peripheral vascular disease.pptx

KING GEORGE’S MEDICAL UNIVERSITY
K.G.M.U. COLLEGE OF NURSING
PERIPHERAL VASCULAR DISEASE
PRESENTED BY-
MS. DIVYA PAL
M.Sc. NURSING I YEAR

Introduction
Peripheral vascular disease is a systemic disorder that involves the narrowing
of peripheral blood vessels (vessels situated away from the heart or the
brain). This happens as a result of arteriosclerosis or a build up of plaque ,
and can happen with veins or arteries.

Definition
 Peripheral Vascular disease is a slow and progressive circulation
disorder caused by narrowing, blockage or spasm in a blood vessel.
 Peripheral Vascular Disease may involve disease in any of the
blood vessels outside of the heart including the arteries, veins or
lymphatic vessels.

Types of Peripheral Vascular Disease
Arterial Venous Lymphatic
P.A.O.D.
Buerger’s Disease Deep Vein Thrombosis Lymphoedema
Raynaud’s Disease Varicose Veins
Aneurysm Venous Ulceration
Arterial Embolism

Types of Arterial Disorders
 Peripheral Arterial Occlusive Disease
 Beurger’s Disease
 Raynaud’s Disease
 Aneurysm
 Arterial embolism

Peripheral Arterial Occlusive Disease
 Peripheral arterial occlusive disease is an accumulation of plaque
(fats and cholesterol) in the arteries of legs and arms. This makes it
harder for blood to carry oxygen and nutrients to the tissues in those
areas. There is risk of getting non healing sore of legs and feet.
 In serious cases of PAOD , these sores can turn into areas of dead
tissue that can make it necessary to remove leg or foot.

PAOD Risk Factors
 Using tobacco products
 Diabetes
 Being age 50 and older

 Family history
 High cholesterol
 Blood clotting disorder

Sign and symptoms of PAOD
 Burning or pain in feet and toes while resting
 Cool skin on feet
 Redness or color changes of skin
 Toes and foot sores that do not heal

Stages of peripheral arterial occlusive disease
 Stage I – Asymptomatic
 II a- Mild Claudication (leg pain during exercise)
 II b- Moderate to severe Claudication
 III- Ischemic rest pain (pain in the legs while rest)
 IV- Ulcers or gangrene

DIAGNOSTIC EVALUATION
Ankle brachial Index Test
 It is a non -invasive and quick test to know the PAOD. The ankle-brachial
index (ABI) is the ratio of the systolic blood pressure (SBP) measured at
the ankle to that measured at the brachial artery.

Ankle brachial Index test
• Start by providing the ABI calculator with the highest systolic pressure taken
in both arms.
• The ankle-brachial index is calculated separately for each leg:
• Input the highest blood pressure measured in your right leg to get your right
ABI.
• Input the highest blood pressure measured in your left leg to get your left
ABI.

Ankle brachial index test
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Pulse Volume Recordings
Pulse volume recording measures the blood flow in legs. It uses
ultrasound to evaluate circulation in arteries. It is painless and non-
invasive test. It is also called pulse volume plethysmography.

Vascular Ultrasound
 It uses high frequency sound waves to create detailed images. These
sound waves pass through the soft tissues and blood vessels.

Medical management
 Control blood sugar.
 Stop smoking.
 Get regular exercise.
 Maintain a healthy weight.
 Controlling high blood pressure.

Surgical management
Balloon Angioplasty/Stenting
 Insertion of a balloon catheter into a narrowed portion of
an artery. Expanding balloon compresses the plaque
against artery wall and reduces the blockage and the
balloon catheter are removed.
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Bypass Grafting
 A surgical procedure to redirect blood flow around an area of
blockage. The procedure creates an alternate channel for blood flow
, bypassing an obstructed or damaged vessel.

Cryoplasty
 It is also called cryo- balloon angioplasty. It is a procedure similar to
angioplasty in which a vascular surgeons inserts a balloon catheter into a
blocked artery to repair an obstruction within the vessel.

