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Clin Med - Cardio II > Peripheral venous disorders > Flashcards

Peripheral venous disorders Flashcards

1
Q

what are varicose veins

A

dilated, tortuous superficial veins in the lower extremities
15% of adults
most commonly affects the great saphenous vein and its branches

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2
Q

pathophys of varicose veins

A
  1. distention of the vein –> weakened/incompetent valves–>dilation along the vein
  2. dilation –> increased pressure and distention of the vein segment below that valve –> progressive failure of the next lower valve –> increased dilation
  3. 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
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3
Q

risk factors for varicose veins

A

genetics
prolonged standing or heavy lifting
pregnancy
congenital or acquired AV fistulas or venous malformations (young pts)

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4
Q

primary varicose veins

A

originate in the superficial system
more common in females than males
1/2 of these pts have a FH of varicose veins

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5
Q

secondary varicose veins

A

originate in deep system (occlusions)and perforating veins (incompetent)

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6
Q

s/s of varicose veins

A
  • 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
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7
Q

imaging of varicose veins

A

-duplex u/s is the test of choice for planning therapy to localize the site of venous reflux

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8
Q

ddx for varicose veins

A
  1. chronic venous insufficiency
  2. leg pain/discomfort from secondary cause: arthritis, radiculopathy, arterial insufficiency
  3. congenital malformation/atresia of deep veins in adolescent pts
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9
Q

complications of varicose veins

A
  • superificial venous thrombosis (rare)
  • bleeding (secondary to trauma, more common in older pts)
  • increased amount of bleeding d/t increased pressure in the varicosity
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10
Q

tx of varicose veins

-nonsurgical

A 
avoid prolonged standing
compression stockings (medium to heavy weight) when standing
leg elevation when possible
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11
Q

tx of varicose vein

-surgical

A

endovenous ablation (radiofrequency or laser) - vein strippin or sclerotherapy
greater saphenous vein striping
phlebectomy
compression sclerotherapy

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12
Q

when to refer to a vascular surgeon for varicose veins

A
  • bleeding from varicose vein
  • superficial venous thrombosis
  • pain
  • cosmetic concerns
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13
Q

what is superficial venous thrombosis

A
  • pain localized to site of superficial thrombus

- indurated,warm, red, tender cord extending along a superficial vein (common along the saphenous vein)

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14
Q

most common cause of superficial venous thrombsis

A

short tern IV cath and PICC lines

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15
Q

superficial venous thrombosis can cause pulmonary emolus T/F

A

FALSE

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16
Q

risk factors for superficial vein thrombosis

A
  1. pregnancy/postpartum
  2. varicose veins
  3. thromboangitits obliterans
  4. trauma
  5. systemic hypercoagulability
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17
Q

ddx of superficial vein thrombosis

A
  1. cellulitis
  2. erythema nodosum
  3. erythem induratum
  4. lympangtitis
  5. DVT
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18
Q

tx of superficial vein thrombosis

A
  1. supportive - elevation, warm compresses, and NSAIDS
  2. 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
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19
Q

definition of chronic venous insufficiency

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 hear from the legs
causes blood to pool or collect in these veins (Stasis)

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20
Q

prevalence of chronic venous insufficiency

A

40% of people in the US have CVI
more frequent in people >50
more common in females than males

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21
Q

causes of chronic venous insufficiency

A
  • changes secondary to acute DVT (post thrombotic syndrome) - delayed complication
  • hx of leg trauma
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22
Q

chronic venous insufficiency is associated with what conditions

A

associated with the following - varicose veins, pelvic tumor/mass that is obstructing the pelvic veins, vascular malformations

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23
Q

pathophys of chronic venous insufficiency

A

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

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24
Q

secondary changes occur from what in chronic venous insufficiency

A

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
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25
Q

risk factors of chronic venous insufficiency

A 
DVT
varicose veins
obesity
pregnancy
inactivity
smoking
extended periods of standing or sitting
females
age >50
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26
Q

primary symptom of chronic venous insufficiency

A

progressive pitting edema of the leg is the primary presenting symptoms

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27
Q

s/s of secondary changes in chronic venous insufficiency

A
  • 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
28
Q

imaging for chronic venous insufficiency

A

duplex U/s - to evaluate for reflux in the superficial and deep systems and to evaluate for obstruction in either system

