Peripheral Vascular Disease
What are symptoms of varicose veins?
Dull ache, heaviness, fatigue with prolonged standing Increased pressure with dependent position Leg cramps, especially at night, that is relieved with elevation
What are symptoms of LE venous thrombosis?
Dull ache, tightness, edema Dilation of superficial vessels Localized temperature, erythema, induration (increase in fibrous tissue) Low grade fever, tachycardia
What are the implications for a PT when working with vasculitis thromboangiitis obliterans (Buerger disease)?
EARLY identification of symptoms and medical referral Encourage smoking CESSATION All other treatment techniques are aimed at improving circulation to the feet and hands: Peripheral neuropathy (altered sensations and burning pain) Functional losses accompanied with muscle weakness and atrophy Graded exercise to avoid or decrease claudication Pain control through relaxation techniques, TENS, and biofeedback Minimize chronic steroid use side effects through exercise, proper nutrition, and medications to decrease bone loss also
What are clinical manifestations of thromboangiitis obliterans (Buerger disease)?
EPISODIC and SEGMENTAL (comes and goes in different areas) FIRST SIGN: Intermittent claudication centered in the foot arch and palm of the hand Burning, rubor (redness), cyanosis, and pain with rest Diminished or absent distal pulses Thin, shiny, hairless skin Paresthesia, ulceration, edema, and gangrene
Compare how DVT clinically manifests early on, and between the LE and UE.
In the early stages, approximately half of the people with DVT are asymptomatic for any signs or symptoms in the affected extremity The LEs appear to be affected most often (more than 90%) but UE venous thrombi can also develop
What are the 3 primary categories of common peripheral vascular diseases?
Inflammatory Arterial occlusive Venous
What is the pathogenesis of thromboangiitis obliterans (Buerger disease)?
Inflammatory lesions of the peripheral blood vessels are accompanied by thrombus formation and vasospasm occluding and eventually obliterating small and medium-size vessels of the FEET and HANDS
What are the 3 categories of inflammatory PVD?
Polyarteritis Nodosa Giant Cell Arteritis Thromboangiitis Obliterans
Specific symptoms of polyarteritis nodosa are dependent on what?
The end organ(s) involved
What is the cause of polyarteritis nodosa? What other conditions is polyarteritis nodosa associated with?
UNKNOWN cause, but is associated with infections Also most commonly associated with IV drug abusers, HIV, Hepatitis B, and C, and older age
What is the most common inflammatory blood vessel disease in therapy practice?
Vasculitis
What blood vessels do vasculitis affect?
Vasculitis can involve blood vessels of ANY size, type, location, and can affect ANY organ system, including the nervous system
Describe the pathway for thrombus formation.
(This is the SAME for any part of the body) Venous stasis (inflammation of the skin in the lower legs), hypercoagulability, and/or venous wall injury causes the formation of a thrombus This causes blood vessel damage, which causes inflammation, which makes veins more sclerotic and less compliant from scarring, which then causes valve damage, which causes blood to regurgitate This increases risk for future deep vein thrombosis and venous insufficiency
What are the THREE results of thrombus formation?
1) The blood clot dissolves on its own, with or without medication 2) The blood clot extends, becomes stable and must be surgically removed, which results in a damaged vein 3) The blood clot is released as an embolus and travels to the lung to occlude a particular area
What percentage of deep vein thrombosis is idiopathic?
50%
What percentage of blockage usually occurs before symptoms even start for arterial occlusive disease?
50-70% (It is a slow, progressive disease as a result)
About what percentage of suspected DVTs turn out negative?
75%
What symptoms are common with polyarteritis nodosa of nerves?
75% have peripheral neuropathy Also includes paresthesia, pain, weakness, and sensory loss, involving many peripheral nerves at once
What is vascular inflammation a central feature of?
Central feature of many rheumatic diseases, especially rheumatoid arthritis and scleroderma
What are some consequences of venous insufficiency?
Decreased return of venous blood from loss of calf muscle pump Bidirectional blood flow instead of unidirectional towards the heart Results commonly in venous hypertension and LE edema Causes inadequate oxygenation, waste removal, with chances of ulceration to tissue
What is peripheral artery occlusive disease (or peripheral arterial disease)?
Defined as an arteriosclerosis in which proliferation of the intima has caused complete obliteration of the lumen of the artery
What do the symptoms of PVD depend on?
Depend on underlying physiology, vessels involved, and the location of the vessels
How is polyarteritis nodosa medically managed?
Diagnosis: Labs, biopsy, imaging Treatment: Long-term steroids Immunosuppressants (Withdrawal from these drugs is often followed by relapse though)
What are the implications for physical therapy with polyarteritis nodosa?
