PERIPHERAL ARTERIAL OCCLUSIVE DISEASE

Arterial insufficiency of the extremities is usually found in individuals older than 50

years of age, most often in men. The legs are most frequently affected; however, the
upper extremities may be involved. The age of onset and the severity are influenced
by the type and number of atherosclerotic risk factors (Chart 31-4).
In peripheral arterial disease, obstructive lesions are predominantly confined to
segments of the arterial system extending from the aorta below the renal arteries to
the popliteal artery (Fig. 31-9).
However, distal occlusive disease is frequently seen in patients with diabetes mellitus
and in elderly patients.

Clinical Manifestations
The hallmark is intermittent claudication. This pain may be described as aching,
cramping, fatigue, or weakness that is consistently reproduced with the same degree
of exercise or activity and relieved with rest. The pain commonly occurs in muscle
groups one joint level below the stenosis or occlusion. As the disease progresses, the
patient may have a decreased ability to walk the same distance or may notice
increased pain with ambulation. When the arterial insufficiency becomes severe, the
patient begins to have rest pain. This pain is associated with critical ischemia of the
distal extremity and is persistent, aching, or boring; it may be so excruciating that it
is unrelieved by opioids. Ischemic rest pain is usually worse at night and often
wakes the patient. Elevating the extremity or placing it in a horizontal position
increases the pain, whereas placing the extremity in a dependent position reduces
the pain. In bed, some patients sleep with the affected leg hanging over the side of
the bed. Some patients sleep in a reclining chair in an attempt to relieve the pain.

Assessment and Diagnostic Findings

A sensation of coldness or numbness in the extremities may accompany intermittent
claudication and is a result of the reduced arterial flow. When the extremity is
examined, it may feel cool to the touch and look pale when elevated or ruddy and
cyanotic when placed in a dependent position. Skin and nail changes, ulcerations,
gangrene, and muscle atrophy may be evident. Bruits may be
auscultated with a stethoscope; a bruit is the sound produced by turbulent blood flow
through an irregular, tortuous, stenotic vessel or through a dilated segment of the
vessel (aneurysm). Peripheral pulses may be diminished or absent. Examining the
peripheral pulses is an important part of assessing arterial occlusive disease. Unequal
pulses between extremities or the absence of a normally palpable pulse is a sign of
peripheral arterial disease. The femoral pulse in the groin and the posterior tibial
pulse beside the medial malleolus are most easily palpated. The popliteal pulse is
sometimes difficult to palpate; the location of the dorsalis pedis artery on the dorsum

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of the foot varies and is normally absent in about 7% of the population. The
presence, location, and extent of arterial occlusive disease are determined by a
careful history of the symptoms and by physical examination. The color and
temperature of the extremity are noted and the pulses palpated. The nails may be
thickened and opaque, and the skin may be shiny, atrophic, and dry, with sparse hair
growth. The assessment includes comparison of the right and left extremities. The
diagnosis of peripheral arterial occlusive disease may be made using CW Doppler and
ankle-brachial indices (ABIs), treadmill testing for claudication, duplex
ultrasonography, or other imaging studies previously described.

