PVD 4-9-13 - Cheryl Herrmanncherylherrmann.com/common/pdf/peripheral-vascular... · There is no...

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Cheryl Herrmann, APN, CCRN, CCNS-CSC-CMC

� Disease of the arteries and veins of the legs or arms that disturb the blood flow;

� Can result from atherosclerosis or "hardening of the arteries" leading to stenosis (blockage), and blood clots.

� It causes either acute or chronic ischemia with initial symptoms of pain and later damage to structures (such as nerves). www.theregeninc.com/glossary.html

� Population is aging Population is aging Population is aging Population is aging

� Each cardiovascular patient has:Each cardiovascular patient has:Each cardiovascular patient has:Each cardiovascular patient has:

◦ 2 carotids2 carotids2 carotids2 carotids

◦ 2 arms2 arms2 arms2 arms

◦ 2 renal arteries2 renal arteries2 renal arteries2 renal arteries

◦ 2 legs2 legs2 legs2 legs

◦ 6+ sites to develop aneurysmal 6+ sites to develop aneurysmal 6+ sites to develop aneurysmal 6+ sites to develop aneurysmal or occlusive diseaseor occlusive diseaseor occlusive diseaseor occlusive disease

YOU DO THE MATH!YOU DO THE MATH!YOU DO THE MATH!YOU DO THE MATH!

Carotid

Renal

Iliac

Aorta

SFA

AndBelow

Subclavian

Definition Diagnosis

� Inadequate peripheral blood flow

� Diagnosis may be made by comparing peripheral pulses in contralateral extremities or by angiography, ultrasonography, and skin temperature tests

� A condition in which the arteries that carry blood to the arms or legs become narrowed or clogged. This interferes with the normal flow of blood

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� Affects about 8 – 12 million people in the USA

� About 1 in every 20 Americans over the age of 50 has PAD

� The risk increase with age

� 1 in 3 people affected◦ If over 70 y/o

◦ Diabetic or smoker over 50 y/o

Retrieved March 27, 2013 from: http://www.nhlbi.nih.gov/health/health-topics/topics/pad/atrisk.html

� Symptoms not reported (pain or cramping in the legs) believing they are a natural part of aging.

� Providers do not ask enough questions◦ Dull cramping or pain during exercise or rest?◦ Changes in skin temperature and color?◦ Hair loss on feet and legs?◦ Numbness or tingling in legs, feet or toes?◦ Has there been an ABI?

� Most wait until there are ulcers and/or pain -- No No No No goodgoodgoodgood treatment options at treatment options at treatment options at treatment options at this pointthis pointthis pointthis point

� Age over 50Age over 50Age over 50Age over 50

� Smoker or history of smokingSmoker or history of smokingSmoker or history of smokingSmoker or history of smoking◦ Up to four times greater risk of PAD

◦ Develop PAD symptoms 10 years earlier than nonsmokers

� DiabetesDiabetesDiabetesDiabetes

� HypertensionHypertensionHypertensionHypertension

� HyperlipidemiaHyperlipidemiaHyperlipidemiaHyperlipidemia

� History of vascular disease, MI, or stroke.History of vascular disease, MI, or stroke.History of vascular disease, MI, or stroke.History of vascular disease, MI, or stroke.◦ One in three chance of also having PAD

� African AmericanAfrican AmericanAfrican AmericanAfrican American

◦ More than twice as likely to have PAD as their white counterparts.

CVD Risk Stratification: Ideal Cardiovascular Health

• Total cholesterol < 200 mg/dL

• BP < 120/<80 mm Hg, untreated

• Fasting blood sugar < 100 mg/dL untreated

• Body mass index < 25 kg/m2

• Abstinence from smoking (never or quit > 12 months)

• Physical activity at goal

• DASH-like diet (“Dietary Approaches to Stop

Hypertension”)

• Ideal patients are rare in most clinical practices,

making up less than 5% of women in most studies

12Source: Mosca 2011; Stampfer 2000, Lloyd-Jones 2006, Akesson 2007

Other Lifestyle Interventions

• Smoking cessation

• Physical activity

• Weight reduction/maintenance

• Heart healthy diet

13Source: Mosca 2011

There is no such thing asThere is no such thing asThere is no such thing asThere is no such thing as aaaa

SUDDENSUDDENSUDDENSUDDENCardiovascular Disease!Cardiovascular Disease!Cardiovascular Disease!Cardiovascular Disease!

