1. CARDIOVASCULAR MODULE: ARTERIAL OCCLUSIVE DISORDER Adult Medical-Surgical Nursing

2. Peripheral Arterial Occlusive Disorder is a disruption of the peripheral arterial circulation obstructing the flow of oxygenated blood to the tissues It may occur as an acute emergency It may be gradual, progressive and chronic Arterial Occlusive Disorder: Description

3. Acute Peripheral Vascular Occlusion:

4. Acute Vascular Occlusion: Aetiology The artery is blocked by: An embolism (the most frequent cause) from: An aneurysm Infective endocarditis Myocardial infarction Mitral valve disease/ atrial fibrillation Prosthetic heart valves Localised trauma

5. Acute Vascular Occlusion: Pathophysiology An embolism from the left side of the heart or from an aneurysm passes to the peripheries: (the limbs or mesenteric arteries) The embolism lodges at a site of arterial branching or atherosclerotic narrowing* This impairs or cuts off the blood supply distal to the occlusion → ischaemia May lead to infarction of the tissue (*Also a thrombus may form at an atherosclerotic site with the same result)

6. Clinical Manifestations Sudden onset of: (6 “p” s) Pain Pallor Pulselessness Paraesthesia Paralysis Poikilothermia (cool to touch) → tissue discoloration of affected limb → gangrene

7. Acute Vascular Occlusion: Diagnosis Acute emergency Diagnosis from history and clinical picture Doppler Ultrasound

8. Emergency Treatment Early treatment to remove embolus/clot and re-establish circulation Anticoagulation to prevent further extension of clot or more emboli Embolectomy by balloon catheters distal and proximal to clot or Surgery: “Thrombo-endarterectomy”: removal of embolus, and stent or graft to keep artery patent Thrombolytic drug may be possible if very recent Anticoagulants or anti-platelet aggregation drugs long-term

9. Follow-up and Long-term Care Follow-up angiogram to ensure full patency Long-term anticoagulant or antiplatelet therapy (to prevent recurrence) INR during anticoagulation Treat the cause if appropriate

10. Nursing Responsibilities ICU post-op: Bedrest with initial immobility of the affected limb Monitor anticoagulant therapy Monitor vital signs and fluid balance Monitor: Colour, temperature, sensation, mobility and pulses of affected limb post-operatively* Observe arterial wound dressing very carefully (risk of major haemorrhage)

11. Chronic Peripheral Arterial Occlusive Disease (PAD):

12. Chronic PAD: Description A progressive insidious narrowing and eventual occlusion of the peripheral arteries to the extremities, usually the legs Occurs in men more than women Age group 60 - 80 years Arteries affected are aorto-iliac, femoral, popliteal, tibial, peroneal

13. Chronic PAD: Pre-disposing Factors Smoking (most important)* Hyperlipidaemia Hypertension Diabetes Mellitus (macrovascular disease – accelerated atherosclerosis) Obesity and sedentary lifestyle Family tendency

14. Chronic PAD: Pathophysiology Atherosclerosis: Leads to gradual thickening of the intima and media of the arteries and narrowing and occlusion of the vessel lumen Tends to be segmented with good patches between atherosclerotic narrowing Gradual development of collateral circulation because of increasing ischaemia to distal tissues Ischaemia can lead to ulceration and gangrene (although collateral circulation may prevent this)

15. Chronic PAD: Clinical Manifestations Note: When symptoms occur there is already 75% narrowing of the arteries

16. Chronic PAD: Clinical Manifestations Calf pain on exercise “intermittent claudication” (lactic acid formation) → later: Pain at rest (mainly feet and toes from nerve ischaemia) Pain is felt more at night Pain relieved by legs dangling below the patient to increase the blood supply by gravity

17. Clinical Manifestations (continued) Paraesthesia: Numbness and tingling, burning Shooting pains to toes and feet Pallor: blanching on elevation Hyperaemia: red or bluish dusky skin when limbs dependent Shiny skin with loss of hair Pulses weak or absent Skin and tissue atrophy: poor healing Ischaemic ulcers on bony toes → gangrene

18. Chronic PAD: Diagnosis Doppler ultrasound: velocity of blood flow Duplex imaging: Doppler mapping Segmental BP: (at thigh, calf, ankle): should be the same as brachial. As disease progresses leg BP ↓ Angiography: aorta and femoral arteries assessed prior to intervention or surgery MRI

19. Chronic PAD: Management This a chronic progressive disease formerly with no treatment apart from palliative care Vasodilators Analgesia Exercise encouraged as condition allows Surgery* may be considered for severe and disabling claudication to avoid risk of amputation: Endarterectomy, By-pass Graft or Stent (the patient’s overall health is an important consideration)* Anti-platelet cover if graft/ stent

20. Chronic PAD: Nursing Considerations Gentle exercise encourages development of collateral circulation Encourage to avoid smoking Avoid obesity Keep feet and legs warm and clean Observe for potential ulcers If surgical intervention: post-operative initial immobility of affected limb Special monitoring of pulses, colour, sensation and temperature of both limbs (to compare)