Peripheral venous disorders Flashcards
what are varicose veins
dilated, tortuous superficial veins in the lower extremities
15% of adults
most commonly affects the great saphenous vein and its branches
pathophys of varicose veins
- distention of the vein –> 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
risk factors for varicose veins
genetics
prolonged standing or heavy lifting
pregnancy
congenital or acquired AV fistulas or venous malformations (young pts)
primary varicose veins
originate in the superficial system
more common in females than males
1/2 of these pts have a FH of varicose veins
secondary varicose veins
originate in deep system (occlusions)and perforating veins (incompetent)
s/s of varicose veins
- does not correlate to the # and size of varicosities
- asymptomatic or symptomatic
- if present, develop after standing for long periods and relieved with rest –> dull ache/heaviness or fatigue of the legs
- venous stasis dermatitis may be present above the ankle or directly over a large varicosities
- veins may be visible when standing
- may only be palpable in obese pts
- if chronic, a brownish pigmentation and thinning of the skin above the ankle may be present
imaging of varicose veins
-duplex u/s is the test of choice for planning therapy to localize the site of venous reflux
ddx for varicose veins
- chronic venous insufficiency
- leg pain/discomfort from secondary cause: arthritis, radiculopathy, arterial insufficiency
- congenital malformation/atresia of deep veins in adolescent pts
complications of varicose veins
- superificial venous thrombosis (rare)
- bleeding (secondary to trauma, more common in older pts)
- increased amount of bleeding d/t increased pressure in the varicosity
tx of varicose veins
-nonsurgical
avoid prolonged standing compression stockings (medium to heavy weight) when standing leg elevation when possible
tx of varicose vein
-surgical
endovenous ablation (radiofrequency or laser) - vein strippin or sclerotherapy
greater saphenous vein striping
phlebectomy
compression sclerotherapy
when to refer to a vascular surgeon for varicose veins
- bleeding from varicose vein
- superficial venous thrombosis
- pain
- cosmetic concerns
what is superficial venous thrombosis
- pain localized to site of superficial thrombus
- indurated,warm, red, tender cord extending along a superficial vein (common along the saphenous vein)
most common cause of superficial venous thrombsis
short tern IV cath and PICC lines
superficial venous thrombosis can cause pulmonary emolus T/F
FALSE
risk factors for superficial vein thrombosis
- pregnancy/postpartum
- varicose veins
- thromboangitits obliterans
- trauma
- systemic hypercoagulability
ddx of superficial vein thrombosis
- cellulitis
- erythema nodosum
- erythem induratum
- lympangtitis
- DVT
tx of superficial vein thrombosis
- 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)
- –to prevent extension of the thrombus into the deep vein system
definition of chronic venous insufficiency
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 hear from the legs
causes blood to pool or collect in these veins (Stasis)
prevalence of chronic venous insufficiency
40% of people in the US have CVI
more frequent in people >50
more common in females than males
causes of chronic venous insufficiency
- changes secondary to acute DVT (post thrombotic syndrome) - delayed complication
- hx of leg trauma
chronic venous insufficiency is associated with what conditions
associated with the following - varicose veins, pelvic tumor/mass that is obstructing the pelvic veins, vascular malformations
pathophys of chronic venous insufficiency
valve leaflets either thickened and scarred (post thrombotic syndrome ) or functionally inadequate (varicose/refluxed vein)
-causes abnormally high hydrostatic forces that are transmitted to the subcutaneous veins and tissues of the lower leg - results in edema which over time causes secondary changes
secondary changes occur from what in chronic venous insufficiency
occur from chronic edema
- fibrosis of the subcutaneous tissue and skin
- pigmentation of the skin (hemosiderin)
- ulcerations that are slow to heal
- varicosities may develop if d/t post thrombotic event
risk factors of chronic venous insufficiency
DVT varicose veins obesity pregnancy inactivity smoking extended periods of standing or sitting females age >50
primary symptom of chronic venous insufficiency
progressive pitting edema of the leg is the primary presenting symptoms
s/s of secondary changes in chronic venous insufficiency
- itching
- dull ache in the leg that is worse with prolonged standing and improves with leg elevation
- skin at ankle becomes tight and shiny from swelling and a brownish pigmentation (hemosiderin)
- subcutaneous tissue becomes thick and fibrous
- ulcerations may occur near the medial and lateral malleolus
- cellulitis is common
imaging for chronic venous insufficiency
duplex U/s - to evaluate for reflux in the superficial and deep systems and to evaluate for obstruction in either system
tx of chronic venous insufficiency
general - compression stockings**mainstay
avoid long periods of sitting/standing
intermittent elevations of legs throut the day, sleeping with legs elevated above the level of the heart
tx of ulcers in chronic venous insufficiency
-wound care specialist
-wet to dry dressings or occlusive hydrocolloid dressings (consists of paste with zinc oxide, calamine, glycerin and gelatin) = UNABOOT
(change every 2-3 days depending on the amount of drainage)
-once ulcer has healed compression stockings to prevent recurrent edema and ulceration
tx of chronic venous insufficiency - surgery
reserved for pts with chronic/recurrent ulcers
-radiofrequency ablation or endovenous laser tx to correct the affected vessels that feed the area of ulceration to promote healing
definition of DVT
a blood clot that develops in the deep venous system. the clot may partially or completely block blood flow thru the vein
-most occur in the lower extremity , but they can also occur in other parts of the body (arm, abdomen, pelvis)
virchows triad in DVT
- venous stasis
- injury to vessel wall
- hypercoagulability
–predisposing factors
etiology of DVT due to venous stasis
- immobilization - recent surgery, long flight/car ride, stroke
- reduced return blood flow to heart - increased blood viscosity (polycythemia vera, dehydration)
- increased central venous pressure (right heart faliure, pt on respirator with PEEP)
- reduced glow through the veins - abd mass, pregnancy resulting in compression of iliac vein or IVC
etiology of DVT due to injury to vein wall
trauma, surgery
etiology of DVT due to hypercoagulable state
primary - genetic mutation, ATIII deficiency, anti phospholipid syndrome, prot C deficiency, protein S def.
