Vascular Diseases1631

7/28/2019 Vascular Diseases1631

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Atherosclerotic

wall weakeningin complicatedlesion

abdominal aorta

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Abdominal Aortic

Aneurysm (AAA)

Thoracic Aortic Aneurysm

(front view)


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A sac or dilation formed at a weak point

Abnormal localized permanent

dilatation of a blood vessel

One or all three layers may be involved

May rupture and lead to death

Sometimes classified by gross

appearance as fusiform or saccular

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False aneurysm

Blood escapes intoconnective tissue,

outside of arterial

wall

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Fusiform aneurysm

Symmetric,

spindle-shapedexpansion

Involves entire

circumference

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Saccular aneurysm

Out-pouching onone side only

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Dissecting aneurysm

Separation of

arterial wall layersthat fills with

blood

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Occurs mostfrequently in men,50 70 yrs of age

Etiology atherosclerosis,hypertension,infection

1/3 die fromrupture

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Vasculitis, syphilis, traumatic (automobile

accidents), collagen vascular disease

(Marfan's syndrome), smoking

S/S depend on size and rate of growth

Substernal pain, dyspnea, neck or back pain

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May be asymptomatic

Chest pain

Dyspnea, hoarseness or dysphagia

Distended neck veins and edema of

head and arms

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Imaging Must be differentiated from other diagnoses (lung

neoplasm, mediastinal masses).

CT scan and MRI very sensitive to assess.

Treatment

Controlling HTN and Beta Blockers may slowgrowth.

Surgery is for patients that have symptoms, >5cm,or rapidly expanding size.

Morbidity and Mortality higher than with AAA

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Chest xray

Transesophagealechocardiogram

CT scan

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Control underlying hypertension

Surgical repair

Resection of aneurysm and

replacement with graft

Repair with endovascular graft

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Depends on type and location

Cardiopulmonary bypass required

Thoracotomy or median sternotomyincision

Graft goes over the aneurysm

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Occurs more frequently in Caucasians,

more in men and elderly clients

Etiology atherosclerosis,

hypertension, trauma, infection,

congenital abnormalities in vessels,

genetic predisposition

Most are infrarenal

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Approximately 60% of clients areasymptomatic

Pulsatile mass in the upper and middle

abdomen Abdominal or low back pain

Bruit may be heard

Diminished femoral and distal pulses Patchy mottling of feet and toes

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Imaging

Abdominal U/S for screening and

monitoring progressionAbdominal CT scan to specifically

measure size and its relationship

with the renal arteries

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Abdominal

ultrasound CT scan, MRI

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The aortic abdominal aneurysm has an intramuralthrombus, and its size is approximately 6.7 cm indiameter. The true lumen of the aorta is indicatedby the arrowheads.


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If small, monitor every 6 months

Keep BP down

Preoperatively

Cardiac evaluation must be done

Cardiac interventions may need to be done before repair of

aneurysm

Treatment

For >5cm surgical intervention with graft replacement

If symptomatic surgical treatment must be immediate regardless ofsize

Stent grafts are treatment Inserted through common femoral arteries

Less than 2 hours, minimal blood loss

May need more complicated repair depending on patient condition

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Complications

Myocardial infarction, bleeding, limb

ischemia, bowel infarction, renal

insufficiency, stroke

Graft infection and graft fistulas can occur

Endoleak

Some patients will develop another

aneurysm in another location

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For high risk surgery patients

Before aneurysm reaches diameter for

elective surgery Inserted through femoral artery

Decreased length of stay in hospital

Still need monitoring for complications

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Pre-repair Post-repair


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Popliteal make up approximately 85% ofperipheral artery aneurysms

Symptoms due to arterial thrombosis, peripheral

embolus, compression of adjacent structures

U/S used for diagnosis and measurement

Surgery >2cm if asymptomatic and for all

symptomatic regardless of size

Femoral

Pulsatile groin masses

Same problems as popliteal

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Occurs from vascular damage, involved

in coronary and cerebral vascular disease

Stable plaque

Unstable plaque

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Arterial Manifestations:

Diminished or absent pulses

Smooth, shiny, dry skin, nohair

No edema

Round, regularly shapedpainful ulcers on distal foot,toes or webs of toes

Dependent rubor

Pallor and pain when legs

elevated

Intermittent claudication

Brittle, thick nails

Venous Manifestations:

Normal pulses

Brown patches ofdiscoloration on lower legs

Dependent edema

Irregularly shaped, usuallypainless ulcers on lower legsand ankles

Dependent cyanosis andpain

Pain relief when legselevated

No intermittent claudication

Normal nails

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Modifiable

Cigarette smoking

Obesity

Diabetes Mellitus

Physical Inactivity

High Cholesterol

High BloodPressure

Non- Modifiable

Personal or familyhistory

Heart disease History of stroke

Age

Male

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Disorders that interfere with naturalflow of blood through peripheralcirculation

