arterial occlusive disease
ar·te·ri·al oc·clu·sive dis·ease
(ahr-tēr'ē-ăl ŏ-klū'siv di-zēz')Arterial Occlusive Disease
| DRG Category: | 253 |
| Mean LOS: | 5.9 days |
| Description: | SURGICAL: Other Vascular Procedures with CC |
| DRG Category: | 299 |
| Mean LOS: | 5.8 days |
| Description: | MEDICAL: Peripheral Vascular Disorders with Major CC |
Arterial occlusive disease, and in particular peripheral arterial occlusive disease (PAOD), is characterized by reduced blood flow through the major blood vessels of the body because of an obstruction or narrowing of the lumen of the aorta and its major branches. Changes in the arterial wall include the accumulation of lipids, calcium, blood components, carbohydrates, and fibrous tissue in the endothelial lining. When a person is at rest, normal blood flow to the muscles of the extremities is 300 to 400 mm/minute, but with exercise, blood flow increases 10 times the normal amount. While patients with PAOD have normal resting blood flow, blood flow to the muscles cannot increase during exercise because of arterial stenoses. When the metabolic demands of the muscle exceed blood flow, the patient experiences claudication (ischemic muscle pain). Arterial occlusive disease, which may be chronic or acute, may affect the celiac, mesenteric, innominate, subclavian, carotid, and vertebral arteries. Arterial disorders that may lead to arterial obstruction include arteriosclerosis obliterans, thromboangiitis obliterans, arterial embolism, and an aneurysm of the lower extremity. A sudden occlusion usually causes tissue ischemia and death, whereas a gradual blockage allows for the development of collateral vessels. Usually, arterial occlusive diseases are only part of a complex disease syndrome that affects the entire body. Complications include severe ischemia, skin ulceration, gangrene, leg amputation, and sepsis.
Causes
Arteries can become occluded by atherosclerotic plaque, thrombi, or emboli. Single or multiple arterial stenoses produce reduced blood flow to the limbs. Subsequent obstruction and damage to the vessels can follow chemical or mechanical trauma and infections or inflammatory processes. Arteriosclerosis obliterans is marked by plaque formation on the intimal wall of medium-sized arteries, causing partial occlusion. In addition, there is calcification of the media and a loss of elasticity that predisposes the patient to dilation or thrombus formation. Thromboangiitis obliterans (Buerger’s disease), which is characterized by an inflammatory infiltration of vessel walls, develops in the small arteries and veins (hands and feet) and tends to be episodic. Risk factors include tobacco use (most important risk factor), hyperlipidemia, hypertension, diabetes mellitus, and a sedentary lifestyle.
Genetic considerations
Familial forms of arterial occlusive disease have been reported, and genetic risk factors may contribute to the various subtypes of vascular disease. A locus strongly linked to the disease has been identified on chromosome 1. On 15q24, a mutation in the CHRNA3 gene is associated with arterial occlusive disease, along with a predisposition to nicotine dependence and lung cancer.
Gender, ethnic/racial, and life span considerations
Thromboangiitis obliterans, a causative factor for arterial occlusive disease, typically occurs in male smokers between the ages of 20 and 40. Arterial insufficiency usually occurs in individuals over 50 years of age and is more common in men than women. PAOD affects 20% of people over 70 years of age in the United States. Ethnicity and race have no known effect on the risk of most arterial occlusive diseases. Buerger’s disease is more common in men than in women and most typically occurs between age 20 to 45.
Global health considerations
Buerger’s disease has a high incidence in people from Southeast Asia and Jews of Ashkenazi descent.
Assessment
History
Elicit a history of previous illnesses or surgeries that were vascular in nature; ask if the patient has been diagnosed with arterial occlusive disease in the past. Determine if a positive family history exists for hypertension or vascular disorders in first-order relatives. Ask if the patient smokes cigarettes; eats a diet high in fats; leads a sedentary lifestyle; or is subject to emotional stress, anxiety, or ulcers. Determine if the patient has experienced any pain, swelling, redness, or pallor. Establish a history of signs and symptoms that may point to the site of occlusion. Determine if the patient has experienced any transient ischemic attacks (TIAs) because of reduced cerebral circulation. Elicit a history of such signs and symptoms as unilateral sensory or motor dysfunction, difficulty in speaking (aphasia), confusion, difficulty with concentration, or headaches, all of which are signs of possible carotid artery involvement. Ask if the patient has experienced signs of vertebrobasilar artery involvement, such as binocular visual disturbances, vertigo, dysarthria, or episodes of falling down. Determine if the patient has experienced lameness in the right arm (claudication), which is a sign of possible innominate artery involvement.
