Peripheral Arterial Disease (PAD)

Arterial Vascular Disease (PAD)

• Arteriosclerosis involves the hardening of arteries
• Arteriosclerosis is the most common disease of the arteries
• The muscle fibers and endothelial lining of arteries thicken and stiffen, restricting blood flow
• Atherosclerosis is a form of arteriosclerosis
• Atherosclerosis involves the buildup of fat, cholesterol, and other substances forming plaque in artery walls
• Plaque formation restricts blood flow
• Ruptured plaque can lead to blood clot formation
• Peripheral arteries are any arteries other than coronary arteries
• Arterial insufficiency often affects the extremities, especially the legs
• Atherosclerosis is the primary cause of PAD
• Other causes of PAD include trauma, embolism, thrombosis, vasospasm, inflammation, or autoimmunity

Clinical Manifestations in PAD

• Claudication refers to pain occurring with activity
• This activity related pain can be excruciating
• Intermittent claudication occurs early in the disease
• Rest pain occurs during later stages of the disease
• Elevating or horizontally positioning the extremity increases pain
• Dependent positioning helps relieve or lessen pain
• PAD can cause a cool, pale, cyanotic extremity when elevated
• Bruits may be present
• Pulses may be diminished or absent
• Thick, opaque nails may be evident
• Shiny, atrophied skin may be present
• Sparse hair growth is observed
• Wounds heal slowly due to poor perfusion, which can also lead to ulcerations

PAD Wounds

• Wounds related to PAD can be described as punched-out in appearance.
• These wounds exhibit well-defined borders.
• They are typically round, small, circular, and deep.
• Wounds can be found between or on the tips of the toes, heels, or outer ankle
• Wounds often present where there is pressure from walking or footwear

The Six P's of PAD

• Pain
• Pallor
• Pulselessness
• Paresis
• Paralysis
• Poikilothermia

Collateral Circulation

• Open, functioning peripheral artery
• Partial peripheral artery closure with collateral circulation becomes established
• Total peripheral artery occlusion with collateral circulation bypasses the occlusion to supply blood to the extremity.
• Channels for collateral blood flow develop the occlusion of the right common iliac artery

Managing PAD

• Risk factor modification, specifically smoking cessation, is critical
• Controlled exercise plans maximize functional status
• Exercise up to the point of pain can stimulate collateral circulation development
• Pharmacologic therapies include antiplatelets/anticoagulants, lipid-lowering medications, and thrombolytic and heparin therapy for acute occlusions
• Pain management is important
• Radiologic endovascular interventions such as angioplasty, stents, and intravascular thrombolytics can be used
• Surgical interventions include bypass grafting, endarterectomy, and amputation
• Patient education emphasizes avoiding pressure on vessels in extremities
• Additional recommendation include: avoiding constrictive clothing compression hose/devices, and elevating extremities
• Trauma should be avoided along with special care with injuries/lesions
• Meticulous foot care is essential, along with never going barefoot, examine feet daily, and medications

Risk factors for PAD

• Modifiable risk factors contributing to PAD are smoking, diet, hypertension, diabetes, hyperlipidemia, stress, sedentary lifestyle, elevated CRP, and elevated homocysteine
• Nonmodifiable risk factors include increasing age, female gender, and family history/genetics

Aneurysms

• Aneurysms are localized sacs or arterial dilations formed at weak points in the artery walls
• Aneurysms are often caused by atherosclerosis
• Rupture of aneurysms can lead to hemorrhage and death
• Collaborative care includes monitoring the size of the aneurysm , treating hypertension, managing other risk factors, and surgical intervention
• Surgical options are endoscopic or open surgical repair

Arterial Dissection

• A tear develops in the intima or media of an atherosclerotic artery
• Blood entering the space creates a false lumen
• Dissection reduces blood flow in the vessel
• May cause blockage from thrombus formation
• Dissection usually spreads, affecting the primary artery and its branches
• Arterial Dissection manifests with abrupt onset, severe persistent tearing pain, and high mortality
• Collaborative care is similar to that of aneurysm patients

Raynaud's Disease

• Vasospastic arterial disorder that causes intermittent arteriolar vasospasm
• It can be primary or secondary
• It is associated with migraines and Prinzmetal angina
• Triphasic color change (pallor, cyanosis, rubor) due to vasospasms
• Other clinical manifestations include numbness, tingling, and burning pain
• Symptoms are typically symmetrical and most often occur in the fingers, but can occur in toes
• Serious complications such as gangrene and amputation are rare
• Collaborative care emphasizes avoiding precipitating factors, such as smoking, cold, trauma, and stress
• Drug interventions include calcium channel blockers
• Ligation of the sympathetic nerve (sympathectomy)

Venous Disorders

• Venous thromboembolism is discussed in the Ventilation Module
• Chronic venous insufficiency is when blood refluxes through veins
• Results from obstruction of venous valves in legs or reflux of blood through the valves and veins distend
• Manifestations include chronic venous stasis/edema and venous stasis ulcers
• Complications include venous stasis ulcers
• Collaborative care involves elevation of legs/avoid leg dangling, compression stockings and protect from injury

Venous Insufficiency

• Aching pain, or heavy sensation
• Presence of edematous foot and ankle
• Ulcers usually occur on ankles
• Usually large in size
• Usually highly exudative
• Ulcers have irregular borders

Peripheral Venous Disease: Teaching Points

• Elevate the legs when sitting
• Flex the feet when sitting
• Avoid prolonged standing
• Avoid dangling of feet and/or pressure on the popliteal area of the leg
• Avoid constrictive clothing
• Apply graduated compression stockings to legs after elevation