Week 4 - Peripheral Artery Disease, Acute Arterial Ischemia, Amputation Flashcards
what is peripheral artery disease
- thickening of the arterial walls that leads to progressive narrowing of the artery lumen
what is the leading cause of PAD
- atherosclerosis
where does PAD occur
- in extremities
what are the most significant risk factors for PAD (5)
- tobacco use
- hyperlipidemia
- elevated CRP
- DM
- HTN
what are other risk factors for PAD? (7)
- FHx
- hypertriglyceridemia
- hyperuricemia
- increasing age
- obesity
- stress
- sedentary lifestyle
what is the classic sign of PAD
- intermittent claudification
what is intermittent claudification
- an ischemic muscle ache or pain that is precipitated by a consistent lvl of exercise
how long does intermittent claudification last
- 10 min or less
- is reproducible
what causes intermittent claudification
- accumulation of end products of anaerobic cellular metabolism ex. lactic acid
what causes intermittent claudification to go away
- once the person stops exercising and the metabolites are cleared
PAD of the aortoiliac arteries produces pain where? (2)
- buttocks
- thinghs
PAD of the femoral or popliteal artery produces pain where? (1)
- calf
what is the best treatment for intermittent claudification (2)
- walking for 30-60 min/day and 3-5 times/week
- meds
what 2 meds are used for intermittent claudification
- pentoxifylline (trental)
- levocarnatine (cranitine)
what are the signs of PAD (9)
- parasthesia of toes or feet
- thin, shiny, hairless and taut skin
- cool skin
- diminished or absent pulses
- intermittent claudification
- neuropathies
- brittle nails
- prolonged cap refill
- non healing ulcers & gangrene (later)
what color does the skin turn in PAD and what impacts this (2)
- pallor if elevated
- red when dependent
how does pain in PAD change w time
- eventually will occur at rest too
what causes rest pain
- when there is insufficient blood flow to meet basic metabolic needs of distal tissues
when is rest pain more promininent during PAD? why?
- at night
- bc cardiac output drops and limbs are at lvl of heart
what position can help relieve pain in PAD (2)
- dangling legs over side of bed
- sleeping in chair
what are signs of critical limb ischemia (3)
- chronic rest pain
- gangrene
- ulceration
what are complications of PAD (6)
- delayed healing
- wound infection
- tissue necrosis
- nonhealing arterial ulcers **
- gangrene **
- amputation
what do arterial ulcers look like (2)
- round, punched out looking
- minimal drainage
where do arterial ulcers most commonly occur (4)
over bony prominences
- toes
- feet
- lower leg
- lateral malleolus
describe what you would find on assessment of an arterial ulcer (3)
- cool to touch
- decreased/absent pedal pulses
- cap refill >3 sec
what can be used to diagnose PAD (5)
- doppler US
- segmental BP at thigh, below knee, and at ankle
- ankle brachial index
- angiography
- magnetic resonance angiography
when is a doppler US useful
- if palpation of a peripheral pulse is difficult bc of severe PAD, it can determine the degree of blood flow
what is the ankle brachial index (2)
- a comparative test of BP of the arm vs ankle to monitor blood flow
- uses a handheld doppler
what are the categories of care for PAD (8)
- risk factor modification
- drug therapy
- exercise therapy
- nutritional therapy
- care of the leg with critical limb ischemia
- complementary and alternative therapy
- interventional radiology catheter-based procedures
- surgery
what risk factor modifications are imp to reduce CVD risk factors (6)
- healthy body weight
- regular physical activity
- smoking cessation
- optimal BP control
- optimal glycemic control
- lower cholestrol (thru diet & meds)
what diabetes increase the risk of for pts with PAD
- amputation
what type of meds are used for treatment of PAD (5)
- antiplt
- pentoxifylline (Trental)
- cilostazol (pletal)
- ACE-I
- alternative med therapy
why are antiplts imp for treatment of PAD (2)
- reduce risks of CVD events
- and reduce risk of death in PAD pts
what 2 antiplt meds are recommended for treatment of PAD
- aspirin OR
- clopidogrel (Plavix)
*combo therapy of the 2 are not recommended)
what are not recommended for prevention of CVD events in pts with PAD
- anticoagulants
what benefit do ACE-I have in treatment for PAD
- decreased morbidity & mortality risks
what 3 drugs are used to treatment intermittent claudification
- pentoxifylline (trental)
- cilostazol (pletal)
- levocarnatine (carnitor)
what does cilostazol do? (3)
promotes effects of prostaglandin :
- increased vasodilation
- inhibits platelet aggregation
what does trental do>
- increases RBC flexibility
- decreases blood viscosity
what are some examples of alternative med therapy that have been investigated in the treatment of intermittent claudifcation (4)
- vitamins
- minerals
- dietary
- herbal supplements
what should pts do prior to using alternative med therapy
- consult with their HCP prior to taking any dietary or herbal supplements if on antiplt, NSAIDs, or anticoags d/t interactions and bleeding risks
describe exercise therapy for a pt with PAD (5)
- walking
- supervised rehab PAD progrsm is best
- home exercise programs