Percutaneous and Laser Atherectomy
 A procedure in which a vascular surgeon inserts a specialized catheter into a
blocked artery to remove a build up of atherosclero -tic plaque from within
the vessel .The catheter contains a sharp rotating blade , grinding bit or laser
filament as well as collection system that permits the surgeon to remove the
plaque from the wall of the vessel and collect or suction any resulting
debris.

Buerger’s Disease
 These are acute inflammatory lesions and occlusive thrombosis of the
arteries and veins. It has strong association with smoking. Commonly occurs
in male between 20-40 years. The hallmark is pain and ischemia in digits.

Buerger’s Disease
 Affects the blood vessel in the body , most commonly in arms and
legs. Blood vessel selling , which can prevent blood flow causing
clots to form. This can leads to pain tissue damage and even
gangrene.

 Risk Factors:- Any form of tobacco, who smokes more than one pack.
 Clinical Manifestations:-
 Intermittent claudication
 Pain during rest
 Coldness
 Paresthesia
 Weak or absent pulse in posterior tibial, dorsalis pedis
 Extremities are cyanotic
 Ulceration and gangrene

Diagnostic Evaluation
 Buerger’s Test-
It is used to check adequacy of the arterial supply to the leg. It is perform in 2
stages. With the patient supine ,elevate both legs to an angle of 45 degrees and hold
for one to two minutes. Observe the color of the feet.

Nursing Management
 Advise patient to stop smoking
 Avoid trauma
 Emotional support
 Avoid injuries to feet
 Amputation of leg is done only when gangrene extends well into foot.

Raynaud’s disease
 Intermittent episodes during which small arteries of left or right arm
constrict causing changes in skin color and temperature. It includes
symmetrical bilateral involvement and may affect only 1 or 2 fingers .It
may occur after exposure to cold, trauma. It is characterized by reduction
of blood flow to fingers manifested by pallor.

Etiology
 Unknown etiology
 Common in women may be stimulated by stress , hypersensitivity to cold.
Clinical Manifestation:-
During arterial spasm- sluggish blood flow occurs.
Following spasm area becomes redenned with tingling and throbbing
sensation.
With longstanding Raynaud’s disease ulceration can develop on fingertips and
toes.

Medical Management
 Aimed at prevention
 Person is advised to protect against exposure to cold.
 Quit smoking
 Drug therapy - calcium channel blockers, vascular smooth muscle relaxants,
vasodilators to promote circulation and reduce pain
 Sympathectomy (cutting off of sympathetic nerve fibers)
 To relieve symptoms in the early stage of advanced ischemia, if
ulceration/gangrene occur, the area may need to be amputated.

 Similar to other arterial disorders o collect data on effect of associated,
factors - emotional stress, exposure to cold,
 Cigarette smoking
 Prevent injury, promote circulation provide comfort
 Teach pt. on effects of smoking, advise to quit

 Discuss ways of avoiding exposure to cold
 Wear adequate clothing to promote warmth
 Wear gloves and socks
 Use caution when cleaning ref. & freezer wear gloves when
handling frozen foods.

 Prevent injury
 Provide comfort
 Avoid smoking
 Avoid exposure to cold
 Wear warm clothing , gloves and socks
 Avoid drug that will cause vasoconstriction

Aneurysm
 It is a localized or diffuse enlargement of an artery at some point along its
course.
 It can occur when the vessel becomes weakened in trauma , congenital
vascular disease, infection or atherosclerosis.

Types of Aneurysm
 Saccular aneurysm
 Fusiform aneurysm
 Dissecting aneurysm
 Thoracic Aortic aneurysm
 Abdominal Aortic aneurysm

 Saccular aneurysm:-It involves only part of the circumference of
the artery.
 Fusiform aneurysm:- It is spindle shaped, involves entire
circumference of the arterial wall.
 Dissecting aneurysm:- It involves haemorrhage into a vessel wall,
which splits and dissects the wall causing a widening of the vessel,
caused by degenerative defect in the tunica media and tunica intima.

