PVD, PE, DVT Flashcards
General term that covers all diseases of the blood vessels outside the heart, and Can affect both the arteries and veins
Peripheral Vascular Disease
PAD
Peripheral Artery Disease
A condition that develops when the arteries that supply blood to the internal organs, arms, and legs become completely or partially blocked as a result of atherosclerosis
Peripheral Artery Disease (PAD)
Obstruction of the large or medium size arteries NOT within the heart or aortic arch
Peripheral Artery Disease (PAD)
Risk Factors for PVD
- Smoking (most important)
- Diabetes
- ↑ Cholesterol
- Hypertension
- Obese, male over 50 y/o, with family history of heart attack or stroke.
Why do people with diabetes have 2-4 times increased risk of PVD?
due to endothelial & smooth muscle cell dysfunction in peripheral arteries
Arteriosclerosis Obliterans AKA
Peripheral Arterial Disease
- Peripheral manifestation of atherosclerosis
- Responsible for 95% of cases of chronic occlusive arterial disease
“Hardening of the Arteries”
Atherosclerosis
When the supply of blood is less than the muscles demand (approximately 50% occlusion) and results in pain, aching, weakness, numbness, cramping, discomfort, tiredness in the involved muscles is produced. It usually decreased with rest.
Intermittent Claudication
Arteriosclerosis Obliterans
Rest pain is common when occlusion is greater than ______ → inadequate perfusion
What might help to relieve pain?
80-90%
Keeping the leg down help relieve the pain
📣
clinical symptoms of Arteriosclerosis Obliterans:
(aka peripheral arterial disease)
- Diminished or absent pulses
- Pallor of the skin
- Trophic changes – decreased hair & nail growth
- Possible presence of a wound/ slow healing
- Extremity is cool to the touch
Arterial thrombus Vs. emboli
- Thrombus: blood clot that narrows an area
- Emboli: piece of that clot that breaks off and goes somewhere else.
- Thrombi & Emboli can cause sudden complete blockage leading to cessation of blood flow and
tissue death
Thrombi & Emboli can cause sudden complete blockage leading to cessation of blood flow and tissue death, Symptoms?
- Abrupt onset of pain
- Pallor
- Cyanosis
- Lack of pulses
Thromboangiitis obliterans, also known as Buerger disease, occurs primarily in
young men who smoke heavily
- Rest pain usually the initial symptom followed by intermittent claudication
- Foot greater than calf
- Direct correlation between cigarette smoking and disease manifestation
Spasm of the arterioles affecting the digits, causing little or no blood flow to the affected body parts → causes cyanosis in the digits when exposed to cold or emotional upset
Raynaud’s Syndrome
- Warming usually restores color to the hands
- Pain is generally not present (but sometimes is) and may be associated with tingling or swelling
Diagnosis of peripheral vascular disease:
-
Ankle Brachial Index: ratio of ankle pressure and arm pressure
- 0.96–1.00 Normal*** 🚨 < 0.3 Ischemic rest pain, possible tissue necrosis
-
Duplex Ultrasound: Shows how blood is flowing through the vessels
- Measures the speed of the flow of blood; Estimate the diameter of a blood vessel; Measures amount of obstruction
- Angiography: Most accurate test to detect the location(s) & severity of artery occlusion, as well as collateral circulations
Most accurate test to detect the location(s) & severity of artery occlusion, as well as collateral circulations
Angiography
Treatments of PAD
- Lifestyle measures: stop smoking, diet, exercise, skin foot checks
- Medications: anticlotting agents, cholesterols lowering agents, meds that control BP
- Angioplasty: with stent, thrombolytic, cryoplasty
- Surgeries: Endarterectomy (clean up the clot), bypass grafting, amputation
Arterial Thrombolysis
contrast material and clot dissolving factor (thrombolytics or tPA) delivered through catheter under x-ray / fluoroscopy guidance
Major risk factor in diseases of the vein is
familial history
which are more prevalent arterial diseases or venous diseases
diseases of the vein
Chronic Venous Insufficiency AKA
Chronic Venous Disease
Condition in which leg veins cannot pump enough blood back to the heart, and also caused by Deep Vein Thrombosis and Phlebitis due to obstructed blood flow
Chronic Venous Insufficiency
Phlebitis means
inflammation of a vein. Thrombophlebitis is due to one or more blood clots in a vein that cause inflammation
Chronic Venous Insufficiency clinical presentation:
- Edema
- Erythema (superficial reddening of the skin), cellulitis, dermatitis, hemosiderin, ulceration, varicose veins
- Leg ulcerations (medial aspect of LE)
Hemosiderin is caused by…
Hemosiderin staining is dark purple or rusty discoloration of the lower legs caused by chronic venous disease. A 2010 study found hemosiderin staining in all subjects with lipodermatosclerosis and venous ulcers. When vein valves fail, regurgitated blood forces red blood cells (RBCs) out of capillaries. Dead RBCs release iron, which is stored in tissues as hemosiderin, staining the skin.
