” om Tells) -1ye| MA ecole «4rata} eR wm Lael (te et am re eLes Colin PMLA) (elelo (+) Bia Mel aCe MOO LAA nA a Tet RMR tee ara) RM ata (eh tamog alae od aA CUM) 4. middle layer of connective tissue, smooth muscle and elastic fibers (media) *outer layer of connective tissue (adventitia) » have smooth muscles that contracts & relaxes to respond changes in blood volume. x al ow heWTS * are thin-walled vessels that transport deoxygenated blood from the capillaries back to the right side of the heart Re Beye ema Terma te Lome Coh ALLA ram aM he Tella ell a connective tissue > makes the veins more distensible > they accumulate large volumes of blood > Major veins, particularly in the lower extremities, have one-way valves ---allow blood flow against gravity * Valves allow blood to be pumped back SC ate mle Ae mol A) draining back into the periphery functioning valvePeripheral Vascular Diseases © charac. by a reduction in blood flow and hence 0, through the Pragl aCee ta Cy © when the need of the tissues for 0, exceeds the supply, areas Ob eraat MMe Mut cee MOL Reavy Factors that can contribute to the development of peripheral atherosclerotic changes Rill eC laud) GiieelipZeurrera # coagulability of blood Ly tart) bd > inflammatory process/infection aDs > 4 Arterial Insufficiency eam MM me tert col oN olelo ALT esa at eu ole tLe) ischemia > pulses one usually diminished or absent > sharp, stabbing pain occurs because of the ischemia, particularly with activity > there is interference with nutrients and 0, arriving to the tissues, leading to ischemic ulcers and changes in the skin. Mtoe ile ule Pam ae MMe (toto toa a oa lle eee Re OR aaa > leads to venous congestion and stasis of blood Pam Kee eee 4 , > lead to edema, skin changes and stasis ulcers aoT) ar aM meme sac ed Ma iM ole Coleg Skin cool or cold, hairless, dry, shiny, pallor on elevation, rubor on dangling sharp, stabbing, worsens w/ activity and walking, lowering feet may relieve pain severely painful, pale, gray base, found on heel, toes, dorsum of foot often absent or diminished infrequent Venous Disease warm, though, thickened, mottled, pigmented areas aching, cramping, activity and walking sometimes help, elevating the feet relieves pain moderately painful, pink base, found on medial aspect of the ankle usually present frequent, esp. at the end of the day and in areas of ulcerationRisk Factors 1, Age (elderly) - blood vessels become less elastic, become thin walled and calcified - 4 PVR - - BP | Sex le) Ue solar nar tinteldlated nicotine causes vasoconstriction and spasm of the arteries - © circulation to the extremities 0, inhaled in cigarette smoke reduces 0, transport to aiECt l daniels tacit) Bee elastic ra be replaced by fibrous collagen tissue > arterial wall become less distensible > ‘resistance to blood flow > “s BP | Hyperlipedimia - atherosclerotic plaque * > | Obesity - places added burden on the heart & blood vessels oa fat contribute to - venous congestion =Risk Factors (cont.) EEE 1, Lack of physical activity - Physical activity - promotes muscle contraction > A Pelee aii Om Laat s CMe Aral am ae or eel a nore aay | Emotional stress - stimulates sympathetic N.S. - peripheral vasoconstriction > 4 BP | Diabetes mellitus - changes in glucose & fat metabolism promote the atherosclerotic process I ily hi throsclerosi: * Cy) heArteriosclerosis Obliterans Cee elue a al meeRMete lent omicet uae) LA} or obstruction of the inner & middle layer of the artery © most common cause of arterial obstructive disease in the aie tulo PCR Ree Aco he MA el 1g sie © common site of disease - femoral artery, iliac arteries, popliteal arteries ® ina diabetic, the disease becomes more progressive, affects et Ce ar alate ela LA a ea *Femoral - artery Anterior —4 tibial arteryArteries become narrowed and blood flow decreases in arteriosclerosis