CHAPTER 38 Vascular Disorders

TABLE 38-2

CHARACTERISTIC
Peripheral pulses
Capillary refill
Ankle-brachial index
Edema

Hair
Ulcer
Location

Margin

Drainage
Tissue

Pain

Nails
Skin color

COMPARISON OF PERIPHERAL
ARTERY AND VENOUS DISEASE
PERIPHERAL
ARTERY
DISEASE

Tips of toes,
foot, or lateral
malleolus
Rounded,
smooth, looks
punched out
Minimal

Near medial malleolus

Thin, shiny, taut

Skin temperature

Cool, temperature
gradient down
the leg
Rarely occurs
Rarely occurs

Dermatitis
Pruritus

VENOUS DISEASE
Present; may be difficult
to palpate with edema
<3 sec
>0.91
Lower leg edema

Skin texture

COLLABORATIVE CARE

Peripheral Artery Disease

Diagnostic

Decreased or
absent
>3 sec
<0.70
Absent unless
leg constantly
in dependent
position
Loss of hair on
legs, feet, toes

Black eschar
or pale pink
granulation
Intermittent
claudication
or rest pain in
foot; ulcer may
or may not be
painful
Thickened; brittle
Dependent rubor;
elevation pallor

TABLE 38-3

875

Health history and physical examination, including palpation of

peripheral pulses
Doppler ultrasound studies
Segmental blood pressures
Ankle-brachial index
Duplex imaging
Angiogram
Magnetic resonance angiography

Collaborative Therapy
Hair may be present
or absent

Irregularly shaped

Moderate to large
amount
Yellow slough or
dark red, ruddy
granulation
Dull ache or heaviness
in calf or thigh; ulcer
often painful

Normal or thickened
Bronze-brown
pigmentation; varicose
veins may be visible
Skin thick, hardened,
and indurated
Warm, no temperature
gradient
Frequently occurs
Frequently occurs

PAD, the Doppler can determine the degree of blood flow.

Apalpable pulse and a Doppler pulse are not equivalent, and
the terms are not interchangeable. Segmental blood pressures
are obtained (using Doppler ultrasound and a sphygmomanometer) at the thigh, below the knee, and at ankle level while
the patient is supine. A drop in segmental BP of greater than
30mm Hg suggests PAD.
The ankle-brachial index (ABI) is performed using a handheld Doppler. The ABI is calculated by dividing the ankle systolic BPs by the higher of the left and right brachial systolic BP.17
A normal ABI is 0.91 to 1.30 and indicates adequate BP in the
extremities. An ABI between 0.71 and 0.90 indicates mild PAD,
between 0.41 and 0.70 indicates moderate PAD, and less than
0.40 indicates severe PAD. The ABI also is used after revascularization to monitor bypass graft patency. An ABI has limited
usefulness when arteries are calcified and noncompressible, as
occurs in patients with diabetes mellitus. In these patients, the
ABI frequently is falsely elevated.
Angiography and magnetic resonance angiography delineate
the location and extent of PAD. In addition, they provide information on inflow and outflow vessels to plan for surgery (see
Table 32-6).

Cardiovascular disease risk factor modification

Smoking cessation
Regular physical exercise
Achieve/maintain ideal body weight
Follow Dietary Approaches to Stop Hypertension (DASH) diet
(see Table 33-7)
Tight glucose control in diabetics
Tight blood pressure control
Treatment of hyperlipidemia and hypertriglyceridemia (see
Table 34-6)
Antiplatelet agent (aspirin or clopidogrel [Plavix])
Angiotensin-converting enzyme inhibitors (see Table 33-8)
Treatment of claudication symptoms
Structured walking/exercise program
Cilostazol (Pletal)
Pentoxifylline (Trental)
Nutrition therapy
Proper foot care (Table 49-22)
Percutaneous transluminal balloon angioplasty with or without
stent
Percutaneous transluminal atherectomy
Percutaneous transluminal cryoplasty
Peripheral artery bypass surgery
Patch graft angioplasty, often in conjunction with bypass surgery
Endarterectomy (for localized stenosis but rarely done)
Thrombolytic therapy (for acute ischemia only)
Amputation

Collaborative Care
Table 38-3 summarizes the collaborative care for a patient
with PAD.
Risk Factor Modification. Due to the high risk for MI, ischemic stroke, and CVD-related death, the first treatment goal is to
aggressively modify CVD risk factors in all patients with PAD
regardless of the severity of symptoms.9,29,30 Risk factors need
to be modified not only with drug therapy but also with lifestyle
changes on the part of the patient and caregiver (see Table 34-5).
Nurse-led clinics have been effective for managing CVD risk factors with PAD.31
Smoking cessation is essential in the management of patients
with PAD to reduce the risk of CVD events and mortality.
Smoking cessation is a complex and difficult process with a high
incidence of smoking relapse. All patients with PAD should
have access to comprehensive smoking cessation interventions.
(Tables 12-4, 12-5, 12-6, and 12-7 discuss smoking cessation.)
Current guidelines recommend aggressive lipid management for all PAD patients with the following goals: low-density
lipoprotein (LDL) less than 100 mg/dL, triglycerides less than
150 mg/dL, and high-density lipoprotein (HDL) greater than
40 mg/dL.9,29 Although dietary change is also recommended,
this alone is unlikely to achieve these goals. Research indicates
that treatment of PAD patients with a statin (e.g., simvastatin