Patients can have arterial and venousdisease

Chronic condition

Systemic manifestation ofatherosclerosis

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Inflow

located above the inguinal ligament

may not cause significant damage Outflow

below superficial femoral artery

typically cause significant damage

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Intermittent claudication pain with

ambulation that stops with rest

Inflow disease discomfort inbuttocks, lower back and thighs

Outflow disease burning or cramping

in ankles, feet, toes and calves, restingpain

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Blood pressure checks in both arms

Palpate pulses and compare with oppositeside

Capillary filling time Inspect extremities for edema,

discoloration, loss of hair, temperature

differences, ulcers Observe for intermittent claudication with

ambulation

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Stage I Asymptomatic

No claudication

Pedal pulses affected

Stage II

Claudication

Pain or burning with exercise but relievedwith rest

Symptoms reproducible by exercise

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Stage III Resting Pain

Awakens patient at night

Numbness or burning quality

Relieved with extremity in dependent position

Stage IV

Necrosis/Gangrene Gangrenous odor

Ulcers and necrotic tissue

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Systolic blood pressure readings Exercise tolerance testing

Plethysmography

Non-invasive technique for measuring theamount of blood flow present or passingthrough, an organ or other part of thebody

Used to diagnose deep vein thrombosisand arterial occlusive disease

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Non-surgical

Exercise

Patient positioning

Medication

Angioplasty

Arthrectomy non-surgical procedure to

open blocked coronary arteries or veingrafts by using a device on the end of a

catheter to cut or shave away

atherosclerotic plaque49


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Surgical

Bypass (inflow and outflow)

Aortoiliac and aortofemoral bypass

Axillofemoral bypass

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Embolus is most common cause Affects both upper and lower extremities History of recent MI or a-fib Severe pain even resting Temperature cool, mottled and no pulse Immediate intervention needed to prevent

loss of extremity

Treatment thrombectomy Must observe extremity for improvement of

condition also for complications

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Pathophysiology blood clots from arteries, left ventricle, or trauma

suddenly break loose and become free flowing, lodge in

bifurcations, causing obstruction distally with acute and

sudden symptoms Assessment

6 Ps pain, pallor, pulselessness, paresthesia, paralysis,

poikilothermia inability to control temp

ABI (ankle-brachial index)


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Decreased Ankle-Brachial Index (ABI)

0.50 to 0.95 indicates mild to moderate

insufficiency

0.25 or less indicates severe

Ankle pressure = ABI (normally 1.0)Brachial pressure

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MedicalAnticoagulants - heparin bolus then 1000

U/hr

Thrombolytics Surgical (depends on occlusion time)

Embolectomy

BypassAngioplasty with stent placement

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Pathophysiology Obstructive and inflammatory disease of small and medium sized

arteries and veins

Believed to be autoimmune

Has exacerbations and remissions

Smoking is very high risk factor

Assessment

Pain and instep claudication

Intense rubor

Absence of distal pulses (pedal, radial, ulnar) Paresthesias

Segmental limb blood pressures

U/S

Angiography

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Medical/Surgical Pain meds

Stop smoking

Treatment of infection and gangrene

Sympathectomy (removal of sympathetic ganglia orbranches-causes permanent vasodilation

Amputation

Nursing

Support stopping smoking

Administer pain meds

Education regarding protection extremities from coldand trauma

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Dilated, tortuous superficial veins of the lower

extremities May be superficial or deep

Symptomatic or asymptomatic Symptoms do not

always correspond to the number and size ofvaricosities

Female, family history, prolonged sitting or

standing

Dull aching feeling after long periods of standing

Complications include ulceration, stasis

dermatitis, superficial venous thrombosis and

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Treatment includes compression stockings wornall day and removed at night

Periodic elevation of legs and exercise arerecommended

Encourage walking and weight loss

Surgery is for patients that have persistent,disabling pain, ulceration, superficialthrombophlebitis

Sclerotherapy can be used for small varicosities

More than one treatment may be needed

This is chronic disease and requires continuedstockings, rest and exercise

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Swollen, dilated,

tortuous veins

Dull aching

Muscle cramps

Increased muscle

fatigue

Ankle edema Diagnosis duplex

ultrasound

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Venous Thrombosis

Thrombus formation in a vein

May be deep (DVT) or superficial Thrombophlebitis

Inflammation of a vein along with

thrombus formation

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Thrombus- a blood clot in a bloodvessel

