peripheral vascular dysfunction

peripheral vascular disease

- arterial

- venous

arterial peripheral vascular disease

- stenosis/occlusion

- aneurysm

- dissection

venous peripheral vascular disease

- stasis/insufficiency

- thromboembolism (DVT, PE)

arterial dysfunction

aneurysm

aneurysm

- part of artery wall weakens, allowing it to balloon out or widen abnormally

- named for location and characteristics (aortic aneurysm)

- can occur in any vessel, most notably in the brain, heart, thoracic aorta, and abdominal aorta

- dissection: tear in intima layer allows blood to leak through, separating inner and middle layers

dissecting aneurysm signs and symptoms

- sudden severe chest or upper back pain

- often described as "tearing or ripping" that can spread to the neck or down the back

- sudden severe stomach pain

- syncope

- SOB

- sudden vision problems, difficulty speaking, and weakness or hemiparesis (similar to CVA)

- unilateral weak pulse in one arm or thigh

PAD

- narrowing or occlusion of arteries outside of the heart --> reduced blood flow to extremities, gut, kidneys, head

- primary cause: atherosclerosis

- collateral circulation may develop if atherosclerosis is gradual

risk factors of PAD

- smoking

- HTN

- hyperlipidemia

- obesity

- diabetes

- older age (15-20% over age 70)

- CAD

PAD signs and symptoms: typical presentation

- intermittent claudication

- limb pain or cramping with exercise, resolves with rest (just like angina)

- 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

- pale or cyanotic, dusky red color

- possible numbness

- weak or absent pulses (dorsals pedis and post tib)

claudication scale

- I: initial discomfort (established, but minimal)

- II: moderate discomfort but attention can be diverted

- III: intense pain (attention CANNOT be diverted)

- IV: excruciating and unbearable pain

claudication (leg pain)

- neurogenic: proximal to distal

- vascular: distal to proximal

claudication (easing)

- neurogenic: sitting, lying

- vascular: standing

claudication (walking)

- neurogenic: uphill easier

- vascular: downhill easier

claudication (cycling)

- neurogenic: no pain

- vascular: painful

claudication (delordosing)

- neurogenic: pain improvement

- vascular: no effect

claudication (lordosing)

- neurogenic: pain exacerbation

- vascular: no effect

claudication (pulse) peripheral

- neurogenic: normal

- vascular: weak

claudication (skin condition)

- neurogenic: normal

- vascular: hair loss, dystrophic

claudication (posture)

- neurogenic: flexed

- vascular: normal

PAD complications

- acute limb ischemia

- critical limb ischemia

- osteomyelitis

- stroke, MI

acute limb ischemia

- sudden decrease in limb perfusion, potentially threatening limb viability

- pain, pallor, paresthesias, poilkilotherma (coldness), pulselessness, paralysis

- due to embolism or thrombosis

critical limb ischemia (chronic)

- pain at rest, with elevation

- arterial insufficiency ulcers

- gangrene

PT management

- maximize quality of life, general health and well-being

- maximize aerobic capacity, O2 transport

- maximize general strength, peripheral O2 extraction

education

- 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 problems/impairments

- pain: claudication

- poor/non-healing wound or ulcer

- decreased exercise/activity tolerance

- impaired peripheral circulation (ABI, palpation)

- impaired muscle function/strength

- impaired aerobic capacity/endurance

- impaired respiration/gas exchange (PE)

vascular exam - inspection

- color

- ulcers

- edema

- symmetry

vascular exam: palpation

- temp

- pulses

- special tests: ABI, rubor of dependency, capillary refill, pitting edema, venous filling time, calf girth

arterial skin changes

- shiny, tight, dry, hairless

- thickened toenails

- cool/cold to touch

- pallor, pale, or bluish color to skin (peripheral cyanosis) : worse with elevation

- ulcers: may or may not be painful, ischemic, gangrene (tissue necrosis), result of trauma: common in toes and heel, develop rapidly

