Venous Disease Flashcards
Aortomesenteric angle NCS
usually < 20 degrees
Most common symptoms of NCS
hematuria
Work of for NCS
1st: UA - if negative hematuria; unlikely diagnosis.
2nd: renal vein venography for pressure measurements
Renal vein venography for NCS pressure gradient
> 3-5 mmHg
Duplex diagnosis of NCS
PSV ratio > 5
Classic CT/MRV finding for NCS
“bird beak” of renal vein
Management of NCS based on age
< 18 years: observation & weight gain –> may self resolve.
> 18 years: RVT (gold standard)
Primary concern for renal vein stenting
Migration of stent and/or stent fracture.
Which side is more common to develop PCS
LEFT reflux much more common
1st line diagnosis of PCS
1st: Transabdominal ultrasound: Dx if ovarian vein dilates to > 6 mm with valsalva. does NOT rely on reflux times.
2nd: transvaginal ultrasound
Best axial imaging for PCS
MRV
Diagnosis of PCS by venography
Ovarian vein dilated > 5-6 mm
Retention of contrast in vein > 20 seconds
1st line treatment for PCS
coil embolization of refluxing segments
What is considered “hemodynamically” significant lesion on venography
> 5 mmHg
Women are at much higher risk compared to men for development of which complication secondary to MTS
PE (9x more likely)
1 year primary patency of iliocaval reconstruction`
~60%
Preferred conduit for surgical venous bypass
contralateral GSV
When should AVF creation be considered as adjunct for surgical vein bypass
PTFE conduit or conduit size > 10 mm
When does majority of venous recanalization occur following acute DVT
first 3 months (~50% thrombus burden reduction)
C1-C6 disease
1: telang/reticular veins
2: varicose veins (> 3 mm)
3: edema
4A: hyperpigmentation or eczema
4B: lipodermatosclerosis / atrophic blanche
5: healed venous ulcer
6: active venous ulcer
Pathologic reflux times
Superficial / Profunda / Perforator: > 0.5 seconds
Femoral vein / popliteal vein: > 1 second
“Pathologic perforator vein”
> 3.5 mm diameter
reflux > 0.5 seconds
adjacent to ulcer (C5 or C6)
–> warrants intervention
Duplicate GSV
~25% population.
If present, duplicate GSV will course in superficial dermis (not deep in parallel)
Most common configuration of popliteal fossa (deep –> superficial)
artery -> vein -> tibial nerve
Most common cause of therapy failure: endo vs. open (CVI)
open: neovascularization
endo: recanalization
Which artery classically crosses between GSV & femoral vein –> AVF after RFA
external pudendal artery
Contraindications to ablation therapies for CVI
Tortuous proximal segment (unable to pass wire/device)
Chronic/acute thrombophlebitis
Vein diameter > 2.5 cm
vein to skin surface < 1 cm
ESCHAR trial
Compared compression vs. compression + GSV Ablation for C5or 6 disease:
Rates of ulcer recurrence were LOWER with combo therapy, but healing rates were similar.
Follow up EVRA trial showed both recurrence and healing time was lower with combo therapy
Deep venous valve transposition
transposing a competent venous valve segment that is DISTAL to an incompetent segment onto a competent segment
IVC develops from which primitive veins? (3)
Supracardinal vein (right)
Subcardinal vein
Posterior cardinal vein
Cuase of duplicate IVC system
persistence of both right & left supracardinal veins (left should normally regress)
Course of IVC relative to aorta with LEFT sided IVC
courses ANTERIOR crossing aorta at level of renal veins
Most common complication of venous ablation therapies
Ecchymosis
FDA approved sclerosing agents
Sotradecol (sodium tetradecol sulfate)
Asclera (pilodocinol)
Patients should avoid _____ ~48 hrs post procedure to avoid reversal
NSAIDS
Warm compress
Most common complication of sclerotherapy
Hyperpigmentation (self resolves)
Telengiectatic matting
Formation of new telangiectasias following sclero therapy –> resolves.
Neurologic symptoms following sclerotherapy treatment
Treat with 100% oxygen
Primary benefit of MOCA compared to ablation therapy
does NOT require tumescent anesthesia
CariVein
Mechanical rotation + sotradecol
VenaSeal
Cyanoacrylate glue
Common complication of VenaSeal
Delayed Type IV HS RXN
Tx: Antihistamines & steroids
DVT PPx in patient with HITT
Fondaparinux
Which patients SHOULD receive DVT PPx throughout pregnancy? How long is this continued?
F5L Homozygous
ATIII deficiency
Prothrombin Homozygous
Continue 6 weeks post partum
This is IRREGARDLESS of DVT history
F5 hetero, Prothrombin hetero & Protein C/S def does NOT require PPx.
Etiology of venous gangrene tissue loss
venous hypertension –> microvessel thrombosis.
Is NOT due to primary arterial hypoperfusion
PT & PTT levels with DIC
both elevated
Most common symptom of LE DVT
pain
T/F. Wells score has proven to be accurate in both outpatient & inpatient setting.
FALSE.
Grossly underestimates DVT in IN-patient setting.
