Peripheral Venous Disease

Question 1

Treatment of varicose veins

Answer 1

Injection with US guided foam sclerotherapy or thermal ablation

Question 2

Superficial thrombophlebitis features and treatment

Answer 2

Saphenous veins and is associated with varicosities

- SC fondaparinux 2.5mg daily- factor Xa inhibitors

Question 3

DVT causes

Answer 3

• Long periods of immobilzation
• After surgery
• ## After cerebral vascular event

Question 4

Clinical features of DVT

Answer 4

Pain in calf unilateral - swelling, redness and engorged superficial veins- temperature
Homan’s sign- pain in the calf on dorsiflexion of the foot is often present
- Venous eczema

Question 5

Pulmonary embolism in DVT

Answer 5

Can occur in DVT but more frequent in iliofemoral thrombosis and is rare with thrombosis confined to vein below the knee

Question 6

Well’s score for likely DVT and subsequent steps

Answer 6

> /2
If aDVT is ‘likely’ (2 points or more)
• a proximal leg vein ultrasound scan should be carried out within 4 hours
○ if the result is positive then a diagnosis of DVT is made and anticoagulant treatment should start
○ if the result is negative a D-dimer test should be arranged. A negative scan and negative D-dimer makes the diagnosis unlikely and alternative diagnoses should be considered
• if a proximal leg vein ultrasound scan cannot be carried out within4 hours a D-dimer test should be performed and interim therapeutic anticoagulationadministered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
○ interim therapeutic anticoagulation used to mean giving low-molecular weight heparin
○ NICE updated their guidance in 2020. They now recommend using an anticoagulant that can be continued if the result is positive.
○ this means normally a direct oral anticoagulant (DOAC) such as apixaban or rivaroxaban
• if the scan is negative but the D-dimer is positive:
○ stop interim therapeutic anticoagulation
offer a repeat proximal leg vein ultrasound scan 6 to 8 days late

Question 7

If DVT is unlikely

Answer 7

/< 2
If aDVT is ‘unlikely’ (1 point or less)
• perform a D-dimer test
○ this should be done within 4 hours. If not, interim therapeutic anticoagulation should be given until the result is available
○ if the result is negative then DVT is unlikely and alternative diagnoses should be considered
○ if the result is positive then a proximal leg vein ultrasound scan should be carried out within 4 hours
○ if a proximal leg vein ultrasound scan cannot be carried outwithin 4 hours interim therapeutic anticoagulationshould be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)

Question 8

Length of time of anti-coagulation after below-knee thrombi

Answer 8

6 weeks

Question 9

Anticoagulation given

Answer 9

• LMWH at first but stopped when the INR is in target range, warfarin is started.
• 3 months of warfarin but 4 weeks is long enough

Question 10

Target INR on anticoagulants

Answer 10

2.5

Question 11

Prophylaxis for DVT

Answer 11

Fondaparinux or LMWH or unfractionated heparin is there is RENAL impairment