Peripheral Venous Disorders Flashcards
Varicose Veins most commonly found
greater saphenous vein and its branches
Varicose Veins pathophysiology
Distention of the vein results in weakened/incompetent valves dilation along the vein
Dilation increased pressure and distention of the vein segment below that valve progressive failure of the next lower valve increased dilation
Perforating veins may become incompetent as well reflux of blood from the deep system into the superficial system which results in increasing venous pressure and distention
Varicose vein RF
Genetics
Prolonged standing or heavy lifting
Pregnancy
Congenital or acquired AV fistulas or venous malformations (young patients)
Varicose Vein S/S
Does not correlate to the # and size of varicosities
Asymptomatic or symptomatic
Dull ache/heaviness or fatigue of the legs after prolonged standing that is relieved w/ leg elevation
Venous stasis dermatitis may be present above the ankle or directly over a large varicosities
May be visible on exam when standing
May only be palpable in obese patients
If chronic, a brownish pigmentation and thinning of the skin above the ankle may be present
What imaging do you want to use for Varicose veins
Duplex Ultrasound
Varicose vein comlications
Superficial venous thrombosis (rare)
Bleeding
Varicose vein treatment non Sx
Avoid prolonged standing
compression stockings
Leg elevation when possible
Varicose Vein TX with Sx
Endovenous ablation (radiofrequency or laser)
Greater saphenous vein stripping
Phlebectomy w/ or w/o correction of reflux
Compression Sclerotherapy
When should you refer a pt with varicose veins to surgeon
Bleeding from varicose vein
Superficial venous thrombosis
Pain
Cosmetic concerns
What is Superficial venous thrombosis
Pain localized to the site of a superficial thrombus
Superficial venous thrombosis S/S
Indurated, warm, red and tender cord extending along a superficial vein, (common along the saphenous vein)
Most common cause: short term intravenous catheterization(IV’s) and PICC lines
Do not result in pulmonary emboli
Superficial venous thrombosis RF
Pregnancy/postpartum Varicose veins Thromboangiitis obliterans Trauma Systemic hypercoagulability (protein s,c or phospholipid insufficiency)
Superficial venous thrombosis TX
Supportive:
Elevation, warm compresses and NSAIDS
Anticoagulation:
Only indicated if a thrombus has developed in the thigh or arm and it is extending toward the saphenofemoral junction (leg) or the cephalo-axillary junction (arm)
CVI definition
A condition that occurs when the venous wall and/or valves in the leg veins are not working effectively
It becomes difficult for blood to return to the heart from the legs
Causes blood to “pool” or collect in these veins
CVI causes
Changes secondary to acute DVT (post thrombotic syndrome)
History of leg trauma
Chronic Venous Insufficiency Pathophysiology
Valve leaflets either thickened and scarred (post thrombotic syndrome) or functionally inadequate (varicose/refluxed vein)
CVI RF
DVT Varicose Veins Obesity Pregnancy Inactivity smoking Extended periods of sitting or standing Female Age over 50 years old
CVI S/S:
Progressive pitting edema of the leg is the primary presenting symptoms
CVI imaging
Duplex US
CVI treatment
Compression stockings mainstay of Tx
can also
Avoid long periods of sitting/standing
Intermittent elevations of legs throughout the day, sleeping w/ legs elevated above the level of the heart
CVI Ulcer TX
Ulcers (involve a wound care specialist):
Wet to dry dressings or occlusive hydrocolloid dressings (consist of paste w/ zinc oxide, calamine, glycerin and gelatin), ex. Unaboot
CVI SX Tx
Radiofrequency ablation or endovenous laser tx to correct superficial reflux/incompetent perforator veins that feed the area of ulceration to promote healing
DVT definition
A blood clot that develops in the deep venous system. The clot may partially or completely block blood flow through the vein.
DVT (Virchow’s Triad):
Venous Stasis
Injury to the vessel wall
Hypercoagulable state
EVT etiology
Mechanical Injury to the Vein Wall
Hypercoagulable state
DVT complications
Pulmonary Embolism
Post thrombotic syndrome (chronic venous insufficiency)
Phlegmasia alba dolens
Phlegmasia cerulea dolens
Phlegmasia Alba Dolens
White Leg
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. Develop edema in the leg which compromises the arterial circulation leg turns white
Phlegmasia cerulea dolens
Venous gangrene
Continuation of alba dolens(white leg) where you develop complete occlusion of the arterial blood supply to the limb
Usually require amputation
DVT RF
Hypercoagulable states Thrombophilia Trauma Obesity Recent Surgery/invasive procedures Immobilization Recent Prolonged Travel Cancer Pregnancy/Post-partum OCP’s/HRT Prior DVT
DVT Signs/symptoms
Leg swelling Leg pain Unilateral leg tenderness Unilateral pitting edema Increased calf circumference (>2-3cm) Calf Tenderness Homan’s Sign (controversial)
DVT diagnosis
D-dimer:
Sensitivity is >80%, not specific
Combination of low-risk assessment (<1 point on Wells) & 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
DVT imaging
Ultra sounds most widely used
DVT immediate TX
Mainstay of tx:
Immediate anti-coagulation with:
Parenteral unfractionated Heparin (UFH),
Low Molecular Weight Heparin (LMWH) or
fondaparinux
** all of above followed by conversion to oral Coumadin ( Warfarin) or Thrombolytics
DVT long term anticoagulation
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)
Immediate Anticoagulation
After 5-7 days of treatment, the residual thrombus will begin to endothelialize in the vein. The meds do not directly dissolve thrombus
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)
Fondaparinux (Arixtra )
Administered SQ once daily
No lab monitoring is required
Weight based dosage
Does not cause heparin induced thrombocytopenia
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
Role of Thromolytics in Acute DVT
Direct attack on the clot, unlike anti-coagulant therapy
Limited role currently
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
Inferior Vena Caval Filters (IVC) indications
Active bleeding that contraindicates anticoagulation
Recurrent venous thrombosis despite intensive anticoagulation
Prophylactically: Major trauma with multiple/complex pelvic fractures, Severe head injuries, patients with advanced malignancy
DVT 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
Provoked DVT in arm/calf (recent surgery, trauma, OCP/HRT, or indwelling catheter) Tx
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
Unprovoked DVT
consider indefinite tx d/t high rate of recurrence