It takes It takes It takes It takes YEARSYEARSYEARSYEARS of of of of preparation and effort!preparation and effort!preparation and effort!preparation and effort!

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BP Classification for Adults > 18 years

Normal <120 <80

Pre Hypertension 120 - 139 80-89

Hypertension Stage I 140-159 90-99

Stage II >160 >100

Systolic Diastolic

Source: JNC 7 2004

Hypertension: The average of two seated blood pressure

measurements should guide care

BP > 180/110 mm Hg

evaluate and treat immediately or within one week depending on the clinical situation

BP > 160/100 mm Hg

evaluate and treat or refer within one month

BP ≥ 140/90 mm Hg

recheck within 2 months, if confirmed, evaluate and treat or refer

BP ≥ 120/80 mm Hg

counsel regarding lifestyle factors, recheck within one year and monitor

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Initial evaluation of the hypertensive patient should include 12-lead EKG, urinalysis, hematocrit, serum glucose, creatinine, calcium, and potassium measurement and a lipid profile

Source: Seventh Report of the Joint National Committee on Prevention, Evaluation, and Treatment of High Blood Pressure 2004.

Age-Adjusted Prevalence of Diagnosed Diabetes Among U.S. Adults

<4.5%Missing data4.5%–5.9% 6.0%–7.4%7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2010

Diabetes Mellitus Recommendations

• Goal: HbA1c < 7 Class 1, Level C

• Lifestyle changes and pharmacotherapy Class 1, Level B

Source: AHA 2007 Guidelines for Prevention of CVD in Women

Cardiovascular Risk FactorsDyslipidemia

� Elevated LDL� Low HDL� Elevated Total Cholesterol � Elevated Triglycerides

Lipid and lipoprotein levels – optimal levels

• LDL-C < 100 mg/dl• LDL-C < 70 mg/dl in very high risk women with CHD

• HDL-C > 50 mg/dl• Triglycerides < 150 mg/dl• Non-HDL-C < 130mg/dl

(total cholesterol minus HDL cholesterol)Class I, Level B


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Total Cholesterol

< 200 Desirable

200 - 239 Borderline High

> 240 High

Source: NCEP ATP III Classifications

HDL Cholesterol

< 40 Low> 50 Desirable> 60 High - Desirable

Source: NCEP ATP III Classifications

•Low HDL more important in women than men♥For every 1 mg/dL increase in HDL there is a 3% decrease in CHD risk for women and 2% decrease in CHD risk for men

Total cholesterol/HDL ratio• Total Cholesterol divided by HDL level• Ratio Risk• < 2.8 Below average risk for CAD

• 2.9 - 4.0 ratio Average risk for CAD

• > 4.0 Above average for CAD

Cholesterol Ratio Examples

LDL 113 135 167HDL 40 72 63Ratio 4.5 3.3 4.1Non-HDL-C 138 166 194

Triglycerides 124 135 135

A B C

Age (female) 40 65 70

Total Cholesterol 178 238 257

Triglycerides < 150 mg/dl

• Triglyceride elevation associated with greater atherogenic significance in women than in men

Source: Maron 2000

Consistently Encourage Healthy Eating Patterns

• Healthy food selections:– Fruits and vegetables (1 serving = 1 cup raw leafy vegetable, 1/2 cup cut-up raw or 1

medium fruit)

– Whole grains, high fiber (1 serving = 1 slice bread, 1 oz. dry cereal, or 1/2 cup cooked rice, pasta, or cereal (all whole-grain))

– Fish, especially oily fish, at least twice per week (1 serving = 3.5 oz. cooked)

– No more than one drink of alcohol per day

– Less than 1500 mg of sodium per day

• Saturated fats < 7% of calories, < 150 mg cholesterol

• Limit sugar and trans fatty acid intake (main dietary sources are baked goods and fried foods made with partially hydrogenated vegetable oil)

• Pregnant women should be counseled to avoid eating fish with the potential for the highest level of mercury contamination(e.g., shark, swordfish, king mackerel or tilefish)


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FAT ALLOWANCE

TOTAL CALORIES SATURATED FAT TOTAL FAT PER DAY IN GRAMS IN GRAMS

1,600 18 OR LESS 53 OR LESS



One cup of Crisco per day!

