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Atherosclerotic wall weakening in complicated lesion abdominal aorta

Abdominal Aortic Aneurysm (AAA)

Thoracic Aortic Aneurysm (front view)

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A sac or dilation formed at a weak point Abnormal localized permanent dilatation of a blood vessel One or all three layers may be involved May rupture and lead to death Sometimes classified by gross appearance as fusiform or saccular

False aneurysm Blood escapes into connective tissue, outside of arterial wall

Fusiform aneurysm Symmetric, spindle-shaped expansion Involves entire circumference

Saccular aneurysm Out-pouching on one side only

Dissecting aneurysm Separation of arterial wall layers that fills with blood

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Occurs most frequently in men, 50 70 yrs of age Etiology atherosclerosis, hypertension, infection 1/3 die from rupture
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Vasculitis, syphilis, traumatic (automobile accidents), collagen vascular disease (Marfan's syndrome), smoking S/S depend on size and rate of growth

Substernal pain, dyspnea, neck or back pain

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May be asymptomatic Chest pain Dyspnea, hoarseness or dysphagia Distended neck veins and edema of head and arms

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Imaging Must be differentiated from other diagnoses (lung neoplasm, mediastinal masses). CT scan and MRI very sensitive to assess. Treatment Controlling HTN and Beta Blockers may slow growth. Surgery is for patients that have symptoms, >5cm, or rapidly expanding size. Morbidity and Mortality higher than with AAA

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Chest xray Transesophageal echocardiogram CT scan

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Control underlying hypertension Surgical repair Resection of aneurysm and replacement with graft Repair with endovascular graft

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Depends on type and location Cardiopulmonary bypass required Thoracotomy or median sternotomy incision Graft goes over the aneurysm

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Occurs more frequently in Caucasians, more in men and elderly clients Etiology atherosclerosis, hypertension, trauma, infection, congenital abnormalities in vessels, genetic predisposition Most are infrarenal
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Approximately 60% of clients are asymptomatic Pulsatile mass in the upper and middle abdomen Abdominal or low back pain Bruit may be heard Diminished femoral and distal pulses Patchy mottling of feet and toes
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Imaging Abdominal U/S for screening and monitoring progression Abdominal CT scan to specifically measure size and its relationship with the renal arteries

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Abdominal ultrasound CT scan, MRI

The aortic abdominal aneurysm has an intramural thrombus, and its size is approximately 6.7 cm in diameter. The true lumen of the aorta is indicated by the arrowheads.
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If small, monitor every 6 months Keep BP down Preoperatively Cardiac evaluation must be done Cardiac interventions may need to be done before repair of aneurysm Treatment For >5cm surgical intervention with graft replacement If symptomatic surgical treatment must be immediate regardless of size Stent grafts are treatment Inserted through common femoral arteries Less than 2 hours, minimal blood loss May need more complicated repair depending on patient condition

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Complications Myocardial infarction, bleeding, limb ischemia, bowel infarction, renal insufficiency, stroke Graft infection and graft fistulas can occur Endoleak Some patients will develop another aneurysm in another location
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For high risk surgery patients Before aneurysm reaches diameter for elective surgery Inserted through femoral artery Decreased length of stay in hospital Still need monitoring for complications

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Pre-repair

Post-repair
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Popliteal make up approximately 85% of peripheral artery aneurysms Symptoms due to arterial thrombosis, peripheral embolus, compression of adjacent structures U/S used for diagnosis and measurement Surgery >2cm if asymptomatic and for all symptomatic regardless of size Femoral Pulsatile groin masses Same problems as popliteal
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Occurs from vascular damage, involved in coronary and cerebral vascular disease

Stable plaque Unstable plaque

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Arterial Manifestations:

Venous Manifestations:

Diminished or absent pulses Smooth, shiny, dry skin, no hair No edema Round, regularly shaped painful ulcers on distal foot, toes or webs of toes Dependent rubor Pallor and pain when legs elevated Intermittent claudication Brittle, thick nails

Normal pulses Brown patches of discoloration on lower legs Dependent edema Irregularly shaped, usually painless ulcers on lower legs and ankles Dependent cyanosis and pain Pain relief when legs elevated No intermittent claudication Normal nails
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Modifiable Cigarette smoking Obesity Diabetes Mellitus Physical Inactivity High Cholesterol High Blood Pressure

