Peripheral Arterial Disease (PAD)

 

WHAT WENT WRONG?

Large peripheral arteries become narrowed and restricted (stenosis) leading to

the temporary (acute) or permanent (chronic) reduction of blood flow to tissues

(ischemia). This is most commonly due to atherosclerosis (plaque on the inner

walls of arteries), but may also be caused by a blood clot (embolism), or from an

inflammatory process. Severe peripheral arterial occlusive disease can lead to skin

ulceration and gangrene. Peripheral arterial occlusive disease is more common in

patients with diabetes or hypertension, in older adults, in those with hyperlipidemia,

and in those who smoke, as these conditions can predispose to diminished

circulation. Vascular disease that happens in one area of the body, e.g. coronary

arteries, is not an isolated process. The plaque build-up caused by long-term elevated

cholesterol levels will happen throughout the body. The most common area

of involvement is the lower extremities.

 PROGNOSIS

Patients typically have progressive disease. It is a chronic problem, getting worse

with age. Symptoms may not be present until there is a 50 percent or greater occlusion

of the vessel. Suspect disease in patients who have risk for other cardiovascular

diseases. Medications can help to improve blood flow to the area and increased

activity will improve exercise tolerance and quality of life. Vascular intervention

may be necessary as the disease progresses.

HALLMARK SIGNS AND SYMPTOMS

• Femoral, popliteal arteries.

• Sudden pain in the affected area because of spontaneous muscle contractions

due to the reduced oxygenation of tissue.

• Intermittent claudication—pain, numbness, and/or weakness with walking

due to increased oxygen demand of the muscle during activity. • Weak or absence of pulse in affected area because blood flow is reduced

or blocked.

• Decreased temperature distal to the blockage because of restricted blood

flow.

• Pallor or patchy coloring (mottling) of affected area because of reduced

tissue oxygenation.

• Dependent rubor (increased redness when legs are lower).

• Hair loss on extremities.

INTERPRETING TEST RESULTS

• Doppler ultrasonography of affected area.

• Arteriography. Dye is injected into the affected artery enabling an outline of

the artery and blockage to be seen in an x-ray.

• Ankle brachial index (ABI) helps to determine the amount of arterial insufficiency.

TREATMENT

The goal of treatment is to maintain adequate blood flow to the area and avoid tissue

damage. Patients are encouraged to maintain activity and reduce risks for disease,

such as smoking, as well as to control blood pressure and monitoring diabetes.

Medical treatment:

• Exercise.

• Smoking cessation.

• Decrease in lipids, depending on what the labwork shows.

Surgical treatment:

• Femoropopliteal bypass graft: A vessel from another part of the body is

removed and grafted to the affected artery, permitting blood to bypass the

blockage.

• Percutaneous transluminal angioplasty: A catheter containing a balloon is

inserted into the affected artery. The balloon is inflated, stretching the artery;

this causes a healing response that breaks up plaque on the artery wall. • Atherectomy: A catheter containing a grinding tool is inserted into the

affected artery and is used to grind plaque from the artery wall.

• Embolectomy: Surgical removal of a blood clot from the affected artery.

• Thromboendarterectomy: Surgical removal of atherosclerotic tissue from the

affected artery.

• Laser angioplasty: A laser-tipped catheter is inserted into the affected artery

to remove the blockage.

• Stent: A metal mesh tube is inserted into the affected artery to keep the

artery open.

• Amputation: Surgical removal of the affected limb that contains gangrene

caused by low blood flow or complete blockage of blood to the affected limb.

• Administer antiplatelets medication to enhance blood flow to the lower extremities.

This helps to get blood through the vessels and alleviates symptoms.

• penoxifylline

• cilostazol

• aspirin

• clopidogrel

• dipyridamole

• ticlopidine

DIAGNOSES

• Fear

• Ineffective tissue perfusion

• Risk for injury

INTERVENTION

• Monitor most distal pulse to assure circulation exists.

• Compare bilateral pulses.

• Monitor temperature, color of affected area indicating tissue perfusion.

• Support hose.

• Check capillary refill.

• Administer anticoagulant (such as heparin, warfarin) as directed.

• Administer pain medication as directed. • Don’t elevate leg or apply heat if occlusion affects the femoral or popliteal

arteries.

• Elevation of the lower extremities makes it harder for the blood flow to get

to the tissues.

• Avoid prolonged sitting, which increases the risk of compression to vessels

(impeding blood flow to lower extremities) and increases risk of clot formation

in lower extremities.

• Explain to the patient:

• How to check pulses in the affected area if there is an absence of a pulse.

• Call the physician if the patient experiences numbness, paralysis, or pain.

• Don’t wear tight clothes; avoid tight knee-high hose, which constricts at

the popliteal space; avoid tight waist bands; ensure wide shoe box.

• Change his/her lifestyle to reduce the risk of peripheral arterial occlusive

disease.

• The importance of regular examinations.

• Foot check daily for open wounds, redness.

• Regular visits to podiatrist.

• Regular consults to vascular MD.

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