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Vascular > lower extremity venous disease and risk factors > Flashcards

lower extremity venous disease and risk factors Flashcards

1
Q

Virchow’s triad

A

stasis

intimal injury

hypercoagulability

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2
Q

risk factors for thrombosis

A

Stasis: bed ridden (paralysis, surgery), elderly, obese, heart disease (CHF, MI, hypotension, COPD)

Trauma:  surgery, fractures, needle stick

Hypercoagulability: pregnancy, oral contraceptives (or estrogen intake), malignancy, myeloproliferative disorders, h/o DVT

Ask about grafts, bypass surgery, anticoagulant or lytic therapy

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3
Q

types of venous disease

A

thrombosis and valve incompetence

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4
Q

types of thrombosis

A

Acute
Chronic
Phlegmasia alba dolens
Phlegmasia cerulea dolens

Superficial thrombosis

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5
Q

what types of valve incompetence are there?

A

Chronic

Varicose Veins: Primary, Secondary

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6
Q

when does thrombosis generally occur?

A

ofter w/ secondary inflammation (thrombophlebitis) and when mechanisms of virchow’s triad are present

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7
Q

signs and symptoms of acute disease

how reliable are clinical symptoms?

what do they entail?

A

less than 50% reliable

constant acute pain, increased with dependence relieved with elevation
  
Edema Erythema
respiratory distress (if emboli)
  
warm leg red streaks
Homan’s sign (pain with dorsiflexion)

Shortness of breath from pulmonary embolism

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8
Q

pulmonary embolism

A

 Emboli from DVT travels to right atrium > right ventricle > pulmonary artery > lungs
 Should not get to left side of heart or systemic arterial circulation unless ASD

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9
Q

what is the greatest acute, life threatening risk factor of DVT?

A

pulmonary embolism

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10
Q

other causes for symptoms (acute disease) aside from pulmonary embolism…

A

Cellulitis

CHF

Baker’s cyst

Pop aneurysm

lymphadenopathy/ lymphangitis (lymphedema)

musculoskeletal injury

extrinsic compression

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11
Q

chronic disease signs and symptoms

A

Pain

Chronic limb swelling (esp. ankle)

Hyperpigmentation

Venous ulcerations (can be treated w/ maggot therapy)

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12
Q

what do this images show sequentially?

A

progression of venous disease

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13
Q

phlegmasia alba dolens spectrum

what does this disease threaten?

what are its symptoms

A

Phlegmasia – heat; inflamation
Alba – white
Phlegmasia alba dolens (white leg, milk leg)

Limb threatening condition

Acute iliofemoral thrombosis
Distal arterial spasms with decreased pulses

Symptoms
Pallor, Swelling, usually without redness, Cool to touch, May follow parturition or acute febrile illness.

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14
Q

phlegmasia cerulea dolens spectrum

A

Phlegmasia – heat; inflamation
Cerulea – blue (se –roo’le-a)
Phlegmasia cerulea dolens –blue phlebitis, blue leg

Limb threateing condition from severe extensive acute iliofemoral thrombosis

Results from severely reduced venous outflow, causing decreased arterial inflow

Acute fulminaing form of DVT

Symptoms: Cyanosis (bluish), Sudden pain, Massive edema, Venous gangrene (Cruveilhier), progression PCD to tissue necrosis

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15
Q

how is superficial vein thrombosis diagnosed?

what is it characterized by?

A

clinically

warmth/local erythema

Localized thenderness

Palpable subcutaneous hard “cord”

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16
Q

what is valvular incompetence?

what type of venous insufficiency does it represent?

What does it cause?

A

dysfuncitoning venous valves allowing reflux

chronic venous insufficiency

Varicose Veins:

Primary - insufficiency of superficial system only
No obvious cause of valve dysfunction
heredity, trauma, inflammation

Secondary - insufficiency of deep with secondary superficial disease.
AKA postthrombotic syndrome
previous DVT

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17
Q

what does chronic venous insufficiiency affect?

what happens to folks w/ this?

