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Integumentary > Lesson 3: Venous Insufficiency > Flashcards

Lesson 3: Venous Insufficiency Flashcards

1
Q

Prevalence of chronic venous insufficiency:

A

9.4%

70–90% of leg ulcers are due to VI

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2
Q

Who is at risk for VI:

A

Women have 3x greater risk

Risk of VI ulcer is 7.5x greater after age 65

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3
Q

Recurrence rate of VI:

A

13–81%

Recurrence correlated with nonadherence

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4
Q

According to research, who is most likely to develop VI?

A

Patients > 60 years old, with history of blindness, cataracts, renal insufficiency, or a history of pressure ulcers

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5
Q

How much blood does the venous system store?

A

70-80% of total blood volume

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6
Q

Anatomy of Leg Veins

A

Deep system
Superficial System
Perforators

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7
Q

Deep Vein Function

A

Lay beneath the muscle fascia
Responsible for 80- 90% of the venous return
Drain the lower extremity musculature
Typically paired with an artery (femoral, popliteal, tibial)

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8
Q

Superficial Vein Function

A

Lay above the deep fascia
Drain the cutaneous microcirculation
Great and small saphenous veins lay between the muscle fascia and the saphenous fascia
Reticular veins lay between the saphenous fascia and the dermis

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9
Q

What do superficial veins assist with?

A

temperature regulation

Carry about 10% of the venous return

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10
Q

Perforators Vein Function

A

Penetrate the deep fascia
Connect the Superficial and deep systems
An average of 64 perforators between the ankle and the groin
1 to 3 valves to direct flow from superficial to deep

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11
Q

What does the intimal layer excrete?

A

antithrombogenics

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12
Q

What does the medial layer contain?

A

3 thin layers of smooth muscle adrenergically innervated muscle weaker than that in arteries

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13
Q

Adventitial layer-

A

thick outer wall rendering veins stiffer than arteries aiding in calf pump

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14
Q

Proximal flow of venous blood relies on

A

Respiratory pump
Calf muscle pump
Valves

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15
Q

Calf Pump

A

Most efficient of the venous pumps (foot, calf, and thigh)

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16
Q

What does calf pump use?

A

crural fascia and extensive valves to generate 65% ejection fraction.

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17
Q

Pressure in venous system:

A

As blood is pushed from deep veins, venous pressure decreases allowing veins to refill from the superficial system through the perforators

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18
Q

Vein Bicuspid Valves

A

Formed from folds of vein endothelium
More numerous distally, lessen toward the hip
Insure flow from superficial to deep and from caudal to cephalad
Close when pressure gradient is reversed, <0.5 second reflux/delay is normal

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19
Q

Common causes of venous insufficiency

A

Vein dysfunction

Calf muscle pump failure

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20
Q

Ulceration Pathophysiology

A

Venous hypertension causes leakage into interstitial space of fluid and white blood cells
Edema and blood products cause inflammation
Inflammation leads to skin failure

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21
Q

Risk factors contributing to VI ulcers

A 
Vein dysfunction
Calf muscle pump failure
Trauma
Previous VI ulcer
Advanced Age
Diabetes
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22
Q

Vein Dysfunction

A 
Venous hypertension
Valve damage
Degeneration
Scarring
Inflammation
Clot sequelae
Varicosity
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23
Q

Calf muscle pump function:

A

Calf weakness/paralysis
Decreased dorsiflexion
Prolonged standing
Incompetent valves

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24
Q

Trauma

A

Benign trauma to venous-insufficient leg may result in ulceration due to edema-induced local tissue hypoxia

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25
Q

Previous VI Ulcer:

A

Recurrence rate as high as 81%
Local tissue hypoxia and malnutrition
Scar tissue from prior ulcer increases risk of skin breakdown
Precipitating factors/wound etiology not successfully addressed

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26
Q

Advanced Age:

A

Anatomical and functional changes that occur
with aging
Valve degeneration

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27
Q

Diabetes:

A

Increased microvascular disease
Impaired immune response
Impairs all 3 phases of wound healing

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28
Q

PT Tests and Measures for VI

A

Clinical Assessment for DVT
Ankle-Brachial Index
Trendelenburg Test
Venous Filling Time

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29
Q

What is the gold standard for DVT:

A

venogram

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30
Q

Trendelenburg Test

A

Supine, leg in 45° elevation for 1 minute
Note venous distension
Tourniquet to distal thigh
Stand upright
Note time for superficial venous distention
Release tourniquet

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31
Q

Trendelenburg Test indications:

A

To differentiate deep or perforating vein incompetence from superficial vein incompetence

