41
Vascular Disorders
Kimberly Day
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Glucose Regulation Tissue Integrity
Perfusion
LEARNING OUTCOMES
1. Relate the etiology and pathophysiology of peripheral 7. Describe the pathophysiology, clinical manifestations, and
artery disease (PAD) to the major risk factors. interprofessional and nursing management of the patient
2. Describe the clinical manifestations and interprofessional with aortic dissection.
and nursing management of the patient with PAD of the 8. Evaluate the patient’s risk factors for developing
lower extremities superficial vein thrombosis or venous thromboembolism
3. Plan appropriate nursing and interprofessional management (VTE).
for the patient with acute arterial ischemic disorders 9. Distinguish between the clinical characteristics of
4. Distinguish the pathophysiology, clinical manifestations, superficial vein thrombosis and VTE.
and nursing and interprofessional management of the 10. Outline the interprofessional and nursing management of
patient with thromboangiitis obliterans (Buerger disease) patients with superficial vein thrombosis and VTE.
and Raynaud phenomenon. 11. Prioritize the key aspects of nursing management for the
5. Distinguish the pathophysiology, clinical manifestations, patient receiving anticoagulant therapy.
and interprofessional and nursing management of patients 12. Relate the pathophysiology and clinical manifestations
with different types of aortic aneurysms. to the interprofessional care of patients with varicose
6. Select appropriate nursing interventions for a patient veins, chronic venous insufficiency, and venous leg
undergoing an aortic aneurysm repair. ulcers.
KEY TERMS
acute arterial ischemia post-thrombotic syndrome (PTS)
aneurysm superficial vein thrombosis
aortic dissection thromboangiitis obliterans (Buerger disease)
chronic venous insufficiency (CVI) varicose veins
critical limb ischemia venous thromboembolism (VTE)
deep vein thrombosis (DVT) venous thrombosis
intermittent claudication Virchow’s triad
peripheral artery disease (PAD)
Vascular system problems include disorders of the arteries, veins, disease is divided into coronary, cerebral, peripheral, mesenteric,
and lymphatic vessels. These problems can result in decreased and renal artery disease.1 This chapter discusses peripheral artery
perfusion and ischemia of the peripheral tissues. Patients often disease, aortic aneurysm and dissection, and venous diseases.
have pain and difficulties with mobility and activities of daily
living. Education is a key part of management. Proper nutrition,
smoking cessation, and exercise are important health promo-
PERIPHERAL ARTERY DISEASE
tion behaviors. Following measures to promote safety, especially Peripheral artery disease (PAD) involves thickening of artery
for those on anticoagulant therapy, is critical. walls. This results in a progressive narrowing of the arteries of
We classify arterial disorders as atherosclerotic, aneurysmal, the upper and lower extremities. PAD prevalence increases with
and nonatherosclerotic vascular diseases. Atherosclerotic vascular age. It typically becomes symptomatic between ages 50 and 70
932
, CHAPTER 41 Vascular Disorders 933
years. In people with diabetes, PAD occurs earlier. In the United PERIPHERAL ARTERY DISEASE OF THE LOWER
States, about 8.5 million people over age 40 have PAD. The prev-
alence is highest in Blacks.2,3
EXTREMITIES
PAD is strongly related to other types of cardiovascular disease Lower extremity PAD may affect the iliac, femoral, popliteal,
(CVD) and their risk factors. Patients with PAD have a signifi- tibial, or peroneal arteries, or any combination of these arteries
cantly higher risk for general mortality, CVD mortality, major (Fig. 41.1). The femoral popliteal area is the most common site
coronary events, and stroke.3 PAD is a marker of advanced sys- in patients without diabetes. Those with diabetes tend to develop
temic atherosclerosis. Patients with PAD are more likely to have PAD in the arteries below the knee. Those with advanced PAD
coronary artery disease (CAD) and/or cerebral artery disease. often have multiple arterial occlusions.
Unfortunately, many people in the United States are unaware
of PAD and its risk factors. PAD remains underdiagnosed and Clinical Manifestations
undertreated. The severity of PAD symptoms depends on the site and extent of
the blockage and the amount of collateral circulation. The classic
Etiology and Pathophysiology symptom of lower extremity PAD is intermittent claudication.
