Pad Vs Pvd Chart 5m7270

CHAPTER 38 Vascular Disorders TABLE 38-2

CHARACTERISTIC Peripheral pulses Capillary refill Ankle-brachial index Edema

Hair Ulcer Location

Margin

Drainage Tissue

Pain

Nails Skin color

COMPARISON OF PERIPHERAL ARTERY AND VENOUS DISEASE PERIPHERAL ARTERY DISEASE

Tips of toes, foot, or lateral malleolus Rounded, smooth, looks “punched out” Minimal

Near medial malleolus

Thin, shiny, taut

Skin temperature

Cool, temperature gradient down the leg Rarely occurs Rarely occurs

Dermatitis Pruritus

VENOUS DISEASE Present; may be difficult to palpate with edema <3 sec >0.91 Lower leg edema

Skin texture

COLLABORATIVE CARE

Peripheral Artery Disease Diagnostic

Decreased or absent >3 sec <0.70 Absent unless leg constantly in dependent position Loss of hair on legs, feet, toes

Black eschar or pale pink granulation Intermittent claudication or rest pain in foot; ulcer may or may not be painful Thickened; brittle Dependent rubor; elevation pallor

TABLE 38-3

875

Health history and physical examination, including palpation of peripheral pulses Doppler ultrasound studies Segmental blood pressures Ankle-brachial index Duplex imaging Angiogram Magnetic resonance angiography

Collaborative Therapy Hair may be present or absent

Irregularly shaped

Moderate to large amount Yellow slough or dark red, “ruddy” granulation Dull ache or heaviness in calf or thigh; ulcer often painful

Normal or thickened Bronze-brown pigmentation; varicose veins may be visible Skin thick, hardened, and indurated Warm, no temperature gradient Frequently occurs Frequently occurs

PAD, the Doppler can determine the degree of blood flow. A palpable pulse and a Doppler pulse are not equivalent, and the are not interchangeable. Segmental blood pressures are obtained (using Doppler ultrasound and a sphygmomanometer) at the thigh, below the knee, and at ankle level while the patient is supine. A drop in segmental BP of greater than 30 mm Hg suggests PAD. The ankle-brachial index (ABI) is performed using a handheld Doppler. The ABI is calculated by dividing the ankle systolic BPs by the higher of the left and right brachial systolic BP.17 A normal ABI is 0.91 to 1.30 and indicates adequate BP in the extremities. An ABI between 0.71 and 0.90 indicates mild PAD, between 0.41 and 0.70 indicates moderate PAD, and less than 0.40 indicates severe PAD. The ABI also is used after revascularization to monitor by graft patency. An ABI has limited usefulness when arteries are calcified and noncompressible, as occurs in patients with diabetes mellitus. In these patients, the ABI frequently is falsely elevated. Angiography and magnetic resonance angiography delineate the location and extent of PAD. In addition, they provide information on inflow and outflow vessels to plan for surgery (see Table 32-6).

Cardiovascular disease risk factor modification • Smoking cessation • Regular physical exercise • Achieve/maintain ideal body weight • Follow Dietary Approaches to Stop Hypertension (DASH) diet (see Table 33-7) • Tight glucose control in diabetics • Tight blood pressure control • Treatment of hyperlipidemia and hypertriglyceridemia (see Table 34-6) • Antiplatelet agent (aspirin or clopidogrel [Plavix]) • Angiotensin-converting enzyme inhibitors (see Table 33-8) Treatment of claudication symptoms • Structured walking/exercise program • Cilostazol (Pletal) • Pentoxifylline (Trental) Nutrition therapy Proper foot care (Table 49-22) Percutaneous transluminal balloon angioplasty with or without stent Percutaneous transluminal atherectomy Percutaneous transluminal cryoplasty Peripheral artery by surgery Patch graft angioplasty, often in conjunction with by surgery Endarterectomy (for localized stenosis but rarely done) Thrombolytic therapy (for acute ischemia only) Amputation

Collaborative Care Table 38-3 summarizes the collaborative care for a patient with PAD. Risk Factor Modification. Due to the high risk for MI, ischemic stroke, and CVD-related death, the first treatment goal is to aggressively modify CVD risk factors in all patients with PAD regardless of the severity of symptoms.9,29,30 Risk factors need to be modified not only with drug therapy but also with lifestyle changes on the part of the patient and caregiver (see Table 34-5). Nurse-led clinics have been effective for managing CVD risk factors with PAD.31 Smoking cessation is essential in the management of patients with PAD to reduce the risk of CVD events and mortality. Smoking cessation is a complex and difficult process with a high incidence of smoking relapse. All patients with PAD should have access to comprehensive smoking cessation interventions. (Tables 12-4, 12-5, 12-6, and 12-7 discuss smoking cessation.) Current guidelines recommend aggressive lipid management for all PAD patients with the following goals: low-density lipoprotein (LDL) less than 100 mg/dL, triglycerides less than 150 mg/dL, and high-density lipoprotein (HDL) greater than 40 mg/dL.9,29 Although dietary change is also recommended, this alone is unlikely to achieve these goals. Research indicates that treatment of PAD patients with a statin (e.g., simvastatin