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32
Q

Brodie-Trendelenburg Test

A

Differentiates between perforator and GSV incompetence
Legs elevated to 45 degrees and tourniquet placed at groin
Patient stands and tourniquet is removed
Vein re-filling determines level of incompetence

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33
Q

Tendelenburg test time to venous distention greater than 20 seconds, tourniquet on:

A

deep or perforator vein incompentence

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34
Q

Tendelenburg test time to venous distention greater than 10 seconds, tourniquet off

A

superificial vein incompetence

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35
Q

Perthes Test

A

Tourniquet placed below knee and 10 heel raises performed
If varicose veins empty, site of reflux is cranial to the tourniquet in the SFJ, SPJ, or thigh perforators
If varicose veins remain distended, site of reflux caudal to the tourniquet in calf perforators
Pain with heel raising indicates possible of deep venous obstruction

36
Q

Indications of venous filling time:

A

Unable to tolerate ABI
ABI > 1.1
History of diabetes or vessel calcification
Suspected concomitant arterial insufficiency

37
Q

Venous Filling Time

A

Predictor for arterial insufficiency
Patient supine, note superficial veins on dorsal foot
Elevate the limb 60° for 1 minute or until veins are drained by gravity
Lower limb to dependent position, note time for veins to refill

38
Q

Doppler Ultrasound

A 
Gold standard for venous system
More subjective than arterial Doppler
Resting test
Augmentation test
Reflux test
39
Q

Indications for Doppler Ultrasound:

A 
Gold standard for venous system
More subjective than arterial Doppler
Resting test
Augmentation test
Reflux test
40
Q

CO

A

asymptomatic

41
Q

CI

A

telangiactasias or spider veins <3mm

42
Q

C2

A

varicose veins>/= 3mm

43
Q

C3

A

leg edema

44
Q

C4

A

skin and subcutaneou tissue change

45
Q

C4A:

A

hemosideran deposition

46
Q

C4B:

A

lipodermatosclerosis

47
Q

C5

A

healed venous ulcer

48
Q

C6

A

current venous ulcer

49
Q

Telangiectasis and Reticular Veins

A

Treated for cosmesis
Indicate early stages of chronic venous insufficiency
Dilation of surface veins causes vein prominence

50
Q

Telangiectaisis/spider veins-

A

0.5 to 1 mm diameter

51
Q

Reticular veins-

A

bluish discoloration- 1-3 mm diameter

52
Q

Varicosities

A

Present in 10-15% of men and 20-25% women in Western population
Dilated >4mm in diameter
Mainly occur in great and short saphenous veins

53
Q

Hemosiderin Staining

A

Venous dilatation allows passage of red blood cells through the endothelium into the interstitium
Breakdown converts hemoglobin to hemosiderin
Brown pigment stain usually occurs on the lower medial third of the leg
Darkens over time

54
Q

Lipodermatosclerosis

A

Inflammation of the layer of fat under the skin

55
Q

Lipodermatosclerosis results in:

A 
Pain
Hardening of skin
Redness
Swelling
Tapering of the legs above the ankles (champagne bottle deformity)
56
Q

VI etiology:

A

Impaired venous return > increased hydrostatic pressure> Stasis hypertension > dermal ulceration

57
Q

Venous signs:

A

Eschar or slough, wet, yellow fibrous
Moderate to heavy exudate
Tortuous veins
Edematous leg

58
Q

Wound edges in VI:

A

Shallow wounds

Irregular wound edges

59
Q

Location of VI insufficiency:

A

Superior to Malleoli, usually medial

Surrounding skin dry and scaly

60
Q

Pulses with VI:

A

present

61
Q

Pain with VI ulcers:

A

Pain in dependent position, decreased with elevation, usually minimal dull ache or heaviness

62
Q

What is pain in VI ulcers caused by?

A

Caused by valvular incompetence, obstruction of deep venous system, or congenital absence or malformation of venous valves
Foot warm, ABI >.8

63
Q

Periwound and Structural Changes

Venous ulcer:

A

Edema
Cellulitis, dermatitis
Hemosideran deposition
Lipodermatosclerosis

64
Q

Temperature in VI:

A

normal to mild warth

65
Q

Healing time for full-thickness venous ulcers with appropriate interventions

A

Average eight weeks
Smaller ulcers 5–7 weeks
Larger ulcers 10–16 weeks

66
Q

VI ulcers with good healing:

A 
Small size
Decrease in size in first 
2–3 wks of treatment
No deep vein involvement
Adherence with compression
67
Q

VI ulcers with poor healing:

