Vascular (2) (Common venous conditions) Flashcards
venous conditions
- Varicose veins
- Haemorrhage
- Thrombophlebitis
- Venous hypertension
- DVT
- Chronic venous insufficiency’s
Chronic venous insufficiency
When blood does not efficiently drain from the legs back to the heart. Usually, this is the result of damage to the valves inside the veins- resulting in venous hypertension
e.g. varicose veins
causes of chronic venous insufficiency
- age
- immobility
- obesity
- prolonged standing
- after a deep vein thrombosis.
- varicose veins.
venous hypertension
The valves are responsible for ensuring blood flows in one direction as the leg muscles contract and squeeze the veins. When the valves are damaged, the pumping effect of the leg muscles becomes less effective in draining blood towards the heart. Blood pools in the veins of the legs, causing venous hypertension.
- Chronic pooling of blood à skin changes à esp Gaiter area
presentation of chronic venous insufficiency
- haemosiderin staining
- venous eczema
- lipodermatosclerosis
- atrophie blance
- cellulitis
- poor healing
- skin ulcers
- pain
Haemosiderin staining
- is a red/brown discolouration caused by haemoglobin leaking into the skin
Venous eczema
- is dry, itchy, flaky, scaly, red, cracked skin. These eczema-like changes are caused by a chronic inflammatory response in the skin.
Lipodermatosclerosis
is hardening and tightening of the skin and tissue beneath the skin. Chronic inflammation causes the subcutaneous tissue to become fibrotic (turning to scar tissue). Inflammation of the subcutaneous fat is called panniculitis. The narrowing of the lower legs causes the typical “inverted champagne bottle” appearance
atrophie blanche
- refers to patches of smooth, porcelain-white scar tissue on the skin, often surrounded by hyperpigmentation.
management of chronic venous insufficiency
-
Keeping skin healthy
- Monitoring skin health and avoiding skin damage
- Regular use of emollients (e.g., diprobase, oilatum, cetraben and doublebase)
- Topical steroids to treat flares of venous eczema
- Very potent topical steroids to treat flares of lipodermatosclerosis
-
Improving venous drainage to the legs
- Weight loss if obese
- Keeping active
- Keeping the legs elevated when resting
- Compression stockings (exclude arterial disease first with an ankle-brachial pressure index)
-
Managing complications
- Antibiotics for infection
- Analgesia for pain
- Wound care for ulceration
Varicose veins
Are distended superficial veins measuring more than 3mm in diameter, usually affecting the legs.
varicose veins pathophysiology
- Veins contain valves that only allow blood to flow in one direction, towards the heart. In the legs, as the muscles contract, they squeeze blood upwards against gravity. The valves prevent gravity from pulling the blood back into the feet.
- When the valves become incompetent, the blood is drawn downwards by gravity and pools in the veins and feet.
- The deep and superficial veins are connected by vessels called the perforating veins (or perforators), which allow blood to flow from the superficial veins to the deep veins. When the valves are incompetent in these perforators, blood flows from the deep veins back into the superficial veins and overloads them.
- This leads to dilatation and engorgement of the superficial veins, forming varicose veins.
RF for varicose veins
Risk Factors
- Increasing age
- Family history
- Female
- Pregnancy
- Obesity
- Prolonged standing (e.g., occupations involving standing for long periods)
- Deep vein thrombosis (causing damage to the valves)
presentation of varicose veins
Varicose veins present with engorged and dilated superficial leg veins. They may be asymptomatic or have symptoms of:
- Heavy or dragging sensation in the legs
- Aching
- Itching
- Burning
- Oedema
- Muscle cramps
- Restless legs
special tests for varicose veins
tap tests
cough test
trendelenburg test
perthes test
duplex US
Tap tests
Saphenofemoral junction (SFJ) and tap the distal varicose vein, feeling for a thrill at the SFJ- thrill suggest incompetent valve between VV and SFJ
Cough test
- Apply pressure to SFJ and ask patient to cough- feel for thrills
- Thrill suggest dilated vein
Trendelenburg test
With the patient lying down, lift the affected leg to drain the veins completely. Then apply a tourniquet to the thigh and stand the patient up. The tourniquet should prevent the varicose veins from reappearing if it is placed distally to the incompetent valve. If the varicose veins appear, the incompetent valve is below the level of the tourniquet. Repeat the test with the tourniquet at different levels to assess the location of the incompetent valves.
