Peripheral Vascular Disease

Peripheral vascular diseases lead to a reduced blood flow through peripheral blood vessels. The physiologic effects of altered blood flow depend on the extent to which tissue demands exceed the supply of oxygen and nutrients available. Tissues then fall prey to ischemia, become malnourished, and ultimately die unless adequate blood flow is restored.

  • What is Peripheral Vascular Disease?
  • What are the different types of peripheral vascular disease?
  • What are the diagnostic assessments used to detect peripheral vascular diseases?
  • What are the recommended medications?
  • What other health teachings are important to a person with peripheral vascular disease?

peripheral vascular disease

What is Peripheral Vascular Disease?

Peripheral vascular disease refers to a group of medical conditions that affects the blood vessels of the lower extremities. It involves the arterial and venous blood systems. Peripheral vascular disease is very common in the elderly or diabetic individuals.

What are the different types of peripheral vascular disease?

Types of peripheral vascular disease are:

  • Arterial Thrombosis and Embolism

-   A thrombus (blood clot) adheres to the vessel wall. Acute arterial thrombi occur where there is injury to an arterial wall, sluggish flow, or plaque formation secondary to atherosclerotic changes.

-   Other causes of arterial thrombosis are polycythemia, dehydration, and repeated arterial needle sticks. If a thrombus breaks off and travels, it becomes an embolism that occludes an arterial vessel that is too small to allow it to pass. Some of the causes of an arterial embolism are dysrhythmias, prosthetic heart valves, and rheumatic heart disease.

-   Watch out for the “six P’s” in detecting signs and symptoms of arterial embolism:

  • Pain
  • Pallor (pale color)
  • Pulselessness (diminished or absent color)
  • Parasthesias (altered local sensation)
  • Paralysis (weakness or inability to move extremity)
  • Poikilothermia (body temperature that varies with environment)
  • Peripheral Arterial Disease

-   Disorders that interrupt or impede arterial peripheral blood flow due to vessel compression, vasospasm, and/or structural defects in the vessel wall. It is sometimes referred to as lower extremity arterial disease (LEAD).

-   Primarily caused by atherosclerosis (local accumulation of lipid and fibrous tissue along the intimal layer of an artery making it narrow and affects blood flow). Other reasons attributed to the development of peripheral arterial disease are trauma, embolism, thrombosis, vasospasm, inflammation, or autoimmunity.

-   Chronic arterial obstruction leads to inadequate oxygenation of the tissues causing intermittent claudication, which is ischemic muscle pain precipitated by a predictable amount of exercise and relived by rest.

-   The person may complain of aching, cramping, fatigue or weakness in the legs that is relived by rest. There will be coldness and paleness with a cyanotic (bluish) color on elevation. Peripheral pulses may be diminished or absent. Nails may be thickened and opaque. The skin on the legs may be shiny with sparse hair growth. In advanced stages, ulcers may be present on the lower extremities in areas affected by reduced circulation with deep pale base and demarcated edges. These ulcers are painful.

  • Raynaud’s Disease

-   A vasoconstrictive and vasospactic response causing ischemia from exposure to cold and stress. It occurs more often in women who live in cold climates.

-   Other causes of the vasospastic attack are caffeine ingestion, tobacco use, and emotional stress.

-   It primarily affects the hands but can also occur in the feet, ears, or nose. To be diagnosed with Raynaud’s disease, the patient must experience intermittent attacks of ischemia for at least 2 years.

-   Symptoms common to Raynaud’s disease is the classic triphasic color changes (pallor, cyanosis [bluish], and rubor [redness]) with accompanying  reduction in skin temperature. Pain is also present and tends to intensify as the disease progress. The skin of the fingertips may thicken and nails may become brittle.

  • Buerger’s Disease

-   A recurring inflammation of small and medium arteries and veins of the lower extremities.

-   The disease, also known as thromboangiitis obliterans, is usually the result of occlusion of the vessels by thrombus formation. The cause is unknown, but heavy cigarette smoking is a major contributing factor. Some studies indicate an autoimmune response to tobacco products as a possible cause. The disorder is more prevalent in young men between the ages of 25 and 40 years.

