PVD part 1

What are the 2 main types of Peripheral Vascular Disease? (PVD)

Arterial and Venous

What are the 3 main Arterial PVD?

• Stenosis/Occlusion

• Aneurysm

• Dissection

What are the 2 main Venous PVD?

• Stasis/Insufficiency

• Thromboembolism

  • PE and DVT

What is an Aneurysm?

Part of artery wall weakens, allowing it to ballon out or widen abnormally

Where are Aneurysms more common? (4)

• Any Vessel

  • Brain

  • Heart

  • Thoracic Aorta

  • Abdominal Aorta

What is a Dissection?

Tear in INTIMA layer allows blood to leak through >> Separating inner and middle layers

2 Primary S/S of Dissecting Aneurysm?

• Sudden severe chest or upper back pain

• Sudden severe stomach pain

Sudden Severe Chest or Upper Back Pain of a Dissecting Aneurysm is often described as what?

" Tearing or Ripping" that can spread to the neck or down the back

Other S/S of Dissecting Aneurysm: cope? breath? Issues similar to what? Unilateral weak/strong what?

• Syncope

• SOB

• Sudden vision problems, difficult speaking, weakness or hemiparesis (Similar to CVA)

• Unilateral weak pulse in one arm or thigh

What is Peripheral Artery Disease (PAD)? Which reduces what?

• Narrowing or occlusion of arteries OUTSIDE of the heart

• Reduced blood flow to extremities, gut, kidneys, head

What is primary cause of PAD? And what else may develop?

• Atherosclerosis

  • Collateral circulation may develop if atherosclerosis is gradual

What’s collateral circulation?

Body generates new blood vessels

What are risk factors for PAD? Habit? BP? Hyper what? Body? Diet? Age? Disease?

• Smoking

• HTN

• Hyperlipidemia

• Obesity

• Diabetes

• Older age (15-20% over age 70)

• Coronary artery disease

Main PAD symptom:

Intermittent Claudication!

What is Intermittent Claudication?

Limb pain or cramping w exercise, resolves w rest (just like angina)

What are other s/s of PAD? In what position? What’s on the LE? Hot/cold?

• Pain (burning, aching) at rest, lying flat/LE elevated

• Ulcers/sores/wounds on toes, feet, or legs that heal slowly, poorly, or not at all

• Coldness in affected extremity

What are other s/s of PAD? What’s the skin color like? Possible what? What’s weak/absent?

• Pale or cyanotic, dusky red color

• Possible numbness

• Weak or absent pulses (Dorsalis Pedis and Post Tib)

Claudication Scale: (1-4)****

• 1 >> Initial Discomfort (Established but minimal)

• 2 >> Moderate Discomfort but attention can be diverted

• 3 >> Intense Pain (Attention cannot be diverted)

• 4 >> Excruciating and Unbearable Pain

Is it okay to exercise if pt has pain? And why?

YES <<

• Exercise through pain to drive blood to periphery

• If pt stays stationary, pt will get worse

Study this?

Differential Dx - Claudication: Delordosing

• Neurogenic: Pain Improvement

• Vascular: No Effect

Differential Dx - Claudication: Lordosing

• Neurogenic: Pain Exacerbation

• Vascular: No Effect

What are the 2 main EMERGENT PAD Complications?

Acute Limb Ischemia and Osteomyelitis

What are the 3 NON-EMERGENT PAD Complications?

• Critical Limb Ischemia >> Chronic

• Stroke

• MI

What is Acute Limb Ischemia?

Sudden decrease in limb perfusion, potentially threatening limb variability

Acute Limb Ischemia S/S (The 6 P's)

• Pn

• Pallor

• Paresthesias

• Poikilothermia (Coldness)

• Pulselessness

• Paralysis

What is Acute Limb Ischemia due to?

Embolism or Thrombosis

3 Critical Limb Ischemia - Chronic S/S:

• Pn at rest, w elevation

• Arterial Insufficiency Ulcers

• Gangrene

PT Management of Arterial PAD: maximize what 3 things?

• Maximize quality of life, general health and well-being

• Maximize aerobic capacity, O2 transport

• Maximize general strength, peripheral O2 extraction

• Education

What should the PT Educate the pt who has PAD? What should they assess daily?

• Atherosclerosis/heart disease process, CAD/cardiac risk factors, disease prevention, self-management

• Good foot and skin care (assess daily for signs of skin breakdown)

Chief Complaints/Impairments of Arterial PAD: (Pt 1) (4)

• Pain > claudication

• Poor/non-healing wound or ulcer

• Decreased exercise/activity tolerance

• Impaired peripheral circulation (ABI, Palpation)

Chief Complaints/Impairments of Arterial PAD: (Pt 2) (3)

• Impaired muscle function/strength

• Impaired aerobic capacity/endurance

• Impaired respiration/gas exchange (PE)

What to INSPECT during Vascular Exam for PAD pts? (4)

• Color

• Ulcers

• Edema

• Symmetry

What to PALPATE during Vascular Exam for PAD pts? (2)

Temp and Pulses

Palpation: What special tests can a PT do on a PAD pt? (6)

• ABI

• Rubor Dependency

• Capillary Refill

• Pitting Edema

• Venous Filling Time

• Calf Girth

Arterial PAD Skin Changes presentation (Pt 1) (4) gets worse with what?

• Shiny, tight, dry, hairless

• Thickened toenails

• Cool/cold to touch

• Pallor, pale or bluish color to skin (peripheral cyanosis) >> worse with elevation

Arterial PAD Skin Changes presentation: what comes out on the LE? What tests for arterial insufficiency?

Ulcers and Rubor of Dependency

Ulcer Presentation: may or not be what? What does it do to the skin? Where? Is it fast/slow?

• May or may not be painful

• Ischemic, gangrene (tissue necrosis)

• Result of trauma - common in toes and heel

• Develop rapidly

What are the 7 main Arteries to palpate for Arterial PAD?

• Dorsalis Pedis

• Post Tib

• Femoral

• Popliteal

• Radial

• Brachial

• Carotid

Pulses Scale

• 4+ = bounding

• 3+ = increased

• 2+ = normal

• 1+ = diminished

• 0 = absent, unable to palpate

Changes in pulse is the most important sign of what?

Arterial Insufficiency

How to perform Capillary Refill test? What’s the normal wait time?

-Compress nailbeds until blanched

• Normal flesh coloration returns in 3-5 sec

Capillary Refill Test: What does Prolonged time (~ 15-20 secs) mean?

Arterial Insufficiency

What does Rubor of Dependency assess?

Arterial Insufficiency

What to watch out for in Rubor Dependency Test? (2)

• Pallor w Elevation

• Deep red color in 20-30 sec in dependent position

What needs to be competent in order to perform Rubor of Dependency Test?

Veins

Step 1 of Rubor Dependncy Test and the grades?****

• Elevate LE 60 deg for 1 min

• 0 = normal, no pallor

• 1 = definite pallor in 60 sec

• 2 = pallor in 30-60 sec

• 3 = pallor in < 30 sec

• 4 = pallor without elevation

Step 2 of Rubor Dependency Test and what do you assess?****

• Put limb in LE dependent

• Assess time for normal flesh color to return

Step 2: what are the 3 Timeframes for Normal Flesh Color to Return

• Normal: 10-15 sec

• Moderate Occlusive Disease: 15-25 sec

• Severe Ischemia: > 40 sec

What color indicates Arterial Insufficiency?****

DEEP RED COLOR >> in 20-30 secs