Peripheral Venous & Lymphatic Vessel Disease Flashcards
What causes varicose veins
high venous pressure
Classic patient of varicose veins
Postpartum women (highest incidence)
Prolonged standing
Heavy lifting
Varicosities develop in over 20% of all adults
how does blood pool up?
Combination of progressive venous reflux and venous hypertension is the hallmark of chronic venous disease
Venous reflux - venous valve does not close appropriately leading to backward blood flow into lower extremities
Venous hypertension - increased venous pressure as a result of reflux
MC vein associated with varicose veins
Great saphenous
What does varicose veins lead to?
Progression, because valve incompetence and reflux
Vein segments below the defective valves distend and progressively fail as well
How do you get secondary varicosities?
May result from obstructive changes and valve damage in the deep venous system following thrombophlebitis
Rarely a result of proximal venous occlusion due to neoplasm or fibrosis
Can be due to congenital or acquired arteriovenous fistulas or venous malformations, especially if present in young patients
Classic clinical presentation of varicose veins
Standing up for long periods
Dull aching heaviness
Itching
Dilated tortuos veins
Chronic venous insufficiency (leading to ankle edema, brownish skin hyperpigmentation, and chronic skin induration of fibrosis)
Is severity of varicose veins have to do with severity of symptoms?
No
What can lead to induration and fibrosis?
Venous stasis, causing fibrotic hard skin leading to ulcerations
How to diagnose varicose veins?
Clinically
Only order imaging (venous duplex US) if you think there is an obstruction and need a surgery
Nonsurgical treatment of varicose veins and issues
Compression stockings (hoes)
Really hard to wear though
leg elevation above the heart (wedge pillows)
When should you use compression stocking
After you get up, because there is the least blood in your legs at that time
compression hoes order
the worse the symptoms, the higher the mmHg you order]
15-20 mmHg
20-30 mmHg
30-40 mmHg
40-50 mmHg
50 mmHg
custom fit
If a patient does not want to use compression stockings, what is a permanent option?
Sclerotherapy, endovenous laser therapy (EVLA), Endovenous Radiofrequency Ablation (EVRFA), vein stripping (last resort)
sclerotherapy procedure
Direct injection of a sclerosing agent¹ → permanent fibrosis and obliteration of the target veins
Recurrence rate is >50% if underlying reflux is not managed
Endovenous laser therapy procedure
Performed with local anesthesia
The laser heats up the small vein and destroys it
Could result in heat-induced thrombosis, requiring prolonged anticoagulation
Endovenous Radiofrequency Ablation (EVRFA) procedure
Better for significant varicose veins with signs of venous insufficiency or for long varicosities
Vein stripping
Involves removing the part of the vein that is torturous
LAST resort
What causes chronic venous insufficiency
Complication of varicose veins, DVT, injury, or something else
venous hypertension
What does chronic venous insufficiency look like?
Edema, (brawny) skin hyperpigmentation, subcutaneous lipodermatosclerosis in the lower leg
Venous ulcers characterized by ulcerations at or above the medial ankle
What is a complicating factor of chronic venous insufficiency
Obesity
leads to lower activity and further problems
Etiology of chronic venous insufficiency
Insufficiency → valve leaflets do not close because they are thickened and scarred (post-thrombotic syndrome) or are functionally inadequate due to vein dilation
Chronic thrombus/scarring causes proximal venous obstruction, worsening the problem
Venous reflux ensues leading to blood back up in the lower leg/foot
The leg develops venous hypertension and an abnormally high hydrostatic force is transmitted to the subcutaneous veins and tissues of the lower leg
The result is edema
what to order if you think there might be heart failure instead of chronic venous insufficiency
BNP
r/o CHF if <100
What are the pathologic changes of chronic venous insufficiency
Muscle biopsy demonstrates interstitial space changes
Enlargement and fibrosis
High levels of fibrinogen and fibrin
Edema and inflammation
Leads to local hypoxia and malnutrition
Increase in the number of capillaries in the subcutaneous tissue
Peri-capillary fibrosis
Manifested as subcutaneous thickening and induration
Hemosiderin deposits resulting from erythrocyte lysis
Clinical manifestations of chronic venous insufficiency
