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Peripheral Vascular Disease

Disorders that alter the natural flow of blood through the arteries and veins of the peripheral circulation



• Affects men and women almost equally
• Higher incidence in African Americans than Caucasian
• Risk is highest for the elderly, those who smoke/have smoked, those with diabetes
• Higher incidence in those with chronic kidney disease or transplant
• Lack of awareness of PAD
• 90% of cases secondary to atherosclerosis
• Risk Factors?
Smokers have double the risk of mortality, disease progression and limb amputation vs non-smokers
Duration of diabetes seems to predict greater disease burden of PAD vs glycemic control
Dyslipidemia and HTN are risk factors as well.



Lack of disease recognition (may be asymptomatic)
Poor understanding of the impact on a person
Under-use of effective therapies


Lower Extremity Arterial Disease S&S

--Most patients asymptomatic or may have atypical presentation
---Intermittent claudication “angina in the legs”
Pain occurs predictably with exertion
Classic IC = pain, ache, tightening, cramping
Relieved by rest
Pain occurs distal to blockage
Only 10-30% have this
---Minority of patients develop rest pain or ischemic ulcers


LEAD- Diagnostic Tests and History

• Hematology and biochem blood work (CBC, FBG, HgbA1c, creatinine, fasting lipid profile, urinalysis (glycosuria and proteinuria)
• Ankle-Brachial Index (ABI)**diagnostic of PAD if less than 0.9
• Ultrasound
• Duplex scan of carotid arteries (if high risk)


6 P’s

Pikilothermia (coldness)


Physical Assessment

Hair loss and dry, scaly, pale or mottled skin and thickened toenails

Severe arterial disease—extremity is cold and gray-blue or darkened; pallor

Pain that occurs even while at rest; numbness and burning


Physical Assessment (Cont’d) Arterial Ulcers

Complains of claudication ('limping') with walking 1-2 blocks
Pain with rest present
Ulcers located between or at end of toes with deep pale ulcer beds, even edges and little granulation tissue
Cool foot with decreased pulses
Hair loss, pallor with elevation, dependent rubor (redness)
Neurological deficits noted


Physical Assessment
Venous Ulcers

No claudication or rest pain
Ulcers located on ankle area with brown pigmentation and ulcer bed pink, superficial uneven and granulation tissue present
Ankle discoloration and edema with pulses present
Full veins when leg slightly dependent
No neurologic deficits


Nonsurgical Management

Exercise- can build up of collateral circulation improving arterial flow to affected limb
Positioning - by elevating feet at rest to decrease swelling but must not elevate legs above heart as this slows arterial flow to legs
Promoting vasodilation- preventing exposure to cold and keeping warmth to extremities (do not apply direct heat), smoking cessation
Drug therapy- includes antiplatelet therapy (ASA)
Invasive Non surgical Treatments include:
Percutaneous transluminal angioplasty - balloon
Laser-assisted angioplasty - laser-tipped catheter is used instead of a balloon catheter

Invasive Non surgical Treatments include:
-Percutaneous transluminal angioplasty – balloon
-Laser-assisted angioplasty - laser-tipped catheter is used instead of a balloon catheter


Health Teaching

Heath Teaching
--Foot Care Cleanliness
wash between toes - rinse thoroughly
mild soap
dry well
cotton socks - extra socks
avoid sunburn
wear soft shoes/slippers
trim nails straight across
no hot water bottles
---Comfort measures
leather shoes
lambs wool
--Prevent constriction of blood vessels
no knee highs, panty hose or garters
do not cross legs at knees
no smoking
encourage - walking
careful with acute venous disease
--Seeking medical attention
skin breakdown, abrasions, blisters, athelete’s foot or pain
no meds on feet
--Corns ,calluses and athlete's foot
do not cut
elevate leg s
avoid standing for long periods - change position


Acute Peripheral Arterial Occlusion

Embolus — the most common cause of occlusions, although local thrombus may be the cause

Assessment -6 P’s
Drug therapy
Surgical therapy
Nursing care


Aneurysms of Central Arteries

• Aneurysm—a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter
• Several types
• Dissecting aneurysm (aortic dissection)
• Abdominal aortic aneurysm
• Thoracic aortic aneurysm


Aneurysm —

a permanent localized dilation of an artery, enlarging the artery to twice its normal diameter


Assessment of Abdominal Aortic Aneurysm (AAA)

 Pain related to AAA is usually steady with a gnawing quality, is unaffected by movement, and may last for hours or days.
 Pain is in the abdomen, flank, or back.
 Abdominal mass is pulsatile.
 Rupture is the most frequent complication and is life threatening.


Diagnostic Assessment

X-ray “eggshell” appearance
Aortic arteriography


Nonsurgical Management

Monitor the growth of the aneurysm

Maintain BP at a normal level to decrease the risk of rupture


Aneurysms of the Peripheral Arteries

Femoral and popliteal aneurysms

Symptoms—limb ischemia, diminished or absent pulses, cool to cold skin, and pain


Postoperative care—monitor for pain


Venous Thromboembolism

 Virchow’s Triad:
Venous stasis
Damage to endothelium
Hypercoagulability of blood

 Thrombus—a blood clot
 Phlebitis – inflammation of a vein
 Thrombophlebitis - inflammation of a vein with blood clot formation
 Deep vein thrombosis (DVT)
 Pulmonary embolism


Assessment Venous Thromboembolism

 Calf or groin tenderness or pain
 Sudden onset of unilateral swelling of the leg
 Checking Homans’ sign—not reliable
 Localized edema
 Venous flow studies—venous duplex ultrasonography
 D-dimer – coagulation monitoring


venous thromboembolism Nonsurgical Management

Rest, drug therapy, preventive measures

Drug therapy includes:
Unfractionated heparin therapy
Low–molecular weight heparin - LMWH
Warfarin therapy - Coumadin
Thrombolytic therapy –Streptokinase, Urokinase


Inferior vena caval interruption-

placement of a filter in the inferior vena cava to trap clots


Raynaud’s Phenomenon

 Caused by vasospasm of the arterioles and arteries of the upper and lower extremities
 Drug therapy—CCBs (Procardia) , Alpha Blockers (Prazosin/Minipress), Vasodilators (NTG ointment)
 *Avoid OTC cold medications and Beta Blockers
 Sympathectomy or Chemical Injection (Botox)
 Reinforcement of patient education; restriction of cold exposure


Venous Insufficiency

Result of prolonged venous hypertension, stretching veins and damaging valves

Stasis dermatitis, stasis ulcers

Management of edema

Management of venous stasis ulcers

Drug therapy

Surgical management


varicose veins

Distended, protruding veins that appear darkened and tortuous (twisted)


Varicose Veins

Distended, protruding veins that appear darkened & tortuous
Collaborative management includes:
• ***Elastic stockings
• Elevation of extremities
• Sclerotherapy
• Surgical removal of veins



Inflammation of the superficial veins

Management—warm, moist soaks and elastic stocking

Complications—tissue necrosis, infection, or pulmonary embolus