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Vascular > Acute Venous Pathophysiology > Flashcards

Acute Venous Pathophysiology Flashcards

1
Q

What type of pressure and flow does a venous system have?

A

Low pressure and spontaneous flow- shows changes with respiration and augmentation

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2
Q

When might a DVT occur?

A

When there is alteration of normal Hemodynamics or architecture of the venous system

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3
Q

Who presented his concepts on the causes of a DVT? When?

A

Rudolph Virchow in 1856

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4
Q

What is the Virchow triangle?

A

3 established factors known to cause DVTs

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5
Q

What is included in the Virchows triangle?

A

Stasis
Hypercoagulability
Intimal injury

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6
Q

What is the most common factor to cause a DVT?

A

Venous stasis

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7
Q

What are some factors that can cause venous stasis? (9)

A 
Immobility
MI
CHF
COPD
Obesity
Pregnancy (L>R)
Previous DVTk
Surgery
Paraplegia
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8
Q

What are some examples of hypercoagulability states? (4)

A

Pregnancy
Cancer
Estrogen intake (BCP)
Genetic blood factors

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9
Q

What are some indications for LE vascular US?

A 
Suspicion of DVT
Suspicion of PE
Incompetent valves and mass causing pain and swelling
Edema/swelling
Limb pain/tenderness
Ulceration 
Discolouration in the gaiter area
Varicose veins
Hypercoagulable state 
Pallor
Cyanosis
Positive d-dimer test result
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10
Q

What are the symptoms of a PE?

A

SOB
Chest pain
Hemoptysis

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11
Q

What is the most common mass/cyst?

A

Bakers cyst

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12
Q

Where are ulceration found and what is their appearance?

A 
Gaiter area (medial malleolus) 
Shallow and round
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13
Q

What disease is suspected with a pallor coloured leg?

A

Phlegmasia alba dolens

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14
Q

What disease is suspected with a cyanotic leg?

A

Phlegmasia cerulean dolens

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15
Q

What are indications for an UE venous US?

A 
Suspicion of DVT
History of catheter lines or drug abuse
Head and neck swelling/edema
Limb redness
Suspected injury after venous puncture/catheterization, esp in IJV
Symptoms of a PE
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16
Q

What might a pts history include when a acute DVT is suspected?

A 
Acute onset of leg pain and swelling
Persistent leg/calf swelling 
Redness/erythema 
Warm skin
Symptoms of a PE 
Previous DVT
Clotting issues (including problems regulating anticoagulation therapy and malignant cancer)
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17
Q

Is persistent leg/calf swelling unilateral or bilateral?

A

Usually unilateral but can be bilateral

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18
Q

Where does thrombus formation usually begin?

A

Soleal sinus/calf veins or at the valve cusps

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19
Q

What is predominately the main reason for thrombus formation?

A

Stasis

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20
Q

What occurs during early thrombus formation? Why?

A

Aggregations of RBCs near valve cusps due to stasis and eddy currents

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21
Q

What does fibrin do? What does it cause?

A

Stabilizes RBCs against endothelium and propagation occurs

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22
Q

What causes enlarged pockets to be formed between the clot and vein wall?

A

Combination of fibrinlysis, thrombus reaction and fragmentation

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23
Q

What is the most common outcome for the venous lumen?

A

Restored venous lumen with intimal thickening

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24
Q

Residual fibrous synechia (scarring or formation) is present in what % of pts?

A

10%

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25
Q

What is considered and acute DVT?

A

Days to 1-2 weeks old and consistent with the timing of clinical symptoms

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26
Q

What does a recent clot appear as compared to the surrounding tissue?

A

Anechoic to low echogenicity

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27
Q

What happens to the clots echogenicity as it ages?

A

Increases slightly

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28
Q

What 2 things will confirm thrombus formation?

A

Dilation of the vein and lack of compressibility

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29
Q

What is the primary diagnostic modality for detection of a lower extremity DVT?

A

Duplex sonography

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30
Q

Why is duplex scanning the primary diagnostic modality for detection of a LE DVT?

A

Due to the few limitations and high accuracy rate

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31
Q

What are some common origins for development of a thrombus?

A 
Muscular veins
Valve sites
Venous confluence
Deep venous system
Superficial venous system
Perforators
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32
Q

What is the sonographic findings of an acute DVT?

A

Vein often enlarged with isoechoic or slightly echogenic material seen distending in vein

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33
Q

Will the acute DVT be compressible?

