Peripheral Vein Disease Flashcards
What structures within the vein assist in pushing blood back towards the heart?
Valves
Define VV (varicose veins)
Dilated, tortuous superficial veins in lower extremeties
What veins are most commonly affected by VV?
Greater saphenous and its branches
what does distention of the vein lead to in VV?
weakened/incompetent valves and dilation along the vein
What does dilation in VV lead to?
Increased pressure and distention of the vein segment below the valve and progressive failure of the next lower level
r/f for VV?
genetics
prolonged standing
pregnancy
congenital or acquired AV fistula
Primary VV orginate in the ______ system?
superficial
VV are more common in ____ than ____
females than males
Secondary VV originate in the _______ system and _______?
deep system and perforating veins
Signs and symptoms of VV
can be asymptomatic
doesn’t correlate to number and size
if present develops after long periods of standing - dull ache/heaviness or fatigue of legs
may be palpablee in obese
Venous stasis dermatitis
brownish pigmentation and thinning of the skin above the ankle
W/u
Duplex imaging is best
DDX of VV
Chronic venous insufficiency Leg pain d/t 2nd cause -arthritis -radiculopathy -arterial insufficiency congenital malformation/atresia of deep vein in adolescent patients
Complications of VV
Superfician Venous thrombosis (rare)
Bleeding (secondary to trauma)
Non-surgical TX for VV
avoid prolonged standing compression stockings (med-heavy) when standing Leg elevation when possible
Surgical Tx for VV
Radio frequency ablation
Greater saphenous vein stripping
Phlebectomy
compression sclerotherapy
When to refer to a vascular surgeon
Bleeding from VV
Superficial VV
Pain
cosmetic concerns
define superficial venous thrombosis
Clot that develops in superficial vein
Signs and symptoms of svt?
indurated warm red tender cord extending along superficial vein
T/f SVT can develop into PE?
F
R/f of SVT?
Pregnancy varicose veins thromboangitis obliterates trama systemic hypercoagulability
DDx for SVT?
cellulits erythema nodosum erythema induratum lymphangitis DVT
Supportive TX for SVT
Supportive:
elevation, warm compress, NSAID
When is anticoag used in the event of an SVT?
only when a thrombus has developed in thigh/arm and is exteding toward the saphenofemoral junction or cephalon-axillary junction (could potentially migrate to the deep system)
Definition of CVI
condition that occurs when wall and/or valves aren’t working effectively. Blood can’t return to heart
How are CVI and VV different
VV is dilation and malfunctioning
CVI is when the walls and valves aren’t working properly
CVI is a complication of VV but not everyone with VV will develop CVI
CVI is mc in _____ than _____
females than males
Causes of CVI
Secondary to DVT Hx of leg trauma VV Pelvic tumor Vaslcular malformation
with CVI the ______ ______ are either thickened or scarred, or functionaly inadequate. This causes abnormally high hydrostatic forces that are transmitted to the ______ and _____ of the lower leg.
Valve leaflets
subcutaneous veins and tissues
What secondary changes can occur from chronic edema?
fibrosis of subcu tissue and skin
pigmentation of skin
ulceration that are slow to heal
Varicosities if d/t post-thrombotic event
R/f for CVI
DVT VV Obestiy Pregnancy inactivity smoking extended periods of sitting/standint female age over 50
What is primary sign/symp of CVI
Progressing pitting edema of leg!!
What are some of the secondary symp/signs for CVI?
itching
dull ache in leg worse with prolonged standing/sitting
skin at ankle tight and shiny w/ brown pigment
subcu tissue becomes thick and fibrous
ulceration may occur near medial and lateral malleolus
cellulitis
w/u for CVI?
US
TX for CVI
compression stocking-mainstay!
Avoid long periods of sitting/standing
intermittent elevations of leg above level of heart
Tx for wounds that develop as result of CVI
Ulcers-wound care specialist referral
Unna’s boot
Once healed compression
Surgical tx for CVI
for pt’s with chronic/recurrent ulcers
RFA (radiofrequency ablation) or laser to area of ulceration to promote healing
Define DVT
blood clot that develops in deep vein system, and may partially/completely block flow through the vein
Where are DVT’s MC found?
lower extremity (but can develop elsewhere)
Define Virchow’s Triad?
Venous stasis
injury to vessel wall
hypercoagulable state
Etiology of DVT?
Venous stasis D/t
-immobilization
-reduced blood flow to heart (polycythemia)
Reduced flow through legs (abd. mass, pregnancy)
Mechanic injury to vein wall-trauma/surgery
Hyper coagulable state
-genetic mutation
-secondary-surgery malignancy
Complications of DVT
PE
post thrombotic syndrome (CVI_
Phlegmasia alba dolens
phlegmasia cerulea dolens
Defile phlegmasia alba dolens
Edema in the leg puts pressure on arteries which decreases blood flow to area-causes a white leg
Define phlegmasia cerulea dolens
progression of white leg-complete occulsion of not only venous system but also arterial system as well. Prognossi is very poor
Symptoms of DVT
often asymptomatic
leg swelling
leg pain
unilateral leg tenderness
signs of DVT
unilateral pitting edema
increased calf circumference
calf tenderness
Homan’s sign
DDX for DVT
ruptured bakers cyst cellulitis lymphedema thrombophlebitis post-thrombotic syndrome trauma CVI bone neoplasm Heart failure Nephrotic syndrome cirrhosis
w/u for DVT
Well’s criteria
D dimer (non-specific)
US
MR venography (when US is non-specific and there is still a high probability)
what is the high risk score for well’s criteria in DVT?
3 points- 75%
What is moderate risk score for well’s criteria for DVT?
1-2 points 17%
What is low risk score of well’s criteria for DVT?
less than 1 point 3%
What factor does US depend on being present to rule in DVT?
non-compressible veins
TX for DVT?
Preventing complications is primary
Mainstay of TX:
-Immediate anticoag w/ UFH, LMWH or fondaparinux followed by conversion to coumadin or thrombolytics
How long does a pt need to be bridged for warfarin tx?
5-10 days
what is coumadin INR target for pts with DVT?
2.5 (range of 2.0-3.0)
What is more commonly used for tx of DVT and why?
LMWH - lovenox, (vs. UFH), this is because it has a greater bioavailability and is more predictable
Other than LMWH and UFH what can be used for immediate anticoag?
Fondaparinux
What is used for long term DVT oral anticoag?
Warfarin
How many days does it take for warfarin to become therapeutic?
minimum of 5 days
what must be monitored while taking warfarin?
INR
What is typical starting dose of WarfarN
/5mg
How do thrombolytics work to tx pt with DVT?
Directly attacks the clot
When are thrombolytics indicated in DVT?
very select extensive DVT, of recent origin, in pt with low bleeding risk
When is an IVC filter indicated?
Active bleeding that contraindicates anticoag
recurrect DVT despite intensive anticoag.
t/f DVT is tx as an outpatient?
T
How long should duration of tx be for pt’s with provoked DVT in arm/calf
3 months
How long should duration of tx be for pt’s with provoked proximal leg DVT?
3-6 mos
How long should duration of tx be for pt’s with cancer?
3-6 most of LMWH w/o warfarin and continue anticoag indefinitely unless pt become cancer free
How long should duration of tx be for pt’s with unprovoked DVT?
Consider indefinite tx d/t high rate of recurrence
In patient with a genetic d/o how long should they be treated for DVT?
indefinite tx
