VASCULAR DISEASES

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  • Left:
    Lateral view of infarenal aortic aneurysm (AAA) with a saggital “DropSlice” shown for context.
    bloodflow (red)
    thrombus and non-calcified plaque (yellow)
    plaque (white)

    Right
    AP view of thoraco-abdominal aortic aneurysm (TAA) with a coronal “DropSlice” shown for context
  • VASCULAR DISEASES

    1. 1. 1
    2. 2. 2
    3. 3. Atherosclerotic  wall weakening in complicated lesion  abdominal aorta 3
    4. 4. 4
    5. 5. 5 Abdominal Aortic Aneurysm (AAA) Thoracic Aortic Aneurysm (front view)
    6. 6.  A sac or dilation formed at a weak point  Abnormal localized permanent dilatation of a blood vessel  One or all three layers may be involved  May rupture and lead to death  Sometimes classified by gross appearance as fusiform or saccular 6
    7. 7. False aneurysm Blood escapes into connective tissue, outside of arterial wall 7
    8. 8. Fusiform aneurysm Symmetric, spindle-shaped expansion Involves entire circumference 8
    9. 9. Saccular aneurysm Out-pouching on one side only 9
    10. 10. Dissecting aneurysm Separation of arterial wall layers that fills with blood 10
    11. 11.  Occurs most frequently in men, 50 – 70 yrs of age  Etiology – atherosclerosis, hypertension, infection  1/3 die from rupture 11
    12. 12.  Vasculitis, syphilis, traumatic (automobile accidents), collagen vascular disease (Marfan's syndrome), smoking  S/S depend on size and rate of growth  Substernal pain, dyspnea, neck or back pain 12
    13. 13.  May be asymptomatic  Chest pain  Dyspnea, hoarseness or dysphagia  Distended neck veins and edema of head and arms 13
    14. 14.  Imaging  Must be differentiated from other diagnoses (lung neoplasm, mediastinal masses).  CT scan and MRI very sensitive to assess.  Treatment  Controlling HTN and Beta Blockers may slow growth.  Surgery is for patients that have symptoms, >5cm, or rapidly expanding size.  Morbidity and Mortality higher than with AAA 14
    15. 15.  Chest xray  Transesophageal echocardiogram  CT scan 15
    16. 16.  Control underlying hypertension  Surgical repair  Resection of aneurysm and replacement with graft  Repair with endovascular graft 16
    17. 17.  Depends on type and location  Cardiopulmonary bypass required  Thoracotomy or median sternotomy incision  Graft goes over the aneurysm 17
    18. 18. 18
    19. 19.  Occurs more frequently in Caucasians, more in men and elderly clients  Etiology – atherosclerosis, hypertension, trauma, infection, congenital abnormalities in vessels, genetic predisposition  Most are infrarenal 19
    20. 20.  Approximately 60% of clients are asymptomatic  Pulsatile mass in the upper and middle abdomen  Abdominal or low back pain  Bruit may be heard  Diminished femoral and distal pulses  Patchy mottling of feet and toes 20
    21. 21.  Imaging  Abdominal U/S for screening and monitoring progression  Abdominal CT scan to specifically measure size and its relationship with the renal arteries 21
    22. 22.  Abdominal ultrasound  CT scan, MRI 22 The aortic abdominal aneurysm has an intramural thrombus, and its size is approximately 6.7 cm in diameter. The true lumen of the aorta is indicated by the arrowheads.
