Arterial insufficiency

iqraishaq07@gmail.com
iqra.ishaq@tuf.edu.pk
Objectives
 Assess the signs and symptoms of lower
extremity arterial disease and ulcers
 Select appropriate vascular laboratory

diagnostic testing for lower extremity arterial

disease
 Evaluate medical and surgical treatment

options for lower extremity arterial disease

 Design appropriate patient education for

prevention and appropriate lifestyle change.

Arterial insufficiency
 Lack of adequate blood flow to a region or
regions of the body.
 Disruption of arterial blood flow to the

extremities is PVD(Peripheral vascular

disease).
 Leading factors are smoking, cardiac disease,

diabetes, HTN, renal disease, elevated

cholesterol and triglycerides.
Arterial insufficiency
 Arteriosclerosis: thickening, hardening, and
loss of elasticity of arterial walls.
 Atherosclerosis: damage to the endothelial

lining of vessels and formation of lipids

plaques.
 Arteriosclerosis obliterans: peripheral

manifestation of atherosclerosis
characterized by intermittent claudication,
rest pain and trophic changes.
Arterial insufficiency
 Thrmoboangitis obliterans (Buerger’s disease):
inflammation leading to arterial occlusion and
tissue ischaemia especially in young men who
smoke.
 Raynaud’s disease: functional vasomotor disease of
small arteries and arteriloesnot likely to cause
ischaemic necrosis.
 Ulceration: a peripheral sign of long standing
disease.
 10 to 25 % LE ulcers are caused by arterial disease.
 Ulceration chance is less but often leads to loss of
limb and death.
Clinical presentation
 LE on lateral malleolus and dosrum of foot.
 Atherosclerotic occlusion is always present.
 Majority of patients also have diabetes.
 Trophic changes are present that include

abnormal nail growth, decreased leg and foot

hair, dry skin.
 Skin is cool upon palpation.
Clinical presentation
 Intermittent claudication and pain in limbs.
 Wound base is necrotic and pale lacking

granulation tissue.
 Skin around the wound is black.
 Decreased pulses, pallor on elevation, rubor

when dependent.
 Pain on elevation.
Subjective History
 Painful cramping or aching of lower extremity
during walking is the most common
complaint.
 Is due to IC when exercising muscles are not

receiving blood perfusion.

 Rest pain that develops at night, awakens the

patient or required analgesic for relief is

considered more severe.
Subjective History
 Pain with elevation.
 Cold hand and feet.
 Color changes of fingers and toes.
 Owning to long latency period of injury and

clinical appearance of disorder, health care

providers, caregivers, families and patients
must join hands.
ABCDEs In diagnosis
 A1C: Hgb A1C refers to the personal or family history of
diabetes or arterial disease.
 Blood pressure: Find out if it is elevated and if they are
on medications.
 Cholesterol: Elevated cholesterol is a risk factor and the
use of statin cholesterol lowering agents may reduce this
risk.
 Diet and obesity: Increased weight especially a body
mass index above 25 indicates an increased risk for
heart and peripheral vascular disease as well as diabetes.
 Exercise:
 Smoking
Test and Measurements
 ABI test designed to examine vascular
system.
 Doplers.
Ankle Brachial Index (ABI)-
Step 1
 Patient flat, explain procedure and
encourage relaxation for 15-20 minutes prior
to test
 Ensure ambient temperature is comfortable
 Remove tight clothing on arm
 Place BP cuff around arm, just above elbow
ABI - Step 2
 Palpate brachial pulse and apply gel to the
site
 Hold Doppler probe between index finger

and thumb at a 45 degree angle and place

over the brachial pulse
 Inflate cuff until Doppler sound disappears

- slowly deflate cuff until sound returns

 This is the BRACHIAL SYSTOLIC PRESSURE
 Record pressure reading
ABI - Step 3
 Place BP cuff around leg,
just above ankle
 Apply gel and locate
posterior tibial or
dorsalis pedis pulse
using Doppler probe
 Inflate cuff until sound
disappears - slowly
deflate cuff until sound
returns
 This is the ANKLE
SYSTOLIC PRESSURE -
record reading
 Photos from www.worldwidewounds.com
Calculating ABI
 Divide ankle pressure reading by the brachial
pressure reading and get a percentage value
 For example:
 Brachial systolic pressure = 120mmHg
 Ankle systolic pressure = 100mmHg
Ankle/Brachial = 100/120 = 0.83
ABI
ABI Interpretation Clinical Significance

>1.2 Non-compressible arteries No value; Recommend

toe pressure test
1.0-1.1 No arterial occlusion Can use compression, if
needed
0.8-0.9 Some arterial involvement Can use compression

0.6-.07 Moderate arterial Use modified

involvement compression with
caution, Vascular
referral
<0.5 Severe occlusion Urgent vascular referral
Capillary refill
 Purpose Indicator of superficial blood flow
 Method Observe color of patient’s skin in the

area of interest
 Apply pressure with enough force to blanch

the patient’s skin

 Monitor the amount of time required before

the patient’s skin color returns to normal

Capillary refill
 Interpretation <3 seconds=Normal capillary
refill time
 >3 to 5 seconds=Surface tissue perfusion is

impaired
 Advantages Quick, noninvasive, painless
 Reliable and valid assessment
 Limitations May be affected by tissue

temperature and patient age

Dependant rubor
Treating the wound
 “When treating vascular ulcers, follow the preparing the
wound bed paradigm.”
 Treat the cause: bypass, stents, or dilation with a consult
to a vascular specialist
 Patient-centered concerns: pain, quality-of-life, and
activities of daily living
 Local wound care:
◦ Healable wound—debridement, moisture balance, and bacterial
balance
◦ Maintenance wound—procedures may be more conservative
because of patient or system factors causing the wound to not
heal
◦ Nonhealable wound—requires conservative debridement,
moisture reduction, and bacterial reduction.
Intervention
 Treatment should enhance gasseous and
chemical homeostasis in wound bed.
 Educate importance of blood flow to the

extremities.
 In co occurrence of arterial and venous

disease condition that is more severe should

be treated first.
 If arterial condition is severe compression

may be inappropriate even when edema is

present.
Intervention
 A non healing wound on ischemic limb may
lead to gangrene, amputation, further
amputation and even death.
 In the most severe cases conditions are

inhospitable to wound closure.

 Necrotic tissues should not be debrid
Intervention
 Antibiotics can not reach wound systemically
and topical agents are too superficial to stop
infection.
 Vascular surgery may be an option.(bypass

graft).
 Living with chronic wounds or coming to

terms are the only options.

 Single most important prevention is to stop

smoking.
Interventions
 Exercise for weight control.
 Improvement of collateral circulation.
 Lipid profiles.
 Management of hypertension.
Arterial ulcer
Patient Teaching
Teaching about arterial ulcers
 Teach the patient with an arterial ulcer to:
 monitor arterial or graft patency by palpating pulses
 recognize signs and symptoms of graft failure and
what to report
 avoid nicotine in any form
 begin or maintain a regular exercise program
 manage blood glucose, if diabetes is present
 control hyperlipidemia
 manage hypertension
 reduce weight, if indicated
 perform meticulous foot care
 manage ulcer care.