Lecture 18: PVD Flashcards
What are the essentials of diagnosis of varicose veins?
- Dilated, tortuous, superficial veins in the leg
- Asymptomatic or aching discomfort/pain
- Often hereditary
- Increased frequency post pregnancy
What are the main contributing factors to varicose veins?
- Postpartum women (MC)
- Prolonged standing
- Heavy lifting
What are the two underlying mechanisms that contribute to varicose veins?
- Poor venous reflux (valves causing backflow)
- Venous Hypertension
What vein is MC affected as a varicose vein?
Great saphenous vein (medial leg)
What are some possible causes of secondary varicosities?
- Thrombophlebitis
- Proximal venous occlusion (rare)
- Congential/AV malformations
What is the MC complaint for varicose veins?
Dull, aching heaviness after periods of standing.
What secondary symptom may occur over varicose veins?
Itching due to venous eczema
Does the # or size of varicosities correlate with symptoms?
NO
What is the chronic condition that may result with long-standing varicose veins?
Chronic venous insufficiency
What characterizes chronic venous insufficiency?
- Ankle edema
- Brownish skin pigmentation
- Chronic skin induration or fibrosis
How are varicose veins diagnosed?
Clinically, but duplex sonography can be ordered as the imaging of choice for planning surgery
What is the nonsurgical tx for varicose veins?
- Compression stockings (20-30 mm Hg)
- Leg elevation
You only wear stockings during waking hours
What is sclerotherapy?
Direct injection of a sclerosing agent to cause permanent fibrosis.
What is endovenous laser therapy?
EVLA requires local anesthesia and a laser to destroy the small vein.
When is endovenous radiofrequency ablation a preferred procedure?
For significant varicose veins with signs of venous insufficiency or long varicosities
When is vein stripping used?
Removing part of the vein that is tortuous
LAST RESORT
What are the essentials of diagnosis of chronic venous insufficiency?
- History of DVT or leg injury
- Edema, brawny skin pigmentation, or subcutaneous lipodermatosclerosis in lower legs
- Ulcerations at or above medial ankle
What is the MC etiology of chronic venous insufficiency?
Prior deep venous thrombophlebitis
What is a major complicating factor for patients with chronic venous insufficiency?
Obesity
What exactly does venous insufficiency lead to in the vein itself?
Failure of the valve leaflets to close due to scarring and thickening
Ultimately leads to edema
If a muscle biopsy were taken of someone with chronic venous insufficiency, what might be seen?
- Interstitial space changes
- Enlargement and fibrosis (elevated fibrinogen and fibrin)
- Edema and inflammation
Leads to more capillaries
What is peri-capillary fibrosis?
Subcutaneous thickening and induration
What results from erythrocyte lysis in chronic venous insufficiency?
Hemosiderin deposits => brownish skin
What is the primary symptom of someone with chronic venous insufficiency?
Progressive, pitting edema of the lower leg.
What are the secondary conditions that may occur in chronic venous insufficiency?
- Stasis dermatitis
- Lymphedema
What does chronic venous insufficiency look like?
- Taut, shiny skin at the ankle
- Hemosiderin staining => brownish skin pigmentation
- Loss of skin integrity => secondary cellulitis
What is lipodermatosclerosis?
- Panniculitis subtype
- Inverted champagne bottle/bowling pin appearance
What is atrophie blanche?
Star-shaped, ivory white atropic plaque
What is corona phlebectatia?
Abnormally dilated veins around the ankles
How is chronic venous insufficiency diagnosed?
Clinically
What is the imaging test of choice for planning therapy in regards to chronic venous insufficiency?
Duplex ultrasonography
What is the backup imaging for chronic venous insufficiency?
MDCT venography or MR venography, but requires dye
Only used if doppler was nondiagnostic
What are the mainstays of treating chronic venous insufficiency?
- Compression stockings
- Avoid sitting a long time
- Pneumatic compression for refractory cases
What is an unna boot and what is it for?
