Session 2
Circulatory course
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Intermittent Claudication
A muscular, cramp-type pain in the
extremities consistently reproduced
with the same degree of exercise or
activity and relieved by rest is
experienced by patients with peripheral
arterial insufficiency.
2
Rubor
The rubor dependency test (variation of the Buerger test) is performed by: Placing
the patient in supine Elevating the leg to 60 degrees from the horizontal plane for 2
minutes, note any appearance of pallor The leg is then moved into the dependent
position for another 2 minutes, note any change in colour.
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PATHOPHYSIOLOGY OF THE VASCULAR SYSTEM
• Reduced blood flow through peripheral blood vessels characterizes all peripheral vascular
diseases.
• The physiologic effects of altered blood flow depend on the extent to which tissue demands
exceed the supply of oxygen and nutrients available. If tissue needs are high, even modestly
reduced blood flow may be inadequate to maintain tissue integrity.
• Tissues then fall prey to ischemia (deficient blood supply), become malnourished, and ultimately
die if adequate blood flow is not restored.
4
Pump Failure
• Inadequate peripheral blood flow occurs when the heart’s pumping action
becomes inefficient.
• Left ventricular failure causes an accumulation of blood in the lungs and a
reduction in forward flow or cardiac output
results in inadequate arterial blood flow to the tissues.
• Right ventricular failure causes systemic venous congestion and a reduction in
forward flow .
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circulatory Insufficiency of the Extremities
Although many types of peripheral vascular diseases exist, most result in ischemia and produce some of
the same symptoms:
• Pain,
• Skin changes
• Diminished pulse,
• And possible edema.
The type and severity of symptoms depend in part on the type, stage, and extent of the disease process
and on the speed with which the disorder develops.
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ARTERIOSCLEROSIS AND ATHEROSCLEROSIS
Arteriosclerosis is the most common disease of the arteries; the term means hardening of the arteries. It is a
diffuse process whereby the muscle fibers and the endothelial lining of the walls of small arteries and
arterioles become thickened.
Atherosclerosis involves a different process, affecting the intima of the large and medium sized arteries.
• These changes consist of the accumulation of lipids, calcium, blood components, carbohydrates, and
fibrous tissue on the intimal layer of the artery.
• These accumulations are referred to as atheroma or plaques.
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Pathophysiology
The most common direct results of atherosclerosis in arteries include :
• Narrowing (stenosis) of the lumen,
• Obstruction by thrombosis, aneurysm, ulceration, and rupture.
Its indirect results are malnutrition and the subsequent fibrosis of the organs that the sclerotic arteries supply
with blood. All actively functioning tissue cells require an abundant supply of nutrients and oxygen and are
sensitive to any reduction in the supply of these nutrients.
If such reductions are severe and permanent, the cells undergo ischemic necrosis (death of cells due to
deficient blood flow) and are replaced by fibrous tissue, which requires much less blood flow.
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Morphologically, atherosclerotic lesions are of
two types: fatty streaks and fibrous plaque.
• are yellow and smooth, protrude slightly into the lumen of the
Fatty streaks artery, and are composed of lipids and elongated smooth
muscle cells.
• characteristic of atherosclerosis is composed of smooth
muscle cells, collagen fibers, plasma components, and lipids.
• It is white to whitish yellow and protrudes in various degrees
fibrous plaque into the arterial lumen, sometimes completely obstructing it.
These plaques are found predominantly in the abdominal
aorta and the coronary, popliteal, and internal carotid arteries.
• This plaque is believed to be an irreversible lesion .
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Risk factors
Modifiable Non modifiable
Nicotine use (ie, tobacco smoking, chewing) Age
Diet (contributing to hyperlipidemin) Gender
Hypertension
Diabetes (which speeds the atherosclerotic
process by thickening
the basement membranes of both large and
small vessels)
Stress
Sedentary lifestyle
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Tobacco use may be one of the
strongest risk factors in the
development of atherosclerotic lesions.
• Nicotine decreases blood flow to the extremities and increases heart rate and blood pressure by
stimulating the sympathetic nervous system, causing vasoconstriction.
• It also increases the risk for clot formation by increasing the aggregation of platelets.
• Carbon monoxide, a toxin produced by burning tobacco, combines more readily with the
hemoglobin than oxygen does, depriving the tissues of oxygen.
• The amount of tobacco use is directly related to the extent of the disease, and cessation of
tobacco use reduces the risks.
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Management & Prevention
Intermittent claudication is a sign of generalized atherosclerosis and may be a marker of occult coronary
artery disease. Because a high-fat diet is suspected of contributing to atherosclerosis, it is reasonable to
measure serum cholesterol and to begin prevention efforts.
Certain medications combined with dietary modification and exercise are being used to reduce blood lipid
levels.
Several classes of medication are used to prevent atherosclerosis. Patients receiving long-term therapy with
these medications require close
The traditional medical management of atherosclerosis involves modification of risk factors, a controlled
exercise program tom improve circulation and increase the functioning capacity of the circulation,
medication, and interventional or surgical graft procedures. 12
SURGICAL MANAGEMENT
Vascular surgical procedures
are divided into two groups:
inflow procedures, which outflow procedures,
provide blood supply from which provide blood
the aorta into the femoral supply to vessels below
artery, the femoral artery.
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RADIOLOGIC INTERVENTIONS
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Cont`
To decrease the risk of reocclusion, stents (small, mesh tubes made of
nitinol, titanium, or stainless steel) may be inserted to support the walls of
blood vessels and prevent collapse immediately after balloon .
A variety of covered wall stents and stent-grafts may be used for short-
segment stenosis.