The leading cause of PAD is atherosclerosis. It is a gradual thick- This ischemic muscle pain is caused by exercise, resolves within
ening of the intima (the innermost layer of the arterial wall) and 10 minutes or less with rest, and is reproducible. The pain is due
media (middle layer of the arterial wall). This results from cho- to the buildup of lactic acid from anaerobic metabolism. Once
lesterol and lipids deposited within the vessel walls, leading to the patient stops exercising, the lactic acid clears, and the pain
narrowing of the artery (see Fig. 37.1). Although we do not know subsides. PAD of the iliac arteries causes pain in the buttocks
the exact cause of atherosclerosis, inflammation and endothelial and thighs. Calf pain occurs with femoral or popliteal artery
injury play a major role (see Chapter 37). Atherosclerosis often involvement.
affects certain segments of the arterial tree. These include the As many as one-third of patients with PAD have classic
coronary, carotid (see Chapter 62), and lower extremity arteries. symptoms. Others have no symptoms or present with atypi-
Symptoms occur when vessels are 60% to 75% blocked. cal leg symptoms (e.g., burning, heaviness, pressure, soreness,
Other risk factors for PAD are similar, but not identical, to tightness, weakness) in atypical locations (e.g., ankle, foot, ham-
those for CAD. Key risk factors for PAD are tobacco use (most string, hip, knee, shin). PAD involving the internal iliac arteries
important), diabetes, hypertension, high cholesterol, and age may result in erectile dysfunction.
over 60 (Box 41.1).2 Having multiple risk factors dramatically Paresthesia (numbness or tingling) in the toes or feet may
increases the risk for PAD. result from nerve tissue ischemia. True peripheral neuropathy
occurs more often in patients with diabetes and in those with
long-standing ischemia. Neuropathy causes severe shooting
BOX 41.1 BIOLOGIC SEX
CONSIDERATIONS
Vascular Disorders Superior
mesenteric Celiac artery
Men artery Renal artery
• Thromboangiitis obliterans (Buerger disease) occurs most often in men Abdominal
younger than 40 years of age aorta Common
• Abdominal aortic aneurysms (AAAs) and aortic dissections are more com- iliac artery
Internal
mon in men iliac External
artery iliac artery
• Men with AAAs are more likely to undergo endovascular aneurysm repair
or open aneurysm repair Deep
• Sexual problems are common after aortic surgery. femoral artery
Women Superficial
• Women with PAD have poorer social functioning and higher rates of femoral artery
depression than men with PAD4
Popliteal
• Women with PAD have faster functional decline and greater mobility loss
artery
than men with PAD
• Raynaud’s phenomenon occurs mainly in women between 15 and 40 years
of age. Anterior
• Risk for VTE is greater in women over age 35 who use tobacco and oral con- tibial artery
traceptives or oral hormone therapy, are pregnant or postpartum, or have a Peroneal artery
family history of VTE
• Primary varicose veins are more common and more symptomatic in women Posterior
• Women with AAAs are at higher risk for rupture tibial artery
• In-hospital mortality is higher in women undergoing revascularization
• Women have more graft thrombosis and amputation after lower extremity
bypass surgery Fig. 41.1 Common anatomic locations of atherosclerotic lesions
(shown in yellow) of the abdominal aorta and lower extremities.
, 934 SECTION 8 Problems of Oxygenation: Perfusion
or burning pain in the extremity. It does not follow particular Critical limb ischemia (CLI) is a condition characterized by
nerve roots and may be present near ulcerated areas. Gradual, chronic ischemic rest pain lasting more than 2 weeks, nonheal-
reduced blood flow to neurons causes loss of sensation to pres- ing arterial leg ulcers, or gangrene of the leg from PAD. Patients
sure and deep pain. So, patients may not notice lower extremity with PAD who have diabetes, heart failure (HF), and a history
injuries. of a stroke have a higher risk for CLI.3
The limb’s appearance gives vital information about reduced
blood flow. The skin becomes thin, shiny, and taut. The lower Complications
legs lose their hair. Pedal, popliteal, or femoral pulses are Lower extremity PAD progresses slowly. Prolonged ischemia
decreased or absent. Pallor (blanching of the foot) develops leads to atrophy of the skin and underlying muscles. Minor
when the leg is elevated (elevation pallor). Conversely, reactive trauma to the feet (e.g., stubbing one’s toe, blister from shoes)
hyperemia (redness of the foot) develops when the limb is in a can result in delayed healing, wound infection, and tissue
dependent position (dependent rubor) (Table 41.1). necrosis, especially in the patient with diabetes. Arterial (isch-
As PAD progresses and involves multiple arterial segments, emic) ulcers most often occur over bony prominences on the
continuous pain develops at rest. Rest pain most often occurs in toes, feet, and lower legs (Table 41.1). Nonhealing arterial ulcers
the foot or toes. It is worse with limb elevation. Rest pain occurs and gangrene are the most serious complications. If PAD devel-
when blood flow does not meet basic metabolic needs of the ops over an extended period, collateral circulation may prevent
distal tissues. It occurs more often at night because cardiac out- gangrene.
