PVD/PAD

• Peripheral Vascular Disease

  A group of disorders in which there is either an incomplete (stenosis) or complete (occlusion) disruption of the flow of blood and lymph thought the veins, arteries or lymphatic systems
• Peripheral Vascular System


  The system of blood vessels that carry blood to and from the body's peripheral tissues

  
• Arteriosclerosis


  Hardening of arteries, calcification of arteries of all sizes, loss of elasticity of arterial walls

  
• Atherosclerosis


  Fibrous "plaque", thickening of inner coat (intima), fatty degeneration of middle layer (media)
• Arteriosclerosis Obliterans


  • Disease of large and medium sized arteries, associated with high blood pressure, hyperlipidemia, arterial occlusion particularly at bifurcations

  
• Other examples of peripheral vascular disease

  • Diabetes
  • Vasculitis
  • Sickle cell disease
• PVD includes a set of disorders of the arterial, venous, and lymphatic systems
• Disruption to the blood flow causes ischemia leading to necrosis in which tissue function is compromised or destroyed as tissue oxygenation decreases
• Key components of the vascular physical examination

  • Pulse examination (carotid, radial/ulnar, femoral, popliteal, dorsalis pedis, posterior tibial)
  • Bilateral arm blood pressure
  • Cardiac examination
  • Palpation of the abdomen for aneurysmal disease
  • Auscultation for bruits
  • Examination of legs and feet

  
• PAD is very common and affects about 10 million individuals in the US
• Early detection, diagnosis, and management is important because if plaque has built up in the arteries of the legs then it is likely that plaque has also built up in the arteries of the heart or neck, and this can lead to an MI or stroke

  
• Causes of peripheral artery occlusion


  • Embolism
  • Thrombosis
  • Vasospasm
  • Edema

  
• Risk factors for peripheral artery disease

  • Gender: male
  • Age: older
  • Smoking
  • Diabetes: hyperglycemia
  • Hypertension
  • Dyslipedemia (total chol., HDL, LDL, triglycerides)
  • Hyperchromocysteinemia (alteration in metabolism of homocysteine)
  • Inflammatory markers: CRP, fibrinogen and alterations in the hemorrheologic properties of the blood
• Factors that increase the risk of occlusion

  • Obesity
  • Sepsis
  • Hypotension
  • Low cardiac output
  • Aneurysms
  • Aortic dissection
  • Bypass grafts

  
• Factors that increase the risk of ischemia

  • Emboli
  • Atrial fibrillation
  • Proximal atheroma: fatty material built up in the arteries
  • Tumor
  • Foreign bodies
• Clinical manifestations of peripheral artery disease

  • Intermittent claudication: tightening pain, sharp cramp, burning, or pressure in calf or buttocks related to decreased blood flow during walking and disappears at rest
  • Rest pain
  • Decreased pulses
  • Delayed wound healing

  
• Symptoms are caused by inadequate supply of oxygen and other nutrients to the legs, and simple activities like walking or climbing stairs may become painful
• Peripheral signs of PVD (the classic 6 P's)

  • Pulselessness
  • Paralysis
  • Paraesthesia (tingling, tickling, prickling, pricking, or burning)
  • Pain
  • Pallor
  • Perishing cold (Polikilothermia)

  
• Ankle-Brachial Index (ABI)


  Compare BP measured at ankle with BP measured at arm, a low number can indicate narrowing or blockage of the arteries in the legs

  
• Ankle-Brachial Index (ABI) values

  • No blockage (1.0 to 1.4) Normal
  • Borderline (0.9 to 0.99)
  • Mild blockage (0.8 to 0.89)
  • Moderate blockage (0.5 to 0.79)
  • Severe blockage (less than 0.5)
  • Rigid arteries (more than 1.4)

  
• Doppler Ultrasound


  Used to diagnose peripheral artery disease
• Treatments for peripheral artery disease

  • Promote arterial flow: Pentoxifylline (Trental)
  • Lifestyle changes – dietary modification, smoking cessation, and regularly exercising
  • Manage and control comorbidities: diabetes, hypertension, obesity, hypercholesterolemia and hyperlipidemia
  • Blood thinners: anticoagulants (heparin or warfarin) or antiplatelets (aspirin, plavix)
  • Prevention of injury (foot care)
  • Percutaneous Transluminal Angioplasty (PTA)

