Week 4 – Vascular
o Peripheral vascular disease: any disease that affects the vascular system related
to altered blood flow through arteries and veins within peripheral circulation.
o Systemic atherosclerosis – slow progression / chronic condition
Peripheral Arterial Disease (PAD):
• PAD: The narrowing or blockage of vessels within arteries, that carry blood from the
heart to the body. Particularly the lower extremities. Widespread narrowing or blockage
is a direct result of systemic atherosclerosis. All over the body
• Lower Extremity Arterial Disease
• Obstructions are classified as in flow or outflow according to the arteries involved and
their relationship to the inguinal ligament.
o Inflow obstructions or aorta iliac artery disease
▪ Involve distal end of the aorta and the common, internal and external
iliac arteries – These are above the inguinal ligament.
o Outflow obstructions
▪ Involve the femoral, popliteal, and tibial arteries – These are below the
superficial femoral arteries or below the inguinal ligament
• Peripheral Arterial Disease Assessment: Recognize cues
o Stage I: Asymptomatic – No leg pain. Bruit or aneurism may be present. or pedal
pulses are decreased or absent.
o Stage II: Claudication –Intermittent claudication: defined as discomfort or pain
that involves specific limb muscle groups during exertion due to exercise induced
ischemia. bc we increased the workload of the heart, and we aren’t perfusing
well enough to meet the demand of workload.
o Another condition that will progress over time and will involve adjacent muscle
groups. Or muscles that are next to each other in the same arterial territory.
The level above the area of pain signifies the level of arterial involvement.
o Stage III: Rest Pain – more critical stage. Ischemic leg pain, numbness, burning,
toothache type pain at rest. May waken the patient at night. Usually occurs in
the most distal region of the leg such as: toes, arche, or heel. This pain is relieved
by placing the extremity in a dependent position due to arterial pressure
increasing with gravity.
o Stage IV: Necrosis/gangrene – most critical stage that occurs with PVD. We have
now decreased blood supply and painful ulcers are developing. Prolonged
occlusion leads to blackened/ necrotic tissue. It typically occurs on the toes,
forefoot, and the heel. The further away from the perfusion (this is the area that
will get hit first.) Arterial ulcers typically have a well-defined border, they may be
, small and round with a punched-out hole or a hollowed-out appearance, they
appear dry looking and have a gangrenous odor.
- Very important we obtain a history of walking impairment and or limp ischemic
symptoms.
- Peripheral Arterial Disease Assessment: Recognize cues
o Hair loss and dry, scaly, pale, or mottled skin, thickened toenails
o Severe arterial disease
▪ Extremity is cold and gray-blue or darkened
▪ Pallor may occur with extremity elevation
▪ Dependent rubor – redness/ dusky redness (more severe)
▪ Muscle atrophy
• Peripheral Arterial Disease Diagnostic Assessment
o Magnetic Resonance Angiography (MRA) Uses contrast dye to visualize
blockages in blood vessels.
o Segmental systolic blood pressure – Measures actual limb BP using doppler.
Typically, it starts at the ankle and moves up along the leg to minimize the
occlusion effect. The other limb is assessed for comparison. Understand that a
large pressure difference or a pressure drop between for ex: thigh and knee
would suggest arterial obstruction in that area.
o Ankle-brachial index (ABI) – This is a measurement used to check for potential
arterial problems. Understand normally systolic BP in the arm and leg are similar.
Calculate: divide the highest systolic BP reading from your leg by the highest
reading from your arm. ABI of >.9 is normal <0.9 is diagnostic of PAD – main
diagnostic tool for PAD. Diabetes causes calcification in the vessels that decrease
compressibility of an artery. Because an artery doesn’t compress well due to that
calcification it directly affects the results of this test.
o Exercise tolerance testing - Provides good information about claudication
without rest pain. The pt walks a treadmill while pulse volumes and pressures
are recorded. Decrease in pulse volume or pressure is suggestive of an abnormal
arterial flow in that extremity.
• Peripheral Arterial Disease (PAD) Interventions
• We would ask the patient to walk until the point of claudication. Stop and rest. Then
walk further. Collateral circulation: this is where smaller vessels enlarge and develop to
compensate for those occluded vessels. This exercise pushes the vessels to open and
provide that circulation.
• Understand that clients with severe rest pain, venous/ arterial ulcers or gangrene
should NOT participate in this exercise.
• Teach to avoid crossing legs / wearing restrictive clothing.