put tends to drop during sleep and the limbs are at heart level. Amputation may be needed if adequate blood flow is not
Patients often try to relieve pain by gravity. They dangle the leg restored or if severe infection occurs. Uncontrolled pain and
over the side of the bed or sleep in a chair. severe, spreading infection are indicators for amputation in
people who are not candidates for revascularization.
TABLE 41.1 Comparison of Peripheral Diagnostic Studies
Artery and Venous Disease Various tests assess blood flow and the vascular system (Table
Peripheral Artery 41.2). Doppler ultrasound with duplex imaging maps blood
Characteristic Disease Venous Disease flow throughout an entire arterial region. It can determine the
Ankle-brachial ≤0.90 >0.90 degree of blood flow when we have difficulty palpating a periph-
index eral pulse due to severe PAD.
Capillary refill >3 sec <3 sec Segmental BPs are obtained using Doppler ultrasound and a
Dermatitis Rarely occurs Often occurs sphygmomanometer at the thigh, below the knee, and at ankle
Edema Absent unless leg constantly Lower leg edema level while the patient is supine. A drop in segmental BP of
in dependent position greater than 30 mm Hg suggests PAD. Angiography and mag-
Hair Loss of hair on legs, feet, toes Hair may be present
netic resonance angiography show the location and extent of
or absent
PAD (see Table 35.10).
Nails Thickened, brittle Normal or thickened
Pain Intermittent claudication or Dull ache or heaviness The ankle-brachial index (ABI) is a PAD screening tool. It is
rest pain in foot in calf or thigh done using a hand-held Doppler. Calculate the ABI for each leg
Ulcer may or may not be painful Ulcer often painful by dividing the ankle systolic BP (SBP) by the higher of the bra-
Peripheral pulses Decreased or absent Present, may be hard to chial SBPs. PAD guidelines recommend uniform reporting of
palpate with edema ABI results (Table 41.3).3 Calcified and stiff arteries in patients
Pruritus Rarely occurs Often occurs who are older or have diabetes often show a falsely elevated ABI.
Skin color Dependent rubor, elevation Bronze-brown
pallor pigmentation Interprofessional Care
Varicose veins may be Table 41.2 outlines the interprofessional care for a patient with
visible
PAD.
Skin temperature Cool, temperature gradient Warm, no temperature
down the leg gradient
Risk Factor Modification
Skin texture Thin, shiny, taut Skin thick, hardened,
and indurated The first treatment goal for patients with PAD is to reduce CVD
Ulcer risk factors. This may require both lifestyle changes and drug
• Location Tips of toes, foot, or lateral Near medial malleolus therapy (see Tables 37.2 to 37.6). Hypertension is a well-known
malleolus risk factor for PAD progression. Encourage reducing sodium
• Margin Rounded, smooth, looks Irregularly shaped intake and following the dietary approaches to stop hyper-
“punched out” tension (DASH) or Mediterranean diet. Chapter 36 discusses
• Drainage Minimal Moderate to large hypertension.
amount Tobacco cessation is essential to reduce the risk for CVD
• Tissue Black eschar or pale pink Yellow slough or
events, PAD progression, and death. This is a difficult process
granulation dark red, “ruddy”
granulation
with a high incidence of relapse. Suggest tobacco cessation strat-
egies (see Tables 11.3–11.6).