    23. 23. 23
    24. 24.  If small, monitor every 6 months  Keep BP down  Preoperatively  Cardiac evaluation must be done  Cardiac interventions may need to be done before repair of aneurysm  Treatment  For >5cm surgical intervention with graft replacement  If symptomatic surgical treatment must be immediate regardless of size  Stent grafts are treatment  Inserted through common femoral arteries  Less than 2 hours, minimal blood loss  May need more complicated repair depending on patient condition 24
    25. 25.  Complications  Myocardial infarction, bleeding, limb ischemia, bowel infarction, renal insufficiency, stroke  Graft infection and graft fistulas can occur  Endoleak  Some patients will develop another aneurysm in another location 25
    26. 26. 26
    27. 27. 27
    28. 28. 28
    29. 29. 29
    30. 30.  For high risk surgery patients  Before aneurysm reaches diameter for elective surgery  Inserted through femoral artery  Decreased length of stay in hospital  Still need monitoring for complications 30
    31. 31. 31
    32. 32. 32
    33. 33. 33 Pre-repair Post-repair
    34. 34.  Popliteal make up approximately 85% of peripheral artery aneurysms  Symptoms due to arterial thrombosis, peripheral embolus, compression of adjacent structures  U/S used for diagnosis and measurement  Surgery – >2cm if asymptomatic and for all symptomatic regardless of size  Femoral  Pulsatile groin masses  Same problems as popliteal 34
    35. 35. 35
    36. 36. 36
    37. 37.  Occurs from vascular damage, involved in coronary and cerebral vascular disease  Stable plaque  Unstable plaque 37
    38. 38.  Arterial Manifestations:  Diminished or absent pulses  Smooth, shiny, dry skin, no hair  No edema  Round, regularly shaped painful ulcers on distal foot, toes or webs of toes  Dependent rubor  Pallor and pain when legs elevated  Intermittent claudication  Brittle, thick nails  Venous Manifestations:  Normal pulses  Brown patches of discoloration on lower legs  Dependent edema  Irregularly shaped, usually painless ulcers on lower legs and ankles  Dependent cyanosis and pain  Pain relief when legs elevated  No intermittent claudication  Normal nails 38
    39. 39. 39
    40. 40. Modifiable  Cigarette smoking  Obesity  Diabetes Mellitus  Physical Inactivity  High Cholesterol  High Blood Pressure Non- Modifiable  Personal or family history  Heart disease  History of stroke  Age  Male 40
    41. 41.  Disorders that interfere with natural flow of blood through peripheral circulation  Patients can have arterial and venous disease  Chronic condition  Systemic manifestation of atherosclerosis 41
    42. 42.  Inflow  located above the inguinal ligament  may not cause significant damage  Outflow  below superficial femoral artery  typically cause significant damage 42
    43. 43.  Intermittent claudication – pain with ambulation that stops with rest  Inflow disease – discomfort in buttocks, lower back and thighs  Outflow disease – burning or cramping in ankles, feet, toes and calves, resting pain 43
    44. 44. 44
    45. 45.  Blood pressure checks in both arms  Palpate pulses and compare with opposite side  Capillary filling time  Inspect extremities for edema, discoloration, loss of hair, temperature differences, ulcers  Observe for intermittent claudication with ambulation 45
    46. 46.  Stage I  Asymptomatic  No claudication  Pedal pulses affected  Stage II  Claudication  Pain or burning with exercise but relieved with rest  Symptoms reproducible by exercise 46
    47. 47.  Stage III  Resting Pain  Awakens patient at night  Numbness or burning quality  Relieved with extremity in dependent position  Stage IV  Necrosis/Gangrene  Gangrenous odor  Ulcers and necrotic tissue 47
    48. 48.  Systolic blood pressure readings  Exercise tolerance testing  Plethysmography  Non-invasive technique for measuring the amount of blood flow present or passing through, an organ or other part of the body  Used to diagnose deep vein thrombosis and arterial occlusive disease 48
    49. 49. Non-surgical  Exercise  Patient positioning  Medication  Angioplasty  Arthrectomy – non-surgical procedure to open blocked coronary arteries or vein grafts by using a device on the end of a catheter to cut or shave away atherosclerotic plaque 49
