Vascular Disease Management in Acute Care

• Management of vascular disease in acute care covers:

  • Etiology/pathophysiology of peripheral arterial disease
  • Signs and symptoms of peripheral arterial disease
  • General medical tests and treatments for peripheral arterial disease
  • Physical therapy post-op management after vascular surgery. Includes exercise, positioning, and mobility
  • Treatment plan development for peripheral arterial disease

• Topics covered:

  • Peripheral Arterial Disease (PAD)
  • Procedures and Surgeries for PAD
  • Aneurysms
  • Abdominal Aortic Artery Aneurysm repairs
  • Venous Disease
  • Management of Venothromboembolism (VTE)

Lecture Goals for Physical Therapy Examinations

• Describe the components of a physical therapy examination of a patient with peripheral arterial disease
• VTE risk factors must be identified and clinical practice guidelines must be applied for VTE management
• Screen patients for potential non-PT problems (patient history, current symptoms, lab values, etc.)
• Contraindications to treatment must be identified
• Develop and defend an appropriate management plan
• Make a physical therapy diagnosis to direct treatment

Peripheral Artery Disease

• Arteries become narrowed due to fatty plaque deposits leading to decreased circulation
• Decreased blood supply is required by muscles, especially during activity
• Ischemia occurs, leading to excessive lactic acid accumulation and pain
• Arteriosclerosis affects large and medium-sized arteries in the body
• Arteriosclerosis is usually the cause of PAD, but PAD can also be related to injury to the vascular system through trauma or radiation
• With arteriosclerosis, fibromuscular plaque narrows arteries

Risk Factors for PAD

• Smoking increases the risk by 2-6 times
• Smoking worsens PAD symptoms
• High blood pressure and Cholesterol are risk factors
• Other risk factors
  • Atherosclerosis
  • Diabetes
  • Obesity
  • Decreased physical activity
• PAD indicates the possibility of heart, cerebrovascular, or major arterial disease
• Equal instances among sex but different incidence among race
  • Those with black race/ethnicity have a higher risk
  • People with Hispanic origin with similar to slightly higher risk
• Older than age 60 (12-20% of individuals older than age 60)

Intermittent Claudication

• Pain caused by ischemia
• Described as muscle cramping, pain, ache, or fatigue
• Location may suggest area of obstruction
  • Claudication in calf indicates femoral popliteal disease
  • Claudication in buttock/thigh/hip indicates abdominal aorta or iliac obstruction
• Claudication at rest with skin necrosis indicates lower leg arterial obstruction
• Pain is usually brought on by activity and relieved with rest
• Its predictable, and occurs after a set period of continuous activity (i.e. 10 minutes of walking)
• Pain is associated with fast relief, within a few minutes of rest, sitting or standing
• Pain is often in the calf, it is cramping in nature, and it happens with a predictable amount of activity

Types of Claudication

• Sensory/motor changes with walking
• The presence or absence of peripheral pulses
• Trophic changes in legs
• Peripheral neuropathy
• If the pain has a known cause

Clinical Signs of PAD

• Intermittent claudication is a primary sign
• Pain worsens with elevation with disease progression
• Trophic changes may occur
• Edema (may or may not be present)
• Skin: absence of hair, shiny, tight; thickened toenails
• Reduced muscle mass
• Dependent rubor
• Decreased sensation, especially light touch
• Pulses become decreased to absent
• Non-healing wounds (small painful ulcers)

Elevation Pallor & Venous Filling Time Test

• This test looks at the arterial circulation though the capillaries and the veins.
• Patient is supine with legs elevated to decrease circulation
• The leg is then placed in a dependent position
• The distal toe is squeezed until it turns white
• 0-3 seconds for color change= normal
• 15 seconds for color change=arterial insufficiency

Rubor Dependency Test

• Rubor is observed in dependent position
• Patient is supine with legs elevated about 40 degrees, then legs go to dependent
• Arterial insufficiency, within 30 seconds leg becomes dark red vs. pink

Ankle Brachial Index

• Gold standard for diagnosing presence or severity of PAD

Ankle SBP ÷ Arm SBP = ABI Score

• Sensitivity: 95%, Specificity: 99%
• Not effective for diabetics with calcified tibial arteries

