Arterial Diff dx
Location- distal digits toes or fingers
Tissue- Dry, necrotic or slough, little or no granulation
Pain- Yes, may have dependent leg syndrome
Skin- Dry, hairless, shiny, thin
Exudate- none unless infected
Venous diff dx
Location- Lower 1/3 of leg gaiter area
Tissue- red pink, bark texture, yellow slough poor granulation
Pain- generally not unless vasculitic
Skin- hemosiderous (dark, browny appearance)
Exudate- Varies may have copious serous drainage
Pressure diff dx
Location- over bony prominences
Tissue- varies from dark to red to eschar
Pain- varies depending on structures involved
Skin- macerated, wet, erythematous
Exudate- varies
Neuropathic diff dx
Location- Weight bearing surface of foot or dorsal digits
Tissue- Callus or blister, slough, may probe to bone, necrotic with PAD
Pain- NO PAIN until infected deep throne
Skin- Dry, thick, scaly,
exudate- varies depending on infection
Critical Limb Ischemia
Reduction in distal tissue perfusion below resting metabolic requirements
Usually associated with atherosclerosis
1st Critical Phase
Initially, circulatory system compensates by forming collateral circulation around occlusions to maintain blood flow
1st critical phase
Collateral circulation is insufficient for needs of the extremity
The limited blood supply goes to the muscles vs. the skin
A wound formed in this phase may be slow to heal and is more likely to become infected
The non-healing wound may be the first indication of PAD
2nd Critical Phase
Occurs when activity causes relative ischemia and pain
Intermittent claudication – muscle pain/cramping w/ exercise
Pain w/ exercise may be the second indication that the pt has PAD
3rd Critical Phase
Sever Ischemia
- Resting pain
- Gangrene
- Non healing wounds in the extremity distal to the occlusion
- Dependent leg syndrome
Phases of PAD
-Phase 1: insufficient collateral circulation for metabolic needs
Delayed healing of wounds on distal extremity
-Phase 2: insufficient muscle perfusion with exercise
Intermittent claudication with exercise
-Phase 3: severe ischemia
Rest pain
Dependent leg syndrome
Distal digit ischemia
Diagnostic tests non-invasive
Pulses
Doppler Exam of pulses
Capillary Refill Time
Rubor of Dependency
ABI
Toe Pressures
Transcutaneous oxygen perfusion
Diagnostic test
Palpate pulses – compare to the contralateral limb
Confirm with hand-held Doppler
2 scales: A: Scale of 0 to 3+ 0: Absent 1+: Diminished pulse 2+: Normal pulse 3+: Pathologically prominent pulse (severe aortic insufficiency of aneurysm)
B: Scale 0 to 4+ 0: Absent 1+: Faint but detectable 2+: Diminished pulse 3+: Normal pulse 4+: Bounding pulse
Capillary Refill Time
- Estimation of microvascular disease
- Press the end of the toe or the skin just proximal to the wound until the color disappears and then measure time for return of original color
- Normal: <3 sec
- BUT this varies greatly
- Screening test to indicate if further test might be needed
Rubor of Dependency
- Screening for ischemia, not definitive for PAD
- Extremity is elevated and observed for pallor
- Foot is then returned to a dependent position
- Normal: color returns within 15 sec
- Severe ischemic disease: color takes 30 sec or more and is dark red vs healthy pink
Ankle Brachial index
Right ABI= Higher of the R ankle systolic pressures/Higher brachial systolic
Left ABI= Higher of the L ankle systolic pressures/ Higher brachial systolic
1-1.2- normal
.8-1.0: minimal peripheral arterial
.5-.8: moderate peripheral arterial disease, often with intermittent claudication;compression is contraindicated if
Segmental pressures
Give an initial indication of location of arterial occlusive lesions
May be falsely elevated in pts with calcified arteries
Toe Pressures
Used in pts w/ calcified vessels or abnormally high ABI
Similar procedure to ABI, but done in the toe
Arteriogram
Radiographs of vascular system after injection of radiopaque dye
Used to determine specific site of lesion prior to bypass surgery
Buerger disease
Also known as thromboangiitis obliterates
Disease of macro vascular circulation
Occurs in feet and/or hands
More common in men, especially heavy smokers
Pathology
–Inflammation of the peripheral arteries with thrombi and vasospasm
Treatment before revascularization
- Do not debride—> Why?
- Leave intact eschar alone
- Debride wet gangrene (infected tissue)
- Keep area dry; protect toes with cotton or sterile gauze between toes
- Use foot cradle and off-load heels
- Discourage limb elevation and elevate head of bed 5-7 degrees Why?
- Keep extremity warm
- Avoid excessive exercise Why?
Open bypass
- Take the saphenous vein from the ipsilateral limb and use it to bypass the stenosed or occluded area
- Advantage: establishes direct blood flow to the area of tissue loss
- Disadvantage: Length of surgery, need to harvest vein (pt may not even have one due to a previous CABG surgery); lifelong monitoring
Revascularization
Angioplasty w/ and w/out stent
-Threads a catheter through the artery and uses a balloon to open it up
-A stent will be put into place by the balloon
Advantages:
-Excellent for pts who may not be surgical candidates
-Shorter recovery time
Disadvantages: Less durable; artery may close again (w/ or w/out stent)
Treatment after revascularization
- Debrede wound of necrotic tissue when granulation tissue is visible at the edges
- Provide moist wound environment
- Protect foot with pillows under calves
- Off-load wound with orthotic, special shoes, assistive device
- Control post-op edema to prevent incisional dehiscence
- Cover incision w/ dry sterile gauze or thin foam
- Apply short stretch bandage in spiral wrap
