VASCULAR DISEASES

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Aneurysms

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Aneurysm

Atherosclerotic wall weakening in

complicated lesion

abdominal aorta

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Aortic Aneurysm

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Abdominal Aortic Aneurysm (AAA)

Thoracic Aortic Aneurysm(front view)

Aortic Aneurysm 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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Characteristics of Aneurysms

False aneurysmBlood escapes into connective tissue, outside of arterial wall

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Characteristics of Aneurysms

Fusiform aneurysm Symmetric, spindle-shaped expansion Involves entire circumference

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Characteristics of Aneurysms

Saccular aneurysmOut-pouching on one side only

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Characteristics of Aneurysms

Dissecting aneurysm Separation of arterial wall layers that fills with blood

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Thoracic Aortic Aneurysm

Occurs most frequently in men, 50 – 70 yrs of age

Etiology – atherosclerosis, hypertension, infection

1/3 die from rupture

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Thoracic Aortic Aneurysm

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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Assessment Findings with Thoracic Aneurysm

May be asymptomatic Chest pain Dyspnea, hoarseness or dysphagia Distended neck veins and edema of

head and arms

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Thoracic Aortic Aneurysm

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 slow

growth. Surgery is for patients that have symptoms, >5cm,

or rapidly expanding size. Morbidity and Mortality higher than with AAA

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Diagnostic Studies

Chest xray Transesophageal

echocardiogram CT scan

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Management of Thoracic Aneurysm

Control underlying hypertension Surgical repair

Resection of aneurysm and replacement with graft

Repair with endovascular graft

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Thoracic Aneurysm Repair

Depends on type and location Cardiopulmonary bypass required Thoracotomy or median sternotomy

incision Graft goes over the aneurysm

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Grafts

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Abdominal Aortic Aneurysm

(AAA) 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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Assessment Findings with AAA

Approximately 60% of clients are asymptomatic

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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Abdominal Aortic Aneurysms

Imaging Abdominal U/S for screening and

monitoring progression Abdominal CT scan to specifically

measure size and its relationship with the renal arteries

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Diagnostic Tests with AAA

Abdominal ultrasound

CT scan, MRI

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The aortic abdominal aneurysm has an intramural thrombus, and its size is approximately 6.7 cm in diameter. The true lumen of the aorta is indicated by the arrowheads.

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Management of AAA 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 of

size 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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Abdominal Aortic Aneurysms

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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Endovascular Repair

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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“Endovascular” Aortic Aneurysm Repair

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Pre-repair Post-repair

Popliteal and Femoral Popliteal make up approximately 85% of

peripheral 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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Atherosclerosis

Occurs from vascular damage, involved in coronary and cerebral vascular disease

Stable plaque Unstable plaque

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Peripheral Vascular Diseases

Arterial Manifestations: Diminished or absent pulses Smooth, shiny, dry skin, no

hair No edema Round, regularly shaped

painful 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 of

discoloration on lower legs Dependent edema Irregularly shaped, usually

painless ulcers on lower legs and ankles

Dependent cyanosis and pain

Pain relief when legs elevated

No intermittent claudication Normal nails

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PAD Risk Factors (same as for atherosclerosis)

Modifiable Cigarette smoking Obesity Diabetes Mellitus Physical Inactivity High Cholesterol High Blood

Pressure

Non- Modifiable Personal or family

history Heart disease History of stroke Age Male

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PVD

Disorders that interfere with natural flow of blood through peripheral circulation

Patients can have arterial and venous disease

Chronic condition Systemic manifestation of

atherosclerosis

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Obstructions

Inflow located above the inguinal ligament may not cause significant damage

Outflow below superficial femoral artery typically cause significant damage

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Assessment

Intermittent claudication – pain with ambulation that stops with rest

Inflow disease – discomfort in buttocks, lower back and thighs

Outflow disease – burning or cramping in ankles, feet, toes and calves, resting pain

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Peripheral Vascular Disease

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Patient Assessment

Blood pressure checks in both arms Palpate pulses and compare with opposite

side Capillary filling time Inspect extremities for edema, discoloration,

loss of hair, temperature differences, ulcers Observe for intermittent claudication with

ambulation

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Stages of PAD Stage I

Asymptomatic No claudication Pedal pulses affected

Stage II Claudication Pain or burning with exercise but relieved

with rest Symptoms reproducible by exercise

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Stages of PAD 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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Diagnostic Exams Systolic blood pressure readings Exercise tolerance testing Plethysmography

Non-invasive technique for measuring the amount of blood flow present or passing through, an organ or other part of the body

Used to diagnose deep vein thrombosis and arterial occlusive disease

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TreatmentNon-surgical Exercise Patient positioning Medication Angioplasty Arthrectomy – non-surgical procedure to

open blocked coronary arteries or vein grafts by using a device on the end of a catheter to cut or shave away atherosclerotic plaque

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Arthrectomy

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Treatment

Surgical Bypass (inflow and outflow)

Aortoiliac and aortofemoral bypass Axillofemoral bypass

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Graft Bypass

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Acute Peripheral Arterial Occlusion

