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Arterial Disorders
Vascular Disorders (ARTERIAL)
| Question | Answer |
|---|---|
| Peripheral Artery Disease | Atherosclerosis (leading cause) Results from cholesterol and lipids deposited within vessel walls Progressive narrowing of artery lumen Inflammation and endothelial injury play a major role Clinical symptoms occur when vessels are 60-75% blocked |
| Atherosclerosis | Gradual thickening of the intima (innermost layer of arterial wall) and the media (middle layer) |
| Peripheral Artery Disease Risk factors (12) | Tobacco use** Diabetes* Uncontrolled hypertension* Hyperlipidemia* Family history Hypertriglyceridemia Increasing age Hyperhomocysteinemia Hyperuricemia Obesity Sedentary lifestyle Stress |
| Peripheral Artery Disease Clinical Manifestations | Intermittent claudication Physical appearance of limb (hair loss, shiny, warmth, sensation, movement, pulses diminshed) Paranesthesia Pallor Reactive hyperemia (redness) Rest pain |
| 6 Ps | Pain Pallor Change in colour Pulselessness Paresthesia Paralysis Poikilothermia (Adaptation of the ischemic limb to its environmental temperature, most often cool) |
| Claudication | Pain in the legs or arms that occurs while walking or using the arms. |
| Peripheral Artery Disease: Critical Limb Ischemia | Characterized by Chronic ischemic rest pain lasting > 2 weeks, Arterial leg ulcers, or Gangrene Patients who have diabetes, heart failure, and history of stroke are at increased risk |
| Peripheral Artery Disease Complications | Progresses slowly Prolonged ischemia: atrophy of skin/muscles Minor trauma: Delayed healing, Wound infection, Tissue necrosis Arterial (ischemic) ulcers over bony prominences Nonhealing ulcers and gangrene Critical limb ischemia Amputation |
| Peripheral Artery Disease Diagnostic Studies | Health history and physical Ankle-brachial index (Ankle SBPs divided by the higher of the left and right brachial SBP) Segmental BPs CT angiography Doppler ultrasound (degree of blood flow) Duplex imaging MRI |
| Peripheral Artery Disease Interprofessional care | Weight, activity, diet Stop smoking Foot care/wound care Medical therapy: antiplatelet agents BP control (antihypertensives) Treat hyperlipidemia and glucose levels (diabetic) Surgical, endovascular interventions Thrombolytic therapy Pain control |
| PAD Interventional Radiological Catheter-Based Procedures | Alternatives to open surgical approaches Similar to angiography • Insertion of specialized catheter into femoral artery |
| Peripheral artery bypass surgery | Bypass or detour blood around lesion • Saphenous vein most common |
| PAD Post-Operative Acute Interventions | Check op. extremity q15 min then hourly for colour, temp, sensation, movement, cap refill, presence of peripheral pulses or Doppler signals • ABI • Compare with patients baseline and opposite limb • Aggressive pain management (tolerance to opioids) |
| Acute Arterial Ischemic Disorders | Sudden interruption in the arterial blood supply to a tissue, organ or extremity • Untreated, can result in tissue death |
| Aortic Aneurysm | Involves aortic arch, thoracic aorta, abdominal aorta (most found) • Growth rate unpredictable, larger = greater chance of rupture • Male, age 65+, smoking are greatest risk factors • CAD, PAD, hypertension, high cholesterol, genetics |
| Thromboangitis obliterans | nonatherosclerotic, segmental, recurrent inflammatory disorder of the small and medium-sized arteries and veins of the upper and lower extremities |
| Raynaud’s phenomenon | episodic vasospastic disorder of small cutaneous arteries most frequently involving the fingers and toes |
| Aortic Dissection | |
| Nutritional Therapy | BMI is less than 25 kg/m2 Waist circumference < 37 men and < 31.5 inches women • Fruits, vegetables and whole grains • Low cholesterol, saturated fat, and salt • Dietary cholesterol < 200 mg/day • Saturated fat reduced • Sodium intake < 2g/day |