 Chest and abdominal X rays – Helps in preliminary diagnosis of aortic
aneurysm.
 Ultrasound- It is useful in determining the size, shape and location of the
aneurysm.
 MRA

Thoracic aortic aneurysm
 Aneurysm in the thoracic area can develop in the ascending , transverse or
descending aorta.
 Sign and symptoms-
 Chest pain
 Cough
 Dyspnea
 Hoarseness
 Dysphagia

Abdominal aortic aneurysm
.
 Abdominal aorta below the renal arteries.
Sign and symptoms:- Pulsatile abdominal mass on palpation.
 Pain or tenderness in the mid or upper arm abdomen
Complications:-
 Rupture of the aneurysm- most feared complication, it can occur if the
aneurysm is large and then it will lead to the death.
Treatment:- Resection of the lesion and replacement with a graft.

Arterial embolism
 Blood clots floating in the circulating arterial blood. The embolus is
frequently a fragment of atherosclerotic plaque loosened from the aorta.
 Emboli will tend to lodge in femoral or popliteal arteries , blood flow is
impaired and ischemia develops.

Clinical manifestations
 Abrupt onset of severe pain.
 Muscular weakness and burning, ache
 Distal pulses are absent and extremity becomes cold , numb and
pale.
 Symptom of shock may develop

Venous Peripheral Vascular Diseases
Deep vein thrombosis
 It occurs at the deep vein due to stasis of blood. There is a major risk during
the acute phase of thrombophlebitis is dislodgment of the thrombus.
 Pulmonary embolus is a serious complication arising from DVT of the lower
extremities.

Clinical manifestations
 Pain and edema of extremity
 Positive homan’s Sign
 Redness tenderness and warmth will occur if the superficial vein
are affected.

 Doppler Ultrasonography
 Ankle brachial index to measure arterial blood flow.
 Color flow imaging
 Transcutaneous Oximetry
 Angiography

Medical management
 Requires hospitalization
 Bed rest with leg elevated to 15-20 degrees
 Application of warm moist heat to reduce pain.
 Elastic stocking or bandage
 Anticoagulants, initially with IV heparin then coumarin
 Fibrinolytic
 To promote arterial blood flow provide Pentoxifylline.
 Trendelenberg position

Pharmacological management
 Antiplatelet agents-
 Ex-Clopidogrel (75mg/day)
 Action-For the reduction of the combined risk of ischemic stroke ,
myocardial infarction or vascular death.
 Lipid lowering agents-
 Ex-Simvastatin (40 mg/day)
 Action- It is an addition to existing treatments to reduce the rates of
myocardial infarction , stroke and revascularization.

Phosphodiestrase III inhibitor
 Ex- Cilostazole
Action- Improves walking distance in people with intermittent claudication

Angiotensin Converting Enzyme Inhibitor-
Ex- Ramipril
Action-Increases pain free walking distance , maximum walking time and
walking improvement.

Calcium Channel Blockers
 Ex-Nifedipine
 Nitrendipine
Action-
 Relaxes blood vessels.
 These are protective against
all causes, cardiovascular and cerebrovascular disease mortality

Assessment
 Condition of the skin (shiny, taut or absence of hair growth )
 Ulcerations or necrotic tissue
 Extremely cold to touch
 Periphreal pulses: diminished, weak , absent , bilateral inequality

Surgical Management
 Arterial Bypass Surgery:- An obstructed arterial segment may be
passed by using a prosthetic material (Teflon) or patient’s own artery
or vein. (sephanous vein)
 Percutaneous Transluminal Angioplasty:- The balloon tip of
catheter in inflated to provide compression of the plaque.
 Amputation

Endarterectomy
 It is a removal of a blood clot and stripping of atherosclerotic plaque along
with the inner arterial wall.

