Adult II Exam V Vascular & Hematology

What is peripheral artery disease? At what age is the risk of PAD increased?

• Peripheral artery disease is a narrowing of the arteries in the extremities caused by thickening of artery walls

• As we get older, around 60-80 years old, the risk for peripheral artery disease increases

What changes occur in the vascular system as we age? What do these changes lead to?

1. Blood vessels walls thicken (as a result of cellular proliferation and fibrosis)

2. Blood vessels stiffen (thinning/calcification of elastin fibers and accumulation of collagen)

These changes lead to:

• Impaired blood flow

• Increased peripheral resistance

• Ischemia

• Left-sided heart failure (caused by increased left ventricular workload as the heart works harder to overcome increased peripheral resistance)

• Thrombosis/hemorrhage in the brain and kidneys

How can a nurse assess for intermittent claudication in patients?

Obtain an in-depth description pain and its precipitating factors

What is intermittent claudication? What causes it?

Intermittent claudication is a symptom of peripheral artery disease (PAD) caused by atherosclerosis, resulting in a muscular, cramp-type pain, discomfort, or fatigue in the extremities consistently reproduced with the same degree of exercise or activity and relieved by rest

What causes it?

• Intermittent claudication is caused by the inability of the arterial system to provide adequate blood supply to the tissues due to the increased demands for nutrients and oxygen during exercise

• Without the proper nutrients and oxygen supply, muscle metabolites and lactic acid are produced in the tissues, and severe pain occurs

How much of a peripheral artery must be occluded for intermittent claudication to occur?

Usually, about 50-75% of the artery must be occluded for intermittent claudication to occur

What decreases/resolves the pain from intermittent claudication?

Rest

For patients with intermittent claudication, how can the progression of PAD be evaluated?

Arterial disease progression can be evaluated by the measurement of the amount of exercise or distance the patient can walk before pain begins

What is rest pain in peripheral artery disease, and what does it indicate? What can help improve rest pain?

Rest pain: Persistent pain in the forefoot when the patient is resting

• Rest pain usually indicates a severe degree of arterial insufficiency and a critical state of ischemia

• The extremity usually has to be lowered to a dependent position to improve perfusion to the distal tissues

During a physical assessment of a patient suspected of having peripheral artery disease, what should you assess as the nurse?

1. Skin color/condition

2. Temperature

3. Peripheral pulses

On inspection of an extremity, what does cool/pale extremities indicate?

Inadequate blood flow

A patient has cool/pale extremities, they elevate the extremity and the lack of color increases. What does this mean?

The increased lack of color in the extremity with elevation means severe reduction of blood flow

On inspection of an extremity, what is rubor, and what does it indicate?

Rubor: A reddish-blue discoloration of the extremities that may be noticed within 20 seconds to 2 minutes after the extremity is placed in the dependent position; if the extremity is changed to an elevated position, it becomes cyanotic

• The presence of rubor suggests severe peripheral arterial damage

List s/s of severe peripheral arterial damage that may be found in affected extremities

1. Cool/pale extremities

2. Rubor

3. Loss of hair

4. Brittle nails

5. Dry or scaling skin

6. Atrophy

7. Edema

8. Ulcerations

9. Necrosis and/or gangrene w/ prolonged, severe ischemia

How should a nurse assess for peripheral pulses?

• Peripheral arterial circulation assessment is done by evaluating the presence, absence, or quality of peripheral pulses

• Never use only the index finger or the thumb to assess pulses (have strong arterial pulsations)

What could stenosis do to a peripheral pulse? What causes this?

• Stenosis (narrowing or constriction) of an extremity is indicated by the absence of a pulse

• Occlusive arterial disease impairs blood flow and can reduce or destroy palpable pulses in the extremities

Describe the general characteristics of the following regarding arterial insufficiency:

1. Pain

2. Pulses

3. Skin

Pain

• Intermittent claudication to sharp, unrelenting, constant

Pulses

• Diminished or absent

Skin

• Dependent rubor; with elevation, pallor of the foot

• Dry, shiny skin

• Cool-to-cold temperature

• Loss of hair over toes and dorsum of foot

• Nails thickened and ridged

Describe the general characteristics of the following regarding Venousinsufficiency:

