Arterial Insufficiency

• there is a deceased blood flow toward the tissues, producing ischemia

• pulses usually diminished or absent
• sharp, stabbing pain occurs because of the ischemia, particularly with
activity
• there is interference with nutrients and O2 arriving to the tissues,
leading to ischemic ulcers and changes in the skin.
Venous Insufficiency
• There is deceased return of blood from the tissues to the heart
• leads to venous congestion and stasis of blood
• pulses are present
• lead to edema, skin changes and stasis ulcers
Chronic lower limb arterial disease
Clinical features

• Pulse: diminished or absent

• Bruits: denote turbulent flow but bear no relationship to the severity
of underlying disease
• Reduced skin temperature
• Pallor on elevation and rubor on dependency (Buerger's sign)
• Muscle wasting
• Skin and nails: dry, thin and brittleLoss of hair
Intermittent claudication
• It is an ischemic pain affecting the muscles of leg upon walking
• Pain most commonly felt in calf muscle because superficial femoral
artery is mostly affected
• Pain in thigh or buttock if iliac arteries are involved
• Pain comes on after a reasonably constant claudication distant
• Pain subsides on stopping walkingABPI (Ankle and brachial pressure
index) 0.5-0.9
Critical limb ischemia
• Rest (night) pain
• Require opiate analgesia Which may be associated with or without
Tissue loss (ulceration or gangrene) , present for more than 2 weeks
• In the presence of an ankle BP of less than 5o mm Hg, usually occurs
at a ABPI below 0.5
• Rest pain only, with ankle BP more than 50 mmHg, is known as sub-
critical limb ischemia (SLI)
• Pain relieved by hanging limb out of bed.
ARTERIAL PERIPHERAL VASCULAR
DISEASES -Mx
Non-pharmacological –Best Medical Therapy for Peripheral Arterial
Disease
• Smoking cessation
• Regular exercise (30 mins of walking, three times perweek)
• Antiplatelet agents (aspirin 75 mg or clopidogrel 75mg daily)
• Reduction of cholesterol (diet and statin therapy)
• Diagnosis and treatment of diabetes mellitus
• Diagnosis and treatment of frequently associatedconditions (e.g.
hypertension, anaemia, heartfailure)
Pharmacological:
• Cilostazol: 100 mg BD
• MOA: Inhibit phosphodiesterase Ill > Inceases CAMP > Vasodilatation
• Naftidrofuryl: 100-200mg TDS
• MOA: Inhibit vascular and platelet 5-HT2 receptor > decreases lactic acidosis

Surgical:
• Angioplasty - Percutaneous Transluminal Angioplasty (first option)
• Arterial Stenting - For recurrent iliac diseases
• Bypass Surgery
• Amputation- If the vascular damage is unreconstructable
Arteriosclerotic Obleterans
• is a disorder in which there is an arteriosclerotic narrowing or
obstruction of the inner & middle layer of the artery
• most common cause of arterial obstructive disease in the extremities
• the lower extremities are involved more than upper extremities
• common site of disease - femoral artery, iliac arteries,popliteal
arteries
• In a diabetic, the disease becomes more progressive, affects the
smaller arteries and often involves vessels below the knee
Clinical Manifestations
• Intermittent claudication - most common
-Pain in the extremity that develops in a muscle that has an inadequate blood
supply during exercise
-the cramping pain disappear w/in 1-2 mins. after stopping the exercise or resting
-the femoral artery is often affected - pain in the calf muscle- common symptom
• pain at rest is indicative of severe disease - gnawing, burning pain, occur more
frequently at night
• feelings of coldness numbness tingling sensation
• advanced arteriosclerosis obliterans > ischemia may lead to necrosis, ulceration
and gangrene - toes and distal foot
Diagnostic Tests
• Doppler ultrasonography - high frequency sound waves directed to
artery or veins through a hand-held transducer moved evenly across
skin surface
• audible tone produced in proportion to blood velocity measure blood
flow through vessels
Management
directed toward prevention of vessel occlusion
• use of vasodilators
• Surgical intervention - in advanced disease - ischemic changes and pain
severely impairs activity.
1. Embolectomy- removal of a blood clot, done when large arteries
areobstructed
2. Endarterectomy-is removal of a blood clot and stripping of
atherosclerotic plaque along with the inner arterial wall.
3. Arterial by-pass surgery - an obstructed arterial segment may be
bypassed by using prosthetic material (Teflon) or the pt's. own artery
orvein (saphenous vein)
4. Percutaneous Transluminal Angioplasty-The balloon tip of the
catheter is inflated to providecompression of the plaque
5. Amputation-with advanced atherosclerosis & gangrene of
extremities
• toes are the most often amputated part of the body