- rubor of dependence

palpation of pulses

- dorsalis pedis: on dorsum of foot, lateral to extensor hallucis longus

- post tibial: behind medial malleolus

- femoral

- popliteal

- radial

- brachial

- carotid

pulses scale

- 4+ = bounding

- 3+ = increased

- 2+ = normal

- 1+ = diminished

- 0 = absent, unable to palpate

- most important sign of arterial insufficiency

capillary refill

- compress nail beds until blanched

- normal flesh coloration returns in 3-5 sec

- prolonged time = arterial insufficiency

rubor of dependency

- assess for arterial insufficiency

- change in color with position

- pallor with elevation

- deep red color in 20-30 secs in dependent position

- veins must be competent

rubor of dependence

- elevate LE 60 degrees for 1 min

- 0= normal, no pallor

- 1 = definite pallor in 60 secs

- 2 = pallor in 30-60 sec

- 3 = pallor in < 30 sec

- 4 = pallor without elevation

rubor of dependency - LE dependent

- assess time for normal flesh color to return

- normal = 10-15 sec

- moderate occlusive disease = 15-25 sec

- severe ischemia = > 40sec

- deep red color in 20-30 sec indicates arterial insufficiency

venous filing time

- identify superficial veins on dorsum of foot, establish baseline appearance

- elevate LE 60 degrees x 1 min and allow gravity to drain

- place LE dependent : observe amount of time for superficial veins to refill and return to baseline appearance

- normal = 10-15 sec

- > 20 sec = mod to severe arterial insufficiency

- < 5 sec = suspect venous insufficiency

ankle brachial index

- to distinguish LE neurogenic vs vascular claudication pain

- compared ratio of systolic BP of arms and legs

- use doppler on posterior tibial or dorsalis pedis artery

ABI procedure

- 2 ratios/patient

- L leg systolic/highest brachial BP

- R leg systolic/highest brachial BP

- use index plus other signs of vascular impairment to determine risk for PAD

- other signs: color, skin changes, sensation

ABI process

- ultrasound device amplifies the sound of arterial blood flow

- systolic pressure recorded in brachial artery of arm

- sound of arterial blood flow located in ankle

- systolic pressure recorded in arteries of the ankle after each arterial flow is located

ABI value: greater than 1.4

- interpretation: calcification/vessel hardening

- recc: refer to vascular specialist

ABI value 1.0-1.4

- interpretation: normal

- recc: none

ABI value 0.9-1.0

- interpretation: acceptable

- recc: none

ABI value 0.5-0.8

- interpretation: moderate arterial disease

- recc: refer to vascular specialist

ABI less than 0.5

- interpretation: severe arterial disease

- recc: refer to vascular specialist

PAD interventions

- at risk for atherosclerotic heart disease

- intermittent claudication: decreased exercise tolerance

PAD - benefit from exercise training

- stimulate development of collateral circulation around stenosed vessel

- improve functional capacity: increased distance walked to pain onset

exercise prescription - PAD

- frequency: 3-5x/week

- intensity: 5-10 min warm up and cool down

- time: start 3-5 min, 1:1 work rest intervals

- type: weight bearing aerobic (walking is mode of choice)

PAD exercise intensity

- moderate 40-60% VO2R

- exercise at level 3/4 claudication pain as long as tolerated (or 3-5/10) (moderate - severe, but tolerable)

- interval training: 8-10 minute bouts of exercise, rest until symptoms subside, repeat

Pad exercise time

- increase by 5 min/session

- goal: accumulate 30-60 min/day of actual exercise

other considerations

- supervised exercise is important for adherence - at least 3 months, > 6 months optimal

- upright positions preferred - maximize LE BP, minimize cardiac workload

- cold may aggravate symptoms of intermittent claudication: need longer warm up

- monitor HR and BP response

- at increased risk of angina or ST segment changes

- resistance exercise (2x/week) for general fitness, not specifically for PAD

- watch foot care

venous insufficiency

- venous dilation, walls weaken, valves unable to close adequately

- venous pump becomes less efficient in returning blood to the heart --> blood pooling (stasis)

- risk factors: age, female, family history DVT, obesity, pregnancy, prolonged sitting or standing, smoking

venous insufficiency signs/symptoms

- dull ache, heaviness or cramping in legs (worse when standing, relieved with elevation of legs)

- flaking, itching skin on legs/feet

- tingling

- skin color changes (redness or hyperpigmentation)

- edema (dependent, worse at end of day)

- ulcers: chronic, slow healing

- often associated with varicose veins

venous skin changes

- warmer than normal

- stasis dermatitis

- ulcers

stasis dermatitis

- itchy, flaky, skin

- edema: red, weepy

- reddish-brown: staining due to burst capillaries

ulcers

- ankle area, most common above medial malleolus

- slowly developing

- shallow base

- unevenly shaped borders

venous dysfunction complications

- cellulitis: bacterial skin infection

- infection of ulcers

- osteomyelitis

- DVT

- PE

cellulitis

- warm, red area of skin, tends to spread/expand

- edema

- pain, tenderness

- fever

pitting edema

- edema pits due to increased tissue fluid: result of high peripheral vascular pressure, movement of fluid into interstitial space

