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DEFINITION
Peripheral vascular disease ( PVD ) is a slow and progressive circulation disorder caused by
narrowing, blockage, or spasms in a blood vessel
PVD may involve disease in any of the blood vessels outside of the heart including the
arteries, veins, or lymphatic vessels

ETIOLOGY AND RISK FACTORS

■ Primarily caused by atherosclerosis
■ Embolism
■ Thrombosis
■ Trauma
■ Vasospasm
■ Obesity
■ Inflammation
■ Family history
■ Sedentary lifestyle
■ Stress
■ Autoimmunity
■ Smoking
■ Hypertension

PATHOPHYSIOLOGY
1. Risk factors
2. Blood cholesterol
3. Plaque formation on intimal wall that causes
4. partial or complete occlusion
5. Calcification of medial layer and gradual loss of elasticity
6. Weakening of arterial wall
7. Predisposes to aneurysms, dilation or thrombus formation
8. Unable to transport adequate blood &O2 to tissues during exercise and rest leading to
appearance of symptoms

CLINICAL MANIFESTATION

Types
■ Thromboangiitis obliterans
■ Raynaud's disease
■ Aneurysm
■ Arterial embolism
■ Deep vein thrombosis(DVT)

Thromboangiitis obliterans
1. Acute inflammatory lesions and occlusive thrombosis of the arteries and veins
2. Strong association with smoking
3. Commonly Occurs In Males Between 20-40 yrs

Clinical manifestation of thromboangiitis obliterans

■ Intermittent claudication
■ Pain during rest
■ Coldness

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■ Paresthesia
Presentation
■ Weak or absent pulse in posterior tibial, dorsalis pedis
■ Extremities are cyanotic
■ Ulceration and gangrene
Interventions
■ Advise patient to stop smoking
■ Avoid trauma
■ Emotional support
■ Avoid injuries to feet
Interventions
■ Amputation of leg is done only when:
○Gangrene extends well into
foot
○Pain is severe
○Severe infection

Raynaud’s disease
■ Intermittent episodes during which small arteries of left or right arm constrict causing
changes in skin color & temperature
■ Symmetric bilateral involvement & may affect only 1 or 2 fingers
■ May occur after exposure to cold, trauma
■ Characterised by reduction of blood flow to fingers manifested by pallor

Etiology
■ Unknown etiology
■ Common in women may be
stimulated by stress,
hypersensitivity to cold
Clinical manifestation of Raynaud’s disease
■ during arterial spasm-sluggish blood flow occurs
■ Following the spasm the area becomes reddened with tingling & throbbing sensation
Clinical manifestation of Raynaud’s disease
■ With longstanding Raynaud's disease-ulcerations can develop on fingertips & toes

Interventions
■ Prevent injury
■ Provide comfort
■ Avoid smoking
■ Avoid exposure to cold
Interventions
■ void drugs that will cause vasoconstriction
■ Suggest anti inflammatory analgesics

Aneurysm
■ Is a localized or diffuse enlargement of an artery at some point along its course
■ Can occur when the vessel becomes weakened from trauma, congenital vascular disease,
infection or atherosclerosis

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Types of Aneurysm
■ Saccular Aneurysm- involves only part of the circumference of the artery
■ Fusiform aneurysm- spindle shaped, involves the entire circumference of the arterial wall
■ Dissecting Aneurysm- involves hemorrhage into a vessel wall, splits and dissects the wall
causing widening of the vessel
■ caused by degenerative defect in the tunica media and tunica intima

Diagnostic tests
■ Chest & abdominal X-rays - helpful in preliminary diagnosis of aortic aneurysm
■ Ultrasound- is useful in determining the size, shape and location of the aneurysm
■ CT & MRA

Thoracic aortic aneurysm

■ Aneurysm in the thoracic area
■ Can develop in the ascending,
inverse or descending aorta

Signs
■ Chest pain
■ Cough
■ Dyspnea
■ Hoarseness
■ Dysphagia
Abdominal aortic aneurysm
■ Abdominal aorta below the renal arteries
■ Pulsatile abdominal mass on palpation
■ Pain or tenderness in the mid-or upper abdomen
Abdominal aortic aneurysm
■ The aneurysm may extend to impinge on the renal, iliac, or mesenteric arteries
■ Stasis of blood favors thrombus formation along the wall of the vessel

Complications
■ Rupture of the aneurysm - most feared complication
- can occur if the aneurysm is
large ( can lead to death )
- Tx: Surgery - resection of the lesion and replacement with a graft

Arterial Embolism
■ Blood clots floating in the circulating arterial blood
■ The embolus is frequently a fragment of arterioschlerotic plaque loosened from the aorta
■ Emboli will tend to lodge in femoral or popliteal arteries, blood flow is impaired and
ischemia develops