FAST FOODS

French Fries, Large 570 cal. 30 FAT Gm 330 mg Sodium

Quarter Pounder 510 cal. 26 FAT Gm 1190 mg Sodium

with Cheese

COKE Medium 210 cal

1290 calories 56 FAT Gm 1520 mg Sodium

Source: McDonald’s Nutrition Facts

CHEESEBURGER20 Years Ago Today

333 calories How many calories are in today’s cheeseburger?

If you lift weights for 1 hour and 30 minutes,you will burn approximately 257 calories.*

*Based on 130-pound person

Maintaining a Healthy Weight is a Balancing Act

Calories In = Calories Out

610 Calories6.9 ounces

Calorie Difference: 400 Calories

FRENCH FRIES20 Years Ago Today


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*Based on 160-pound person

If you walk leisurely for 1 hour and 10 minutesyou will burn approximately 400 calories.*

Calories In = Calories Out

Calorie Difference: 165 Calories

250 Calories20 ounces


SODA20 Years Ago Today

For the extra 822 calories, you will need to exercise an additional 3 ¼ hours

CHICKEN CAESAR SALAD

20 Years Ago Today

390 calories1 ½ cups


Calorie Difference: 400 calories


820 calories320 calories

TURKEY SANDWICH20 Years Ago Today

CHICKEN STIR FRY20 Years Ago Today

435 calories2 cups



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COFFEE20 Years Ago

Coffee(with whole milk and sugar)

Today

Mocha Coffee(with steamed whole milk and

mocha syrup)

45 calories8 ounces

350 calories16 ounces

Calorie Difference: 305 caloriesSource: www.nhlbi.nih.gov

Cardiovascular Risk FactorsObesity

• Maintain/achieve♥ BMI between 18.5 and 24.9 kg/m2

♥ Waist circumference <35 inchesClass I, Level B


Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes

Among U.S. Adults Aged 18 Years or older

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2010

2010

Cardiovascular Risk FactorsPhysical Inactivity - Sedentary Lifestyle• The relative risk of CDH associated with physical

inactivity ranges from 1.5 to 2.4• A risk comparable to that observed for

♥ high cholesterol

♥ high blood pressure

♥ cigarette smoking.

Source: CDC, U.S. Surgeon General 1996, AHA

Physical Activity

• Consistently encourage the following:– Moderate Exercise – 150 minutes per week, OR– Vigorous Exercise – 75 minutes per week, OR– An equivalent combination of the two

• Aerobic exercise should be performed in episodes of at least 10 minutes, preferably spread throughout the week

• Muscle strengthening activities that involve all major muscle groups should be performed 2 or more days/week

• Moderate exercise includes:– Dancing fast for 30 minutes – Raking leaves for 30 minutes– Gardening for 30-45 minutes– Pushing a stroller 1 mile in 30 minutes

70Source: Mosca 2011; Surgeon General Call-to-Action 2007

Physical Activity

• Women who need to lose weight or sustain weight loss should accumulate a minimum of 60-90 minutes of moderate-intensity physical activity on most, and preferably all, days of the week


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Slide Source

Lipids Online Slide Librarywww.lipidsonline.org

Risk Factor Defining Level

Abdominal obesity

(Waist circumference)

Men

Women

>102 cm (>40 in)

>88 cm (>35 in)

TG ≥150 mg/dL

HDL-C

Men

Women

<40 mg/dL

<50 mg/dL

Blood pressure ≥130/≥85 mm Hg

Fasting glucose ≥110 mg/dL

ATP III: The Metabolic Syndrome

Expert Panel on Detection, Evaluation, and Treatment of High

Blood Cholesterol in Adults. JAMA 2001;285:2486-2497.

Diagnosis is established when ≥3 risk factors are present:� Intermittent claudicationIntermittent claudicationIntermittent claudicationIntermittent claudication

� Fatigue, heaviness, tiredness, cramping in the leg muscles (buttocks, thigh, or calf) that occurs during activity such as walking or climbing stairs.