Primary symptom: progressive pitting edema of the lower leg
Secondary changes in the skin and subcutaneous tissues develop over time
Stasis dermatitis
Other common symptoms are itching, a dull discomfort made worse by periods of standing, and pain if an ulceration is present
Secondary lymphedema can occur
Progressive sclerosis of lymph channels
Taut, shiny skin at the ankle due to edema
Brownish skin pigmentation
Also known as hemosiderin staining
Eventual loss of skin integrity with ulceration
Can develop secondary cellulitis aggravating the process
Diagnosed by blanching erythema with pain
Can eventually have relative fixation of the ankle joint secondary to tissue fibrosis
What is stasis dermatitis presentation
antibiotics from prescriber thinking it was cellulitis, except there is no pain, no recovery, not hot to touch
also bilateral
crusty, friable
where do you see hemosiderin staining
permanent discolation near the medial malleolus
Lipodermatosclerosis
manifestation of chronic venous insufficiency
It is a type of panniculitis
Affected legs typically have the following characteristics:
Skin induration
Increased pigmentation
Swelling
Redness
“Inverted champagne bottle” or “bowling pin” appearance
Atrophie Blanche
white star deformities from decreased capillary blood flow to tissue
Star-shaped or polyangular, ivory-white depressed atrophic plaques
Prominent red dots within the scar due to enlarged capillary blood vessels
Surrounding hyperpigmentation
spider veins under you medial malleolus
Corona Phlebectatica
Characterized by abnormally dilated veins around the ankle
how to know if an ulcer is venous or arterial?
arterial lesions have well-defined borders (skin is warm, has pulses)
venous lesions do not have well-defined borders (worse pulses)
How is chronic venous insufficiency diagnosed?
Clinically
Duplex ultrasonography is the test of choice for planning therapy
Multidetector computed tomographic (MDCT) venography and magnetic resonance (MR) venography could be considered
Used if doppler US nondiagnostic
Requires injection of IV dye
$$
for chronic venous insufficiency
Mainstay treatment of chronic venous insufficiency
Same as vericose veins
compression stockings during day or evening first line
pneumatic compression if severe
Unna Boot
Paste gauze compression dressing for chronic venous insufficiency prescribed by wound care
takes FORVER to do
allows venous blood to compress back up to
What can happen if you do not take care of an underlying ulcer formation after removal of an Unna boot
It can come back
What can an IV lead to?
Superficial Venous Thrombophlebitis (inflammation)
Essentials of diagnosis of Superficial Venous Thrombophlebitis
Red, painful induration along a superficial vein
Commonly occurs at the site of a recent IV line
Marked swelling of the extremity may occur
Definition of Superficial Venous Thrombophlebitis
inflammation of a superficial vein, which typically results in a clot
Where is the clinical presentation of superficial venous thrombophlebitis
inflammation of a superficial vein, which typically results in a clot
complications of superficial venous thrombophlebitis
Complications in superficial thrombophlebitis:
Extension into the deep venous system
Hyperpigmentation over the affected vein
Persistent, firm nodule in subcutaneous tissues at the site of the affected vein
Conversion to suppurative thrombophlebitis
supportive thrombophlebitis
fluid and blood goes out of opening
Metastatic abscess formation
Septicemia
Septic emboli
not good to have
Superficial Venous Thrombophlebitis diagnosis
clinically
WBC is elevated, but does not help change treatment
Venous doppler ultrasound ONLY if involves the proximal lower extremity or if patient has mixed picture
management of mild Superficial Venous Thrombophlebitis
Mild, localized disease → mild analgesics, such as aspirin or NSAIDs, and the use of some type of elastic support usually are sufficient
Patients are encouraged to continue their usual daily activities
Management of severe Superficial Venous Thrombophlebitis (>5 cm)
More severe, larger, associated with pain and redness → elevate the extremity and apply massive, hot, wet compresses
5 cm or longer → prophylactic dose Fondaparinux (Arixtra), LMWH, or Rivaroxaban (Xarelto) x 45 days
Rapidly progressing disease or extension into deep system → full dose anticoagulation
Superficial Venous Thrombophlebitis with a cannula or catheter
removed and the device is cultured
if a patient is septic from Superficial Venous Thrombophlebitis, what do you do?