    50. 50. 50
    51. 51. Surgical  Bypass (inflow and outflow)  Aortoiliac and aortofemoral bypass  Axillofemoral bypass 51
    52. 52. 52
    53. 53.  Embolus is most common cause  Affects both upper and lower extremities  History of recent MI or a-fib  Severe pain even resting  Temperature cool, mottled and no pulse  Immediate intervention needed to prevent loss of extremity  Treatment – thrombectomy  Must observe extremity for improvement of condition also for complications 53
    54. 54.  Pathophysiology  blood clots from arteries, left ventricle, or trauma suddenly break loose and become free flowing, lodge in bifurcations, causing obstruction distally with acute and sudden symptoms  Assessment  6 P’s – pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia – inability to control temp  ABI (ankle-brachial index) <1  U/S  MRI  Angiography 54
    55. 55.  Decreased Ankle-Brachial Index (ABI)  0.50 to 0.95 indicates mild to moderate insufficiency  0.25 or less indicates severe Ankle pressure = ABI (normally 1.0) Brachial pressure 55
    56. 56.  Medical  Anticoagulants - heparin bolus then 1000 U/hr  Thrombolytics  Surgical (depends on occlusion time)  Embolectomy  Bypass  Angioplasty with stent placement 56
    57. 57.  Pathophysiology  Obstructive and inflammatory disease of small and medium sized arteries and veins  Believed to be autoimmune  Has exacerbations and remissions  Smoking is very high risk factor  Assessment  Pain and instep claudication  Intense rubor  Absence of distal pulses (pedal, radial, ulnar)  Paresthesias  Segmental limb blood pressures  U/S  Angiography 57
    58. 58.  Medical/Surgical  Pain meds  Stop smoking  Treatment of infection and gangrene  Sympathectomy (removal of sympathetic ganglia or branches-causes permanent vasodilation  Amputation  Nursing  Support stopping smoking  Administer pain meds  Education regarding protection extremities from cold and trauma 58
    59. 59. 59
    60. 60. 60
    61. 61.  Dilated, tortuous superficial veins of the lower extremities  May be superficial or deep  Symptomatic or asymptomatic – Symptoms do not always correspond to the number and size of varicosities  Female, family history, prolonged sitting or standing  Dull aching feeling after long periods of standing  Complications include ulceration, stasis dermatitis, superficial venous thrombosis and thrombophlebitis 61
    62. 62.  Treatment includes compression stockings worn all day and removed at night  Periodic elevation of legs and exercise are recommended  Encourage walking and weight loss  Surgery is for patients that have persistent, disabling pain, ulceration, superficial thrombophlebitis  Sclerotherapy can be used for small varicosities  More than one treatment may be needed  This is chronic disease and requires continued stockings, rest and exercise 62
    63. 63.  Swollen, dilated, tortuous veins  Dull aching  Muscle cramps  Increased muscle fatigue  Ankle edema  Diagnosis – duplex ultrasound 63
    64. 64.  Venous Thrombosis  Thrombus formation in a vein  May be deep (DVT) or superficial  Thrombophlebitis  Inflammation of a vein along with thrombus formation 64
    65. 65.  Thrombus- a blood clot in a blood vessel  Embolism- a clot that travels and blocks a vessel  DVT (deep vein thrombosis) – serious because it can cause a pulmonary embolism  DVT most common in legs but can occur in the upper extremities also  Thrombus formation is associated with Virchow’s Triad 65
    66. 66. 66
    67. 67.  Venous stasis  due to reduced blood flow  Injury to the intimal lining  creates site for clot formation  Hypercoagulability  increased tendency to clot 67
    68. 68.  Pain  Tenderness  Redness  Warmth  Palpable cord 68
    69. 69.  Pulmonary embolus  Chronic venous insufficiency  Venous stasis ulcers  Chronic edema 69
    70. 70.  Elevation of extremity  Warm compresses to area  Analgesics and possibly NSAIDS  Possibly antibiotics 70
    71. 71.  Active or passive leg exercises  Intermittent pneumatic compression devices  Compression stockings  Encourage post-op deep breathing  Avoid using pillows under knees 71
    72. 72. 72
