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Vascular > Chronic Venous Pathophysiology > Flashcards

Chronic Venous Pathophysiology Flashcards

1
Q

What is chronic venous dx mainly due to?

A

Failure of function rather then obstruction

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2
Q

What are the most common cases of chronic dysfunction?

A

Reflux through failed veins which can involve the superficial and/or deep systems

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3
Q

What are other symptoms that some patients have with chronic venous dx?

A

Post-thrombotic symptoms

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4
Q

What does chronic venous disease include? (3)

A
  1. Post-thrombotic syndrome
  2. Reflux (venous insufficiency)
  3. Primary and secondary varicose veins
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5
Q

What are the symptoms of chronic venous insufficiency? (8)

A 
Swelling/edema (pitting edema)  
Heaviness/ache
Discolouration/ hyperpigmentation/ brawny discolouration 
Ulcers- mild pain
Varicosities
Venous claudication/ intense burning or cramping in calf
Stasis dermatitis/dry, flakey skin
Increased venous pressure
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6
Q

What causes pitting edema?

A

Venous hypertension or ambulatory hypertension

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7
Q

What are the 2 medical treatment for a chronic DVT?

A
  1. Injection sclerotherapy

2. Controlling the risk factors

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8
Q

What is injection sclerotherapy?

A

For small varicose veins sodium tetradecyl sulfate is injected into the varix which causes obliteration of the lumen

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9
Q

What are some risk factors that can be controlled?

A

Limiting long periods of inactivity
Promote venous drainage: compression stockings, elevating legs, unna boots, reducing weight on calf compression pumps during or after surgery

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10
Q

What are the surgical treatments for chronic DVTs?

A
  1. Ligation
  2. Vein stripping
  3. Venous ablation
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11
Q

What does the surgical treatments of ligation involve?

A

Ligation of incompetent superficial veins

Valvular reconstruction or valve transplantation

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12
Q

What is the endovascular treatment for chronic DVTs?

A
  1. Radio frequency ablation
  2. Trans illuminated power phlebectomy (TIPP)
  3. Laser-Thermal ablation
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13
Q

Who exclusively refers to the term post-thrombotic syndrome?

A

Pts who have previously experienced DVTs

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14
Q

What term is used for pts with similar symptoms as a DVT without previous history?

A

Chronic venous insufficiency (CVI)

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15
Q

Do fibrous strands remain after resolution of a DVT?

A

Yes

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16
Q

Is fibrous material a risk for embolization?

A

No

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17
Q

Does fibrous material create a site that is predisposed to recurrent acute DVT?

A

Yes

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18
Q

What occurs to the flow as a result of recannalization?

A

Produces irregular flow surfaces that impede flow

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19
Q

How does damage to the vessels affect the integrity of the venous valves from a chronic DVT?

A

Causes thickening, scarring and shortening of the leaflets

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20
Q

What can happen to the valves when they are thickened, scarred and have shortened of the leaflets?

A

Reflux

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21
Q

Explain the evolution of a thrombus.

A
  1. Spontaneous lyse- small thrombi lyse over in a short period of time due to natural fibrinolytic activity
  2. Propagation or embolization (acute state)
  3. Recannalization over time- fibrin strands produce irregular channels or scarred valve cusps
  4. Permanent occlusion- thrombus retracts causing vein to shrink into a fibrous cord (hard to visualize)
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22
Q

What causes reflux in the veins of the LE?

A

Absent or incompetent valves

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23
Q

What can lead to or cause venous hypertension?

A

Failed valves- allow full gravitational/hydrostatic pressure exerted on the vein walls
Calf muscle pump ineffective- decreasing ejection of blood resulting in increased residual venous volume
Failure of perforating veins- allowing flow to reverse from deep to superficial veins

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24
Q

What are some symptoms when flow is reversed within the perforators?

A

Heaviness and aching

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25
Q

What are varicose veins?

A

Veins that are palpable, distended and greater then 4mm in diameter

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26
Q

Describe PRIMARY varicose veins

A

Dilated tortuous veins that may be hereditary (congenital absence of valves) and restricted to the superficial system

Increased intraluminal pressure due to pregnancy, obesity and prolonged standing

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27
Q

Do pts with primary varicose veins have a favourable outcome?

A

Yes

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28
Q

What is the treatment for primary varicose veins?

A

Surgical ligation

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29
Q

What causes the development of secondary varicose veins?

A

Obstructive conditions such as previous DVT (damage to valves)

30
Q

What is the appropriate therapy for secondary varicose veins?