Vascular Disorders
Kimberly Day
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Glucose Regulation Tissue Integrity
Perfusion
LEARNING OUTCOMES
1. Relate the etiology and pathophysiology of peripheral 7. Describe the pathophysiology, clinical manifestations, and
artery disease (PAD) to the major risk factors. interprofessional and nursing management of the patient
2. Describe the clinical manifestations and interprofessional with aortic dissection.
and nursing management of the patient with PAD of the 8. Evaluate the patient’s risk factors for developing
lower extremities superficial vein thrombosis or venous thromboembolism
3. Plan appropriate nursing and interprofessional management (VTE).
for the patient with acute arterial ischemic disorders 9. Distinguish between the clinical characteristics of
4. Distinguish the pathophysiology, clinical manifestations, superficial vein thrombosis and VTE.
and nursing and interprofessional management of the 10. Outline the interprofessional and nursing management of
patient with thromboangiitis obliterans (Buerger disease) patients with superficial vein thrombosis and VTE.
and Raynaud phenomenon. 11. Prioritize the key aspects of nursing management for the
5. Distinguish the pathophysiology, clinical manifestations, patient receiving anticoagulant therapy.
and interprofessional and nursing management of patients 12. Relate the pathophysiology and clinical manifestations
with different types of aortic aneurysms. to the interprofessional care of patients with varicose
6. Select appropriate nursing interventions for a patient veins, chronic venous insufficiency, and venous leg
undergoing an aortic aneurysm repair. ulcers.
KEY TERMS
acute arterial ischemia post-thrombotic syndrome (PTS)
aneurysm superficial vein thrombosis
aortic dissection thromboangiitis obliterans (Buerger disease)
chronic venous insufficiency (CVI) varicose veins
critical limb ischemia venous thromboembolism (VTE)
deep vein thrombosis (DVT) venous thrombosis
intermittent claudication Virchow’s triad
peripheral artery disease (PAD)
Vascular system problems include disorders of the arteries, veins, disease is divided into coronary, cerebral, peripheral, mesenteric,
and lymphatic vessels. These problems can result in decreased and renal artery disease.1 This chapter discusses peripheral artery
perfusion and ischemia of the peripheral tissues. Patients often disease, aortic aneurysm and dissection, and venous diseases.
have pain and difficulties with mobility and activities of daily
living. Education is a key part of management. Proper nutrition,
smoking cessation, and exercise are important health promo-
PERIPHERAL ARTERY DISEASE
tion behaviors. Following measures to promote safety, especially Peripheral artery disease (PAD) involves thickening of artery
for those on anticoagulant therapy, is critical. walls. This results in a progressive narrowing of the arteries of
We classify arterial disorders as atherosclerotic, aneurysmal, the upper and lower extremities. PAD prevalence increases with
and nonatherosclerotic vascular diseases. Atherosclerotic vascular age. It typically becomes symptomatic between ages 50 and 70
932
, CHAPTER 41 Vascular Disorders 933
years. In people with diabetes, PAD occurs earlier. In the United PERIPHERAL ARTERY DISEASE OF THE LOWER
States, about 8.5 million people over age 40 have PAD. The prev-
alence is highest in Blacks.2,3
EXTREMITIES
PAD is strongly related to other types of cardiovascular disease Lower extremity PAD may affect the iliac, femoral, popliteal,
(CVD) and their risk factors. Patients with PAD have a signifi- tibial, or peroneal arteries, or any combination of these arteries
cantly higher risk for general mortality, CVD mortality, major (Fig. 41.1). The femoral popliteal area is the most common site
coronary events, and stroke.3 PAD is a marker of advanced sys- in patients without diabetes. Those with diabetes tend to develop
temic atherosclerosis. Patients with PAD are more likely to have PAD in the arteries below the knee. Those with advanced PAD
coronary artery disease (CAD) and/or cerebral artery disease. often have multiple arterial occlusions.
Unfortunately, many people in the United States are unaware
of PAD and its risk factors. PAD remains underdiagnosed and Clinical Manifestations
undertreated. The severity of PAD symptoms depends on the site and extent of
the blockage and the amount of collateral circulation. The classic
Etiology and Pathophysiology symptom of lower extremity PAD is intermittent claudication.
