Peripheral Vascular
Disease/Deep Vein Thrombosis
PRESENTED BY:
SUSANNE LESTER-BENNETT
& JULIE DILLENBECK-JUERS
Definition of Problem
 Peripheral Vascular Disease (PVD):
 Two
distinct types of PVD (arterial, and venous).
 Both
involve the blood vessels of the lower
extremities.
Dunphy, Winland-Brown, Porter, & Thomas (2011)
Mosby’s Dictionary of Medicine, Nursing, & Health Professions (2006)
Reed, J. (2009)
Two Types of PVD

ARTERIAL--Arteriosclerosis of the arteries impedes circulation from
the heart to the lower extremities, causing ischemia of the muscles in
the lower extremities; also known as peripheral artery disease (PAD).

VENOUS--Valve weakening, venous stasis, venous clot formation,
chronic venous insufficiency, & deep vein thromboembolism are
the major types of venous PVD. There are different degrees of
PVD and they are characterized by a variety of signs and
symptoms.
Dunphy, Winland-Brown, Porter, & Thomas (2011)
Mosby’s Dictionary of Medicine, Nursing, & Health Professions (2006)
Reed, J. (2009)
Etiology
 PVD:
 Atherosclerosis is the most common cause of arterial stenoses.
 DVT:
 Abnormalities of coagulation, endothelial injury, and/or
venous stasis contribute to DVT’s.
Domino, F. (2013)
Incidence
 Prevalence is estimated to be between 8 to 12 million.


Many are asymptomatic and therefore are not diagnosed with this
disease.
In a study done (Reed, J.) from 1999-2004 in men & women aged
40-69 and 70+, results showed women 40-69 were 1.8 times more
likely than men to have PAD, diabetics were 3.1 more likely than
non-diabetics, and hypertensive patients were 3.1 times more likely
than those with blood pressures of <140/90 to have PAD. Similar
patterns were identified in those 70 or older.
 DVT: 100/100,000 per year; higher incidence among
Caucasians and African Americans.
 PVD: 1-2.7/1,000 per year
Chesbro, Carter, Martinez, & Evans (2011)
Domino, F. (2013)
Differential Diagnosis
 PVD:
 Phlebitis, polycythemia, anemia, Raynaud’s disease, Buerger’s
disease, aneurysms, or peripheral neuropathy.
 DVT:
 Cellulitis, lymphedema, muscle strain/tear, fracture,
compression of vein, compartment syndrome, localized
allergic reaction, fatigue, or filariasis (A disease caused by
filarial worms in body tissues; tend to infest the lymph nodes).
Domino, F. (2013)
Pathophysiology of Arterial PVD
 Primarily characterized by narrowing of the arteries caused by




atherosclerosis.
Metabolic demand during exertion fails to be met when
arterial stenoses causes inadequate blood flow in distal limbs.
During ambulation/exercise muscle pain occurs due to
ischemia and lack of arterial blood flow.
Claudication (extremity pain) results when acidic products of
anaerobic metabolism build up within the muscle.
As disease worsens, arterial circulation diminishes, and pain
worsens with minimal activity.
Chesbro, Carter, Martinez, & Evans (2011)
Domino, F. (2013)
Dunphy, Winland-Brown, Porter, & Thomas (2011)
Risk Factors of PVD
 Smoking
 Race/ethnicity
 Inactivity
 Education
 Hypertension
 Depression
 Hypercholesterolemia
 Alcohol
 Diabetes mellitus
 Sedentary
 Coagulation abnormalities  Occupation
 Abdominal/pelvic surgery  Elevated BMI/obesity
 Estrogen/oral
contraceptives
 Pregnancy
 Heart disease
 Decreased kidney function
 Age
Brach, Solomon, Naydeck, Sutton-Tyrrell, Enright, Jenny,
Chaves, & Newman ( 2008)
Reed, J. (2009)
Screening for Arterial PVD
 Resting ankle-brachial index (ABI)
 most commonly used test in screening for the detection of PAD
in the clinical setting.
 It is calculated as the systolic blood pressure obtained at the
ankle divided by the systolic blood pressure obtained at the
brachial artery while the patient is lying down (Moyer, V.,
2013).
 An ABI score of less than 0.90 is indicative of PVD.
Moyer, V. , M. D. ( 2013)
Clinical Findings for Arterial PVD
 Subjective:
 Intermittent leg pain in both calves that increases in severity
with ambulation, lasts for minutes, and resolves within 10
minutes of walking cessation, mobility loss, and functional
decline.
 Objective:
 Delayed wound healing, thick toenails, purple/black color on
lower legs and ankles, dependent edema, varicose veins, dry
skin, peripheral pulses may be decreased or absent, thin skin,
leg ulcers, affected extremity may be cool, pale, hairless, &
smaller in size; An ABI less than 0.90.
McDermott, Ferrucci, Liu, Guralnik, Tian, Liao, & Cruqui (2010)
Management/Treatment Guidelines
(Pharmacological/Non-Pharmacological)
 Treatment aimed at improving blood flow or
lessening cause of impaired circulation.
 Usually involves education and lifestyle changes.
 Minimize or eliminate risk factors.