A

More severe and effecting the deep venous system

Damaged or absent valves allow retrograde flow leading to venous hypertension
Calf muscle pump no longer workds
Often secondary to previous DVT that damage the valves (postthrombotic syndrome)

Progression to: Pitting edema or Ulcerations

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18
Q

where do symptoms of chronic venous insufficiency usually appear?

what do they cause?

A

Symptoms usually on medial calf and ankle, less commonly lateral side (“Gator zone”)

Hyperpigmentation – “brawny discoloration”
Stasis dermatitis
Edema

Progression to: Pitting edema and Ulcerations

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19
Q

what does this look like?

A

postthrombotic syndrome

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20
Q

What zone are venous ulcerations generally in?

A

the “gator zone”

Brown or deep red
Shallow but wide
Irregular boarders

21
Q

venous ulceration etiology (theory)

A
  1. Chronic increase in intraluminal pressure.
  2. Increased vein wall permeability, plasma and fibrinogen leak out into surrounding tissue.
  3. Fibrinogen converts to fibrin.
  4. Barrier formation between capillaries and tissue,
    results in a decrease of O2 and nutrient delivery.
  5. Subcutaneous bacteria invasion
22
Q

what is ambulatory venous hypertension?

what does the insufficiency result in?

What does it do to the calf pressure?

what does it cause?

A

Increase in venous pressure when person walks or stands

Insufficiency results in early refilling of venous pool after muscle contraction

Causes progressive and sustained increase in calf vein pressure

Causing: Edema, Varicosities or Ulcers

23
Q

What is the difference between primary and secondary varicose veins?

A

Primary: Superficial system only, unrelated to deep system

Caused by: Hereditary
Congenital absence of valves
Venous hypertension
Trauma
Inflammation

Secondary: Valve damage from previous DVT
Can result in incompetency of: Perforating veins, Superficial veins, Deep veins, Combination of all

24
Q

what could these be?

A

posterior calf varicosities

25
Q

what types of diagnostic testing are available?

A

Venography (angiography)

Isotope venography (Nuclear medicine)

Lung perfusion (nuclear medicine)

CT

MRI

Duplex

Plethysmography

d-Dimer assay

26
Q

venography (angiography) & its limitations

A

Once considered “gold standard”, not currently used

Limitations: Invasive, Venous assess may be difficult, Inadequate contrast filling

27
Q

what type of test is this? what does it look for?

A

Venograms

Intraluminal thrombus, arrows

Calf collaterals

28
Q

May Thurner’s Syndrom

A

Compression of left CIV by right CIA

29
Q

what type of test is a Nuc Med study demonstrates peripheral and pulmonary veins. Very sensitive to actively developing thrombus and calf thrombus.

what are it’s limitations?

A

isotope venography

Limitations: cannot detect established thrombus
sensitive to clinically insignificant thrombus
24 hours to do test

30
Q

what test detects pulmonary perfusion defects m/l from emboli? what are its limitations?

A

lung perfusion scan (VQ scan)

many conditions can cause pulmonary emboli
not specific to venous thrombus

31
Q

what does nuclear medicine look for?

A

evluation for PE, secondary to DVT

32
Q

what type of test shows cross section from pelvis into LE and can reconstruct images?

what are this tests’ limitations?

A

CT or MRI w/ contrast

requires injections, more costly

33
Q

What type of noninvasive tests are available for venous insufficiency.

A

Duplex: 2D, Color Doppler, Spectral Pulsed wave Doppler

Plethysmography: PPG, strain- gauge

34
Q

what type of blood (laboratory) tests are out there

A

d-Dimer

Prothrombin Time (PT)

Partial Thromboplastin time (PTT)

International Normalized Ratio (INR)

Platelet count

Fibrinogen

35
Q

what does the d-Dimer assay test for?

What is elevated d-Dimer test mean?

what other reasons would u see an elevated d-Dimer?

