Peripheral Vascular Disease

Peripheral Vascular Disease

Diseases of the blood vessels (arteries and veins) located outside the heart and brain

Causes of PVD

-Flow problem

-Damage or obstruction

-arteries: thrombus, plaque, trauma, Atherosclerosis most common cause

-Veins: thrombus, incompetent valves

-Pump problems: RHF or LHF

-Lymph problems: Cancer surgery, rafiation

Peripheral Artery Disease: Atherosclerosis

-most common chronic arterial disorder

-Deposit of fat and fibrin obstructs and hardens arteries

-5 P’s: Pulses, pain, pale, paresthesia, paralysis

-Most common cause of amputations

PVD: Risk factors and prevalence

-Risk factors: HTN, family history, metabolic syndrome, DM, african-american, smoking, hyperlipidemia

-Prevalence: older than 70, younger 50-69→ related to smoking

Assessment- Skin appearance

-Mottled appearance

-Dependent rudor

-Weak or no pulses, may need a doppler

-cold or numb toes, brittle nails, necrotic tissues

Assessment- Pain

-Intermittent claudication

-Pain when walking because the muscles need more oxygen, destructed in vessels, ischemia, when they sit down the pain will go away

-Early symptom

Assessment- Blood Flow

-Capillary refill- may be longer

-Pulses: may need doppler to find

Ankle Brachial index

-Average ankle pressure/ average arm pressure

>1.4: non-compressible calcification of vessel→ refer to vascular specialist

-1.0-1.4: normal, no blockage→ no treatment

-0.9-1.0: borderline→ your ABI is slightly lower than normal but not low enough to diagnose PAD

-0.8-0.99: mild arterial disease→ treat risk factors

-0.5-0.79: moderate blockage→ refer to vascular specialist

-<0.5: severe blockage→ refer to vascular specialist

Peripheral Arterial Disease- management

-Reduce risk factors

-Smoking cessation→ EBP: reduced progression and risk of amputation

-Lipid lowering diet→ EBP: regression, less claudication

-Disease Management program: Diabetes control, HTN control

-Promote circulation/vasodilation

-EBP= walking regimen decreased symptoms greater than angioplasty→ goal: 50 minutes/ 3x week

-EBP= anti-platelet agent: Aspirin (1st choice), Plavix, Pletal, Trental

-Promote circulation to lower extremities→ do not criss legs, position limbs dependently, keep extremities warm

Treatment for PAD

-walking

-Arterial stents

-Bypass vessels

-Amputation

Varicose Veins

-Irregular torturous veins

-Usually effects veins of lower extremities (saphenous veins)

-Caused by long standing increased venous pressure

-Veins valves become incompetent

Varicose Veins- Incidence and risk factors

-Nursings at high risks

-Age

-occupations with long periods of standing

-family history

-Caucasians

-pregnancy

-increase with older adults 

Varicose Veins- Manifestations

-Dilated veins

-Aching

-leg fatigue

-itching

-feelings of heat

-thin discolored skin above the ankle

Varicose Vein- treatment

-Conservative

• Compression stockings (augment muscle pumping action of legs), leg elevation, exercise

-Ablation therapy

-Sclerotherapy

-Vein stripping

Vein Ablation

-Laser or radio frequency

-Heated catheter creates scare tissue and causes vein to close

-treats varicose veins and chronic venous insufficiency

Chronic Venous Insufficiency

-Inadequate venous return over a period of time

-Valve injury, can’t prevent back flow

Symptoms: pain described as aching or heavy, edema, altered pigmentation, dilated superficial veins, and stasis dermatitis, brownish discoloration of the skin if RBC leaking into tissue surrounding veins

Venous stasis ulcer

-Common complication of CVI

-Comprise 50%-70% of leg ulcers

The lymphatic system

-essential for fluid balance in the body

-Removes macromolecules too large for reabsorption into circulatory system

-Lymphedema occurs when there is damage or destruction of the lymphatic pathway

-Primary Lymphedema

-Secondary Lymphedema

Lymphedema

-Chronic debilitating disease

-Requires lifelong management

-If untreated can progress causing:

• Continued proliferation of fibrotic tissue

• increase in size of infected limb

• chronic infections

-Results in an increase in functional impairment and a decrease in quality of life

Lymphedema- treatment

-Complete decongestive therapy

-Standard treatment for management of lympedema

-Manual lymph drainage

-Bandaging

-Exercise

-Skin and nail care

-Instruction in self care

Lymphedema- Home care to prevent injury

-Inspect daily for problems: changes in temp, appearance, edema

-Wash and moisturize feet daily

-Between toes, mild soap, lukewarm water

-rinse, pat dry versus rub dry

-Apply moisturizer (avoid excess)

-Do not apply moisturizer between toes

-Prevent injury: trim nails, always wear socks and shoes, protect feet from hot and cold, choose well fitting shoes

-Promote circulation: avoid crossing legs, regular walking, stop smoking

-Educate regarding when to contact HCP: any skin breakdown, redness, or pain

Lymphedema- Surgery

-Lymphaticovenular Bypass

-Microscopic surgery

-Lymphatic fluid is redirected to drain through small veins

Deep Vein Thrombosis (DVT)

-The formation of blood clots in the deep veins of an extremity

-Can originate in any extremity

-80% originate in deep veins of calf

-Most common complication of surgery and immobility

Venous Thromboembolism (DVT/PE)

-Increased risk for surgical patient without DVT prophylaxis

-Pulmonary embolism major complication

-Roughly 1 out of 10 hospital deaths are related to blood clots in the lungs

-Blood clots may remain in the vein or dislodge and travel to the lungs causing pulmonary embolism