secondary - surgery, malignancy, pregnancy, birth control
complications of DVT
PE
post thrombotic syndrom (chronic venous insuffciency)
phlegmasia alba dolens
phlegmasia cerulea dolens
what is phlegmasia alba dolens
“white leg”
- occurs when there is massive deep thrombosis with total occlusion of the deep venous system
- venous drainage falls on the superficial system which is unable to handle the load = develop edema in the leg which comprises the arterial circulation –>leg turns white
- reversed with emergent intervention (thrombolytic therapy)
what is phlegmasia cerulea dolens
“venous gangrene”
- continuation of alba dolens where you develop complete occlusion of arterial blood supply to limb
- skin and toes become gangrenous
- prognosis is poor and usually requires emergent leg amputation
risk factors of DVT
hypercoagulability thrombophilia trauma obesity recent surgery invasive procedure immobilization recent prolonged travel cancer prengancy/post partum OCPs/HRT prior DVT
symptoms of DVT
often asymptomatic
leg swelling
leg pain
unilateral leg tenderness
signs of DVT
unilateral pitting edem
increased calf circumference (>2-3cm)
calf tenderness
Homan’s sign (controversial)
ddx of DVT
ruptured baker's cyst cellulitis lymphedema thrombophelbitis post thrombotic syndrome chronic venous insufficiency trauma bone neoplasm heart failure nephrotic syndrome cirrhosis
dx of DVT
classic symptoms of DVT as well as classic signs are of LOW PREDICTIVE VALUE
however combos of clinical features can be used to stratify pts into risk categories
what is the name of the criteria system to determine risk for DVT
Wells criteria
list factors on wells criteria to determine risk of DVT
active cancer paralysis/paresis or recent immobilization of lower leg bedridden for >3days or major surgery localized tenderness along the dep veins entire leg swollen calf swelling >3cm compared to other leg unilateral pitting edema collateral superficial veins previously documented DVT alternative dx as likely as or more than DVT
wells criteria risk score interpretation
3pts: high risk (75%)
1-2pts (medium risk 17%)
labs for DVT
DDIMER
- sensitivity is >80% NOT specific
- combo of low risk assessment (
imaging for DVT
- U/S: most widely used study
- MR venography with gadolinium contrast
U/S for DVT
- relies on loss of vein compressibility as the primary criteria for DVT, visualization of thrombus and abnormal doppler flow
- used in combo with wells criteria fairly accurately (80-85% sensitivity and specificity)
- negative study in high probability pt requires addnl investigation to r/o DVT
when is MR venography used for DVT
when US is equivocal and there is high probability
tx of DVT
- primary objective: prevent complications
- mainstay of tx: immediate anticoag followed by long term anticoag
immediate anticoag tx of DVT
parenteral unfractionated heparin
low molecular weight heparin
fondaparinux
(all above followed by conversion to oral coumadin or thrombolytics)
long term anticoags for DVT
warfarin which is started at the same time as parenteral agent
takes 5-7 days to achieve therapeutic dosage of coumadin (INR target 2.5 with a range of 2.0-3.0)
4 venous disorders
- varicose vein
- superficial venous thrombophlebitis
- chronic venous insufficiency
- DVT
after 5-7 days of tx for DVT, the residual thrombus will what?
endothelialize in the vein
do anti coags directly dissolve the thrombus in DVT
no
about UFH
- dosed to achieve a target aPTT of 2-3 times the upper limits of normal (60-70)
- short half life therefore may require repeated blood sampling and dose adjustment every 4-6 hours
- monitor for risk of developing heparin induced thrombocytopenia
about LMWH
- has greate bioavailability, a more predictable dose response and a longer half life than UFH
- no monitoring or dose adjustments is required unless the pt is markedly obese or has CKD
ex. enoxaparin (LOvanox) - 1mg/kg or 2mg QD til INR levels are at goal on warfarin
about fondapinux
-administered SQ once daily
no lab monitoring is required
weight based dosage
-does not cause heparin induced thrombocytopenia
about warfarin
-requires a minimum of 5 days to be therapeutic
-monitor INR
typical starting dose is 5mg QD
dose is titrated to achieve the target INR
“other” DVT tx
thrombolytics
- direct attack on the clot, unlike anticoags
- limited role: only used in very select cases of extensive DVT or recent origin in a pt with low bleeding risks
- complications of bleeding high
what are inferior vena caval filters and when are they indicated
-active bleeding that contraindicates anticoagulation
recurrent venous thrombosis despite intensive anticoagulation
–prophylactically - major trauma with multiple/complex pelvic fx’s severe head injuries, pts with advanced malignancy
are DVTs treated inpt or outpt?
typically OP - only if: pt/family can administer the parenteral anticoag
- pt has good support system
- pt has permanent residence, telephone, and no hearing/language impairment is present
duration of tx in DVT
- provoked DVT in arm/ calf: recent surgery, trauma, OCP/HRT, or indwelling catheter: 3 months of tx
- provoked proximal leg DVT: 3-6 months
- pts with cancer: 3-6 months of LMWH w/o warfarin and continue anticoag indefinietly unless pt becomes cancer free
- unprovoked DVT: consider indefinite tx d/t high rate of recurrence
- in pts w/ genetic d/o - indefinite tx