*The surgical goal is the remove the least amt. of tissue possible and
create a stump adequate for the fitting of prosthesis
Post - operative
is monitored care
for signs of decreased
to promote circulation & comfort
for arterial
circulation in the affectedsurgery pt
limb and interventions done

• Assess and report changes in skin color and temperature distal tothe surgical site, every
2-4 hrs.
• Assess peripheral pulses
-sudden absence of pulse may indicate thrombosis
-mark location of pulse with a pen to facilitate frequent assessment
• Assess wound for redness, swelling and drainage
• promote circulation
-reposition pt every 2 hrs
-tell pt. not to cross legs
encourage progressive activity with analgesics to reduce pain
Thromboangitis Obliterans (Buerger
Disease)
• characterized by acute inflammatory lesions and occlusive thrombosis
of the arteries & veins
• has a very strong assoc. with cigarette smoking
• commonly occurs in male - bet. 20-40 y.o
• may involve the arteries of the upper extremities (wrists)usually affect
the lower leg. toes, feet
Clinical Manifestation
• intermittent claudication in the arch of the foot
• pain during rest –toes
• coldness - due to persistent ischemia
• Paresthesia
• pulsation in posterior tibial, dorsalis pedis - weak or absent
• extremities are red or cyanotic
• ulceration & gangrene are frequent complications –early
• can occur spontaneously but often follow trauma
Interventions
• advise the person to stop smoking
• Vasodilators- prevent progression of disease
• avoid trauma to ischemic tissues
• relieve pain
• Provide emotional support
• advise pt. to avoid mechanical, chemical or thermal injuries tothe feet
• Amputation of the leg is done only when the following. occurs
-gangrene extends well into the foot
-pain is severe and cannot be controlled
-severe infection or toxicity occurs
 Raynaud's phenomenon
• refers to intermittent episodes of spasm of small arteries or arterioles of L and R arm
causing changes in skin colour and temperature
• Generally unilateral and may affect only 1 or 2 fingers
• May occur after trauma, neurogenic lesions, occlusive arterial disease, connective
tissues disease
• charac.by reduction in blood flow to the fingers manifested by cutaneous vessel
constriction and resulting in blanching (pallor)
• Raynauds Disease-
-ideopathic disorder which is common in women 20-40 yr
-unknown etiology, may be due to immunologic abnormalities
-maybe stimulated by emotional stress, hypersensitivity tocold, alteration in sympathetic
innervation
Clinical Manifestation
• usually bilateral -(both arms or feet are affected)
• during arterial spasm - sluggish blood flow causes pallor, coldness,
numbness, cutaneous cyanosis and pain
• following the spasm - the involved area becomes intensely reddened
with tingling and throbbing sensations
• with longstanding or prolonged Raynaud's disease – ulcerations can
develop on the fingertips and toes
Medical Management
• aimed at prevention
• person advised protect against exposure to cold
• quit smoking
• Drug therapy - calcium channel blockers, vascular smoothmuscle
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 beamputated
Venous Disorders
• Alteration in the transport/flow of blood from the capillary back to
the heart
• Due to changes in smooth muscle and connective tissue which make
the veins less distensible with limited recoil capacity
• valves may malfunction, causing backflow of blood
Thrombophlebitis
• inflammation of the veins caused by thrombus or blood clot
Factors associated :
• venous stasis
• Damage to the vessel wall
• Hypercoagulability of the blood – oral contraceptive use
• common to hospitalized pts., undergone major surgery (pelvic or hip surgery), MI
Pathophysiology