Nursing Management
 Advice the patient to do exercise daily
Stop smoking
Keep legs and feet clean , dry and comfortable-
clean with the warm water and mild soap
Pat dry using soft towel
Apply cream after drying
Wear a pair of cotton socks everyday.

Prevent accidents and injuries to health-
 Don’t go barefoot
 Walk on ground levels
Improve blood supply to legs and feet-
 Don’t cross legs
 Don’t wear knee stockings
 Don’t swim in cold water

 Do passive exercise of legs
 Walk for atleast 30 minutes daily
 Avoid cold water for bathing
 Stop smoking
 If edema occurs , then elevate the legs
 Dorsiflex legs at regular intervals to prevent venous pooling
 Avoid massaging the affected extremity Keep extremity warm but do not heat.
 Use elastic stockings on affected leg.

Venous Ulceration
 A venous ulcer , also known as static ulcer , is a wound that takes longer than
usual to heal. It’s due to vein and blood flow issues and often occurs on legs
near the ankle. It can take several months to heal. In severe cases the ulcer
never heals.

Risk factors
 Deep vein thrombosis
 Family history of venous disease
 Obesity
 Older age
 Paralysis
 Previous injury
 Smoking, sedentary life style , surgery such as knee replacement

Symptoms
 Dull ache
 Foul odor
 Itching
 Pus or other fluid that oozes from the sore
 Swelling.

 Ankle-brachial index, which takes blood pressure readings of arms
and legs.
 Doppler study to listen to blood flowing through veins.
 Imaging studies, such as a CT scan to identify damaged or non
functioning valves.

Medical management
 Growth factor therapy- Injectable substances that attract healthy
cells to heal ulcers.

 Hyperbaric oxygen therapy- A treatment in which patient sit in a special
pressurized chamber and inhale pure oxygen.

 Skin graft- Replacing diseased skin with healthy skin from another part
of the body.
 Venous disease treatment- To correct blood pooling problems and
improve circulation.
 Antibiotics if there's an infection.
 Compression bandages or stockings to improve circulation.

 Lymphedema therapy: Massage, skin care and bandaging techniques that
clear fluid build up.

 Stem cell therapy: Injections of bone marrow (the substance inside of
bones) to generate healthy tissue.

 Ointments that protect against germs.
 Pain relievers and other therapies to quiet overactive nerves.
 Antibiotics

Surgical management
Debridement - Debridement is often done when a venous ulcer shows signs of
infection such as when there is fever, elevated white blood count, and persistent
or increased drainage.

Nursing Management
 Special bandages and dressings to keep the ulcer covered.
 Wound cleaning daily to flush out bacteria and remove dead tissue.
 Compression bandages or stockings to improve circulation.

Varicose veins
 Varicose veins are swollen, twisted vein that lie just under the skin and
usually occur in the legs. This health topic focuses on varicose veins in
the legs, but sometimes varicose veins form in other parts of the body.
 It is caused due to weak vein walls.
 Also called spider veins.

Causes
 Pregnancy
 Menopause
 Age over 50
 Standing for long periods of time
 Obesity
 Family history of varicose veins

Symptoms of varicose veins
 Bulging, bluish vein
 Swelling in the legs
 Aching pain in the legs
 A feeling of heaviness in the legs and feet
 Itching around the veins
 Skin color changes around the vein or veins
 Night time leg cramps

 Ultrasound: To check blood flow. This is a non invasive test that uses high-
frequency sound waves. It allows to see how blood is flowing in veins.
 Venogram : It is done to further assess veins. During this test, doctor injects
a special dye into legs and takes X- rays of the area. The dye appears on the
X-rays, giving a better view that how blood is flowing.

Medical Management
 Microsclerotherapy: Using a liquid chemical injection to block off
smaller veins.(Sclerosant chemical).
 Endoscopic vein surgery: Using a small lighted scope inserted through a
small incision to block off a large vein.

