Module 5 : Chronic Venous Pathology Flashcards
chronic venous disease - underlying causes
- dysfunctional valves
- chronic outflow obstruction
dysfunctional valves
- primary = congenital
\+ absence of valves
\+ structure of valves mess d up
- secondary
\+ previous DVT
\+ post thrombotic syndromechronic outflow obstruction
- iliofemoral veins post DVT
- recanalized vein or collaterals
+ decreased venous return
+ increase venous pressures - limb swelling and pain
symptoms of chronic venous insufficiency
- swelling and edema
- heaviness/ache
- discolouration/hyperpigmentation/brawny discolouration - gaiter sone
- varicosities
- venous claudication = intense burning
- stasis dermatitis/dry flaky skin
- telangiectasia
skin changes specific to chronic insufficiency
- edema
- brawny discoloration
- ulceration
- redness/rubor
edema
- fluid accumulation in tissue due to increase venous pressure
brawny discoloration
- browns color in gaiter zone
- result of leakage of RBC into surrounding tissue
ulceration
- tissue breakdown
- usually near medial malleolus
- typically occurs with deep vein GSV SSV incompetence
redness/rubor
- inflammation
- cellulitis
reflux
- retrograde flow in the veins
- caused by absent or incompetent valves
- results in venous hypertension due to
+ failed valves
+ calf muscle pump is ineffective
+ failure of perforating vein
venous hypertension - failed valves
- allows full gravitational/hydrostatic pressure exerted on the vein walls
venous hypertension - calf muscle pump is ineffective
- decreases ejection of blood that results in increased residual venous volume
venous hypertension - failure of perforating veins
- allows flow to reverse from deep to superficial veins
- high pressure in deep system is transferred to the weaker superficial system
- causes symptoms of heaviness and aching
varicose veins
- palpable
- distended greater than 4mm in diameter
- primary and secondary
varicose veins - primary
- dilated tortuous
- restricted to the superficial system
+ increased intraluminal pressure due to pregnancy obesity and prolonged standing - treatment : surgical ligation (vein stripping)
varicose veins - secondary
- due to obstructive conditions such as a previous DVT
- treatment
+ do not benefit from vein stripping
+ support stockings
+ surgical ligation of perforators
intraluminal pressure and perforators
- INCREASED DEEP VEIN INTRALUMINAL PRESSURE MAY CAUSE PERFORATORS TO DILATE AND BECOME INCOMPETENT
lower extremity venous insufficiency duplex exam - position
- patient standing or with the bed in an extreme reverse trendelenberg
- supine position ineffective for reflux assessment
- standing
+ uses stool or platform with handrail
+ holds handrail
+ rotate leg outward
+ transfers weight to opposite leg - calf veins examined
+ sitting or legs over bed
lower extremity venous insufficiency duplex exam - provocative maneuvers - valsalva
- assess PROXIMAL VENOUS VALVES FOR COMPETENCY
- inhale deeply hold their breath and contract the abdomen
- ask patient to release breath and relax abdomen after 1-2 seconds
lower extremity venous insufficiency duplex exam - provocative maneuvers - augmentation
- used to determine reflux below the knee
protocol
- rule out DVT in deep system
+ compression - assess deep venous system for phasicity and reflux
+ color and spectral waveform
+ use valsalva and distal leg augmentation
protocol - assessing the superficial system - gsv
- gsv
+ measure diameter
- transverse plane prod mid distal
+ color and spectral
- valsalva and augmentation for reflux
- SFJ (superficial femoral junction)
- look for accessory veins, duplication, varicosity
protocol - assessing superficial system - ssv
- measure diameter
+ transverse plane
+ start at ankle and work superior to SPJ
+ if less than 2mm mot likely competent - color and spectral
+ saphenopopliteal junction SPJ
protocol - assessing superficial system - assess perforators
- normally difficult to see
- seated
- medial calf to cocketts
- transverse plane tibiomedial condyle
- check for flow
+ should be towards the deep veins and < 3mm - best assessed with color
normal valve closure time
- within 0.5 seconds
abnormal perforators looks
- have bidirectional flow and lumen of > 4mm
+ endoscopic perforator surgery has become popular in recent years and location and size of these connecting veins essential - limitation of exam ar obesity, pitting edema, bony structures, cat and bandages
abnormal reflux time
- deep : >/= 1 sec
- superficial : >/= o.5 sec
- perforator : >/= o.35 sec
size of GSV at SFJ
- > 9mm
size of GSV at mid thigh
- > 7mm
size of GSV at mid calf
- > 5mm
continuous wave doppler assessment
- effective to determine the presence and origin of reflux
- GSV and SSV as well as calf perforators
- acute disease and chronic
- no image
- based on evaluation of auditory signals n the resting position and comparison to signal received
- need good knowledge of anatomy
treatment - medical - injection sclerotherapy
- for small varicose vein
- injecting sodium tetradecyl sulphate into the varied
- which causes fibrosis and eventual obliteration of lumen
treatment - medical - controlling risk factors
- limit long periods of inactivity
- promote venous drainage
+ support stockings
+ elevate legs
+ unna boots (medicated compression dressings)
treatment - surgical - ligation
- incompetent superficial veins
- rarely valvular reconstruction or valve transplant
treatment - surgical - vein stripping
- varicose vein therapy involves stepping entire saphenous vein or local excision of varicosities
treatment - surgical - Venous ablation
- inject chemical into GSV to occlude it
treatment - surgical - traditional phlebotomy
- multiple incision then hook and pull out
- vein tied off
- wire threaded up through leg
endovascular treatment
- radio frequency ablation
- transilluminated power phlebotomy
+ minimally invasive
+ illuminating device into vein
+ vein sucked out - laserthermal ablation
preoperative venous mapping
- duplex ultrasound used to determine availability of superficial veins for use as bypass conduits
- most common use if for CABG (coronary artery bypass graft) and lower extremity grafts
- autologous (native) veins remain the conduit of choice due to long term latency and greater durability
preoperative venous mapping method
- first choice GSV (excellent length )
- preoperative marking of vein along with written report as to size length and branching is essential
+ marking allows surgeon to cut directly to vein - evaluate GSV
+ standing and reverse trendelenbeg - keep warm to keep veins dilated
- prove latency
- asses for anatomic variation and structural abnormalities
- obtain diameter along vein
+ 2.5mm in trans - vein marked on skin to identify location