1. Pain

2. Pulses

3. Skin Characteristics

Pain

• Aching, throbbing, cramping

Pulses

• Present, but may be difficult to palpate through edema

Skin

• Pigmentation in gaiter area (area of medial and lateral malleolus)

• Skin thickened and tough

• Skin may be reddish blue, frequently with associated dermatitis

Describe the following characteristics of arterial ulcers:

1. Location

2. Pain

3. Depth of ulcer

4. Shape

5. Ulcer base

6. Leg edema

Location

• Tip of toes, web spaces, heel or other pressure points if patient is immobile

Pain

• Very painful

Depth of ulcer

• Deep, often involving the joint space

Shape

• Circular

Ulcer base

• Pale to black and wet to dry gangrene

Leg edema

• Minimal unless extremity kept in dependent position constantly to relieve pain

Describe the following characteristics of venous ulcers:

1. Location

2. Pain

3. Depth of ulcer

4. Shape

5. Ulcer base

6. Leg edema

Location

• Medial malleolus, lateral malleolus, or anterior tibial area

Pain

• Minimal pain to very painful

Depth of ulcer

• Superficial

Shape

• Irregular border

Ulcer base

• Granulation tissue—beefy red to yellow fibrinous in chronic long-term ulcer

Leg edema

• Moderate to severe

What are doppler US flow studies used for?

• Machine used to assess for pulses when they cannot be easily palpated

• Used to detect the blood flow in vessels

• Can complete an ankle-brachial index (ABI) using a doppler US

What is an ankle-brachial index (ABI), and what does it quantify?

• The ankle-brachial index (ABI) is the ratio of the systolic blood pressure in the ankle to the systolic blood pressure in the arm

• This index is an objective indicator of arterial disease that allows the examiner to quantify the degree of stenosis

What ankle-brachial index (ABI) would a patient with claudication have?

Patients with claudication usually have an ABI of 0.90 to 0.50 (mild to moderate insufficiency)

What ankle-brachial index (ABI) would a patient with ischemic rest pain have?

Patients with ischemic rest pain have an ABI of less than 0.50

What ankle-brachial index (ABI) would a patient with severe ischemia or tissue loss have?

Patients with severe ischemia or tissue loss have an ABI of 0.40 or less

List nursing interventions for ABIs via Doppler US

1. Educate the patient about the study prior to the test

2. Instruct patients that they should avoid use of tobacco products or drinking caffeinated beverages for at least 2 hours prior to testing

List types of patients that a nurse should have a baseline ABI on.

Nurses should have a baseline ABI on any of the following patients:

1. Patient with decreased pulses

2. Any patient 70 years or older, especially patients with a history of diabetes or tobacco use

3. Patients who undergo an arterial interventional procedure or surgery

4. Patients with sudden cold or painful limbs

What is exercise testing used to determine?

What is a normal response? Abnormal?

• Used to determine how long a patient can walk and to measure the ankle systolic blood pressure in response to walking

Normal Response:

• A normal response to the test is little or no drop in ankle systolic pressure after exercise

Abnormal response:

• The ankle pressure drops in a patient with true vascular claudication

How is exercise testing performed?

• The patient walks on a treadmill at 1.5 mph with a 12% incline for a maximum of 5 minutes, or the test can be modified to walking a set distance in a hallway

• This test requires no running; the patient may have to walk on a slight incline

What is duplex ultrasonography used to evaluate?

What is it considered the gold standard for?

Duplex Ultrasonography: Using portable equipment, the extent of venous disease/the chronicity of the disease are determined

Used to:

1. Image and assess blood flow

2. Evaluate the flow of distal vessels

3. Locate the vascular disease (i.e., stenosis vs occlusion)

4. Determine the anatomic and hemodynamic significance of plaque causing stenosis

• It is the gold standard exam for diagnosing lower extremity venous thrombosis

What should you educate the patient prior to duplex ultrasonography?

1. The test is noninvasive and involves no patient preparation activities

2. The patient has to be NPO for at least 6 hours prior to the exam to decrease bowel gas production that can interfere with the exam

What does CT scanning provide?

What does it involve?

Provide:

• Computed tomography (CT) scanning provides cross-sectional views of soft tissue and visualizes the area of volume changes to an extremity and the compartment where the changes take place

• Can perform a CT on a lymphedematous arm or leg to view the extremity from multiple angles

Involve:

• The CT scan only requires a short period of time

• The patient is exposed to x-rays, and has a contrast agent injected into their blood vessels

In which patients is the use of a contrast agent for diagnostic imaging contraindicated?

