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PERIPHERAL VASCULAR DISEASE NOTES!
1. VENOUS DISORDERS
A. THROMBOPHLEBITIS – aka VTE – Venous Thromboembolism
o PREVENTABLE o Clot formation in the vein with inflammation of vein o DVT = deep vein thrombosis – normally in lower extremities VIRCHOW’S TRIAD o These three conditions must be met in order for a VTE (clot) to form: Venous stasis – for example, patients that aren’t mobile; patient on long airplane ride; post-surgery, bed rest, ICU, etc. Endothelial damage – could be due to trauma; IV/ venous puncture; can result from diabetes; sepsis Hypercoagulability – patient whose coagulation system is on overdrive – occurs when a patient is septic, dehydrated, pregnant, etc. RISK FACTORS o Surgery o Immobility o Smoking o Trauma with fracture o Obesity o Diabetes o Hypercoagulability/hypercoagulable state o Oral contraceptives CLINICAL MANIFESTATIONS AND COMPLICATIONS: o Varies depending on the size of the thrombus and the area affected Superficial vs Deep vein – usually in lower extremities ; can occasionally occur in upper extremities, and that’s almost always related to an IV they had in their arm, most often related to PICC line o Area red, warm to touch, painful – but many patients may have NONE of these signs and symptoms – still need to be on lookout for DVT o Pulmonary embolus – this the #1 thing I’m concerned about – clot breaking off, going to their lungs o Chronic venous insufficiency can develop later on – leg can be chronically swollen/painful, don’t get good venous return from that extremity related to VTE I had; can lead to infection, ulcer, etc o Ulceration with gangrene DIAGNOSIS o Doppler studies – probably most common Doppler ultrasound on BOTH extremities to compare – to see if there’s a clot o Venogram X-ray using contrast to look for slots o Spiral CT scan Looking for presence of pulmonary embolism o Pulmonary arteriogram X-ray with contrast Looking for PE - Location and size of PE o Coagulation studies PT (Coumadin) - Therapeutic range for PT = INR of 2-3 (which means 2-3x the normal PT of 9- seconds) o PTT (Heparin) - therapeutic range = 46-70 seconds
TREATMENT: DVT
o Primary goal of treatment is PREVENT AN EMBOLISM! o MEDICATION: Anticoagulants Most likely put patient on a Heparin drip (20K units) to treat a DVT o more than 5,000 SQ as this is a preventative measure) Patient teaching – if they’re going home on Lovenox or Coumadin, tell them about diet, what to look for in terms of bleeding, bleeding precautions, etc Analgesics may be needed depending on how painful it is o Bedrest 3-6 days with extremity elevated (maybe) – can be controversial since bedrest is what caused this issue in the first place Now we know if they’re well anticoagulated, they can get up and be moving around pretty quickly Elevating, often there is swelling o Prevention Early elevation Support hose Smoking cessation Talking to them about diet, exercise, etc – prevention, managing risk factors o Surgical treatment Thrombectomy – going in to actually remove the clot, but this is not that common Greenfield filter – aka IVC filter (inferior vena cava filter) – opens like a little umbrella, catches the clots that are traveling back up to the rest of the body Occasionally could get clogged up, filter can be removed/replaced as necessary, but usually stays in place these interventions would likely be used with patients who have a high risk of clot but can’t use anticoagulants – like a patient with a trauma injury, especially a head injury, too risky to put on anticoagulants; could be a patient with Heparin allergy or Heparin- induced thrombocytopenia An IVC filter is one method to help prevent pulmonary embolism. Your inferior vena cava (IVC) is the major vein that brings oxygen-poor blood from the lower body back to the heart. The heart then pumps the blood to the lungs to pick up oxygen. An IVC filter is a small, wiry device. When the filter is placed in your IVC, the blood flows past the filter. The filter catches blood clots and stops them from moving up to the heart and lungs. This helps to prevent a pulmonary embolism.
B. VARICOSE VEINS
Dilated subcutaneous veins o Caused by increased venous pressure and incompetent valves RISK FACTORS = Obesity **Pregnancy Trauma Crossing your legs o Vessel wall becomes very weak and susceptible to dilation o Can be painful , legs may feel very heavy, people do not like appearance of them – seek treatment
Varicose veins are a common condition caused by weak or damaged vein walls and
valves. Veins have one-way valves inside them that open and close to keep blood
flowing toward the heart. Weak or damaged valves or walls in the veins can cause
o Pain – patient will not be still in the bed, terrible pain o Pallor – compare their feet; the affected extremity will be very pale o Pulselessness – missing pulse in that extremity Not a proble m for venous. May be hard to find a pulse in a venous issue b/c of swelling o Paresthesia – numb, tingling, feeling weird, pins and needles, etc o Paralysis – unable to wiggle toes, do plantar flexion, etc – this is a later sign o Poikilothermia – aka cold skin COMPLICATIONS: o Arterial blood flow stops o Causes tissue death from point where blood flow stops o Can cause death, especially if emboli go to brain or pulmonary system from DVT; sepsis; etc DIAGNOSTIC TESTS: o Doppler flow studies, doppler ultrasounds, arterial studies o Spiral CT of chest to look for PE Spiral computed tomography is 3D CT scan that uses X-rays to produce cross-sectional images, useful for diagnosing conditions such as pulmonary embolism. o Need to be able to figure out WHERE this occlusion is in order to treat it CHRONIC: WHAT IS IT?: o Progressive narrowing in arterial blood flow to extremity with eventual arterial obstruction o Usually in lower extremities o Slow, progressive symptoms – pain, decreased pulse, pallor, numbness/tingling PATHOLOGY: o Atherosclerotic changes – can impact patient all over body o Risk factors include – smoking , high lipids, diabetes, HTN, obesity, etc – same as cardiovascular risk factors – because this