Tibial artery occlusive disease is one of the arterial occlusive diseases. It usually affects tibial artery. Tibial artery location is in lower leg. The tibial artery occlusion disease interups blood flow. Generally, acute or chronic occlusion causes ischemia, skin ulcer, and severe gangrene.

Tibial artery occlusive disease is associated with ‘claudication’ word which mean reproducible ischemic muscle pain. This claudication caused by atherosclerosis. It often occurs during physical activity and is relived after a short rest. The most common symptoms in tibial artery occlusive disease is pain on leg. This is because of inadequate blood flow. Angiography is a standard imaging examination to diagnose tibial artery occlusive disease. The image below shows a blood flow deficits.

angiography for tibial artery occlusive disease

angiography for tibial artery occlusive disease

The History of Tibial Artery Occlusive Disease

Claudication typically raises a painful feeling that occurs with physical activity. First determining how much physical activity is needed to the onset of pain, the vascular surgeon then expressed the onset of pain in terms of street blocks. So this determination could help quantify patient’s condition before and after the tibial artery occlusive disease treatment.

Other aspects of claudication pain are that pain is reproducible within the same muscle groups. The pain may rest about 2 to 5 minutes. The most common location of artery occlusive disease is in popliteal artery above the knee joint.

When a vascular disease, atherosclerosis is distributed throughout the aortoiliac area, thigh and buttock muscle claudication predominates.

Claudication is variable. Patients usually accept a decrease in walking distance as a normal aging process. About 50 to 90% of patients with definite intermittent claudication do not report this symptom to their doctors.

If we take the way back, atherosclerosis is a systemic disease that affects all of body systems. Patients with tibial artery occlusive disease can be expected to have atherosclerosis elsewhere. So full assessment, head to toe of the patient, including patient’s risk factors for vascular disease should be performed. Some of the risk factors for artery occlusive disease include the following:

  • Diabetes
  • Hypertension
  • Hyperlipidemia
  • Family history
  • Sedentary lifestyle
  • Tobacco use
  • Chronic kidney disease

Tobacco use or smoking is the greatest of all of atherosclerosis risk factors. The mechanism of it is still unknown. What is known is that the degree of damage is directly related to the amount of tobacco used.

Other condition like low kidney function has been linked with the development of tibial artery occlusive disease. In fact, a study from Japan found that prevalence of peripheral artery occlusive disease to be 17,2% among patients with estimated glomerular filtration rates lower than 60 mL/min/1.73 m2, compared with 7% in those with GFRs higher than 60 mL/min/1.73 m2. The chronic kidney disease is the largest risk factor for peripheral artery occlusive disease, including tibial artery occlusive disease.

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Prognosis

The tibial artery occlusive disease could end to amputation. Continuous bad habit, smoking, has been identified as the worse habit for disease, especially for cardiovascular. It associated with the progression of tibial artery occlusive disease. The development of tibial artery occlusive disease depend on some factors like the presence of diabetes mellitus, hypertension, etc.

To identify patients’ risk factor for tibial artery occlusive disease (progression to critical limb ischemia (CLI)), a simple risk score for tibial artery occlusive disease was developed. It is Graz CLI score.

occlusive coronary artery disease (2)

occlusive coronary artery disease is such a major contributor for tibial artery occlusive disease outcome

The majority of patient with vascular disease, survival is less than that of age-matched control groups. Coronary artery occlusive disease is such a major contributor for tibial artery occlusive disease outcome. Predicted all-cause mortality for tibial artery occlusive disease patient with claudication is about 30 percent at 5 years of follow-up, 50 percent at 10 years, and increasingly about 70% at 15 years.

Etiology

  • Atherosclerosis
  • Endogenous, it is because embolus or thrombosis formation
  • Exogenous, it is because trauma or fracture.