The dye is contraindicated in children and patients with impaired renal function

What should the nurse monitor patients for after a CT w/ contrast is completed?

1. Patient’s urine output should be monitored post-procedure; it should be at least 0.5 mL/kg/hr

2. Monitor CT patients for contrast-induced acute kidney injury (can occur in 48-96 hours post-procedure)

3. Monitor for contrast-induced neuropathy

How can nurses help prevent contrast-induced neuropathy following multi-detector CT use?

• Oral or IV hydration 6-12 hours pre-procedure or administration of sodium bicarb, which alkalinizes the urine and protects the kidneys

You have a patient with allergies to iodine and/or shellfish, and they require a CT, what can be done to allow them to complete the CT?

Premedicate with steroids and antihistamines

What is angiography and why is it used?

Angiography: An arteriogram that is used to confirm the diagnosis of occlusive arterial disease when surgery or other interventions are considered; during the exam, a radiopaque contrast agent is directly injected into the arterial system to visualize the vessels

• The location of a vascular obstruction or aneurysm and the collateral circulation can be determined

What does a patient experience during an angiography?

• The patient experiences a temporary sensation of warmth as the contrast agent is injected

• The patient may also have local irritation at the injection site

What reactions could a patient have to the iodine in the contrast agent used for angiography? List the s/s of this.

What additional complications could occur from an angiography?

• The patient can have an immediate or delayed reaction to the iodine in the contrast agent

• S/s of a reaction: Dyspnea, nausea/vomiting, sweating, tachycardia, and numbness of the extremities)

Additional Complications from an Angiography:

1. Vessel injury

2. Acute arterial occlusion

3. Bleeding

4. Contrast nephropathy

What medications are used in the treatment of a reaction to contrast dye?

Treatment for a reaction to the dye: Epinephrine, antihistamine, or corticosteroid administration

How is magnetic resonance angiography performed/what is it used to do?

• Performed with an MRI w/ IV contrast dye and special software to isolate the blood vessels

• Can view the images from multiple angles

When is magnetic resonance angiography contraindicated?

• Contraindicated in patients with metal implants or devices (pacemakers, old tattoos)

• Requires the use of IV contrast dye, so the same nursing contraindications as CTs (contraindicated in children and patients with renal impairment)

List nursing interventions for the performance of magnetic resonance angiography.

Same as CT since it uses IV contrast dye:

1. Patient’s urine output should be monitored post-procedure; it should be at least 0.5 mL/kg/hr

2. Monitor these patients for contrast-induced acute kidney injury (can occur in 48-96 hours post-procedure)

3. Patients with allergies to iodine or shellfish may need to be pre-medicated with steroids and antihistamines

What should nurses educate patients/prepare them for regarding magnetic resonance angiography?

1. The nurse should educate the patient about what to expect before and after the procedure

2. Inform the patient that they have to lie on a cold, hard table that slides into an enclosed, small tube

3. May have to sedate claustrophobic patients.

What occurs during contrast phlebography (venography), and when is it typically performed?

• During contrast phlebography (venography), a radiopaque contrast dye is injected into the venous system to enhance x-ray imaging

• This test is generally performed if the patient has to undergo thrombolytic therapy

What result on contrast phlebography (venography) indicates that there is a thrombus?

If there is a thrombus, the x-ray will show an unfilled segment of a vein, and the rest of the vein will be filled

What should the nurse educate a patient on before contrast phlebography (venography)?

The patient has to be informed that he/she may feel painful vein inflammation for a brief period

What should the nurse monitor for after contrast phlebography (venography)

• The patient has to be monitored 2 hours post-test for access site oozing or hematoma formation

Other considerations are the same as CT since it uses IV contrast dye:

1. Patient’s urine output should be monitored post-procedure; it should be at least 0.5 mL/kg/hr

2. Monitor these patients for contrast-induced acute kidney injury (can occur in 48-96 hours post-procedure)

3. Patients with allergies to iodine or shellfish may need to be pre-medicated with steroids and antihistamines

What does lymphoscintigraphy involve, and what is it used to study?