Chronic Venous Insufficiency; risk Factors and PMH
- Overweight
- smoking
- sedentary (long periods of sitting)
- family Hx
- HTN
- CHF
- Women over 50
Arterial Insufficiency Physical Exam (objective findings)
- Skin color and temperature
- Edema
- Decreased pulses
- Possible bruit (abnormal sound heard over arteries)
- Ankle Brachial Index
What happens when you elevate the legs of a patient with arterial insufficiency?
they may have more pain
Chronic Venous insufficiency physical exam findings
- Rarely report intermittent claudication or rest pain
- Edema resolves with elevation
- Hemosiderin staining may be present
- Presence of edema
attributed to prevalence of incompetent valves → produces increased venous pressure and
overstretches the vein; can be described as large, bulbous, tortuous
Varicose Veins
diagnostic tests for varicose veins
-
Duplex Ultrasound 👍🏼
- Measure speed of blood flow
- Determine structure or leg veins
-
Venogram
- X-ray with injected dye to see the anatomy of veins
treatment of varicose veins
- compression stockings
- education (keep moving)
- exercise
- surgeries
📣
Difference Between Arterial & Venous Ulcers
- Arterial ulcers ulcers are most likely are perfectly round with smooth, well defined edges, minimal
drainage, no odor, faint to absent pedal pulse - Venous ulcers edges are NOT A PERFECT CIRCLE, wet all the time, normal leg & foot pulses
thromboprophylaxis reduces
DVT & PE
Fatal PE is prevented by
thromboprophylaxis
is the most common preventable cause of hospital death
PE
Blood cells (platelets) clump together and produce chemicals that activate the clotting process (thrombin) → **Thrombin** activates production of another protein called fibrin → **Fibrin** binds the platelets together, forming a **blood clot**
DVT
Types of Thrombosis
- Superficial Venous Thrombosis; does not lead to PE
- Deep Vein Thrombosis; can be proximal or distal
types of DVT
- Distal: lower rate of PE, Generally small and asymptomatic
- Proximal DVT: cranial (proximal) popliteal vein or more proximal, less common BUT most
serious form of DVT
A sudden blockage in a lung artery usually caused by a DVT
Pulmonary Embolism
If left untreated, about ____ percent of patients who have PE will die; most within the first few hours of the event
30
Other than blood clot, other types of emboli to the lungs
- fat emboli
- air emboli
- amniotic fluid
Medical Conditions and risks factor which Can Lead to DVT Risk factors
- Cancer
- Physical Trauma
- Stroke
- Heart failure
- Surgery
- Immobilization; Long haul flights = “economy class syndrome”
- Compression of veins
three tools to determine risk for developing DVT or PE
- Virchow’s Triad and Risk factors for VTE
- Wells’s Clinical Prediction Rule
- Classification of “Level of Risk”
Virchow’s Triad: three main factors that predispose to thrombosis:
- Hypercoagulability
- Hemodynamic changes (stasis, turbulence)
- Endothelial injury/dysfunction
Well’s Clinical Prediction Rule for PE; 2 points or more =
DVT likely
Well’s Clinical Prediction Rule for PE;
