PVD

Question 1

Types of Venous Disorders?

Answer 1

• Varicose Veins
• Superficial Venous Thrombophlebitis
• Chronic Venous Insufficiency
• Deep Vein Thrombosis

Question 2

Varicose Veins?

Answer 2

– Dilated, tortuous superficial veins in the lower extremities

– MC greater saphenous vein and its tributaries

– Distention of the vein results in weakened/incompetent valves à dilation along the vein

Question 3

Primary and Secondary Varicose Veins?

Answer 3

Primary:
– MC type superficial system (genetic)
– More common in females than males
– ½ of these patients have a FHx of varicose veins

Secondary:
– Originate from deep venous insufficiency and incompetent perforating veins or from deep venous occlusion that results in enlargement of superficial veins b/c they are acting as collaterals

Question 4

Signs/symptoms of Varicose Veins?

Answer 4

– Asymptomatic or symptomatic
– Dull ache/heaviness or fatigue of the legs
– Venous stasis dermatitis may be present
– May be visible or only be palpable.
– Brownish pigmentation and thinning of the skin above the ankle may be present

Question 5

what is the Imaging of chic for Varicose Veins?

Answer 5

– Duplex Ultrasound

Question 6

Complications Varicose Veins?

Answer 6

– Superficial venous thrombosis (rare)

– Bleeding (secondary to trauma)

Question 7

Non-Surgical & Surgical tx of Varicose Veins?

Answer 7

Non-surgical:
      •	Avoid prolonged standing
      •	Compression stockings (medium to heavy weight) when standing
      •	Leg elevation when possible
      •	Varicose Veins

Surgical:
• Endovenous ablation (radiofrequency or laser – collapsing vain)
• Greater saphenous vein stripping (works well)
• Phlebectomy w/ or w/o correction of reflux
• Compression Sclerotherapy

Question 8

When to refer a pt w/ Varicose Veine to a vascular surgeon?

Answer 8

– Bleeding from varicose vein
– Superficial venous thrombosis
– Pain
– Cosmetic concerns

Question 9

About Superficial Venous Thrombosis?

Answer 9

– Superficial thrombus
– Indurated, warm, red and tender cord extending along a superficial vein, (common along the saphenous vein)

– MC short term IV’s & PICC lines
– Do not result in pulmonary emboli

Question 10

Tx for Superficial Venous Thrombosis?

Answer 10

Supportive:
• Elevation, warm compresses and NSAIDS

Anticoagulation:
•To prevent extension of the thrombus into the deep vein system

Question 11

About Chronic Venous Insufficiency (CVI)?

Answer 11

– A condition that occurs when the venous wall and/or valves in the leg veins are not working effectively, making it difficult for blood to return to the heart from the legs. It causes blood to “pool” or collect in these veins (stasis).

Question 12

What Causes CVI?

Answer 12

• History of leg trauma
• Superficial venous reflux
• Varicose veins
• Pelvic tumors obstructing the pelvic veins
• Vascular malformations

Question 13

Physiology of VCI?

Answer 13

– Thickened Valves and scarred
– Results in an abnormally high hydrostatic force transmitted to the subcutaneous veins and tissues of the lower leg
• Results in 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

Question 14

Risk Factors of CVI?

Answer 14

–	DVT 
–	Varicose Veins
–	Obesity
–	Pregnancy
–	Inactivity
–	Smoking
–	Extended periods of standing or sitting
–	Female Sex
–	Age over 50

Question 15

Signs/symptoms of CVI?

Answer 15

– Progressive pitting edema o
– Secondary Changes develop over time (progressive):
• Itching
• Dull ache in the leg that worsens w/ prolonged standing and resolves w/ leg elevation
• Skin at ankle is usually taut from swelling, shiny and a brownish pigmentation (hemosiderin)
• Thick and fibrous Subcutaneous
• Ulcerations may occur near the medial and lateral malleolus
• Cellulitis is common (blanching erythema)
• Varicosities may develop

Question 16

Imaging for CVI?

Answer 16

Duplex U/S

Question 17

Tx for CVI?

Answer 17

Generalized:
• Compression stockings - mainstay
• Avoid long periods of sitting/standing
• Intermittent elevations of legs/sleeping w/ legs elevated above the level of the heart

Ulcers
• Wet to dry dressings or occlusive hydrocolloid dressings
• Once ulcer has healed, compression stockings w/ graduated compression below the knee are used to prevent recurrent edema and ulceration

Surgery:
• Radiofrequency ablation or endovenous laser tx at the area of ulceration to promote healing

Question 18

About DVT?

Answer 18

– A blood clot that develops in a deep vain.

