PERIPHERAL ARTERY

DISEASE

NIKHIL VAISHNAV
M.Sc.(Nursing)

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 CONTENT
• Introduction • Assessment & Diagnostic
evaluation
• Definition
• Medical & surgical
• Incidence management
• Classification • Nursing management
• Etiology

• Risk factors

• Clinical menifestations

• Complications

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 INTRODUCTION

Peripheral artery disease (PAD) is an

abnormal narrowing of arteries other than
those that supply the heart or brain.

PAD is a common circulatory problem in

which narrowed arteries reduce blood
flow to limbs.

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 DEFINITION
• PAD is the thickening of the artery walls that
results in a progressive narrowing of the
arteries of the upper and lower extremities.
• Peripheral artery disease most commonly
affects the legs, but other arteries may also
be involved.
• PAD is a marker of advanced systemic
atheroslcerosis.

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 • This condition may be reducing blood
flow to the heart and brain as well.
• PAD can be treated with exercise, with
a healthy diet, quitting smoking.
• Early diagnosis & treatment is
important in the treatment to stop the
heart disease and stroke.

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 INCIDENCE

In 2010, 202 million people around the world

were living with PAD.

The majority of individuals with PAD (70 percent)

live in low/middle income regions of the world,
including 55 million individuals in southeast Asia
and 46 million in the Western Pacific Region.

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 ETIOLOGY
• ATHEROSCLEROSIS:
The leading cause of
PAD. It results from
the deposit of
cholesterol and lipids
within the vessels
walls and leads to
progressive
narrowing of the
artery.
•
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 • Less commonly PAD is also caused by blood
vessels inflammation , injury to limbs,
unusual anatomy of ligaments or muscles, or
radiation exposure.

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 IMPORTANT RISK
FACTORS
• Smoking: single greatest risk factor of peripheral
artery disease. Greater than 80%-90% of patients
with lower extremity peripheral arterial disease are
current or former smokers.
• Diabetes: DM does this by causing endothelial and
smooth-muscle cell dysfunction in peripheral
arteries.
• Chronic kidney disease
• Hypertension
• Hypercholesterolemia
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 OTHER RISK FACTORS
C –reactive protein.

Family history.

Increasing age.

Hyperhomocysteinemia.

Hyperuricemia.

Obesity.

Sedentary lifestyle

Stress.

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 PATHOPHYSIOLOGY

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 PAD OF THE LOWER
EXTREMITIES
• Lower extremity PAD may affect iliac,
femoral , popliteal, tibial, peroneal
arteries, or any combination of these
arteries.
• Patients with DM tend to develop PAD
in the arteries below the knee.
• Femoral, Popliteal area is the most
common site in non diabetic patients.
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 INTERMITTENT
CLAUDICATION
•Classic symptom of
lower extremity PAD.
This ischemic pain is
caused by exercise,
resolves within 10
minutes or less with
rest.

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 OTHER SYMPTOMS
• Numbness or tingling in the toes or feet due
to nerve tissue ischemia.
• Coldness in lower leg or foot, especially when
compared with the other side
• Sores on toes, feet or legs that won't heal
• A change in the color of legs
• Due to neuropathy severe shooting, burning
pain in extremities.

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• Hair loss or slower hair growth on feet and
legs.
• Gradually loss of pressure and deep pain
sensations.
• Slower growth of toenails
• Shiny skin on legs
• No pulse or a weak pulse in legs or feet
• Erectile dysfunction in men
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 REST PAIN
• If peripheral artery disease progresses, pain may
even occur at rest or when lying down (ischemic
rest pain).
• Rest pain is aggravated by limb elevation.
• It occurs more often at night because of drop in
cardiac output.
• It may be intense enough to disrupt sleep.
• Hanging legs over the edge of bed or walking
around room may temporarily relieve the pain.
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 CRITICAL LIMB
ISCHEMIA
• It is a condition characterized by
chronic ischemic rest pain lasting more
than 2 weeks, arterial leg ulcers or
gangrene of the legs due to PAD.
• Patients with PAD who have diabetes,
heart failure, stroke history are at
increased risk for critical limb ischemia.

