Varicose Veins, Chronic Venous Insufficiency, & Venous Thromboembolis (pathology) Flashcards
What are varicose veins? What is their pathophysiology?
- Caused by superficial venous insufficiency
- Distended damaged vein due to damage to valves
What are the risk factors for varicose veins (4)?
- Pregnancy (hormonal changes and uterus sitting on deep iliac veins causing back pressure)
- Tumours
- Trauma (surgical or direct)
- Previous DVT
What are the symptoms of varicose veins (9)?
- Distended veins - go away when they lay down
- Pain
- Infection
- Ulcers
- Swelling
- Bleeding
- Tightness
- Discoloration
- Eczema
What is the “look” approach of the look, listen, feel for varicose veins?
Ask patient to stand (can see veins in worse state)
- Tortuous dilated long saphenous in severe disease
- Look for oedema, discolouration, eczema
What is the “listen” approach of the look, listen, feel for varicose veins?
Doppler
- Monophasic= normal
- Biphasic= REFLUX
What is the “feel” approach of the look, listen, feel for varicose veins?
- Palpate vein for thrombosis
- Feel if vein is compressible
Special tests: - Trendelenburg
• Lay patient flat
• Raise leg above level of heart and press at saphenofemoral junction
• Ask patient to stand -> see if vein fills
• No filling when junction occluded-> region of incompetence
• Filling-> region of incompetence is lower - Doppler to assess flow within vessel
- Tap test
• Lay patient flat
• Tap on long saphenous vein above knee
- Tapping transmitted to saphenofemoral (for long s.) or saphenopopliteal (for short s.) =incompetent
- No transmission= competent
What are the investigations for varicose veins (2)?
- Complete full peripheral vascular examination
- All pulses (femoral, popliteal, posterior tibial, dorsalis pedis)
- ABPI (check for arterial supply because treatment for venous disease is compression-> worsens Limb Ischaemia)
- Venous duplex US scan
- Shows flow, size of vessel and backflow
- Can see whether incompetence is in superficial or deep venous system
- Secondary care
What is the CEAP classification system for varicose veins?
C=clinical cause
C4= changes in skin and subcutaneous tissue secondary to chronic venous disease
Above C4-> no referral for surgical treatment
C5= ulcers
C6= healed ulcers
*To become C6 need to go through C5
How does the laser or RF treatment option for varicose veins work?
Surgical intervention for superficial varicose veins:
- endovenous treatment with laser or radio frequency ablation
- cannula to long s. below knee —> wire through cannula
- wire up to saphenofemoral junction take cannula off wire insert sheath with laser or RF fibre
- Look on US to see that fibre is at saphenofemoral junction
- Intensely heating inside of vein —> damage to tissue —> veins sticks to itself and closes off
- Local anaesthetic + fluid
- Compression bandaging immediately after treatment to keep veins stuck together
- cannula to long s. below knee —> wire through cannula
What alternative treatment is available if laser/RF treatment is unsuitable?
Open surgery
- Remove diseased vein but now rarely used
- Bleeding but stopped with compression bandages
- painful for patient
What is chronic venous insufficiency?
- Prolonged damage to venous system- over time
- Involves BOTH superficial and deep system
- Failure of calf pump
Vicious cycle —> venous ulceration
What are the risk factors for chronic venous insufficiency (4)?
- Increasing age
- Female sex due to hormones and pregnancy
- Previous DVT or trauma
- Prolonged standing-> increased venous pressure
What are the symptoms of chronic venous insufficiency?
- Telangiectasia (spider veins)
- Lipodermatosclerosis- leg looking like inverted champagne bottle
- Venous eczema
- Ulceration
What is the treatment/management for deep venous insufficiency?
Management is conservative
- Compression bandaging and elevation if no arterial compromise —> reduced oedema + stops vicious cycle
- Intermittent flares of cellulitis + oedema if not compliant with compression band
What is a thromboembolism? What are 2 common thromboembolisms?
Thromboembolism = movement of blood clot along a vessel
deep vein thrombosis
Pulmonary embolsim
What is deep vein thrombosis?
clot (red thrombus= RBC + fibrin) in deep veins
What is the pathophysiology of DVT?
- Congestion= relative excess of blood in vessel of tissue or organ- passive process (distinct from active hyperaemia)
- Vein blocked causing Localised Acute Congestion ↓ blood outflow ↓ pressure gradient, NO O2 —> ischemia + infarction
What are the risk factors for thromboembolsim (5)?
Young females due to female hormones (oestrogen) Blood stasis: - Immobility - Long haul travel (not unique risk factor) Endothelial dysfunction: - Hypertension - Smoking - High cholesterol Endothelial damage: - Indwelling venous catheters - Trauma - Surgery - Intravenous drug users Hypercoagulability: - Inherited - Pregnancy= sex hormones make blood sticky - Cancer= adenocarcinomas secrete coagulability factors - Sepsis
What are the signs and symptoms of DVT (7)?
- UNILATERAL limb swelling
- Persisting discomfort
- Calf tenderness
- Erythema
- Warmth
- Prominent collateral veins
- Unilateral pitting oedema
May be clinically silent
What are the signs and symptoms of a pulmonary embolism (5)?
- Pleuritic chest pain
- SOB
- Haemoptysis if infarction
- Tachycardia
- Pleural rub on auscultation
Not very specific (like pneumonia, MI, pericarditis)
What are the signs and symptoms of a MASSIVE pulmonary embolism (6)?
- Severe SOB of sudden onset
- Collapse
- Central cyanosis (blue tongue/ lips)
- Tachycardia
- Low BP
- ↑ JVP
May cause sudden death
How is DVT diagnosed?
Wells score:
- ≤ 1 in 75% patients - 10% chance of DVT
- D-dimer + doppler USS
- ≥ 2 in 40% patients – 33% chance of DVT
- No D-dimer- venogram + doppler USS
- Bloods- D-dimer = breakdown of fibrinolysis
- ↑ -ve predictive value
- ↓ +ve predictive value (not specific enough)
Imaging—> compression USS if +ve D-dimer or high pre-test score
How is pulmonary embolism diagnosed?
Diagnosis of PE
Wells score:
- ≤ 4 in 60% patients 5% chance of DVT
- ≥ 4.5 in 40% patients 33% chance of DVT
- Low wells score-> D-dimer-> -ve D-dimer= exclude DVT/PE
- +ve D-dimer or high Wells score-> imaging -> V/Q scan/ CT pulmonary angiogram
Check for cause-> recent surgery/hospital stay
- Clear cause=stop treatment after 3 months
Check for malignancy – occult renal tumour, LFTs
Risk of recurrence (DASH score, HERDoo2)
How is a venous thromboembolism prevented (3)?
- Early mobilisation
- Anti-embolism stocking to push blood up to heart in immobile patients
- Pharmacological thromboprophylaxis – HEPARINS
What is the medical treatment for thromboembolism?
Anticoagulation
- Clear cause= 3-month treatment - Unprovoked = lifelong treatment - DOACs – RIVAROXABAN, DABIGATRAN - Warfarin in obese patients (BMI>35/40) - low molecular weight heparin in cancer patients - do NOT use if GFR <30- IV - unfractionated heparin if GFR<30 – close monitoring
What is the surgical treatment for thromboembolism?
- vascular surgical intervention in massive DVTs
- thrombolysis – ALTEPLASE- for massive PE
What are the long term effects of DVT?
Post thrombotic syndrome: - Damage to venous valves • Swelling • Discomfort • Pigmentation • Ulcers - Pulmonary arterial hypertension (surgically treated by clot removal from pulmonary artery)