Build up of fatty substances in the wall of the arteryPathophysiology » Plaque formation on the intimal wall that causes partial or Cecoli olt ak aelorelULoAy » Calcification of the medial layer and a gradual loss of elasticity > weakens the arterial walls came ae Doro aa (eh COTO ere ola ToL artery is unable to transport an adequate blood volume to the tissues during exercise or rest * Symptoms appear when the blood vessels can no longer provide enough blood to supply 0, and nutrients and removge metabolic waste products aClinical Manifestations Ce ieAuiia me tah meee eh Tolima umm COL) = pain in the extremity that develops in a muscle that has an inadequate blood supply during exercise - the cramping pain disappear w/in 1-2 mins. after stopping the (ol a Ae Sen Caco eel Mele mM ACL toute Real tM eel lL = common symptom ® pain at rest is indicative of severe disease Same Meat em el el mle mia a AO CLA © feelings of coldness Lt lela} © tingling sensation Dg > © advanced arteriosclerosis obliterans > ischemia may to necrosis, ulceration and gangrene - toes and distal foo Ga ap ogDoppler ultrasonography - high frequency sound waves directed to artery or veins through a hand-held transducer Cathe UI Aamo ToRe AUNT La (ak audible tone produced in proportion to blood velocity Pinterecst] gal o (oLoLe le mu) eA = t ip __- Transducer® Doppler ultrasound amplifies the sound ‘of arterial blood flow ‘© Sound of anteriat blood flow located in ankle @ Pressure recorded in the brachial srtory of the arm Blood pressure cuff o Pressure recorded Brachial in arteries of the ankle artery after each arterial flow is located DopplerManagement - directed toward prevention of vessel occlusion Reema a) Surgical intervention - in advanced disease - ischemic changes ele Delle e NACL Ig e Embolectomy - removal of a blood clot, done when large arteries are leat aire] ®@ Endarterectomy - is removal of a blood clot and stripping of atherosclerotic plaque along with the inner arterial wall. baal eseceetae nm - an obstructed arterial segment may be bypassed by rer. ¢ » a prosthetic material (Teflon) or the pt's. own artery or Pa Cll uty R AL)Endarterectomy pS = FIGURE 31-10. in an aortoiliac endarcereetomy, the vascular surgeon (A) identifies the diseased area, (B) clamps off the blood supply to the vessel, (C) removes the plaque, and (D) sutures the vessel shut, after which blood Row is restored, Adapted with permission from Rutherford, R. B. (2005), Vascular surgery: Vol. # and 2 (6th ed.). Philadelphia: Elsevier aa c \Atherosclerotic plaque ®ADAM.= a2 2 G =Saphenous vein bypasses plaque Atherosclerotic plaque ®ADAM.Management © Percutaneous Transluminal Angioplasty. Somat -a orl Mohan aroha ake Mtg (arto ce Luho Coan Come a Late td © Amputation - with advanced atherosclerosis & gangrene of extremities - toes are the most often amputated part of the body * The surgical goal is the remove the least amt. of tissue possible and create a stump adequate for the fitting of a get Lol xrae eet g Se rErEErE Eun UE EEUU Creda DM LAAT AMR TOLL Age ed MeL teal TL (indicates poor circulation) » ulcerations/ necrotic tissues Extremely cold to touch Peripheral pulses: diminished, weak, absent, bilateral inequality Grading O- absent 1+ weak & thready relate) 3+ full & bounding Prolonged (> 3 sec.) or absent capillary refill of nailbeds loss of muscle tone or weakness D > al oe xDTS epee * prevent further progression of existing disease Acute care SNM ae CM a aero oe coerulea) (ore alam Ca alan ae © arterial flow ~ pale & cool (initially) > bluish/darker > tissue become necrotic & black © activities that cause pain should be avoided * give vasodilators if prescribed - relaxation of vascular smooth muscle > decreases the pain © comfort measures - proper body positioning to dec. pressure on affected area vePost - operative