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 COMPLICATIONS

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 HISTORY COLLECTION
 Ask about risk factors.
 Diet history.
 Medication history.
 Family history of heart & blood vessels
disorders.

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 PHYSICAL
EXAMINATION
• Look for the signs of PAD.
• Check blood flows in legs/feet to see weak/
absent pulses.
• With stethoscope hear bruit sound in leg
arteries. A bruit may be a warning sign of a
narrowed or blocked artery.
• Segmental blood pressure: to measure
actual limb blood pressures to look at arterial
occlusion. In the leg pressures are measured at
the ankle, below the knee, above the knee and
mid-thigh.
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 DIAGNOSTIC TESTS
 Doppler Ultrasound.
 Ankle- brachial index.
 Treadmill test.
 Magnetic Resonance Angiogram.
 Arteriogram
 Blood tests.
 Duplex imaging.

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 DOPPLER ULTRASOUND
• Doppler ultrasound, can help evaluate blood
flow through blood vessels and identify
blocked or narrowed arteries.

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 ANKLE- BRACHIAL
INDEX
Common test used to diagnose PAD.
 It is determined by using a handheld
Doppler.
 It compares the blood pressure in ankle
with the blood pressure in arm.
 A normal ABI is 0.91 to 1.30 .
 Patients who have PAD with DM shows false
elevated ABI due to calcified and non
compressive arteries.
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 TREADMILL TESTS
• A treadmill test can show
the severity of symptoms
and the level of exercise
that brings them on.
• It will show whether
patient has any problem
while walking.
• Patient may have an ABI
test before and after the
treadmill test.

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 MAGNETIC RESONANCE
ANGIOGRAM
• A magnetic resonance angiogram (MRA) uses
magnetic and radio wave energy to take
pictures of blood vessels.
• An MRA can show the location and severity
of a blocked blood vessel.

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 ARTERIOGRAM
• It is used to further delineate the location
and extent of the disease process.
• It is useful when an intervention is indicated.

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 BLOOD TESTS
• blood tests can help diagnose conditions
such as diabetes and high blood cholesterol.

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 DUPLEX IMAGING
• It uses color Doppler system to map blood
flow throughout the entire region of an
artery.
• Provides anatomic and physiologic
information about blood vessels.

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 MANAGEMENT
 Risk factor modification.
 Drug therapy.
 Exercise therapy.
 Nutritional therapy.
 Care of leg with CLI.
 Minimally invasive procedures.
 Surgical therapy.
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 RISK FACTOR
MODIFICATION
• Tobacco cessation is essential to reduce the
risk of CVD events, PAD progression.
• Patients with diabetes should maintain a
Glycosylated hemoglobin(A1C) below 7%.
• For lipid management both dietary
interventions and drug therapy are needed.
Statins(simvastatin) and a fibric acid
(gemfibrozil) may be used.

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 • ACE inhibitors ( ramipril) are used for
symptomatic patients with PAD to control
hypertension. DASH diet and lifestyle changes
are recommended.
•

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 DRUG THERAPY
• Oral antipletlet therapy should include 75 to
325 mg/day of aspirin.
• To treat intermittent Claudication: Cilo-stazol
& Pentoxifylline.
• Cilostazol a Phosphodiesterase inhibitors,
inhibit platelet aggregation.
• Pentoxifylline a xanthine derivative ,
decreases fibrinogen concentration.

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 NUTRITIONAL THERAPY
• Teach patients with PAD to maintain a body
mass index less than 25 kg/m2.
• Recommend a diet reduced in calories and
salt for obese or overweight individuals with
PAD.

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 CARE OF LEG WITH CLI

Peripheral artery bypass surgery using an

autogenous vein.

