Vascular Diseases: DVT and Pulmonary Embolism

• Presentation on Peripheral Vascular Disease, Pulmonary Embolism, and Deep Vein Thrombosis
• Presentation date: February 3 - February 10, 2025

Patient Evaluation Example

• A 69-year-old woman admitted post cystoscopy, transvaginal hysterectomy, and bilateral salpingo-oophorectomy (BSO) for uterine prolapse.
• Patient evaluation on 5/21 revealed that when sitting at the edge of the bed, they needed minimal to moderate assistance due to session-related nausea and trembling
• Vitals assessment information is in the flowsheet
• The patient was on electronic patient-controlled analgesia (ePCA) with Foley catheter, and peripheral intravenous line (PIV).
• Follow-up physical therapy session on 5/22 for a complete functional assessment included the above interventions.
• Oxygen delivered at 2L via nasal cannula
• Administered pain medications before the session.
• Mobility required close supervision/contact guard assistance.
• Ambulation achieved 40 ft x1 and 70 ft x1 using a rolling walker and close supervision.
• Contact guard was required with a noted decrease in patient cadence.
• Ambulation up/down two steps with hand on wall needed contact guard/minimal assistance to manage step-to gait pattern

Patient Vital Statistics (Example)

• Resting vitals when reclined measured a heart rate of 82, blood pressure of 121/73, and oxygen saturation of 95% on room air (RA).
• Vitals when sitting measured a heart rate of 91, blood pressure of 132/72, and oxygen saturation of 91-93% on 2L of oxygen.
• Post-ambulation vitals while seated measured a heart rate of 80, blood pressure of 117/65, and oxygen saturation of 88-91% on room air.
• Heart rate varied between 50s, 60s, and 70s per dinamap.
• Radial palpitation detected missed beats.
• Post Incentive Spirometry (IS) seated vitals measured a heart rate of 92 and oxygen saturation of 94% on room air

Objectives covered

• Basics of peripheral vascular disease (PVD).
• Risk factors for peripheral vascular disease.
• Definition of intermittent claudication.
• Differences between arterial and venous disease (signs, symptoms, and interventions).
• Basic tests and interventions for PVD.
• Differences between arterial and venous ulcers.
• Definition of deep vein thrombosis (DVT) and pulmonary embolism (PE), including their signs and symptoms.
• Risk factors and screening tools for DVT and PE.
• Diagnostic tests for DVT and PE.
• Mechanical methods for DVT and PE prevention and treatment.
• Medications for DVT and PE prevention and treatment, including related lab tests.
• Familiarity with APTA Clinical Practice Guideline for Venous Thromboembolism.
• Benefits and risks of mobilizing patients with DVT and PE.

Peripheral Vascular Disease (PVD)

• PVD is a general term for diseases of blood vessels outside the heart, affecting both arteries and veins.
• PVD includes three distinct systems: arterial, venous, and lymphatic such as Peripheral Arterial Disease (PAD) and Peripheral Venous Disease

Peripheral Artery Disease (PAD)

• PAD develops when arteries supplying blood to internal organs, arms, and legs are completely or partially blocked by atherosclerosis.
• PAD is similar to coronary artery disease (CAD), but it involves obstruction in large/medium-sized arteries OUTSIDE the heart or aortic arch.

Arterial System Review

• Arteries tend to be elastic & muscular.
• Arteries carry oxygenated blood.
• Vessels closer to the heart are more elastic.
• Distal vessels are more muscular
• Arteries branch into arterioles, then capillaries.

Risk Factors for PVD

• Smoking: Tobacco use is the most important modifiable cause
• Diabetes: Increases risk by 2-4 times due to endothelial and smooth muscle cell dysfunction
• Increased Cholesterol: High LDL and low HDL can lead to accelerated PVD
• Hypertension (HTN): Correlated with increased risk of PVD, heart attack, and stroke
• Risk of PVD increases in:
  • People over 50 years of age
  • Males
  • Obese people
  • People with a family history of heart attack and/or stroke.