Laser surgery- Using light energy to block off a large vein.

 Sclerotherapy:- using a liquid or foam chemical injection to block off a
vein.

Endovenous ablation therapy:- Using heat and radiofrequency waves to
block off a vein.

LYMPHATIC PERIPHERAL VASCULAR DISEASE
Lymphoedema
Definition:-
 Lymphoedema may be defined as abnormal limb swelling caused by the
accumulation of increased amounts of high protein.

Types of lymphoedema
 Primary lymphoedema
Primary lymphoedema is much more common in the legs than the arms .
 All cases of primary lymphoedema are due to an inherited abnormality of
the lymphatic system, sometimes termed 'congenital lymphatic dysplasia'.

Secondary Lymphoedema
 This is the most common form of lymphoedema. There are several
well- recognised causes including infection, inflammation, neoplasia
and trauma.

Risk factors
Upper limb/trunk lymphoedema
 Surgery for lymph node dissection.
 Breast surgery.
 Radiotherapy to breast or to axilary, subclaviclar lymph nodes.
 Wound complications

 Cancer
 Obesity
 Hypertension
 Chronic skin disorders
 Air travel .
 Congenital predisposition

Lower limb lymphoedema
 Obesity
 Varicose vein stripping
 Advance cancer
 Orthopedic surgery
 Surgery with inguinal lymph node dissection
 Postoperative pelvic radiotherapy
 Genetic predisposition/family history of chronic oedema
 Thrombophlebitis and chronic venous insufficiency

Routine tests
 Lymphangiography- An X ray study of the lymphatic
system. Dye is injected into a lymphatic vessel .
 Isotope lymphoscintigraphy-Dye is injected and special
machine used to see how dye is travel into nearby lymph
node .

 Computerised tomography
 Magnetic resonance imaging
 Ultrasound
 Pathological examination

Medical management
 Relief of pain
 Decongestive lymphoedema therapy (DLT)
 Skin care
 Manual lymphatic drainage
 Multilayer lymphoedema bandaging and compression garments
 Exercise
 Control of swelling

Surgical management
Only a small minority of patients with lymphoedema benefit from surgery.
Operations fall into two categories:
1. Bypass procedures
 Lymphovenous bypass creates a path for lymphatic fluid to flow away from
the arms. Anastomosis is done. Lymphaticovenular anastomosis ,aims to
remedy the obstruction of blood flow by redirecting lymphatic fluid into
veins in arms or legs.

Nursing management
 Keep skin and nail clean and cared for, to prevent infection.
 Avoid blocking the flow of fluids through the body. Keep blood from pooling
in the affected limb.
 Reduce edema in affected area via manual lymph drainage ( light massage) and
compression .
 Activities that promote lymph fluid drainage.

 Appropriate use of preventive compression garments.
 Safe practices that avoid trauma to at the risk area of limb (avoiding heavy
use of the extremity, phlebotomy, or blood pressure readings in the affected
limb.

Nursing Diagnosis
 Acute pain related to vascular system blockage as evidenced by burning
pain in feet.
 Ineffective tissue perfusion related to reduced blood flow as evidenced
by edema.
 Risk for injury related to altered peripheral sensation as evidenced by
impaired balance.
 Risk for infection related to edema as evidence by skin peeling.

Conclusion
 Peripheral Vascular Disease is very prevalent in patients with
cardiac disease. It is underdiagnosed and undertreated. There is high
mortality with PVD is usually due to cardiac causes. There are many
revascularization options available to patients to improve quality of
life.

Summary
 Peripheral Vascular disease is a slow and progressive circulation
disorder. Narrowing , blockage or spasm in a blood vessel can cause
Peripheral Vascular Disease. It may affect any blood vessel outside
of the heart including the arteries, veins or lymphatic vessels.

Recapitulation
 What is the Peripheral Vascular Disease?
 List down the classifications of Peripheral vascular disease?
 Write the Nursing management of PVD?

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