Vancomycin + Ceftriaxone
Urgent treatment with Heparin or Arixtra
Prognosis of Superficial Venous Thrombophlebitis
Overall prognosis for most patients is good, as it is usually self-limiting, benign, and brief
If associated with septicemia, mortality rate is 20% or more
Lymphangitis
Red streaking from wound or cellulitis towards regional lymph nodes, which are typically enlarged and tender
Chills, fever, malaise may be present
overview of lymphangitis
Inflammation of the lymphatic channels
May be infectious or noninfectious
Lymphatic system function → resorb fluid and protein from tissues and extravascular spaces
Lymphatic channels are situated in the deep dermis and subdermal tissues parallel to the veins and have a series of valves to ensure one-way flow
it is the garbage truck
What does lymphangitis arise from and lead to
hemolytic streptococci or S. aureus
red skin streaking extending proximally
Wuchereria bancrofti
filarial nematode that is a major cause of acute lymphangitis worldwide; leads to a chronic Filariasis resulting in subsequent lymphedema with thickening of skin and subcutaneous tissue
Is lymphangitis reversible?
Not really :(
Nodular lymphangitis
→ painful or painless nodular subcutaneous swellings along the course of the lymphatic channels
What can you do if an open infection looks abnormal?
culture it
CC of lymphangitis?
malignancy
What is the classic clinical presenatation of lymphadentis
distal abrasian and follwing the streak up you see the lymph node
Diagnostic and eval of lymphangitis
CBC w/ diff and blood cultures must be obtained
Wound culture, abscess I&D if possible
Consider involving infectious disease to assist in the diagnostic workup
Imaging may be helpful for defining anatomic abnormalities → rarely useful for diagnosis of infectious etiologies
Lymphangiography and lymphoscintigraphy have been used to evaluate for lymphedemaand/orlymphatic obstruction (inject dye into lymph system and see what happens)
Treatment of lymphagitis
covering for GABHS
Keflex is common
Oral outpatient therapy
for patients who appear nontoxic, are afebrile, and not immunocompromised
symptomatic management of lymphangitis
Analgesics and/or anti-inflammatories for pain
Can also help reduce inflammation and swelling
Hot, moist compresses also help to reduce inflammation and pain
Elevate and immobilize affected areas to reduce swelling, pain, and the spread of infection if possible
An abscess may require surgical drainage
Nodular lymphangitis often require surgical intervention
Lymphedema essentials of diagnosis
PAINLESS persistent edema of one or both lower extremities, primarily in young women
PITTING edema w/o ulceration, varicosities, or stasis pigmentation
Lymphangitis and cellulitis may develop
two types of lymphedema
Congenital (lymph vessels are over or under developed)
Secondary damage: involves inflammatory or mechanical lymphatic obstruction from trauma, regional lymph node resection/irradiation, or malignant disease or filariasis
May occur following surgical removal of the lymph nodes in the groin or axilla
What leads to secondary dilation of lymphedema
can occur in both forms → leads to incompetence of the valve system, poor lymphatic fluid flow, and results in progressive stasis of a protein-rich fluid
Can result in episodes of acute and chronic inflammation, worsening the edema
What makes lymphedma different from others
PAINLESS
mainly leads to unsightly and trouble with ADLs
Treatment of lymphedema
No cure for lymphedema (LIFELONG):
Treatment aimed at controlling lymphedema and allowing normal function
Common treatment strategies
Edema control
Intermittent leg elevation, especially while sleeping (foot of bed elevated 15–20 degrees)
Constant use of graduated elastic compression stockings
Massage toward the trunk (either by hand or with pneumatic pressure devices designed to “milk” edema out of an extremity”)
Common treatment strategies
Referral to wound care centers
Stress good hygiene and treatment of any secondary infection
Intermittent use of diuretics therapy is rarely helpful
Amputation is used only for the rare complication of lymphangiosarcoma in the extremity
do diuertics work on lymph vessels?
No :(
which is why it cannot be used for lymphedema
