Peripheral Vascular Disease

Peripheral Vascular Disease Study Notes

Overview

Educators:

• A. Flemmer, DNP, RN, AGNP, CNE

• Reviewed by: E. Hopson, RN, MSN-Ed, CNE, & L. Templeton, DNP

• Date: Fall 2023

Arterial Disease

Peripheral Arterial Disease (PAD)

• Causes:

  • Atherosclerosis

  • Thromboembolic events

  • Partial or total arterial occlusion leads to deprivation of oxygen and nutrients, resulting in tissue damage.

Recognizing Cues: Risk Factors

• Non-Modifiable Risk Factors:

  • Age

  • Gender (Women)

  • African American ethnicity

• Modifiable Risk Factors:

  • Smoking

  • Diabetes

  • Hyperlipidemia

  • Hypertension

• C-Reactive Protein Levels:

  • Normal: Below 3.0 mg/L

  • Above 3.0 mg/L indicates high risk for heart disease

• Homocysteine Levels:

  • Normal: 5 to 15 μmol/L

  • Elevated levels can damage blood vessels.

Recognizing Cues: Symptoms of PAD

Intermittent Claudication

• Description:

  • Most common symptom of PAD.

  • Presents during ambulation/exercise.

  • Pain location varies based on area of blockage.

  • Pain is reproducible and may remain stable for years.

• Other Indicators:

  • Muscle/limb weakness

  • Absent or diminished pulses

  • Poor hair growth

  • The quality of the posterior tibial pulse is the most sensitive and specific indicator of arterial function.

Severe Arterial Occlusion Symptoms

• Symptoms include:

  • Resting limb pain

  • Paresthesia

  • Ulcer formation (painful arterial ulcers commonly develop on toes or upper foot and show poor healing)

  • Loss of hair on the lower calf, ankle, and foot

  • Dry, scaly skin

  • Thickened toenails

  • Color changes (elevation = pallor, dependency = rubor)

  • Cool or cold extremities

Analyzing Cues: Diagnostic Procedures

• Procedures include:

  • Resting ankle-brachial index (ABI)

  • Treadmill exercise arterial studies (best for assessing intermittent claudication)

  • Duplex ultrasound (best for deep vein thrombosis)

  • Segmental arterial pressures

  • Angiography

  • Computed Tomography (CT) scan

  • Magnetic Resonance Imaging (MRI)

  • Magnetic Resonance Angiography (MRA)

Analyzing Cues: Ankle Brachial Index (ABI)

• Process:

  • Blood pressure (BP) is measured on both upper and lower extremities then compared.

• Normal ABI:

  • 0.95 to 1.1

  • ABI ≤ 0.9 indicates PAD

  • ABI ≤ 0.4 indicates advanced ischemic disease, requiring emergent revascularization.

• Limitations:

  • May be unreliable in patients with diabetes or heavily calcified vessels.

  • If ABI > 1.3 or ankle pressure > 300 mmHg, suspect calcified arteries.

Analyzing Cues: Other Diagnostics

Treadmill Exercise Arterial Studies

• Utility:

  • ABI assessed with exercise.

  • A decrease in the ABI after exercise indicates arterial insufficiency.

  • Intermittent claudication (IC) indicated by a decrease of 20 mmHg or more in ABI within one minute following exercise.

Duplex Ultrasound

• Function:

  • Identifies areas of stenosis in arterial vessels, the severity of stenosis, and areas of turbulent flow.

The 6 P’s of Acute Arterial Insufficiency

1. Absent pulse with palpation and Doppler (pulselessness)

2. Pale pallor

3. Worse when elevated

4. Unilateral pain

5. Numbness or tingling (early signs include paresthesia)

6. Loss of movement (late signs include paralysis)

7. Cool to touch (poikilothermia)

Note: These symptoms are unilateral.

Generate Solutions: Health Promotion

• Educational Strategies:

  • Educate patients and families about risk factors and management.

• Lifestyle Changes:

  • Smoking cessation

  • Control blood glucose levels for diabetic patients with PAD

  • Use lipid-lowering agents

  • Control blood pressure

  • Employ medications, including vasodilators, to improve symptoms of PAD

  • Adhere to medication regimens.

