Venous Flashcards
Define Phlegmasia alba/cerulea dolens
Extreme form of iliofemoral DVT where swelling is so extensive the arterial circulation is compromised. Can lead to gangrene and limb loss.
What is the most dangerous complication of DVT?
PE
What is the most common complication of DVT?
venous insufficiency
Give five ways venous anatomy differs from arterial anatomy.
thinner walls flow direction shape changes (circular to dumbbell) based on pressure presence of valves perforators
Name the leg perforators.
Perforators of the Femoral Canal
Peritibial Perforators
Posterior Tibial Perforators
What are the five Doppler characteristics of normal venous flow?
Spontaneous: flow exists in medium to large veins
Phasicity: velocity varies with respiration
Augmentation: confirms patency
Valsalva response: shows if valves are competent
Competency: unidirectional flow toward heart through valves, if not, reflux
What two methods are used in duplex examination of veins?
Compression/coaptation on short axis
Doppler evaluation on long axis
What is effort thrombosis? What is its other name?
Compression of the subclavian vein causing thrombosis.
Paget-Schroetter Syndrome
Thrombosis in the vein causes what sort of response?
Inflammatory - pain in first two weeks
What skin changes are noted with venous disease?
Edema Rubor from inflammatory process Brawney color Pallor - phegmasia alba dolens Cyanosis - plegmasia cerulea dolens
What will lyse the thrombus? In what % of cases?
Plasminogen, in 20% of cases.
Describe the progression of DVT, in three stages.
Acute: first 2 weeks; hypoechoic, spongey, dilated, may have free floating tail, collaterals, active inflammation & pain
Subacute: weeks to 6 months: more hyperechoic, well adhered, may be dilated, collaterals
Chronic: bright, calcific, fibrous cords, retracted, wall thickening, sequelae occur
What are the risk factors for DVT?
Virchow’s Triad:
- Stasis: ICU/CCU, bedrest, long ride, stroke
- Trauma: surgery, accident
- Hypercoaguable: cancer, pregnancy, dehydration, Protein C, Protein S, Factor V Leiden, Antithrombin 3 deficiency
Describe the difference between primary and secondary varicose veins.
Primary: limited to superficial system
Secondary: underlying deep venous incompetence and/or obstruction
Describe venous insufficiency.
Valvular incompetence (deep, superficial, or perforating) permits flow reversal (reflux), leading to venous HTN, venous claudication, ulcers, stasis dermatitis, etc.
What is VI caused by? (3)
Recanalized segments of thrombosed veins
Dilation of veins
Congenital absence of competent valves
List six sequellae of chronic VI.
Edema Fibrous deposits Ulceration Hemociterin - brawny appearance Pain
What are the three goals of a venous exam for VI?
Determine the venous systems involved.
Determine the level.
Determine if VI is due to incompetence or obstruction or both.
What are the invasive tests for VI?
Venography, both ascending and descending. Ascending looks for DVT, descending looks for VI.
Ambulatory venous pressures: uses needle in foot for pressure readings.
What are the non-invasive tests for VI?
CW Doppler
Photoplethysmography (PPG) - infrared sensor, dorsiflexion. Refill time > 20 sec. is normal.
Air Plethysmography (APG)
Duplex: reversal .5–1.0 mild, > 1 significant
What does APG measure:
Is there VI?
Is there venous HTN distally?
Does the calf muscle work?
What is the duplex protocol for checking for VI?
• Evaluate for DVT
• Sample sites for VI/reflux: superficial and deep, B-Mode & Doppler
• Check perforators
Determines presence and location of VI and outflow obstruction.
What is the size at which perforators are probably incompetent?
> 4mm
What are the advantages of Duplex exam for VI?
Specific localization in deep & superficial veins
Documentation of outflow obstruction
Identification of incompetent perforators
What are the disadvantages of Duplex exam for VI?
Strength of augmentation is not standardized.
Time consuming.
Tech dependent.
Not well standardized.
What are the mimics of DVT? (give 4)
Venous congestion (excessive swelling from CHF, fluid overload) Adenopathy (enlarged lymph nodes) Abcesses Hematoma Soft tissue tumors Popliteal cysts Joint effusion (from knee injury) Lymphedema Lipoma
What are the two types of heparin and their advantages/disadvantages?
Unfractionated: IV infusion, frequent complications
Low molecular weight: outpatient, belly injection, less monitoring, fewer complications
When is heparin used?
Pre-, intra, and post-op Acute arterial occulsion Angiography DVT, PE, embolisms Flushing
What is HIT?
Heparin Induced Thrombocytopenia - clots in arteries and veins. Antibodies cause bleeding and/or formation of thrombus.
When is Coumadin used?
Outpatient: A-fib Post heparin for DVT, PE, etc. Prosthetic heart valve Coaguation disorders
How is Coumadin monitored?
PT/INR
List three thrombolytic agents.
Tissue Plasminogen Activator (tPA)
Urokinase
Streptokinase
What are the medical treatments of STP?
Acute STP: ASA, elevation, hot soaks, compression socks.
What are the medical treatments of DVT?
Acute DVT:
Prophylaxis: activity, compression boots, elevation, heparin, coumadin, ASA
Treatment: Heparin to Coumadin, Thrombolytics
What are the medical treatments of Chronic VI?
Chronic VI: compression socks, elevation, Unna boots
What are the surgical treatments of superficial venous disease?
Sclerotherapy: injection into small varicosities or spider veins Endovenous ablation (VNUS, ELVS) Ligation, stripping
What are the surgical treatments of acute DVT?
Thrombectomy (iliofem)
Vena caval interruption (filters)
Decompression of left iliac vein
What are the surgical treatments of chronic VI?
Valve repair
Ligation of perforators
Linton: direct ligation of incompetent perfs through incision - ulcers repaired with skin graft
SEPS (Subcutaneous Endovascular Perforator System): perfs occluded with titanium clips endoscopically
Distinguish between gastrocs and soleal veins.
Gastrocs: paired around artery, dumbbell shape, seen as they drain into pop
Soleal: single sinuses in soleal muscle, drain into PTs or peroneals - common site for thrombosis
Most common variant in LE venous anatomy?
Bifed systems
Patients with CHF usually have pulsatile venous Doppler signals in their legs - True or False?
True
Acute venous thrombosis resolves completely in only what percent of cases?
20%
What can be used to determine patency of the iliac veins?
Valsalva maneuver, with Doppler in CFV. Valsalva will stop flow, at release flow will continue. This shows valves are competent and veins patent.
Name the membrane superficial to the PTs and Peroneals when examining the calf.
Soleal septum
Name the membrane deep to the PTs and Peroneals when examining the calf (from the tibia to the fibula).
Interosseus membrane
The confluence of which two veins forms the Axillary vein?
Basilic and Brachial veins.
The confluence of which two veins forms the Subclavian vein?
Axillary and Cephalic veins.
Is the left iliac vein anterior or posterior to the right iliac artery?
Posterior. Compression can cause thrombus formation in this vein.
List four causes of lymphedema.
trauma
infection
inflammation
radiation and chemotherapy
Symptoms of post-phlebitic syndrome?
pain (aching or cramping)
heaviness
swelling (edema)
What is the cause of nephrotic syndrome?
Damage to the glomeruli.
Define diaphoresis.
Profuse sweating.
Two side effects of heparin.
Bleeding (hematoma)
Thrombocytopenia
Symptoms of Pulmonary Embolism?
Chest pain Sudden cough Tachypnea Tachycardia Shortness of breath
Are venous ulcers painful?
Not usually.