Chronic Arterial Insufficiency

• Atherosclerosis is characterized by nodular deposits of fatty material that line the walls of the artery (plaques)
• Vessel walls may also lose their elasticity and become sclerotic
• Arteriosclerosis obliterans is a peripheral manifestation of atherosclerosis
• Arteriosclerosis obliterans is responsible for 95% of cases of chronic occlusive arterial disease

Intermittent Claudication

• Blood supply is less than the muscles demand in intermittent claudication
• Produces pain, aching, weakness, numbness, cramping, discomfort, and tiredness in the involved muscles, which decreases with rest
• The calf muscle is typically the most affected
• Approximately 50% occlusion is associated with the disease

Arteriosclerosis Obliterans (Continued)

• Rest pain is common when occlusion is greater than 80-90%, resulting in inadequate perfusion.
• Other clinical symptoms include
  • Diminished or absent pulses
  • Pallor of the skin
  • Trophic changes such as decreased hair and nail growth
  • Possible presence of a wound/ slow healing
  • Extremity is cool to the touch

Classification Based on Symptoms

• Mild Claudication
• Moderate Claudication
• Severe Claudication
• Ischemic Pain at Rest
• Tissue Loss (Minor to Major)

Acute Arterial Occlusive Disease

• Arterial Thrombosis and Embolism: Thrombi & Emboli causes sudden complete blockage leading to cessation of blood flow and tissue death
• Symptoms of blockage include
  • Abrupt onset of pain
  • Pallor
  • Cyanosis
  • Lack of pulses
• Symptoms of blocked lead to progression of ischemia

Arterial Thrombus vs Embolism

• Arterial Thrombus
  • Leads to increase in blood flow turbulence
  • Blockage can be partial or complete
• Arterial Embolism
  • Portions of formed thrombus break off
  • Travel through vascular system until lodge in smaller diameter artery

Thromboangiitis Obliterans

• Aka "Burger's disease"
• Primarily occurs in young men who smoke heavily
• Affects smaller vessels distally and moves proximally
• There is direct correlation between cigarette smoking and disease manifestation
• Rest pain is usually the initial symptom followed by intermittent claudication
• The foot is greater than the calf

Raynaud's Syndrome

• Spasm of arterioles (affecting the digits) causes little or no blood flow to the affected body parts, causing cyanosis in the digits when exposed to cold or emotional upset
• Warming restores color to the hands
• Pain is generally not present (but sometimes is) and may be associated with swelling or tingling

Arterial Insufficiency Physical Examination

• Subjective symptoms of arterial insufficiency examination are
  • History
  • Coldness of hands or feet
  • Color changes in the digits
  • Pain
• Objective symptoms of arterial insufficiency examination are
  • Skin Color
  • Skin Temperature
  • Edema
  • Pulses
  • Possible bruit
  • ABI (Ankle Brachial Index)

Diagnosis of PVD: ABI

• Ankle Brachial Index (ABI) is a ratio of ankle pressure and arm pressure
• ABI (Ankle Brachial Index) = PLeg/Parm

ABI Interpretations

• 0.96-1.00: Normal***
• Less than 0.95: Abnormal, stress testing is appropriate
• Less Than 0.8: Probable Claudication
• Less Than 0.5: Multi -level disease or long segment occlusion
• Less Than 0.3: Ischemic rest pain and possible tissue necrosis
• Integrated Ultrasound Reference Guide, SDMS Ed Foundation, 1996
• DeTurk and references consider above .90 normal.

Acute Care Handbook: ABI scores

• ≥1.0-1.3: normal range.
• ≥0.7-0.8: borderline perfusion
• ≤0.5: severe ischemia
• ≤0.4: critical limb ischemia

Board Review Book: ABI scores

• ≥1.30: Rigid arteries; need ultrasound to check for PAD
• 1.0-1.3: Normal/no blockage
• 0.8-0.99: Mild blockage; beginning of PAD.
• 0.4-0.79: Moderate blockage; may be associated with intermittent claudication
• <0.4: Severe blockage, suggestive of severe PAD, may have claudication pain at rest, possible tissue necrosis.

