarterectomy = open artery and remove plaque
Patch graft angioplasty = open artery, remove plaque, sew patch to widen lumen
Amputation
-if necrosis, gangrene, or osteomyelitis
nursing diagnoses for LE PAD
ineffective tissue perfusion
activity intolerance
Overall goals for PAD
adequate tissue perforation
relief of pain
exercise tolerance
intact, healthy skin
increased knowledge
Acute care in recovery after surgery or radiologic intervention
Frequently monitor
-skin color and temp
-capillary refill
-peripheral pulses!!! NOTIFY HCP OF CHANGES
-sensation/movement of extremety
Acute care after leaving recovery for surgery
continued circulatory assessment
-monitor for potential complications (increased pain, loss of pulse, pallor/cyanosis, numbness/tingling)
-avoid knee-flexed positions
-turn and position frequently; oob, ambulate; avoid prolonged sitting
-compression stockings
Ambulatory care
-don’t smoke
-long term antiplatelet/ASA therapy
-supervised exercise after revascularization
-meticulous foot care
Foot care
daily inspection of feet
comfy shoes w/ rounded toes, soft insoles, and lightly laced
Check skin temp, cap refill, and pulses
Acute arterial ischemic disorders: definition and causes
-sudden interuption in arterial blood supply that can result in necrosis
-Caused by trauma or clots
-usually due to embolization of thrombus from heart r/t IE, mitral valve disease, Afib, cardiomyopathies, and prosthetic heart valves
Noncardiac causes: aneurysms, ulverated atherosclerotic plaque, endovacular procedures, venous thrombi
Acute arterial ischemic disorders:
-Left sided thrombi
-atherosclerotic plaque
may dislodge and travel anywhere systemically –> most block leg artery
Sudden loval thrombosis can occur at site of atherosclerotic plaque
-predisposing factors: hypovolemia, hyperviscosity, hypercoagulability
acute ischemic disorder:
-trauma
-procedure-related
Trauma injury to extremety can cause blockage
arterial dissection of carotid artery or aorta can happen
Manifestations of Acute Arterial ischemic disorder
6 P’s
-Pain
-Pallor
-Pulselessness
-Paresthesia
-Paralysis (late sign)
-Poikilothermia (adaptation of limb to enviro-temp)
**need immediate intervention
How to treat acute arterial ischemic disorder
IV heparin
Restore bloodflow - remove thrombus
-thrombectomy
-percutaneous catheter-directed thrombolytic therapy
-percutaneous mechanical thrombectomy w/ or w/o thrombolytic therapy
-surgical bypass
Percutaneous catheter-directed thrombolytic therapy
-catheter has alteplase or urokinase if ischemia is less than 14 days old
-dissolves clot over 24-48 hrs
-need close monitoring to avoid catheter movement or bleeding
When to use surgical revascularization, amputation, and long term anticoagulants when dealing with acute arterial ischemic disorder
Surgical revascularization
-trauma or arterial blockage
Amputation
-ischemic rest pain and tissue loss
Long-term anticoagulation
-if risk of further embolization exists
Thromboangitis Obliterans/ Buerger’s disease
-what is it?
-who’s affected?
Nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium arteries and veins in arms and legs
Men under 45 who smoke anything and DONT have other CVD risks
Acute vs chronic phase of thromboangitis obliterans
Acute
-inflammatory thrombus blocks vessel
Chronic
-thrombosis and fibrosis cause ischemia
Symptoms of Thromboangiitis obliterans
intermittent claudication
rest pain
ischemic ulcerations
changes in color and temp
paresthesia
superficial vein thrombosis
cold sensitivity
Diagnosis of thromboangiitis obliterans
no specific tests
based on history, symptoms, and ruling out other stuff
Treatment of Thromboangiitis Obliterans
-stop smoking everything
Conservative
-avoid cold
-take walks
-antibiotics for ulcers
-analgesia for pain
-avoid trauma
Drugs
-IV iloprost promotes vasodilation
Surgery
-lumbar sympathectomy
-spinal cord stimulator
-microsurgical flap and omental transfer
-bypass
-amputatio
Stem cell therapy
Raynaud’s Phenomenon
-what is it?
-who gets it?
Episodic vsospastic disorder of small cutaneous arteries in fingers and toes
-more common in women aged 15-40
Raynaud’s pathogenesis
abnormalities in vasculature, intravasculature, and neuronal mechanisms that cause vasodilation
Contributing factors to Raynauds
-use of vibrating machinery
-work in cold enviro
-exposure to heavy metals
-high homocysteine levels
Symptoms of Raynauds
(diagnosis?)
