Vascular

Question 1

DVT ?

Answer 1

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)

Question 2

PTS ?

Answer 2

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

Question 3

Peripheral venous system?

Answer 3

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

Question 4

LOWER extremity deep veins ?

Answer 4

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

Question 5

Anterior Tibial Vein ?

Answer 5

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

Question 6

Forms the popliteal veins ?

Answer 6

Anterior and posterior tibial veins (tibial - peroneal trunk)

Question 7

Posterior tibial veins ?

Answer 7

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

Question 8

Peroneal veins ?

Answer 8

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

Question 9

Soleal veins and gastrocnemius / sural veins ?

Answer 9

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

Question 10

Popliteal vein?

Answer 10

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

Question 11

Femoral vein ?

Answer 11

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”

Question 12

Profundis femoris vein?

Answer 12

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)

Question 13

Common femoral vein ?

Answer 13

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

Question 14

External Iliac Vein?

Answer 14

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

Question 15

Common femoral vein is formed by ?

Answer 15

Profunda femoris vein / deep femoral vein and superficial / femoral vein

Question 16

Internal iliac veins ?

Answer 16

Serves to drain the pelvis before it joins the external iliac vein

Question 17

Common iliac veins ?

Answer 17

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

Question 18

Most common side for DVT found and why ?

Answer 18

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

Question 19

May Thurner syndrome ?

Answer 19

Continued compression of the left common iliac vein by the right common iliac artery which can result in venous entrapment disorder

Question 20

Superficial veins ?

Answer 20

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

Question 21

Great saphenous vein ?

Answer 21

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

Question 22

Small Saphenous vein ?

Answer 22

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

Question 23

Posterior arch vein ?

Answer 23

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

Question 24

Perforating veins ?

Answer 24

Connect superficial vessels to the deep venous system

Cocketts
Boyds
Dodds
Hunterian

Question 25

Cockett perforator ?

Answer 25

Communicates with the superficial posterior arch vein and are found in the lower leg

Question 26

Boyd’s perforator ?

Answer 26

Located around the level of the knees

Question 27

Dodds perforator?

Answer 27

In distal thigh

Question 28

Hunterian perforator ?

Answer 28

In the proximal thigh

Question 29

Virchows Triad ?

Answer 29

Hypercoagulable state Venous stasis / blood pools in the vein Vein wall injury / endothelium of vessel wall is damaged

Question 30

Signs and symptoms of DVT ?

Answer 30

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)

Question 31

Superficial venous thrombosis symptoms/ clinical findings ?

Answer 31

Local erythema Tenderness or pain Palpable subcutaneous “cord”

Question 32

Pulmonary Embolus symptoms and clinical findings ?

Answer 32

Dyspnea Chest pain Hemoptysis / spitting blood Sweats Cough

Question 33

Risk factors of DVT ?

Answer 33

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

Question 34

Acute DVT?

Answer 34

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

Question 35

Conservative treatment of DVT/ SVT/ acute / chronic ?

Answer 35

Elevation Compression stocking and/ or bed rest

Question 36

Most common treatment of acute DVT?

Answer 36

Anticoagulation or Antiplatelet, agent administeration, and / or thrombolytic therapy

Question 37

Anticoagulants ?

Answer 37

Heparin Warfarin Lovenox

Question 38

Common antiplatelet medications ?

Answer 38

Aspirin Thienopyridines Ticlopidine

Question 39

CHRONIC DVT ?

Answer 39

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

Question 40

Severe chronic DVT can lead to ?

Answer 40

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

Question 41

Primary varicose veins ?

Answer 41

Congenital Stemming from an inherent weakness of the venous walls and occur without coexisting deep venous disease

Question 42

Secondary varicose veins ?

Answer 42

Occur secondary to pathology / chronic DVT of the deep venous system

Question 43

Superficial venous thrombosis?

Answer 43

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

Question 44

Venous insufficiency ?

Answer 44

More commonly in superficial venous system (Venous reflux )

Question 45

Venous insufficiency ?

Answer 45

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

Question 46

Venous insufficiency symptoms and treatment ?

Answer 46

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)

Question 47

DVT patient assessment sonographic techniques and patient positioning ?

Answer 47

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

Question 48

DVT 2D / gray - scale Imaging techniques and findings ?

Answer 48

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)

Question 49

sonographic findings of normal veins in the lower extremity?

Answer 49

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

Question 50

Sonographic findings of normal arteries within the lower extremity ?

Answer 50

Vessel does not collapse with pressure applied with the transducer Triphasic high velocity doppler signal Pulsations of vessel walls is present

Question 51

Steps of DVT assessment ?

Answer 51

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