Post-Surgical Examination-Pitting Edema Scale

• 1+ Barely detectable impression when finger pressed into skin, 2 mm depression*
• 2+ Slight indentation, 15 seconds to rebound, 4 mm depression*
• 3+ Deeper indentation, 30 seconds, 6 mm depression*
• 4+ >30 seconds rebound, 8 mm depression*

Medical treatments for PAD

• Smoking cessation
• Control diabetes
• Treat hypercholesterolemia
• Thrombolytics
• Anti-hypertensive Meds
• Prostaglandins
• Vasodilators

Physical Therapy

• Educate about skin care
• Educate about avoidance of cold-vasoconstriction
• Protect skin, modify shoes, use multipodis boots
• Exercise programs
• Balance training

Claudication Discomfort Scale

• I – Initial discomfort (established but minimal)
• II – Moderate discomfort but attention can be diverted
• III – Intense pain (attention cannot be diverted)
• IV – Excruciating and unbearable pain.

Ambulation with PAD

• Use the Claudification Discomfort Scale to determine how far a patient can walk.
• Exercise should increase to 1 hour/day
• Some authors want patient to exercise until claudication begins, others want level 3 of the claudication scale
• Patient should be allowed to rest once at level 2 to subside symptoms if they get that far
• Patient will be able to ambulate increased time/distance before onset of claudication

Ambulation & PAD Evidence

• 156 patients with PAD randomly assigned supervised treadmill exercise, LE resistance training, or to a control group
• Outcomes measured included 6MWT, short physical performance battery, brachial artery flow-mediated dilation, treadmill walking, Walking Impairment Questionnaire, and the (SF-36 PF) score
• Supervised treadmill training improved 6MWT, treadmill walking performance, brachial artery flow-mediated dilation, and quality of life
• LE resistance training improved treadmill walking, quality of life, and stair climbing ability

Meta-Analysis Evidence

• Exercise with Intermittent Claudication was performed in a meta-analysis with RCTs
• Programs of ≥ 2 days/week improved walking time and distances
• Improvements were seen up to 2 years

Supervised vs. Non-supervised Exercise for IC

• Explores if super vision matters for patients
• Meta Analysis has RCT's with those with supervision and those with in home HEP
• Supervised group walked a little more
• Maintained this for a period

Walking Speed, Sedentary Lifestyle, Walking Times, and PAD

• Patients had higher mortality if they have
  • Slower community walking speeds
  • Spent 8-9 hours or more lying down
• Structured home-based exercise programs were beneficial

Procedures for PAD

• Endarterectomy: affected artery opened to remove occlusions
• Angioplasty: Balloon placed in area to be unblocked. Balloon compresses against the arterial wall . A stent (metal device) is usually placed

Physical Therapy after Angioplasty

• Encourage lifestyle changes and avoid cold-vasoconstriction
• Educate about skin care -Use multipodus boots
• Balance training and ambulating based on claudication guidelines
• Possible need for cardiac rehab

Angiogram

• Determines occlusion from plaques (how much)
• dye gets Injected and x-ray’d to determine location and extent of occlusion

Functional Outcomes of PT

• Pre-operative functional levels can predict recovery after revascularization surgery
• Non-ambulatory patients experience
  • Increased adverse events
  • Unplanned reinterventions
  • Poor long term survival

Bypass Graft

• 2 different examples
  • Femoral-femoral artery
  • Aortoiliac graft

Lower Extremity Bypass Surgeries

• Calf pain at rest means a potential limb loss is setting in
• Occluded artery bypassed from the common femoral artery
• Best results happen if saphenous vein is used NOT a prosthetic
• Precautions during this type of surgery last 2-6 weeks in most

PT Considerations after Aortoiliac Bypass graft

• No abdominals after surgery/Log roll
• Splint if need transfer and don't pull or lift too much
• Fall prevention needs to be emphasized
• Avoid Upright sitting and prolonged sitting
• Deep breathing and IS are very important

Axillary Femoral Bypass Graft

• Long graft means a thoracotomy occurs
• No trunk flexion OOB until day one post/op

PT after Fem-Pop

• No hip/knee after op
• Usually not OOB/Ambulating until day 1
• Pt may need assistance due to swelling/pain

Early Ambulation after Fem-Pop

• Weight shifting on the limb is really crucial/ also do UE as well

PT Examination/Operative

• Get general history
• Meds/ lab
• INR, HB/ Hemocrit,BUN/Creatinine
• Objective
• Cognition,vitals,pulses and all the testing of functions stated