� This pain or discomfort goes away once the activity is stopped and during rest.

� Rest pain

� Pain in the legs and/or feet that disturbs sleep

� BP ↓ 10 – 20 mmHg at night

� ↓ blood flow to an extremity that already has ↓ flow

� Tissues become ischemic

� Causes pain

� Burning pain� Atypical symptoms (nonspecific

exercise intolerance, hip or other joint pain)

� Two very characteristic types of pain: � intermittent claudication and ischemic rest pain

� Weak or absent pulses in the legs or feet

� Sores or wounds on the toes, feet, or legs that heal slowly, poorly, or not at all

� Color changes in the skin of the feet, including paleness or blueness.

� Dependent rubor

� Elevating the foot causes loss of color and worsens ischemic pain

� A lower temperature in one leg compared to the other leg

� Poor nail growth on the toes and decreased hair growth on the legs

� Affected leg may sweat excessively and become cyanotic

� Erectile dysfunction, especially among men who have diabetes

However, most people with PAD do not experience symptoms

� Ms. A.K. Ms. A.K. Ms. A.K. Ms. A.K. LeggsLeggsLeggsLeggs is a 66is a 66is a 66is a 66----yearyearyearyear----old female that presents to your old female that presents to your old female that presents to your old female that presents to your office with complaints of left lower extremity pain. She states office with complaints of left lower extremity pain. She states office with complaints of left lower extremity pain. She states office with complaints of left lower extremity pain. She states that while walking on the golf course she gets pain in her that while walking on the golf course she gets pain in her that while walking on the golf course she gets pain in her that while walking on the golf course she gets pain in her lower calf, primarily on her left side. She states that when lower calf, primarily on her left side. She states that when lower calf, primarily on her left side. She states that when lower calf, primarily on her left side. She states that when she stops and rests on a bench at the next tee, the pain she stops and rests on a bench at the next tee, the pain she stops and rests on a bench at the next tee, the pain she stops and rests on a bench at the next tee, the pain slowly resolves. She does not have the pain when she uses a slowly resolves. She does not have the pain when she uses a slowly resolves. She does not have the pain when she uses a slowly resolves. She does not have the pain when she uses a golf cart. golf cart. golf cart. golf cart.

� Her past history is significant for HTN, hyperlipidemia Her past history is significant for HTN, hyperlipidemia Her past history is significant for HTN, hyperlipidemia Her past history is significant for HTN, hyperlipidemia (Recent: LDL 160, Triglycerides of 210). She takes HCTZ, (Recent: LDL 160, Triglycerides of 210). She takes HCTZ, (Recent: LDL 160, Triglycerides of 210). She takes HCTZ, (Recent: LDL 160, Triglycerides of 210). She takes HCTZ, and was recently started on atorvastatin 10mg after her and was recently started on atorvastatin 10mg after her and was recently started on atorvastatin 10mg after her and was recently started on atorvastatin 10mg after her recent lab work. recent lab work. recent lab work. recent lab work.

� Examination of her legs shows that her left leg is slightly Examination of her legs shows that her left leg is slightly Examination of her legs shows that her left leg is slightly Examination of her legs shows that her left leg is slightly cooler to the touch than her right. There is paucity of hair on cooler to the touch than her right. There is paucity of hair on cooler to the touch than her right. There is paucity of hair on cooler to the touch than her right. There is paucity of hair on her lower leg and on exam you note a diminished posterior her lower leg and on exam you note a diminished posterior her lower leg and on exam you note a diminished posterior her lower leg and on exam you note a diminished posterior tibialtibialtibialtibial pulsation.pulsation.pulsation.pulsation.

�

� Ankle Brachial Index (ABI)

� Magnetic resonance angiography

◦ Noninvasive

◦ Minimal damage to kidneys

� Ultrasonography and Doppler color flow imaging

◦ Noninvasive

◦ Indicated before revascularization or surveillance of grafts

� Angiography

◦ Used for patients being considered for revascularization

◦ Not preferred due to risk of contrast induced nephrotoxicity

� CT angiography

� Most effective, accurate, practical way to assess for PA

� ADA recommends diabetic patients over 50 y/o be assessed with ABI

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� A resting ankle-brachial index of less than 1is abnormal. If the ABI is:

• Less than 0.95, significant narrowing of one or more blood vessels in the legs is indicated.