Medical Management
Generally, patients feel better with some type of exercise program. If this program is
combined with weight reduction and cessation of tobacco use, patients often can
improve their activity tolerance. Patients should not be promised that their symptoms
will be relieved if they stop tobacco use, because claudication may persist, and they
may lose their motivation to stop using tobacco.
PHARMACOLOGIC THERAPY
Various medications are prescribed to treat the symptoms of peripheral arterial
disease. Pentoxifylline (Trental) increases erythrocyte flexibility and reduces blood
viscosity, and it is therefore thought to improve the supply of oxygenated blood to
the muscle. Cilostazol (Pletal) works by inhibiting platelet aggregation, inhibiting
smooth muscle cell proliferation, and increasing vasodilation. Antiplatelet
aggregating agents such as aspirin, ticlopidine (Ticlid), and clopidogrel (Plavix) are
thought to improve circulation throughout diseased arteries or prevent intimal
hyperplasia leading to stenosis.
SURGICAL MANAGEMENT
In most patients, when intermittent claudication becomes severe and disabling or
when the limb is at risk for amputation because of tissue loss, vascular grafting or
endarterectomy is the treatment of choice. The choice of the surgical procedure
depends on the degree and location of the stenosis or occlusion. Other important
considerations are the overall health of the patient and the length of the procedure
that can be tolerated. It is sometimes necessary to provide the palliative therapy of
primary amputation rather than an arterial bypass. If endarterectomy is performed,
an incision is made into the artery, and the atheromatous obstruction is removed.
The artery is then sutured closed to restore vascular integrity (Fig. 31-10). Bypass
grafts are performed to reroute the blood flow around the stenosis or occlusion.
Before bypass grafting, the surgeon determines where the distal anastomosis (site
where the vessels are surgically joined) will be placed. The distal outflow vessel must
be at least 50% patent for the graft to remain patent. A higher bypass graft patency
rate is associated with keeping the length of the bypass as short as possible. If the
atherosclerotic occlusion is below the inguinal ligament in the superficial femoral
artery, the surgical procedure of choice is the femoral-to-popliteal graft. This
procedure is further classified as above-knee and below-knee grafts, referring to the
location of the distal anastomosis. Lower leg or ankle vessels with occlusions may
also require grafts. Occasionally, the entire popliteal artery is occluded, and there is
only collateral circulation. The distal anastomosis may be made onto any of the tibial
arteries (posterior tibial, anterior tibial, or peroneal arteries) or the dorsalis pedis or
plantar artery. The distal anastomosis site is determined by the ease of exposure of
the vessel in surgery and by which vessel provides the best flow to the distal limb.
These grafts require the use of native vein to ensure patency. Native vein is
autologous vein (the patient’s own vein). The greater or lesser saphenous vein or a
combination of one of the saphenous veins and an upper extremity vein such as the
cephalic vein are used to meet the required length. How long the graft remains
patent is determined by several factors, including the size of the graft, graft location,
and development of intimal hyperplasia at anastomosis sites. Bypass grafts may be

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synthetic or autologous vein. Several synthetic materials are available for use as a
peripheral bypass graft: woven or knitted Dacron, expanded polytetrafluoroethylene
(ePTFE, such as Gore- Tex or Impra), collagen-impregnated, and umbilical vein.
Infection is a problem that threatens survival of the graft and almost always requires
removal of the graft. If a vein graft is the surgical choice, care must be taken in the
operating room not to damage the vein after harvesting (removing the vein from the
patient’s body). The vein is occluded at one end and inflated with a heparinized
solution to check for leakage and competency. When this is done, the graft is placed
in a heparinized solution to keep it from becoming dry and brittle.

Nursing Management
MAINTAINING CIRCULATION
The primary objective in the postoperative management of patients who have
undergone vascular procedures is to maintain adequate circulation through the
arterial repair. Pulses, Doppler assessment, color and temperature of the extremity,
capillary refill, and sensory and motor function of the affected extremities are
checked, compared with those of the other extremity, and recorded every hour for
the first 8 hours and then every 2 hours for 24 hours. Doppler evaluation of the
vessels distal to the bypass graft should be performed for all postoperative vascular
patients, because it is more sensitive than palpation for pulses. The ABI is monitored
at least once every 8 hours for the first 24 hours and then once each day until
discharge (not usually assessed for pedal artery bypasses). An adequate circulating
blood volume should be established and maintained. Disappearance of a pulse that
was present may indicate thrombotic occlusion of the graft; the surgeon is
immediately notified.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS
Continuous monitoring of urine output (more than 30 mL/hour), central venous
pressure, mental status, and pulse rate and volume permit early recognition and
treatment of fluid imbalances. Bleeding can result from the heparin administered
during surgery or from an anastomotic leak. A hematoma may form as well. Leg
crossing and prolonged extremity dependency are avoided to prevent thrombosis.
Edema is a normal postoperative finding; however, elevating the extremities and
encouraging the patient to exercise the extremities while in bed reduces edema.
Elastic compression stockings may be prescribed for some patients, but care must be
taken to avoid compressing distal vessel bypass grafts. Severe edema of the
extremity, pain, and decreased sensation of toes or fingers can be an indication of
compartment syndrome.
PROMOTING HOME AND COMMUNITY-BASED CARE
Discharge planning includes assessing the patient’s ability to manage independently.
The nurse determines if the patient has a network of family and friends to assist with
activities of daily living. The patient may need to be encouraged to make the lifestyle
changes necessary with a chronic disease, including pain management and
modifications in diet, activity, and hygiene (skin care). The nurse ensures that the
patient has the knowledge and ability to assess for any postoperative complications
such as infection, occlusion of the artery or graft, and decreased blood flow.The
nurse assists the patient in developing a plan to stop using tobacco. The Plan of
Nursing Care describes nursing care for patients with peripheral vascular disease.

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