  
• Nursing care for peripheral artery disease

  • History taking
  • Physical assessment
  • Promote arterial flow
  • Pain management
  • Skin care
  • Activity intolerance
  • Education to reduce risk
• Physical examination for peripheral artery disease

  • Inspection (thick shiny skin, hair loss, brittle nails, colour changes, ulcers, muscle wasting)
  • Palpation (temperature, pulses, capillary refill, sensation/movement)
  • Auscultation (femoral bruits)
  • Ankle Brachial Index (ABI)
  • Buerger's Test

  
• Surgical management of peripheral artery disease

  • Endovascular interventions: angioplasty, atherectomy, and stent placement
  • Arterial bypass: revascularize limbs, reverse the saphenous vein for femoro-popliteal bypass, synthetic prosthesis for aorto-iliac or ilio-femoral bypass

  
• Foot care instructions for peripheral artery disease

  • Wash feet everyday with warm water and mild soap
  • Dry feet gently and well especially between the toes
  • Keep skin soft and smooth with moisturizer
  • Trim toenails straight across and file edges
  • Check feet daily for sores, cuts, bruises, rashes, corns, calluses, blisters, red spots, swelling, ingrown toenails, and pain

  
• Raynaud's Disease


  A rare disorder that affects the arteries, characterized by brief episodes of vasospasms reducing blood flow to the fingers and toes

  
• Types of Raynaud's Disease


  • Primary Raynaud's (Raynaud's disease), cause unknown and less severe
  • Secondary Raynaud's (Raynaud's phenomenon), caused by an underlying disease, condition, or other factor
• Causes of secondary Raynaud's disease

  • Connective tissue diseases
  • Diseases of the arteries
  • Carpal tunnel syndrome
  • Repetitive action or vibration
  • Smoking
  • Injuries
  • Medications

  
• Signs and symptoms of Raynaud's Disease

  • Turn pale or white and then blue
  • Feel numb, cold, or painful
  • Turn red, throb, tingle, burn, or feel numb as blood flow returns

  
• Diagnostic tests for Raynaud's Disease

  • Cold stimulation test
  • Nailfold Capillaroscopy
  • Assess for other conditions that may cause Raynaud's phenomenon: antinuclear antibody (ANA), erythrocyte sedimentation rate (ESR ), and C-reactive protein (CRP) blood tests

  
• Treatments for Raynaud's Disease

  • Lifestyle changes: avoid cold temperatures, emotional stress, workplace or recreational factors, and contact with certain chemicals or medicines
  • Physical activity
  • Limit repetitive hand actions
  • Medications: calcium channel blockers, alpha blockers, prescription skin creams, and ACE inhibitors

  
• Buerger's Disease


  A rare disease of the arteries and veins in the arms and legs, where blood vessels become inflamed, swell and can become blocked with blood clots

  
• Nailfold capillaroscopy


  Nailfold capillaries are visualized under the microscope to detect abnormalities
• Assessing for other conditions that may cause Raynaud's phenomenon

  1. Antinuclear antibody (ANA) test

  2. Erythrocyte sedimentation rate (ESR) test

  3. C-reactive protein (CRP) blood test

  
• Raynaud's disease


  A condition where blood vessels in the fingers and toes overreact to cold temperatures or stress

  
• Lifestyle changes for Raynaud's disease treatment


  • Avoid cold temperatures
  • Avoid emotional stress
  • Avoid workplace or recreational factors
  • Avoid contact with certain chemicals or medicines
  • Educate patient to protect themselves from exposure to cold temperatures
  • Physical activity
  • Limit repetitive hand actions, such as typing or playing the piano

  
• Medications for Raynaud's disease treatment

  • Calcium channel blockers
  • Alpha blockers
  • Prescription skin creams
  • ACE inhibitors (used less often)
• Buerger's disease


  A rare disease of the arteries and veins in the arms and legs where blood vessels become inflamed, swell and can become blocked with blood clots (thrombi) and may damage or destroy skin tissues and may lead to infection and gangrene

  
• Causes of Buerger's disease

  • Genetic predisposition in people in Middle East and Far East
  • Unknown
  • Smoking
  • Gum disease