Predisposing factors

  • Aging process
  • Condition like hypertension, hyperlipidemia, and diabetes
  • Vascular disturbance history like myocardium infarction or stroke
  • Smoking

Pathophysiology

Partial or total, or single or multiple artery block will impair hemodynamics at the tissue level in patients with tibial artery occlusive disease. The artery occlusion or constriction lead to alterations in the distal perfusion pressures available to affected muscle groups.

peripheral artery occlusive disease

peripheral artery occlusive disease

The blood flows to extremities normally about 300 to 400 mL/min at resting. During exercising, blood flow increases about 10-fold as a consequence of the increase in cardiac output and compensatory vasodilation at the tissue level. The muscle groups need extra oxygen demand. When exercise stops, blood flow backs to normal within minutes.

Patient with tibial artery occlusive disease blood flow during resting is as same as healthy people. In tibial artery occlusive disease, blood flow cannot increase in muscle tissue during exercise. It is because the narrowed distal artery prevent compensatory vasodilatation. When the metabolism demands of the muscle exceed blood flow, claudication symptoms occur. A long recovery period is required for blood flow to return to normal when exercise stopped at the same time.

The distal perfusion pressure is also change than normal condition. Normally, the blood pressure alteration from heart to toe is no more than a few mmHg. As pressure travels distally, the systolic pressure during the examination increases. It is because of the higher resistance encountered in smaller-diameter blood vessels.

In normal people, they have higher blood pressure of the leg than arm and no changes during exercising.

If atherosclerosis occurs in small branch of artery, the muscle groups will experience low blood pressure. At the blood pressure measurement of ankle, the result is low than healthy person. Once exercise begins, the reduction in pressure produced by atherosclerosis becomes more significant, and the distal blood pressure diminished. Poiseuille calculate energy losses across area of resistance with this following equation:

Pressure difference = 8QvL/πr4

Q : blood flow

V : viscosity

L: The length of the stenotic

r: radius of the open area within the stenosis

In the equation above, the pressure gradient is directly proportional to the flow and the length of the stenosis and inversely proportional to the fourth power of the radius. Thus, although incrasing the flow rate directly increases the pressure gradient at any given radius, these effects are much less marked than those due to changes in the radius of the stenosis.

Because the radius is raised to the fourth power, it is the factor that has the most dramatic impact on a pressure gradient across a lesion. This impact is additive when two or more occlusive lesions are located sequentially within the same artery.

Epidemiology

United States and International Statistics

Vascular disease, atherosclerosis affects up to 10% of the Western population. It affects 65 years old people. The elderly population expected to increase about 22% by the year 2040. Experts predicted that atherosclerosis had impacted financial.

Tibial artery occlusive disease prevalence in the general US population was about 4.3 percent, according to National Health and Nutrition Examination Survey (NHANES) data. That number increases with age; therefore, as the population ages the number of people affected by peripheral artery occlusive disease increase.

Claudication is a tibial artery occlusive disease indicator. About 2% of the population aged 40 to 60 years old and 6 % of the population older than 70 years old are affected with this kind of vascular disease.

Intermittent claudication condition often occurred in men over 50 years old. Although younger patients may have consistent symptoms with intermittent claudication, other causes of leg pain and claudication (popliteal entrapment syndrome) must be strongly considered. There are the presence of prevalence of peripheral artery occlusive disease in non-Hispanic blacks.

Sign and symptoms

Femoral, popliteal, and tibial Artery (aneurysm formation):

  • Leg intermittent claudication while using energy; ischemia pain in lower leg; pretropic pain ( necrosis and ulcer pain); pale and cold feeling on upper leg; lower leg become paler while elevate it; gangrene, no palpable pulse in popliteal and femoral area.

According to Medscape the sign and symptoms of tibial artery occlusive disease are:

  • Pain occurs with physical activity.
  • Other signs and symptoms of tibial artery occlusive disease include the following:
    • Pain is reproducible within same muscle groups; pain ceases with a resting period of 2-5 minutes
    • The most common location of arterial lesions is the distal superficial tibial artery, which corresponds to claudication in the calf muscle area

Physical Examination

To do physical assessment, the patient with claudication needs assessment of lower-extremity evaluation and pulse examination, including assessment of segmental pressure. The symptoms that may appear at tibial artery occlusive disease are such muscle atrophy, loss of extremity hair, and thickened toenails.