• develops in both the deep and superficial veins of the lower extremity
• deep veins – femoral, popliteal, small calf veins
• superficial veins – saphenous vein
*Thrombus – form in the veins from accumulation of fibrin, WBC and RBC on
accumulation of platelets.
Deep Vein Thrombosis (DVT)t
• Tends to occur at bifurcations of the deep veins. which are sites of turbulent blood flow
• a major risk during the acute phase of thrombophlebitis is dislodgment of the thrombus >
embolus
• pulmonary embolus - is a serious complication arising from DVT of the lower extremities
Clinical Manifestations:
• pain and edema of extremity - obstruction of venous flow
• increased circumference of the thigh or calf
• (+) Homan's sign - dorsiflexion of the foot produces calf pain
• Do not check for the Homan's sign if DVT is already known to be present (increase risk of
embolus formation)
• if superficial veins are affected - signs of inflammation may be noted - redness, warmth,
tenderness along the course of the vein,the veins feel hard and thready & sensitive to pressure
Medical Management
Superficial thrombophlebitis -
• bed rest with legs elevated
• apply moist heat
• NSAID’s ( Non - steroidal anti-inflammatory drugs) – aspirin
Deep vein Thrombosis :
• requires hospitalization
• bed rest w/ legs elevated to 15-20 degrees above heart level , knees slightly flexed, trunk horizontal
(head may be raised) to promote venous return and help prevent further emboli and prevent
edema
• application of warm moist heat to reduce pain, promotes venous return
• elastic stocking or bandage
• Anticoagulantion with IV heparin
• fibrinolytic to resolve the thrombus
• vasodilator if needed to control vessel spasm and improve.circulation
Surgery - if the thrombus is recurrent and extensive or if the pt. is at
high risk for pulmonary embolism
• Thrombectomy- incising the common femoral vein in the groin and
extracting the clots
• Vena caval interruption- transvenous placement of a grid or umbrella
filter in the vena cava to block the passage of emboli
Chronic Venous Insufficiency
• Results from obstruction of venous valves in legs or reflux of blood
back through valves
• Venous ulceration is serious complication
• Pharmacological therapy is antibiotics for infections
• Debridement to promote healing
• Topical Therapy may be used with cleansing anddebridement
Varicose Veins
• are abnormally dilated veins with incompetent valves
• occurring most often in the lower extremities
• usually affected are woman 30-50 years old.
• Causes:congenital absence of a valve
• incompetent valves due to external pressure on the veins
• from pregnancy, ascites or abdominal tumors
• sustained increase in venous pressure due to CHF, cirrhosis
Prevention :
• wear elastic stockings during activities that require longstanding or when pregnant,
• moderate exercise, elevation of legs
Trendelenburg test - assess competency of venous valves through
measurement of venous filling time
• the pt. lies down with the affected leg raised to allow for venous
emptying
• a tourniquet is then applied above the knee and the pt stands.
• the direction and filling time are recorded both before & after the
tourniquet is removed
• Incompetent valves are evident when the veins fill rapidly from
backward blood flow
Surgical Intervention
• indicated or done for prevention or relief of edema, for recurrent leg
ulcers or pain or for cosmetic purposes
Vein ligation and stripping-
• the great sapheneous vein is ligated (tied) close to the femoral
junction
• the veins are stripped out through small incisions at the groin above &
below the knee and at the ankles.
• sterile dressing are placed over the incisions and an elastic bandage
extending from the foot to the groin is firmlyapplied