A

The veins will not coapt

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34
Q

What determines the degree of obstruction and extent of DVT?

A

Color Doppler

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35
Q

What will the proximal end of the clot appear to do if it is not attached to the vein wall?

A

“Float” or “wave”

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36
Q

What is collateralization?

A

Accessory vessels that re-route flow around an obstruction

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37
Q

When does collateralization occur? Can it be seen on US?

A

Occur readily in the presence of a DVT and can be seen on US

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38
Q

How are incompetent valves diagnosed?

A

Demonstrate reverse flow in response to valsalva or compression proximal to the site of the valve

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39
Q

Is continuous venous flow, without respiratory phasicity normal?

A

No it is abnormal

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40
Q

What does continuous venous flow, without respiratory phasicity suggest?

A

Proximal disease

See page 5

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41
Q

What is a sub-acute thrombus?

A

Thrombus 1-2 months old

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42
Q

How does the sonographic appearance change with a sub-acute thrombus?

A

Increasing echogenicity and decreasing vein diameter with losing of clot

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43
Q

What is recanalization?

A

Some resumption through the clot

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44
Q

In what type of thrombus can recanalization occur?

A

Sub-acute thrombus with formation of collaterals

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45
Q

What is chronic thrombus scarring?

A

The result of venous thrombosis that occurred months to years after the initial date

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46
Q

What does the fibrous tissue that remained from a chronic thrombus appear like?

A

Moderate to high echogenicity and may be isoechoic to surrounding tissue making it difficult to access

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47
Q

What are chronic thrombosis difficult to assess?

A

May appear isoechoic to surrounding tissues

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48
Q

What are the sonographic findings of a chronic DVT? (4)

A

Echogenic thrombus
Vein smaller then artery
Presence of collaterals
Recannalization

See page 9

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49
Q

What is the normal criteria for venous duplex exam? (5)

A
  1. Complete coaption with little pressure
  2. Absent intraluminal echos
  3. Color flow fills lumen
  4. Normal Doppler spontaneity, phasicity and augmentation
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50
Q

What is the abnormal criteria for a venous duplex exam? (5)

A
  1. Lack of complete vein compression
  2. Intraluminal echos present
  3. Decrease or absence of color flow
  4. Abnormal Doppler spontaneity, phacisity and augmentation
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51
Q

What are ACUTE thrombus descriptions & Characteristics? (4)

A
  1. Light to medium echogenic or anechoic
  2. Spongy texture on compression (homogeneous)
  3. Poorly attached or free floating
  4. Dilated vein (if not completely occluded)
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52
Q

What are CHRONIC thrombus descriptions & Characteristics? (5)

A
  1. Bright heterogenous echos
  2. Irregular texture (heterogenous)
  3. Attached
  4. Same size as artery or vein is contracted
  5. Collateral veins may be seen
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53
Q

Can veins be completely or partially compressible in both acute and chronic stages?

A

Yes combination of events can occur

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54
Q

What is a chronic thrombus with partial recanalization seen as?

A

Small color flow channels within the thrombus

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55
Q

Is the age of the clot always detectable?

A

No sometimes indeterminate

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56
Q

Where is the most common site for a calf vein DVT?

A

Soleal sinus - clinical importance still unknown - propagation into popliteal varies widely

57
Q

What are the current approaches to treat a calf vein DVT? (2)

A
  1. Surveillance with duplex US to check for propagation to larger veins
  2. Therapeutic anticoagulation for 6 weeks
58
Q

What other thrombus management is similar to that of a iliac DVT?

A

Femoropopliteal thrombus

59
Q

What DVT is difficult to image with US?

A

Iliac DVT

60
Q

How is a iliac DVT examined?

A

Indirect assessment with Doppler signal

61
Q

How is an iliac DVT diagnosed?

A

Venography

62
Q

What is Mary-Thunder syndrome?

A

Compression of the Lt CIV b/w CIA and spine

63
Q

What vessels are compared to rule out iliac obstruction?

A

Bilateral CFV waveforms compared

See page 13

64
Q

What causes an increase of DVTs in the UE?

A

Use of central venous catheters

65
Q

What can predispose an axillosubclavian vein thrombus formation?

A

Previous radiation treatment
Pt hx of mediastinal lymphoma
Trauma or surgery to area

66
Q

Thrombosis is the disease mechanism…T/F

A

True

67
Q

Are superficial or deep thrombosis more common? Is it potentially fatal?