- at home, strive for 30-40 min/day 3-5x/week
- the pt should walk to the point of discomfort, stop & rest, and then resume walking until it recurs
what nutritional therapy should be implemented for a pt with PAD (6)
- adjust their dietary intake so at a healthy weight
- high fruits & veggies
- high whole grains
- low cholestrol
- low sat fat
- low sat
how much cholestrol should a pt with PAD have per day
- less than 200 mg/day
how much salt should a pt with PAD have per day
- 2g/day
what is critical limb ischemia
- condition characterized by pain at rest or night and tissue loss such as gangrene or ulcers that attributed to PAD
what is optimal therapy for critical limb ischemia (3)
- revascularization via surgery or endovascular procedure
- aggressive CVS risk factor modification
- antiplt therapy to prevent CVD events
describe conservative management for critical limb ischemia (8)
- protect extremitiy from trauma
- decrease ischemic pain
- prevent and controll infection
- maximize perfusion
- avoid soaking feet to prevent skin maceration
- cover ulcers w dry, sterile dressing
- inspect, cleanse, and lubricate feet to prevent cracking and infection
- keep feet free of pressure
what teaching should be given to the pt regarding critical limb ischemia (2)
- select soft, roomy, protective footwear
- healing is unlikely without increased blood flood
what can be used to decrease pain r/t critical limb ischemia
- opioid analgesics
what bed position can decrease pain & increase perfusion to lower extremities r/t critical limb ischemia
- reverse trendelenburg
what 3 therapies could help prevent amputation in pts with critical limb ischemia
- spinal cord stimulation
- hyperbaric O2 therapy
- angiogenesis
what are interventional radiology catheter-based procedures
- alternatives to open surgical approaches for treatment of lower extremities PAD
describe ambulation after an interventional radiology catheter-based procedure
- most can ambulate same day
- and return to normal activity 24-48 h after
what do interventional radiology catheter-based procedures involve
- insertion of a specialized catheter into the femoral artery
what are 3 types of interventional radiology catheter-based procedures
- percutaneous transluminal balloon angioplasty
- atherectomy
- cyroplasty
what is the percutaneous transluminal balloon angioplasty procedure
- procedure that uses a catheter that contains a cylindrical balloon at the tip
- catheter is advanced to the narrowed (stenotic) area of the aerty
- when in place, balloon is inflated to open the artery
what is immeditaely deployed after balloon angioplasty? why?
- stent
- which acts as a scaffold to keep the artery open
what is an athrectomy
- removal of the obstructing plaque
what are the 2 types of atherectomy
- direct
- laser
what is direct atherectomy (2)
- catheter is inserted into femoral artery to break up plaque by cutting or rotation
- a cutting disc or rotational tip attached to end of catheter that pulverizes plaque to smaller than a RBC
what is a laser atherectomy
- same as direct
- but uses ultraviolet energy to break up the plaque
what is cyroplasty
- combines 2 procedures: balloon angioplasty and cold therapy
how does cyroplasty work (3)
- catheter inserted via femoral artery to narrowed area
- balloon is inflated w nitrous oxide that changes from liquid to gas as it enters the baloon
- expansion of the gas causes cooling to -10* which minimizes re-stenosis
what is required after interventional radiology catheter-based procedures
- antiplatelet meds to decrease risk of restenosis –> long term, low dose asa recommended
when is surgery indicated for PAD treatment (2)
- for long areas of stenosis
- or severely calcified arteries
what is the most common surgical therapy uses to improve blood flow beyond a stenotic or occluded artery
- peripheral artery bypass operation
what is a periperal artery bypass
- use of an autologous or artificial vein to bypass the diseased portion of the artery
what are typically used for peripheral artery bypass
- synthetic grafts
what are 2 other surgical options for PAD
- endarectomy
- patch graft angioplasty
what is an endarectomy
- opening of the artery & removing the plaque
what is a patch graft angioplasty
- opening of the artery, removing the plaque, and sewing a patch to the opening to widen the lumen
what is the least desired surgical option for PAD
- amputation
what should you teach a pt with PAD (8)
- how to reduce risk factors
- diet modification to reduce cholestrol, salt, sat fat
- proper care of feet
- infection control
- avoidance of injury to extremities
- tobacco use contraindicated
- physical activity imp
- instruct to inspect legs daily for mottling, changes in color, skin texture, amt of subcut fat, reduction in hair growth, skin temp, cap refill, pedal pulses
- report any changes to legs to HCP
- keep follow up appts
- monitor for worsening symptoms (rest pain)
imp to inspect daily bc they may have peripheral neuropathy = cant feel if something is wrong
describe post-op/post-procedure care for a pt with PAD (9)
- check operative extremity q15 min then q1h
- VS
- monitor for complications
- avoid placing pt in a knee flexed position (besides exercise)