Clinical Consideration/Application

• Patient is a 48-year-old male, mildly overweight, and a weekend exerciser
• He smoked 20 years x 1.5 packs per day
• He comes to outpatient PT for his Achilles pain
• The patient reports cramping in his ankle/calf after playing basketball for 3 minutes and needing to rest
• Upon assessment, no obvious muscle injury was found

Diagnostic Testing

• Duplex Ultrasound is a non-invasive technique to study the arteries
  • It indicates how blood is flowing through the vessels
  • Measures the speed of flow
  • Estimates the diameter of blood
  • Measures the amount of obstruction
• Angiography is an imaging to study the peripheral blood vessels
  • It is the most accurate test to detect the location(s) & severity of artery occlusion, as well as collateral circulations

Treatment goals for PAD

• Relieving the pain of intermittent claudication
• Improving exercise tolerance
• Preventing critical artery occlusion that can lead to foot ulcers, gangrene, and amputation
• Preventing heart attacks and strokes

Treatment of PAD Includes

• Lifestyle measures
• Supervised exercises
• Medications
• Angioplasty
• Surgery

Lifestyle Measures to treat PAD

• Stop smoking is key
• Controlling Diet
• Exercise through Vascular Rehab Program
• Conduct Skin Foot Checks

Medications for PAD

• Anticlotting Agents
• Cholesterol-lowering drugs
• Increase blood supply to extremities
• Medications that control blood pressure

Treatment Procedures and Surgeries for PAD

• Angioplasty with Stent, Thrombolytic, or Cryoplasty
• Endarterectomy
• Bypass grafting
• Amputation

Arterial Thrombolysis

• Contrast material and clot dissolving factor (thrombolytics)
• Delivered through catheter under x-ray/fluoroscopy guidance

Venous System Function

• Relies on a system of valves to keep blood flowing in one direction
• Blood flow is dependent on muscle contraction and valves

Diseases of the Vein

• A major risk factor for vein disease is familial history
• Vein diseases are more prevalent than arterial disease
• Vein diseases include Chronic Venous Insufficiency, Varicose Veins

Chronic Venous Insufficiency (CVI)

• CVI is also known as Chronic Venous Disease (CVD)
• CVI is when leg veins cannot pump enough blood back to the heart
• CVI is also caused by Deep Vein Thrombosis (DVT) and Phlebitis due to obstructed blood flow

Clinical Presentation of CVI

• Edema
• Erythema
• Cellulitis
• Dermatitis
• Hemosiderin
• Ulceration
• Varicose veins
• Redness
• Rashes
• Sores
• Leg Ulcerations: Often happen along the medial aspect of lower extremity (medial malleolus) and in areas of trauma like anterior shin

Risk Factors and PMH for Chronic Venous Insufficiency

• Overweight
• Pregnancy
• Decreased exercise and long periods of sitting or standing
• Smoking
• Diabetes
• Hypertension
• Congestive Heart Failure
• History of DVT (deep vein thrombosis)
• Prevalence and family history of varicosities
• More common in women > age 50

CVI Physical Exam

• CVI Subjective: Symptoms report of heavy, tired, and restless or achy legs with rare intermittent claudication; edema resolves with elevation; skin may appear darker
• CVI Objective: Symptoms observed with hemosiderin, warmth of extremities, and edema

Varicose Veins

• Pathology attributed to prevalence of incompetent valves
• Produces increased venous pressure and overstretches the vein
• Can be described as large, bulbous, tortuous

Diagnostic Tests for Vein Diseases

• Duplex Ultrasound measures speed of blood flow and determines structure of leg veins
• Venogram uses x-rays with dye to see the anatomy of veins

Treatment for Vein Diseases

• Setting goals to increase function and decrease pain
• Prescribing Compression Stockings
• Patient Education
• Exercise

Surgical Treatment

• Vein Injections – Sclerotherapy
• Ablation
• Vein Stripping
• Bypass
• Valve Repair
• Angioplasty and stenting

Arterial Ulcers as compared to Venous Ulcers

• Arterial: Ulcers are round with smooth, well-defined edges, minimal drainage, no odor, may or may not have swelling of LE, tight and cool to touch, also thin & dry, may see thickened toenails, no hair on the toes or legs, pain with walking (claudication
• Venous: Ulcer edges are NOT A PERFECT CIRCLE, ulcers are wet drainage dependent on length of time LEs dangle, leg may be warm, normal LE pulses, complaints of discomfort with standing up

Arterial vs Venous Ulcers (Cont.)