• Less than 0.8, pain in the foot, leg, or buttock may occur during exercise (intermittent claudication).

• Less than 0.4, symptoms may occur when at rest.

• 0.25 or below, severe limb-threatening PAD is probably present

Above 0.90 Normal0.71 – 0.90 Mild Obstruction0.41 - 0.70 Moderate Obstruction0.00 – 0.40 Severe Obstruction

� Face wall – place fingertips against the wall for balance

� Keep legs straight, raise heels as high as possible

� Lower heels back to floor

� Repeat 30 – 50 times or until patient uncomfortable

� Lie supine take ankle pressure

� With normal circulation, ABI should be the same with moderate exercise as with rest

� With PAD, ankle pressure will drop to a low or indeterminate level with exercise and back to baseline with rest

• Severe disabling claudication of the right lower extremity – only able to walk three blocks

• No resting ischemia

• PMH– Diabetes. HgA1c 6.5 with metformin

– Hypertension controlled < 130/80 on several meds

– Hyperlipidemia treated with statin. LDL controlled < 100

– A Fib

– Quit smoking 14 years ago

– EF 60%, mild AS, mild AR

– Bilateral carotid stenosis < 60% (no benefit for surgery if asymptomatic)

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� Right ABI = 0.62◦ Drops to 0.25 post exercise

� Left ABI = 1.12◦ Drops to 0.76 post exercise

1. 1. 1. 1. Risk Risk Risk Risk factor factor factor factor modificationmodificationmodificationmodification

◦ Smoking cessation and control of diabetes, dyslipidemia, hypertension

2. Exercise 2. Exercise 2. Exercise 2. Exercise training or rehabilitationtraining or rehabilitationtraining or rehabilitationtraining or rehabilitation

◦ 35 to 50 min of treadmill or track walking in an exercise-rest-exercise pattern 3 to 4 times/week

◦ The greatest improvements in walking ability occurred when each exercise session lasted more than 30 minutes with at least three exercise sessions per week, when the patient walked until near maximal pain was reached at each session, and when the program continued for at least six months.

◦ By exercising PAD patients have been able to increase the distance they can walk painfree, increase their total walking distance, and improve functional ability

3. Pharmacologic therapy3. Pharmacologic therapy3. Pharmacologic therapy3. Pharmacologic therapy

� Three Treatment modalitiesThree Treatment modalitiesThree Treatment modalitiesThree Treatment modalities

1. 1. 1. 1. Risk Risk Risk Risk factor factor factor factor modificationmodificationmodificationmodification

◦ Smoking cessation and control of diabetes, dyslipidemia, hypertension

2. Exercise 2. Exercise 2. Exercise 2. Exercise training or rehabilitationtraining or rehabilitationtraining or rehabilitationtraining or rehabilitation

◦ 35 to 50 min of treadmill or track walking in an exercise-rest-exercise pattern 3 to 4 times/week

◦ The greatest improvements in walking ability occurred when each exercise session lasted more than 30 minutes with at least three exercise sessions per week, when the patient walked until near maximal pain was reached at each session, and when the program continued for at least six months.

◦ By exercising PAD patients have been able to increase the distance they can walk painfree, increase their total walking distance, and improve functional ability

3. Pharmacologic therapy3. Pharmacologic therapy3. Pharmacologic therapy3. Pharmacologic therapy

� Three Treatment modalitiesThree Treatment modalitiesThree Treatment modalitiesThree Treatment modalities

� Antiplatelet drugs to reduce risk of MI, stroke or vascular death

◦ Aspirin 75 - 325 mg daily (LOE = A)

◦ Clopidogrel (Plavix) 75 mg po daily – alternate to ASA (LOE = B)

� Meds to reduce symptoms of intermittent claudication

◦ Pentoxfylline (Trental) 400 mg

◦ Improves blood flow by reducing blood viscosity

◦ Take with meals

◦ Cilostazol (PLETAL) 100 mg po bid (contraindicated in HF)

◦ Take on an empty stomach

◦ May take up to 3 months to show benefits

◦ Avoid grapefruit juice

� Keep Keep Keep Keep the legs below heart levelthe legs below heart levelthe legs below heart levelthe legs below heart level

� β-Blockers are safe unless PAD is very severe

� Elevate HOB

� Avoid cold and drugs that cause vasoconstriction

� Preventive foot care

� Early treatment of PAD can restore mobility, decrease the risk for MI and stroke, and possibly save your life/leg.

