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Cardiovascular System > Varicose Veins, Chronic Venous Insufficiency, & Venous Thromboembolis (pathology) > Flashcards

Varicose Veins, Chronic Venous Insufficiency, & Venous Thromboembolis (pathology) Flashcards

1
Q

What are varicose veins? What is their pathophysiology?

A
  • Caused by superficial venous insufficiency

- Distended damaged vein due to damage to valves

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2
Q

What are the risk factors for varicose veins (4)?

A
  • Pregnancy (hormonal changes and uterus sitting on deep iliac veins causing back pressure)
  • Tumours
  • Trauma (surgical or direct)
  • Previous DVT
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3
Q

What are the symptoms of varicose veins (9)?

A
  • Distended veins - go away when they lay down
  • Pain
  • Infection
  • Ulcers
  • Swelling
  • Bleeding
  • Tightness
  • Discoloration
  • Eczema
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4
Q

What is the “look” approach of the look, listen, feel for varicose veins?

A

Ask patient to stand (can see veins in worse state)

  • Tortuous dilated long saphenous in severe disease
  • Look for oedema, discolouration, eczema
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5
Q

What is the “listen” approach of the look, listen, feel for varicose veins?

A

Doppler

  • Monophasic= normal
  • Biphasic= REFLUX
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6
Q

What is the “feel” approach of the look, listen, feel for varicose veins?

A
  • 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
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7
Q

What are the investigations for varicose veins (2)?

A
  • 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
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8
Q

What is the CEAP classification system for varicose veins?

A

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

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9
Q

How does the laser or RF treatment option for varicose veins work?

A

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
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10
Q

What alternative treatment is available if laser/RF treatment is unsuitable?

A

Open surgery

  • Remove diseased vein but now rarely used
    • Bleeding but stopped with compression bandages
    • painful for patient
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11
Q

What is chronic venous insufficiency?

A
  • Prolonged damage to venous system- over time
  • Involves BOTH superficial and deep system
  • Failure of calf pump

Vicious cycle —> venous ulceration

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12
Q

What are the risk factors for chronic venous insufficiency (4)?

A
  • Increasing age
  • Female sex due to hormones and pregnancy
  • Previous DVT or trauma
  • Prolonged standing-> increased venous pressure
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13
Q

What are the symptoms of chronic venous insufficiency?

A
  • Telangiectasia (spider veins)
  • Lipodermatosclerosis- leg looking like inverted champagne bottle
  • Venous eczema
  • Ulceration
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14
Q

What is the treatment/management for deep venous insufficiency?

A

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
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15
Q

What is a thromboembolism? What are 2 common thromboembolisms?

A

Thromboembolism = movement of blood clot along a vessel

deep vein thrombosis
Pulmonary embolsim

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16
Q

What is deep vein thrombosis?

A

clot (red thrombus= RBC + fibrin) in deep veins

17
Q

What is the pathophysiology of DVT?

A
  • 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
18
Q

What are the risk factors for thromboembolsim (5)?

A 
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
19
Q

What are the signs and symptoms of DVT (7)?

A
  • UNILATERAL limb swelling
  • Persisting discomfort
  • Calf tenderness
  • Erythema
  • Warmth
  • Prominent collateral veins
  • Unilateral pitting oedema
    May be clinically silent
20
Q

What are the signs and symptoms of a pulmonary embolism (5)?

A
  • Pleuritic chest pain
  • SOB
  • Haemoptysis if infarction
  • Tachycardia
  • Pleural rub on auscultation
    Not very specific (like pneumonia, MI, pericarditis)
21
Q

What are the signs and symptoms of a MASSIVE pulmonary embolism (6)?

A
  • Severe SOB of sudden onset
  • Collapse
  • Central cyanosis (blue tongue/ lips)
  • Tachycardia
  • Low BP
  • ↑ JVP
    May cause sudden death
22
Q

How is DVT diagnosed?

A

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

23
Q

How is pulmonary embolism diagnosed?

A

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)

24
Q

How is a venous thromboembolism prevented (3)?

A
  • Early mobilisation
  • Anti-embolism stocking to push blood up to heart in immobile patients
  • Pharmacological thromboprophylaxis – HEPARINS
25
Q

What is the medical treatment for thromboembolism?

A

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
26
Q

What is the surgical treatment for thromboembolism?

A
  • vascular surgical intervention in massive DVTs

- thrombolysis – ALTEPLASE- for massive PE

27
Q

What are the long term effects of DVT?

A 
Post thrombotic syndrome: 
-	Damage to venous valves
	•	Swelling 
	•	Discomfort 
	•	Pigmentation 
	•	Ulcers 
-	Pulmonary arterial hypertension (surgically treated by clot removal from pulmonary artery)

Cardiovascular System (37 decks)

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