PAD
Aggressively manage hypertension, diabetes.
 Encourage walking 30 min 4 x per week.
 Any ulcers/trauma will need immediate care.
 Keep legs in a dependent position to encourage circulation.
 No tight stockings or socks, meticulous foot care.
 Aspirin daily

Dunphy, L., Winland-Brown, J. Porter, B., Thomas, D. (2011)
Management/Treatment Guidelines
(Pharmacological/Non-pharmacological)
Clopidergrel- inhibits platelet aggregation
 Cilostazol- vasodilation and inhibits platelet aggregation; should not be used
with heart failure.
 Angioplasty may be an option for select patients.
 Watch for signs of progressive ischemia (increased pain, pallor or pain at rest)
 F/U every 3 months.
DVT
 Inpatient or outpatient (if no comorbidities)
 If inpatient treat aggressively with IV unfractionated heparin or
SQ low molecular weight heparin.
 Initiate warfarin after patient has been on heparin therapy for 1-5
days. (5-10 mg p.o. daily until PT/INR is therapeutic [2-3]).
 If not a candidate for anticoagulant therapy then vena cava filter to
prevent clot migration.

Esherick, J., Clark, D., Slater, E. (2013)
Dunphy, L., Winland-Brown, J. Porter, B., Thomas, D. (2011)
PVD/DVT Social/Environmental Considerations
 Controlling hypertension
 Controlling diabetes
 Exercise
 Healthy diet
 Increased activity: such as walking, swimming, etc.
 Smoking cessation
 Weight loss
Brach, Solomon, Naydeck, Sutton-Tyrrell, Enright, Jenny, Chaves, & Newman (2008)
DVT Definition of Problem, cont…
 Deep vein thrombosis (DVT):





Disorder involving a thrombus (blood clot) in one of the deep veins
of the body (pelvis or extremities).
An aggregation of fibrin, clotting factors, platelets, and cellular
elements of blood attach to the interior wall of a vein or artery
occluding the lumen of the vessel.
The iliac or femoral vein are most commonly affected.
DVT’s can embolize (travel), propagate (expands), or lyses (breaks
down) spontaneously.
Pulmonary embolism results when a clot breaks away from the vessel
wall and lodges in the lung, making this situation potentially life
threatening.
Mosby’s Dictionary of Medicine, Nursing, & Health Professions (2006)
DVT Risk Factors
 DVT:












Critically ill patients in ICU (immobility/prolonged sedentary position)
venous insufficiency
post-stroke
trauma
indwelling intravenous catheters
oral contraceptives or hormone replacement therapy
implantation of permanent pacemaker
implantable cardioverter-defibrillator
pelvic or acetabular fractures
cancer
inherited coagulation abnormalities
Advanced heart disease
Lee, Zierler, & Zierler (2012)
Clinical Findings for DVT
 Subjective:
 May be asymptomatic especially initially. May have pain.
 Objective:
 Warmth, erythema, tenderness, swelling of effected limb.
 Possible swelling without limb tenderness.
 Thrombosed vein-may feel a palpated “cord” over the effected
vein.
 Positive Homan’s sign-maybe?-this has a low sensitivity/low
specificity.
Hollier, A., Hensley, R. (2011)
DVT
New Pharmacological Treatment

Oral Factor Xa Inhibitor Apixaban(Eliquis)-5395 patients enrolled in randomized double
blind study. It suggests that apixaban was not inferior to
warfarin for treatment of venous thromboembolism and was
associated with significantly less bleeding. (Agnelli, 2013).
 Rivaroxaban(Xarelto)-8282 patients enrolled. Meta-analysis
showed that rivaroxaban can be used as a single drug approach
to DVT and or PE (Prins, et al., 2013).
 Edoxaban-(Lixiana)-Randomized trial, 4921 patients with acute
VTE, compared with warfarin was as effective with a lower risk
of bleeding. (Buller, H., Decousus, H., 2013).
DVT
New Pharmacological Treatment continued…

Direct Thrombin inhibitor Dabigatran(Pradaxa)-Several large randomized controlled trails
suggest that dabigatran is as efficacious as warfarin.
• Randomized double blind trail, 2539 patients with acute VTE, given
either dose adjusted warfarin or dabigatran, both has similar safety
and efficacy, and incidence of recurrent VTE (Schulman, S. Kearon,
C., Kakkar, A., et al., 2009).
Advantages/Disadvantages of these Agents
Advantages