• • We ask the patients to let their effected leg hang. PAD: Arteries Down
, • Teach pt to avoid raising their leg above the level of the heart. This reduces perfusion to
the more distal regions of that extremity. Teach the importance of looking at feet daily.
o Promoting Vasodilation- we ask pt to apply indirect warmth to the effected area
– ask pt to wear socks/ insulated shoes/ keep environment warm. Avoid direct
heat. Sensitivity is altered due to poor perfusion = cannot sense the warmth of
direct heat which can result in burns. This results in wounds (these areas do not
heal well) Also avoid prolonged exposure to cold. This is due to the
vasocontraction that happens when exposed to extreme cold.
o Emotional stress, caffeine, nicotine can cause vasoconstriction too.
Drug therapy
-Anticoagulation agents: reduces the risk of clots forming. – heparin or levonox
-Antiplatelet agents: reduce risk of platelets clumping – trental
o Percutaneous vascular intervention – promote vasodilation. Open the vessels
and improve arterial flow. Stents may be placed to ensure adequate BF from a
stenosed vessel.
o Atherectomy can also be used. Improves BF to ischemic legs to scrape plaque
and remove it from inside the arterial wall with minimal surface damage. There
is a risk of puncture and bleeding occurring.
o Arterial revascularization – allows blood to bypass the narrow area or occlusion
within the femoral arteries through vein grafting
• Aortoiliac and Aortafemoral Bypass
o Midline incision into the abdominal cavity is required, with an additional incision
in each groin’. Graft is tunneled from the aorta to the groin incisions
o Postoperative
▪ Deep breathing and incentive spirometry every 1-2 hours
▪ Monitor for graft occlusion – Patients will exhibit some pain, warmth,
redness, edema, this is often an expected outcome because of increased
arterial perfusion.
▪ Distal pulse sites should be marked for baseline assessment to monitor
graft patency (specifically postural tibial bc it is a great indicator for
arterial function.)
▪ Moniter VS: BP promotes graft patency. notify the surgeon if the BP is
high or low according to baseline. Hypotension could indicate
hypovolemia – which increases pt risk of clotting. hypertension – could
bust through where the graft was sewn in.
▪ Check for pain out of proportion. Ischemic pain Not relieved by PCA
pump. May indicate graft occlusion.
, ▪ Treatment of graft occlusion – pt may need an emergency thrombectomy
or they may receive local, interatrial thrombolytic therapy. Thrombolytics
are used to bust up a clot - you may insert this medication into the clot
itself. Monitor for bleeding if received a thrombolytic, increased risk of
bleeding anywhere. (brain) get baseline neuro assessment. Baseline
vascular assessment: strong pulses, sensation, color, warmth, can move
extremities.
▪ Controlling BP decreases patient bleeding risk with that graft site. But if
they received thrombolytic with high BP there is an increase pressure in
the brain and could hemorrhage. Monitor for stroke like symptoms
related to hemorrhagic stroke. Mental status, slurred speech, paralysis on
one side, unequal pupil size, signs of increase ICP: projectile vomiting,
altered LOC and unequal pupils
▪ Monitor for compartment syndrome – area of ischemia has developed
and we start releasing fluid in the compartment where that muscle group
is in causes swelling to occur. When swelling occurs it puts more pressure
on vessels and nerves which increases Edema that occurs in that muscle
group and can lose muscle function and reduced perfusion.
▪ Assess for infection – monitoring for graft or wound infections. Wound
care – using sterile technique, contact precautions, assess areas for
induration, erythema, tenderness, warmth, edema, drainage, fever, or
increase WBC.
• Axillofemoral Bypass – graft material that subcutaneously tunnels from a cath in the
chest to the iliac crest. This procedure is done when a patient has a really high risk of
abdominal complications rt their aorta and the surgeon is opting to not cut the aorta
open because of increase disease that is happening in that area or high-risk
complications to any abdominal incisions that are recurring.
Acute Peripheral Arterial Occlusion
o Pathophysiology overview – Either a thrombus dislodges and becomes an
embolus, or some type of plaque material has broken off and has now become
an embolus or a traveling clot. This traveling clot ends up in a part of our
extremities – legs or arms. Very sudden!!! Quickly – emergency.
o May have severe pain below the level of occlusion
• 6 Ps of Arterial Insufficiency: Assess these things if chronic or acute. Also known as a
neurovascular assessment. (motor function and sensory function)
o Pain – when they have an acute Arterial occlusion they describe pain as: sudden,
severe, below the level of occlusion even at rest
o Pallor – pale, moddtled, cyanotic, blackened due to lack of perfusion.