| Percutaneous transluminal angioplasty (PTA) | Catheter that contains cylindrical balloon at the tip • End of catheter advanced to narrowed (stenotic) area • Balloon inflated, compressing atherosclerotic lining • Stents placed within artery to hold artery open |
| Arthrectomy | Removal of obstructing plaque • High-speed cutting disc built into catheter end cuts long strips of atheroma |
| Cryoplasty | Combines PTA and cold therapy • Balloon filled with liquid nitrous oxide expansion of gas results in cooling to -10oC • Cold temperature limits restenosis by reducing smooth muscle cell activity |
| Endartectomy | Opening artery and removing obstructing plaque |
| Patch graft angioplasty | Opening artery, removing plaque, sewing a patch to the opening to widen the lumen |
| Endovascular intervention | PTA and stenting used in combination with bypass surgery • Less invasive, less wound healing |
| Amputation | Required if tissue necrosis is extensive, if infectious gangrene or osteomyelitis develops, or if all major arteries in limb are occluded • Every effort made to preserve as much of limb as possible |
| Ongoing acute intervention | Monitor: perfusion to extremities, complications, infection Do not place patient in knee-flexed position Turned and positioned frequently with pillows Discourage prolonged sitting with leg dependency |
| Acute Arterial ischemia Causes | Embolism • Endocarditis, mitral valve disease, Afib, cardiomyopathy, prosthetic heart valve • Noncardiac sources – aneurysms, atherosclerosis, venous thrombi Thrombosis often obstruct lower extremity artery (iliofemoral, popliteal, tibial) • Trauma |
| Acute Arterial Ischemic Disorders Clinical Manifestations | Pain Pallor Change in colour Pulselessness Paresthesia Paralysis Poikilothermia (Adaptation of the ischemic limb to its environmental temperature, most often cool) |
| Acute Arterial Ischemic Disorders Complications | Necrosis and gangrene (within hrs without intervention) Paralysis (late sign- death of nerves supplying extremity) Footdrop (nerve damage) Tissue extremely sensitive to hypoxia |
| Acute Arterial Ischemic Disorders Interprofessional Care | Early diagnosis and treatment IV unfractionated heparin (anticoagulant to prevent thrombus/embolization) Embolectomy Catheter, thrombectomy, bypass Amputation |
| Aorta | largest artery that supplies oxygen and blood to all vital organs |
| Aneurysm | Permanent, localized outpouching or dilation of vessel wall (degenerative, congenital, mechanical, inflammatory, infectious) • Atherosclerosis most common cause |
| True Aortic Aneurysm | Wall of artery forms the aneurysm, with at least one vessel layer still intact Either Fusiform or Saccular |
| Fusiform | Circumferential and uniform in shape |
| Saccular | Pouchlike with narrow neck connecting the budge to one side of the arterial wall (MORE susceptible to rupture) |
| False (pseudoaneurysm) | NOT an aneurysm A disruption of all layers of arterial wall, resulting in bleeding that is contained by surrounding structures Caused by Trauma, infection, after peripheral artery bypass graft, arterial leakage after removal of catheter and IABP |
| Aortic aneurysm (thoracic) Clinical Manifestations | Deep, diffuse chest pain extending to intrascapular area |
| Aortic aneurysm (ascending aorta and aortic arch) Clinical Manifestations | Angina from decreased blood flow • Transient ischemic attacks • Coughing, shortness of breath, hoarseness, and/or difficulty swallowing from pressure on laryngeal nerve • If pressing on supervisor vena cava, decreased venous return JVD and edema |
| Aortic aneurysm (abdominal aortic) Clinical Manifestations | Mass in periumbilical area slightly to the left of midline • Bruits on auscultation • Back pain, epigastric discomfort, alteration in bowel elimination and intermittent claudication (from compression on nearby aortic autonomic structures and nerves) |
| Aortic Aneurysm Complications | Rupture of blood that leaks into retroperitoneal space Severe back pain • Back or flank ecchymosis • Blood leaks into thoracic or abdominal cavity 90% patients die from hemorrhage • Hypovolemic shock |
