Peripheral Arterial Disease (PAD)

Etiology
 Progressive narrowing and degeneration of arteries
 Atherosclerosis leading cause
 R/T other manifestations of CV disease
 60-80 years old, earlier with DM
 Men>women
 3X greater in African-American

Risk Factors
 Cigarette Smoking!!!!
 Hyperlipidemia
 HTN
 Diabetes Mellitus
 Others:
 Obesity
 Hypertriglyceridemia
 Family history
 Sedentary lifestyle
 Stress

Description
 PAD may affect
 Aortoiliac artery
 Femoral artery
 Popliteal artery
 Tibial artery
 Peroneal artery

Clinical Manifestations
Intermittent claudication
 Classic symptom of PAD
 Ischemic muscle ache or pain that is precipitated by a constant level of exercise
 Resolves within 10 minutes or less with rest
 Reproducible
 Anaerobic metabolism-lactic acid
 Femoral-popliteal: calf
 Aortoiliac: buttocks, thighs
 Internal iliac: impotence
 Sedentary people may never exhibit symptoms, not enough exertion
 6 P’s of PAD
 Pain
 Pallor
 Pulselessness
 Paresthesia – tingling, prickling or numbness
 Paralysis – loss of muscle function/ loss of feeling in the affected area
 Poikilothermia-same temp as environment, usually cool
 Paresthesia: numbness, tingling toes, feet>>>nerve ischemia
 Thin, shiny, and taut skin
 Loss of hair on the lower legs
 Diminished/absent pedal, popliteal, or femoral pulses
 Reactive hyperemia – redness of the foot
 Reactive hyperemia is observed when the limb is hung in a dependent position
(depedent rubor)).
 Pallor
  Rest pain
 With disease progression
 In the forefoot or toes and is aggravated by limb elevation
 From insufficient blood flow
 More often at night, decreased CO

Arterial Insufficiency Venous Insufficiency

Pulses Decreased or absent peripheral pulses Present

Edema None Present-ankle

Hair Loss on legs, feet, toes Present
Ulcers or gangrene over bony
Ulcers prominences, pressure points on toes Around ankle
and feet
Pain Intermittent Claudication, numbness, Dull ache, or heaviness in calf, thigh
tingling
Nails Thick, brittle Normal

Skin Color Dependent rubor, pallor w/ elevation Dependent cyanosis, brown pigment

Skin Texture Thin, shiny, dry Scaly, stasis dermatitis

Skin Temp Cool Warm

Complications
 Atrophy of the skin and underlying muscles
 Delayed healing
 Wound infection
 Tissue necrosis
 Arterial ulcers
 Amputation

Diagnostic Tests
 Doppler ultrasound
 Segmental blood pressures
 Sound waves test velocity of blood
 Can diagnose arterial or venous occlusion
 Duplex imaging
 Non invasive test
 Uses as Bidirectional, color Doppler
 To systemically map blood flow throughout the entire region of an artery

 Ankle-Brachial Index (ABI)

 Ankle SBP divided by Highest Brachial SBP
 Normal ankle pressure is EQUAL to or HIGHER than brachial pressure
 Normal = .90 -1.3
 .41 - .89 = mild to moderate disease
 0 - .40 = SEVERE disease
 The lower the ABI, the worse the disease
 Can use to monitor graft patency post-bypass
  Angiogram
 Location and extend of disease
 Inflow/outflow vessels
 Magnetic resonance angiography (MRA)
 MRI w/ angiography capability
 X-ray of the spinal column after injection of the contract medium into the subarachnoid
space via a catheter.

Overall Goals
 Adequate tissue perfusion
 Relief of pain
 Increased exercise tolerance
 Intact, healthy skin on extremities
 Protect from trauma
 Prevent/treat infection

Collaborative Care: Risk Factor Modification

 Smoking cessation: most important!!!
 Vasoconstriction
 Increases blood viscosity
 Impairs transport of cellular O2
 Aggressive treatment of hyperlipidemia
 LDL < 100 mg/dl, triglycerides < 150mg/dl
 Hypertension:
 BP maintained < 130/80
 Diabetes Mellitus:
 Glycosylated hemoglobin < 7.0% for diabetics