Preferred anticoagulation during pregnancy
Lovenox
Classic EKG for PE
Most common EKG for PE
S1Q3T3
Sinus tachycardia
RV:LV end-diastolic ratio to suggest severe PE on TTE
> 1.0: RV-strain
> 1.5: “severe PE”
McConnell Sign
TTE shows RV basal hypokenesis with sparing of apex –> suggests PE
When is V/Q scan considered
Dx of PE
COnsidered during pregnancy and/or poor renal function
V/Q: 0.8 = normal
V/Q: > 0.8 –> mismatch –> consistent with PE
Regular
Submassive
Massive PE
Regular; stable & no RV strain
Submassive: stable, + RV strain
Massive: unstable, + RV strain
When is systemic tPA and/or CDT therapy indicated for PE
Massive PE
FDA approved CDT catheters for PE
Ekos catheter (ultrasound lysis) FlowTreiver
Most common cause of death with PE
acute RV failure
When is risk of PE highest during pregnancy?
Immediate post-partum period
Most common location for primary SVT
GSV
Trousseaue Syndrome
Migratory primary SVT; likely undiagnosed malignancy (pancreatic most common)
SVT saltans vs. migrans
Saltans: SVT in several Separate veins
Migrans: SVT in several segments of the Same vein
CALISTO Trial
SVT in GSV: >5 cm length AND < 5 cm from SFJ: treat with PPx dosing Fondo (2.5 mg BID) or LMWH for 45 days
Management of purulent thrombophlebitis
Remove offending IV/line
IV antibiotics
+/- excision of infected vein if refractory to medical management and/or gross purulence tracking
ATTRACT trial
Acute LE DVT: CDT + AC vs. AC alone.
For iliofemoral DVT: CDT therapy reduced SEVERITY of PTS at 2 years follow up, but did NOT reduce incidence of PTS or recurrent DVT
NO benefit of CDT for fem/pop DVT without iliac vein involvement.
Technique for distal femoral/pop open venous thrombectomy
Attempt ESMARC exsanguination FIRST (balloon can damage valves); but if fails then proceed with balloon embolectomy.
Most common cause of SVC syndrome
Malignant etiology (NSCL)
Malignant etiology ~60%
Benign etiology ~40%
Type I-IV SVC syndrome
I: antegrade flow maintained through SVC (< 90% stenosis)
II: antegrade flow lost through SVC (> 90% stenosis), antegrade flow maintained through Azygous
III: retrograde flow through azygous & IVC
IV: no flow through azygous system, all flow retrograde through IVC
SVC syndrome management
All managed conservatively at first.
If malignant etiology: focus should be on tumor burden reduction (chemo/radiation)
Endovascular first line invasive therapy
Open surgical management of SVC syndrome
Typically only considered in those planned for open tumor resection and/or young patients
Spiral saphenous vein graft preferred (rPTFE if not available) –> IJ/innominate –> atrial appendage.
CVC with highest associated thrombotic & infection compications
Femoral vein (both)
3 subtypes of primary aortic tumors
Intimal (most common) - branch occlusion
Polypoid - embolic potential
Adventitial - grows OUTWARDS, invades adjacent organs
Most common Primary & Secondary IVC tumor
Leiomyosarcoma & RP Leiomyosarcoma
Most common secondary IVC tumor to cause tumor thrombus
RCC
Neves & Zencke classification (RCC)
Tumor thrombus extent
I: < 2 cm from renal vein ostium (out into IVC)
II: > 2 cm out from renal ostium (into IVC)
III: retrohepatic
IV: Supra diaphragm / right atrium
When to perform IVC primary repair vs. patch/interposition
< 50% residual stenosis: primary repair OK
> 50% residual stenosis: patch or interposition
Patch diameter estimate for IVC reconstruction
patch diameter = 3.14 x IVC diameter x % resection
Conduit for IVC reconstruction
rPTFE (1st line)
Spiral vein graft if concern for infection
Largest IVC filter
Birds Nest: < 40 mm IVC diameter.
Majority of filters treat up to 30 mm IVC
PREPIC-1 & PREPIC-2 Trial
1: IVC filter increases risk of recurrent LE DVT at 2 years follow up.
2: filter + AC vs. AC alone is NOT superior for prevention of PE
Variable most associated with failure of IVC filter removal
Duration of placement.
Most common peripheral venous aneurysm
Popliteal
Treat > 2 asymptomatic and/or Symptomatic any size.
lateral venorraphy with aneurysmectomy
Primary concern with venous aneurysms
thromboembolic»_space;» rupture
Type I-IV IVC aneurysm
I: suprahepatic NO obstruction
II: OBSTRUCTION
III: infrarenal NO obstruction
IV: anything else
Most common visceral venous aneurysm
Portal vein (> 1.5-2 cm)
All visceral venous aneurysm treat when > 3 cm.
Splenic vein: any size child-bearing age.
Race & blood type PROTECTIVE of VTE
Japanese
Blood type O
Malignancy most associated with VTE complications
Pancreatic
T/F. chemotherapy increases risk of VTE
True.
Most common heritable hypercoag condition
F5L deficiency (F5 is resistant to protein C degredation)
Blood type with increased VTE risk
A
Most common location for acute DVT
calf vein > femoral > popliteal