A

Deep DVTs more common and potentially fatal

68
Q

What % of PE originate from the LE?

A

90%

69
Q

What % of pts who have had a DVT develop chronic venous insufficiency?

A

60%

70
Q

Can a calf vein cause a DVT? Can it be fatal? Why?

A

A calf vein can cause a DVT but to small to be fatal

71
Q

What are the medical treatments for an acute DVT? (3)

A
  1. Anticoagulation
  2. Thrombolytic agent
  3. Control the risk factors
72
Q

What is anticoagulation?

A

Therapy for 3-6months (heparin/warfarin) prevents clot propagation

73
Q

Does anticoagulation dissolve the thrombus?

A

No

74
Q

What is considered the standard medical treatment for an acute DVT?

A

Anticoagulation

75
Q

What is a thrombolytic agent?

A

A thrombolytic agent (streptokinase) may be injected into the UE to dissolve a thrombus

76
Q

What helps to control the risk factors to promote venous return in the case of an acute DVT?

A

Limiting long periods of activity
Wearing support hoses
Elevating legs
Checking for hypercoagulabilty states ad factors in the blood

77
Q

What are the surgical treatments for an acute DVT? (3)

A
  1. IVC filter
  2. Venous thrombectomy
  3. Bypass grafting
78
Q

When is an IVC filter used as a treatment for an acute DVT?

A

In pts who cannot be anticoagulated

79
Q

When is bypass grafting considered?

A

Caval occulsion

80
Q

What are the endovascular treatments for a acute DVT? (3)

A
  1. Catheter directed thrombolysis
  2. Balloon venoplasty and stenting
  3. Mechanical thrombectomy
81
Q

What thrombolysis is used for an acute DVT?

A

Urokinase

82
Q

What vein is balloon venoplasty and stenting most often used?

A

Chronic iliofemoral DVT

83
Q

What is an example of mechanical thrombectomy?

A

Angiojet

84
Q

What is phlegmasia Alba Dolens?

A

Decreased venous drainage due to thrombosis of the extremity deep veins without collateral vein involvement

85
Q

What color may the pts leg look like with phlegmasia Alba Dolens?

A

White

86
Q

What causes the white coloured appearance in phlegmasia Alba Dolens?

A

Extensive edema obscures circulation

87
Q

What is an contributing factor in phlegmasia Alba Dolens?

A

Arterial spasms

88
Q

What can phlegmasia Alba Dolens progress into?

A

Phelgmasia cerulea dolens

89
Q

What is Phelgmasia cerulea dolens?

A

Massive venous occlusion due to multi segment thrombosis of extremity deep veins; iliofemoral, lower leg veins and their collaterals

90
Q

What causes Phelgmasia cerulea dolens?

A

Massive obstruction of venous outflow reduces arterial inflow causing arterial vasoconstriction and potentially arteriolar thrombosis

91
Q

What causes the discolouration of the skin in Phelgmasia cerulea dolens? What color does it turn?

A

Venous congestion resulting from significant iliac vein thrombosis causes a blue color

92
Q

What are some signs of Phelgmasia cerulea dolens?

A

Massive thigh and leg swelling

93
Q

Acute onset of Phelgmasia cerulea dolens leads to what?

A

Starts with hypoxia and leads to gangrene

94
Q

Is Phelgmasia cerulea dolens a surgical emergency?

A

Yes

95
Q

What is May-Thurner syndrome?

A

Compression of the left CIV by the right CIA and spine (5th lumbar vertebrae), increasing the risk for DVT

96
Q

What can May-Thurner syndrome result in?

A

Left CIV stenosis and left leg swelling

97
Q

What is Paget-Schroetter syndrome?

A

Most common form of axillosubclavian thrombosis in ambulatory healthy people

98
Q

What is another name for phelgmasia cerulea dolens

A

Effort thrombosis

99
Q

Are men or woman most effect by the Paget-Schroetter syndrome?

A

Men

100
Q

What is Paget-Schroetter syndrome caused by?

A

Anatomical variations of muscle and bone in the thoracic inlet

101
Q

When does the Paget-Schroetter syndrome occur?

A

When there is thrombosis of the axillary/subclavian vein at the thoracic inlet (b/w muscle/bone)

102
Q

What is thrombophlebitis (superficial)?

A

Inflammation with thrombus formation

103
Q

How is thrombophlebitis diagnosed?