Embolism- a clot that travels andblocks a vessel

DVT (deep vein thrombosis) seriousbecause it can cause a pulmonaryembolism

DVT most common in legs but canoccur in the upper extremities also

Thrombus formation is associated with

Virchows Triad 65


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Venous stasis due to reduced

blood flow

Injury to the intimallining

creates site for clot

formation

Hypercoagulability

increased tendency

to clot

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Pain

Tenderness

Redness

Warmth

Palpable cord

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Pulmonary embolus

Chronic venous insufficiency

Venous stasis ulcers

Chronic edema

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Elevation of extremity

Warm compresses to area Analgesics and possibly NSAIDS

Possibly antibiotics

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Active or passive leg exercises

Intermittent pneumatic compression

devices

Compression stockings

Encourage post-op deep breathing Avoid using pillows under knees

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Swelling or edema of involved extremity Tenderness

Homans sign

Signs of pulmonary embolus

Chest pain

Hemoptysis

Dyspnea

Apprehension Hypotension

Cardiac arrest

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Results from faulty venous valveswhich allow reflux of blood

Venous pressure increases and venous

stasis occurs. Edema also occurs. Small veins rupture and RBCs escape

into surrounding tissues.

Brown discoloration of tissues occurs Stasis ulcers develop

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Swollen limb

Dry, itchy, coarse,

leathery skin Reddish brown skin on

lower extremity above

ankles

Stasis ulcers above

ankles

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75% result from chronic venousinsufficiency and 20% from PAD

Appear as an open, inflamed sore

Eschar may be present Venous ulcers usually present above the

malleolus

Arterial ulcers usually occur on or betweentoes

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Take long time to treat and heal

Venous insufficiency

Stasis dermatitis

Stasis ulcer

Over the malleolus (more medial than

lateral)

If not controlled they can lose extremity

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Claudication after walking short distance

Pain at ulcer site

Between or top of toes

Cold feet

Decreased or absent pulses

Possible gangrene Atrophy of skin

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Wound culture

Oral antibiotics if infection present

Debridement of nonviable tissue

Surgical debridement

Enzymatic debridement

Wet to dry dressings

Calcium algenate dressings

Keep ulcer clean and moist while healing

Hydrocolloid dressing Unna boot

Improve nutrition

Hyperbaric oxygen therapy (HBO)

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Inhibits platelet aggregationReduces ability of blood to clot

Contraindications

Allergy, GI bleed, bleeding disorder,children


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Inhibits formation of new clots

Does not dissolve existing clot but prevents itsextension

Contraindications

Active bleeding, hemophilia, thrombocytopenia,suspected intracranial hemorrhage

Monitor

H/H, platelets (prior and regular intervals), PTT

PROTECT FROM INJURY

Avoid IM injections

Report

Drop in BP, bleeding

ANTIDOTE

Protamine sulfate 1% sol (heparin antagonist)86


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Anticoagulant Prevention of DVT

Treatment of DVT, PTE, Acute Coronary Syndrome

Contraindication GI bleed, active bleeding, bleeding disorder,

thrombocytopenia

Monitor

H/H, platelets Report

Signs of bleeding, drop in platelet count

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Prevents new clots from forming

Treatment of A-Fib

Prophylactic if prosthetic heart valve Contraindications

Hemophilia, active bleeding, esophageal varices, severehepatic disease

Antidote

Holding one or more doses, Vit K, blood transfusion maybe needed

Monitor

PT, INR

Report Bleeding (nose, mouth, gums, urine, stool)

Take at the same time each day

Maintain consistency in diet with Vit K foods (broccoli,cabbage, lettuce, green tea, spinach, tomatoes)

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Antiplatelet

Irreversible on platelets

Contraindications

Intracranial hemorrhage, active bleeding Education

Discontinue one week before having

surgery Monitor

Signs of bleeding, platelet count

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Thrombolytic

For CVA patients within *3* hour time frame fromonset of s/s

Contraindications

Active internal bleeding, recent surgery ortrauma, bleeding disorder, use of oralanticoagulants, uncontrolled HTN

Monitor

Bleeding, neuro checks, cardiac rhythm Education

IM contraindicated, no invasive procedures,quiet and on bed rest during administration

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Decreases blood viscosity and improves

blood flow

Results in reducing tissue hypoxia,

decreased pain and paresthesias

Contraindications

Intracranial bleed

MonitorRelief from pain and cramping, improved

walking tolerance

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Antidote for overdose of Coumadin

Contraindication

Severe liver disease Monitor

Patient, PT/INR, Bleeding

IV route for emergencies only

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Antidote for heparin overdose

Used after stopping heparin

Contraindication- hypersensitivity tofish

Monitor- patient and vital signs

Documents

Vascular Diseases1631