Peripheral Vascular Disease Alternative Names:Peripheral vascular disease; PVD; Peripheral arterial disease; PAD; Arteriosclerosis

obliterans Definition:Arteriosclerosis of the extremities is a disease of the blood vessels characterized by

narrowing and hardening of the arteries that supply the legs and feet. This causes a decrease in blood flow that can injure nerves and other tissues. Causes, incidence, and risk factors:Arteriosclerosis

, or "hardening of the arteries," commonly shows its effects first in the legs and feet. The narrowing of the arteries may progress to total closure (occlusion) of the vessel. The vessel walls become less elastic and cannot dilate to allow greater blood flow when needed (such as during exercise). Calcium deposits in the walls of the arteries contribute to the narrowing and stiffness. The effects of these deposits may be seen on ordinary X-rays.This is a common disorder, usually affecting men over 50 years old. People are at

higher risk if they have a personal or family history of coronary artery disease (heart disease) or cerebrovascular disease (stroke), diabetes , smoking, hypertension (high blood pressure), or kidney disease involving hemodialysis . Pathophysiology: Lab Findings: Routine blood tests generally are indicated in the evaluation of patients with suspected serious compromise of vascular flow to an extremity. CBC, BUN, creatinine, and electrolytes studies help evaluate factors that might lead to worsening of peripheral perfusion. Risk factors for the development of vascular disease (lipid profile, coagulation tests) also can be evaluated, although not necessarily in the ED setting. An ECG may be obtained to look for evidence of dysrhythmia, chamber enlargement, or MI. Imaging studies: Doppler ultrasound studies are useful as primary noninvasive studies to determine flow status. Magnetic resonance imaging (MRI) Plaques are imaged easily, as is the difference between vessel wall and flowing blood. Other Tests:

The ankle-brachial index (ABI) is a useful test to compare pressures in the lower extremity to the upper extremity. Blood pressure normally is slightly higher in the lower extremities than in the upper extremities. Comparison to the contralateral side may suggest the degree of ischemia. Transcutaneous oximetry affords assessment of impaired flow secondary to both microvascular and macrovascular disruption. Its use is increasing, especially in the realm of wound care and patients with diabetes.

Medical Surgical ManagementVascular a.

Surgical Procedure Inflow procedure- Provide blood supply from the Aorta. b. Outflow procedure- Provide blood supply to vessels below the femoral artery. Surgical Treatment arterial bypass Peripheral arterial bypass surgery is required for atherosclerotic lesions in the arteries of the leg. This surgery involves using a vein graft (saphenous vein), taken from the same leg, and suturing the vein into the artery to bypass the blockage. While the patient is anesthetized using general or spinal anesthesia, an incision is made in the inside of the leg from the groin to below the knee.

endarterectomy

patch graft angioplasty angioplasty is used to repair a partial disruption of a vessel wall or longitudinal incision, where simple suture would result in narrowing of the vessel.

Patch

amputation

Nursing Interventions1. 2.

Lower the extremity below the level of the heart. Encourage moderate amount of walking or graded extremity exercise. 3. Encourage active postural exercise (Buerger Allen Exercise). 4. Discourage standing still or sitting for a long period of time. 5. Maintain warm temperature and avoid chilling. 6. Discourage nicotine use. 7. Counsel patient about stress management.8.

Encourage the avoidance of constrictive clothing and accessory. 9. Encourage avoidance of leg crossing. 10. Administer vasodilator medication and adrenergic blocking agents as prescribed. 11. Instruct patient ways to avoid trauma.

12.

Encourage patient to wear protective shoes and padding for pressure area. 13. Encourage meticulous hygiene. 14. Caution patient to avoid scratching or vigorous rubbing. 15. Promote good nutrition. Management: ExerciseEfficacyWalking

improves claudication distance types Walking (standard walking or on a treadmill) Stair stepping Time for Exercise Start: 3-5 times per week for 30 minutes per time Increase by 5 minutes until 50 minutes/session Continue program for at least 6 monthsExercise Speed

and grade selection that provokes claudication at 3-5 minutes Continue to increase intensity as ability improves claudication should occur at every session Intermittent walking technique Walk until moderate to near maximal claudication pain Rest briefly at severe claudication symptoms Rest in sitting or standing position Restart walking when claudication symptoms tolerableIntensity

Management: MedicationsAntiplateletFirst-Line

Medications agents

Aspirin

Second-Line

(alternatives if Aspirin intollerant) Ticlopidine (Ticlid) Clopidogrel (Plavix) Phosphodiesterase inhibitor medications Cilostazol (Pletal) Significant benefits in claudication distance Preferred agent over Pentoxifylline Higher frequency of adverse effects Contraindicated in Congestive Heart Failure Pentoxifylline (Trental) Only small benefits in claudication distance Consider 3 month trial before assessing benefits