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� Peripheral angioplasty with or without stenting

� Thrombolysis with intrarterial streptokinase, t-PA, or urokinase

� Thromboendarterectomy (surgical removal of an occlusive lesion)

� Revascularization (femoropopliteal bypass grafting) helps prevent limb amputation and relieve claudication

� Amputation (last resort) indicated for uncontrolled infection, unrelenting rest pain, and progressive gangrene.

� Suitable lesions are flow-limiting, short iliac stenoses (< 3 cm) and short, single or multiple stenoses of the superficial femoropopliteal segment

� PTA is also useful for localized iliac stenosis proximal to a bypass of the femoropopliteal artery

� Success rate

◦ 85-95% for iliac arteries

◦ 50-70% for thigh and calf arteries

� Recurrence rates are relatively high

(25-35% at 3 yr)

� In patients with critical limb ischemia revascularization is recommended for limb savage

◦ Endovascular

◦ Open surgical treatment

� Two year follow-up: no significant difference in amputation free survival and overall survival in both treatment options

� However bypass first approach was associated with a significant increase in overall survival of 7.3 months and trend towards improved amputation-free survival of 5.9 months for those who survived 2 years

Definition Signs & Symptoms

� Occurs when distal arteriole pressure is so low there is not adequate pressure to provide tissue perfusion

� Prognosis is very poor the limb once for CLI develops unless blood flow restores

� Ischemic rest pain� Pain requiring

narcotics� Ulcers/gangrene� Impending limb loss� Dependent redness� Pallor on elevation of

extremities� Shiny, scaly skin� Loss of hair on feet� Reduced capillary fill

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Popliteal Case StudyPopliteal Case Study

Clinical History and BackgroundClinical History and BackgroundClinical History and BackgroundClinical History and Background

● Age:Age:Age:Age: 82, female82, female82, female82, female

● Hx: Rest pain in the left foot; foot is Hx: Rest pain in the left foot; foot is Hx: Rest pain in the left foot; foot is Hx: Rest pain in the left foot; foot is discoloreddiscoloreddiscoloreddiscolored

● Left ABI = 0.30; Rutherford Category IVLeft ABI = 0.30; Rutherford Category IVLeft ABI = 0.30; Rutherford Category IVLeft ABI = 0.30; Rutherford Category IV

● Occlusion of left popliteal artery distal to Occlusion of left popliteal artery distal to Occlusion of left popliteal artery distal to Occlusion of left popliteal artery distal to SFA stentsSFA stentsSFA stentsSFA stents

Pre-Stent

Results Post-StentResults Post-Stent

Rest pain resolved, and patient is Rest pain resolved, and patient is Rest pain resolved, and patient is Rest pain resolved, and patient is ambulating without difficulty ambulating without difficulty ambulating without difficulty ambulating without difficulty upon followupon followupon followupon follow----upupupup

Definition Causes

� Sudden decrease in limb perfusion

� Threatens limb viability

� Thrombosis associated with plaque rupture

� Thrombosis of lower extremity bypass graft

� Thromboemboliziation from an aneurysm

� Arterial embolization is suspected when onset is sudden and there is a suspected embolic source

Signs – 6 Ps Diagnosis

� Severe Pain

� Polar (cold) unilateral

� Pallor unilateral –followed by cyanosis if left unattended

� Pulselessness

� Parathesias

� Paralysis

� Immediate angiography is required to confirm location of the occlusion, identify collateral flow, and guide therapy Popliteal artery occlusion

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� Embolectomy (catheter or surgical)

� Thrombolysis (tPA)

� Bypass surgery

Embolectomy

� Surgery to bypass blocked arteries and restore blood flow to the leg.

