Venous Disease

Question 1

vein structure?

Answer 1

adventitia
media
intima
intima lined with endothelial cells
layer of smooth muscle cells (thinner than in arteries)

Question 2

are veins pulsatile?

Answer 2

no

Question 3

vein physiology?

Answer 3

thin walled
non pulsatile
elastic and collapsable
carries 65% of circulating volume

Question 4

venous flow = cardiac output, how is this?

Answer 4

cardiac output depends on venous return to the heart so venous flow = cardiac output

Question 5

do veins have tone?

Answer 5

yes
some but not loads or as much as arteries
valves more responsible for preventing backflow

Question 6

what is vis-a-front?

Answer 6

suction effect of diastole in the heart and low CVP creating a pressure gradient
pulls blood forward in veins

Question 7

what is vis-a-tergo?

Answer 7

pressure from behind pushing blood through veins

pressure gradient between capillary pressure (20-25) and venous pressure (0)

Question 8

what else encourages venous flow?

Answer 8

muscle pump in lower limb
thoracic pump (intra-abdominal pressure decreases in expiration which increases flow)
5% also drains via lymphatics

Question 9

common venous problems?

Answer 9

varicose veins
venous ulcers
DVT
chronic venous insufficiency

Question 10

what are varicose veins?

Answer 10

dilated, tortuous, superficial veins

can expand to 3-4mm (defined as dilated)

Question 11

types of varicose veins?

Answer 11

idiopathic
obstructive (DVT, pregnancy, pelvic mass)
congenital (klippel trenauney syndrome)

Question 12

venous drainage in legs?

Answer 12

blood drains from foot into deep veins at saphenofemoral junction and saphenopopiliteal junction

Question 13

what is klippel trenauney syndrome?

Answer 13

rare congenital disorder characterised by a triad of cutaneous capillary malformation (port wine stain), lymphatic anomalies and abnormal veins in association with variable overgrowth of bone and soft tissues

Question 14

investuigation of varicose veins?

Answer 14

doppler (look for venous insuficiency, reflux(blood backflow))

Question 15

conservative management of varicose?

Answer 15

compression
lifestyle (elevate legs, don't stand for too long etc)

Question 16

interventional management of varicose?

Answer 16

endovenous ablation
foam sclerotherapy
phlebectomy
open

Question 17

what is chronic venous insufficiency?

Answer 17

funcitonal changes in lower extremity due to persistent elevation of venous pressure

Question 18

symptoms of chronic venous insufficiency?

Answer 18

pressure feeling
aching
pain
itch
bleeding
cosmetic disturbance

Question 19

signs of chronic venous insufficiency?

Answer 19

pitting oedema
venous eczema
lipodermatosclerosis
haemosiderin deposition (breakdown of haemoglobin causing brown staining)
venous ulceration

Question 20

features of a venous ulcer?

Answer 20

in gaiter region (medial leg around medial malleolus)
usually shallow
sloping edges
irregular

Question 21

arterial ulcers?

Answer 21

bottom of foot
punched out
very painful

Question 22

management of venous ulcers?

Answer 22

compression (bandages etc to keep venous system intact)

manage infection, diabetes if present and eczema which is often present too

Question 23

virchows triad?

Answer 23

3 things causing DVT

• stasis of blood flow
• endothelial injury
• hypercoagulability (oral contraceptive, malignancy, thrombophilia etc)

Question 24

risk factors for DVT?

Answer 24

major surgery (lower limb and pelvic esp)
major trauma
immobility
dehydration
OCP
coagulopathy
malignancy
pregnancy

Question 25

complications of DVT?

Answer 25

PE +/- sudden death
recurrence
post-thrombotic syndrome
ischaemia
pulmonary hypertension
budd-chiari syndrome (Hepatic venous outflow obstruction)

Question 26

what is post thrombotic syndrome?

Answer 26

end stage of chronic venous insufficiency

valvular incompetence, venous hypertension, ulceration)

Question 27

what is wells score?

Answer 27

scoring to assess probability of DVT

2+ points = DVT is likely

Question 28

how is DVT investigated?

Answer 28

D dimer
then do doppler to confirm DVT if D dimer +ve, contrast venography (technically gold standard but V invasive)
thrombophilia screen

Question 29

what is D dimer +ve but doppler -ve

Answer 29

stop anticoagulation

bring back in 2 weeks and do another doppler as you need 2 consecutive -ve dopplers to rule out DVT

Question 30

conservative management of DVT?

Answer 30

exercise, compression

Question 31

medical management of DVT?

Answer 31

current guidelines = rivaroxaban 15mg BD for 3 months then 20mg OD (duration depends on whether provoked or unprovoked)

Question 32

DVT prophylaxis?

Answer 32

IVC filter can be used to prevent PE from DVT in high risk (pregnant women etc)
fragmin??, LMWH 2500/5000 units and TED stockings in high risk

Question 33

who should get prophylaxis?

Answer 33

older, frail, immobile, background of malignancy

Question 34

components of Wells score?

Answer 34

active cancer
paralysis/recent immobilization of the legs
recently bedridden or surgery in past 12 weeks
localized tenderness along venous area
entire leg swollen
calf swelling >3cm compared to normal
pitting oedema
collateral superficial veins (non varicose)
previously documented DVT