Non- Modifiable Personal or family history Heart disease History of stroke Age Male

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Disorders that interfere with natural flow of blood through peripheral circulation Patients can have arterial and venous disease Chronic condition Systemic manifestation of atherosclerosis
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Inflow located above the inguinal ligament may not cause significant damage Outflow below superficial femoral artery typically cause significant damage

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Intermittent claudication pain with ambulation that stops with rest Inflow disease discomfort in buttocks, lower back and thighs Outflow disease burning or cramping in ankles, feet, toes and calves, resting pain
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Blood pressure checks in both arms Palpate pulses and compare with opposite side Capillary filling time Inspect extremities for edema, discoloration, loss of hair, temperature differences, ulcers Observe for intermittent claudication with ambulation
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Stage I Asymptomatic No claudication Pedal pulses affected Stage II Claudication Pain or burning with exercise but relieved with rest Symptoms reproducible by exercise
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Stage III Resting Pain Awakens patient at night Numbness or burning quality Relieved with extremity in dependent position Stage IV Necrosis/Gangrene Gangrenous odor Ulcers and necrotic tissue
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Systolic blood pressure readings Exercise tolerance testing Plethysmography Non-invasive technique for measuring the amount of blood flow present or passing through, an organ or other part of the body Used to diagnose deep vein thrombosis and arterial occlusive disease
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Non-surgical Exercise Patient positioning Medication Angioplasty Arthrectomy non-surgical procedure to open blocked coronary arteries or vein grafts by using a device on the end of a catheter to cut or shave away atherosclerotic plaque
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Surgical Bypass (inflow and outflow) Aortoiliac and aortofemoral bypass Axillofemoral bypass

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Embolus is most common cause Affects both upper and lower extremities History of recent MI or a-fib Severe pain even resting Temperature cool, mottled and no pulse Immediate intervention needed to prevent loss of extremity Treatment thrombectomy Must observe extremity for improvement of condition also for complications
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Pathophysiology blood clots from arteries, left ventricle, or trauma suddenly break loose and become free flowing, lodge in bifurcations, causing obstruction distally with acute and sudden symptoms Assessment 6 Ps pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia inability to control temp ABI (ankle-brachial index) <1 U/S MRI Angiography
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Decreased Ankle-Brachial Index (ABI) 0.50 to 0.95 indicates mild to moderate insufficiency 0.25 or less indicates severe Ankle pressure = ABI (normally 1.0) Brachial pressure
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Medical Anticoagulants - heparin bolus then 1000 U/hr Thrombolytics Surgical (depends on occlusion time) Embolectomy Bypass Angioplasty with stent placement

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Pathophysiology Obstructive and inflammatory disease of small and medium sized arteries and veins Believed to be autoimmune Has exacerbations and remissions Smoking is very high risk factor Assessment Pain and instep claudication Intense rubor Absence of distal pulses (pedal, radial, ulnar) Paresthesias Segmental limb blood pressures U/S Angiography
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Medical/Surgical Pain meds Stop smoking Treatment of infection and gangrene Sympathectomy (removal of sympathetic ganglia or branches-causes permanent vasodilation Amputation Nursing Support stopping smoking Administer pain meds Education regarding protection extremities from cold and trauma
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Dilated, tortuous superficial veins of the lower extremities May be superficial or deep Symptomatic or asymptomatic Symptoms do not always correspond to the number and size of varicosities Female, family history, prolonged sitting or standing Dull aching feeling after long periods of standing Complications include ulceration, stasis dermatitis, superficial venous thrombosis and thrombophlebitis
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Treatment includes compression stockings worn all day and removed at night Periodic elevation of legs and exercise are recommended Encourage walking and weight loss Surgery is for patients that have persistent, disabling pain, ulceration, superficial thrombophlebitis Sclerotherapy can be used for small varicosities More than one treatment may be needed This is chronic disease and requires continued stockings, rest and exercise
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Swollen, dilated, tortuous veins Dull aching Muscle cramps Increased muscle fatigue Ankle edema Diagnosis duplex ultrasound
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Venous Thrombosis Thrombus formation in a vein May be deep (DVT) or superficial Thrombophlebitis Inflammation of a vein along with thrombus formation