DVT- Who is at risk

-Hospitalized, immobile

-Surgery→ 20% increase, 50% increase for orthopedic surgery

-Obesity

-Smokers

-Oral contraceptives

-Central venous catheters

DVT assessment

-Symptoms of affected extremity

• Dull, aching pain, tenderness, warmth, erythema

• Edema (increase in extremity circumference)

-May be asymptomatic

-Pulmonary emboli may be the first sign

DVT- management

-Prophylaxis→ early ambulation, sequential compression devices, compression stockings

-Vast number of RCT prove that primary prophylaxis can reduce the incidence of DVTs

-Medications: LMWH, Heparin

DVT- Diagnosis

-Duplex venous ultrasonography: measure the velocity of flow in veins

-D-Dimer: Lab test, a compound formed after thrombin converts fibrinogen to fibrin, negative result use to rule out presence of a blood clot

Treatment for venous thromboembolism

-Anticoagulants= 1 of 3 most dangerous classes of meds associated with adverse events

-Heparin

-Warfarin (coumadin)

-Complex management during: Prescribing, administering, monitoring, Pt education, reversal and recognition of complications

PTT or Anti-Xa

-Partial Thromboplastin Time

-drawn frequently, every 2-6 hours as per nomogram

-All values are drawn STAT

-pt must achieve 2 consecutive therapeutic PTTs or Anti-Xa to be able to then draw PTT or Anti-Xa once daily

Anti-Xa

-Test that measures anti-thrombin activated factor Xa levels in plasma

-Levels of factor Xa inhibition can help calculate heparin concentration present in blood sample

-Less factors that interfere with Anti-Xa levels compared to PTT

-Therapeutic range: 0.3-0.7 IU/mL

-Therapeutic range can vary according to indication for heparin therapy

Management of IV heparin therapy (DVT)

-Baseline PT/PTT, Anti-Xa, H/H, and Platelet count required before therapy is initiated

-Platelet count and H/H QD

-Assess for HIT (heparin-induced thrombocytopenia)→ report Plt count: <150,000 or a 30-50% reduction

-Assess for signs of bleeding: stool guiac, hematuria

-Reversal agent: Protamine Sulfate

Management of Warfarin (DVT)

-given simultaneously with heparin until Warfarin is therapeutic and then heparin is discontinued

-Should be given same time every day

-Usually on for 3-5 months

-INR monitored frequently, range is 2-3 usually

-Pt education essential → safety

-Dietary instruction

-Reversal agent: Vitamin K

-Do not take any OTC meds or herbal supplements without consulting MD first

-Wear medical alert bracelet

-NO smoking or alcohol

-Obtain blood work as ordered

-Take precautions to avoid bleeding

-Report to ED for episode of bleeding

Factor Xa inhibitors- Anticoagulants

-Rivaroxiban, Apixaban

-Does not effect platelet aggregation

-Short half life so can discontinue 2 days before surgery and resume 6-10 hours post surgery

-Interacts with many meds and OTC herbals

-Contraindicated in renal impairment (CrCl <30ml/min) and hepatic impairment

Surgery for Venous Thromboembolism

-Inferior vena cava filter→ catch blood clots from going into the lungs, done if they can’t take anticoagulant therapy

-Thrombectomy

Layers of Artery

-Tunica Intima

-Tunica Media

-Tunica Externa

Thoracic and Abdominal Artery Aneurysms

-Localized dilation of aorta

-Common causes: atherosclerosis, HTN

-Types:

-True: saccular, fusiform

-False: dissecting

-Can involve aortic arch, thoracic aorta, and abdominal aorta

Thoracic and Abdominal Aneurysms- At risk

-Male, 6th or 7th decade, increase BP, atherosclerosis, smoker

-Increase in size means increase in risk of rupture

-Subjective data: depends on location, size, growth

Thoracic and Abdominal Aneurysms- diagnosis

-Angiogram

-Chest X-ray

-Echocardiogram

-Computed Tomography (CT)

-Magnetic resonance imaging (MRI)

Abdominal Artery Aneurysms

-If asymptomatic: aggressive BP control, serial imaging, surgery when >= 5.5 cm

-Surgical management

-Two types

-Endovascular grafting (EVSG) or Endovascular Aneurysm repair (EVAR)

-Open approach

-Mortality: Less then 5% for elective and 40% for emergent

Abdominal Artery Aneurysms- Nursing management

-Pt teaching: surveillance

-Unexplained back, chest, flank pain

-Falling BP or hematocrit

-Smoking cessation

Postoperative: monitor vital signs (BP WNL), assess peripheral pulses, assess bleeding, pain, fever; avoid coughing, sneezing, vomiting

-Do not want to put on any increased pressure

Aortic Dissection

-Life-threatening emergency if Type A

-Tear in the tunica intima of the aorta

-Hemorrhage into tunica media

-Splits the vessel wall, forming a blood filled area between the 2 layers

-HTN accounts for 70% of dissections

-Sudden severe excruciating (tearing or ripping) pain located in the back and/or chest

-Other symptoms include: syncope, dyspnea, hypotension, absent peripheral pulses

-If major arteries effected: ischemia or effect to major organs

Type A Aortic Disseciton

-Emergent surgery

-High risk for life threatening complications

-Only contraindication for surgery is if presence of comorbidities impact survival to one year or less

Type B Aortic Dissection

-Surgery reserved for development of complications related to dissection

-If uncomplicated generally manage medically

-More for abdominal aneurisms

-Medical management

-BP control

-Imaging surveillance