Peripheral Venous Disorders Flashcards

Question

Imaging for Chronic Venous Insufficiency

Answer 1

Duplex U/S to determine whether superficial reflux is present and to evaluate the degree of deep reflux and obstruction

Answer 2

``` Compression stockings (mid foot to just below knee)- mainstay of treatment*** 1ST LINE Avoid long periods of sitting/standing Intermittent elevations of legs/sleeping w/ legs elevated above the level of the heart ```

Answer 3

Wet to dry dressings or occlusive hydrocolloid dressings (consist of paste w/ zinc oxide, calamine, glycerin and gelatin) Change every 2-3 days depending on the amount of drainage Once ulcer has healed, compression stockings w/ graduated compression below the knee are used to prevent recurrent edema and ulceration

Answer 4

Radiofrequency ablation or endovenous laser tx to correct superficial reflux/incompetent perforator veins that feed the area of ulceration to promote healing

Answer 5

A blood clot that develops in a vein deep in the body. The clot may partially or completely block blood flow through the vein. Most occur in the lower extemity, but they can also occur in other parts of the body (ex. Arm, abdomen, pelvis, etc)

Answer 6

Venous Stasis Injury to the vessel wall Hypercoagulable state

Answer 7

Pulmonary Embolism Post thrombotic syndrome (chronic venous insufficiency) Phlegmasia alba dolens Phlegmasia cerulea dolens

Answer 8

Immobilization… Transient ( s/p Operation/surgery under general anaesthesia or Transcontinental flight) Extended: Confined hospitalization after pelvic, hip or spinal surgery; Due to stroke or Paraplegia Reduced return blood flow to the heart Increased blood viscosity: (Polycythemia vera, Severe dehydration) Increased Central Venous pressure (Rt. Heart failure, Pt. on Respirator with PEEP) Reduced flow thru’ the leg veins Abd. mass compressing Iliac Vein or IVC; Enlarged or Pregnant Uterus

Answer 9

Obvious: ex. Trauma, Surgery Obscure: ex. Hip Arthroplasty with Femoral Vein manipulation, Old DVT with persistent endothelial vein damage.

Answer 10

Primary: Mostly secondary to a genetic mutation leading to altered coagulation cascade eg. Antithrombin III deficiency, antiphospholipid syndrome, Protein C deficiency, Protein S deficiency) Secondary: Surgery, Malignancy, Pregnancy, Oral Contraceptive Use etc.

Answer 11

Occurs when there is massive deep thrombosis with total occlusion of the deep venous system. The venous drainage falls on the superficial system which is unable to handle the load. The leg becomes edematous which compromises the arterial circulation resulting in the leg turning white May be reversed with emergent intervention possibly using Thrombolytic therapy

Answer 12

Continuation of the process(alba dolens) leads to complete occlusion of arterial supply to the limb Without blood supply, the skin and toes become gangrenous Prognosis very poor, usually requires emergent leg amputation.

Answer 13

``` Hypercoagulable states Thrombophilia Trauma Obesity Recent Surgery/invasive procedures Immobilization Recent Prolonged Travel Cancer Pregnancy/Post-partum OCP’s/HRT Prior VTE ```

Answer 14

Unilateral pitting edema Increased calf circumference (>3cm) Calf Tenderness Homan’s Sign (controversial)

Answer 15

Often asymptomatic (if subclinical) Leg swelling Leg pain Unilateral leg tenderness