A

r/o active blood clot formation (Fragment D-dimer; Fibrin degradation fragment)

Normal d-Dimer r/o possibility of active thrombotic formation

Elevated d-Dimer abnormally high level of fibrin degradation products present BUT does not mean a blood clot is present JUST indicates that additional testing may be needed to look for a clot

Other reasons for elevated d-Dimer: recent surgery, trauma, infection, liver disease, pregnancy, eclampsia, heart disease, and some cancers

36
Q

what blood tests evaluate:

the ability of blood to clot properly

the function of all coagulation factors, used to screen patients for any previously undetected bleeding problems prior to surgical procedures and monitor patients on anti-coagulant drugs (i.e. warfarin (Coumadin) and heparin)

What does a decrease in these times indicates

A

PT (prothrombin time) and PTT (partial thromboplastin time)

increased risk for clotting

37
Q

what is the international normalized ratio (INR)?

How has the World Health Organization addressed this system variability problem?

A

Calculate ratio used to standardize reporting of patient blood clotting properties

INR = (patient PT/mean normal PT)ISI
Normal INR is 2-3

Prothrombin Time (PT) is known to be very system-dependent

  1. establishment of primary and secondary international reference preparations
  2. development of a statistical model for the calibration of thromboplastins to derive the International Sensitivity Index (ISI) and the INR.
38
Q

what can platelet tests tell you?

A

platelet perform clotting functions

determination of the number of platelets present and/or their ability to function correctly

39
Q

what do fibrinogen tests tell you?

A

Fibrinogen is usually ordered with other blood clotting tests to evaluate ability to form a blood clot.

40
Q

what are ICD9 codes for venous exam?

A

Patient’s must have one of these symptoms or diagnosis to request the exam.

Exams performed without appropriate codes are subject to denial of payment by insurers.

Note the symptoms listed and think about the connection between these symptoms and LE venous disease.

Also note, an arterial and venous exam can not be ordered for the same day – these will not be reimbursed.

41
Q

when would a sonographic test of the LE venous system be ordered?

A

in cases of acute or chronic deep vein thrombosis

42
Q

what type of medical therapy is availabe for thrombus?

A

Controlling risk factors – limit bedrest, elastic stockings, elevation , pneumatic calf compression, Unna Boot for ulcers (medicated compression dressing

Anticoagulant therapy for prophylaxis – low dose heparin

Anticoagulant therapy for acute DVT or PE – loading dose of heparin to prevent propagation of thrombus (will not lyse the clot), oral anticoagulation (coumadin). PT and PTT monitored, regulated at 1.5-2 times normal. Treatment for 5-10 days. Patient remains on coumadin for 3-6 months.

43
Q

what type of surgery thrombosis is available for thrombus?

A

IVC filter (Greenfield or bird’s nest) with acute DVT in patients where anticoagulant therapy is contraindicated. Done via flouro

External IVC clip can be placed during surgical procedures

Thrombolytic therapy – streptokinase or urokinase to dissolve clot

Thrombectomy in cases of complete obstruction and possible limb loss from phlegmasia cerulea dolens (blue phlebitis), fulminating form of DVT with arterial spasm, pronounced edema, severe cyanosis, purpuric areas and petechiae

44
Q

what type of therapy is available for varicose veins?

A

Valvular reconstruction or transplantation for chronic insufficiency – uncommonly done

Ligation of incompetent superficial veins

Vein stripping or excision for varicosities

Percutaneous interventional therapy for varicosities

Sclerotherapy on small varicosities (sodium tetradecyl sulfate)

45
Q

what is the goal of an endovenous occlusion?

how is this accomplished?

A

to permanantly collapse the vein.

Accomplished via catheter placement, entering at approximately the knee and advanced to 1-2 cm below SFV.

Occlude the vein from proximal to distal.

Ultrasound required for pre-procedure evaluation, guidance during the procedure and post-procedure evaluation.

46
Q

what is this procedure?

A

venous ablation technique w/ ultrasound guidance.

2 - diagram of the radio freqency venous ablation

47
Q

what type of procedur sends out radiofrequency, a form of electrical energy, to heat the vessel wall causing collagen contraction.

how do they acheive maximum heat?

what is used to stop clot formation?

A

endovenous radiofrequency closure device

Must have physical contact with the wall, so the catheter has flexible, expandable electrodes.

For maximum heating, blood flow must be stopped during the procedure. Compression at SFJ accomplishes this goal.

Heparinized saline is infused to stop clot formation on the electrodes.

48
Q

what procedure is being done here?

A

US guidance and ablation

49
Q
A

Vascular (9 decks)

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