Definition
A.Peripheral vascular disease (PVD) is a general term that encompasses all occlusive or inflammatory diseases that occur within the peripheral arteries, veins, and lymphatics. PVD includes deep vein thrombosis (DVT). DVT is a condition in which a thrombus forms in one or more veins. DVT greatly increases the risk of pulmonary embolism (PE).
Incidence
A.The Centers for Disease Control and Prevention (CDC) estimates that between 300,000 and 900,000 Americans are diagnosed with a DVT annually. Of those, between 60,000 and 100,000 persons die from complications from DVT, usually PE.
B.The Vascular Disease Foundation states that approximately 5% of the world’s population will have a DVT during their lifetime.
Pathogenesis
A.Changes within the venous system precipitate the formation of a DVT. These changes are formally called Virchow’s triad. This triad includes hypercoagulability, venous stasis, and injury to the vessel wall. At least two of the triad must be present for a DVT to form. Essentially, an injury to the vessel wall causes inflammation that attracts platelets, especially in a state of altered coagulation. The thrombus that forms spreads in the direction of blood flow and additional layers of platelets are added to the thrombus as time progresses. As it grows, the vessel becomes more occluded and the patient becomes symptomatic.
Predisposing Factors
A.Age, 60 years and older.
B.Hip or femur fracture.
C.Recent surgery, especially cardiac or extremity surgery.
D.Prolonged inactivity/immobility.
E.Pregnancy.
F.Medication:
1.Hormone replacement therapy (HRT).
2.Oral contraceptives.
3.Tamoxifen.
G.Smoking.
H.Obesity.
I.Cancer.
J.Inherited hypercoagulable conditions.
Common Complaints
Note: Symptoms of a DVT are usually unilateral and have a sudden onset.
A.Extremity edema.
B.Extremity pain.
C.Increased temperature of extremity.
D.Change in color or extremity.
E.Asymptomatic, depending on the size and location of the thrombus.
Potential Complications
A.PE.
B.Arterial embolism with AV shunting.
C.Myocardial infarction (MI).
D.Chronic venous insufficiency (CVI).
E.Postphlebitic syndrome.
F.Phlegmasia cerulea dolens.
Subjective Data
A.Ask patient when the symptom(s) were first noticed.
B.Have patient describe duration of symptoms.
C.Ask patient to describe pain, for example, crushing, stabbing, or burning.
D.Ask the patient what makes the symptoms better and what makes them worse.
E.Have patient rate pain on a scale of 0 to 10, with 0 being no pain.
F.Ask patient to list all medications currently being taken, particularly substances not prescribed and illicit drugs such as cocaine.
G.Review recent history of invasive procedures or surgery.
Physical Examination
Patients presenting with acute shortness of breath (SOB) and/or chest pain should be quickly assessed for the need to call emergency services/911 for immediate transport to the hospital.
Patients presenting with symptoms of DVT that include cyanosis of the distal extremity should be quickly assessed for the need to call emergency services/911 for immediate transport to the hospital.
A.Vital signs:
1.Check blood pressure (BP) and document resting heart rate, respirations, height, and weight.
B.Inspect:
1.Assess for signs of erythema, increased temperature, and edema.
2.Assess for a Homans’ sign (i.e., calf pain with forced plantar flexion).
3.Assess for Moses’ or Bancroft’s sign (i.e., pain when calf muscle is compressed forward against the tibia).
4.Assess Lisker’s sign (i.e., pain upon tibial percussion).
C.Palpate:
1.Palpate pulses distal to affected area, noting symmetry.
2.Palpate capillary refill.
3.Palpate extremity for tenderness. Do not perform deep palpation.
D.Auscultate:
1.Auscultate heart: Rate, rhythm, heart sounds, murmur, and gallops.
2.Auscultate lungs: Lung sounds in all fields.
Diagnostic Tests
A.DVT:
1.Serum laboratory testing:
a.D-dimer.
b.Complete blood count (CBC) with differential.
c.Coagulation panel (prothrombin time [PT], partial thromboplastin time [PTT], international normalized ratio [INR]).
d.Testing for idiopathic DVT: Add Factor V Leiden, homocysteine, G20210A Prothrombin, Factor VIII, lupus anticoagulant, protein C and S levels, anticardiolipin antibodies, and antithrombin.
2.Compression ultrasound.
3.MRI, if thrombus is suspected in the pelvic veins or vena cava.
4.Venography, not utilized often because of expense and risk of phlebitis.
Differential Diagnosis
A.DVT.
B.Cellulitis.
C.Fracture.
