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Cardiology > Peripheral Venous & Lymphatic Vessel Disease > Flashcards

Peripheral Venous & Lymphatic Vessel Disease Flashcards

1
Q

What causes varicose veins

A

high venous pressure

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2
Q

Classic patient of varicose veins

A

Postpartum women (highest incidence)
Prolonged standing
Heavy lifting
Varicosities develop in over 20% of all adults

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3
Q

how does blood pool up?

A

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

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4
Q

MC vein associated with varicose veins

A

Great saphenous

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5
Q

What does varicose veins lead to?

A

Progression, because valve incompetence and reflux
Vein segments below the defective valves distend and progressively fail as well

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6
Q

How do you get secondary varicosities?

A

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

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7
Q

Classic clinical presentation of varicose veins

A

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)

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8
Q

Is severity of varicose veins have to do with severity of symptoms?

A

No

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9
Q

What can lead to induration and fibrosis?

A

Venous stasis, causing fibrotic hard skin leading to ulcerations

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10
Q

How to diagnose varicose veins?

A

Clinically

Only order imaging (venous duplex US) if you think there is an obstruction and need a surgery

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11
Q

Nonsurgical treatment of varicose veins and issues

A

Compression stockings (hoes)
Really hard to wear though

leg elevation above the heart (wedge pillows)

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12
Q

When should you use compression stocking

A

After you get up, because there is the least blood in your legs at that time

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13
Q

compression hoes order

A

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

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14
Q

If a patient does not want to use compression stockings, what is a permanent option?

A

Sclerotherapy, endovenous laser therapy (EVLA), Endovenous Radiofrequency Ablation (EVRFA), vein stripping (last resort)

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15
Q

sclerotherapy procedure

A

Direct injection of a sclerosing agent¹ → permanent fibrosis and obliteration of the target veins
Recurrence rate is >50% if underlying reflux is not managed

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16
Q

Endovenous laser therapy procedure

A

Performed with local anesthesia
The laser heats up the small vein and destroys it
Could result in heat-induced thrombosis, requiring prolonged anticoagulation

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17
Q

Endovenous Radiofrequency Ablation (EVRFA) procedure

A

Better for significant varicose veins with signs of venous insufficiency or for long varicosities

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18
Q

Vein stripping

A

Involves removing the part of the vein that is torturous

LAST resort

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19
Q

What causes chronic venous insufficiency

A

Complication of varicose veins, DVT, injury, or something else

venous hypertension

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20
Q

What does chronic venous insufficiency look like?

A

Edema, (brawny) skin hyperpigmentation, subcutaneous lipodermatosclerosis in the lower leg
Venous ulcers characterized by ulcerations at or above the medial ankle

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21
Q

What is a complicating factor of chronic venous insufficiency

A

Obesity

leads to lower activity and further problems

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22
Q

Etiology of chronic venous insufficiency

A

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

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23
Q

what to order if you think there might be heart failure instead of chronic venous insufficiency

A

BNP

r/o CHF if <100

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24
Q

What are the pathologic changes of chronic venous insufficiency

A

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

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25
Q

Clinical manifestations of chronic venous insufficiency

A

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

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26
Q

What is stasis dermatitis presentation

A

antibiotics from prescriber thinking it was cellulitis, except there is no pain, no recovery, not hot to touch

also bilateral

crusty, friable

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27
Q

where do you see hemosiderin staining

A

permanent discolation near the medial malleolus

28
Q

Lipodermatosclerosis

A

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

29
Q

Atrophie Blanche

A

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

30
Q

spider veins under you medial malleolus

A

Corona Phlebectatica

Characterized by abnormally dilated veins around the ankle

31
Q

how to know if an ulcer is venous or arterial?

A

arterial lesions have well-defined borders (skin is warm, has pulses)
venous lesions do not have well-defined borders (worse pulses)

32
Q

How is chronic venous insufficiency diagnosed?

A

Clinically

Duplex ultrasonography is the test of choice for planning therapy

33
Q

Multidetector computed tomographic (MDCT) venography and magnetic resonance (MR) venography could be considered

A

Used if doppler US nondiagnostic
Requires injection of IV dye
$$

for chronic venous insufficiency

34
Q

Mainstay treatment of chronic venous insufficiency

A

Same as vericose veins

compression stockings during day or evening first line
pneumatic compression if severe

35
Q

Unna Boot

A

Paste gauze compression dressing for chronic venous insufficiency prescribed by wound care

takes FORVER to do

allows venous blood to compress back up to

36
Q

What can happen if you do not take care of an underlying ulcer formation after removal of an Unna boot

A

It can come back

37
Q

What can an IV lead to?

A

Superficial Venous Thrombophlebitis (inflammation)

38
Q

Essentials of diagnosis of Superficial Venous Thrombophlebitis

A

Red, painful induration along a superficial vein
Commonly occurs at the site of a recent IV line
Marked swelling of the extremity may occur

39
Q

Definition of Superficial Venous Thrombophlebitis

A

inflammation of a superficial vein, which typically results in a clot

40
Q

Where is the clinical presentation of superficial venous thrombophlebitis

A

inflammation of a superficial vein, which typically results in a clot

41
Q

complications of superficial venous thrombophlebitis

A

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

42
Q

supportive thrombophlebitis

A

fluid and blood goes out of opening
Metastatic abscess formation
Septicemia
Septic emboli

not good to have

43
Q

Superficial Venous Thrombophlebitis diagnosis

A

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

44
Q

management of mild Superficial Venous Thrombophlebitis

A

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

45
Q

Management of severe Superficial Venous Thrombophlebitis (>5 cm)

A

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

46
Q

Superficial Venous Thrombophlebitis with a cannula or catheter

A

removed and the device is cultured

47
Q

if a patient is septic from Superficial Venous Thrombophlebitis, what do you do?

A

Vancomycin + Ceftriaxone
Urgent treatment with Heparin or Arixtra

48
Q

Prognosis of Superficial Venous Thrombophlebitis

A

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

49
Q

Lymphangitis

A

Red streaking from wound or cellulitis towards regional lymph nodes, which are typically enlarged and tender

Chills, fever, malaise may be present

50
Q

overview of lymphangitis

A

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

51
Q

What does lymphangitis arise from and lead to

A

hemolytic streptococci or S. aureus

red skin streaking extending proximally

52
Q

Wuchereria bancrofti

A

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

53
Q

Is lymphangitis reversible?

A

Not really :(

54
Q

Nodular lymphangitis

A

→ painful or painless nodular subcutaneous swellings along the course of the lymphatic channels

55
Q

What can you do if an open infection looks abnormal?

A

culture it

56
Q

CC of lymphangitis?

A

malignancy

57
Q

What is the classic clinical presenatation of lymphadentis

A

distal abrasian and follwing the streak up you see the lymph node

58
Q

Diagnostic and eval of lymphangitis

A

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)

59
Q

Treatment of lymphagitis

A

covering for GABHS

Keflex is common

60
Q

Oral outpatient therapy

A

for patients who appear nontoxic, are afebrile, and not immunocompromised

61
Q

symptomatic management of lymphangitis

A

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

62
Q

Lymphedema essentials of diagnosis

A

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

63
Q

two types of lymphedema

A

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

64
Q

What leads to secondary dilation of lymphedema

A

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

65
Q

What makes lymphedma different from others

A

PAINLESS

mainly leads to unsightly and trouble with ADLs

66
Q

Treatment of lymphedema

A

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

67
Q

do diuertics work on lymph vessels?

A

No :(

which is why it cannot be used for lymphedema

Cardiology (22 decks)

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