Take Action: Surgical Management

• Indications for Surgical Revascularization:

  • Debilitating PAD

  • Uncontrolled infection

  • Uncontrollable pain

  • Extensive tissue loss

• Options:

  • Arterial bypass

  • Amputation

Take Action: Nursing Management

• Assessment and Education:

  • Workup for PAD similar to coronary artery disease (CAD) required.

  • Assess pulses (Posterior tibial/Dorsalis pedis)

  • Assess temperature and skin color in various positions

  • Educate patients on:

  • Risk factors

  • Medications (including oral vasodilators and topical nitroglycerin)

  • Anticoagulation therapy

  • Exercise programs (e.g., cardiac rehabilitation)

  • Avoid trauma, heat, or sunburn to legs and feet

  • Dangling extremity to increase blood flow and avoid elevation which decreases blood flow.

Take Action: Interdisciplinary Team

• Team Members:

  • Nursing staff

  • Physical and Occupational Therapies

  • Vascular surgeon

  • Cardiologist

  • Imaging technicians

Evaluate Outcomes: Treatment Effectiveness

• Indicators of Improvement:

  • Improved pulses

  • Better activity endurance

  • Positive wound healing

  • Controlled cholesterol and triglyceride levels

  • Successful revascularization

Venous Insufficiency Overview

Definition

• Alters the natural flow of blood through the veins of the peripheral circulation.

• Venous blood flow may be altered due to thrombosis formation and defective valves.

• Thrombus Formation Causes:

  • Stasis of blood flow

  • Endothelial injury

  • Hypercoagulability (known as Virchow’s triad)

Recognize Cues: Phlebitis & DVT

Phlebitis

• Inflammation in veins.

Deep Vein Thrombosis (DVT)

• Most common type of thrombophlebitis, presenting a higher risk of pulmonary embolism.

• Common Sites:

  • Legs

  • Upper arms

Analyze Cues: Venous Insufficiency

• Consequences of Prolonged Venous Hypertension:

  • Stretching and damage to veins/valves

  • Swelling

  • Venous stasis ulcers

  • Cellulitis

  • Discoloration of the lower extremity

  • Minimal pain.

Analyze Cues: DVT Symptoms

• Symptoms include:

  • Calf or groin tenderness and pain

  • Unilateral swelling of the leg

  • Warmth and edema of the extremity

  • Induration (hardening) along the blood vessel

  • Localized pitting edema

  • Positive D-Dimer test result

Generate Solutions: Venous Insufficiency

• Educational Strategies:

  • Educate patient/family on increased risk for venous thrombophlebitis events

  • Encourage smoking cessation

  • Control blood glucose for diabetic patients with PAD

  • Consider lipid-lowering agents

  • Control blood pressure

  • Adhere to medication regimen.

Take Action: Nursing Interventions for Venous Insufficiency

• Strategies:

  • Educate the patient about thromboembolic events

  • Recommend wearing elastic or compression stockings in the day/evening

  • Elevate legs for 20 minutes four to five times a day

  • Continue anticoagulation therapy (AAT)

  • Avoid prolonged periods of inactivity (no more than 2 hours)

  • Wound care as needed.

Take Action: Nursing Interventions for DVT

• Strategies:

  • Educate patient about thromboembolic risk

  • Elevate legs as with venous insufficiency

  • Continue anticoagulation therapy for at least 6 months

  • Consider clopidogrel as part of the treatment regime.

Peripheral Vascular Disease (PVD)

Comparison: Arterial vs. Venous Ulcers

Additional Indicators of Conditions

• Arterial Disease Symptoms:

  • Cool temperature

  • Absent hair growth

  • Ulcers on lower leg

  • Redness/ruddiness

  • Leathery texture of skin

  • Muscle atrophy

  • Intermittent claudication

  • Poor toenail growth

  • ABI of 0.7

  • Upper foot ulceration

  • Increased warmth

  • Coronary Artery Disease (CAD) presence

  • Risk of gangrene

  • Darkening of skin

• Venous Disease Symptoms:

  • Edema

  • Skin discoloration and texture changes

  • Signs of potential venous thrombosis.

Conclusion

• Understanding Peripheral Vascular Disease (PVD):

  • It is crucial for the early recognition and effective management, potentially reducing complications and improving patient outcomes.