Week 2: Arterial & Venous Insufficiency Wounds

Arterial insufficiency wound results from

lack of blood flow, deprives the area of oxygen

Arterial wound commonly occur from ____ to an already ischemic limb

Trauma

layers of artery

tunica intima, tunica media, tunica adventitia

Tunica intima

Delicate inner layer, makes direct contact with blood cells

Tunica media

muscle layer. Smooth muscle receives sympathetic innervation for vasodilation and vasoconstriction

Tunica adventitia

Protective outer layer

pressure in large arteries close to the heart are _____ than those further from the heart

HIGHER

Etiology (causes) of arterial insufficiency

-Trauma to artery

-Acute embolism (clot stops BF)

-Diabetes and arthritis

-Thromboangiitis (burger's disease)

-Arteriosclerosis

What is the number one cause of arterial insufficiency

Arterioslcerosis

What is arteriosclerosis?

hardening or thickening of the arteries.

Atherosclerosis

Narrowing of the arteries.

Intermittent claudication

activity specific discomfort due to local ischemia, stops when activity ceases

Symptoms of intermittent claudication

burning, cramping, fatigue.

____ % stenosis must be occur to have claudication

50

Where is pain typically located with intermittent claudication?

Distal to the site of the occlusion.

Ischemic rest pain

Burning that is exacerbated with elevation and is relieved with activity.

How does ulceration occur with AI?

Increasing tissue O2 demand upsets the balance between O2 supply and tissue demand.

Typical sequence of events from an AI to an ulcer

AI -> intermittent claudication -> ischemic rest pain -> ulcer

Gangrene

death of tissue associated with loss of blood and oxygen supply

Where does gangrene mostly occur?

distal extremities.

Dead (gangrene) tissue characteristics

dry, dark, cold, contracted

is dry or wet gangrene more stable?

Dry is more stable due to circulation proximal to it.

Contributing factors to arterial disease

-Hyperlipidemia

-Smoking

-Diabetes

-Advanced age

-Trauma

-Hypertension

Why is smoking a contributing factor to arterial disease?

Decreases wound and oxygen saturation. Nicotine causes vasoconstriction and lack of blood flow.

Why is diabetes a contributing factor to arterial disease?

Can result in calcification (hardening) of vessel walls, and stenosis.

Why is hyperglycemia a contributing factor to arterial disease?

Impairs all phases of wound healing, and decreases infection fighting ability.

Top range of normal for A1c levels?

5.7

A1c recommendation for diabetics

<7

why is advanced age a contributing factor for arterial disease?

Skin is more susceptible to wounds and complicates healing.

Why is hypertension a contributing factor for arterial disease?

Pressure inside the artery damages fragile endothelial layers of cell.

Is systolic of diastolic hypertension more damaging to arteries?

Diastolic.

an ulcer is caused by

underlying pathology

a wound is caused by

trauma

Pain level of AI

severe due to lack of BF. Increased pain with elevation

Location of AI

-Primarily LE

-Distal toes, dorsal foot.

-Areas of trauma

Presentation of AI

Regular appearance, punched out, possible black eschar, gangrene, little to no drainage.

peri-wound and extrinsic tissue with AI

-Thin, shiny

-loss of hair.

-Thick yellow nails

-Pale, cyanotic skin

-possible rubor.

Pulses with AI

decreased or AI

Temperature with AI

cool or decreased.

PT tests for AI

-Pulses

-Doppler ultrasound

-Ankle-Brachial Index (ABI)

-Rubor of dependency

-Capillary Refill

-Venous Filling time

Most common site of occlusion for AI

Femoral artery

Pulse grading scale

0-3+ (absent-bounding)

Normal pulse grade

2+

Indications for doppler ultrasound

decreased, or absent pulses.

What is a doppler ultrasound helpful for assessing?

-arterial patency

-pulses that cannot be easily palpated.

How is a doppler ultrasound held in relation to the artery?

at a 45-60 degree angle.

What is the first line of defense for AI testing?

Ankle-brachial index (ABI)

What does the ABI measure?

systolic BP of the lower extremity / systolic pressure of the upper extremity.

A systolic BP < _____ will have poor healing potential

60=80

<0.3 ABI interpretation

rest pain and gangrene

revascularization or amputation

<0.5 ABI interpretation

Severe arterial insufficiency, rest pain. Wound unlikely to heal without revascularization, limb threatening AI.

0.5-0.7 ABI interpretation

moderate arterial insufficiency, intermittent claudication. Clinical judgement required for debridement

0.7-0.9 ABI interpretation

mild to moderate arterial insufficiency. Conservative intervention normally provide satisfactory wound healing. Clinical judgement for debridement.

0.9-1.1 ABI interpretation

Normal, okay to debride.

1.1 - 1.3 ABI interpretation

Vessel calcification, Invalid measure of tissue perfusion. Refer to vascular.