Early recognition with provider referral (identify the signs to prevent poorer survival rates) SLOW progression of conditioning and strengthening Teaching energy conservation Skin care, wound care, positioning, breathing techniques, and pain control
Does elevation alleviate or increase symptoms of peripheral artery occlusive disease?
Elevation INCREASES pain (Because of the already poor circulation)
What are the Wells Clinical Decision Rules (Wells Risk Assessment Tool)?
Evidence-based tool used to screen and estimate the probability that DVT is present
Why are anticoagulants also very risky?
Falls can kill someone who is on anticoagulants Patients MUST be educated or trained with fall prevention because someone on anticoagulants can bleed out very easily
How is thromboangiitis obliterans (Buerger disease) treated?
Focus is on increasing circulation to the foot and hand Treated through smoking cessation and avoiding secondhand smoke Use of medications (vasodilators, pain meds) Amputation or wound care (physical therapy)
Is venous occlusive disease more common in the LE or UE?
LE/pelvis is more common than UE (UE can be more severe though)
What are the screening physical therapy implications for peripheral arterial occlusive disease?
MUST have a thorough history, screening, and tests and measures Can use exercise tolerance testing with an established training heart rate Utilize prescriptive graded/treadmill protocols Capillary refill and skin assessments Comparison of pedal pulses for all patients greater than 55 Take blood pressure Ankle Brachial Index (ABI)
What is the relationship between surgery and DVT?
Major surgeries that are more invasive and long are risk factors for DVT If the DVT occurs, most of the time it appears after inpatient discharge (making it dangerous)
What are treatments for DVT?
Medications like anticoagulants (blood thinners) to prevent formation/extension of thrombus and to promote fluid movement Mobility while in bed WITH COMPRESSION (TEDs compression stockings) Ambulate post medications and compression Compression must be applied while ambulating or upright to promote fluid movement
Giant cell arteritis is most common in what ages? What demographic is most likely?
More common in older adults Primarily in women aged 70-79
What visceral organs does peripheral vascular disease most commonly affect?
Most often affects the blood vessels supplying the intestines and kidneys
What are the primary target organs of vasculitis?
Muscle and peripheral nerve Skin, testicle, and kidney The CNS (less often)
How life-threatening is thromboangiitis obliterans (Buerger disease)?
NOT life-threatening, but does lead to poor quality of life and is a progressive disability with pain
What is a normal capillary refill rate?
Normal is less than or equal to 2 seconds
The symptoms of arterial occlusive diseases depend on the location. Compare the symptoms of: Occlusive cerebrovascular disease Occlusive disease in the intestines Occlusive coronary disease
Occlusive cerebrovascular disease: Weakness, dizziness, blurred vision, CVA Occlusive disease in the intestines: Acute intestinal ischemia or ischemic colitis (ischemia to colon/large intestine) Occlusive coronary disease: Angina, MI, arrhythmia
What demographic is thromboangiitis obliterans (Buerger disease) commonly found in?
Often found in males under 40 who are heavy smokers (Incidence in women is increasing)
What are some moderate risk factors for DVT?
PREGNANCY/post-partum Arthroscopic knee surgery Central venous lines Chemotherapy Heart failure and respiratory failure Hormone replacement therapy Thrombophilia (tendency to form clots) and previous thromboembolism Malignancy Oral contraceptives CVA Smoking
What are some implications of DVT to a PT's practice with that patient?
PT should be careful with soft tissue mobilization, manual therapy, modalities, and wound care/debridement PT should implement deep breathing/coughing exercises and ROM PT should educate patients on anticoagulants about fall prevention and should keep compression stockings (not TEDs) on the patient for 6-8 weeks (or longer) post-DVT
What is inflammatory PVD?
PVD often triggered by immunologic conditions (autoimmune disease), that leads to inflammation Inflammation leads to damage to large and small vessels (arteries/veins), which then causes ischemia, which causes end-stage organ damage
Describe the pain that patients suffering from peripheral artery occlusive disease experience.
Pain with elevation Pain at night Pain at rest
What are 5 STRONG risk factors for DVT?
Pelvis or LE fracture Total hip and knee replacements Major general surgery Major trauma Spinal cord injury
What symptoms are common with polyarteritis nodosa of the heart?
Pericarditis (inflammation of pericardium), myocarditis (inflammation of cardiac muscle), arrhythmias, and myocardial infarction
What is the most common arterial occlusive disease?
Peripheral arterial disease It accounts for about 95% of cases
What is the leading cause of disability for people over 60 years old?
Peripheral vascular disease
What symptoms are common with polyarteritis nodosa of the respiratory tract?
Pneumonitis (inflammation of lung tissue), sinusitis (inflammation of the sinus cavities)
What are common comorbidities with Giant cell arteritis?
Polymyalgia rheumatica, hypertension, spine pain, and osteoporosis
How is Giant cell arteritis diagnosed?
