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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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www.memorialcare.com
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www.azheart.com 36
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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