Fixed oral dose
Convenience
No laboratory monitoring
or dose adjustments.
Disadvantages
o
o
Uncontrolled bleeding/no readily available
antidote.
Hemodialysis for dabigatran
o
(Khadzhynov, D., Wagner, F.
et al., 2013).
3 or 4-factor prothrombin
complexes may reverse
rivaroxaban(has not been
studied in humans),
(Erenberg, E., Kamphuisen,
P., et al., 2011).
DVT
Non-pharmacological Treatment
Compression Hose•
•
•
30-40 mmHg of ankle pressure has mixed benefit preventing VTE; causes no harm
Should be started after anticoagulation therapy (within two weeks of diagnosis) and
worn for two years (Prandoni, P., Lensing, A., et al., 2004).
Worn for two years reduce the risk of post thrombotic syndrome by 50% without
increasing frequency of VTE (Brandjes, D., Buller, H.,
et al., 1997).
Ambulation•
Ambulation is safe and should be encouraged as soon as feasible, despite concern
of embolization (Kahn, S., Shrier, I., Kearon, C., 2008).
•
Ambulation does not increase the risk of recurrent VTE
Prandoni, P., Lensing, A., et al. (2004)
Brandjes, D., Buller, H., et al. (1997)
Questions

1) The etiology of DVT’s consist of all but:
A)
B)
C)
D)

Abnormalities of coagulation
Endothelial injury
Venous stasis
Atherosclerosis
2) The incidence of DVT is higher among:
A)
B)
C)
D)
Asians
Hispanics
African Americans
Amish
3) Screening for PVD is done by:
A)
MRI
B)
X-Ray
C)
Pain Level
D)
ABI
Questions, cont…

4) Risk factors for PVD include:
A)
Smoking
B)
Hypertension
C)
Hypercholesterolemia
D)
All of the above

5) Clinical findings of PAD consist of:
A)
Continuous leg pain in both calves
B)
Pain that lasts for hours
C)
Pain that does not resolve with rest
D)
An ABI less than 0.90
6) When treating PAD, compression stockings should be worn for:
A)
6 months
B)
12 months
C)
24 months
D)
Not at all

Questions, cont…

7) What is the most commonly used test to screen for PAD?
A) Doppler U/S
B) ABI’s
C) Claudication

8) When evaluation DVT which test is the least reliable?
A) ABI’s
B) Doppler U/S
C) Homan’s sign
D) venogram

9) What is an effective way an effective way to remove dabigatran from the bloodstream?
A) Antidote drug
B) 3 or 4 Factor Prothrombin
C) Hemodialysis

10) Clinical findings of DVT include:
A) erythema, warmth, pain, swelling, possible palpable cord
B) erythema, warmth, no pain, swelling, possible palpable chord
C) erythema, warmth, pain or no pain, swelling, possible palpable chord
D) None of the above
Answers & Rationales








1) (D) Plaques of cholesterol, lipids, and cellular debris located in the inner layers of the
walls of the arteries. This leads to narrowing and hardening of the arteries, and reduced
oxygenated blood flow to the extremities (Hollier & Hensley, 2011).
2) (C) Non-Hispanic blacks are 2.25 times more likely to have PAD than non-Hispanic
whites (Mc Dermott, 2010).
3) (D) An ankle-brachial index of less than 0.9 defines PVD. It is considered the goldstandard to screen and diagnose PVD (Hollier & Hensley, 2011).
4) (D) Age, BMI, Alcohol consumed, diabetes, depression, less than 0.8 ABI, male, and
African-American (Hollier & Hensley, 2011).
5) (D) An ABI score of less than 0.90 is indicative of PVD (Moyer, V. , M. D., 2013).
6) (C) 30-40 mmHg of ankle pressure has mixed benefit preventing VTE; causes no
harm. Should be started after anticoagulation therapy (within two weeks of diagnosis)
and worn for two years (Prandoni, P., Lensing, A., et al., 2004).
7) (B) ABI is the most commonly used test in screening for the detection of PAD in the
clinical setting (Moyer, V. , M. D., 2013).
8) (C) Homan’s sign hast low specificity and sensitivity (Hollier, A., Hensley, R., 2011)
9) (C) Hemodialysis can be used to eliminate dabigatran from the bloodstream
(Khadzhynov, D., Wagner, F. et al., 2013).
10) (C) Erythema, warmth, pain or no pain, swelling, possible palpable chord (Hollier,
A., Hensley, R., 2011).
References