� Blood is redirected through a graft

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� Routine post-procedure checks plus frequent assessment to ensure graft patency

� Vascular Checks ◦ q 15 min x 4, q 30 min x 4, q 1 hour x 4

◦ Pulses: distal to treatment area: popliteal, dorsalis pedis, posterior tibial

◦ Capillary refill, skin color

◦ Sensation, motor function

◦ Compare to baseline, if available

� Good feet/skin care◦ Sheep skin

◦ Warm blankets to feet

◦ Foot cradle

� Re-vascularization pain

� Bleeding

� Limb Ischemia

� Distal embolization

� Graft thrombosis

� Respiratory failure◦ Results from effusion or hemothorax after a left thoracotomy or

from inadvertent pneumothorax during exposure of the axillary artery

◦ Thoracofemoral bypass, axillofemoral bypass

◦ Also from atelectasis due to general anesthesia

◦ All bypass surgeries

� Paraplegia◦ Results from the sacrifice of intercostal vessels supplying the

anterior spinal artery

◦ Thoracofemoral bypass

� Arm paralysis◦ Results from injury to the deep and superiorly oriented brachial

plexus

◦ Axillofemoral bypass

� Ureteral injury◦ Results from ureters overlying the iliac vessels

◦ Aortoiliac endarterectomy, iliofemoral bypass, axillofemoral bypass

� Impotence◦ Results from damage to the autonomic nerve fibers around the

origin of the left common iliac artery

◦ Aortoiliac endarterectomy, iliofemoral bypass, axillofemoral bypass

� Renal failure◦ Results from acute tubular necrosis or embolization when a

suprarenal aortic clamp is used

◦ Thoracofemoral bypass and aortobifemoral bypass

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� Colonic ischemia or infarction,

◦ Results from hindered primary flow via the inferior mesenteric artery or collateral vessels from the hypogastric arteries

◦ All bypass surgeries

� Buttock claudication◦ Results from disruption of inline flow to the pelvic circulation

◦ all bypass surgeries

� Aortoduodenal fistula◦ Resulting from incomplete coverage of an aortic graft

◦ Aortofemoral and iliofemoral bypass

� Graft infection

� Recurrent disease

� Pseudoaneurysm formation

� Best treatment is management of risk factors and exercise

� Wounds may fail to respond to standard care because of low oxygen levels and impaired circulation

� Foot ulcers in diabetics are one such problem

� By increasing oxygen levels within the wound tissues, hyperbaric therapy promotes healing.

� Soft Tissue Infections:Soft Tissue Infections:Soft Tissue Infections:Soft Tissue Infections: These are serious infections -- in which tissue is dying -- that may be complicated by conditions such as diabetes or vascular disease.

� While primary treatments are removing the infected tissue and administering antibiotics, hyperbaric oxygen may inhibit bacteria from growing and enhance the ability of white blood cells to kill bacteria.

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� Patients undergoing hyperbaric treatment are placed in a chamber where 100% oxygen is circulated

� The oxygen is pressurized so that air pressure may be 2-3 times greater than normal.

� This allows the lungs and skin to absorb more concentrated oxygen in a shorter period of time.

� Main effect of hyperbaric oxygen therapy in arterial ulcers is in providing adequate oxygen for stopping further damage and salvage of viable tissue.

� New capillary growth induced by HBO can counteract the reduced blood supply due to arterial disease.

� Majority of patients are asymptomatic

� Goal is to prevent stroke

� Treatment is carotid endarterectomy or carotid stent◦ Both carry the primary risk of stroke

◦ Risk and benefit must be weighed

Diagnosis Treatment

� Most patients asymptomatic

� May present with ischemic stroke symptoms

� Carotid artery bruit – may or may not be present

� Duplex ultrasound

� CT

� MRI

� Angiogram – not used as much with the improvement of noninvasive tests

� Medical◦ Aspirin

◦ Ticlopindin (Ticlid) or Clopidogrel (Plavix)

� Surgical/Endovascular◦ Carotid Endarterectomy◦ Carotid angioplasty and

stent� Needs Clopidogrel (Plavix)

preprocedure

� Risk of distal embolization during procedure

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Straight StentStraight Stent

