31 - Venous Disease Flashcards
What is venous insufficiency?
Inadequate venous drainage of the lower extremities
What causes venous insufficiency?
- Clot
- Inherited abnormality of the veins
- Increased pressure in the venous system (mechanical or metabolic)
What is superficial venous insufficiency called?
Varicose veins
What is deep venous insufficiency called?
Chronic venous insufficiency
What is a thrombus?
Presence of a clot
What is phlebitis?
Inflammation within a vien
What is thrombophlebitis?
A broad term for inflammation of a view with or without the presence of a clot
What vein is most commonly involved in a superficial thrombophlebitis?
Great saphenous vein
This is more common than the lesser saphenous vein
How common is superficial thrombophlebitis?
3-11% of the general population
What are the risk factors associated with superficial thrombophlebitis?
Associated with conditions that increase the risk of thrombosis
- Coagulation abnormalities
- Endothelial dysfunction
- Venous therapy (following vein ablation)
- Malignancy and hypercoagulable states
What is the patient presentation of a superficial phlebitis?
- Tenderness, induration, pain and erythema along course of superficial vein, palpable cord***
What should you be thinking if a pateint presents like this?
High index of suspicion for DVT in patients with risk factors (such as a previous DVT)
How do you treat a superficial thrombophlebitis?
- Treatment is aimed at alleviating symptoms such as pain and swelling (NSAIDs, warm compression, elevation)
- Thrombus PREVENTION in deep veins
- Coagulation in patients with extensive involvement or high risk patients
What is one type of superficial venous insufficiency?
Varicose veins
Describe varicose veins
- Dilated, elongated tortuous
- Involves superficial veins 3 mm or greater is size
- Effects 10-30% of the population
- Seen more often in older patients
What is the pathology behind varicose veins?
- Inadequate muscle pump
- Incompetent valves leading to reflux
- Venous obstruction
What do the pathological aspects of varicose veins lead to?
Increased venous pressure - known also as “venous hypertension”
Note:
- Venous hypertension –> vein dilation –> skin changes —> skin ulceration
Describe the effect of incompetent valves
Valves become incompetent, veins are permeable the fluid in the blood leaks out and produces edema and fluid accumulation
How do you diagnose varicose veins?
- Diagnosis correlates with the degree of venous “reflux”
- It is identified by venous duplex ultrasound as retrograde (reversed) flow of greater than 0.5 seconds in duration
How do you manage varicose veins?
You treat according to the severity and etiology of the underlying reflux
- Conservative treatment includes elevaion, compression and exercise
- Invasive treatment is ablation therapy
What is chronic venous insufficiency again?
The presence of thrombophlebitis in a deep vein
- The chronic insufficiency is associated with structural and histological changes
What structural and histological changes occur in chronic venous insufficiency?
- Capillary microcirculatory disorders
- Fibrin deposition
- Inflammation
What do these histological changes lead to?
- All of the histological and structural changes lead to impaired oxygenation of the skin and subcutaneous tissue
- This results in edema, hyperpigmentation, fibrosis (feels like elephant skin) and ulcer formation
How can you differentiate between an infection and chronic venous insufficiency?
Bilateral usually means it is chronic venous insufficiency rather than an infection
What are the treatment goals for chronic venous insufficiency?
- Improve symptoms
- Reduce lower extremity edema
- Healing and prevention of ulcers
How do you reach these goals?