Rubor of dependency procedure

elevate LE to 60 degrees for one min, note foot color. little to no color change = normal arterial flow.

return leg to surface and note time to turn to original color. Returns to normal color in 15-20 seconds = normal arterial flow.

Rubor of dependency indications

Unable to tolerate ABI, ABI >1.1, vessel calcification.

Rubor of dependency, Pallor after 45-60 seconds of elevation =

mild AI

Rubor of dependency, Pallor after 30-45 seconds of elevation =

moderate AI

Rubor of dependency, pallor within 25 seconds of elevation =

Severe AI, dependent Rubor.

Capillary refill procedure

Push tip of the toe with enough pressure to blanch the skin, and hold for 5 seconds.

Capillary refill indications

digit ulcer, abnormal doppler ultrasound ABI.

Normal capillary refill

<3 seconds for color to return

Capillary refill for arterial insufficiency

delayed refill time

Venous filing time procedure

-Patient supine, note superficial veins on dorsal foot.

-Elevate the limb to 60 degrees for 1 min or until veins drained by gravity

-Lower the limb back to dependent position, note the time for veins to refill.

Venous filling time interpretation, >25 seconds

severe arterial insufficiency

venous filling time interpretation, >20 seconds

arterial insufficiency

venous filling time interpretation, 5-15 seconds

normal

Venous filling time interpretation, <5 seconds

venous insufficiency

Medical testing for blood flow

-Plethysmography

-Duplex scanning

-Transcutaneous oxygen monitoring

-Toe pressures

-Arteriography

Plethysmography

-Non-invasive measure for regional blood flow and calcified arteries.

-Photo, air, electrical impedance.

Duplex scanning

Doppler with a scanner. Measures blood flow, velocity, and turbulence of vessels.

Transcutaneous oxygen monitoring

For slow healing wounds to assess for peripheral vascular disease.

Electrodes measure oxygen tension of the peri-wound. Measures macro and microvascular perfusion.

Toe pressure

BEST screening for peripheral vascular disease. Checks distal (micro) circulation. Not affected by calcified arteries.

what toes pressure indicates good healing potential

>30 mmHg

Arteriography

Dye injected into the artery to visualize blood flow into the vessel. Usually performed if surgery is considered.

medical/surgical interventions for AI

-Risk factor management

-Prescription drugs

-Sympathetic block

-Debridement

-Revascularization

-Percutaneous angioplasty balloon

-Amputation

What can prescription drugs do for AI

-reduce pain

-increase circulation

-reduce platelet aggregation

-increase flexibility of RBC's

-Decrease blood viscosity.

Sympathetic block

Eliminate CNS control of vasoconstriction to promote vasodilation

Debridement

cutting off dead tissue

revascularization

open up narrowing vessels or bypass blockages

percutaneous angioplasty balloon

balloon tip catheter expanded at site of stenosis compressing plaque obstructing blood flow and opening the vessel.

What education is necessary for protecting the limb with AI?

-Protect from trauma, damaging chemical, excessive heat/cold, open wounds.

-Live healthy

-Contact care provider sooner rather than later.

Local wound care for Ai

-Protect surrounding skin

-Address the wound bed

-Maximize circulation

-Educate the patient/caregiver

methods for protecting surrounding skin for AI

-moisture

-avoid adhesives

-reduce friction between toes

-provide padding to protect ischemic tissue

how to properly address the wound bed with AI

choose dressings to moisten the wound bed, and debride necrotic tissue if appropriate.

How to maximize circulation with AI

avoid compression, and choose footwear to accommodate bandages and decrease stress.

why should you avoid compression with arterial insufficiency?

compression can constrict vessels and decrease blood flow.

PT is of limited value for patients with what?

Low ABI's and without prior revascularization

Gangrenous tissue must be...

surgically removed.

for patients with low ABI's avoid sharp debridement of...

dry, eschar, uninfected ulcers.

when to refer out for AI

-invalid ABI

-wound fails to progress

-suspected infection

-exposed capsule or bone

Therapeutic exercise and activities for AI

-Gait and mobility

-Aerobics

-Resistive exercise

-Positioning

-Ankle pumps

Why must you be mindful with aerobic exercise prescription for those with AI?

60-90% of those with AI have coronary artery disease.

Why is resistive exercise important for those with AI?

Muscles are prone to atrophy due to lack of oxygen supply.

Why is stretching important for those with AI?

Loss of mobility is common due to guarding because if pain.

why should you avoid excess knee and hip flexion for those with AI?

major arterial vessel location

Importance of ankle pumps for AI

keeps vessels moving and pumps blood up to the heart.

Temporary footwear for those with AI

casts, rocker-bottoms, enclosed shoes.

Permanent footwear for those with AI

extra depth toe boxes, adequate length, soft/flexible, specialized if needed via orthotist.