Probability of DVT; less than 2 points =
DVT unlikely
Well’s Scoring Interpretation
Risk Score Interpretation Probability of PE
- less than 2 points = low risk
- 2-6 points = moderate
- more than 6 points = high risk
📣
low risk of DVT/PE
- Age < 40
- Uncomplicated or minor surgery (<30 min)
- No clinical Risk factors
📣
moderate risk of DVT/PE
- Minor surgery in age 40-60 with 1 clinical risk factor
- Major surgery (>30 min) in age < 40 with 1 clinical risk factor
📣
high risk of DVT/PE
- Major surgery in pt >40
- h/o DVT/PE
- h/o cancer
- Hip or knee surgery
- Surgical repair of hip fx
- Major trauma
- SCI
Sign and Symptoms of DVT
- Swelling of affected limb
- Pain or tenderness
- Warmth
- Maybe chills, fever, malaise, cyanosis
Sign and Symptoms of PE
- Chest pain
- SOB, thachypnea
- Tachycardia (low O2 levels)
- Light headed, faint
- Cyanosis
- Anxiety
- Low BP
Best way to diagnose a DVT
- Duplex or Doppler ultrasound
- MRI (for pelvic DVT)
- Venography (old gold standard)
Diagnosis of PE
- Medical Hx + Physical Exam + Test results
- Spiral CT – VQ (lung ventilation/perfusion) scan
- Pulmonary Angiography
- Blood Tests
- ABG
- D-Dimer assay
difference between intravenous venography and duplex imaging/US
- intravenous venography: accurate, costly, invasive
- Duplex imaging: accurate, noninvasive, no radiation, can be repeated, decreased cost
Dye injected into vein, makes blood vessels visible on x-ray -> reveals blockage in lungs
Gold standard for PE
Spiral CT
Uses radioactive substances to show how well O2 & blood are flowing to all areas of lungs
VQ Scan
(ventilation/perfusion)
What is a D-Dimer test?
- is a blood test used to measures substances in the blood that are released when a clot breaks up (fibrin degradation product)
- rule out blood clot
- highly sensitive, 50% specific
Thrombectomy laid over the approximate location in the leg vein where it developed
DVT Diagnostic Tests by PT
- Homan’s Test: very nonspecific, lack sensitivity
- Pratt’s Sign: very nonspecific; pain with squeezing the posterior calf
- Place BP cuff around calf → + test if pain when inflated to 160-180mmHg
(Well’s risk factor are better than any of these)
Factors that reduce DVT
- Mobilization
- Hydration
- Anti-coagulation
- Pressure stockings
- Compression devices
Advantages and disadvantages of mechanical prevention/treatment of DVT
- Advantages: do not increase the risk of bleeding, can be used in pt with risk of bleeding, enhances anticoagulants/thrombophylaxis , may reduce swelling.
- Disadvantages: Greater effect in decreasing calf DVT than proximal DVT, haven’t been assessed in clinical trial, cost, No established standards for size, pressure, physiologic features
what is the goal of Inferior Vena cava (IVC) Filter?
to prevent embolism from reaching the lungs
when are Inferior Vena Cava filters used?
when a pt cannot be anticoagulated with medication
A pt is considered immediately “anticoagulated” once IVC Filter is in if no pharm agents used
what are the primary concerns with inferior vena cava filters?