A

Diagnosed clinically- “hard cord”

US used to delineate extent of thrombus, particularly at major confluences into the deep system

104
Q

Approximately what % of superficial thrombosis has a recurrent DVT?

A

20%

105
Q

What is the treatment for thrombophlebitis?

A

Ambulation and compression therapy along with anti-inflammatory drug admission

106
Q

How does congestive heart failure affect pulsatility?

A

Increases pulsatility

107
Q

Congestive heart failure results in what? Why?

A

Bilateral lower extremity edema from hydrostatic pressure

108
Q

What is a hematoma?

A

Accumulation of blood within tissue

109
Q

Why is a hematoma difficult to distinguish from the effects of a DVT?

A

They cause pain and swelling similar to that of a DVT

110
Q

How do extremity soft tissue hematoma occur?

A

Trauma, anticoagulation therapy or vigorous exercise

111
Q

What does a hematoma appear as on US?

A

Hypoechoic mass with ill defined border, contained within muscles or tissues

112
Q

What occurs to the hematoma sonographically with time?

A

Will become more echogenic and heterogeneous

113
Q

What occurs to the blood in the hematoma once it lysis?

A

May appear once again anechoic in the final stages

114
Q

What may a large hematoma do to surrounding veins?

A

Compress the vein causing venous distension and sluggish flow

115
Q

What causes an abscess & cellulitis?

A

Bacterial infection

116
Q

What is an abscess?

A

Enclosed collection of pus

117
Q

What is cellulitis?

A

Diffuse collection of fluid within subcutaneous tissue

118
Q

What can abscess and cellulitis cause?

A

Swelling, erythema, pain and tenderness

119
Q

What can the signs and symptoms of a abscess/cellulitis resemble?

A

Venous thrombosis

120
Q

Why is US for abscess and cellulitis?

A

Used to confirm that the venous system is patent

Refer to page 18

121
Q

What is a Bakers cyst?

A

Dilation of bursae (sac of synovial fluid) that communicates with the knee joint

122
Q

What types of pts are bakers cysts most common in?

A

Pts with degenerative joint dx and rheumatoid arthritis

123
Q

Why do bakers cysts cause pain, tenderness and swelling?

A

As the cysts enlarge they extend into the muscle planes

124
Q

Where are the bakers cyst commonly located?

A

Medial aspect of the knee joint

Crescent shape at the upper end of the knee jt with further extension going inferior into the calf

125
Q

What is the sonographic appearance of a bakers cyst?

A

Anechoic but may contain debris and have septations

126
Q

How should the bakers cyst appear with color Doppler?

A

No flow within them

127
Q

What happens when the cysts rupture and track between the tissues into the calf?

A

Exacerbate the symptoms that mimic DVT and causing severe pain

128
Q

How do you rule out a hematoma?

A

By demonstrating communication with the jt space

129
Q

Describe potential tumors found within the legs

A

Malignant or benign
Solid with areas of necrosis
May resemble other benign pathologies so its important to demonstrate blood flow in the solid portions

130
Q

Describe enlarged lymph nodes (adenopathy)

A

Can be mistaken for thrombosed vein

May cause leg swelling, compression of veins

131
Q

What is Lymphedema?

A

Chronic leg swelling due to failure of lymphatic drainage system

132
Q

Where is lymphedema most common?

A

Calf and upper extremity

2/3 of cases are unilateral

133
Q

What is the US appearance of lymphedema?

A

Thickened subcutaneous tissue which degrades the 2D image

“Ant farm” appearance

134
Q

Are deep or superficial veins more difficult to assess with lymphedema?

A

Deep veins

135
Q

When should a popliteal aneurysm be suspected?

A

When a pt presents with a lump (swelling) or pain behind the knee

136
Q

What information does color flow provide within a popliteal aneurysm?

A

Color flow would be seen within the aneurysm providing it is patent

137
Q

What are other medical tests to aid in diagnosing thrombosis?

A 
Venography
Pulmonary angiogram
VQ scan (ventilation Quotient)/ lung scan 
Isotope venography 
D-dimer assay
138
Q

What is a venogram?

A

Contrast injected into the small veins of the foot and X-rays taken of the whole leg

Ascending for acute disease
Descending for valve disorders

139
Q

Why is a venogram considered the gold standard exam?

A

The accuracy of other studies is compared to the venogram

Vascular (5 decks)

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