Peripheral Vascular Dz

• Smoking
• DM
• Hyperlipidemia
• Elevated CRP
• Uncontrolled HTN
• Family Hx
• Age
• Obesity
• Sedentary lifestyle
• Stress

• It is a non-atherosclerotic inflammatory dz of the small-medium sized arteries and veins.
• It affects the vessels of the upper and lower extremities
• It is mostly in young men who smoke cigarettes or marijuana.
•  - Can also occur from poor oral care (peridontal infections)

• Acute: inflammation and clot formation (thrombus)
• Chronic: (over time, thrombus becomes more organized, with lowered inflammation) Thrombosis and fibrosis occurs causing tissue ischemia. 
• s/s: intermittent claudication
•  - rest pain
•  - ischemic ulcerations
•  - skin (color, temp, paresthesias, cold sensitivity)

• Avoid: smoking, cold, sedentary 
• Meds: abx
•  - calcium channel blockers
•  - Cilostazol (antiplatelet) for intermittent claudication
•  - Sildenafil
•  - Iloprostal (vasodilator and most promising)
• Surgery:
•  - amputation
•  - symathectomy (the surgical cutting of a sympathetic nerve or removal of a ganglion to relieve a condition affected by its stimulation.)

• An episodic vasospastic disorder of small arteries, most often in fingers and toes.
• s/s: causes color changes to distal extremities
•  - when blood flow is restored, rubor occurs (throbbing, aching pain, tingling and swelling)
• Triggers: cold environments, stress, emotional upset
• Others: vibrating machinery, heavy metal exposure
• More common in women around 15-40

• Loose warm clothing (wool)
• Avoid extreme temps
• Protect from cold
• Avoid: tobacco, caffeine, cocaine, meth, pseudophedrine (nasal sprays)
• Manage stress
• Meds:
•  - calcium channel blockers
•  - For critical ischemia: iloprost, bosentan
• Surgery: sympathectomy for sever cases (the surgical cutting of a sympathetic nerve or removal of a ganglion to relieve a condition affected by its stimulation.)

• Class: Vasodilator
• Indication: Raynaud's 
• Adverse: hepatotoxicity
• Considerations: 
•  - monitor AST, ALT, bilirubin for liver dmg
•  - drug is contraindicated during pregnancy (birth defects) 
•  - men - decrease sperm count

3cm

• Thoracic: will have chest pain
•  - will show: JVD, hoarseness, dyspyhagia, etc., based on location of pressure
• Abdominal: may mimic MI, back pain, kidney/flank pain, epigastric pain.

• Small: no tx, prevent rupture. 
•  - identify and modify risk factors
•  - annual monitoring of size 
• Consider surgery when:
•  - >5.5cm
•  - expands too rapidly
•  - genetic disorder
•  - becomes symptomatic
•  - high risk of rupture

• 1. involves large abdominal incision, and cuts into diseased aortic segment
• 2. Remove any thrombus or plaque
• 3. Suture a synthetic graft into aorta
• 4. Then suture the native aortic wall around the graft

**surgeons will do an aortic cross-clamping that are proximal and distal to the aneurysm, this means if cross clamping is applied above renal arteries, there must be adequate renal blood flow after clamp removal. Assess for AKI**

• Indication: Abdominal Aortic Aneurysm (AAA)
• A flexible graft is inserted in both femoral arteries, which are released and deployed against the vessel wall by balloon.
•  - This diverts blood through the graft, causing the aneurysmal wall to shrink. 
• Complication: endoleak (seepage of blood back into the old aneurysm, caused by inadequate seal at either graft end, tear, or between overlapping graft segments. 
• Follow ups: pt. must have routine CT or MRI for the rest of their life to monitor for complications.

0-5

• It is a potentially lethal complication after an emergency repair of a ruptured AAA (abdominal aortic aneurysm)
•  - Intraabdominal HTN occurs (IAH), with associated abdominal compartment syndrome (ACS)
•  - ACS results in multisystem organ failure with a mortality rate up to 70%
• Confirmed: measuring patient's intraabdominal pressure indirectly through a cath and transducer system, typically using an indwelling urinary cath. 
• Tx: controlling IAH - raise HOB, hemodynamic instability, controlling pain and anxiety. 
•  - Be ready for vast fluid and blood replacement

• Assess peripheral perfusion: pulse assessment, skin color, temp, movement, etc.
•  - Use doppler if needed
• Renal perfusion status:
•  - urinary output
•  - fluid intake and daily weight
•  - CVP/PA pressure
•  - BUN/Cr

• Instruct pt to gradually increase activities
• NO heavy lifting
• Teach about s/s of infection, neurovascular changes

• Pain characterized as:
•  - sudden, sever pain in anterior part of chest or intrascapular pain radiating down spin to abd. or legs
•  - Sharp and "worst ever"
•  - May mimic MI
• Aortic arch: exibits neurologic deficits
•  - ALOC
•  - weakened or absent carotid or temporal pulses
•  - dizziness or syncope

• Cardiac Tamponade: occurs when blood from dissrection leaks into the pericardial sac
• Clinical manifestation: HYPOtension, narrowed pulse pressure, JVD, muffled heart sounds, and pulses parodoxus

• Initial goal: Lower BP and myocardial contractility to diminish pulsatile forces within aorta
• Drugs:
•  - IV Beta-adrenergic blocker (Esmolol)
•  - Other antihypertensives (calcium channel blockers, nitroprusside, ACE inh)
•  - Morphine

• Preop:
• Put in semi-fowler's
• Maintain quiet environment
• Manage anxiety and pain
• Administer IV HTN meds
• ECG and intraarterial pressure monitor
• Assess quality and changes of peripheral pulses
• Postop:
•  - Therapeutic regimen (HTN drugs and side effects)
•  - If pain returns, or s/s progress, instruct pt to seek immediate help

• From Chronic Venous insufficiency, it is described into 3 parts: 
• 1. venous stasis
• 2. damage of the endothelium (inner lining of the vein)
• 3. hypercoagulability of the blood

• Most common with women and older adults
• It occurs after DVT in 80% of cases
• s/s:
•  - swollen legs
•  - skin around ankles appear thick, coarse, red/brown
• Stasis dermatitis and ulcer

• No prolonged sitting or standing
• Avoid: prolonged sitting or standing, and leg crossing
•  - also avoid tight belts and socks
• Encourage: walking and leg exercises 
•  - Elevate legs and FOB
• Provide: elastic support hose or TED hose or Jobst stockings
• Assess: for infection and osteomyelitis
• Surgery: saphenous venous stripping
•  - amputation