• Arterial: Found on tips of toes, b/t toes, over phalangeal heads, above lateral malleolus, on sides/soles of feet and have deep pale base and sometimes necrotic edges. A leg may become elevated and may have neuropathy. Pain decreases with leg being moved to dependent position
• Venous: Located lower 1/3 of leg in pre-tibial area, anterior to medial malleolus and may have ruddy, granular tissue and leaky, macerated itchy skin; may see dilated tortuous veins

Venous Thromboembolism (VTE)

• VTE includes Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE)

Statistics of VTE

• Around 900,000 people in the US are affeced each year
• 9 out of 10 times Pulmonary Embolisms start out a DVT
• Pulmonary Embolisms are the most serious complication from DVTs
• Estimates average that 60,000 to 100,000 Americans die of DVT/PE complications each year
• Sudden death is the first symptom in about one-quarter (25%) of the people who have a PE.
• Among people who have had a DVT, 1/3 to 1/2 will have long-term complications from thrombotic syndrome
• 1/3 or 33% of the people with DVT/PE will have a recurrence within 10 years
• VTE- leading cause of preventable hospital deaths in US
• 5th most frequent reason for unplanned hospital readmission (3rd most frequent in patients undergoing post-total hip arthroplasty (THR) or total knee arthroplasty (TKR)) As many as 70% of cases of healthcare associates VTE are preventable with some measures like anticoagulation, compression stockings to name a few.

DVT and PE (Statistics continued)

• Of the 7 million plus patients discharged from American acute care hospitals, VTE was the second most common medical complication
• Post-op VTE was the second most common medical complication
• Leading to the second most common cause of excess length of stay (LOS)
• Causing the third-most common cause of excess mortality and charges associated to the hospital
• For a majority of patients, thrombi are clinically silent, resolve quickly without any short or long term sequelae
• As many as 27% have hip fractures and on prophylaxis that develops into DVT
• After primary thromboprophylaxis reduces DVT & PE for a majority of patients
• Additionally PE (pulmonary embolism) may be preventable to help reduce other deaths from hospital complications to patients

What is a DVT?

• Blood cells (platelets) clump together and produce chemicals that activate the clotting process (thrombin)
• Thrombin activates production of another protein called fibrin
• Fibrin binds the platelets together, forming a blood clot (usually made up of fibrin with platelets and some WBCs)

Superficial and Deep Venous Thrombosis

• Superficial Thrombosis is little concern - Does not lead to PE; not limited by PT; may be seen on ultrasound.
• Deep Vein Thrombosis includes a "Distal Deep VT", and "Proximal Deep VT" (more serious).

Distal DVT

• Generally small and asymptomatic
• Can extend into proximal vein
• Lower rate of PE

Proximal DVT

• Popliteal vein or more cranial (proximal)
• Less common BUT most serious form of DVT
• More likely to have symptoms and PE
• If not treated can lead to PE in 40-50% of patients

What is a PE?

• PE is a sudden blockage in a lung artery, usually caused by a DVT
• PE may damage the lung tissue or cause low oxygen levels in the blood. PE may also damage other organs in the body due to lack of oxygen
• If large enough it can cause death
• Look for signs of right heart failure
• If left untreated, about 30 percent of patients who have PE will die, mostly within the first few hours of the event
• Besides blood clot, other types of objects that have been identified as blocking include embolito the lungs

Medical Conditions that can lead to DVT

• Compression of veins
• Physical trauma
• Cancer
• Infections
• Inflammatory diseases
• Stroke
• Heart failure

