Venous Flashcards
normal PPG refil time
> 20 seconds
reflux PPG refill time
<20 seconds
what indicates superficial vein reflux ONLY
PPG <20 seconds without a tourniquet but >20 seconds with a tourniquet
normal venous flow on duplex
less than or equal to 0.5 seconds
reflux venous flow on duplex
More than 0.5 seconds
C in CEAP classification
- teleangiectasia <3mm
- reticular veins >3mm
- edema
- skin changes - discoloration
- healed ulcer
- active ulcer
E in CEAP
etiology
c - congenital
p - primary
s - secondary
A in CEAP
anatomy
s - superficial
d - depp
p - perforator
P in CEAP
patophysiology
r - reflux
o - obstruction
r,o - both
direction of venous flow in upper extremity
UP with INSPIRATION
down with expiration
(augmented with negative pressure in the chest)
direction of venous flow in lower extremity
down with INSPIRATION
UP with expiration
indication for suprarenal IVC filter
- duplicated IVC
- malposition of the IVC filter
- pregnancy
- ovarian vein thrombosis
common femoral vein size
10mm
saphenous vein size
5mm`
what is the point of origin for lower extremity venosu thrombus
soleal sinus
how do you perform venous PPG
patient does dorsiflexio / plantarflexion while sitting wihich activates the calf muscle pump. Upon cessation, time required to refill the calf compartments is measured.
what are characteristics of deep venous reflux?
on PPG <20 seconds regardless of turniquet
how do you perform venous insufficiency study (doppler)
inflate pressure cuff around calf to 80-100mHg reduces calf muscle blood volume. With rapid deflation in normal person valve closure limits pop venous flow reversal to less than 0.5sec
What does it mean if Valsalva generates reflux in a vein
there are no competent valves between that vein and diaphragm
ACCP recommendations for treatment of acute DVT in lower extremity
LMWH or fundaparineux rather than unfractionated heparin
daily LMWH is preferred
may be treated at home
may walk
what is the association of brachial, axillary and subclavian DVT with complications
5% PE
20% post thrombotic syndrome
8% recurrence
ACCP recommendations for treatment of upper extremity DVT
- central line association - if line is needed, leave and anticoagulate for the time line is in and 3 months
- axillary and proximal - full anticoagulation with LMWH or fundaparineux; selective thrombolysis
- isolated brachial vein - full anticoagulation if symptomatic, + cancer and + TLC (for 3 months)
Anatomical anomalies of IVC
- retroaortic or circumaortic left renal vein 5-7%
- IVC transposition 0.2-0.5%
- IVC duplication 0.2-0.3%
- IVC agenesis
Greater saphenous vein tributaries
- inferior epigastric vein
- superficial circumflex iliac vein
- lateral accessory saphenous vein
- medial accessory saphenous vein
- deep external pudendal vein
- superficial external pudendal vein
size of teleangiectasia
0.1 - 1 mm
methods of femoral vein valve reconstruction
- internal valvuloplasty
- external valvuloplasty
- external banding
- valve transposition
- valve transplantation
Indications for iliac vein stenting
C0-2 limbs with severe diffuse venous limb pain not relieved by compression
C3-6 limbs failing compression
Treatment algorithm for postthrombotic venous insufficiency
Treat saphenous reflux first, provided gsv is at least 5mm in size
Treat perforator reflux underneath the ulcer if larger than 3.5 mm and reflux in >500ms
Correct obstruction next
Correct reflux if all of the above fails
How do you size stents for veins
CIV normal size is 16 mm, oversize 2mm —> 18 mm stet
EIV normal size 14mm, —> 16 stent
CFV normal size 12mm, —> 12 stent
Stent patency in nonthrombotic venous obstruction
79% primary
100% primary assistant
Thrombosis extremely rare
Patency if venous stent for recanalization thrombotic occlusion
54% for primary,
68% for primary assisted
74% secondary
What does lack of femoral venous respiratory variation mean
Iliofemora occlusion
Phasicity
Cyclic vartiation with respiration
Augmentation
Produced by distal compression or release of proximal compression
Valvular competence in venous duplex
Presence or absence of reverse flow in response to proximal compression or Valsalva maneuver
Flow reversal >0.5sec abnormal
Characteristics of acute DVT on duplex
Echolucent, spongy / incompressible, dilated vein, homogenous vein, smooth luminal surface, absent collateral, confluent flow channel, +/- present free floating rail
Chronic DVT duplex characteristics
Echogenic Firm vein Contracted vein Heterogenous inside of vein Irregular luminal surface Present collaterals Multiple flow channels Absent free floating tail
