Diseases of vasculature: Veins

Question 1

Deep vein thrombosis is caused by virchow’s triad: What are the three parts of it?

Answer 1

Endothelial injury, venous stasis, hypercoagulability

Question 2

What are risk factors of deep vein thrombosis that contribute to virchow’s triad

Answer 2

1. ) Prior history of DVT/PE/varicose veins
2. ) Hypercoaguable state: Antithrombin 3 deficiency, factor V leiden, protein C/S deficiency, pregnancy, estrogen use
3. ) CHF, obesity, surgery/trauma, age, malignancy

Question 3

How does one present clinically with deep vein thrombosis

Answer 3

Pain/swelling in legs that is worse with walking

Homans sign (pain on ankle dorsiflexion)

Palpable with fever

Question 4

When diagnosing a patient with suspected DVT, what is the initial test

Answer 4

Doppler/Duplex Ultrasound - better for detecting proximal thrombi (popliteal, femoral) than distal (calf)

Question 5

Although not the initial test, what is the most accurate test for a DVT

Answer 5

Venography: Visualizes everything but invasive

Question 6

What test could you use to rule out DVT but has to be done with other tests for confirmation

Answer 6

D-dimer test: The rule out test - High sensitivity, low specificity, combine with doppler

If negative, high likelihood you don’t have it

Question 7

Once the diagnosis of DVT is confirmed via doppler, what is the first step in treatment. What happens if doppler is negative?

Answer 7

If positive, begin anticoagulation (heparin followed by warfarin due to warfarin’s slow onset)

If negative, repeat ultrasounds

Question 8

What are three complications of deep vein thrombosis

Answer 8

1. ) Pulmonary embolus
2. ) Chronic venous insufficiency - can lead to ambulatory HTN
3. ) Phlegmasia cerulea dolens - so much swelling that arteries compromised, leading to motor and sensory symptoms, must do venous thrombectomy

Question 9

In summary, what were all the diagnostic tests discussed for DVT

Answer 9

1.) Doppler/Duplex
2 .) Venography
3.) D-dimer test

Question 10

What is chronic venous insufficiency and what does it usually occur after

Answer 10

When a history of DVT (the underlying cause) causes destruction of the venous valves in deep venous system, resulting in blood pooling at the bottom of legs from gravity. It also destroys the venous valves in the perforation veins, preventing transmission of blood from superficial to deep veins.

Question 11

What is the main result of chronic venous insufficiency

Answer 11

Ambulatory venous HTN, resulting in interstitial fluid accumulation (edema), and extravasion of plasma proteins and RBCs causing brawny induration and pigmentation of skin

Question 12

Besides causing ambulatory venous HTN in chronic venous insufficiency, what is a consequence in terms of capillary blood flow

Answer 12

Capillary blood flow diminished, causing hypoxia so even mild trauma can cause tissue death and ulcer formation, and venous ulcers form

Question 13

What are the clinical features seen in chronic venous insufficiency and compare it to DVT

Answer 13

1. ) Swelling of lower leg, causing aching and tightness that is worsened by sitting or inactive standing (DVT just got worse with walking but relieved with rest)
2. ) Skin changes (brawny induration), and venous ulcers above medial malleolus - DVT did not have these, and arterial insufficiency ulcers are much more painful

Question 14

What relieves the swelling in legs in chronic venous insufficiency, and compare with arterial insufficiency

Answer 14

Leg elevation (opposite is true for arterial insufficiency)

Question 15

The treatments for chronic venous insufficiency differs if there are ulcers vs. if there are no ulcers. What is the treatment for each?

Answer 15

1. ) No ulcers - Leg elevation, stockings
2. ) Ulcers - wet to dry saline dressings, compression stockings, split thickness skin graft if compression stockings doesn’t work

Question 16

What is superficial thrombophlebitis caused by, and what is the different reasons for upper extremity vs. lower extremity

Answer 16

Caused by virchow’s triad

Upper extremity: IV infusion site
Lower extremity: Varicose veins in greater saphenous system 2ndary to static blood flow

Question 17

How does superficial thrombophlebitis look and feel

Answer 17

Pain and erythema along vein

Question 18

In superficial thrombophlebitis, is anticoagulation indicated?

Answer 18

No

Question 19

The treatment of superficial thrombophlebitis depends on whether its localized or severe with pain and cellulitis. What is the treatment for each?

Answer 19

Localized: Aspirin, continue activity

Severe with cellulitis: Bed rest, elastic stockings when ambulating, may drain if suppurative, if septic then do antibiotics

Question 20

What is the treatment for deep vein thrombosis and the order you must do it in, including INR values and timelines

Answer 20

Thrombolytic therapy: Only if massive PE, hemodynamically unstable, RVF, or no contraindications

Anti coagulation: Heparin until 1.5-2x PTT, then start warfarin once PTT is therapeutic and get INR to 2.0-3.0 and continue for 3 to 6 months. You can stop heparin once therapeutic INR for 48 hours

Question 21

When would you consider placing a prophylactic IVC filter for DVT patients

Answer 21

Contraindicated to everything else, but can only prevent PE (makes sense)

Question 22

What should you start thinking about if you see superficial thrombophlebitis develop in different locations in a short amount of time

Answer 22

Migratory superficial thrombophlebitis: Secondary to malignancy of pancreas - do ct scan