Pulse palpation should be performed from abdominal aorta to the lower artery. Bruits may be listened during auscultation in the abdomen and pelvic regions. The auscultation could be very difficult in obese patients. It is because the pulse may be hidden under a deep fat layers.

Absence pulse signifies complete arterial obstruction proximal to the area palpated. For instance, if there is no femoral artery pulse, the peripheral artery occlusive disease is present in the aortoiliac distribution. So if there is no dorsalis pedis artery pulse, it signifies the obstruction in tibial artery. Then there is tibial artery occlusive disease. The exception is the rare case of a congenital absence of a pulse (persistent sciatic artery).

Patients with intermittent claudication and have palpable pulses can be a clinical dilemma. For this case, doctor examine the patient to walk around the office (or perform toe raises) until the symptoms are appeared and palpate for pulses. The exercise usually diminishes the pulse strength at distal part of the lesion.

When palpable pulses are not exist, further assessment can be used Doppler equipment. An audible Doppler signal assures the doctor that blood flow is perfusing the leg area. If there is no Doppler signals can be heard, a vascular surgeon should be consulted immediately. Besides that, pressure measurements can be performed to gain objective data on the circulatory status. To make the assessment accuracy, makes sure you;

  1. Place the pneumatic cuff around the ankle area
  2. Position the Doppler probe over dorsalis pedis or the posterior of tibial artery
  3. Inflate the cuff to a reading above the systolic pressure and deflate; the systolic tone at the ankle vessel is the pressure recorded.

Normally, a healthy person has no pressure drop from the heart to the ankle. Normal ankle pressure is about 10 to 20 mmHg higher because of the augmentation of the pressure wave with travel distally. If patient with tibial artery occlusive disease, the pressure at the ankle will be diminished to some extent.

The most common and effective tool in assessing a patient with tibial artery occlusive disease is the ankle-brachial index (ABI). It is a calculation as the ratio of systolic blood pressure at the ankle and arm. ABI can help quantify the presence and the severity of tibial artery occlusive disease. A normal result of ABI is about 0.9 to 1.1. it means that patient with ABI result is lower than 0.9, have some degree of tibial artery occlusive disease or peripheral artery occlusive disease.

ABI examination

ABI examination

Recent study shown that ABI is not for knowing cardiovascular risks. Cardiovascular risks were determined on the basis of the Framingham Risk Score;

56,3% : low risk of cardiovascular disease
25,8% : intermediate risk of cardiovascular disease
17,9% : high risk of cardiovascular disease

The study above shown and demonstrated the close link of cardiovascular disease with tibial artery occlusive disease.

ABI examination may be less accurate tool for patient with tibial artery occlusive disease with diabetes. The patient may have extensive medial-layer calcinosis. It renders the blood vessel resistant to compression by the pneumatic cuff in ABI. Patient with diabetic should be referred to a vascular laboratory for further evaluation. For this case, the use of the toe-brachial index may be helpful.

Diagnosis Examination

Examination of patient with tibial artery occlusive disease include;

  • Lower extremity examination
  • Measuring segmental pressures.

First step of diagnosing tibial artery occlusive disease is physical anamnesis and examination; palpating pulses from the abdominal aorta to the lower body part, auscultation of bruits in the abdominal to toe regions. While there is no palpable pulse in lower part of the body, Doppler device may be used to assess circulation accurately.

We have known that ankle-brachial index (ABI), which is a non-invasive procedure for establishing the presence of tibial artery occlusive disease, is calculated as the ratio of systolic blood pressure at the ankle to that in the arm. The normal range is 0.9 to 1.1, lower than 0.9 ABI means peripheral artery occlusive disease.

Laboratory

Laboratory diagnosis may helpful only for identifying changes in kidney function and elevated lipid profiles.

Imaging Studies

  • Arteriography shows types (thrombus or emboli), location, and obstruction degree and collateral circulation.
  • Arteriography is useful for chronic disease or evaluating patient’s readiness toward reconstructive surgery
  • Doppler ultrasonography and pletismography are non-invasive diagnosis examination that show blood flow disease toward occlusion
  • Magnetic resonance angiography (MRA) – it is useful for imaging claudication in large or small vessels.
  • Computed tomography angiography (CTA) – it help imaging arterial disease but it requires large amount of contrast media and an upgraded CT scanner to reconstruct helpful images.