| Aortic Aneurysm Diagnostic Studies | Chest and abdominal X-ray (width and calcification) ECG (MI) Echocardiogram (function of aorta) Ultrasound (size) CT scan (length and diameter) MRI (location and severity) Angiography |
| Hypovolemic shock | Tachycardia, hypotension, pale clammy skin, decreased urine output, altered LOC, abdominal tenderness |
| Pre-op Aortic Aneurysm | Hydration and electrolyte balance Coagulation, hematocrit abnormalities corrected |
| Open repair Aortic Aneurysm | Large abdominal incision to remove thrombus and plaque |
| Minimally invasive endovascular aneurysm repair (EVAR) | Alternative to open repair • Sutureless aortic graft in abdominal aorta inside the aneurysm via femoral artery • Blood flows through graft preventing further expansion of aneurysm • Angiography performed to check for leaks and confirm patency |
| Complications of Open and Endovascular Repair | Endoleak Aneurysm growth or rupture around the graft Aortic dissection, bleeding renal artery occlusion (stent migration) Graft thrombosis Incisional site hematoma or infection Inta-abdominal hypertension with abdominal compartment syndrome (lethal) |
| Aortic Aneurysm Interprofessional Care | Prevent aneurysm rupture (Early detection/treatment) • Conservative medical therapy for small, asymptomatic aneurysm • Risk factor modification • Smoking cessation • Decreasing BP • Optimizing lipid profile • Gradually increasing physical activity |
| Aortic Aneurysm Acute Intervention | Chest tubes if thorax was opened ECG, SpO2, BP Pain control Respiratory function Fluid/electrolyte balance Intake/output (hourly); maintain 0.5 mL-1 mL/kg Peripheral perfusion Mark pulses Colour, skin temp, movement, sensation (hourly) |
| Dissection | Tearing of the inner layer of the vessel Results from creation of false lumen, between intima and media, through which blood flows • Classification based on anatomical location (ascending vs. descending) |
| Aortic Dissection | Nontraumatic aortic dissection caused by weakened elastic fibres in arterial wall • Chronic hypertension accelerates the degradation process • With each systolic pulsation, increased pressure is put on damaged area which further increases dissection |
| Aortic Dissection Clinical Manifestations | Ascending: Abrupt onset of severe anterior chest or back pain Descending aorta: Pain in back, abdomen or legs Pain can overlap between ascending and descending dissections: Sharp, “worst ever”, tearing, ripping or stabbing Aortic arch: neuro deficits |
| Aortic Dissection Complications | Cardiac tamponade, Hemorrhage • Exsanguination and death • Spinal cord ischemia • Renal ischemia renal failure • Abdominal ischemia abdominal pain, decreased bowel sounds, altered bowel function, bowel ischemia |
| Aortic Dissection Diagnostic Studies | Health history and physical exam • Chest X-ray • Widening of mediastinum and pleural effusion • CT scan angiography • ECG • MRI • Transesophageal echocardiography (TEE) |
| Aortic Dissection Pre/Post-Operative Care | Bed rest, semi-Fowler’s position, quiet environment Keep SBP low IV antihypertensives Continuous ECG and vital signs monitoring Change in peripheral pulses Increased pain, restlessness and anxiety Post-op care similar to aortic aneurysm repair |
| Conservative management Aortic Dissection | for acute descending aortic dissection without complications • Pain relief, BP control < 120-140 systolic, HR control, risk factor modification |
| Endovascular intervention Aortic Dissection | for acute descending aortic dissections with complications (e.g., hemodynamic instability, peripheral ischemia) |
| Surgical intervention Aortic Dissection | indicated when medical therapy inefficient or when complications occur • Aorta fragile after dissection • Resection of aortic segment with the intimal tear and replacement with a synthetic graft • High mortality rate |
Created by:
selenay15
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