1. This exam involves the injection of a radioactively labeled colloid subcutaneously into the second interdigital space

2. The extremity is then exercised

3. After exercising the extremities, serial images are obtained at preset intervals

Used to Study:

• The lymphatic system

• Used a lot with breast cancer patients

List nursing implications for lymphoscintigraphy.

1. Make sure the patient is educated about the procedure

2. The blue dye used for this procedure may stain the injection site.

3. If the patient has a leak (usually with groin incisions), the incision area may drain blue dye for several days until it clears out of the system

What is arteriosclerosis?

Arteriosclerosis is a thickening, or hardening, of the arterial wall that is often associated with aging

• Arterio = Artery hardening

What is the number one cause of peripheral artery disease?

Arteriosclerosis

• Art has PAD

Do arteriosclerosis and atherosclerosis tend to occur together, or separately?

Although arteriosclerosis and atherosclerosis have different pathologic processes, one disease does not usually occur without the other

What is atherosclerosis?

Atherosclerosis is a type of arteriosclerosis where there is plaque formation (of lipids, calcium, blood components, carbohydrates, and fibrous tissue) within the arterial wall, causing them to narrow

• Athero = A-fatty-plaque-buildup

What is atherosclerosis the leading risk factor for?

Atherosclerosis is the leading risk factor for heart disease

• A hero’s heart is diseased

Explain what occurs in atherosclerosis

The exact pathophysiology is unknown, but what happens is:

1. There is a thickening of the innermost and middle layers of the arterial wall which narrows the lumen of the artery, most often affecting the intima of large and medium-sized arteries

2. When the lumen of the artery is narrowed, blood flow decreases, which causes the signs and symptoms of the disease

3. With the atherosclerosis process, the arteriole lumens narrow; the blood flow decreases; and then the disease process begins

A patient is found to have atherosclerosis of the vessels in their legs, what does this mean regarding the rest of their arteries?

When the disease is present in the extremities, it is usually present elsewhere in the body

What arteries are most often affected by atherosclerosis?

LARGE arteries:

• Usually, the disease affects the larger arteries, such as the aorta, carotid, vertebral arteries, renal, iliac, and femoral arteries

What are the direct results of atherosclerosis in the arteries?

1. Narrowing (stenosis) of the lumen

2. Obstruction by thrombosis

3. Aneurysm

4. Ulceration

5. Rupture

What are the types of atherosclerotic lesions?

1. Fatty streaks

2. Fibrous plaques

Describe the atherosclerotic lesion, fatty streaks, including:

1. What are they composed of?

2. In what age groups are they found?

3. What are they associated with or not associated with?

4. What sx do they produce?

Fatty streaks are composed of lipids and elongated smooth muscle

• The lesions have been found in people of all ages, including infants

• It is not clear if the fatty streaks predispose a person to the formation of plaques or not

• People with fatty streaks do not usually have clinical symptoms

Describe the atherosclerotic lesion, fibrous plaque, including:

1. Appearance

2. What are they composed of?

1. The fibrous plaque is elevated and protrudes into the vessel lumen, either partially or completely obstructing blood flow through the artery

2. They are composed of smooth muscle cells, collagen fibers, plasma components, and lipids

Where are fibrous plaques typically found?

They are usually found in the:

1. Abdominal aorta

2. Coronary arteries

3. Popliteal arteries

4. Internal carotid arteries

How are fibrous plaques classified?

1. Stable plaques

2. Unstable plaques

1. What do unstable plaques have a high risk of?

2. What does this cause?

1. Unstable plaques have a high risk of rupturing and are often clinically silent if and when they do

2. Unstable plaque rupture causes more severe damage

—>They result in rapid thrombus formation that may suddenly block a blood vessel

—>The blockage can lead to ischemia and/or a myocardial infarction

What happens to fibrous plaques in the final stage of atherosclerosis?

In the final stage of atherosclerosis, the fibrous plaques become calcified, hemorrhagic, ulcerated, or thrombosed, and affect all the layers of the arterial vessel

What occurs when a stable plaque ruptures?

When a stable plaque ruptures, thrombosis (blood clot) and constriction obstruct the vessel lumen, causing inadequate perfusion and oxygenation to distal vessels

List the controllable (modifiable) risk factors for atherosclerosis.

