Diseases of vasculature: Veins Flashcards
Deep vein thrombosis is caused by virchow’s triad: What are the three parts of it?
Endothelial injury, venous stasis, hypercoagulability
What are risk factors of deep vein thrombosis that contribute to virchow’s triad
- ) Prior history of DVT/PE/varicose veins
- ) Hypercoaguable state: Antithrombin 3 deficiency, factor V leiden, protein C/S deficiency, pregnancy, estrogen use
- ) CHF, obesity, surgery/trauma, age, malignancy
How does one present clinically with deep vein thrombosis
Pain/swelling in legs that is worse with walking
Homans sign (pain on ankle dorsiflexion)
Palpable with fever
When diagnosing a patient with suspected DVT, what is the initial test
Doppler/Duplex Ultrasound - better for detecting proximal thrombi (popliteal, femoral) than distal (calf)
Although not the initial test, what is the most accurate test for a DVT
Venography: Visualizes everything but invasive
What test could you use to rule out DVT but has to be done with other tests for confirmation
D-dimer test: The rule out test - High sensitivity, low specificity, combine with doppler
If negative, high likelihood you don’t have it
Once the diagnosis of DVT is confirmed via doppler, what is the first step in treatment. What happens if doppler is negative?
If positive, begin anticoagulation (heparin followed by warfarin due to warfarin’s slow onset)
If negative, repeat ultrasounds
What are three complications of deep vein thrombosis
- ) Pulmonary embolus
- ) Chronic venous insufficiency - can lead to ambulatory HTN
- ) Phlegmasia cerulea dolens - so much swelling that arteries compromised, leading to motor and sensory symptoms, must do venous thrombectomy
In summary, what were all the diagnostic tests discussed for DVT
1.) Doppler/Duplex
2 .) Venography
3.) D-dimer test
What is chronic venous insufficiency and what does it usually occur after
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.
What is the main result of chronic venous insufficiency
Ambulatory venous HTN, resulting in interstitial fluid accumulation (edema), and extravasion of plasma proteins and RBCs causing brawny induration and pigmentation of skin
Besides causing ambulatory venous HTN in chronic venous insufficiency, what is a consequence in terms of capillary blood flow
Capillary blood flow diminished, causing hypoxia so even mild trauma can cause tissue death and ulcer formation, and venous ulcers form
What are the clinical features seen in chronic venous insufficiency and compare it to DVT
- ) 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)
- ) Skin changes (brawny induration), and venous ulcers above medial malleolus - DVT did not have these, and arterial insufficiency ulcers are much more painful
What relieves the swelling in legs in chronic venous insufficiency, and compare with arterial insufficiency
Leg elevation (opposite is true for arterial insufficiency)
The treatments for chronic venous insufficiency differs if there are ulcers vs. if there are no ulcers. What is the treatment for each?
- ) No ulcers - Leg elevation, stockings
- ) Ulcers - wet to dry saline dressings, compression stockings, split thickness skin graft if compression stockings doesn’t work
What is superficial thrombophlebitis caused by, and what is the different reasons for upper extremity vs. lower extremity
Caused by virchow’s triad
Upper extremity: IV infusion site
Lower extremity: Varicose veins in greater saphenous system 2ndary to static blood flow
How does superficial thrombophlebitis look and feel
Pain and erythema along vein
In superficial thrombophlebitis, is anticoagulation indicated?
No
The treatment of superficial thrombophlebitis depends on whether its localized or severe with pain and cellulitis. What is the treatment for each?
Localized: Aspirin, continue activity
Severe with cellulitis: Bed rest, elastic stockings when ambulating, may drain if suppurative, if septic then do antibiotics
What is the treatment for deep vein thrombosis and the order you must do it in, including INR values and timelines
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
When would you consider placing a prophylactic IVC filter for DVT patients
Contraindicated to everything else, but can only prevent PE (makes sense)
What should you start thinking about if you see superficial thrombophlebitis develop in different locations in a short amount of time
Migratory superficial thrombophlebitis: Secondary to malignancy of pancreas - do ct scan
