Vascular Flashcards
DVT ?
Defined by thrombus or clot within the deep veins
Most medically concerning since it can cause a PE/ pulmonary embolism if the thrombus/ clot is dislodged from the vein and propagates to the pulmonary arteries
Most commonly on the LEFT side and frequently seen on venous valves or within the soleal sinus’
Can affect a single vein or extensive involving many veins
Symptoms and clinical finding are common and nonspecific
VTE / venous thromboembolism
Other complications of DVT includes ;
PTS (post thrombotic syndrome)
PTS ?
Post thrombotic syndrome which is a less severe complication of DVT ;
Chronic leg pain
Inflammation
Redness
Ulcers
Deep and superficial venous insufficiency
Varicose veins.
Recurrent DVT
Peripheral venous system?
Located in the upper and lower extremities
Consist of deep, superficial, and perforating / communicating vein located within them
RETURNS DEOXYGENATED blood from organs and tissue back to the heart
TUNICA MEDIA is poorly developed in veins, compared to the arteries
More elastic and collapse under pressure if no thrombus or intraluminal object is present
Contain venous valves, which increase in number more distal within the extremities to counteract gravity and hydrostatic pressure and maintain antegrade flow to the heart
LOWER extremity deep veins ?
Located deep within the muscles of the legs and serves as the primary route of drainage for the leg
Typically larger than superficial branches
ATVs
PTVs
Peroneal / fibular veins
Gastrocnemius / sural veins and Soleal sinus’
Popliteal veins
Femoral veins
Profunda femoris vein / deep femoral veins
CFV/ common femoral veins
External Iliac veins
Internal Iliac veins
Common Iliac veins
Anterior Tibial Vein ?
Ascend the lower leg with the anterior tibial artery
Drain blood from the dorsum of the foot and the anterior compartment of the calf
Originates near the tibia and the level of the ankle
ATVs join the PTVs to form the popliteal vein
Forms the popliteal veins ?
Anterior and posterior tibial veins (tibial - peroneal trunk)
Posterior tibial veins ?
PTVs
Drains the posterior compartment of the lower leg and originate from the plantar veins (superficial and deep) of the foot
Ascend along the medial calf beginning at the level of the medial malleolus, parallel to the PTAs
Combines with the peroneal veins to form the peroneal - tibial trunk, just before uniting with the ATVs to form the popliteal vein
Peroneal veins ?
Fibular veins
Drain blood from the lateral compartment of the lower leg
Parallel path with the PTVs and located deep to the soleus and gastrocnemius muscles along the fibula
In the proximal calf the peroneal veins join the PTVs to the form the tibial - peroneal trunk
Soleal veins and gastrocnemius / sural veins ?
Veins are located deep within the muscular compartments of the soleus and gastrocnemius muscles
Ascend the leg in the medial and lateral gastrocnemius muscles, before draining directly into the popliteal vein
Popliteal vein?
Drains blood of the lower leg and originates from the tibial peroneal trunk / PTV / ATV veins in the popliteal fossa which is medial and superior the popliteal artery
Continues to ascend until passing through the hunters canal / adductors at the knee joint and becomes the femoral vein/ arteries
Femoral vein ?
Originates from the popliteal vein in the distal thigh at the adductors/ hunters canal
Accompanied by the femoral artery
Courses deep through the median thigh and terminates in the Scarps / femoral triangle at its confluence with the deep Profunda femoris / deep femoral vein
“Superficial”
Profundis femoris vein?
AKA deep femoral vein
Drains the deep muscles of the proximal thigh
Ascends the upper leg until it joins the FV to form the common femoral vein
(Distal to the bifurcation of the common femoral artery)
Common femoral vein ?
Formed by the confluence of FV and profundis/ deep femoral vein
Receives the great saphenous vein at the level of the saphenofemoral junction
Lies in the scarpas triangle / medial to the common femoral artery
Terminates at the level of the inguinal ligament — where it becomes the external iliac vein
External Iliac Vein?
Originates at the level of the inguinal ligament as a continuation of the common femoral vein
Joins the internal iliac vein to become the common iliac vein
Common femoral vein is formed by ?
Profunda femoris vein / deep femoral vein and superficial / femoral vein
Internal iliac veins ?