1. Tobacco use

2. Diabetes (speeds the atherosclerotic process by thickening the basement membranes of both large and small vessels)

3. Hypertension

4. Hyperlipidemia (elevated LDLs and low HDLs = chemical injury to arterial walls)

5. Diet (contributing to hyperlipidemia)

6. Obesity

7. Sedentary lifestyle

8. Stress

9. Elevated C-reactive protein

10. Hyperhomocysteinemia

List the non-modifiable risk factors for atherosclerosis. Why are these risk factors?

1. Increasing age

2. Female gender

3. Familial predisposition/genetics

4. Trauma

Why?: All of these can weaken arterial vessels

What is one of the most important controllable (modifiable) risk factors for atherosclerosis?

Why?

• Tobacco is one of the most important risk factors

Why?

• Nicotine decreases blood flow to the extremities (vasoconstriction) and increases heart rate and blood pressure to increase

• Smoking can increase the risk of clot formation

What can cause chemical injuries to the arterial vessel walls, raising the risk for atherosclerosis?

1. Elevated LDLs (bad cholesterol) and low HDLs (good cholesterol)

2. Elevated levels of toxins in the bloodstream (i.e., like in renal failure)

3. Carbon monoxide in the bloodstream (i.e., from smoking)

What chronic disease can cause premature and severe atherosclerosis in adults of any age?

Why?

What else does this condition increase the risk for?

• Adult patients of any age with severe diabetes mellitus frequently have premature and severe atherosclerosis from microvascular damage

• Premature atherosclerosis occurs because diabetes promotes an increase in LDL-C and triglycerides (lipids) in plasma

• Diabetes can increase the overall risk of PAD two to four-fold (have an earlier and more rapid onset), and increase the risk for amputations

What are c-reactive protein levels associated with regarding vascular disease?

• C-reactive protein levels have been a sensitive marker for cardiovascular inflammation

• Increased levels are associated with an increased risk of damage in the vasculature, especially when accompanied by other risk factors

What is hyperhomocysteinemia, what is it correlated with, and how can you manage this?

Hyperhomocysteinemia: High levels of homocysteine, a protein that promotes coagulation. in the blood

• Correlated with increased risks of peripheral, cerebrovascular, and coronary artery disease as well as venous thromboembolism

• Folic acid and vitamin B12 have been reported to reduce serum homocysteine levels (may not reduce adverse cardiovascular events).

What is included in the assessment of a patient with atherosclerosis?

1. The assessment of a patient with atherosclerosis includes a complete assessment of the cardiovascular system because these patients often have associated heart disease

2. Be sure to check the blood pressure in both arms of the patient

3. Palpate the pulses of the patient, checking for consistency

4. Check the extremities for temperature differences and circulation

5. Assess the patient’s carotid, femoral, and popliteal arteries for a bruit

Why is it important to assess BP in both arms of a patient with known atherosclerosis?

• Taking Bp in both arms helps identify narrowed arteries (subclavian stenosis) and assess cardiovascular risk

• A consistent difference in systolic BP of >10 mmHg between arms indicates arterial plaque buildup, signaling a higher risk of stroke, heart attack, and peripheral artery disease

A nurse is assessing a patient with atherosclerosis. Why is it important for the nurse to check the extremities for temperature differences and circulation?

If the patient has atherosclerosis, the extremity may be cool or cold with a diminished or absent pulse

What is a bruit?

How and where can the nurse find a bruit?

• Many patients have a bruit (turbulent swishing sound) in the larger arteries that can be heard with a stethoscope or a Doppler

—>A bruit is heard as a result of blood trying to pass through a narrowed artery

• A bruit is considered abnormal, but it does not indicate the severity of the disease

• They are often found in the carotid, femoral, and popliteal arteries

What lab is typically elevated in patients with atherosclerosis?

Patients with atherosclerosis often have elevated lipid levels, including cholesterol and triglycerides (can get a lipid panel—HDL and LDL tests—to check these)

What is a normal cholesterol level (total cholesterol)?

Cholesterol levels should be below 200

What triglyceride level in men and women is considered hypertriglyceridemia?

• Triglyceride level of 160 mg/dL or above in men = hypertriglyceridemia

• 135 mg/dL or above in women = hypertriglyceridemia

What is the ideal LDL-C (bad cholesterol) level in healthy people?

What level is ideal for patients with cardiovascular disease or diabetes?