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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Acute Arterial Occlusive Disease (arterial embolism)

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 P’s – pain, pallor, pulselessness, paresthesia, paralysis,

poikilothermia – inability to control temp ABI (ankle-brachial index) <1 U/S MRI Angiography

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Diagnostic Findings With Arterial Occlusive

Disease 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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Management of Arterial Embolism

Medical Anticoagulants - heparin bolus then 1000

U/hr Thrombolytics

Surgical (depends on occlusion time) Embolectomy Bypass Angioplasty with stent placement

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Buerger’s Disease (thromboangiitis

obliterans) 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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Management of Buerger’s Disease

Medical/Surgical Pain meds Stop smoking Treatment of infection and gangrene Sympathectomy (removal of sympathetic ganglia or

branches-causes permanent vasodilation Amputation

Nursing Support stopping smoking Administer pain meds Education regarding protection extremities from cold

and trauma

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Thromboangiitis Obliterans

(Buerger’s disease)

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Thromboangiitis Obliterans

(Buerger’s disease)

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Varicose Veins 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 of varicosities

Female, family history, prolonged sitting or standing

Dull aching feeling after long periods of standing Complications include ulceration, stasis

dermatitis, superficial venous thrombosis and thrombophlebitis

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Varicose Veins Treatment includes compression stockings worn all

day and removed at night Periodic elevation of legs and exercise are

recommended Encourage walking and weight loss Surgery is for patients that have persistent,

disabling pain, ulceration, superficial thrombophlebitis

Sclerotherapy can be used for small varicosities More than one treatment may be needed

This is chronic disease and requires continued stockings, rest and exercise

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Clinical Manifestations of Varicose Veins

Swollen, dilated, tortuous veins

Dull aching Muscle cramps Increased muscle

fatigue Ankle edema Diagnosis – duplex

ultrasound

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Other Venous Disorders

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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Venous Thromboembolism

Thrombus- a blood clot in a blood vessel

Embolism- a clot that travels and blocks a vessel

DVT (deep vein thrombosis) – serious because it can cause a pulmonary embolism

DVT most common in legs but can occur in the upper extremities also

Thrombus formation is associated with Virchow’s Triad

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VIRCHOW’S TRIAD

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Virchow’s Triad Venous stasis

due to reduced blood flow

Injury to the intimal lining creates site for clot

formation Hypercoagulability

increased tendency to clot

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Clinical Manifestations of Superficial Venous Thrombosis

Pain Tenderness Redness Warmth Palpable cord

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Complications Of Venous Thrombosis

Pulmonary embolus Chronic venous insufficiency Venous stasis ulcers Chronic edema

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Medical Management Of Superficial

Thrombophlebitis Elevation of extremity Warm compresses to area Analgesics and possibly NSAIDS Possibly antibiotics

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Preventative Measures For Venous Thrombosis and Thrombophlebitis

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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Sequential Compression Device

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Clinical Manifestations Of DVT

Swelling or edema of involved extremity Tenderness Homan’s sign Signs of pulmonary embolus

Chest pain Hemoptysis Dyspnea Apprehension Hypotension Cardiac arrest

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DVT Filter

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Chronic Venous Insufficiency

Results from faulty venous valves which 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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Clinical Manifestations Of Chronic Venous

Insufficiency Swollen limb Dry, itchy, coarse,

leathery skin Reddish brown skin on

lower extremity above ankles

Stasis ulcers above ankles

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Leg Ulcers

75% result from chronic venous insufficiency 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 between

toes

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Venous Leg Ulcer

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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Arterial Ulcers

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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Treatment of Stasis Ulcer(Venous or Arterial)

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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Aspirin

Inhibits platelet aggregation Reduces ability of blood to clot

Contraindications Allergy, GI bleed, bleeding disorder,

children <18 with viral infection Report

Signs of bleeding, petechiae, ecchymoses, bleeding gums, black or bloody stools

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Heparin Inhibits formation of new clots Does not dissolve existing clot but prevents its extension 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

Lovenox (low molecular weight heparin)

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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Coumadin (warfarin sodium) Prevents new clots from forming

Treatment of A-Fib Prophylactic if prosthetic heart valve Contraindications

Hemophilia, active bleeding, esophageal varices, severe hepatic disease

Antidote Holding one or more doses, Vit K, blood transfusion may

be 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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Plavix 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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Tissue Plasminogen Activator

Thrombolytic For CVA patients within *3* hour time frame from

onset of s/s Contraindications

Active internal bleeding, recent surgery or trauma, bleeding disorder, use of oral anticoagulants, 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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Trental (pentoxifylline) Decreases blood viscosity and improves

blood flow Results in reducing tissue hypoxia,

decreased pain and paresthesias Contraindications

Intracranial bleed Monitor

Relief from pain and cramping, improved walking tolerance

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Vit K

Antidote for overdose of Coumadin Contraindication

Severe liver disease Monitor

Patient, PT/INR, Bleeding IV route for emergencies only

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Protamine Sulfate

Antidote for heparin overdose Used after stopping heparin Contraindication- hypersensitivity to

fish Monitor- patient and vital signs

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