Examination LE's

• Integumentary
• MMT
• Sensation levels of 3/5 because of precaution

Deciding on Ambulation

• MMT available standing balance, Ability to shift

Clinical Considerations for LE and what to do before

• ROM
• Shift Weight in standing

Renovascular diseases

• affect Renal artery as well
• HTN in child now or later age can mean can also cause clots

Rehab after renovascular patients

• Labs
• Watch vitals skin
• Promode Motility and Balance

Abdominal Aneurysm

• Arterial wall is weakened resulting in 50% vessel diameter

• Typically in males diagnoses AAA in 100%

Aneurysm Symptoms

• 75% dont have one
• look for AA but don’t stress patient

Open Surgery

• Incision is made from diploid to pubis
• low mortality

Endovascular repair is less

• 50% can be repair and graft is placed
• less invasive then abdominal

Evaluation and how to check

• labs , meds watch BP and sensation

Surgical Pt considerations and what to provide.

• valsalua and need binder

Vascular Surgeries

• Fasciotomy and is used to treat compartment syndrome
• Also thorastic outlet/ amptutations

After Fasciotomy, what to do

• High risk for contraction and Edema Drainage can cause issues

Thoracic Syndrome, Etilogy and Pressure

• Pressure causes artery to be in pain, Numb and swells
• Caused by faulty posture

Tos/ signs

s/sx are UE issues and decrease pulse with limited mobility.

Tos Implicatiton

• Check UE and neck as well with limited resistance, shoulder
• Support UE for confort

Tos Patient Out or in

• check ROM don’t damage rotator cuff strength

Can be both trauma and vascular issues

Heel shoe, Gait is what also could be and needs to be checked

T-M-A/ Toe Amputatiion

• Could cause gait
• Heel strike can cause balancing problems

BKA and AKA

• Rom and Bed train
• Ambulate and do everything they did before

Pros

• Deseitizaton , position , edema and contractures

Venous Disease Thrombolytic

• Formation of blood clots in that system
• Clots is the biggest cause

Thromobolic and how it occurs

• Occludes DVT
• occurs at high rates in the US

Blood clots caused

• bed ridden ,decreased motion as well as a fib

Riek high patients with venous

• surgery, cent lines and can start to the trauma

Pt consideration with VE

asses vitals increase rate

Thromboltic Diagnostic

• Ultrasounds, MRI can be used

Anticoagulent Medical treatment

• the clot can also be extracted
• DVT , heparin meds ancougnlent can slow down

IvC filter

• usedto stop blood travel through.
• used also tp trap clots with mechanical measures

Patients get mobilized quick

• medication
• after the clot
• VTE
• Screen Fall risk also

Risk Factors for VTE

• Previous Pulmonary Thromboembolism is the biggest risk factor
• At least 80% of VTE can be linked to patient risk factors
• VTE occurs secondary to (Virchow's Triad)
  • Venous stasis
  • Hyper-coagulation
  • Endothelial damage

Risk Factors for VTE: Venous Stasis

• Occurs in patients who are/have:
  • On bed rest (>3 days)
  • With decreased mobility
  • Paralysis (CVA or SCI)
  • Varicose veins

Risk Factors for VTE: Hypercoagulation

• Hypercoagulation states leading to an increase in blood clotting with patients with:
  • Cancer
  • Increased estrogen i.e. pregnancy, oral contraceptive and hormone replacement
  • Or medical conditions considered as prothrombotic disorders i.e. atherosclerotic disease, collagen-vascular disease
  • Inherited thrombophilias i.e. Factor V Leiden mutation
  • Medications such antipsychotics, anti-arrhythmias, and some HTN meds.