Agnelli, G., Buller, H., Cohen, A., Curto, M., Gallus, A., Johnson, M., Masiukiewicz, U., Pak, R., Thompson, M., Raskob,
G., Weitz, J., Oral apixaban for the treatment of acute venous thromboembolism, New England Journal of Medicine,
doi: 10.1056/NEJMoa1302507
Brach, J., Solomon, C., Naydeck, B., Sutton-Tyrrell, K., Enright, P., Jenny, N., & Newman, A. (2008). Incident physical
disability in people with lower extremity peripheral arterial disease: the role of cardiovascular disease. Journal of The
American Geriatrics Society, 56(6), 1037-1044. doi: 10.1111/j.1532.5415.2008.01719.x
Brandjes, D., Buller, H., Heijboer, H.(1997). Randomized trial of effect of compression stockings in patients with
symptomatic proximal-vein thrombosis. Lancet, (349), 759.
Buller, H., Prins, M. (2012). Oral rivaroxaban for symptomatic venous thromboembolism, New England Journal of
Medicine (366), 1287.
Chesbro, S., Carter, C., Martinez, M., & Evans, G. (2011). Screening for peripheral arterial disease in a long-term care
facility: considerations for clinical practice. Cardiopulmonary Physical Therapy Journal, 22(4), 36-37.
Domino, F. (2013). The 5-Minute Clinical Consult 2013. (21st Ed.). Wolters Kluwer/Lippincott Williams & Wilkins:
Philadelphia, PA.
Dunphy, L., Winland-Brown, J., Porter, B., & Thomas, D. (2011). Primary Care: The Art and Science of Advanced
Practice Nursing. (3rd Ed.). F. A. Davis Company: Philadelphia, PA.
Erenberg, E., Kamphuisen, P., Sijpken, M.(2011). Reversal of rivaroxaban and dabigatran by prothrombin complex
concentrate: A randomized, placebo-controlled, crossover study in healthy subject, Circulation (124), 1573.
Esherick, J. S., Clark, D. S., & Slater, E. D. (2012). Current practice guidelines in primary care 2013. McGraw Hill
Professional.
Hollier, A., Hensley, R. (2011). Clinical guidelines in primary care, Lafayette, LA: Advanced Practice Education
Associates, Inc.
Khadzhynov, D., Wagner, F., Formella, S.(2013). Effective elimination of dabigatran by hemodialysis. A phase I single
centre study in patients with end-stage renal disease. Journal of Thrombosis and Haemostasis, (109), 596.
Lee, J., Zierier, B., & Zierier, E. (2012). The Risk Factors and Clinical Outcomes of Upper Extremity Deep Vein
Thrombosis. Vascular & Endovascular Surgery, 46(2), 139-144. doi: 10.1177/1538574411432145.
References, cont…








McDermott, M., Ferrucci, L., Liu, K., Guralnik, J., Tian, L., Liao, Y., & Criqui, M. (2010). Leg Symptom Categories and
Rates of Mobility Decline in Peripheral Arterial Disease. Journal of The American Geriatrics Study, 58(7), 1256-1262.
doi: 10.1111/j. 1532-5415.2010.02941.x
Mosby’s Dictionary of Medicine, Nursing, & Health Professions. (2006). (7th Ed.). St. Louis, MO: Mosby.
Moyer, V. (2013). Screening for peripheral artery disease and cardiovascular disease risk assessment with the anklebrachial index in adults: U.S. perventive services task force recommendation statement. Annals of Internal Medicine,
159(5), 342-348. doi: 10.7326/0003-4819-159-5-201309030-00008.
Prandoni, P., Lensing, A., Prins, M. (2004). Below knee elastic compression stockings to prevent post-thrombotic
syndrome: a randomized, controlled trial. Annals of Internal Medicine, (141), 249.
Prins, M., Lensing, A., Bauersachs, R., van Bellan, B., Bounameaux, H., Brighton, T., Cohen, A., Davidson, B., Decousus,
H., Raskob, G., Berkowitz, S., Wells, P., Thrombosis Journal, (11), 21.
Reed, J. (2009). Risk factors for peripheral arterial disease in United States asymptomatic patients aged 40-69 and
asymptomatic patients aged greater than or equal to 70: results from NHANES 1999-2004. Internet Journal Of
Epidemiology, 7(2).
Schulman, S., Kearon, C., Kakkar, A. (2009). Dabigatran versus warfarin in the treatment of acute venous
thromboembolism. New England Journal of Medicine, (361) 2342.
Schulman, S., Kearon, C., Kakkar, A. (2013). Extended use of dabigatran, warfarin, or placebo in venous
thromboembolism. New England Journal of Medicine, (368),709.