- Possibility of new DVT Especially in pts with previous PE
- Possible migration/displacement of filter
goal of Graduated Compression Stockings
- Prevent venous stasis
- Keep mural clot attached to endothelial wall and help w/ re-absorption
- Facilitate venous return
disadvantages of graduated compression stockings:
- compliance
- improper use and fit
- May fail to produce proper gradient (especially if wrong mmHg size used)
goal of Intermittent Pneumatic (Calf) Compression
- Increase venous return and prevent stasis
- May contribute to fibrin breakdown
Intermittent Pneumatic (Calf) Compression More effective in preventing DVT in orthopedic pt’s when used with \_\_\_\_\_\_\_ than \_\_\_\_\_\_ alone
Low Molecular weight Heparin
-PHARMACOLOGIC Prevention & Treatment of DVT
- Aspirin: prevents platelets from sticking to one another; is cheap; GI bleeding, tinnitus
-
Heparin: derived from pg, Stops formation fibrin; quickly increases the effect of
antithrombin III protein.- High Molecular Weight Heparin: via IV, quick acting
- Low Molecular Weight Heparin: Used to prevent or treat thrombosis
- Coumadin (warfarin): orally; takes 3-4 days to reach therapeutic range; Inhibits Vit K regeneration in liver → decreased synthesis of certain clotting factors
Heparin-induced thrombocytopenia (HIT) is a
complication of heparin therapy. There are two types of HIT. Type 1 HIT presents within the first 2 days after exposure to heparin, and the platelet count normalizes with continued heparin therapy. Type 1 HIT is a nonimmune disorder that results from the direct effect of heparin on platelet activation
These patients can’t take heparin products
Low Molecular Weight Heparin vs High Molecular Weight Heparin for Treatment of DVT and PE
- High Molecular Weight Heparin: Standard of care in hospitalized patients – Easier to reverse effects as compared to LMWH
- Low Molecular Weight Heparin: Prevention → Treatment; can be used at home; Longer half life than UFH → faster stabilization of clot
Enoxaparin (Lovenox), ardeparin (Normiflo), dalteparin (Fragmin), fraxiparine
Low Molecular Weight Heparin (LMWH)
Inhibits Vit K regeneration in liver → decreased synthesis of certain clotting factors
Coumadin (warfarin)
NOAC (Novel Anticoagulant Drugs):
– Pradaxa (Dabigatran)
– Eliquis (Apixaban)
– Xarelto (Rivaroxaban)
– Savaysa (Edoxaban)
- May have a lower rate of hemorrhagic stroke
- May have less major bleeding
- Need to look at renal and liver functions and also other medications a patient is taking
- Additional advantages over warfarin therapy:
- – fixed doses
- – predictable pharmacokinetics
- – minimal food and drug interactions
- – lack of requirement for blood test monitoring
All patients with venous thromboembolism be treated acutely with
either ______ vs ______ for at least 5 days with bridging to long-term therapy for at least 3 months
Hig Molecular Heparin vs LMWH
Coumadin (warfarin)
- Administered orally
- Prevention & long term treatment of DVT/PE
- Takes 3-5 days to reach therapeutic range
5 main responsibilities of PTs to our patients re: DVT/VTE
- Prevention of VTE
- Screening for LE DVT
- Contribute to health care team re: safe mobility
- Patient education/shared decision making
- Prevention of long term consequences of LE DVT
Mobilization with acute VTE
- LMWH vs UFH vs IVC Filter
- Mobilize once anticoagulation started
- Don’t be scared
- Will I cause the DVT to break off and become PE? NO
- Monitor signs and symptoms closely
- New PE pts are tachycardic even after ACG
- Will keeping the pt on bed rest help? NO
Thrombolysis
also known as thrombolytic therapy, is a treatment to dissolve dangerous clots in blood vessels,
– Enzymatic destruction of clot
– Plasminogen activator (tPA)
Thrombectomy
- mechanically remove clot
- Surgical intervention
- Can be used for large embolus to lung or for lung DVT
- Angiovac
Summary
- All patients with acute fracture should be on DVT prophylaxis (in hospital and upon d/c)
- Use of mechanical interventions combined with pharmacological thromboprophylaxis are more effective
- Mobilization after acute DVT does NOT increase risk of PE
- HOW DO YOU DECIDE WHAT TO DO?
- Use clinical prediction rules