– MC’ly in LE

Question 19

Classic triad for DVT?

Answer 19

Virchow’s Triad

                     PANCE QUESTION

Question 20

Virchow’s Triad ?

Answer 20

– Venous Stasis
– Injury to the vessel wall
– Hypercoagulable state

Question 21

Causes of Venous Stasis?

Answer 21

Immobilization:
– Transient ( s/p Operation/surgery under general anaesthesia or Transcontinental flight)
– Extended: Confined hospitalization after pelvic, hip or spinal surgery; Due to stroke or Paraplegia

Reduced return blood flow to the heart:
– Increased blood viscosity: (Polycythemia vera, Severe dehydration)
– Increased Central Venous pressure (Rt. Heart failure, Pt. on Respirator with PEEP)

Reduced flow thru’ the leg veins:
– Abd. mass compressing Iliac Vein or IVC; Enlarged or Pregnant Uterus

Question 22

Mechanical Injury to the Vein Wall of Venous Stasis?

Answer 22

• Obvious:
ex. Trauma, Surgery

• Obscure:
ex. Hip Arthroplasty with Femoral Vein manipulation, Old DVT with persistent endothelial vein damage.

Question 23

Hypercoagulable State of Venous Stasis?

Answer 23

Primary -> genetic mutation:
        Antithrombin III deficiency,
        Antiphospholipid syndrome, 
        Protein C deficiency, 
        Protein S deficiency

Secondary:  
         Surgery, 
         Malignancy, 
         Pregnancy,  
         Oral Contraceptive Use

Question 24

Complications of DVT?

Answer 24

– PE
– CVI
– Phlegmasia alba dolens → Common PANCE Questions
– Phlegmasia cerulea dolens → Common PANCE Questions

Question 25

About Phlegmasia Alba Dolens (White Leg)?

Answer 25

– 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. The leg becomes edematous which compromises the arterial circulation resulting in the leg turning white
– May be reversed with emergent intervention possibly using Thrombolytic therapy

Question 26

About Phlegmasia cerulea dolens (Venous Gangrene)?

Answer 26

– Continuation of the process (alba dolens) leads to complete occlusion of arterial supply to the limb
– Without blood supply, the skin and toes become gangrenous
– Prognosis very poor, usually requires emergent leg amputation.

Question 27

Risk Factors of DVT?

Answer 27

–	Hypercoagulable states
–	Thrombophilia
–	Trauma
–	Obesity
–	Recent Surgery/invasive procedures
–	Immobilization
–	Recent Prolonged Travel
–	Cancer
–	Pregnancy/Post-partum
–	OCP’s/HRT
–	Prior VTE

Question 28

Symptoms OF DVT?

Answer 28

– Often asymptomatic (if subclinical)
– Leg swelling
– Leg pain
– Unilateral leg tenderness

Question 29

Signs of DVT?

Answer 29

– Unilateral pitting edema
– Increased calf circumference (>3cm)
– Calf Tenderness
– Homan’s Sign (controversial)

Question 30

Diagnosis of DVT?

Answer 30

– Classic symptoms of DVT as well as classic signs are of LOW PREDICTIVE VALUE

– D-dimer

– US - MC’ly used

Question 31

What is Wells Criteria?

Answer 31

Helps you grade severity of DVT

Question 32

Risk Score Interpretation of Wells Criteria?

Answer 32

– 3 points: high risk (75%)
– 1 to 2 pts: Medium Risk (17%)
– < 1 point: Low Risk(3%)

Question 33

DVT work up?

Answer 33

Low probability:
  •D-dimer:
      •	Neg -> r/o DVT
      •	Pos -> US:
                      •	Neg -> r/o DVT
                      •	Pos -> DVT Confirmed

Mod - High Probability:
  • US:
      •	Pos -> DVT Confirmed
      •	Neg -> D-dimer
              • Neg r/o
              • Pos -> follow up studies (repeat US)

Question 34

Tx for DVT?

Answer 34

– Prevent complications → Prevent PE

– Mainstay of this objective is immediate anti-coagulation:
• Heparin (UFH),
• Low Molecular Weight Heparin or
• Fondaparinux followed by conversion to oral Coumadin (Warfarin) or Thrombolytics

Question 35

What is the long term Oral Anticoagulation for DVT?

Answer 35

– Warfarin
• Requires a minimum of 5 days to be therapeutic

  •Typically treated as an outpatient

Question 36

Duration of Treatment for DVT?

Answer 36

– Provoked DVT in arm/calf -> 3 months

– 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 (including long travel): consider indefinite tx d/t high rate of recurrence vs 6 months of tx
• w/ target INR b/w 2-3 followed by
• a lower target INR of 1.5-2