What increases VTE risk 10 fold
Antithrombin deficiency
Protein C and S deficiency
How much does factor V Laiden increase VTE risk
5 fold for heterozygotws
50 fold for honozygotes
Classification of the antiphospholipid syndrome
Clinical criteria:
- Vascular thrombosis (one or more episodes of arterial, venous or small Vassell thrombosis within any tissue or organ)
- Unexplained death of a normal fetus >10 week gestation
- Premature birth or normal neonates less than 34 weeks gestation due to eclampsia, preeclampsia, placenta insufficiency
- 3 or more spontaneous abortions less than 10 week gestation
Laboratory criteria
- Lupus anticoagulant two or more occasions more than 12 weeks apart
- Anticardiolipin igg or igm on two or more occasions more than 12 weeks apart
- Anti beta 2 GP1 IGG or IGM on two or more occasions more than 12 weeks apart
Secondary theomboprophylwxis with antiphospholipid syndrome
1 venous event - indifinite with INR 2-3
Arterial event - indefinite with INR 3-4 and ASA
Recurrent events - indefinite with INR 3-4 or lovenox
Malignancy associated with arterial thrombosis
Leukemia Myeloproliferarive disorder (JAK2 mutation) Multiple myeloma Neurofibromatosia Lung Transitional cell Breast Ovarian Colorectal Unknown primary
Vascular complications associated with l- asparinginase
CVA
Vascular complications associated with cis platinum
CVA, peripheral arterial events, aortic thrombosis
Vascular complications associated with fluorouracil
Coronary vasospasm mediated ischemia
Vascular complications associated with bevacizumab
Coronary thrombosis mediated ischemia, CVA
Vascular complications associated with gembotabine
Digital ischemia, thrombotic microangiopathy
Vascular complications associated with thalidomide
Arterial thrombosis
Vascular complications associated with sorafenib, sunitinib
Myocardial infarction, CVA
Clinics criteria for HIT
Unexplained thrombocytopenia (less than 100)
Or decrease in platelet count more than 30-50%
Positive assays for HAABs (platelet aggregation teat, 2point platelet aggregation assay, C14-serotonin release assay)
Positive ELISA (40% discordance vs platelet aggregation, IGG, IGM)
Arterial and o venous thrombus
Purpose of tumescent infiltration in endogenous ablation
Helps uniformly compression vein around heating element
Creates fluid cushion to exanguinatr treatment vein
Create depth between skin surface and anterior vein wall
Acts as heat sink to protect perivenous tissue from thermal injury
EHIT levels
- Before the branches to GSV around the SFJ
- Past inferior epigastric vein branch but still in GSV
- At the GSV deep vein junction, not extending into CFV
- Extending into CFV <50%
- Extending into CFV >50%
- Occluding CFV
EHIT treatment
Level 1-2 no treatment
Level 3 surgeons choice
Level 4-5 lovenox until the clot retracts to level 3
Level 6 lovenox abd warfarin for 3 months
What is May - Husni procedure
Popliteo - femoral venous bypass using GSV
Palma procedure
Femoral femoral venous bypass with GSV
PEIHO trial
Randomized double blinded
Patients with intermediate risk PE
TEnecteplase vs heparin
Endpoint: death, hemodynamic collapse
Statistically lower primary outcome and hemodynamic collaps in lysis group but higher (much) stroke rate and major bleeding
Patients received therapeutic heparin during lysis
Recommended treatment for superficial thrombophlebitis
In those with SVT >5cm use prophylactic dose fundapsrinha or LMWH for 45 days
Contraindication to endovascular venous ablation
Absolute: active superficial vein thrombosis
GSV close to the skin
Relative: pacemaker, arterial insufficiency, GSV less than 5mm (or 2?) and over than 15mm and tortuous GSV
Cyaniacrylate vein closure
VeClose shows noninferioriry with EVLA
Closure rates are comparable
CAE does not require anesthesia
Decrease post op ecchymosis
No other difference
What’s a superficial accessory great saphenous vein
Any venous segment ascending parallel to the GSV and located more superficially above saphenous faascia both in the leg and in the thigh
What is anterior accessory great saphenous vein
Any venous segment ascending parallel to GSV and located anteriorly both in the leg and in the thigh
What is vein of Giacomini
Cranial extension of the SSV that communicates with the GSV via posterior thigh circumflex vein
whats the energy delivery in EVLA over length
withdraw the catheter to deliver 30-50 joules/cm
Speed of withdrawal for EVLA
1-2mm/sec for first 10 seconds, followed by 2-3mm for the remainder