- Leg elevation
- Exercise
- Compression therapy
- Skin care
Describe leg elevation
- Level of heart or above 30 minutes 3-4 times/day
- Helps to improve microcirculation and reduce edema
Describe exercise
Walking or ankle flexion exercise to help with muscle pump
Describe compression therapy
Choice of compression varies from patient to patient
Describe skin care
- Emollients to lubricate dry skin
- Be kind of careful, don’t get too much lubrication, it will cause it’s own ulcer
Describe the general approach to ulcer care
- Debridement
- Topical agents
- Growth factors
- Dressing options
- Skin grafting and skin substitutions
Describe ulcer debridement
- Removes devitalized tissue
- Typically need to numb patient or do it in the OR because it is a very painful procedure
Describe topical agents used to treat ulcers
- Enzymatic agents
- Silver sulfadiazine
Describe growth factors used to treat ulcers
- Oasis
- Epifix (amniotic membrane, placental origin)
Describe dressing options used in treating ulcers
- Hydrocolloids
- Absorbent dressings
- Occlusive dressings
Describe skin grafting and substitutes for treating ulcers
- Dermagraft
- Apligraft
- STSG (split thickness skin graft)
- STSG is taking skin from calf and putting it over the wound
Note…
The last 10 slides were on DEEP VEIN THROMBOSIS and he said “know this material… we will spend the majority of our time on this”
What is a is another name for a deep vein thrombosis?
Venous thromboembolism (VTE)
What are the two types of DVT?
- Distal DVT
- Proximal DVT
Describe a distal DVT
Thrombus remains in the deep calf vein
****
Describe a proximal DVT
- Thrombus involves popliteal, femoral or iliac veins
What is very important to know about a proximal DVT?
- It is more commonly associated with the development of pulmonary embolus
- If you have a clot, the more proximal you are, the more likely they throw a clot (DVT) which isn’t necessarily fatal, but you need to catch it and you need to treat it ***
How common is DVT?
- Responsible for 1% of hospitalizations in the U.S.
- Estimated 900,000 cases of DVT and PE per year resulting in 60,000 to 300,000 deaths per year
How do you approach a patient with a suspected DVT?
- Use the validated algorithm to evaluate patients
- Assess risk factors in all patients
What are the risk factors for DVT?
- Prolonged immobilization or bed rest
- Recent surgery
- Obesity
- Prior thromboembolism
- Lower extremity trauma
- Malignancy
- Oral contraceptives or hormone replacement therapy
- Pregnancy or postpartum
Stroke
What is the clinical presentation of a DVT?
- Palpable cord
- Calf pain
- Unilateral leg edema with an increase in calf diameter
- Warmth
- Tenderness
- Erythema
- Hohman’s sign
- Wells score criteria
What is the Well’s score criteria?
There are many different versions
- Some say that if you have a Well’s score greater than 1, you have a risk of DVT
Some say that if you have 3+ and pain, you are at risk of PE
- How do you use the well’s score in conjunction with your physical exam???
TEST QUESTION
- Just know the general concept
If you see a very swollen leg unilaterally…
If you see this and there is pain, get an ultrasound, admit them, start prophylaxis, get medicine on board (internal med) so that they can follow them after they are discharged, they will probably be on warfarin for 6 months and will follow up with medicine physician
How do you diagnose a DVT?
- Compression ultrasonography (venous duplex)
- Non invasive choice of diagnosis
- Positive predictive value of 94%
How else can you diagnose a DVT?
A D-dimer test
- A negative D-dimer test as a stand alone test may not be valid (need to look for more signs)
- Often used in conjuction with a Wells Score (pre-test probability)
- This is where the Wells score comes into play
How do you rule out DVT?
** Patient with low probability Wells score and negative D-dimer is UNLIKELY to have DVT and are said to NOT need further testing **
Patients with moderate or high probability Wells score should be sent for ultrasound
KNOW THIS
How do you treat a proximal DVT?
** Anticoagulation therapy – Indicated in patient with symptomatic PROXIMAL DVT **
Describe the risk of PE in untreated patients
PE is likely to occur in up to 50% of untreated patients
Describe the initial treatment of proximal DVT
- Initial treatment of anticoagulation should be started acutely
- Duration of treatment varies
What is an alternative treatment?
Inferior vena cava filter – In cases where anticoagulation is contraindicated or complicated or patient is high risk for PE
An inferior vena cava filter (IVC filter) is a type of vascular filter, a medical device that is implanted by interventional radiologists or vascular surgeons into the inferior vena cava to presumably prevent life-threatening pulmonary emboli (PEs)