Symptoms
-fingers, toes, ears, and nose turn red, white, blue
-coldness/numbness followed by throbbing, aching pain, tingling, and swelling
-long or often attacks cause thick skin, brittle nails, punctate lesions, and gangrenous ulcers
-Triggers = cold, emotions, tobacco, caffeine
Diagnosed if persistant symptoms for 2 yrs
Nursing care of Raynaud’s
Prevention!
-avoid temp extremes
-wear appropriate clothing
-no tobacco
-no caffeine
-no vasoconstricting drugs
Drug therapy for Raynauds
-sustained release CCBs to decrease vasoplasm
-vasodilators
Raynaud’s: Digital Ulceration or critical ischemia
Requires
-prostacyclin infusion, antibiotics, analgesia
-surgical debridement
-botox and statins
-sympathectomy (in severe cases)
Aortic Aneurysms
-what is it?
-who does it affect?
Permanent, localized outpouching or dilation of wall of aorta
-can happen at more than one spot
-more in men, whites, and older ppl
Abdominal aortic aneurysm
-3/4 of aortic aneurysms (the rest are thoracic)
-usually below renal arteries
-the bigger the aneurysm, the greater the risk of rupture
Causes of aortic aneurysms
-can be degenerative, congenital, mechanical (trauma), inflammatory, or infectious
Aortic Aneurysm risk factors
age
male
htn
CAD
fam history
tobacco
high cholesterol
LE PAD
CAD
previous stroke
obesity
Aortic aneurysm genetic link
Familial tendency r/t congenital abnormalities
-bicuspid aortic valve
-coarctation of aorta
-Turner’s syndrome
-Autosomal dominant PKD
-Ehlers-Danlos syndrome
-Loeys-Dietz syndrome
-Marfan’s syndrome
Two types of aortic aneurysms
true
-wall of artery forms aneurysm
-at least one vessel layer still in tact
-“fusiform” = circumferential, relatively uniform shape
-“saccular” = pouchlike with narrow neck connecting bulge to one side of arterial wall
False/pseudo
-not an aneurysm
-disruption of all layers in arterial wall
-results in bleeding contained by surroundig structures
-from trauma, infection, peripheral artery bypass graft surgery, or arterial leakage after removal of cannulae
Thoracic aortic aneurysm
usually asymptomatic
Manifests as:
-deep diffuse chest pain
-pain may extend to intercapsular area
Manifestation of aneurysm in ascending aorta/ aortic arch
-angina
-transient ischemic attacks
-coughing, SOB, hoarseness and/or dysphagia
If pressess of SVC
-decreased venous return
-distended neck veins
-edema of face and arms
AAA manifestations
-usually asymptomatic
-Detected during routine physical or when getting images for another issue
-pulsatile mass in periumbilical area slightly left of midline
-bruit over aneurysm
-back pain, epigastric discomfort, altered pooping, intermittent claudication
might spontaneously embolize plaque (blue toe syndrome)
Aortic aneurysm complications
RUPTURE
into retroperitoneal space
-bleeding may be tamponaded by surrounding structures preventing exsanguination and death
-SEVERE back pain
-may/may not have back/flank ecchymosis (Grey Turner’s syndrome)
into thoracic or abdominal cavity
-massive hemorrhage causes hypovolemic shock
-most do not survive long enough to get to hospital
- if they survive, need simultaneous resuscitation and immediate surgery (53% mortality)
Aortic aneurysm diagnostic studies
Xrays
-chest: demonstrate mediastinal silhouette and any abnormal widening of thoracic aorta
-abdomen: may show calcification w/in wall of AAA
ECG
-to rule out MI
Echo
-assesses aortic valve function
Ultrasonography
-screening for aneurysms
-monitors aneurysm size
CT or MRI
-diagnose and assess location and severity
Angiography
-anatomic mapping of aortic system using contrast
How to care for a small aneurysm
(<5.4 cm)
Risk factor modification
-decrease blood pressure; stop tobacco; decrease lipids; increase activity
If 4-5.4 cm
-ultrasound and CT scan monitoring every 6-12 months
If <4cm
-ultrasound every 3 yrs
How to care for big aneurysm
5.5 cm+
Surgical repair
Surgery also appropriate in ppl w/ smaller aneurysms if
-genetic disorder
-rapidly expanding aneurysm
-symptomatic
-high rupture risk
may be necessary to correct other carotid or coronary artery blockages before surgery
Surgery preop
hydration
-stabilize electrolytes, coagulation, and hematocrit
If it ruptures, emergency surgery –> 90% mortality w/ ruptured AAAs