The specific finding in PAOD is intermittent claudication. The pain is insidious in onset, occurring with exercise and relieved by resting for 2 to 5 minutes; determining how much physical activity is needed before the onset of pain is crucial. The onset of pain is often related to a particular walking distance in terms of street blocks, which helps to quantify patients with some standard measure of walking distance before and after therapy.
Determine if the patient’s mesenteric artery is involved by asking if he or she has experienced acute abdominal pain, nausea, vomiting, or diarrhea. Ask the patient if she or he has experienced numbness, tingling (paresthesia), paralysis, muscle weakness, or sudden pain in both legs, which are all signs of aortic bifurcation occlusion. Determine if the patient has experienced sporadic claudication of the lower back, buttocks, and thighs or impotence in male patients, all of which are indicators of iliac artery occlusion. Elicit a history of sporadic claudication of the patient’s calves after exertion; ask if the patient has experienced pain in the feet—these are signs of femoral and popliteal artery involvement.
Physical examination
Observe both legs, noting alterations in color or temperature of the affected limb. Cold, pale legs may suggest aortic bifurcation occlusion. Inspect the patient’s legs for signs of cyanosis, ulcers, or gangrene. Limb perfusion may be inadequate, resulting in thickened and opaque nails, shiny and atrophic skin, decreased hair growth, dry or fissured heels, and loss of subcutaneous tissue in the digits. Check the patient’s skin on a daily basis.
The most important part of the examination is palpation of the peripheral pulses. Absence of a normally palpable pulse is the most reliable sign of occlusive disease. Comparison of pulses in both extremities is helpful. Ascertain, also, whether the arterial wall is palpable, tortuous, or calcified. Auscultation over the main arteries is useful, as a bruit (sound produced by turbulent flow of blood through an irregular or stenotic lumen) often indicates an atheromatous plaque. A bruit over the right side of the neck is a possible indication of innominate artery involvement.
Psychosocial
Occlusive diseases are chronic or lead to chronic illness. They are usually slow in onset, and much irreversible vascular damage may have occurred before symptoms are severe enough to bring the patient for treatment. Treatment is often long and tedious and brings additional concerns regarding finances, curtailment of usual social outlets, and innumerable other problems. Assess the patient’s ability to cope with a chronic illness.
Diagnostic highlights
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Ultrasound arteriography (Doppler ultrasonography) | Negative for presence of aneurysm or atherosclerosis or thrombus; normal blood flow velocity | Narrowed lumen, reduced blood velocity, or both | Reflects the velocity of blood flowing in the underlying vessel, structure, and size |
| Segmental arterial pressure monitoring | Blood pressure readings in thigh and calf are higher than in upper extremities | Blood pressure readings in thigh and calf are lower than in upper extremities with the presence of arterial disease | Simultaneous sphygmomanometer readings of systolic pressure placed on the extremities to measure pressure differences between upper and lower and between like extremities |
Other Tests: Magnetic resonance angiography, computerized tomographic angiography, plethysmography, ophthalmodynamometry, digital vascular imaging, arteriogram, exercise testing, magnetic resonance imaging
Primary nursing diagnosis
Diagnosis
Altered tissue perfusion (peripheral) related to decreased arterial flow.Outcomes
Fluid balance; Muscle function; Tissue integrity: PeripheralInterventions
Circulatory care; Circulatory precautions; Fluid management; Medication management; Peripheral sensation management; Positioning; Pressure ulcer prevention; Skin surveillance; Embolus precautions; Exercise therapyPlanning and implementation
Collaborative
surgical.
Surgery is indicated for patients who have advanced arterial disease or for those with severe pain that impairs activities. Surgical procedures include arterial bypass surgery, embolectomy, angioplasty, sympathectomy, and amputation.If arteriosclerosis obliterans is rapidly progressing or has not responded to conservative management and intermittent claudication has become disabling, lower extremity arterial bypass is performed. The femoropopliteal arterial segment is the most common site of occlusion. The diseased femoropopliteal segment can be bypassed with a synthetic prosthetic material (Teflon or Dacron), or an autogenous vein graft, such as with the saphenous vein, can be performed. Care following femoropopliteal bypass is the same as for other arterial surgery.
perioperative care.