A 
Large size
Increase in size over 
4 wks of treatment
Concomitant PAD
Older age, higher BMI
68
Q

Not Predictive of CVI Healing

A

Gender
Race
Skin condition
Presence of infection

69
Q

Patient/Client-Related Instruction

A

Educate about etiology
Explain link between disease process and interventions for wound healing
Inform of risk factors for re-ulceration
Identify patient and caregivers’ beliefs about treatment to maximize adherence and outcomes

70
Q

Provide guidelines

A 
Control swelling
Protect your feet and legs
Live healthy
Know when to call clinician
Inform patients of proper positioning and exercises to enhance venous return
71
Q

Request for Further Medical Testing

A

Patients scoring 3 or more on DVT clinical prediction guidelines
Wounds that fail to progress
Wound culture and sensitivity if suspect infection
Bone scan/X-rays if exposed capsule or bone
Wounds that do not present with typical VI ulcer characteristics

72
Q

Keys to Local Wound Care

A

Protect surrounding skin
Address wound bed
Enhance venous return
Educate patient/caregiver

73
Q

Protect Surrounding Skin

A

Moisturize dry, scaling skin
Use topical steroids to decrease inflammation or weeping
Use topical agents prudently to avoid sensitization

74
Q

Intervention Goals

A

Non adherent dressings to protect delicate skin
Gentle debridement- enzymatic or autolytic due to severe tenderness
Compression to promote venous return- 4-layer wraps, short stretch wraps, compression stockings
Elevation
Exercise to promote venous return

75
Q

Effects of Compression

A 
enhances calf muscle pump
improves venous return
decreases peripheral edema
reduces venous distention
increases tissue oxygenation
softens lipdodermtosclerosis
protects limb from trauma
limits need for prolonged elevation/bed rest
76
Q

Compression Parameters

A

30–40 mm Hg at ankle
10 mm Hg at infrapatellar notch
If severe VI, can increase to 40–50 mm Hg
If mild AI, can decrease to 20–30 mm Hg

77
Q

Contraindications to Compression

A 
ABI < 0.7
Acute infection
Pulmonary edema
Uncontrolled or severe congestive heart failure
Active DVT
Claustrophobia (relative)
78
Q

Therapeutic Exercise

A

Range of motion exercise
Aerobic exercise
Gait and mobility training
Focus on Calf pump!!!!

79
Q

Stripping and Ligation of the Great Saphenous Vein

A

A Saphenectomy strips the vein from the SFJ to the popliteal fossa
Stripping into the calf can be complicated by Saphenous nerve injury
Skeletonization or ligating and disconnection of each saphenous tributary in the groin contributes

80
Q

Varicose Vein Ligation

A

In the 70’s-80’s segmental ligation of visible varicosities utilizing multiple incisions was performed but missed affected veins not visible
Research shows venous insufficiency must be addressed at its point of highest reflux

81
Q

Microphlebectomy

A

May be performed alone or in combination with other vein procedures
Hooks are used to pick up the vein and bring it through the incision where it is transected
Used to remove visible varicose saphenous tributaries or clusters are associated with incompetent perforating veins

82
Q

Endovenous Vein Obliteration

A

Radiofrequency (RF) or laser thermal energy used to destroy the vein endovascularly
Mostly used to treat great and small saphenous veins
Preoperative vein mapping with duplex ultrasound to determine location to be treated
Need to perform at least 2 cm distal from the SFJ to prevent femoral vein DVT

83
Q

Sclerotherapy

A

Non-surgical option for ablation
Injection of a special chemical (sclerosant) damages and scars the inside lining of the vein causing the vein to close.
May cause staining visible through the skin

84
Q

Liton’s Procedure

A

1950s technique
Surgical ligation of subfascial perforators through three long calf incisions
Abandoned because of wound complications
Later modified using smaller incisions and skin grafts but complications still common

85
Q

Phlebotome Device

A

Introduced through a small incision just below the knee and is advanced subfascially toward the medial malleolus
Disrupts the perforators blindly as it is advanced

86
Q

SEPS

Subfascial Endoscopic Perforator Surgery

A

Instruments are introduced into the subfascial space through two small incisions
Each perforator is identified and clipped
Often combined with saphenous vein ablation

87
Q

Valvuloplasty

A

most frequent procedure used for primary deep reflux
Good result in 70% of cases in freedom of ulcer recurrence and the reduction of pain, valve competence and hemodynamic improvement 5 years post
External transmural valvuloplasty not as reliable as internal valvuloplasty in providing long-term valve competence or ulcer free-survival

Integumentary (18 decks)

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