Perthes test
apply a tourniquet to the thigh and ask the patient to pump their calf muscles by performing heel raises whilst standing. If the superficial veins disappear, the deep veins are functioning. Increased dilation of the superficial veins indicates a problem in the deep veins, such as deep vein thrombosis.
duplex US
- US that shows speed and volume of blood flow (assess the extent of varicose veins)
management of VV
- VV in pregnancy improves after delivery
- Simple treatment
- Weight loss
- Staying physically active
- Keep leg elevate
- Compression stocking
- Surgical
surgery for VV
- Endothermal ablation – inserting a catheter into the vein to apply radiofrequency ablation
- Sclerotherapy – injecting the vein with an irritant foam that causes closure of the vein
- Stripping – the veins are ligated and pulled out of the leg
complications of VV
heavy bleeding after trauma, superficial thrombophlebitis, DVT, chronic venous insufficiency
Pathophysiology of VTE
Clots (thrombi) developing in the circulation. This usually occurs secondary to stagnation of blood and hyper-coagulable states.
pathophysiology of DVT and complications
- When a thrombus develops in the venous circulation, it is called a deep vein thrombosis (DVT).
- Once a thrombus has developed, it can travel (embolise) from the deep veins, through the right side of the heart and into the lungs, where it becomes lodged in the pulmonary arteries. This blocks blood flow to areas of the lungs and is called a pulmonary embolism (PE).
- If the patient has a hole in their heart (for example, an atrial septal defect), the blood clot can pass through to the left side of the heart and into the systemic circulation. If it travels to the brain, it can cause a large stroke.
Risk factors for DVT
- Immobility
- Recent surgery
- Long haul travel
- Pregnancy
- Hormone therapy with oestrogen (combined oral contraceptive pill and hormone replacement therapy)
- Malignancy
- Polycythaemia
- Systemic lupus erythematosus
- Thrombophilia
scoring system for DVT
Wells score- predicts risk of patient presenting with symptoms of DVT or PE
DVT presentation
- Unilateral
- Calf or leg swelling
- Dilated superficial veins
- Tenderness to calf
- Oedema
- Colour change
exam for DVT
- measure circumference of calf 10cm below the tibial tuberosity. If >3cm difference between calves= signif
prophylaxis for DVT before surgery
- LMWH e.g. enoxaparin
- contraindication: active bleeding or existing anticoagulation with warfarin or DOAC
- Anti-embolic compression stockings
- Contraindication- peripheral arterial disease
diagnosis of DVT
- D-dimer is 95% sensitive but not specific – helps exclude VTE when low suspicious. Can be raised by other conditions e.g. pneumonia, malignancy, HF, surgery
- Doppler US
- PE diagnosed with CTPAA of VQ scan
Thrombopilias
Thrombophilias are conditions that predispose patients to develop blood clots. There are a large number of these:
- Antiphospholipid syndrome
- Factor V Leiden
- Antithrombin deficiency
- Protein C or S deficiency
- Hyperhomocysteinaemia
- Prothombin gene variant
- Activated protein C resistance
management of DVT
-
Anticoagulation
- Apixaban or rivaroxaban
- Catheter directed thrombolysis in patients with symptomatic iliofemoral DVT and symptoms lasting less than 14 days
-
Long term anticoagulation
- DOAC
- Do not require monitoring
- Warfarin
- Target INR between 2 and 3 for VTE
- LMWH
- First line in pregnancy
- DOAC
management of recurrent PE
-
Inferior vena cava filter- for recurrent PE
- Catches clots travelling from venous system towards the heart and lungs acting like a sieve
warfarin target for long term anticoag to prevent DVT
- Target INR between 2 and 3 for VTE
Unprovoked DVT
NICE recommends considering testing for:
- Antiphospholipid syndrome (check antiphospholipid antibodies)
- Hereditary thrombophilias (only if they have a first-degree relative also affected by a DVT or PE)
Leg ulcers
Breaks in the skin that do not heal or heal slowly due to underlying pathology. They can get bigger and more diff to heal.
