Peripheral Venous Disease

Question 1

Pathophysiology Classification of Edema

Answer 1

● Venous Hypertension

● Anasarca / decreased oncotic pressure

● Lymphatic dysfunction

● Plain-old fat

● Lipedema

Question 2

Venous hypertension

Answer 2

● Right heart failure

● Venous insufficiency
- Sclerosis from thrombosis, vessicant drugs, ideopathic, venous insufficiency begets VI elsewhere, venodilating drugs

● Venous thrombosis (acute/chronic)

● Thrombophlebitis

● Venous access / infusions

● Arterial/venous fistula / shunting

Question 3

Anasarca

Answer 3

● Cirrhosis / malnutrition

● Mineralocorticoid problems – free water retention / SIADH

● Nephrotic syndrome

● Extracorporeal protein loss (ECMO/dialysis/etc)

● Protein-losing enteropathy

● Myxedema

Question 4

Lymphatic dysfunction
(lymphedema)

Answer 4

● Cancer

● Lymphomas

● Direct tumoral invasion/compression

● Metastatic infiltration

● Lymphatic damage (surgery, trauma, anatomy)

● Lymphatic filariasis, Hansen’s

● Lymphatic reflux/hypertension

Question 5

Lipedema

Answer 5

● Symmetric, painful, dysregulation of adipose
tissue (weight-loss doesn’t help)

● Frequently with comorbid lymphedema

● Idiopathic

● Non-pitting

Question 6

Complications of Venous

Hypertension

Answer 6

● Worsening venous hypertension/reflux

● Ulcerations

● Increased infection risk

● Thrombosis risk

Question 7

Treatment of venous hypertension

Answer 7

● Address reversible causes (heart failure, etc)

● Compression

• Compression hose
• ACE wraps
• Elevate limb

● Venous mapping/perforator vein ablation

● Exercise – THE venous pump of choice

Question 8

Deep venous thrombosis

Answer 8

Virchow’s Triad
● Endothelial injury
● Hypercoagulability
● Stasis

Risk factor for pulmonary embolism

Presents with pain, swelling, erythema

Question 9

Diagnosis of DVT

Answer 9

Pretest probability
● Well’s criteria
● D-dimer (very high negative predictive value)
− Extremely non-specific

Venography
● Invasive, rarely used, but gold-standard

Duplex venous doppler ultrasound

Question 10

Prevention of DVT

Answer 10

● Hospitalized patients, especially surgical
patients are at high risk

● Cancer patients

● Thrombophilia

● CAPRINI score

● Compression hose

● Early ambulation

● Pharmacologic prophylaxis

• Warfarin
• Heparin
• Enoxaparin
• Fondaparinux
• Dabigatran/edoxaban/rivaroxaban/etc.

● Sequential (pneumatic) compression devices

Question 11

Treatment of DVT

Answer 11

● Warfarin

● Heparin/enoxaparin

● Rivaroxaban/dabigatran/edoxaban/apixaban

● 6 months for first DVT

● Lifelong for second DVT, or if thrombophilia identified

● Thrombolysis, thrombectomy

● If untreated, 50% risk of PE