Risk Factors for VTE: Endothelial Damage

• Endothelial damage or injury to the vein happens in patients:
  • Post-operatively
  • With central lines
  • 2nd to trauma

Other Risk Factors for VTE

• General anesthesia
• Auto-immune disease/deficiency
• Obesity
• Blood type
• Age
• HIT-Heparin induced thrombocytopenia

Pulmonary Embolism

• Most common symptom is ↑respiratory rate/dyspnea
• Assess vital signs, especially respiratory rate, if recent history of or suspect a PE. They may have a normal SpO2
• Signs/symptoms of a massive PE: dyspnea, syncope, hypotension and cyanosis
• Signs/symptoms of a smaller PE: diffuse chest discomfort (can be pleuritic in nature, can mimic angina but will not go away with rest), hemoptysis, persistent cough
• Other classic signs include: anxiety, ↑HR, apprehension and low grade fever

Pulmonary Embolism-Diagnosis

• Diagnosed with a ventilation/perfusion or VQ scan
  • Scan that measures airflow and blood flow in the lungs
• May also be diagnosed with a pulmonary CT Scan

Signs of DVT

• Ipsilateral edema
• Pain
• Discoloration in extremity
• Warmth
• "Palpable cord” showing a thrombosed vein

DVT: Diagnosis

• Compression ultrasonography can be used to diagnose proximal DVT with up to 100% sensitivity and 99% specificity
• Doppler ultrasounds may be used for lower leg
• Venography is a "gold standard" but may not be used 2nd to risks and cost
• MRI may be used for clots in the pelvis or vena cava
• Homan’s signs not recommended – has poor sensitivity (10-54%) and poor specificity (39-89%)
• Asymmetrical calf swelling ≥ 2 cm (sensitivity 61%, specificity 70%)
• Wells score (clinical decision rule to predict DVT)
  • Was more predictive of DVT than any of the single scores
  • Prediction was lessened in older patients with more comorbidities

DVT: Medical Treatment

• IVC Filter
  • The goal of the filter is to trap venous emboli dislodged from the legs or pelvic area. It stops the traveling clots from reaching the lungs without disrupting blood flow.
• Thrombolysis:
  • A radiologist places a catheter into the vein and a thrombolytic medication such as streptokinase or tPA is then administrated directly into the clot
  • The clot can also be mechanically removed

DVT: IVC Filter

• An image illustrates a filter is a device used to prevent clots from traveling to the lungs

DVT: Prophylaxis

• Prophylaxis may include anticoagulation, compression garments, compression devices, and/or IVC Filter
• Sequential compression device inflates with air to accelerate venous blood return.

DVT: Anticoagulation

• Heparin
• Coumadin (oral)
• Lovenox
  • A low molecular weight heparin given by subcutaneous injection
• These are anticoagulants that can slow or stop the progression of a new clot and decreased the risk of other new clots but does NOT remove a thrombus already present
• These anticoagulants are used for DVT prophylaxis and treatment of DVT

DVT - When to ambulate?

• Trujillo-Sanchez looked at a database of 2650 patients with a DVT or PE who were managed with a variety of methods including bedrest and mobility. Patients were followed for 6 months
• Concluded that it is safe to mobilize patients with a DVT/PE when managed with anticoagulation and LE compression dressings
• Bedrest had no influence on the development of PE among patients with acute LE DVT

DVT - When to ambulate?

• A meta-analysis by Aissaoui looked at 3048 patients with DVT, PE, or both, managed with bed rest versus early ambulation, in addition to anticoagulation
• Findings were that there was no higher risk of a new PE or other problems in an ambulatory group compared to a bed rest group
• Recommendations were for the following:
  • early ambulation once effective anticoagulation given
  • Early ambulation unless hemodynamically unstable or significant respiratory compromise

DVT – Bottom Line

• With proper medication, LE compression dressings and no evidence of a PE prior to ambulation, early ambulation of a patient with a DVT is safe

VTE Clinical Guidelines

• Advocate for mobility (1-A)
• Screen for risk of VTE during initial session (1-A)
• Provide preventative measures LE DVT (1-A)
• Recommend mechanical compression for DVT prevention if at moderate/high risk (1-A)
• Identify likelihood of LE DVT when signs and symptoms present (2-B)
• Communicate the likelihood of LE DVT and recommend further testing(1-A)
• Verify that patient is taking an anticoagulant (5-D)
• Mobilize patients who are at therapeutic levels of anticoagulation (1-A)

VTE Clinical Guidelines

• Do not recommend mechanical compression for patients with LE DVT (2-B)
• Mobilize patients after IVC filter placed when stable (5-P Best Practice)
• Consult with medical team when patient without IVC filter and not anticoagulated (5-P Best Practice)
• Screen for fall risk when patient taking anticoagulant(3-C)
• Recommend mechanical compression when signs of PTS are present (1-A)
• Provide management strategies to prevent recurrent VTE and minimize secondary VTE complications (5-P Best practice)