Complications

The most fatal complication of tibial artery occlusive disease is severe limb-threatening ischemia leading to amputation. However, study found that amputation is uncommon and very rare. In Boyd study shown that only 12.2% required amputation. In the Framingham study, only 1.6% of patient reached the amputation after 8.3 years of follow-up.

Treatment

  1. For chronic tibial artery occlusive disease, supportive treatment are like limiting smoking activity, controlling hypertension, and walking program
  2. Antiplatelet therapy can be done with dipyridamole and aspirin or clipidogrel
  3. For intermittent claudication in chronic occlusion disease, pentoxifylline can increase blood supply in the capillary, especially for patient with improper to do surgery
  4. Acute tibial artery occlusive disease needs surgery to restore blood supply to occlusion artery area. The procedures that can be done are embolectomy, thromboendarterectomy, graft, artrectomy graft bypass
  5. Thrombolytic therapy with urokinase, streptokinase, or alteplase can be prescribed
  6. Angioplasties balloon will suppress the obstruction

    angioplasty for tibial artery occlusive disease

    angioplasty for tibial artery occlusive disease

  7. Laser angioplasty can be done (it will evaporate the obstruction)
  8. Stent to prevent recurrence of artery obstruction

All of therapy above can be combined

  1. Sympatectomy can be considered as adjuvant operation depend on simpatetic nervous system condition
  2. Amputation can be done if there is no recovery after surgery and a present of gangrene, persistent infection, or chronic pain
  3. Heparin can be prescribed to prevent embolus
  4. Intestine resection can be done after restoring blood supply

Prevention

Preventions for tibial artery occlusive disease including;

  1. Stop smoking
  2. Regular exercise
  3. Control lipid, diabetes, and hypertension

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Management

In breif of treatment of claudication is medical, with surgery reserved for severe cases. Medical management includes the following:

  • Tobacco cessation in patients who smoke
  • Regular exercise
  • Control of lipid profile, diabetes, and hypertension

Pharmacotherapy

The following medications are used in the management of PAOD:

  • Antiplatelet agents (eg, aspirin, clopidogrel, cilostazol, and pentoxifylline)
  • Antilipemic agents (eg, simvastatin)

Surgery

For patients in whom medical and exercise therapy fail or those who have claudication symptoms that are lifestyle-limiting, surgical treatment includes either open bypass surgery or endovascular therapy (eg, stents, balloons, or atherectomy devices).

Tibial Artery Occlusive Disease Nursing Care

  1. Give patient comprehensive teaching about how to take leg care. Explain about diagnosis examination procedure. Suggest patient to stop smoking and avoid all of contra medication activity

Pre-operative care (acute period)

  1. Assess patient’s tibial artery circulation by assessing distal pulse and assessing skin color and temperature
  2. Give patient an analgesic
  3. Give heparin as needed in infusion drops. Use a tool that can determine and maintain drops in infusion
  4. Change patient’s leg to prevent decubitus or pressure ulcer; do not lift up the leg or compress with warm compress
  5. Look and pay attention toward fluid and electrolyte balance, monitor intake and output of patient to know patient’s kidney condition (probably urine can decrease about 30 ml/hour)

Post-operative nursing care

  1. Monitor patient’s vital signs. Assess the circulation status continuously by checking skin color and temperature, and assessing the distal pulse. Compare the result before and after surgery. Check the hemorrhage signs like tachycardia and hypotension, and check the bandage to know the patient’s excessive bleeding
  2. If patient has femoral, femoral, or tibial artery occlusion , suggest patient not to sit for long time
  3. After amputation, check the point of leg drainage , note the color, amount, and time of checking. Lift up the point of patient’s leg and give patient an analgesic. Generally, patient will feel pain, explain this condition to him / her.
  4. If patient is ready to go home, ask patient to know the sign and symptoms of recurrence occlusion. Its sign and symptoms are like pain, pale, paralysis, no pulse that is caused by graft occlusion or other occlusion in certain places. Remind the patient no to use tight clothes.

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