Tapered StentTapered Stent

Pictures courtesy of Dr. Moreno, Policlínico de Vigo, S.A. (POVISA), Spain

Carotid lesion prior to treatment

Retrieval of RX ACCUNET

RX ACCUNET with captured material

Assessments Neurological exam for nerve injury

� Routine post procedure care plus

� Peripheral Circulation◦ Facial pulses

� Incision assessment◦ Bleeding◦ Hematoma

� Maintain adequate airway if hematoma present

◦ Increased neck size

� BP: May be labile –hypertensive/hypotensive due to manipulation of carotid bodies

� Carotid stents – “yawning” indication of lack of blood flow to brain

� Ask patient to talk◦ Assesses cranial nerve (CN)

XII and X� Stick out their tongue

◦ Assesses CN XII� Swallow

◦ Assesses CN X and IX� Smile

◦ Assesses CN VII� Shrug shoulders

◦ Assesses XI� Deficits are result of

traction during surgery

On

Old

Olympus

Towering

Tops

A

Finn

And

German

Viewed

Some

Hops

Spinal

� Controls sense of smell

Source: American Nurse Today November 2006

� Controls central and peripheral vision

� Count how many fingers holding up

� Use index finger to test superior and inferior fields


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� Controls pupillary constriction


� Moves eyes downward towards nose


� Covers most of the face

� Check sensation of forehead, cheek, and jaw


� Controls movements to the sides

� Follow examiners fingers through the 6 cardinal fields of gaze


� Facial movements and expressions


� Controls hearing


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� Innervate the tongue and throat


� Controls shoulder and neck movements


� Innervates the tongue


Risk Factors

� Virchow Triad◦ Blood stasis

� Elderly

� Obesity

� Immobilization or hospitalization

◦ Vessel injury� Chermotherapy

� Vasculitis

� Surgery/Trauma

� Intravascular catheters

� Smoking

◦ Hypercoagulability� Malignancy

� Pregnancy

� Hormone replacement therapy

VTE includesDVT (deep vein

thrombosis) and PE (pulmonary

embolus)

DVT

� Classical sign: Unilateral swelling with possible tenderness with palpitation

� Pedal pulses may be diminished if arterial flow is compromised

� Positive Homan’s sign (pain with forced dorsiflexion of the foot when the leg is raised) – has many false positives so not considered a good test

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PE – sudden onset

� Symptoms depend on severity

� Dyspnea/Tachypnea- use of accessary muscles

� Tachycardia� Pallor or cyanosis � Sharp, pleuritic chest pain ..

worse with deep inspiration� Anxiety – feeling of

impending doom

Major PE – one causing hemodynamic instability is an ominous emergency!

DVT DVT and PE

� Venous Duplex

� Can differentiate between chronic venous obstruction and acute venous thrombosis

� D-dimer◦ Positive indicates

abnormally high levels of fibrin degradation products � significant thrombus formation and breakdown in the body

◦ Doesn’t give the location of the fibrin degradation

◦ Can be elevated with surgery, trauma, infection, heart disease, pregnancy

PE

� Computed Tomography Venography (CTV)◦ Highly sensitive and

specific◦ Expensive so not first line

test

� Pulmonary Angiogram◦ Gold standard for

establishing diagnosis PE◦ May or may not be

available and expensive so other tests used first.

� Spiral computed tomography

� Ventilation/perfusion (V/Q) lung scan

◦ Assesses airflow patterns and circulation of lungs

◦ With PE, shows obstructed pulmonary artery blood flow and any under perfused areas of the lungs

◦ Has high false positive rate

Reduce risk… Anticoagulation

� Reduce risk ◦ Intersperse activity during

periods of inactivity

◦ Stop smoking

� Anticoagulation◦ Do not break up clot

◦ Inhibit clot formation

◦ Heparin

◦ Low-molecular weight heparin

◦ Warfarin

� Thrombolytic therapy for PE◦ NOT recommended unless

patient hemodynamicallyunstable and low risk to bleed

� Vena Caval Interruption◦ Only recommended for

patients unable to take anticoagulation or those with recurrent VTE despite adequate anticoagulation

Arterial Venous

� Excruciating pain

� Pallor

� Cool/cold extremities

� No edema

� Diminished or absent pulses

� Crampy pain� Normal or ruddy color� Warm color� Edema – may be severe� Normal pulses

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