Serves to drain the pelvis before it joins the external iliac vein
Common iliac veins ?
Formed by the confluence of the internal and external iliac veins.
Left branch lies medial to the left common iliac artery
(Crosses beneath the right common iliac artery)
Right branch is shorter and lies vertically as it ascends posterior than lateral
MAY - THURNER syndrome
Most common side for DVT found and why ?
LEFT side is more prevalent because of of ;
Continued compression of the left common iliac vein by the right common iliac artery (May Thurner syndrome)
Stenting may be needed to ensure it’s patency and prevent DVT formation
May Thurner syndrome ?
Continued compression of the left common iliac vein by the right common iliac artery which can result in venous entrapment disorder
Superficial veins ?
Located within the subcutaneous tissue
Drains blood from the tissues and transport it to the deep system
NOT paired with an artery and smaller in size
Venous insufficiency is much more common in superficial veins than deep venous system
GSV
Posterior arch vein/ Leonardo
Perforating veins
Great saphenous vein ?
Superficial vein
Longest vein in the body and has 10 - 20 valves
Originates on the dorsum of the foot and travels anterior to the medial mallelous and ascends the anteromedial side of the calf and thigh
Terminates as it joins the common femoral vein aka saphenofemoral junction
Small Saphenous vein ?
SSV / lesser saphenous vein
Originates on the dorsum foot travels posterior to the lateral malleolus and ascends along the midline of the posterior calf
Joins the popliteal vein as it terminates
Posterior arch vein ?
Vein of Leonardo
Arises posterior to the medial malleolus and courses parallel and posterior to the GSV before it terminates into the GSV just below the knee
Communicates with the PTV via.
COCKETT perforator
Drains blood from the medial ankle
Perforating veins ?
Connect superficial vessels to the deep venous system
Cocketts
Boyds
Dodds
Hunterian
Cockett perforator ?
Communicates with the superficial posterior arch vein and are found in the lower leg
Boyd’s perforator ?
Located around the level of the knees
Dodds perforator?
In distal thigh
Hunterian perforator ?
In the proximal thigh
Virchows Triad ?
Hypercoagulable state
Venous stasis / blood pools in the vein
Vein wall injury / endothelium of vessel wall is damaged
Signs and symptoms of DVT ?
Persistent calf/ / leg/ or arm swellling
Pain or tenderness of the leg (usually the posterior calf) or arm / shoulder region
Venous distention
Increased temperature and redness
Superficial venous dilation
Homans sign (calf discomfort on passive dorisflexion)
Superficial venous thrombosis symptoms/ clinical findings ?
Local erythema
Tenderness or pain
Palpable subcutaneous “cord”
Pulmonary Embolus symptoms and clinical findings ?
Dyspnea
Chest pain
Hemoptysis / spitting blood
Sweats
Cough
Risk factors of DVT ?
Age > 40 years old
Malignancy / cancer
Previous DVT or PE
Immobilization / bed rest, paralysis of legs, extended travel
Fracture of hip, pelvis, or long bones
Myocardial infarction , stroke
Congestive heart failure or respiratory failure
Pregnancy or postpartum
Oral contraceptive use and HRT
Extensive dissection at major surgery/ especially orthopaedic
Trauma / multiple
Hereditary factors (anti thrombin deficiencym protein C and protein S deficiencies
Obesity
Central venous lines
Pacemakers
IV drug abuse
Acute DVT?
No more than a week old
Soft nature
May or may not envelope the entire cross section of the vessel
Asymptomatic or suffer from ;
Phlegmasia alba dolens
Phlegmasia cerulea dolens
(Swollen painful leg white or cyanotic)
Pain
Warmth
Erythema / redness
Edema
Appears low density, low echogenicity / anechoic
More likely to dislodge from the vein wall due to its soft spongy appearance
Therefore the management and treatment are aggressive and ultimate goal is to disolve or remove the clot / thrombus
The more proximal the thrombus occurs — the higher risk of PE occuring
Conservative treatment of DVT/ SVT/ acute / chronic ?
Elevation
Compression stocking and/ or bed rest
Most common treatment of acute DVT?
Anticoagulation or Antiplatelet, agent administeration, and / or thrombolytic therapy
Anticoagulants ?
Heparin
Warfarin
Lovenox
Common antiplatelet medications ?