care for arterial Ele a a NTI wa a aT a ga > and interventions done to promote circulation & comfort aoe a emollient a Oma Aw e a Ce) the surgical site, every 2-4 hrs. RRC ela) ae ley - sudden absence of pulse may indicate thrombosis - mark location of pulse with a pen to facilitate frequent assessment - use a dapper if pulse in difficult to palpate ! assess wound for redness, swelling and drainage | promote circulation = reposition pt. every 2 hrs. - tell pt. not to cross legs a - encourage progressive activity when permitted » | medication with analgesics to reduce pain > 4Arterial by-pass surgery Post-operative care © assess sensation and movement of the limb SMMC aR hae TUN Meola eC er SUC ae ela Mol mean cel (ola eal aCe octal slel a CAL TTNTeh on m Se Aue ele OUT) CNTR Ma SMR Ae a Me CeCe CALE decreased circulation to the graft. a *Thromboangitis Obliterans ( Buerger's Disease) © characterized by acute inflammatory lesions and occlusive thrombosis of the arteries & veins SNM waa Reel MAMA ACL Ae] © commonly occurs in male - bet. 20-40 y.o Sa SAUNA Ae CO a A) AT CC) © usually affect the lower leg, toes, feet a * by im |Clinical Manifestation © intermittent claudication in the arch of the foot © pain during rest - toes © coldness - due to persistent ischemia eeu Ce) © pulsation in posterior tibial, dorsalis pedis - weak or absent © extremities are red or cyanotic * ulceration & gangrene are frequent complications - early > can occur spontaneously but often follow trauma ia *Diminished blood supply causes damage and death of tissue Obstructed blood vesselMelani telat © advise the person to stop smoking Sn AeNel (ecole) * prevent progression of disease SN oem cel em con eat em eet 2) Se ara yea ® provide emotional support © whiskey or brandy may be of some value during periods of Pale Apolo Cie meer lei loy © advise pt. to avoid mechanical, chemical or thermal injuries to Satay als Laren ea Mon mat eM Molle Mela a at ala Am aaol cell a Cul aCe a on a ana * » pain is severe and cannot be controlled severe infection or toxicity occurs adRaynaud's phenomenon ON Se COM NC sol an alo etal ela ol Ola tat gee OMe Moule me) SN Reet le eter A skin color and temperature Ceri rtuel | mene uceiel ele MSN aco ele a eC Lay may occur after trauma, neurogenic lesions, occlusive arterial disease, connective tissues disease charac. by reduction of blood flow to the fingers manifested Ae el etn yea Leen LAMe eee Tete (relate) (pallor) Raynauds' Disease *» unknown etiology, may be due to immunologic abnormalities Se MM elt uae ee ek xe) * » maybe stimulated by emotional stress, hypersensitivity to _cold, alteration in sympathetic innervation‘Constricted digital artorios block blood to finger tips, causing discoloration Normal Constdeted Sigital arteryClinical Manifestations © usually bilateral -(both arms or feet are affected) © during arterial spasm - sluggish blood flow causes pallor, coldness, numbness, cutaneous cyanosis and pain bre) Te eC Mook ale eM ol Lec MA CAN reddened with tingling and throbbing sensations with longstanding or prolonged Raynaud's disease - ulcerations can develop on the fingertips and toes Lol = xRaynauds' DiseaseMedical Management See oM wm MAL oAe Santee MMe hI Ae rol lene Len metel (am toler a a folks) Seneca) © Drug therapy - calcium channel blockers, vascular smooth muscle relaxants, vasodilators - to promote circulation and [ute era ote Si Mu eared me dll e)) to relieve symptoms in the early stage of advanced ischemia Timex aweuicol rele e |e Melee amma ele eMule Mat (oll ol en ehceat zel Sd os x PeDS epee Tana lata Re rol uo aay © collect data on effect of assoc. factors - emotional stress, exposure to cold, cigarette smoking Se AMA el Pa a anon ol oe provide comfort ® teach pt. on effects of smoking, advise to quit * discuss ways of avoiding exposure to cold wear