Complications associated with stent or stent-graft use include :
• distal embolization
• intimal damage (dissection
• dislodgment.
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ARTERIAL THROMBOSIS
• Acute vascular occlusion may be caused by an embolus or acute
• thrombosis.
• Acute arterial occlusions may result from iatrogenic injury, which can occur during
insertion of invasive catheters such as those used for
1. arteriography, PTA or stent placement,
2. an intra-aortic balloon pump.
3. Other causes include trauma from a fracture, crush injury, and penetrating wounds that
disrupt the
4. arterial intima.
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Pathophysiology
Arterial emboli arise most
These thrombi become
commonly from thrombi that
detached and are carried from Emboli may also develop in
develop in the chambers of the
the left side of the heart into advanced aortic atherosclerosis
heart as a result of atrial
the arterial system, where they because the atheromatous
fibrillation, myocardial
lodge in and obstruct an artery plaques ulcerate or become
infarction, infective
that is smaller than the rough.
endocarditis, or chronic heart
embolus.
failure.
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Clinical Manifestations
• The symptoms of arterial emboli depend primarily on the size of the embolus, the organ involved, and
the state of the collateral vessels.
The immediate effect is
cessation of distal blood flow.
• The blockage can progress above and below the obstruction.
• Secondary vasospasm can contribute to the ischemia.
• The embolus can fragment or break apart, resulting in occlusion of distal vessels.
• Emboli tend to lodge at arterial bifurcations and areas narrowed by atherosclerosis.
• Cerebral, mesenteric, renal, and coronary arteries are often involved in addition to the large arteries
of the extremities.
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The six Ps associated with acute arterial embolism are
1. pain
2. pallor
3. pulselessness The symptoms of acute arterial embolism in
extremities with poor collateral flow are
4. paresthesia acute, severe pain and a gradual loss of
sensory and motor function.
[Link] (coldness),
6. paralysis.
Eventually, superficial veins may collapse because of decreased blood flow to the extremity. The part of the
extremity below the occlusion is markedly colder and paler than the part above the occlusion because of
ischemia.
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Assessment and Diagnostic Findings
• An arterial embolus is usually diagnosed on the basis of the sudden nature of the onset of
symptoms and an apparent source for the embolus.
• Two-dimensional echocardiography or transesophageal echocardiography, chest x-ray, and
electrocardiography may reveal underlying cardiac disease.
• Noninvasive duplex and Doppler ultrasonography can determine the presence and extent of
underlying atherosclerosis, and arteriography may be performed.
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Medical Management
Management of arterial thrombosis depends on its cause.
Management of acute embolic occlusion usually requires surgery because time is of the essence.
.Heparin therapy is initiated immediately to prevent further development of emboli and to hamper
the extension of existing thrombi.
Typically, an initial bolus of 5,000 to 10,000 units is administered intravenously, followed by a
continuous infusion of 1,000 units per hour until the patient is able to undergo surgery.
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SURGICAL MANAGEMENT
Emergency embolectomy is the procedure of choice
only if the involved extremity is viable . Arterial
emboli are usually treated by insertion of an
embolectomy catheter.
The catheter is passed through a groin incision into
the affected artery and advanced past the occlusion.
The balloon is inflated with sterile saline solution, and
the thrombus is extracted as the catheter is
withdrawn.
This procedure involves incising the vessel and
removing the clot.
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PHARMACOLOGIC THERAPY
When the patient has collateral circulation, treatment may include intravenous
anticoagulation with heparin, which can prevent the thrombus from spreading and reduce
muscle necrosis.
The use of intra-arterial thrombolytic medications helps to dissolve the embolus. Fibrin-
specific thrombolytic medications and single-chain urokinase-type plasminogen activator
……
A catheter is advanced under x-ray visualization to the clot, and the thrombolytic agent is
infused.
Contraindications to thrombolytic therapy include active internal bleeding, CVA (brain
attack, stroke), recent major surgery, uncontrolled hypertension, and pregnancy.
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Nursing Management
1. Before surgery, the patient remains on bed rest with the extremity level or slightly
dependent (15 degrees).
2. The affected part is kept at room temperature and protected from trauma.
3. Heating and cooling pads are contraindicated because ischemic extremities are easily
traumatized by alterations in temperature.
4. If possible, tape and electrocardiogram electrodes should not be used on the extremity;
sheepskin and foot cradles are used to protect the leg from mechanical trauma.
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Cont`
1. If the patient is treated with thrombolytic therapy, she or he s accurately weighed in
kilograms, and the dose of thrombolytic therapy is determined based on the
patient’s weight.
2. The patient is admitted to a critical care unit for continuous monitoring.
3. Vital signs are taken every 15 minutes for 2 hours, then every 30 minutes for the
next 6 hours, and then every hour for 16 hours.
4. Bleeding is the most common side effect of thrombolytic therapy, and the patient is
closely monitored for any signs of bleeding.
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During the postoperative period,
1. the nurse collaborates with the surgeon about the patient’s appropriate activity level based
on the patient’s condition.
2. Anticoagulant therapy may be continued after surgery to prevent thrombosis of the affected
artery and to diminish the development of subsequent thrombi at the initiating site.
3. The nurse assesses for evidence of local and systemic hemorrhage, including mental status
changes, which can occur when anticoagulants are administered.
4. Pulses, Doppler signals, ABI, and motor and sensory function are assessed every hour for
the first 24 hours, because significant changes may indicate reocclusion.
5. Metabolic abnormalities, renal failure, and compartment syndrome may be complications
after an acute arterial occlusion
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Medical
surgical
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