Aspirin
Thienopyridines
Ticlopidine
CHRONIC DVT ?
Greater than week old clot / thrombus
More dense and often calcified —
Appearing more echogenic and caused diffuse wall thickening
Typically adhere firmly to the vessel wall and therefore do not have a high risk for PE occuring like ACUTE DVT does
Often obstructive and can cause formation of collateral veins and varicose veins
Suffer from symptom involving the entire extremity such as;
Edema, hyperpigmentation (brown discoloration), limb heaviness, varicose veins, and in severe cases — venous ulcerations
Treatment includes ;
Limb elevation, compression stockings, and bed rest
Severe chronic DVT can lead to ?
Post- thrombotic syndrome
Which is caused by increased ambulatory venous pressure/ venous hypertension
Unable to overcome hydrostatic pressure, resulting in blood stasis in the lower leg
This can lead to ulceration if left untreated
Can be a result of venous obstruction / chronic DVT and / or incompetent venous valves
Primary varicose veins ?
Congenital
Stemming from an inherent weakness of the venous walls and occur without coexisting deep venous disease
Secondary varicose veins ?
Occur secondary to pathology / chronic DVT of the deep venous system
Superficial venous thrombosis?
Typically seen in greater and superficial saphenous veins — but can also present in varicose veins or venous valves
Presence of chronic SVT can cause valvular incompetence, leading to insufficiency of the superficial system
Typically symptoms are localized to the area where the thrombus is located
Localized erythema and tenderness
Occlusion palpation of a hard subcutaneous ‘cord’
Treatment ;
Compression stockings
Limb elevation and application of heat over the area
Venous insufficiency ?
More commonly in superficial venous system
(Venous reflux )
Venous insufficiency ?
Aka venous reflux caused by incompetent venous valves
Results in restrograde flow / reversal leading to venous stasis and hypertension in the lower limbs
Can be also caused by ;
Previous DVT that causes venous valve incompetence after being damaged
Typically occurs from long periods of standing or pregnancy
Venous insufficiency symptoms and treatment ?
Chronic leg swelling
Induration / hard/ firm leather- like skin appearance around the ankles
Varicose veins
And in severe cases ; stasis ulcerations
Noninvasive treatments;
Limb elevation & compression stockings
Surgical intervention ;
Ultrasound guided venous ablation, varicose vein phlebectomies and sclerotherapy
(Which all aim to reduce venous pressure in the afflicted limb)
DVT patient assessment sonographic techniques and patient positioning ?
Patient is in supine reverse trendelenburg / head elevated with leg being examined is externally rotated with the knee slightly flexed
Combination of
2D gray scale with compression maneuver, Colour doppler, and spectral doppler evaluation as well with a higher linear frequency transducer (5 to 7.5 MHz)
Increased body habitus / or presence of large amounts of edema present will need to be assessed with a 3 to 5 MHz curvilinear or sector transducer
DVT 2D / gray - scale Imaging techniques and findings ?
Transverse plane is used to located the veins
Veins will normally change in size with respiration and collapse with compression with the transducer
Confirmation of no intraluminal contents when the vein anterior and posterior wall “touch” when the vessel is compressed
(Vein will reopen when the pressure from the transdcuer is released)
sonographic findings of normal veins in the lower extremity?
Vessel walls collapse with pressure applied with the transducer
Phasic low velocity doppler signals augment with distal limb compression
Common femoral vein changes in size with respiration
Sonographic findings of normal arteries within the lower extremity ?
Vessel does not collapse with pressure applied with the transducer
Triphasic high velocity doppler signal
Pulsations of vessel walls is present
Steps of DVT assessment ?
Starting at the common femoral vein, located at the level of the inguinal crease
Assessing for compressibility of the CFV
More distally is the saphenofemoral junction (great saphenous vein/ CFV/CFA) are assessed for compressibility
(The GSV is superficial so if not seen ease up on pressure of transducer to see if there is unintentional compression of the superficial vessel)
PROX GSV should be assessed to rule out DVT present since this is a common area for the clot/ thrombus to develop
More distal is the femoral vein ; prox/ mid/ distal compression of all segment of the femoral vein should be assessed
Vessel can be assessed with colour doppler to determine patency since no flow will be present over a clot or thrombus
