Vascular: Chronic Venous Insufficiency Flashcards
Pathophysiology of venous HTN and chronic venous insufficiency
Incompetent veins –> calf muscle pump dysfunction and valvular incompetence.
Get reflux of blood down vessels and blood pooling. Venous HTN then causes extravasation of fluid and blood into tissue of limb.
Caused by phlebitis, varicostities, DVT, venous obstruction.
Classification of chronic venous disease (C0 -> C6)
C0: no sign of disease.
C1: telangiectasia
C2: Varicose veins
C3: edema (ankle and calf pain)
C4: skin pigmentation and lipodermatosclerosis.
C5: healed ulcer.
C6: active ulcers (shallow, medial malleolus, pink, granulation tissue, weeping, painless, irregular outline).
Describe the superficial and deep venous system in legs.
Superficial system: small and great saphenous veins.
Deep system: femoral vein.
Sapheno-femoral junction = union of superficial and deep systems.
Conservative tx of chronic venous insufficiency
Avoid prolonged standing or sitting, frequent leg elevation, compression stockings (30-40 mmHg better for healing ulcers), lose weight.
For ulcers, use multilayer compression bandage, antibiotics prn
Define primary and secondary varicose veins and their etiology
Varicose vein: dilated, bulging, tortuous superficial veins resulting from incompetent valves in the deep, superficial or perforator systems.
Primary: venous valve incompetence or obstruction in superficial system. Result from defective structure/function of valves in saphenous veins, intrinsic weakness of vein wall, high intraluminal pressure. Contributing factors include age, OCPs, occupations requiring prolonged standing, pregnancy, obesity.
Secondary: results from venous HTN. Associated with deep venous insufficiency and incompetent perforating veins resulting in enlargement of superficial veins.
Symptoms of varicose veins
Dull ache, throbbing, heaviness or pressure sensation in legs with standing.
Superficial vein thrombosis may occur.
Varicosities may rupture/bleed
Conservative mgmt of varicose veins
Elevation of legs, avoid prolonged standing, compression stockings (helpful for symptoms, don’t prevent progression)
Surgical mgmt of varicose veins
Indicated if persistent symptoms (pain, bleeding, recurrent thrombophlebitis), cosmesis, complications.
Multiple tx options:
1) endovenous thermal ablation: venous occlusion of great saphenous vein.
2) Sclerotherapy: fibrosis and obstruction via chemical injection.
3) Ligation and stripping
4) endovascular interventions, bypass, reconstruction.
Define Virchow’s triad
1) Endothelial damage: exposes endothelium to promote hemostasis. Decreased inhibition of coagulation and local fibrinolysis.
2) Venous stasis: inhibits clearance and dilution of clotting factors.
3) Hypercoagulability: inherited or acquired.
Results in: Increased clotting factors, decreased anticoagulants and decreased fibrinolysis which additively promote thrombus formation.
Symptoms + RF of DVT
May be asymptomatic.
Unilateral leg edema, erythema, warmth and tenderness.
Calf swelling >3cm compared to other leg (measured 10 cm below tibial tuberosity).
Feel for palpable cord (thrombosed vein).
Well’s Criteria.
RF: immobility, trauma/surgery, obesity, pregnancy, Hx CHF, malignancy, previous DVT. Increased age.
Diagnostic tests for DVT
Labs: D-Dimer (to rule out), INR, PTT, platelets (monitor anticoagulation), coagulation w/u for thrombophilia (protein C/S, antithrombin 3, factor 5 leiden, lupus anticoagulant, Hb/hct).
Doppler US: most sensitive and specific test (proximal DVT > calf DVT). If high probability DVT, skip D-Dimer, just do US.
Tx of DVT and PE
Anticoagulation with coumadin x3-6 months with heparin bridge therapy until INR in therapeutic range.
Compression treatment of leg.
If contraindication to anticoagulation (e.g. bleeding risk), use compression stockings. May need IVC filter to prevent PE.