- turn and position pt frequently w pillows to support incision
- encourage ambulation asap
- discourage long hours of sitting w legs dependent
- postop wound assessment
- pain management
what should you assess regarding the operative extremity (7)
- color
- temp
- cap refill
- peripheral pulses
- sensation
- movement
- pain
what complications should you monitor for post-op for PAD (6)
- bleedings
- hematoma
- compartment syndrome
- thrombosis
- embolization
- occlusion of stent
what are signs of occlusion of the stent or graft (6)
- dramatic increase in pain
- loss of previously palpable pulses
- extremitity pallor or cyanosis
- decreased ABIs
- numbness/tingling
- cold extremity
why should a post-op pt with PAD avoid prolonged sitting w leg dependency (4)
- pain
- edema
- increases risk of venous thrombosis
- places stress on suture line
what should you do if the pt experiences edema post-op (3)
- position pt supine
- and elevate edematous leg above heart
- may use compression sock
how can pts protect their extremities from trauma (7)
- protective roomy footwear
- clean cotton socks
- non restrictive clothing
- avoid heat & cold
- avoid pressure
- change position frequently
- avoid leg crossing
what should we teach pts regarding infection control w PAD (3)
- keep feet clean
- keep well lubricated (but not between toes)
- cover ulcers w sterile dressing
what is acute arterial ischemia
- sudden interruption in the arterial blood supply to a tissue, organ, or extremity
what can acute arterial ischemia lead to
- tissue death & gangrene if left untreated & after just a few hours
what can cause acute arterial ischemia (9)
- embolism (ex. from heart)
- thrombosis of athersclerotic artery
- trauma
- IE
- MI
- afib
- hypovolemia
- hyperviscosity
- hypercoaguability
what are the 6 P’s of acute arterial ischemia
- Pain
- Pallor
- Paralysis
- Pulselessness
- Paresthesia
- Poikilothermia
what is Poikilothermia
- adaptation of the limb to the environmental temp, most often cool
what is imp for acute arteril ischemia
- early treatment and intervention to keep the affected limb viable
what is the first step in treatment for acute arterial ishcemia (2)
- call physician
- keep client at rest
what type of meds are used for treatment of acute arterial ischemia
- anticoagulant (unfractured heparin, warfarin)
why are anticoagulants used for acute arterial ischemia
- prevent thrombus enlargement
- inhibit further embolization
if a pt is undergoing embolectomy, what should the pt be on after for long-term?
- long-term anticoag with warfarin
what is done to restore blood flow in acute arterial ischemia
- remove/dissolve clot
what are options for clot removal/dissolving
- percutaneous catheter-directed thrombolytic therapy
- percutaneous mechanical thromboectomy
- surgical thrombectomy
- surgical bypass
describe what percutaneous catheter-directed thrombolytic therapy is
- where a percutaneous catheter is inserted into the femoral artery, threaded to the site, and the thrombolytic drug is infused to break up the thrombus
how long does it take for thrombolytics to dissolve the clot
- 24-48 hr
the catheter may also act as…. in treatment of acute arterial ischemia
- mechanical thrombectomy device (can remove or fragment the thrombus)
when is surgical intervention indicated in acute arterial ischemia
- if have ischemia for more then 14 days when catheter-based interventions are not possible
what are surgical options for acute arterial ischemia
- direct arteriotomy
- surgical revascularization
- open artery, remove clot or bypass it*
when is amputation considered in acute arterial ischemia
- pts with ischemic rest pain & tissue loss
- and limb salave is not possible
what is the goal of amputation
- preserve extremity length and function while removing all infected, pathologically compromise, or ishemic tissue
describe what happens during amputationq
- skin and muscle layers cut
- major blood vessels clamped and severed
- bone is cute w special saw
- muscle stitched over bone
- skin closed over wound
describe preop management for a pt undergoing amputation (3)
- instruct on upper extremitity exercises to promote arm strength for crutch walking and gait training
- general post op care discussed
- educate on phantom limb sensation & phantom limb pain
describe post-op care after amputation (8)
- monitor for PTSD
- monitor VS
- monitor dressings
- prevent contractures
- keep clean
- monitor for infection
- pain control
- exercise regimen and crutch walking
describe how we should monitor for infection post amputaion
- inspect residual limb daily for irritation, excoriation, infection
what should you do if excoriation develops and the pt is using a prosthetic
- d/c use
describe how to keep the residual limb clean (3)
- wash every night
- no alcohol, powders, or oil to residual limb
- change limb sock daily
describe how to prevent contractures post-amputation (4)
- perform ROM daily
- do not elevate limb on pillow
- lay prone w hip in extension for 30 min, 3x/day
- avoid sitting in change for more than 1 hr with hip flexed
what can be used to treat pain post-amputation (3)
- opioids
- analgesics
- mirror therapy