- 1+ barely detectable impression

- 2+ slight indentation, rebounds < 15 sec

- 3+ deeper indentation, rebounds 15-30 sec

- 4+ rebounds > 30 sec

calf girth

- objectively measures LE edema

- circumference around calf at 10 cm below tibial tuberosity

- compare bilaterally

interventions for venous stasis

- prevent DVT: early mobilization, ankle pumps

- compression stockings: promote venous return

venous thromboembolism (VTE)

- deep vein thrombosis (DVT)

- pulmonary embolism (PE)

- blood clot (thrombus) formed in the vein, caused by slowing or changes in blood flow

- can travel to other parts of the body (embolize)

risk factors of venous thromboembolism

- older age

- recent major surgery especially ortho

- LE fractures

- multiple trauma (several serious injuries from something like a fall, attack, or car crash)

- smoking

- cancer

- prior hx of VTE

- oral contraceptives

- pregnancy

- family history

- obesity

- prolonged immobility (bedrest, long distance travel)

DVT signs/symptoms

- changes in skin color and temp: redness and warmth

- leg pain, tenderness especially in calf

- edema

PE signs and symptoms

- sudden, unexplained with SOB

- tachypnea

- tachycardia

- chest pain: worse with deep breath

- cough, hemoptysis

- falling BP

- lightheadedness or syncope

- anxiety

DVT screen

- homan's sign

- wells clinical prediction rule

homan's sign

gentle squeezing of affected calf or slow dorsiflexion of ankle produces calf pain

well's clinical prediction rule

- 0 = low probability

- 1-2 = moderate probability

- > 3 = high probability

well's clinical prediction rule for DVT

-active CA or w/in last 6 months

-paralysis, paresis or recent immobilization

-bedridden for 3+ days

-surgery requiring anesthesia in last 12 wks

-localized tenderness along deep vein

-entire leg swelling

-calf swelling at least 3 cm larger than asymptomatic leg (10 cm below tib tube)

-pitting edema in symptomatic leg

-superficial veins

-prev DVT

-high prob if >3, mod if 1-2, low

anti-coagulation

- used prophylactically to prevent blood clot formation

- may also be used to prevent emboli when thrombus is already formed: PE, DVT, atrial fibrillation

- inhibits thrombin formation and function of clotting factors

- ex: heparin, warfarin (Coumadin), Xarelto

PAD arterial ulcers

- intermittent claudication pain

- no edema

- no pulse or weak pulse no drainage

- round smooth sores

- black eschar

- location of soreness: toes and feet

venous ulcers

- dull, achy pain

- lower leg edema

- pulse present drainage

- sores with irregular borders

- yellow slough or ruddy skin

- location of sores: ankles

clinical practice guidelines action statements

- advocate for a culture of mobility and physical activity

- screen for risk of VTE

- provide preventative measures for LE DVT

- recommend mechanical compression as a preventative measure and for patients with LE DVT

- identify the likelihood of LE DVT when signs and symptoms are present (wells prediction)

- communicate the likelihood of LE DVT and recommend further medical testing

- verify the patient is taking an anticoagulant

- mobilize patients who are at a therapeutic level of anticoagulation

- mobilize patients after IVC filter placement once hemodynamically stable

- consult with the medical team when a patient is not taking anticoagulants and has no IVC filter

- screen for fall risk

- implement management strategies to prevent further VTE

PAD case study: 75 y/o male with CC of increasing difficulty walking over past 6 months, hindering ability to exercise and

socialize in the community.

HPI: Difficulty walking around the block due to

increasing pain and cramping in LEs. Unable to walk >

10 min without 8/10 pain and cramping. Pt reports

stopping and taking a break with stretching tends to

relieve all pain in his legs. Pt has also been suffering

from back pain over the past year.

C:

PMH: smokes 1 pack/day, drinks whiskey 4 glasses/wk,

L4-L5-S1 degeneration

Occupation: retired musician

PLOF: used to walk 2-3 miles with wife every night, has

been cutting back over past 6 months due to increasing

pain in legs. Plays backgammon 1x/wk.

Diagnostic tests: ABI = 0.75

S:

PMH: HTN, hypercholesterolemia, atherosclerosis,

diabetes, overweight, heart disease, kidney disease,

smoking

ROS: any co-morbidities that share risk factors

Neuro, cardiovascular, pulmonary

Pain: onset, timing, aggs/eases, association with activity

Claudication scale

Exercise/activity tolerance

Screen for DVT?