    73. 73. 73
    74. 74.  Swelling or edema of involved extremity  Tenderness  Homan’s sign  Signs of pulmonary embolus  Chest pain  Hemoptysis  Dyspnea  Apprehension  Hypotension  Cardiac arrest 74
    75. 75. 75
    76. 76.  Results from faulty venous valves which allow reflux of blood  Venous pressure increases and venous stasis occurs. Edema also occurs.  Small veins rupture and RBCs escape into surrounding tissues.  Brown discoloration of tissues occurs  Stasis ulcers develop 76
    77. 77.  Swollen limb  Dry, itchy, coarse, leathery skin  Reddish brown skin on lower extremity above ankles  Stasis ulcers above ankles 77
    78. 78.  75% result from chronic venous insufficiency and 20% from PAD  Appear as an open, inflamed sore  Eschar may be present  Venous ulcers usually present above the malleolus  Arterial ulcers usually occur on or between toes 78
    79. 79.  Take long time to treat and heal  Venous insufficiency  Stasis dermatitis  Stasis ulcer  Over the malleolus (more medial than lateral)  If not controlled they can lose extremity 79
    80. 80. 80
    81. 81.  Claudication after walking short distance  Pain at ulcer site  Between or top of toes  Cold feet  Decreased or absent pulses  Possible gangrene  Atrophy of skin 81
    82. 82. 82
    83. 83. 83
    84. 84.  Wound culture  Oral antibiotics if infection present  Debridement of nonviable tissue  Surgical debridement  Enzymatic debridement  Wet to dry dressings  Calcium algenate dressings  Keep ulcer clean and moist while healing  Hydrocolloid dressing  Unna boot  Improve nutrition  Hyperbaric oxygen therapy (HBO) 84
    85. 85.  Inhibits platelet aggregation  Reduces ability of blood to clot  Contraindications  Allergy, GI bleed, bleeding disorder, children <18 with viral infection  Report  Signs of bleeding, petechiae, ecchymoses, bleeding gums, black or bloody stools 85
    86. 86.  Inhibits formation of new clots  Does not dissolve existing clot but prevents its extension  Contraindications  Active bleeding, hemophilia, thrombocytopenia, suspected intracranial hemorrhage  Monitor  H/H, platelets (prior and regular intervals), PTT  PROTECT FROM INJURY  Avoid IM injections  Report  Drop in BP, bleeding  ANTIDOTE  Protamine sulfate 1% sol (heparin antagonist) 86
    87. 87.  Anticoagulant  Prevention of DVT  Treatment of DVT, PTE, Acute Coronary Syndrome  Contraindication  GI bleed, active bleeding, bleeding disorder, thrombocytopenia  Monitor  H/H, platelets  Report  Signs of bleeding, drop in platelet count 87
    88. 88.  Prevents new clots from forming  Treatment of A-Fib  Prophylactic if prosthetic heart valve  Contraindications  Hemophilia, active bleeding, esophageal varices, severe hepatic disease  Antidote  Holding one or more doses, Vit K, blood transfusion may be needed  Monitor  PT, INR  Report  Bleeding (nose, mouth, gums, urine, stool)  Take at the same time each day  Maintain consistency in diet with Vit K foods (broccoli, cabbage, lettuce, green tea, spinach, tomatoes) 88
    89. 89.  Antiplatelet  Irreversible on platelets  Contraindications  Intracranial hemorrhage, active bleeding  Education  Discontinue one week before having surgery  Monitor  Signs of bleeding, platelet count 89
    90. 90.  Thrombolytic  For CVA patients within *3* hour time frame from onset of s/s  Contraindications  Active internal bleeding, recent surgery or trauma, bleeding disorder, use of oral anticoagulants, uncontrolled HTN  Monitor  Bleeding, neuro checks, cardiac rhythm  Education  IM contraindicated, no invasive procedures, quiet and on bed rest during administration 90
    91. 91.  Decreases blood viscosity and improves blood flow  Results in reducing tissue hypoxia, decreased pain and paresthesias  Contraindications  Intracranial bleed  Monitor  Relief from pain and cramping, improved walking tolerance 91
    92. 92.  Antidote for overdose of Coumadin  Contraindication  Severe liver disease  Monitor  Patient, PT/INR, Bleeding  IV route for emergencies only 92
    93. 93.  Antidote for heparin overdose  Used after stopping heparin  Contraindication- hypersensitivity to fish  Monitor- patient and vital signs 93

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