MS22.pdf

10/19/23, 3:29 AM Realizeit for Student Medical Management Generally, patients feel better and have fewer symptoms of claudication after they participate in a SET program. SET programs are covered by insurance for a specific number of sessions. Reimbursement requires that SET is administered under...

10/19/23, 3:29 AM Realizeit for Student Medical Management Generally, patients feel better and have fewer symptoms of claudication after they participate in a SET program. SET programs are covered by insurance for a specific number of sessions. Reimbursement requires that SET is administered under direct provider supervision. A provider (e.g., physician, nurse practitioner, clinical nurse specialist, physician assistant) must be immediately and physically available, although not necessarily physically present, while SET is provided. The person providing the program supervision must be trained in the optimal delivery of SET and in both basic life support and advanced cardiac life support techniques. Unsupervised walking exercise programs are attractive for many patients with PAD with limited access to a SET program. Two recent trials in patients with PAD had similar findings between the supervised and unsupervised groups, suggesting no greater therapeutic benefit for those who engage in supervised walking programs (McDermott, 2018). These findings suggest that home-based programs may be a viable and efficacious option for patients unable to participate in a structured, on-site, supervised exercise program. If a walking program is combined with weight reduction and cessation of nicotine use, patients often can further improve their activity tolerance. Patients should not be promised that their symptoms will be relieved if they stop nicotine use, however, because claudication may persist, and they may lose their motivation to stop using nicotine. In addition to these interventions, arm-ergometer exercise training effectively improves physical fitness, central cardiorespiratory function, and walking capacity in patients with claudication (Treat-Jacobson, McDermott, Beckman, et al., 2019). Endovascular Management Endovascular interventions can include a balloon angioplasty, stent, stent graft, or an atherectomy. These revascularization procedures are less invasive than conventional surgery; their objective is to establish adequate inflow to the distal vessels. A meta-analysis reported that the efficacy and safety of all of these endovascular procedures are comparable to surgical interventions. Some stents that may be selected are drug eluting. Although costly, these are particularly efficacious in patients who have recurrent disease. By releasing antiproliferative drugs, drug-eluting balloons and stents have been shown to reduce the risk of restenosis. Eligible candidates for drug-eluting stents must be able to take antiplatelet medications for at least 6 months post procedure (Sidawy & Perler, 2019). Surgical Management Surgery is reserved for the treatment of rest pain, severe and disabling claudication, or when the limb is at risk for amputation because of tissue necrosis. The choice of the surgical procedure depends on the degree, length, and location of the stenosis or occlusion and whether there are single or multiple lesions. Other important considerations are the overall health of the patient, the length of the procedure, and anesthesia required. If endarterectomy is performed, an incision is made into the artery and the atheromatous obstruction is removed (see Fig. 26-10). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IagsrRDoag8O5uY%2buyG45kbB3bvIg9mMgs36U0K0gCcv… 1/3 10/19/23, 3:29 AM Realizeit for Student Bypass grafts are performed to reroute the blood flow around the stenosis or occlusion. Before bypass grafting, the surgeon determines where the distal anastomosis (site where the vessels are surgically joined) will be placed. The distal outflow vessel must be at least 50% patent for the graft to remain open. If the atherosclerotic occlusion is below the inguinal ligament in the superficial femoral artery, the surgical procedure of choice is the femoral-to-popliteal graft. This procedure is further classified as above- and below-knee grafts, referring to the location of the distal anastomosis. Bypass grafts may be synthetic materials or autologous vein. Several synthetic materials are available for use as a peripheral bypass graft: woven or knitted Dacron or expanded polytetrafluoroethylene (PTFE). Cryopreserved saphenous veins and umbilical veins are also available. When using an autologous conduit (i.e., the patient’s own veins), the vein is either grafted to the artery in situ (the vein remains in place with the valves stripped and the vein is anastomosed to the proximal and distal target arteries), or the vein is harvested, reversed, and anastomosed to the proximal and distal target arteries. Lower leg or ankle vessels with occlusions may also require grafts. Occasionally, the popliteal artery is completely occluded and only collateral vessels maintain perfusion. The distal anastomosis may be made onto any of the tibial arteries (posterior tibial, anterior tibial, or peroneal arteries) or the dorsalis pedis or plantar artery. The distal anastomosis site is determined by the ease of exposure of the vessel in surgery and by which vessel provides the best flow to the distal limb. These grafts require the use of an autologous vein to ensure patency. The greater or lesser saphenous vein or a combination of one of the saphenous veins and an upper extremity vein such as the cephalic vein is used to provide the required length. How long the graft remains patent is determined by several factors, including the size of the graft, graft location, and development of intimal hyperplasia at anastomosis sites (Sidawy & Perler, 2019). Infection of synthetic grafts may result in sepsis and almost always requires removal. If a vein graft is the surgical choice, care must be taken in the operating room not to damage the vein after harvesting (removing the vein from the patient’s body). The vein is occluded at one end and inflated with a heparinized solution to check for leakage and competency. The graft is then placed in a heparinized solution to keep it from becoming dry and brittle until use during the operative procedure. For patients who cannot tolerate an extensive vascular surgical procedure, a palliative approach involving primary amputation rather than an endarterectomy or bypass may be considered (Conte et al., 2019). https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IagsrRDoag8O5uY%2buyG45kbB3bvIg9mMgs36U0K0gCcv… 2/3 10/19/23, 3:29 AM Realizeit for Student https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IagsrRDoag8O5uY%2buyG45kbB3bvIg9mMgs36U0K0gCcv… 3/3