LDL-C (“bad” cholesterol) should be below 130 for healthy people and below 70 for patients with CVD or Diabetes

What is the desired HDL-C (good cholesterol) level in men and women?

Men: 45mg/dL or above

Women: 55mg/dL or above

What must LDL-C and HDL-C levels be for atherosclerosis to occur?

For atherosclerosis to occur, the LDL-C must be elevated and the HDL-C will be decreased

Why is it common for atherosclerosis not to be found until it is in its later stages?

Atherosclerosis progresses for years before clinical signs/symptoms occur

How often is it recommended that low-risk people, 20 years of age or older, have their total serum cholesterol checked in the U.S.?

• Because of the high incidence in the U.S., low-risk people 20 years of age or older, are advised to have their total serum cholesterol level checked at least once every 5 years

What are patients with multiple risk factors for atherosclerosis called?

Coronary disease equivalents

What do interventions for coronary disease equivalent patients focus on? List example interventions.

Interventions for these patients focus on lifestyle changes:

1. Teach these patients to make these changes by avoiding or minimizing modifiable risk factors, such as smoking, weight management, and increasing exercise

2. Nutrition is one of the most important interventions of the lifestyle plan

List nutritional recommendations for lowering LDL-C levels

1. Consuming a diet high in vegetables, fruits, and whole grains

2. Consuming low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils (like canola), and nuts

3. Limiting the intake of sweets, sugar-sweetened beverages, and red meats

4. Aiming for a dietary pattern that includes 5-6% of calories from saturated fat

5. Reducing the percent of calories eaten that come from trans fat

6. Instruct the patient to increase the dietary fiber to 30 g per day

What physical activity level/amount is recommended to reduce LDL-C levels?

• Aerobic physical activity 3-4 times per week, each session lasting at least 40 minutes and involving moderate-to-vigorous activity

What is the first-line pharmacologic option for treating hyperlipidemia?

3-hydroxyl-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors, or ‘statins’

What do statins do? List example statins.

Statins lower both LDL-C and triglyceride levels

Example Statins:

1. Lovastatin (Mevacor)

2. Simvastatin (Zocor)

3. Pitavastatin (Livalo)

What is Ezetimibe (Zetia) used to treat and how?

• Ezetimibe (Zetia) may be used in place of or in combination with statin medications to reduce a patient’s cholesterol levels

• This drug inhibits the absorption of cholesterol through the small intestine

What is Vytorin, and what is it used to tx?

Vytorin is a drug used for atherosclerosis that works by reducing the absorption of cholesterol and by decreasing the amount of cholesterol synthesis in the liver; it is a combination of Zetia and Simvastatin

List statin combination drugs

1. Vytorin (Zetia and Simvastatin(

2. Adicor (niacin and Lovastatin)

3. Pravigard (Aspirin and Pravastatin)

4. Caduet (Amlodipine [Norvasc] and Atorvastatin)—>Caduet lowers BP, decreases triglycerides, increases HDL-C, and lowers LDL-C

List bile acid sequestrant medications used to reduce lipid levels.

1. Cholestyramine (Questran)

2. Colesevelam (WelChol)

3. Colestipol (Colestid)

What vitamin might lower cholesterol/help to manage atherosclerosis?

• Nicotinic acid (niacin), a B vitamin, may lower LDL-C and VLDL (very low-density lipoprotein) cholesterol levels and increase HDL-C levels in some patients

• This medication can be used alone or with a statin drug

• There is lacking evidence to support the effectiveness of this medication

What is recommended with the use of Niacin to lower cholesterol/manage atherosclerosis? Why?

• Low doses are recommended because many patients experience flushing and a very warm feeling all over.

• Higher doses can result in the elevation of hepatic enzymes

What is Lovaza, and what does it do?

• Lovaza (omega-3 ethyl esters) is another alternative FDA-approved therapy used as an adjunct to diet to reduce triglyceride levels greater than 500

• This drug also decreases plaque growth and inflammation to reduce clot formation

List the groups of surgical procedures used to manage atherosclerosis

Surgical procedures are divided into two groups:

1. Inflow procedures

2. Outflow procedures

What are inflow procedures?

Inflow procedures are used in the surgical management of atherosclerosis to improve blood supply from the aorta into the femoral artery

• These procedures are done with diseases of the aorta