Primarily made with symptom identification Also with ultrasonography, PET and CT scans, and lab work
What are arterial occlusive diseases?
Progressive systemic disease in which the arteries throughout the body gradually become narrowed, and is primarily caused by atherosclerosis
What value on ABI indicates a diagnosis of peripheral arterial disease?
Ratio < 0.90 at rest = PAD This indicates increased arterial narrowing, which causes a progressive fall in systolic pressure distal to the sites of involvement
What is polyarteritis nodosa?
Refers to a condition consisting of MULTIPLE sites of inflammation and destructive lesions in the arterial system The lesions are small masses of tissue in the form of NODES or projections
What is peripheral vascular disease? (PVD)
Refers to pathological conditions of blood vessels (arteries and veins) Involves vessel damage that leads to decreased blood flow, that leads to complications and damage to areas fed by those blood vessels, ultimately causing inflammation, trauma, and arterial stiffness as a result
What are physical therapy implications for PAD when it comes to screening, forming exercise programs, protection, and education?
Screen idiopathic back/buttock/LE pain (spontaneous, unknown cause pain) Make a progressive conditioning program (and measure HR, BP, angina, claudication) while increasing speed, incline, and changing the walk surface as appropriate Avoid chill/prolonged cold exposure or heat modalities Protect and promote skin care Educate the patient to position themselves correctly (don't cross the legs, don't elevate LE)
What position should patients with DVT particularly avoid?
Should avoid prolonged sitting and standing (don't want to enhance blood pooling and more vein dysfunction)
Describe how prescriptive/graded treadmill protocols are used for peripheral arterial occlusive disease.
Start with a walking speed of 2 mph and increase the grade by 2% every 2 minutes Record the time it takes for the patient to start experiencing pain and their maximum walking time (when claudication occurs) See if there is anginal pain, and if there is, decrease intensity
Widespread arterial disease leads to increased risk of what other conditions?
Stroke (CVA) and MI
What are the two types of venous thrombosis?
Superficial and deep
How can a PT education a patient with DVT?
Teach patient to avoid static positions for long periods of time Teach patient to avoid pillows under LE post-op and elevate to just above heart level
What is venous insufficiency?
The one-way valves of the veins are damaged, do not close correctly and entirely as a result, allowing venous blood to regurgitate and backflow into the distal extremity, resulting in inadequate venous return over a long period of time This follows most severe cases of DVT
What are clinical manifestations of Giant cell arteritis?
The onset of this disease is SUDDEN and SEVERE It manifests itself as continuous, unilateral throbbing headaches (temporal/scalp, jaw), and cervical pain Flu-like symptoms with possible permanent visual disturbances (BLURRING leading to BLINDNESS) without treatment A tender temporal artery, jaw claudication with chewing, talking, and swallowing Radiating pain to occipital area, face, and side of the neck
Differentiate between what the superficial and deep thrombosis of the LE comprise.
The superficial veins in the LE are comprised of the great (long) and small (short) saphenous veins The deep veins in the LE are divided into proximal and distal: Proximal deep veins: popliteal, superficial femoral, deep femoral, common femoral, and external iliac veins Distal deep veins: anterior tibial, posterior tibial, and peroneal veins
What is thrombophlebitis?
The swelling of a vein because of a vein wall inflammation occurring as a result of thrombus (blood clot) in the vein
What is giant cell arteritis?
This is a vasculitis primarily involving multiple sites of temporal and cranial arteries of the head and neck, caused by an autoimmune response in vessel walls, where vessel walls become inflamed
What are the three types of acute venous occlusion diseases?
Thrombophlebitis Deep vein thrombosis (DVT) Pulmonary embolism (PE)
Differentiate between the consequences of proximal and deep veins associated with venous thrombosis.
Thrombosis of proximal deep veins carries an increased risk of severe consequences, like pulmonary embolism Thrombosis of distal deep veins is more built up and can be silent
What are other causes of arterial occlusive diseases other than atherosclerosis?
Trauma, thrombus/embolus, vasculitis, vasomotor disorders, complex regional pain syndrome, arterial punctures, polycythemia
Is arterial occlusive disease life-threatening?
Typically not if the blockage occurs in the LEs It just results in a significant decrease in quality of life
Chronic artery obstruction commonly leads to what?
Vessel collateralization (homeostasis) This is the growth of a blood vessel or several blood vessels that serve the same end-organ or vascular bed as another blood vessel, but cannot adequately supply that end-organ or vascular bed sufficiently like the main artery could
What gender suffers from LE varicose veins more often?
Women are affected with leg varicosities more often than men until age 70
What is thromboangiitis obliterans (Buerger disease)?
A vasculitis of unknown cause that affects the peripheral blood vessels (both arteries and veins) primarily in the extremities
What is claudication?
A condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries
What is venous thromboembolism (VTE)?
A condition that includes BOTH deep vein thrombosis (DVT) and pulmonary embolism (PE)
What is vasculitis?
A group of disorders that share a common pathogenesis of inflammation of the blood vessels, involving arteries, veins, or nerves, resulting in narrowing or occlusion of the lumen or formation of aneurysms that can rupture
What symptoms are common with polyarteritis nodosa of the GI tract?
Abdominal pain, nausea, and vomiting
How much compression should be applied for a patient with DVT while ambulating or upright?
About 20-30 mmHg of increased pressure/distention
What are general symptoms of polyarteritis nodosa?
Abrupt fever and chills Tachycardia Arthralgia (joint stiffness) Myositis (inflamed muscles that are tender with palpation)
What are the two types of venous occlusion disease?
Acute and Chronic
What body parts does peripheral vascular disease most commonly affect?
Affects the blood vessels supplying the extremities and major abdominal organs LE is more common than the UE
What are varicose veins?
An abnormal dilation/distension of superficial veins, usually the saphenous veins of the LEs, that leads to tortuosity (twisting and turning) of the vessels, valve incompetence, and a propensity to thrombosis The failure of the valves causes blood to pool in superficial veins
What blood pressure measures would act as a red flag for peripheral vascular disease?
An unexplained 10-15 point difference in SBP between the left and right UEs This indicates a red flag for PVD of the UE/LE and necessitates a provider referral
What are the three complications of polyarteritis nodosa?
Aneurysm Hemorrhage Thrombosis
How is Giant cell arteritis treated?
Anti-inflammatories, steroids, methotrexate (autoimmune suppressor) With treatment, this condition is self-limiting for 6-12 months BUT there is about a 30% relapse with a 1 year taper off these drugs
Arterial PVD is most common the result of what other condition?
Atherosclerosis
What is the Ankle Brachial Index (ABI) and how is it used?
BP is measured on the unilateral UE and dorsal pedis or posterior tibialis with the client supine Systolic ankle pressure is DIVIDED by brachial systolic pressure (where a normal value = 1)
What are some weak risk factors for DVT?
Bed rest greater than 3 days Varicose veins Immobility due to sitting Increasing age Obesity Pregnancy/antepartum (before labor onset)
Varicose veins develops between what ages for all persons?
Between 30-50 years old
What are ways to diagnose thromboangiitis obliterans (Buerger disease)?
Biopsy, angiography Testing amino acid levels (homocysteine) Associated with increased risk of atherosclerosis
What is the most common vasculitis in the US?
Giant cell arteritis
What is the mortality rate of esophageal varices?
HIGH mortality rate with rupture It needs surgery before it ends up in a rupture and potentially kills someone
What are some preventative methods against arterial occlusive disease?
Healthy diet Daily prescribed exercise before tissue breakdown Collateralization improves with stress to tissue (exercise leading to more circulation) Skin care and limb protection to avoid injury Stop smoking
Polyarteritis nodosa becomes more complicated when combined with what other condition?
Hepatitis B (Medications exacerbate the hepatic disease)
What are side effects of vasculitis medications?
Hypertension, diabetes, bruising/bleeding Osteoporosis Muscle atrophy, increased potential tendon rupture Delayed tissue healing Decrease in inflammatory response Weight gain with increased appetite Hair loss, glaucoma
What is the relationship between suspecting DVT and post-casting the LE?
If someone has been immobilized for several weeks, and then a cast comes off, you are expecting to see atrophy in the immobilized area If you don't see atrophy, but instead see the same circumference or one that is about 1 cm larger than the uninvolved side, then you should suspect edema with DVT
What primary LE blood vessels are affected by peripheral artery occlusive disease?
Iliac, popliteal, tibial, common peroneal arteries
What are the risk factors involved in thrombophlebitis?
Immobility Trauma, lifestyle, hypercoagulation, diabetes
What is intermittent claudication?
Impairment in walking, or pain, discomfort or tiredness in the legs that occurs during walking and is relieved by rest, usually caused by lack of blood flow (peripheral artery disease) It is most common in the calves but it can also affect the feet, thighs, hips, and glutes
What is the first sign of thromboangiitis obliterans (Buerger disease)?
Intermittent claudication centered in the foot arch and palm of the hand
What are other symptoms of peripheral artery occlusive disease?
Intermittent claudication with exercise, standing, and walking (weakness, tiredness, cramping, and pain specifically in the foot, calf, thigh, and glutes) that is relieved by rest Cool body temperature Muscle weakness and muscle spasm Skin changes (tight, shiny, pale, hairless skin) Tissue instability and breakdown (minor injuries become unable to heal) Can lead to chronic wounds, gangrene, and amputation (because of lack of healing from lack of circulation)
