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 Management

Vascular Surgical Procedure

a. 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

Patch 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.

 amputation

Nursing Interventions

1. Lower the extremity below the level of the heart.

2. 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: Exercise

Efficacy
Walking improves claudication distance
Exercise 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 months

Speed and grade selection

Intensity 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 tolerable

Management: Medications

Antiplatelet Medications
First-Line 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