-   The initial signs and symptoms are usually evident as color changes (bluish)in a toe or finger and a feeling of coldness in the affected limb. There is also pain as the nerves are also inflamed. Ischemic ulcers and gangrene formation are common complications as the condition worsens.

  • Aortic Aneurysm

-   An aneurysm is a bulging, ballooning, or dilation at a weakened point of an artery. Aortic aneurysm is a localized dilation or outpouching of a weakened area in the aorta that is classified by region as thoracic or abdominal, or as dissecting.

-   Aneurysms occur more often in men and their incidence increases with age.

-   The major risk factor for the development of aneurysm is atherosclerosis.

-   The danger about aneurysm is that it is undetectable (asymptomatic) until it ruptures. Signs and symptoms include back pain, flank pain, abdominal fullness, nausea, pulsating mass in the abdomen, severe sudden back pain with rupture, and shock from blood loss. Other symptoms to consider are dysphagia (difficulty in swallowing), dyspnea (difficulty in breathing), cough when pressing on the esophagus or laryngeal nerve.

-   For a dissecting aneurysm, the pain can be described as “tearing” or “ripping” in the anterior chest or the back. Pain may extend to teh shoulder, epigastric area, or abdomen. Possible syncope (fainting) and paralysis of lower extremities may be present.

  • Varicose Veins

-   Vein(s) are elongated, tortuous, dilated, palpable veins because of blood pooling in the lower extremities.

-   The exact cause is unknown; however, the condition tends to be familial or those with a positive family history of varicosities. They are also common in women over 35, those who are obese, pregnant, and those who stand for long periods of time.

-   The cause of varicose veins is attributed to incompetent valves within the veins can cause blockage of blood flow and lead to dilated veins.

-   The person may complain of aching, heaviness, itching, swelling, and unsightly appearance to the leg(s)

  • Venous Insufficiency

-   Damaged or aging valves within the veins interfere with blood return to the heart, causing pooling of blood in the lower extremities. Chronic venous insufficiency can lead to venous stasis ulcers.

-   Causes of venous insufficiency include: prolonged venous hypertension, after thrombus formation or when valves are not functioning correctly, which may result from:

  • Prolonged sitting/standing (teachers, waitresses, nurses, office workers)
  • Pregnancy and obesity
  • Signs of venous insufficiency include:
    • Edema of the lower legs that may extend to the knee
    • Thick, coarse, brownish skin around the ankles and feet
    • Stasis ulcers, usually in the malleolar area (ruddy base, uneven edges)

     

Video of Peripheral Vascular diseases

What are the diagnostic assessments used to detect peripheral vascular diseases?

There are several diagnostic procedures to help the physician diagnose the type of peripheral vascular disease.

  1. Doppler ultrasound: Measures the velocity of blood flow through a vessel and emits an audible signal; when arterial palpation is difficult or impossible because of occlusive disease, a Doppler can be useful in determining blood flow; a palpable pulse and a Doppler pulse are not equivalent and should not be used interchangeably.
  2. Plethysmography: Records biologic changes in volume in apportion of the body associated with cardiac contractions or in response to pneumatic venous occlusion; can detect and quantify vascular disease on the basis of changes in pulse contour, blood pressure, or arterial/venous blood flow.
  3. Digital intravenous angiography : utilizing computer technology, visualization of blood vessels occur after IV injection of contrast material; allows for small peripheral venous injections of contrast medium, compared with large doses that must be injected via arterial cannulation.
  4. Venography: injection of radiopaque dye into veins; serial x-rays are taken to detect deep vein thrombosis and incompetent valves.
  5. Angiography: injection of radiopaque dye into arteries to detect plaques, occlusions, injury, etc.
  6. Ankle-brachial index (ABI): most commonly used parameter for overall evaluation of extremity status; ankle pressure normally is the same or slightly higher than brachial systolic pressure; expected ABI is 0.8 to 1.0
  7. Computed tomography: allows for visualization of the arterial wall and its structures; used in the diagnosis of abdominal aortic aneurysm (AAA) and postoperative vascular complications such as graft occlusion and hemorrhage.
  8. Magnetic resonance imaging (MRI): uses magnetic fields rather than radiation; used with angiography to detect abnormalities, especially in people who are unable to have dye injected.