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Thrombus- a blood clot in a blood vessel Embolism- a clot that travels and blocks a vessel DVT (deep vein thrombosis) serious because it can cause a pulmonary embolism DVT most common in legs but can occur in the upper extremities also Thrombus formation is associated with Virchows Triad
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Venous stasis due to reduced blood flow Injury to the intimal lining creates site for clot formation Hypercoagulability increased tendency to clot
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Pain Tenderness Redness Warmth Palpable cord

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Pulmonary embolus Chronic venous insufficiency Venous stasis ulcers Chronic edema

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Elevation of extremity Warm compresses to area Analgesics and possibly NSAIDS Possibly antibiotics

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Active or passive leg exercises Intermittent pneumatic compression devices Compression stockings Encourage post-op deep breathing Avoid using pillows under knees
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Swelling or edema of involved extremity Tenderness Homans sign Signs of pulmonary embolus Chest pain Hemoptysis Dyspnea Apprehension Hypotension Cardiac arrest
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Results from faulty venous valves which allow reflux of blood Venous pressure increases and venous stasis occurs. Edema also occurs. Small veins rupture and RBCs escape into surrounding tissues. Brown discoloration of tissues occurs Stasis ulcers develop
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Swollen limb Dry, itchy, coarse, leathery skin Reddish brown skin on lower extremity above ankles Stasis ulcers above ankles
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75% result from chronic venous insufficiency and 20% from PAD Appear as an open, inflamed sore Eschar may be present Venous ulcers usually present above the malleolus Arterial ulcers usually occur on or between toes

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Take long time to treat and heal Venous insufficiency Stasis dermatitis Stasis ulcer Over the malleolus (more medial than lateral) If not controlled they can lose extremity

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Claudication after walking short distance Pain at ulcer site Between or top of toes Cold feet Decreased or absent pulses Possible gangrene Atrophy of skin
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Wound culture Oral antibiotics if infection present Debridement of nonviable tissue Surgical debridement Enzymatic debridement Wet to dry dressings Calcium algenate dressings Keep ulcer clean and moist while healing Hydrocolloid dressing Unna boot Improve nutrition Hyperbaric oxygen therapy (HBO)
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Inhibits platelet aggregation Reduces ability of blood to clot Contraindications Allergy, GI bleed, bleeding disorder, children <18 with viral infection Report Signs of bleeding, petechiae, ecchymoses, bleeding gums, black or bloody stools
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Inhibits formation of new clots Does not dissolve existing clot but prevents its extension Contraindications Active bleeding, hemophilia, thrombocytopenia, suspected intracranial hemorrhage Monitor H/H, platelets (prior and regular intervals), PTT PROTECT FROM INJURY Avoid IM injections Report Drop in BP, bleeding ANTIDOTE Protamine sulfate 1% sol (heparin antagonist)
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Anticoagulant Prevention of DVT Treatment of DVT, PTE, Acute Coronary Syndrome Contraindication GI bleed, active bleeding, bleeding disorder, thrombocytopenia Monitor H/H, platelets Report Signs of bleeding, drop in platelet count
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Prevents new clots from forming Treatment of A-Fib Prophylactic if prosthetic heart valve Contraindications Hemophilia, active bleeding, esophageal varices, severe hepatic disease Antidote Holding one or more doses, Vit K, blood transfusion may be needed Monitor PT, INR Report Bleeding (nose, mouth, gums, urine, stool) Take at the same time each day Maintain consistency in diet with Vit K foods (broccoli, cabbage, lettuce, green tea, spinach, tomatoes)
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Antiplatelet Irreversible on platelets Contraindications Intracranial hemorrhage, active bleeding Education Discontinue one week before having surgery Monitor Signs of bleeding, platelet count
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Thrombolytic For CVA patients within *3* hour time frame from onset of s/s Contraindications Active internal bleeding, recent surgery or trauma, bleeding disorder, use of oral anticoagulants, uncontrolled HTN Monitor Bleeding, neuro checks, cardiac rhythm Education IM contraindicated, no invasive procedures, quiet and on bed rest during administration
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Decreases blood viscosity and improves blood flow Results in reducing tissue hypoxia, decreased pain and paresthesias Contraindications Intracranial bleed Monitor Relief from pain and cramping, improved walking tolerance
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Antidote for overdose of Coumadin Contraindication Severe liver disease Monitor Patient, PT/INR, Bleeding IV route for emergencies only
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Antidote for heparin overdose Used after stopping heparin Contraindication- hypersensitivity to fish Monitor- patient and vital signs

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