adequate clothing to promote warmth wear gloves and socks use caution when cleaning ref. & freezer wear gloves when handling frozen foods © avoid drugs that will cause vasoconstriction (birth aan » pills, ergotamine) soley ae MEANT EKO AUMT ef Cea La NCOL BS € Aat ae) © isa localized or diffuse enlargement of an artery at some point along its course Sameera a MA kM or oe el Ce Ae MOLTO Ce LLCO congenital vascular disease, infection or atherosclerosis Patho fell * enlargement of a segment of an artery > the tunica media (middle layer composed of smooth muscle & elastic tissue) is damaged > progressive dilation, degeneration > risk of Padded Seen MNCL aaa Cod © may develop in any blood vessel * » xBR ye era i 1, Saccular aneurysm = involves only part of the circumference of the artery, it takes the form of a sac or pouch-like eet Mo Cotes le RCM aCe My Mela 2. Fusiform aneurysm - spindle shaped, involves the entire Cece mK Mere ell) 3. Dissecting aneurysm - involves hemorrhage into a vessel wall, which splits and dissects the wall causing a widening of the At) caused by degenerative defect in the tunica media and ie ace anatiatey Diagnostic Tests © chest & abdominal x-rays - helpful in preliminary diagnosis,of Cla tremet eT Sd > Ultrasound - is useful in determining the size, shapeyand TT Man a UL aBlood vessels (arteries) in brainNormal aorta Aorta with large abdominal aneurysmAortic dissection Aorta Blood in wall of arteryThroracic Aortic Aneurysm ei UM la Collomel eset © occur most frequently in hypertensive men bet. 40-70 y.o © can develop in the ascending, transverse or descending aorta SyESy-4 © chest pain - most frequent; perceived when pt. is in a supine position me) 1a) * a Elbe Ae ee Rohm atl tz) aneurysm pressing against internal Sa steer A} structures © dysphagia Pa * iF |° Aorta exiting heart F— Abdominal aorta | Thoracic aortic aneurysmAbdominal Aortic Aneurysm SMM CM MRM CMCC aN) inal aorta below the renal arteri S/Sx: presence of a pulsatile abdominal mass on palpation pain or tenderness in the mid-or upper abdomen Bitola MN a alae MK illite aa Let adel PLT e Coola itera egomarc} EA CCM y MelleleLe che mileel elem mela ull mel emi aa (elf ORAL © Rupture of the aneurysm - most feared complication © can occur if the aneurysm is large. © can lead to death > 4 > Tx: Surgery - resection of the lesion and estas re) aaSurgical damp on aorta Surgical clamp Trimmed aorta, on aorta ‘Ascending aortic aneurysm | Ascending aortic aneurysm Haart Incision ine parte gat ——> implant ‘ori vale suture 7 line:coronary artery Surgical ies to hold being sutured to edges of aneurysm Fight cononany artery gflabave vatve out of operative fe‘Aorta (cross-section) Stent graft released from catheter (catheters, y/ lowly ’ ‘aortic aneurysm Catheter inserted into leg artery Catheter needed for other side Blood flows through stent graft Endovascular stent graft in placeArterial Embolism Bae 5 errs to am aos a a emo (go Ta = * the embolus is frequently a fragment of arterioscherotic plaque loosened from the aorta * emboli will tend to lodge in femoral or popliteal arteries, belfetote ALM Ml lel te Kero relate A Ale) inical i ions: © S/Sx depends on the size of the embolus, the presence of collateral circulation and if it is close to a major organ Sel lull meme AC Mle del ACI oe ume outa e Cell gett] ona © muscular weakness and burning, aching pain occur © distal pulses are absent and extremity becomes cold, numb and pale Dg © symptoms of shock may develop if the embolus eee ase Relat |Medical Management d * anticoagulants - prolong the clotting time of the blood and are eyo MeN ai mam acne Malm aiuto) a} Ex, 1. heparin - inhibits thrombin action - prevents clotting IV or SQ, antidote - Protamine sulfate 2. Warfarin sodium - inhibits Vit. K dependent clotting factor (Coumadin) synthesis, Y prothrombin