Paste gauze compression dressing used for both compression and topical therapy
Weekly changed
If a patient develops an ulcer in chronic venous insufficiency, what do they need?
A wound care team
What are the essentials of diagnosing superficial venous thrombophlebitis?
- Red, painful induration along a superficial vein
- Commonly occurs at the site of a recent IV line
- Marked swelling of extremity may occur
What is the MCC of superficial venous thrombophlebitis?
Recent catheter placement
Caused by staph
Where does superficial venous thrombophlebitis typically occur?
Lower extremities
MCC: Great saphenous vein
What is the lingering thing that may occur with superficial venous thrombophlebitis?
Palpable cord
What is the main complication of superficial venous thrombophlebitis?
Suppurative thrombophlebitis
How is superficial venous thrombophlebitis diagnosed?
Clinically.
What are the 3 complications of suppurative thrombophlebitis?
- Metastatic abscess formation
- Septicemia
- Septic emboli
When is venous doppler ultrasound indicated for superficial venous thrombophlebitis?
ONLY if involves proximal lower extremity or mixed picture
How do we manage superficial venous thrombophlebitis?
- NSAIDs & compression stockings with no limitations on daily activities.
- Larger/more painful ones may require hot, wet compresses and leg elevation as well.
What would indicate us to use anticoagulants for superficial venous thrombophlebitis? And what are the 3 anticoagulants?
If it is 5cm or longer.
Use: arixtra/fondaparinux, LMWH, or xarelto for 45days
Full-dose if it is rapidly progressing
If the patient ends up septic from superficial venous thrombophlebitis, what is the goto ABX combo?
Rocephin + Vanco + (LWMH or fondaparinux)
The goto
What are the essentials of diagnosing lymphangitis?
- Red streaking from wound or cellulitis towards regional lymph nodes, which are typically enlarged and tender.
- Chills, fever, malaise may be present.
Ang = channels
Extends proximally!
What is the MCC of lymphangitis and the 2 main causative organisms?
Cutaneous inoculation of hemolytic strep or Staph
What is lymphatic filariasis?
Lymphedema caused by a mosquito (Wuchereria bancrofti).
MC cause of acute lymphangitis worldwide previously
What is nodular lymphangitis?
Painful or painless nodular subcutaneous swelling along lymphatic channel.
Always consider malignancy!
What is the MC malignancy that causes lymphangitis?
Breast cancer
How does lymphangitis typically present in the clinic?
Trauma/abrasion DISTALLY to infection site
How do we diagnose lymphangitis?
- CBC w/diff and blood cultures are a MUST.
- Wound culture and I&D
- Imaging for anatomic abnormalities
What imaging may be indicated for lymphangitis?
Lymphangiography and lymphoscintigraphy
What is the empiric ABX therapy for lymphangitis?
GABHS coverage: Dicloxacillin, keflex, ancef, rocephin, bactrim, etc
Who can undergo oral abx therapy outpatient for lymphangitis?
- Non-toxic
- Non-febrile
- Not immunocompromised
What kind of compresses help lymphangitis?
Hot
What kind of lymphangitis usually needs surgical intervention?
Nodular lymphangitis
What are the essentials of lymphedema?
- Painless, persistent edema of one or both legs, usually young women.
- Pitting edema w/o ulceration, varicosities, or stasis pigmentation.
- Lymphangitis and cellulitis could also develop
What is the primary form of lymphedema?
Congenital hypo/hyperplastic lymphatics.
Worsening condition: pelvic or lumbar involvement.
What is the secondary form of lymphedema?
Inflammatory or mechanical lymphatic obstruction from trauma, regional lymph node resection/irradiation, or malignancy, often following surgical removal of the lymph nodes in the groin or axilla.
What can happen in both forms of lymphedema?
Secondary dilation of the lymphatics
How is lymphedema diagnosed?
Clinically. MRI only for identifying masses.
How is lymphedema managed?
- Intermittent leg elevation
- Compression stockings
- Massage toward the trunk
- Wound care
- Good hygiene
- Amputation for lymphangiosarcoma