The leading cause of PAD is atherosclerosis. It is a gradual thick- This ischemic muscle pain is caused by exercise, resolves within
ening of the intima (the innermost layer of the arterial wall) and 10 minutes or less with rest, and is reproducible. The pain is due
media (middle layer of the arterial wall). This results from cho- to the buildup of lactic acid from anaerobic metabolism. Once
lesterol and lipids deposited within the vessel walls, leading to the patient stops exercising, the lactic acid clears, and the pain
narrowing of the artery (see Fig. 37.1). Although we do not know subsides. PAD of the iliac arteries causes pain in the buttocks
the exact cause of atherosclerosis, inflammation and endothelial and thighs. Calf pain occurs with femoral or popliteal artery
injury play a major role (see Chapter 37). Atherosclerosis often involvement.
affects certain segments of the arterial tree. These include the As many as one-third of patients with PAD have classic
coronary, carotid (see Chapter 62), and lower extremity arteries. symptoms. Others have no symptoms or present with atypi-
Symptoms occur when vessels are 60% to 75% blocked. cal leg symptoms (e.g., burning, heaviness, pressure, soreness,
Other risk factors for PAD are similar, but not identical, to tightness, weakness) in atypical locations (e.g., ankle, foot, ham-
those for CAD. Key risk factors for PAD are tobacco use (most string, hip, knee, shin). PAD involving the internal iliac arteries
important), diabetes, hypertension, high cholesterol, and age may result in erectile dysfunction.
over 60 (Box 41.1).2 Having multiple risk factors dramatically Paresthesia (numbness or tingling) in the toes or feet may
increases the risk for PAD. result from nerve tissue ischemia. True peripheral neuropathy
occurs more often in patients with diabetes and in those with
long-standing ischemia. Neuropathy causes severe shooting
BOX 41.1 BIOLOGIC SEX
CONSIDERATIONS
Vascular Disorders Superior
mesenteric Celiac artery
Men artery Renal artery
• Thromboangiitis obliterans (Buerger disease) occurs most often in men Abdominal
younger than 40 years of age aorta Common
• Abdominal aortic aneurysms (AAAs) and aortic dissections are more com- iliac artery
Internal
mon in men iliac External
artery iliac artery
• Men with AAAs are more likely to undergo endovascular aneurysm repair
or open aneurysm repair Deep
• Sexual problems are common after aortic surgery. femoral artery
Women Superficial
• Women with PAD have poorer social functioning and higher rates of femoral artery
depression than men with PAD4
Popliteal
• Women with PAD have faster functional decline and greater mobility loss
artery
than men with PAD
• Raynaud’s phenomenon occurs mainly in women between 15 and 40 years
of age. Anterior
• Risk for VTE is greater in women over age 35 who use tobacco and oral con- tibial artery
traceptives or oral hormone therapy, are pregnant or postpartum, or have a Peroneal artery
family history of VTE
• Primary varicose veins are more common and more symptomatic in women Posterior
• Women with AAAs are at higher risk for rupture tibial artery
• In-hospital mortality is higher in women undergoing revascularization
• Women have more graft thrombosis and amputation after lower extremity
bypass surgery Fig. 41.1 Common anatomic locations of atherosclerotic lesions
(shown in yellow) of the abdominal aorta and lower extremities.
, 934 SECTION 8 Problems of Oxygenation: Perfusion
or burning pain in the extremity. It does not follow particular Critical limb ischemia (CLI) is a condition characterized by
nerve roots and may be present near ulcerated areas. Gradual, chronic ischemic rest pain lasting more than 2 weeks, nonheal-
reduced blood flow to neurons causes loss of sensation to pres- ing arterial leg ulcers, or gangrene of the leg from PAD. Patients
sure and deep pain. So, patients may not notice lower extremity with PAD who have diabetes, heart failure (HF), and a history
injuries. of a stroke have a higher risk for CLI.3
The limb’s appearance gives vital information about reduced
blood flow. The skin becomes thin, shiny, and taut. The lower Complications
legs lose their hair. Pedal, popliteal, or femoral pulses are Lower extremity PAD progresses slowly. Prolonged ischemia
decreased or absent. Pallor (blanching of the foot) develops leads to atrophy of the skin and underlying muscles. Minor
when the leg is elevated (elevation pallor). Conversely, reactive trauma to the feet (e.g., stubbing one’s toe, blister from shoes)
hyperemia (redness of the foot) develops when the limb is in a can result in delayed healing, wound infection, and tissue
dependent position (dependent rubor) (Table 41.1). necrosis, especially in the patient with diabetes. Arterial (isch-
As PAD progresses and involves multiple arterial segments, emic) ulcers most often occur over bony prominences on the
continuous pain develops at rest. Rest pain most often occurs in toes, feet, and lower legs (Table 41.1). Nonhealing arterial ulcers
the foot or toes. It is worse with limb elevation. Rest pain occurs and gangrene are the most serious complications. If PAD devel-
when blood flow does not meet basic metabolic needs of the ops over an extended period, collateral circulation may prevent
distal tissues. It occurs more often at night because cardiac out- gangrene.