D.Lymphedema.
E.Congestive heart failure (CHF).
F.Vein compression (caused by enlarged lymph nodes or mass).
G.Filariasis (parasitic disease).
H.Allergic reaction, localized.
I.Compartment syndrome.
Plan
A. 
See Section III: Patient Teaching Guide “Deep Vein Thrombosis“:
1.Patients taking Coumadin should be educated regarding foods that are high in vitamin K.
2.Avoid prolonged standing or sitting.
3.Avoid crossing the legs.
4.Gradually resume normal activity.
5.Avoid immobility.
6.Exercise on a regular basis.
7.Stop smoking.
8.Encourage strategies to better manage other chronic medical conditions that directly affect the progression of peripheral arterial disease (PAD), that is, diabetes, dyslipidemia, obesity, and hypertension (HTN).
B.Nonpharmaceutical therapy:
1.Compression stockings.
C.Pharmaceutical therapy:
1.Thrombolytics: Administered in the inpatient setting.
2.Anticoagulants:
a.Heparin, intravenous (IV), administered in the inpatient setting.
b.Coumadin (warfarin sodium, Jantoven):
i.Doses: 1, 2, 2.5, 3, 4, 5, 6, 7.5, and 10 mg tablets.
ii.See section Atrial Fibrillation
for specifics on Coumadin therapy.
3.Low-molecular-weight heparin (LMWH):
a.Lovenox (enoxaparin sodium):
i.Doses: 300 mg/3 mL multidose vial.
ii.Doses: 30 mg/0.3 mL, 40 mg/0.4 mL, 60 mg/0.6 mL, 80 mg/0.8 mL, 100 mg/mL, 120 mg/0.8 mL, and 150 mg/mL prefilled syringes.
b.Fragmin (dalteparin sodium):
i.Doses: 95,000 IU/9.5 mL multidose vial.
ii.Doses: 2,500 IU/0.2 mL, 5,000 IU/0.2 mL, 7,500 IU/0.3 mL, 10,000 IU/0.4 mL, 10,000 IU/mL, 12,500 IU/0.5 mL, 15,000 IU/0.6 mL, 18,000 IU/0.72 mL by injection.
4.Specific factor Xa inhibitor:
a.Arixtra (fondaparinux sodium):
i.Doses: 2.5 mg/0.5 mL, 5 mg/0.4 mL, 7.5 mg/0.6 mL, and 10 mg/0.8 mL by injection.
D.Surgery:
1.Insertion of vena cava filter to prevent PE.
2.Venous thrombectomy.
Follow-Up
A.Follow-up is determined by patient’s needs, frequency and intensity of symptoms, and presence of other medical conditions.
B.DVT manifesting persistent symptoms should always be followed by a cardiologist.
C.Patients taking anticoagulants are best followed by an anticoagulant clinic and/or cardiologist.
Emergent Issues/Instructions
A.Patients should go to the ED if they have any of the following symptoms:
1.Sudden SOB.
2.Chest pain.
3.A change in color of a foot or hand.
4.If taking an anticoagulant and have any of these symptoms:
a.Nosebleed that will not stop with pressure.
b.Coughing up blood.
B.Patients should contact the office if they are experiencing any of the following:
1.Fever over 101°F.
2.Increased redness, pain, tenderness to touch, swelling, and/or warmth.
3.New wound or sore on the affected arm or leg.
4.If taking an anticoagulant and have any of these symptoms:
a.Vomiting or other illness causes them to miss more than one dose of their medications.
b.Vomit that is bright red or dark and looks like coffee grounds or grape jelly.
c.Bright red blood in their stools or black, tarry stools.
C.Patients should contact the office if they are experiencing any new symptom(s) not present at their last office visit.
Consultation/Referral
A.If you suspect acute limb ischemia, refer patient for immediate hospitalization to obtain diagnostic testing to determine the presence of a thrombus and restore circulation to the affected extremity.
B.If chronic limb ischemia has led to ulceration and/or superimposed infection, hospitalization is indicated to initiate a wound care consultation and diagnostic testing to determine the degree of arterial occlusion.
C.Referral to a cardiologist is indicated in the presence of persistent PVD symptoms.
D.Refer to pain management if pain is resistant to treatment.
E.Refer to a registered dietitian as indicated by the patient’s understanding of dietary modification necessary to improve status of risk factors.
Individual Considerations
A.Nonambulatory patients:
1.Using rocking chairs is a possible substitute for persons unable to participate in a walking program.
B.Geriatrics:
1.Be alert to the following geriatric syndrome: Depression related to immobility and pain.