activity - oral (10-15 mg/day) antidote - Vit. K Fibrinolytics or thrombolytics - are useful for dissolving existing Aisluelinls)' Molen uC taMnel eel Lola onan tat ae ohm Me Lae fe preserve organ and limb function Ex. Streptokinase, Urokinase IV side effect - bleeding atl oC ee el ee Ue eld a arteries are obstructed Beale eR Ae ON em AL tee Gary Ta him laste NiNursing Management oni C fl a Ce aia) istal TO [el fo) * assess for increasing pallor, cyanosis, coldness of the skin > indicates vessel occlusion keep the extremity warm, but do not apply heat, avoid chilling MR lam otal aC Aue ol Some Wo pV ol ocelot nes) ee Ara a alee lel lm tet Ti » keep affected extremity flat or slightly dependent position to promote circulation * monitor anticoagulant or fibrinolytic therapy & assess for signs of bleeding - nose or gum bleeding , petechiae (pinpoint red areas on Skin), ecchymosis (bruising) , hematoma formation * monitor urine, stool, emesis and gastric secretions for bloo avoid IM injections, use soft toothbrush, use electric razor ratht than razor blade, avoid rectal thermometerVenous Disorders SAM UO Ma UT ara tel malo olole aa wel tat aol =I] Cela Lelelol SCA a © changes in smooth muscle and connective tissue make the Wale Melee te Meee el Leo » valves may malfunction, causing backflow of blood ee Ma lel CCM ele LAC altered blood coagulation Pa .Thrombophlebitis © inflammation of the veins caused by thrombus or blood clot ith Sa waco ca hlebiti: en ee) Sree Ce me NCAR el hypercoagulability of the blood - oral contraceptive use. * common to hospitalized pts. , undergone major surgery (pelvic or hip surgery), MI Pathophysiology * develops in both the deep and superficial veins of the lower are suling deep veins - femoral, popliteal, small calf veins © superficial veins - saphenous vein * Semcon CMM Cle mae meCCet Ne CeCe Mohave ee mt hee (olsto 12164 7| Clot in venous systemDeep Vein Thrombosis (DVT) mas. meio * amajor risk during the acute phase of thrombophlebitis is dislodgment of the thrombus > embolus pulmonary embolus - is a serious complication arising from DVT of Bist oly angie nd Clinical Manifestations: * pain and edema of extremity - obstruction of venous flow * @ circumference of the thigh or calf (+) Homan's sign - dorsiflexion of the foot produces calf pain SM clo y aol Lol Colt AM liar RII MAM Seley A Calo) elmo old present > # risk of embolus formation aad out Ce TM i. o noted - redness, warmth, tenderness along the course of the veifty the veins feel hard and thready & sensitive to cao 4Direction of blood flow Superficial vein wy, Thrombosi: in deep vein ‘Swelling and inflammation below blockageClot ees in heart Venous blood return deposits clot in heartMedical Management er tehe om TMs erate Bs) Ea © NSAID‘s ( Non - steroidal anti-inflammatory drugs) - aspirin i i f ® requires hospitalization * bed rest w/ legs elevated to 15-20 degrees above heart level (knees slightly flexed, trunk horizontal (head may be raised) to Peele uel Mua Ree Me AC m late ule e AT Ane edema ee siren Meme ete Mel math mee ello Mell Miata lel Maal a | SUC S acolo dale Mela ole allele ® anticoagulants, initially with IV heparin then coumadin > > Seni Sale anm Come o)hy Lat Mala alee * vasodilator if needed to control vessel spasm and improWcirculation wsSurgery Sisal Meme el ae ee RaSh a a ee © Thrombectomy - incising the common femoral vein in the groin and extracting the clots * Vena caval interruption - transvenous placement of a grid or ileal Mane me eh ola CoM) LoL eat eck ele ato) emboli Paki Ceili © characteristic of the pain © onset & duration of symptoms history of thrombophlebitis or venous disorders © color & temp. of extremity eee eC Re mt > legs for comparison avGreenfield filter is inserted into inferior vena cava to catch blood clotsSequential compression device inflates with air