put tends to drop during sleep and the limbs are at heart level. Amputation may be needed if adequate blood flow is not
Patients often try to relieve pain by gravity. They dangle the leg restored or if severe infection occurs. Uncontrolled pain and
over the side of the bed or sleep in a chair. severe, spreading infection are indicators for amputation in
people who are not candidates for revascularization.
TABLE 41.1 Comparison of Peripheral Diagnostic Studies
Artery and Venous Disease Various tests assess blood flow and the vascular system (Table
Peripheral Artery 41.2). Doppler ultrasound with duplex imaging maps blood
Characteristic Disease Venous Disease flow throughout an entire arterial region. It can determine the
Ankle-brachial ≤0.90 >0.90 degree of blood flow when we have difficulty palpating a periph-
index eral pulse due to severe PAD.
Capillary refill >3 sec <3 sec Segmental BPs are obtained using Doppler ultrasound and a
Dermatitis Rarely occurs Often occurs sphygmomanometer at the thigh, below the knee, and at ankle
Edema Absent unless leg constantly Lower leg edema level while the patient is supine. A drop in segmental BP of
in dependent position greater than 30 mm Hg suggests PAD. Angiography and mag-
Hair Loss of hair on legs, feet, toes Hair may be present
netic resonance angiography show the location and extent of
or absent
PAD (see Table 35.10).
Nails Thickened, brittle Normal or thickened
Pain Intermittent claudication or Dull ache or heaviness The ankle-brachial index (ABI) is a PAD screening tool. It is
rest pain in foot in calf or thigh done using a hand-held Doppler. Calculate the ABI for each leg
Ulcer may or may not be painful Ulcer often painful by dividing the ankle systolic BP (SBP) by the higher of the bra-
Peripheral pulses Decreased or absent Present, may be hard to chial SBPs. PAD guidelines recommend uniform reporting of
palpate with edema ABI results (Table 41.3).3 Calcified and stiff arteries in patients
Pruritus Rarely occurs Often occurs who are older or have diabetes often show a falsely elevated ABI.
Skin color Dependent rubor, elevation Bronze-brown
pallor pigmentation Interprofessional Care
Varicose veins may be Table 41.2 outlines the interprofessional care for a patient with
visible
PAD.
Skin temperature Cool, temperature gradient Warm, no temperature
down the leg gradient
Risk Factor Modification
Skin texture Thin, shiny, taut Skin thick, hardened,
and indurated The first treatment goal for patients with PAD is to reduce CVD
Ulcer risk factors. This may require both lifestyle changes and drug
• Location Tips of toes, foot, or lateral Near medial malleolus therapy (see Tables 37.2 to 37.6). Hypertension is a well-known
malleolus risk factor for PAD progression. Encourage reducing sodium
• Margin Rounded, smooth, looks Irregularly shaped intake and following the dietary approaches to stop hyper-
“punched out” tension (DASH) or Mediterranean diet. Chapter 36 discusses
• Drainage Minimal Moderate to large hypertension.
amount Tobacco cessation is essential to reduce the risk for CVD
• Tissue Black eschar or pale pink Yellow slough or
events, PAD progression, and death. This is a difficult process
granulation dark red, “ruddy”
granulation
with a high incidence of relapse. Suggest tobacco cessation strat-
egies (see Tables 11.3–11.6).