Clinical Manifestations
■ Abrupt onset of severe pain
■ Muscular weakness and burning, aching pain
■ Distal pulses are absent and
extremity becomes cold, numb, and pale
■ Symptoms of shock may develop
Deep vein thrombosis ( DVT )

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■ Tends to occur at the deep veins due to stasis of blood
■ A major risk during the acute phase of thrombophlebitis is dislodgment of the thrombus

Deep vein thrombosis ( DVT )

■ Pulmonary embolus - is a serious complication arising from DVT of the lower extremities

Clinical Manifestations
■ Pain and edema of extremity ■ (+) Homan's sign
■ Do not check for the Homan's
sign if DVT is already known
to be present risk of embolus
formation
■ If superficial veins are affected redness, warmth, tenderness will occur, the veins feel hard
and thready & sensitive to pressure

Medical management
■ Requires hospitalization
■ Bed rest with legs elevated to 5-20 degrees
■ Application of warm moist heat to reduce pain
■ Elastic stocking or bandage
Medical management
■ Anticoagulants, initially with VI heparin and Coumarin
■ Fibrinolytic
■ Vasodilator if needed to control vessel spasm

Assessment
■ Condition of the skin: shiny, taut, absence of hair growth
■ Ulcerations/ necrotic tissues
■ Extremely cold to touch
■ Peripheral pulses: diminished,
weak, absent, bilateral inequality
■ Grading 0- absent
1+ weak & thready
2+ normal
3+ full & bounding
■ Prolonged(> 3 secs) or absent capillary refill of nail beds
■ Loss of muscle tone or weakness
Diagnostic evaluation
■ Doppler ultrasonography
■ Ankle brachial index to
measure arterial blood flow
■ Colour flow imaging
■ Transcutaneous Oximetry
■ Angiography
Complications
■ Gangrene
■ Extremity amputation
■ Possible infection and sepsis

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Medical management
■ Weight reduction
■ Exercise
■ Stop smoking
■ Blood lipid reduction
■ Statins, Nicotinic acid,
fibric acid derivative, bile
acid resins
■ Promote arterial flow- Pentoxifylline
■ Cilostazol - vasodilator & anti platelet
■ Trendelenburg position

Surgical interventions
■ Embolectomy
■ Endarterectomy is removal of amblood clot and stripping of atherosclerotic plaque along
with the inner arterial wall
■ Arterial bypass surgery- an obstructed arterial segment may be by passed by using a
prosthetic material teflon) or patient's own artery or vein (saphenous vein)
■ Percutaneous Transluminal Angioplasty- the balloon tip of the catheter is inflated to
provide compression of the plaque
■ Amputation

Nursing diagnosis
■ Ineffective peripheral tissue perfusion
■ Activity intolerance related to poor blood flow to the lower extremities
■ Ineffective health maintenance related to smoking and lack of information about disease
■ Risk for impaired skin integrity related to ischemic tissues of legs and feet

FOOT CARE FOR PATIENTS WITH PERIPHERAL ATHEROSCLEROSIS

1. Keep legs & feet clean, dry & comfortable
o Clean with warm water & mild soap
o Pat dry using soft towel
o Apply cream after drying
o Wear a pair of cotton socks everyday
2. Prevent accidents and injuries to health
o Always wear shoes
o Walk on ground levels
o Don't go barefoot
o Report if there is any foot problems
3. Improve blood supply to legs & feet
o Don't cross legs
o Don't wear knee stockings
o Don't swim in cold water

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Preventions
■ Do passive exercise of legs
■ Walk for at least 30 mins
daily
■ Avoid cold water for bathing ■ Stop smoking
■ if edema occurs, then elevate
the legs
■ Dorsiflex legs at regular intervals to prevent venous pooling
■ Avoid massaging the affected extremity
■ Keep extremity warm but do not heat
■ Use elastic stockings on affected leg

Health teaching
■ Stop smoking
■ Lose weight
■ Eat low fat diet
■ Avoid walking barefoot
■ Begin walking & exercise programme
■ Don't wear restrictive clothing
■ Wear proper fitting shoes

BIBLIOGRAPHY
1. Casillas JM, Troisgros O, Hannequin A, Gremeaux V, Ader P, Rapin A, Laurent Y.
Rehabilitation in patients with peripheral arterial disease.Ann Phys Rehabil Med.
2011 Oct;54(7):443-61. English, French. doi:
10.1016/j.rehab.2011.07.001. Epub 2011 Aug .5
PMID: 21917541.
2. Hamburg NM, Balady GJ. Exercise in peripheral artery disease: functional impact and
mechanisms of benefits. Circulation. 2011;123(1):87-97.
do:10.1161/CIRCULATIONAHA.109.881888