to accelerate venous blood retum scDUTES Teenie Preventive care © prevent long periods of standing or sitting that impair venous iets) Bia eRe eh a ane mum elt Cole CA ol) are eA Molo) ate) © if edema occurs, elevate above heart level © regular exercise program to promote circulation Selo Me eel eM (eC Mel ma) * avoid wearing constrictive clothing such as tight bands around Ele colar atl} © use elastic stocking on affected leg ae » do leg exercises during periods of enforced immobility such > CR arage ala eaNursing Management * explain purpose of bed rest and leg elevation * use elastic stockings monitor pt. on anticoagulant & fibrinolytic therapy for signs of bleeding © monitor for signs of pulmonary embolism - sudden onset of chest pain, dyspnea, rapid breathing, tachycardia Nsg. intervention often surgery of vena caval interruption © assess insertion site - bleeding, hematoma, apply pressure over site and inform physician © keep pt. on bed rest for 1* 24 hrs. then encourage ROM exercises to promote venous return * assist pt. in ambulation when permitted, elevate legs Cue ha * keep elastic bandage a NoMa esol eMart eM Att oto a eu x ees ee TENA LCN me LO ON Moh MeelisChronic Venous Insufficiency r r Results from obstruction of venous valves in legs or reflux of blood back through valves CAC a lade Ce aa meeli teeta Pharmacological therapy is antibiotics for infections Debridement to promote healing Topical Therapy may be used with cleansing and Ce(solmle ant ahe og > a i aVenous ulcerationVaricose Veins nn Se Mele liclua te Ace onrom ALR LAM T-Sh occurring most often in the lower extremities ® usually affected are woman 30-50 years old, faetty congenital absence of a valve incompetent valves due to external pressure on the veins bax eLuM aero ocr cme eleLel Cel mel oe) sustained 4 in venous pressure due to CHF, cirrhosis Prevention wear elastic stockings during activities that require lon Standing or when pregnant re moderate exercise, elevation of legs aQormal vein © varicose veinPathophysiology aia Melee Ru Ue Cael ALM MAAN weakening of the vein wall > does not withstand normal pressure ¥ veins dilate , pooling of blood valves become stretched and incompetent C7 more accumulation of blood in the veins ei a xClinical Manifestations © Primary varicosities - gradual onset and affect superficial veins, appearance of dark tortuous veins S/sx - dull aches, muscle cramps, pressure, heaviness or fatigue arising from reduced blood flow to the tissues © Secondary Varicosities - affect the deep veins occur due to chronic venous insufficiency or venous Rte S/sx - edema, pain, changes in skin color, ulcerations may Colo aL CC)ai fa [a (eter ANAM MN Teel nal Mecano Neem alae ma » the pt. lies down with the affected leg raised to allow for venous emptying merle a elt mamta ge) 9) (Xe el ol NT mA Catt ae Ce) stands. The direction and filling time are recorded both before & after the tourniquet is removed See ol Acme ATC a La etl from backward blood flow al heSurgical Intervention © indicated or done for prevention or relief of edema, for = recurrent leg ulcers or pain or for cosmetic purposes Vein ligation and stripping the great sapheneous vein is ligated (tied) close to the femoral junction the veins are stripped out through small incisions at the eu (MeL All UC ae WO Re L a ARSC sterile dressing are placed over the incisions and an elastic lelelsTe lee Marne lem AC NCLCA AR MLL ALAN applied x beVein ligation and stripping© Monitor for signs of bleeding, esp. on 1% post-op day if there is bleeding, elevate the leg, apply pressure over Rit M ole se Melo M a Mia nat ae ola) © Keep pt. flat on bed for first 4 hrs. after surgery, elevate leg CN aon Real eM aC UM Leo MT MLA] © Medicate 30 mins. before ambulation and assist patient © Keep elastic bandage snug and intact, do not remove bandage Lea *