A

Support stockings

31
Q

What is the treatment for secondary varicose veins?

A

Surgical ligation of the perforators

32
Q

What are the skin changes specific to chronic insufficiency?

A

Edema- due to increase venous pressure
Brawny discolouration- result of leakage of RBCs into surrounding tissue
Ulceration
Redness/rubor-itis/cellulitis

33
Q

Does secondary varicose veins include the superficial or deep systems?

A

Both systems

34
Q

What does testing with a CW Doppler probe determine?

A

Presence and origin of reflux

35
Q

What other veins are assessed with the CW Doppler probe?

A

GSV, SSV and perforators

36
Q

What are the factors evaluated in acute dx using CW Doppler?

A

Spontaneity, phasicity and response to distal and proximal compressions

37
Q

What is the factor evaluated in chronic dx using CW Doppler?

A

Valve competency

38
Q

What is the evaluation of CW based on?

A

Evaluation of auditory signals in the resting position

Comparison to the signal received after manual compressions or valsalva maneuvers or rapid cuff deflation

39
Q

Does CW show a picture?

A

No

40
Q

What does color duplex Doppler demonstrate?

A

Reflux using valsalva and compression techniques

41
Q

What is the perfered position the pt be in when examining with color duplex Doppler?

A

Standing

42
Q

What allows for visualization of specific sites with the ability to collect flow velocity data?

A

Color duplex

43
Q

How long does it take a normal valve to close?

A

0.5 sec

44
Q

Should there be flow reversal seen with proximal compression or valsalva maneuver?

A

Minimal to no flow reversal seen

45
Q

How should the pt be positioned with complete proximal compressions?

A

Supine

46
Q

What is distal augmentation used for?

A

Looks for reversed flow immediately following release of squeeze

47
Q

What type of Doppler is used to best interrogate perforator veins?

A

Color Doppler

48
Q

What is the normal caliber of perforator veins?

A

<3mm

49
Q

Abnormal perforators will have bi-directional flow and a lumen diameter of what?

A

<4mm

50
Q

What are some limitations of the color duplex exam?

A

Obesity, pitting edema, bony structures, casts and bandages

51
Q

Is it common for there to be complete recannalization with restoration of flow?

A

Yes

52
Q

What may the only indication of a previous DVT be?

A

Minimal valvular incompetence

53
Q

What can happen when echogenic material is left in the lumen vessel?

A

Incompressibility

54
Q

How do the echos appear within the vein the longer the chronic obstruction or partial residual fibrin deposits exist?

A

Brighter and stronger echos are seen in the vein

55
Q

Is the presence of fibrin strands seen within the vein?

A

May be seen

56
Q

Is the development of CVI and post-thrombotic symptoms such as ulcers and skin changes seen in the UE?

A

Rare to be seen in the UE

57
Q

What type of US mode is used when there is uncertainty as to the availability of superficial veins for the use of bypass conduits?

A

Duplex US

58
Q

What is the most common use for preoperative venous mapping?

A

CABG and LE grafts

59
Q

What are the advantages for preoperative assessment?

A

Documentation of length, diameter, branching, and anomalies before procedure

60
Q

What veins are considered suitable for harvest?

A

When the diameter is greater then 2.5mm

61
Q

Why are the autologous (native) veins the conduit of choice for bypass procedures?

A

Due to long term patency and greater durability rather then prosthetic materials

62
Q

What is the first choice of veins for surgeons for bypass procedures?

A

GSV

63
Q

Why is the GSV the first choice for surgeons when preforming bypass procedures?

A

Excellent length and dimensional features

64
Q

When evaluating the GSV, how should the pt be positioned?

A

1st choice is standing

2nd choice reverse trendelenburg position at 30deg with leg fully externally rotated and knee flexed

65
Q

Why should the pt be kept warm when scanning their leg?

A

To keep veins dilated

66
Q

What type if probe is used for preoperative scanning?

A

10MHz

67
Q

What other vessels are evaluated for preoperative scanning?

A

SSV, femoral vein and basilic and cephalic of the UE

68
Q

What is the preoperative vessels assessed for?

A

Anatomic variants, structural abnormalities, wall thickening, varicosities and valvular incompetence

69
Q

When are diameter measurements taken within the vein?

A

Obtained at intervals along vein

70
Q

What is done when the vein has a borderline diameter?

A

The pt must stand and be remeasured with a tourniquet to obtain max distension

71
Q

In the case of a in-situ graft, can US be used to identify the valves allowing lysis under angioscopic guidance?

A

Yes

Vascular (5 decks)

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