o Peripheral vascular disease: any disease that affects the vascular system related
to altered blood flow through arteries and veins within peripheral circulation.
o Systemic atherosclerosis – slow progression / chronic condition
Peripheral Arterial Disease (PAD):
• PAD: The narrowing or blockage of vessels within arteries, that carry blood from the
heart to the body. Particularly the lower extremities. Widespread narrowing or blockage
is a direct result of systemic atherosclerosis. All over the body
• Lower Extremity Arterial Disease
• Obstructions are classified as in flow or outflow according to the arteries involved and
their relationship to the inguinal ligament.
o Inflow obstructions or aorta iliac artery disease
▪ Involve distal end of the aorta and the common, internal and external
iliac arteries – These are above the inguinal ligament.
o Outflow obstructions
▪ Involve the femoral, popliteal, and tibial arteries – These are below the
superficial femoral arteries or below the inguinal ligament
• Peripheral Arterial Disease Assessment: Recognize cues
o Stage I: Asymptomatic – No leg pain. Bruit or aneurism may be present. or pedal
pulses are decreased or absent.
o Stage II: Claudication –Intermittent claudication: defined as discomfort or pain
that involves specific limb muscle groups during exertion due to exercise induced
ischemia. bc we increased the workload of the heart, and we aren’t perfusing
well enough to meet the demand of workload.
o Another condition that will progress over time and will involve adjacent muscle
groups. Or muscles that are next to each other in the same arterial territory.
The level above the area of pain signifies the level of arterial involvement.
o Stage III: Rest Pain – more critical stage. Ischemic leg pain, numbness, burning,
toothache type pain at rest. May waken the patient at night. Usually occurs in
the most distal region of the leg such as: toes, arche, or heel. This pain is relieved
by placing the extremity in a dependent position due to arterial pressure
increasing with gravity.
o Stage IV: Necrosis/gangrene – most critical stage that occurs with PVD. We have
now decreased blood supply and painful ulcers are developing. Prolonged
occlusion leads to blackened/ necrotic tissue. It typically occurs on the toes,
forefoot, and the heel. The further away from the perfusion (this is the area that
will get hit first.) Arterial ulcers typically have a well-defined border, they may be
, small and round with a punched-out hole or a hollowed-out appearance, they
appear dry looking and have a gangrenous odor.
- Very important we obtain a history of walking impairment and or limp ischemic
symptoms.
- Peripheral Arterial Disease Assessment: Recognize cues
o Hair loss and dry, scaly, pale, or mottled skin, thickened toenails
o Severe arterial disease
▪ Extremity is cold and gray-blue or darkened
▪ Pallor may occur with extremity elevation
▪ Dependent rubor – redness/ dusky redness (more severe)
▪ Muscle atrophy
• Peripheral Arterial Disease Diagnostic Assessment
o Magnetic Resonance Angiography (MRA) Uses contrast dye to visualize
blockages in blood vessels.
o Segmental systolic blood pressure – Measures actual limb BP using doppler.
Typically, it starts at the ankle and moves up along the leg to minimize the
occlusion effect. The other limb is assessed for comparison. Understand that a
large pressure difference or a pressure drop between for ex: thigh and knee
would suggest arterial obstruction in that area.
o Ankle-brachial index (ABI) – This is a measurement used to check for potential
arterial problems. Understand normally systolic BP in the arm and leg are similar.
Calculate: divide the highest systolic BP reading from your leg by the highest
reading from your arm. ABI of >.9 is normal <0.9 is diagnostic of PAD – main
diagnostic tool for PAD. Diabetes causes calcification in the vessels that decrease
compressibility of an artery. Because an artery doesn’t compress well due to that
calcification it directly affects the results of this test.
o Exercise tolerance testing - Provides good information about claudication
without rest pain. The pt walks a treadmill while pulse volumes and pressures
are recorded. Decrease in pulse volume or pressure is suggestive of an abnormal
arterial flow in that extremity.
• Peripheral Arterial Disease (PAD) Interventions
• We would ask the patient to walk until the point of claudication. Stop and rest. Then
walk further. Collateral circulation: this is where smaller vessels enlarge and develop to
compensate for those occluded vessels. This exercise pushes the vessels to open and
provide that circulation.
• Understand that clients with severe rest pain, venous/ arterial ulcers or gangrene
should NOT participate in this exercise.
• Teach to avoid crossing legs / wearing restrictive clothing.