What are the recommended medications?

For every type of peripheral vascular disease, there is a specific medication that the physician may recommend. Remember, medications need physician’s prescription and instructions before taking them. Don’t self-medicate or take advices from friends to take certain medications even if they have the same presenting problems.

For the purpose of presentation, the following medications are intended to treat or manage peripheral vascular diseases:

  • Pentoxifylline – decreases blood viscosity to increase blood flow to the microcirculation and tissues of the extremities
  • Cilostazol – inhibits platelet aggregation and enhances vasodilation
  • Aspirin and Clopidrogel – inhibits platelet aggregation
  • Calcium channel blockers – to ease vasospasm
  • Analgesics (NSAIDS) – to reduce pain and relieve inflammation
  • Heparin and warfarin – anti-coagulant therapy; inhibits clotting factors that would extend thrombus formation; will not induce thrombolysis but prevents clot extension
  • Streptokinase and alteplase – thrombolytic therapy; dissolve blood clots by imitating natural enzymatic processes
  • Topical agents, such as hydrocortisone, antifungals, or zinc oxide – to treat skin ulcers
  • Oral or IV antibiotics – when skin ulcers become infected or cellulitis occurs.
  • Sclerosing agents – may be used to occlude blood flow in a vein, causing disappearance of the varicosity; this may be followed up with use of compression bandage for a short period of time

What other health teachings are important to a person with peripheral vascular disease?

            Individuals with peripheral vascular diseases need to conform to several health behaviours in order to help promote healing and preventing further complications in the future. The following health teachings can help meet this goal. It is imperative that while teaching them these points, special attention should be placed to the rationale of each action as well.

  • Stop smoking. Nicotine in all tobacco products causes vasospasm, which impedes peripheral circulation.
  • Lose weight and eat a low-fat diet. Obesity places more weight on the lower extremities and pose a threat for problems in movement, thus causing blood pooling and the possibility of blood clot formation and trauma to the vessel walls.
  • Do not cross legs while sitting. Crossing the legs causes compression of vessels with subsequent impediment of circulation, resulting in venous stasis.
  • Elevate feet at rest, but not above heart level. Elevation of extremities counteracts gravity, promotes venous return, and prevents venous stasis.
  • Do not stand or sit for long periods of time. Prolonged standing still or sitting promotes venous stasis.
  • Do not wear restrictive clothing. Constrictive clothing and accessories impede circulation and promote venous stasis.
  • Keep affected extremity warm but never apply direct heat. Warmth promotes arterial flow by preventing the vasoconstriction effects of chilling.
  • Inspect feet daily and keep them clean and dry. Neutral soaps and lotions prevent drying and cracking of skin; avoid lotion between toes as the increased moisture can lead to maceration of tissue.
  • Avoid walking barefoot; wear proper-fitting shoes. Protective shoes and padding prevent foot injuries and blisters.
  • Avoid mechanical or thermal injury to the legs and feet. Scratching and rubbing can cause skin abrasions and bacterial invasion.
  • Begin and maintain an exercise and walking program. Walking promotes venous return by activating the “muscle pump.”
  • Notify healthcare provider of any changes in color, sensation, temperature, or pulses in extremities.
  • Counsel in ways to avoid emotional upsets; stress management. Emotional stress causes peripheral vasoconstriction by stimulating the sympathetic nervous system.

Education for Anticoagulant Therapy

                  For persons taking anticoagulant medications, the following health teachings are important:

  • Wear a medical identification bracelet.
  • Take medication at approximately the same time each day.
  • Stress the importance of routine lab work.
  • Do not use aspirin-containing products or non-steroidal anti-inflammatory drugs (NSAIDs).
  • Avoid trauma.
  • Shave with an electric razor.
  • Use a soft toothbrush.
  • Report possible adverse side effects immediately to healthcare provider;

-   Any bleeding that does not stop within several minutes.

-   Unusual bleeding anywhere else in the body.

-   Weakness or dizziness.

 

We will be expanding on this important topic in future articles. While I recommend you to register to download an e-book: “Adult Prevention Guide” for better health, a FREE

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