Open aneurysm repair
-incises diseased segment of aorta
-removes thrombus or plaque
-inserts synthetic graft to aorta proximal and distal to aneurysm
-structures native aortic wall around graft (acts as protective cover)
EVAR (endovascular graft procedure)
-alternative to OAR (minimally invasive)
Criteria: iliofemoral vessels are safe for graft insertion and vessels are adequate length and width to support a graft
Involves placement of sutureless aortic graft into abdominal aorta inside aneurysm
Graft is made from Dacron cylinder and its surface is supported with rings of flexible wire –> its delivered thru a sheath to the predetermined point via femoral artery catheter w/ balloon –> anchored wo vessel with small hooks
Need to do post procedure angiography to check for leaks and confirm patency
Potential complications of EVAR
Endoleak = common –> seepage of blood into old aneurysm
-aneurysm growth
-aneurysm rupture
-aortic dissection
-bleeding
Renal artery occlusion due to
-stent migration
-graft thrombosis
-incisional site hematoma
-site infection
Intraabdominal hypertension (IAH)
-potentially lethal compmlication in emergency repain of AAA
-intraabdominal pressure measured with catheter and transducer
Associated with abdominal compartment syndrome
-reduces blood flow to viscera
-end-organ perfusion impaired results in multisystem organ failure
Treatment of IAH
open surgical decompression
percutaneous drainage
percutaneous drainage w/ thrombolytic infusion
Why is it important to get baseline measurements?
so you can compare them after the procedure
Signs of aneurysm rupture
-diaphoresis
-pallor
-weakness
-tachycardia
-hypotension
-abdominal, back, groin, or periumbilical pain
-changes in LOC
-pulsating abdominal mass
What to assess when looking for aortic aneurysms
Peripheral pulses
renal and neuro status
skin lesions on lower extremeties
Preop for aortic aneurysms
teach ab disease, treatment plans, and postop
-emotional support
Preop routines
-bowel prep
-NPO
-shower
-IV antibiotics right before incision
Post-op ICU monitoring
24-48 hrs
Devices
-arterial line
-CVP or PA catheter
-ET tube and mech ventilation
-peripheral IVs
-urinary cath
-NG tube
-MAYBE chest tube and lumbar drain
Needs continuous ECG monitor
Pulsox
Pain meds
Postop: maintaining graft patency
ensure
-normal BP
-IV fluids and blood components for adequate blood flow
-CVP or PA pressure monitoring
-Urinary output monitoring –> hourly
-Avoid severe hypertension –> might need drugs for that
Postop CV status
-continuous ECG
-electrolyte monitoring
-ABG monitoring
-give O2
-antidysrhythmic and antihypertensive meds
-pain control
-resume heart meds
Postop: infection
-antibiotic administration
-assess temp
-monitor WBC
-adequate nutrition
-look at wound site
-Hand hygiene and aseptic technique for all invasive catheters
-Perineal care to decrease risk of UTI
Postop GI status
-monitor for paralytic ileus –> bowel sounds
-passing of flatus
-record amt and character of NG tube output
-while NPO –> provide oral care
-abdominal assessment
-assess for bowel ischemia: no bowel sounds, feverm abdominal distention, diarrhea, bloody stools
Postop neuro status
LOC
ascending aorta
-pupil size and response to light
-facial symmetry
-speech
-ability to move upper extremeties
-quality of hand grasps
descending aorta
- neurovascular check to lower extremeties
Postop: peripheral perfusion status –> pulse assessment
frequent pulse assessment
-use doppler if needed
-mark pulse locations with felt-tip pen
ascending aorta and aortic arch
-carotid, radial, and temporal
descending aorta
-femoral, popliteal, posterior tibial, and dorsalis pedis
Post op: peripheral perfusion status
extremity assessment
-temp, color, capillary refill time, sensation, and movement of extremeties
vasospasm and hypothermia can cause absence of lower extremety pulses
absent pulses and cool/pale/mottled/painful extremety means embolization or graft occlusion –> REPORT IMMEDIATELY
Postop: renal perfusion status
-hourly urinary output (at first)
-accurate I and O
-daily weight
-CVP pressure
-blood urea nitrogen/creatine
-decrease in renal perfusion may occur with embolization of plaque to renal arteries, hypotension, prolonged aortic clamping or blood loss