• • We ask the patients to let their effected leg hang. PAD: Arteries Down
, • Teach pt to avoid raising their leg above the level of the heart. This reduces perfusion to
the more distal regions of that extremity. Teach the importance of looking at feet daily.
o Promoting Vasodilation- we ask pt to apply indirect warmth to the effected area
– ask pt to wear socks/ insulated shoes/ keep environment warm. Avoid direct
heat. Sensitivity is altered due to poor perfusion = cannot sense the warmth of
direct heat which can result in burns. This results in wounds (these areas do not
heal well) Also avoid prolonged exposure to cold. This is due to the
vasocontraction that happens when exposed to extreme cold.
o Emotional stress, caffeine, nicotine can cause vasoconstriction too.
Drug therapy
-Anticoagulation agents: reduces the risk of clots forming. – heparin or levonox
-Antiplatelet agents: reduce risk of platelets clumping – trental
o Percutaneous vascular intervention – promote vasodilation. Open the vessels
and improve arterial flow. Stents may be placed to ensure adequate BF from a
stenosed vessel.
o Atherectomy can also be used. Improves BF to ischemic legs to scrape plaque
and remove it from inside the arterial wall with minimal surface damage. There
is a risk of puncture and bleeding occurring.
o Arterial revascularization – allows blood to bypass the narrow area or occlusion
within the femoral arteries through vein grafting
• Aortoiliac and Aortafemoral Bypass
o Midline incision into the abdominal cavity is required, with an additional incision
in each groin’. Graft is tunneled from the aorta to the groin incisions
o Postoperative
▪ Deep breathing and incentive spirometry every 1-2 hours
▪ Monitor for graft occlusion – Patients will exhibit some pain, warmth,
redness, edema, this is often an expected outcome because of increased
arterial perfusion.
▪ Distal pulse sites should be marked for baseline assessment to monitor
graft patency (specifically postural tibial bc it is a great indicator for
arterial function.)
▪ Moniter VS: BP promotes graft patency. notify the surgeon if the BP is
high or low according to baseline. Hypotension could indicate
hypovolemia – which increases pt risk of clotting. hypertension – could
bust through where the graft was sewn in.
▪ Check for pain out of proportion. Ischemic pain Not relieved by PCA
pump. May indicate graft occlusion.
, ▪ Treatment of graft occlusion – pt may need an emergency thrombectomy
or they may receive local, interatrial thrombolytic therapy. Thrombolytics
are used to bust up a clot - you may insert this medication into the clot
itself. Monitor for bleeding if received a thrombolytic, increased risk of
bleeding anywhere. (brain) get baseline neuro assessment. Baseline
vascular assessment: strong pulses, sensation, color, warmth, can move
extremities.
▪ Controlling BP decreases patient bleeding risk with that graft site. But if
they received thrombolytic with high BP there is an increase pressure in
the brain and could hemorrhage. Monitor for stroke like symptoms
related to hemorrhagic stroke. Mental status, slurred speech, paralysis on
one side, unequal pupil size, signs of increase ICP: projectile vomiting,
altered LOC and unequal pupils
▪ Monitor for compartment syndrome – area of ischemia has developed
and we start releasing fluid in the compartment where that muscle group
is in causes swelling to occur. When swelling occurs it puts more pressure
on vessels and nerves which increases Edema that occurs in that muscle
group and can lose muscle function and reduced perfusion.
▪ Assess for infection – monitoring for graft or wound infections. Wound
care – using sterile technique, contact precautions, assess areas for
induration, erythema, tenderness, warmth, edema, drainage, fever, or
increase WBC.
• Axillofemoral Bypass – graft material that subcutaneously tunnels from a cath in the
chest to the iliac crest. This procedure is done when a patient has a really high risk of
abdominal complications rt their aorta and the surgeon is opting to not cut the aorta
open because of increase disease that is happening in that area or high-risk
complications to any abdominal incisions that are recurring.
Acute Peripheral Arterial Occlusion
o Pathophysiology overview – Either a thrombus dislodges and becomes an
embolus, or some type of plaque material has broken off and has now become
an embolus or a traveling clot. This traveling clot ends up in a part of our
extremities – legs or arms. Very sudden!!! Quickly – emergency.
o May have severe pain below the level of occlusion
• 6 Ps of Arterial Insufficiency: Assess these things if chronic or acute. Also known as a
neurovascular assessment. (motor function and sensory function)
o Pain – when they have an acute Arterial occlusion they describe pain as: sudden,
severe, below the level of occlusion even at rest
o Pallor – pale, moddtled, cyanotic, blackened due to lack of perfusion.