Collaborative Care: Drug Therapy

 Antiplatelet agents: after surgery for graft patency, inhibit platelet activity, adhesion
 Aspirin – cause GI distress
 Ticlopidine (Ticlid) – monitor for thrombocytopenia, neutropenia
 Clopidogrel (Plavix): more effective than aspirin
 Reduce risk for MI, Stroke, other CV events
 Pentoxifylline (Trental):
 Increases erythrocyte flexibility, reduces blood viscosity, improves oxygenation to
ischemic muscle
 Treat Intermittent Claudication
 Cilostazol (Pletal):
 Newest medication
 Inhibits platelet aggregation, increases vasodilation, inhibits smooth muscle cell
production
 It is a Phosphodiesterase inhibitor
 Treat Intermittent claudication
 Increases pain-free walk distance
 ACE inhibitors
 Ramipril (Altacel)
 ↓ Cardiovascular morbidity
 ↓ Mortality
 ↑ Peripheral blood flow
 ↑ABI
  ↑ Walking distance
Collaborative Care: Exercise Therapy
 Exercise improves oxygen extraction in the legs and skeletal metabolism
 Walking is the most effective exercise for individuals with claudication
 30 to 40 minutes/day
 Walk to point of pain, rest, walk again

Collaborative Care: Nutritional Therapy

 Dietary cholesterol less than 200 mg/day
 Decrease intake of saturated fat
 Soy products can be used in place of animal protein
 Maintain optimal weight

Collaborative Care: Critical Limb Ischemia

 Protect from trauma
 Decrease vasospasm
 Prevent/control infection
 Maximize arterial perfusion

Collaborative Care: Interventional Radiologic Procedures

 Indications
 Intermittent claudication symptoms become incapacitating
 Experience pain at rest
 Ulceration or gangrene severe enough to threaten viability of the limb
 Percutaneous Transluminal Angioplasty (PTA)
 Involves the insertion of a catheter through the femoral artery
 Catheter contains a cylindric balloon
 Balloon is inflated dilating the vessel by cracking the confining atherosclerotic intimal
shell
 May also place stent – a rigid or flexible metallic device; positioned within the artery
immediately after the balloon angioplasty is performed

Collaborative Care: Surgical

 Peripheral Arterial Bypass: Operation with autogenous vein or synthetic graft material, bypass
blood around the lesion
 Endarterectomy: Open artery, remove plaque
 Patch graft angioplasty: Opening the artery, removing plaque, and sewing a patch to the opening
to widen the lumen)
 Amputation: end stage surgical option; required if gangrene is extensive, infection is present in
the bone (osteomyelitis) or all major arteries in the limb are occluded

Nursing Interventions
 Frequent monitoring after surgery:
1. Skin color and temperature
2. Capillary refill
3. Presence of peripheral pulses distal to the operative site
4. Sensation and movement of extremity
5. Knee-flexed positions should be avoided except for exercise
6. Turn and position frequently
7. Monitor ABI
 Ambulatory and Home Care
1. Comfortable shoes with rounded toes and soft insoles
2. Shoes lightly laced
3. Frequent inspection of the feet
4. Management of risk factors
 5. Importance of meticulous foot care
6. Clean, light-colored, all-cotton or all-wool socks
Nursing Diagnosis
 Ineffective tissue perfusion (peripheral)  Activity intolerance
 Impaired skin integrity  Ineffective therapeutic regimen
 Acute pain management

Educative Interventions
 Teaching Guide for post-op peripheral artery bypass
1. Stop smoking/ or use of tobacco products, control BP and blood glucose levels, lower cholesterol
and triglycerides
2. Mechanism of action of medications such as anti-platelets, antihypertensive, anti-cholesterol
therapy and pain meds and how long anticipated therapy will last.
3. Eat healthy – Increase fluid intake, eat well balanced diet (high fiber foods and fresh fruits and
vegetables), eat less fried and high fat foods.
4. Daily walk / exercise program. Short walks a day and rest between activities. Gradually increase
walking to 30 to 40 minutes a day
5. Foot/leg care. Wash daily. Wear clean cotton socks and well fitting shoes. File toenails straight
across. Avoid sitting with legs crossed, extreme hot/cold temperatures, prolong standing.
6. Wound care – clean and dry. Increase intake in protein, Vit C , A and zinc
7. Signs /symptoms of impaired healing or infection of the leg incision. Notify HCP if :
 Prolong drainage, or pus from the incision
 Increased redness, warmth, pain and hardness along incision
 Separation of wound edges
 Temperature greater than 100 F
8. Keep F/U appts with HCP
9. Notify HCP immediately if: experienced increased leg or foot pain or a change in the
color/temperature of foot and leg.