Four common types:
- Venous
- Arterial
- Diabetic
- Pressure
investigations for leg ulcers
- Blood tests may help assess for infection (FBC and CRP) and co-morbidities (HbA1c for diabetes, FBC for anaemia and albumin for malnutrition).
- Ankle-brachial pressure index (ABPI)
- Charcoal swabs may be helpful where infection is suspected, to determine the causative organism.
- Skin biopsy may be required in patients where skin cancer (e.g., squamous cell carcinoma) is suspected as a differential diagnosis. This will require a two week wait referral to dermatology.
ABPI
- is used to assess for arterial disease. This is required in both arterial and venous ulcers.
- ratio of the ankle systolic blood pressure to the brachial systolic blood pressure and can be measured using a sphygmomanometer and a hand held Doppler device
arterial ulcers
result from insufficient blood supply to the skin due to peripheral arterial disease.
presentation of arterial ulcers
- Occur distally, affecting the toes or dorsum of the foot
- Are associated with peripheral arterial disease, with absent pulses, pallor and intermittent claudication
- Are smaller than venous ulcers
- Are deeper than venous ulcers
- Have well defined borders
- Have a “punched-out” appearance
- Are pale colour due to poor blood supply
- Are less likely to bleed
- Are painful
- Have pain worse at night (when lying horizontally)
- Have pain is worse on elevating and improved by lowering the leg (gravity helps the circulation)
management of arterial ulcers
- Same as peripheral arterial diseaseà urgent referral for surgical revascularisation
- If underlying arterial disease effectively treated ulcer should heal rapidly
- Debridement and compression are not used in arterial ulcers
venous ulcers
Occur due to the pooling of blood and waste products in the skin secondary to venous insufficiency.
presentation of venous ulcers
- Occur in the gaiter area (between the top of the foot and bottom of the calf muscle)
- Are associated with chronic venous changes, such as hyperpigmentation, venous eczema and lipodermatosclerosis
- Occur after a minor injury to the leg
- Are larger than arterial ulcers
- Are more superficial than arterial ulcers
- Have irregular, gently sloping border
- Are more likely to bleed
- Are less painful than arterial ulcers
- Have pain relieved by elevation and worse on lowering the leg
management of venous ulcers
General
- Vascular surgery where mixed or arterial ulcers are suspected
- Tissue viability / specialist leg ulcer clinics in complex or non-healing ulcers
- Dermatology where an alternative diagnosis is suspected, such as skin cancer
- Pain clinics if the pain is difficult to manage
- Diabetic ulcer services (for patients with diabetic ulcers)
Patients require input from experienced nurses, such as the district nurses or tissue viability nurses. Good wound care involves:
- Cleaning the wound
- Debridement (removing dead tissue)
- Dressing the wound
Specific
- Compression therapy is used to treat venous ulcers (after arterial disease is excluded with an ABPI).
- Pentoxifylline (taken orally) can improve healing in venous ulcers (but is not licensed).
- Antibiotics are used to treat infection.
- Analgesia is used to manage pain (avoid NSAIDs as they can worsen the condition).
Diabetic foot ulcers
are more common in patients with diabetic neuropathy. Patients who have lost the sensation in their feet are less likely to realise they have injured their feet or have poorly fitting shoes. Additionally, damage to both the small and large blood vessels impairs the blood supply and wound healing. Raised blood sugar, immune system changes and autonomic neuropathy also contribute to ulceration and poor healing. Osteomyelitis(infection in the bone) is an important complication.
Pressure ulcers
typically occur in patients with reduced mobility, where prolonged pressure on particular areas (e.g., the sacrum whilst sitting) lead to the skin breaking down. This happens due to a combination of reduced blood supply and localised ischaemia, reduced lymph drainage and an abnormal change in shape (deformation) of the tissues under pressure. Extensive effort should be taken to prevent pressure ulcers, including individual risk assessments, regular repositioning, special inflating mattresses, regular skin checks and protective dressings and creams.
the waterlow score
is a commonly used risk assessment tool for estimating an individual patient’s risk of developing a pressure ulcer.
thrombophlebitis
a more superficial DVT
treatment: Compression stockings are recommended for superficial thrombophlebitis
for DVT give heparin or DOAC
apixaban or rivaroxaban (both DOACs) should be offered first-line following the diagnosis of a DVT