Percutaneous transluminal angioplasty(PTA) is

recommended when bypass is not feasible.

I.V. Prostanoids( Ilioprost) who are not suitable for

PTA or bypass .It may decrease rest pain and
improve ulcer healing.

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 Continue optimal drug therapy( statin, antipletlet, ACE
inhibitor, Beta blocker ) to reduce the risk of CVD event.

Protect the extremity from trauma, control infection,

improve perfusion.

Cover any ulcer with a dry, sterile dressing to maintain

cleanliness.

Systemic antibiotics are used in patients with CLI, skin

infections and limb infection.

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 Encourage the patient to select soft, roomy and
protective footwear and avoid extremes of heat an
cold.

Trendelenburg position may control pain and

increase perfusion to the lower extremities.

Spinal cord stimulation may be helpful in managing

pain and preventing amputation in patients with
CLI.

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 MINIMALLY INVASIVE
PROCEDURES.

Percutaneous transluminal angioplasty(PTA)

procedure a catheter that contains a
balloon at the tip. The end of the catheter is
moved to the stenotic area of the artery.

Stents are placed within the artery

immediately after the balloon angioplasty is
done.

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 • Atherectomy is the removal of the
obstructing plaque.
• Cryoplasty combines two procedures: PTA
and cold therapy.

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 PERIPHERAL ARTERY BYPASS
SURGERY

Peripheral artery bypass surgery should be done

with an autogenous vein to bypass the lesion.

Synthetic grafts are used for long bypasses such

as axillary –femoral bypass.

PTA with stenting may also be used in

combination with bypass surgery.

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 ENDARTERECTOMY
• Opening the artery and removing the
obstructing plaque.

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 PATCH GRAFT
ANGIOPLASTY
• Opening the artery , removing plaque, and
sewing a patch to the opening to widen the
lumen.

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 AMPUTATION
• Amputation may be required if tissue
necrosis is extensive , gangrene or
Osteomyelitis develops, or all major arteries
in the limbs are blocked .

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 NURSING ASSESSMENT
• Auscultate abdomen and listen for presence
of bruits.
• Observe lower extremities for color ,
sensation and temperature . Compare
bilaterally for differences.
• Palpate pulses and record.
• Inspect nails for thickening and opacity:
inspect skin for shiny , atrophic, hairless, and
dry appearance
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 • Assess for pain: Severe abdominal pain after
eating, Pain in the legs with exercise and pain
in feet at rest.
• Assess for ulcers of toes and feet.

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 NURSING DIAGNOSES
• Ineffective peripheral tissue perfusion related
to deficient knowledge of contributing
factors.
• Activity intolerance related to imbalance
between O2 supply and demand.
• Chronic pain related to ischemia,
inflammation, and swelling.
• Ineffective health management related to
lack of knowledge of disease and self-care
measures.
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 PROMOTING TISSUE
PERFUSION
• Perform frequent neurovascular checks of
affected extremity.
• Inspect lower extremity and feet for new
areas of ulceration or extension of existing
ulceration.
• Provide and encourage well balanced diet to
enhance would healing.
• Encourage walking or performance of ROM
exercise to increase blood flow , increase
collateral circulation.
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 PROTECTING LOWER
EXTREMITIES
• Encourage patient to wear protective
footwear such as rubber soled slippers or
shoes with closed .
• Instruct patient and family to keep hallways
and walkways free of clutter to avoid injury.
• Avoid tight fitting socks and shoes.
• Perform and teach foot care , including
washing and carefully drying and inspecting
feet daily.
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 PREVENTING
INFCETION
• Applying moisturizing lotion to intact skin of
lower extremities to prevent drying and cracking
of the skin.
• Encourage patient to wear clean hose or socks
daily : woolen socks for winter and cotton for
summer.
• Instruct patient to check with physician before
using any OTC or topical lotions or creams on
wound.
• Administer antibiotics postoperatively to prevent
infection around prosthetic graft material.
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