In the preoperative stage, assess the patient’s circulatory status by observing skin color and temperature and checking peripheral pulses. Provide analgesia as needed. Use an infusion monitor or pump to administer heparin intravenously. Note any signs of cerebrovascular accident, such as periodic blindness or numbness in a limb.Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Aspirin | 80–325 mg | Antiplatelet | Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2 |
| Anticoagulants | Varies by drug | Prolongs clotting time | Prevents extension of a clot and inhibits further clot formation |
| Fibrinolytics | Varies by drug | Dissolves existing thrombi | Used when required to preserve organ and limb function |
Other Drugs: Intermittent claudication caused by chronic arterial occlusive disease may be treated with pentoxifylline (Trental), which can improve blood flow through the capillaries by increasing red blood cell flexibility. Antiplatelet agents: dipyridamole, ticlopidine, clopidogrel bisulfate (Plavix), cilostazol (Pletal); Anticoagulant: enoxaparin sodium (Lovenox).
Independent
prevention and teaching.
Emphasize to the patient the need to quit smoking or using tobacco and limit caffeine intake. Recommend maintaining a warm environmental temperature of about 21°C (70°F) to prevent chilling. Teach the patient to avoid elevating the legs or using the knee gatch on the bed to keep legs in a slightly dependent position for periods during the day, to avoid crossing the legs at the knees or ankles, and to wear support stockings. Explain why the patient needs to avoid pressure and vigorous massage on the affected extremity and recommend the use of padding for ischemic areas.Stress the importance of regular aerobic exercise to the patient. Explain that activity improves circulation through muscle contraction and relaxation. Exercise also stimulates collateral circulation that increases blood flow to the ischemic area. Recommend 30 to 40 minutes of activity with warm-up and cool-down activities on alternate days. Also suggest walking at a slow pace and performing ankle rotations, ankle pumps, and knee extensions daily. Recommend Buerger-Allen exercises if indicated. If intermittent claudication is present, stress to the patient the importance of allowing adequate time for rest between exercise and of monitoring one’s tolerance for exercise.
Provide good skin care and teach the patient to monitor and protect the skin. Recommend the use of moisturizing lotion for dry areas and demonstrate meticulous foot care. Advise the patient to wear cotton socks and comfortable, protective shoes at all times and to change socks daily. Advise the patient to seek professional advice for thickened or deformed nails, blisters, corns, and calluses. Stress the importance of avoiding the application of direct heat to the skin. The patient also needs to know that arterial disorders are usually chronic. Medical follow-up is necessary at the onset of skin breakdown such as abrasions, lesions, or ulcerations to prevent advanced disease with necrosis.
Evidence-Based Practice and Health Policy
Aubert, C.E., Cluzel, P., Kemel, S., Michel, P.L., Lajat-Kiss, F., Dadon, M., …Bourron, O. (2013). Influence of peripheral vascular calcification on efficiency of screening tests for peripheral arterial occlusive disease in diabetes—a cross-sectional study. Diabetic Medicine. Advanced online publication. doi 10.1111/dme.12309
- Pulse palpation and determination of the ankle brachial index are commonly recommended to screen for PAOD.
- In one study, investigators examined the efficacy of these screening measures among a sample of 200 diabetic patients, of whom 39.5% were subsequently diagnosed with PAOD using ultrasonography. The dorsalis pedis and posterior tibial pulses were palpated by a single physician and graded as normal, weak, or missing. Ankle brachial indexes were determined by measuring posterior tibial and brachial arterial systolic blood pressures with a Doppler.
- Missing pulses alone demonstrated 69.2% sensitivity in detecting PAOD, compared to missing and/or weak pulses, which demonstrated 90% sensitivity (p < 0.0001). However, specificities for ruling out participants without PAOD was 71.9% for missing pulses alone but only 38.9% for missing and/or weak pulses (p < 0.0001). The ankle brachial index alone demonstrated a sensitivity of 42.3% and specificity of 80%.
- Using both missing and/or weak pulses along with the ankle brachial index had the highest sensitivity in identifying patients with PAOD (92.3%) but the lowest specificity in ruling out patients without PAOD (32.6%) (p < 0.0001).
Documentation guidelines
- Physical findings: Presence of redness, pallor, skin temperature, peripheral pulses, trophic changes, asymmetrical changes in pulse quality, capillary blanch, condition of skin
- Neurological deficits: Tenderness to touch, lameness, sensory or motor dysfunction
- Response to balanced activity: Lameness, pain, level of activity that produces pain
- Presence of complications: Infection, ulcers, gangrene, loss pulses
- Adherence to the rehabilitation program: Attitude toward exercise, changes in symptoms as response to exercise