Risk Factors of DVT

• Surgery and surgery that requires hospitalization
• Immobilization and bed rest such as the type cause by being in a cast for along period of time.
• Long haul flights
• Smoking and other forms of Tobacco use
• Obesity
• Age
• Drugs, estrogen, erythropoietin, Factor V
• Thrombophilia
• Pregnancy and postpartum care
• A history of having previous DVT or blood clot in lower pelvis from vein that was thrombosed
• Having a surgery from orthopedic in lower extremity from hip, ankle or toe
• Patients whom take Oral contraceptives medication treatment

Important clinical information on VTE

• Congestive Heart Failure or CHF
• Heart problems with high blood pressure
• Immobility and long duration of sitting without standing to move for a specific period of time
• Being of Age from years of experience

Risk Stratification

• Multiple tools to determine risk for developing DVT or PE:
  • Virchow's Triad and Risk factors for VTE
  • Wells's Clinical Prediction Rule
  • Classification of "Level of Risk"

Virchow's Triad

• Virchow's Triad consists of three main factors that predispose to thrombosis
  • Hypercoagulability
  • Hemodynamic changes (stasis, turbulence)
  • Endothelial injury/dysfunction

Well's Clinical Prediction Rule for DVT Points

• Points associated to: Active cancer (1), Paralysis (1), Bedridden (1), Tenderness (1), Leg Swelling (1), Pitting Edema (1), Superficial veins (1), DVT History (1), Alternative Diagnoses DVT (-2),
• Clinical probability simplified score for DVT: Dvt Likely 2 points or more, Dvt Unlikely less than 2 points.

Well's Clinical Prediction Rule for PE Points

• Symptoms of DVT (3), Other diagnoses than PE (3), Heart Rate Greater than 100 beats/min (1.5), immobilization or surgery w/i past 4 weeks (1.5), Previous DVT or PE (1.5), Hemoptysis (3), Maglinancy (1).

Interpretation of Risk Based off Wells Scoring

• Determining Risk Score for DVT
• Likely - Scoring over ~2 points is cause is indication of risk of DVT's appearing
  -Unlikely Scoring less than ~2 points indicates minimal risk of DVT's appearing Determining the Risk Score of PE
• High Risk- scoring greater than or equal to 6 indicates a potential risk of (78.4%)
• Moderate Risk -Scoring between 2-6 points implies a moderate risk of (27.8%)
• Low Risk- Measuring greater than 2 points points shows low risk of PE (3.4%)

Level of Risk for DVT/PE

• Low Risk
  • Age <40
  • Uncomplicated or minor surgery (<30 min)
  • No clinical Risk factors
• Moderate Risk
  • Minor surgery in age 40-60 with one clinical risk factor
  • Major surgery (>30 min) in age <40 with one clinical risk factor
• High Risk
  • Major surgery in pt>40
  • History of DVT/PE
  • History of CA

Level of Risk For DVT/PE (Continued)

- HIstory of CA 
- Surgery of the hip or surgery of the knee   
- High risk pt due to potential harm at anytime
 - Surgery to repair a hip fx
 - Major Trauma that may effect major portions of the body
  - Spinal Cord Injury  that could potentially cause temporary or perminant damage over time 

Symptoms Of DVT

• Visible or sensory swelling of limb mostly effecting lower extremities
• The leg may become tendered with mild touch or from sensory imput in leg
• Feeling of warmth in area
• Skin discoloration appearing abnormal
• Also Experiencing Fever Chills and Malaise as symtoms

Physical indications of PE (Pulmonary Embolism)

• Sudden pain, a sign to be wary to observe may affect chest
• Difficulty with breathing during simple exertion or daily activity is important to note by measuring respiration and difficulty speaking
• Unusual amount of breathing as indicated during resting rates that is higher
• Excessive beats per minute and measuring that beats are normal and not in irregular pattern
• Blood content and coloration of fluid being extracted from the oral passages