29
Q

tx of chronic venous insufficiency

A

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

30
Q

tx of ulcers in chronic venous insufficiency

A

-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

31
Q

tx of chronic venous insufficiency - surgery

A

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

32
Q

definition of DVT

A

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)

33
Q

virchows triad in DVT

A
  1. venous stasis
  2. injury to vessel wall
  3. hypercoagulability

–predisposing factors

34
Q

etiology of DVT due to venous stasis

A
  • 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
35
Q

etiology of DVT due to injury to vein wall

A

trauma, surgery

36
Q

etiology of DVT due to hypercoagulable state

A

primary - genetic mutation, ATIII deficiency, anti phospholipid syndrome, prot C deficiency, protein S def.

secondary - surgery, malignancy, pregnancy, birth control

37
Q

complications of DVT

A

PE
post thrombotic syndrom (chronic venous insuffciency)
phlegmasia alba dolens
phlegmasia cerulea dolens

38
Q

what is phlegmasia alba dolens

A

“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)
39
Q

what is phlegmasia cerulea dolens

A

“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
40
Q

risk factors of DVT

A 
hypercoagulability
thrombophilia
trauma
obesity
recent surgery
invasive procedure
immobilization
recent prolonged travel
cancer
prengancy/post partum
OCPs/HRT
prior DVT
41
Q

symptoms of DVT

A

often asymptomatic
leg swelling
leg pain
unilateral leg tenderness

42
Q

signs of DVT

A

unilateral pitting edem
increased calf circumference (>2-3cm)
calf tenderness
Homan’s sign (controversial)

43
Q

ddx of DVT

A 
ruptured baker's cyst
cellulitis
lymphedema
thrombophelbitis
post thrombotic syndrome
chronic venous insufficiency
trauma
bone neoplasm
heart failure
nephrotic syndrome
cirrhosis
44
Q

dx of DVT

A

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

45
Q

what is the name of the criteria system to determine risk for DVT

A

Wells criteria

46
Q

list factors on wells criteria to determine risk of DVT

A 
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
47
Q

wells criteria risk score interpretation

A

3pts: high risk (75%)

1-2pts (medium risk 17%)

48
Q

labs for DVT

A

DDIMER

  • sensitivity is >80% NOT specific
  • combo of low risk assessment (
49
Q

imaging for DVT

A
  • U/S: most widely used study

- MR venography with gadolinium contrast

50
Q

U/S for DVT

A
  • 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
51
Q

when is MR venography used for DVT

A

when US is equivocal and there is high probability

52
Q

tx of DVT

A
  • primary objective: prevent complications

- mainstay of tx: immediate anticoag followed by long term anticoag

53
Q

immediate anticoag tx of DVT

A

parenteral unfractionated heparin
low molecular weight heparin
fondaparinux
(all above followed by conversion to oral coumadin or thrombolytics)

54
Q

long term anticoags for DVT

A

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)

55
Q

4 venous disorders

A
  1. varicose vein
  2. superficial venous thrombophlebitis
  3. chronic venous insufficiency
  4. DVT
56
Q

after 5-7 days of tx for DVT, the residual thrombus will what?

A

endothelialize in the vein

57
Q

do anti coags directly dissolve the thrombus in DVT

A

no

58
Q

about UFH

A
  • 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
59
Q

about LMWH

A
  • 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
60
Q

about fondapinux

A

-administered SQ once daily
no lab monitoring is required
weight based dosage
-does not cause heparin induced thrombocytopenia

61
Q

about warfarin

A

-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

62
Q

“other” DVT tx

A

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
63
Q

what are inferior vena caval filters and when are they indicated

A

-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

64
Q

are DVTs treated inpt or outpt?

A

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
65
Q

duration of tx in DVT

A
  1. provoked DVT in arm/ calf: recent surgery, trauma, OCP/HRT, or indwelling catheter: 3 months of tx
  2. provoked proximal leg DVT: 3-6 months
  3. pts with cancer: 3-6 months of LMWH w/o warfarin and continue anticoag indefinietly unless pt becomes cancer free
  4. unprovoked DVT: consider indefinite tx d/t high rate of recurrence
  5. in pts w/ genetic d/o - indefinite tx

Clin Med - Cardio II (12 decks)

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