Answer 16

``` Ruptured Baker’s Cyst Cellulitis Lymphedema Thrombophlebitis Post-thrombotic syndrome Chronic Venous insufficiency Trauma Bone neoplasm Heart failure Nephrotic syndrome Cirrhosis ```

Answer 17

Classic symptoms of DVT as well as classic signs are of LOW PREDICTIVE VALUE However, combinations of clinical features in the form of clinical prediction can be useful to stratify patients into risk categories Wells Criteria

Answer 18

D-Dimer Sensitivity is >80%, not specific Combination of low-risk assessment & negative D-dimer assay effectively rules out DVT Positive d-Dimer test does not raise the likelihood of DVT False +: MI, Sepsis, Cancer, Post-op state, Late Pregnancy

Answer 19

Ultrasound- Most widely used study Relies on loss of vein compressibility as the primary criteria for DVT, Visualization of thrombus and abnormal Doppler flow Used in combination with Wells Criteria fairly accurately ( 80-85% Sensitivity & Specificity). However, negative study in high-probability patient requires additional investigation to R/O DVT. MR Venography w/ gadolinium contrast Used when ultrasound is equivocal and there is high probability

Answer 20

Primary objective is to prevent complications Mainstay of this objective is immediate anti-coagulation with parenteral unfractionated Heparin (UFH), Low Molecular Weight Heparin (LMWH) or fondaparinux followed by conversion to oral Coumadin ( Warfarin) or Thrombolytics Continued as a “bridge” to long term anticoagulation with Warfarin which is started at the same time as parenteral agent Takes 5-7 days to achieve therapeutic dosage of Coumadin (INR target of 2.5 w/ a range of 2.0-3.0)

Answer 21

After 5-7 days of treatment, the residual thrombus will begin to endothelialize in the vein. The meds do not directly dissolve thrombus

Answer 22

LMWH Has a greater bioavailability, a more predictable dose response and a longer half life than UFH No monitoring or dose adjustment is required unless the patient is markedly obese or has CKD (reduce dose) Enoxaparin (Lovenox): approved as a bridge to warfarin 1mg/kg bid till INR levels are at goal on Warfarin

Answer 23

Administered SQ once daily in a prefilled syringe as a bridge to Warfarin No lab monitoring is required Weight based dosage Does not cause heparin induced thrombocytopenia

Answer 24

Warfarin Requires a minimum of 5 days to be therapeutic Monitor INR (assesses the anticoagulant effect) Typical starting dose is 5mg QD Dose is titrated to achieve the target INR

Answer 25

Role of Thromolystics in Acute DVT Direct attack on the clot, unlike anti-coagulant therapy Limited role at present Only used in very select cases of Extensive DVT (Ileo-Femoral) of recent origin, in a pt. with low bleeding risks Complications of bleeding high

Answer 26

Indications include: Active bleeding that contraindicates anticoagulation Recurrent venous thrombosis despite intensive anticoagulation Can be used prophylactically: Multiple trauma with complex pelvic fractures, Severe head injury with Glasgow Coma scale < 8, patients with advanced malignancy

Answer 27

Typically treated as an outpatient if: patient/family can administer the parenteral anticoagulant, The patient has a good support system, Ths patient has a permanent residence, telephone service and no hearing/language impairment is present

Answer 28

Provoked DVT in arm/calf (recent surgery, trauma, OCP/HRT, or indwelling catheter): 3 months of tx Provoked proximal leg DVT: 3-6 months Patients w/ cancer: 3-6 months of LMWH w/o warfarin and continue anticoagulation indefinitely unless patient becomes cancer-free ? LMWH or Warfarin Unprovoked DVT (including long travel): consider indefinite tx d/t high rate of recurrence vs 6 months of tx w/ target INR b/w 2-3 followed by a lower target INR of 1.5-2 If mod-high levels of anticardiolipin Ab: indefinite duration recommended

Answer 29

Active Cancer……………………………………………………………….+1 point Paralysis/Paresis or recent immobilization of lower leg…+1 pt Bedridden for > 3 days or major surgery(within 4 wks)…+1 point Localized tenderness along the deep veins…………..+1 point Entire Leg Swollen………………………………………………………..+1 point Calf swelling >3cm compared to other leg…………………….+1 point Unilateral Pitting Edema……………………………………………….+1 point Collateral (nonvaricose) Superficial Veins……………………..+1 point Previously documented DVT…………………………………………+1 point Alternative Diagnosis as likely as or more than DVT …….-2point Risk Score Interpretation: 3 points: high risk (75%) 1 to 2 pts: Medium Risk (17%) < 1 point: Low Risk(3%)