is caused by not having good blood flow to that extremity o Ischemia is from inadequate oxygenation to peripheral tissues Placing patient’s bed in the reverse trendelenburg’s position will increase perfusion to the lower extremities and help with limb ischemia SYMPTOMS: o Intermittent claudication Pain with activity; will eventually progress to pain at rest as well Less pain with legs dependent (when legs are down) – makes it easier for blood to flow into the legs Alterations in arterial circulation cause pain that worsens with leg elevation and is relieved when the extremity is dangled because gravity assists in arterial circulation o Paresthesia – numbness/tingling o Pallor with elevation o Redness with dependent position o Absent/diminished pedal pulses o Nighttime leg pain r/t the ischemic resting pain of PAD o Loss of hair on the legs, feet, and toes COMPLICATIONS: o Skin atrophies Thinning of the skin o Ischemic ulcers – usually in the lower leg and ankle areas Very hard to heal r/t lack of good blood flow to the area Leaves skin dark and discolored from ulcers DIAGNOSTICS: o Doppler ultrasound o Ankle-brachial index – compares the blood pressure in the upper and lower limbs
(systolic pressure at the ankle, divided by the systolic pressure at the arm) quick, simple way to check for peripheral artery disease (PAD). these numbers should be about the same, or indicates compromised circulation to lower extremity < 0.90 is abnormal In diabetic patients, arteries are calcified and noncompressible which results in a falsely elevated ABI o Different types of imaging studies – duplex imaging – to determine adequacy of blood flow o Angiography o Maybe even MRI (less common) GOALS OF CARE: o Save extremity – maintain or improve circulation o Protect extremity from injury – be careful when moving this person, etc o Inspect extremity frequently – teach clients good foot and skin care o Reduce risk factors – quit smoking, improve diet/cholesterol, manage HTN, etc – or else this problem can become really chronic and just progressively get worse (amputation of toes, then foot, then BKA, AKA, etc) TREATMENT: o Angioplasty – put a balloon into area to open up a narrow or obstructed artery o Atherectomy – cutting technique with angioplasty to break up clots, remove plaque/build up o Stent – many patients will need stent put in afterwards to keep that blood vessel open o BYPASS – Aortic-Femoral Bypass Graft – bypass from aorta down to femoral arteries, bypassing some of the areas that may have blockages Do not sit with legs crossed as it can increase pain, edema, and risk for venous thrombosis Pus from the incision, increased redness and hardness along the incision, and separation of wound edges are symptoms of infection of the incision site To avoid blockage of the graft/stent, patient should walk several times on post-op day one. Sitting in the chair (knees are flexed) and bedrest increases risk of venous thrombosis and may place stress on suture lines Check for palpable pulses, sensation and movement of extremities, q15 inspections of operative extremitt Changes in doppler sounds after surgery indicate complications o Endarterectomy – going in and surgically removing plaque from blood vessel o Amputation – very last thing we would do to safe the patient’s life -areas in yellow are where blockages most often occur -with diabetic patients, most problems in ankle area, def below the knee -in non-diabetic patients, you can see popliteal all the way up to femoral
DRUG THERAPY:
Meds to manage cholesterol, BP etc as needed o ACE inhibitor to control hypertension (ex: ramipril) o Statins (ex: simvastatin) is used for lipid management Aspirin – most common antiplatelet Plavix (Clopidogrel) – only used for patients who can’t tolerate Aspirin; do not combine with Aspirin Trental (Pentoxifylline) o Increases erythrocyte flexibility o Reduces blood viscosity o Can be used to treat intermittent claudication Pletal (Cilostazol) o FIRST-LINE DRUG most commonly used for intermittent claudication Inhibits platelet aggregation and increases vasodilation in a patient who doesn’t respond to exercise therapy o Inhibits smooth muscle cell proliferation o All these things improve circulation to the extremities! o Helps relieve symptoms of intermittent claudication
B. THROMBOANGIITIS OBLITERANS
Also known as Buerger’s disease Inflammatory, thrombotic disorder of the medium-sized arteries and veins of the upper or lower extremities Direct link to cigarette smoking MUST STOP SMOKING!! o Occurs most commonly in young adults with a long history of tobacco/marijuana use Teach good foot care; take care of arms and legs – monitoring for ulcers, sores, etc, notify physician of any problem Do not expose self to extremes in temperature Predominantly a male disorder – mostly younger men Often results in amputation Treatment o IV iloprost to improve rest pain and promote healing of ulcerations, this decreasing need for amputation o Sympathectomy is a procedure that involves transection of a nerve, ganglion, or plexus of the SNS to relieve pain A nurse is providing discharge info to a patient with Buerger’s disease. Which of the following info should be included in instructions? Avoid crossing the legs to improve perfusion as much as possible From which interventions may a patient with Buerger’s disease benefit? Administering analgesic medications to manage ischemic pain Stopping use of all marijuana as it will worsen symptoms Calcium channel blockers may be prescribed to decrease pain Avoid cold room temperatures because of cold sensitivity. NO nicotine replacement products b/c contraindication
C. RAYNAUD’S PHENOMENON
Spasm of SMALLER arteries o Hands and fingers o Usually precipitated by a stimulus like cold or stress, even caffeine o PAIN! o Hereditary o Women more than men o Intermittent process THREE SKIN COLOR CHANGES: o White/pallor = constriction
o Blue = lack of O o Red = recirculation Sometimes treated with calcium channel blockers (amlodipine, diltiazem, verapamil, nifedipine) o May only need this in the winter o Wear mittens, stay inside in winter, etc