How is Diagnostic of DVT and PE performed

• Diagnosing of the PE
• (Old standard practices) Gold standard medical history and physical Examination to test patient for results
• Spiral test such as the CT, a unique scan specific to DVT
• Testing Lung perfusing air ventilation if in contact with the chest area that indicates the PE - pulmonary Embolisms causing pressure to the blood
• For Testing with with either DVT and PE, may result in using (ABG such arterial blockage gases testing)- D-Dimer

Diagnostic Tests VTE

• Intravenous Venography uses radiation techniques to be extremely Accurate when used to test.
• This unique process is not often used.
• This is not often used due to rare uses caused by non interventional processes
• Duplex imagine US (ultrasound) creates image that reveal abnormalities by using the the reflected waves in leg to produce accurate results and easy testing ability to make diagnosis while also not causing radiation the process is able to be cost efficient for all patients

What are diagnostic exams used to properly identify Internal Trauma

• Spinal CT is is to be used - (With PE to specify if it is to be used) The radiation will illuminate the fluid and inner problems on the imaging in lung tissue to see if airways are Blocked Vq used by a small- use a radioactive to help to assist to see any issue or blockages that may be occurring internally by measuring oxygen in all the areas in the designated locations and tissues.

Blood is Testing To See What Levels Are in the Patient

-Testing AGB Arterial blood sample help measures the amount of oxygen and carbon Dioxide

• This test helps to determine of to examine released substances of blood by product that brake down —the test that highly effective and sensitive.

Main ways PE are shown or made visible

• By inserting thrombectomy over the selected area. This procedure will extract fluid build pressure and stress to relieve the blocked area
• At least 90% of PE are thought to originate in major leg veins so it important to determine origin

PE Complications With Lungs and Clots Over Veins or Vascular Tissue

• Left side in image shows pulmonary Arteries with large clots due to blocked tissue and fluid
• The right image display a saddle from embolus coming form the trunk of upper arteries( yellow)

PT Consideration for exams

• Check the Lower extremity limb for any sensory changes, check leg if indications show
• Inspect Venous tract with your hands to feel for areas or portions show indications of heat, and fluid blocked vascular or nerve.
• Inform PCP of problems

Diagnostic tools to test for trauma

• Do to sensory and other problems
• Homan's, it's Non helpful.
• Press to check it's not the best to do
• Put device to to tell if the test to see it to indicate for that particular area

How Can someone can take measures to Reduce

• Mobility to help pumping stasis
• Hydration
• Anti-coagulation medication
• Use stocking
• Devices

Prevention and what that is able to prevent the problem for the patient

• IVC by helping to prevent fluid or substance to travel further into body by implant devise to slow the amount of substance
• Medication like aspirin that helps with inflammation to prevent major substance related to heart to ensure healthy flow

Advantages Mechanical:

• Is to help a bleeding problem prevent
• Easy to apply
• May give a lot of assist in reducing effects related to blood
• may ensure less fluid build from area

Mechanical:

• Is to help reduce blockage by inserting and implanted device that is to make sure the clot from preventing further damage and or more substance blockages to insure quality to maintain the health and to not create more problems or fluid by doing so.
• The implant has guidelines to mobilizing
• Has ACG rules for if problems. Has problem.

Problem or dis. from using device:

• Can cause new problem and if the device moved it will have new problems

- Implanted into people. that already has a problem

GCS- Graded Compression Stocking

• It has (GCS). To help slow.
• It worn to slow down blood the by pressure the legs.

Goals and what it's con's of of stock

• To reduce, reduce
• May not feel proper.

The Pneumatic

• Different of the timing to use for what you have in the area that you are going to test
• It's function is related to the return
• By using the pump.
• Use the pump. Help to prevent or slow down

Important things to Consider

• This to what they should consider, to help to prevent for the the paten .
• To help with treatment. To help with side problems - the problems

PHARMACOLOGIC

• It can help
• Heparin to help maintain the healthy amount that to help to improve by to to stop in process

It may be helpful to know that some "hit - that some products have a

It Is Important to Know for Each Patient Treatment

• If they have that in what problems is related to in. It's also good is know what the test does and what's may also include. It that may have a part a the help for this it

It It's Good That The Treatment Is Helpful

• It can improve And treat the problem It may help to test area