Venous Disease + Pulmonary Embolism Flashcards
What is a venous thrombus
Fibrin and red cells
Develops in areas of stagnant blood causing back pressure
What is an arterial thrombus
Fibrin and platelets
Causes ischaemia and infarction
What causes a venous thrombus
Stasis
Hypercoagulable
Vessel damage
What makes VTE unlikely
If on anti-coagulation
What are the symptoms of a DVT
Leg swelling - measure diff in calf circumference as well as swelling Calf tenderness Pitting oedema Warmth Erythema Prominent veins Mild pyrexia Tachycardia
What is differential of DVT
Gout
Popliteal cyst
Arthiritis
What are the RF for DVT split into general, underlying, drug
What is high risk surgery
Age Obesity Immobility e.g. bed rest / long haul flight Trauma Post op - pelvic / orthopaedic Pregnancy - up to 6 weeks post partum Varicose veins PMH FH
Underlying
- Malignancy - pelvic
- HF
- Nephrotic
- Heritale thrombophilia- Factor V leiden / anti-phosphoplipid
- Polycythaemia
- Sickle cell
Drug
- HRT
- OCP
- Tamoxifen
- Anti-psychotic
How do you investigate suspected DVT
Well's score If low risk = D-dimer If D-dimer -ve can exclude DVT If high risk or +ve D-dimer = doppler USS If USS +Ve = treat as DVT If USS -ve = can exclude DVT
What does Wells look at
Paralysis / immobilisation >3 days Active cancer Surgery >12 weeks Tenderness Enitre leg swollen Calf >3cm asymptomatic Pitting oedema Collateral superficial veins Previous DVT Another Dx more likely = -2
How do you treat DVT and how do you monitor
SC LMWH for 5 days or until INR 2-3 Unfractioned heparin - used in renal failure Give if delay in USS / Dx APTT to monitor Anti-coagulation for 3 months - Warfarin - DOAC - Or through cancer / pregnancy If clot idiopathic / low risk of bleeding continue for longer
How do you prevent DVT
What is preferred in orthopaedic surgery
TED stockings
Early mobilisation
Daily LMWH injections to all immobile patients
Fondaparinux (factor Xa inhibitor) decrease risk of DVT over LMWH in major ortho surgery
Stop OCP / HRT before surgery (4 weeks)
When ae graduated compression stockings indicated
Chronic venous insufficiency Varicose Oedema Post-phlebetic Not to treat DVT
What is post phlebitis / thrombotic syndrome and how do you manage
Chronic venous insufficiency after DVT due to hypertension Swelling Discomfort Heavy calf Itch Pigmentation Varicose vein Ulceration Manage with compression stockings
What is a D-dimer and what else is it raised in
Breakdown product
Sensitie marker of thrombus but not specific
Also raised in malignancy / HF / renal / infarction / sickle / surgery / trauma so not reliable
e.g. PE common after hip fracture but D-dimer will be raised post-trauma / surgery
What causes PE
DVT - usually in proximal femoral or iliac 50% idiopathic and 50% underlying cause Rarely RV thrombus post MI Septic emboli R side IE Fat / air / amniotic fluid
What are the symptoms
Pleuritic chest pain Sudden onset SOB + no chest signs = think PE Cough Haemoptysis Hypoxia Dizzy / syncope Tachycardia Tachypnoea Pleural rub Crackles Fever
What are signs of massive PE
Severe SOB and tahcy Pleural effusion Dullness on percussion Collapse due to drop in CO Cyanosis Low BP Raised JVP Altered heart sounds - 4th HS Cardiac arrest
How do you Dx PE
FBC, U+E, clotting
CXR to exclude other cause (enlarged artery / decreased vascular) - always order first
ECG
ABG - alkalosis due to hyperventilation (pH normal due to anaerobic respiration buffering) but low O2 (hyperventilation due to anxiety = high O2)
Calculate Geneva
What does Geneva score look at
S+S DVT Other Dx unlikely Tacycardia Surgery Previous Active cancer Haemoptysis
If moderate or high risk what happens
CTPA or V/Q scan
No place for D-dimer
When would you do V/Q
Pregnancy
Renal failure
Allergy to contrast
What do you do if low risk
D-dimer
If high = CTPA
How do you treat VTE
Oxygen if hypoxic
Thrombolysis = 1st line if circulatory failure e.g. hypotension
DOAC = 1st line for 3 months
If low risk of bleed can continue for longer or if malignancy
Shorter if on anti-platelet / bleeding risk
LMWH if delay in Dx or if using warfarin as takes a few days till INR 2-3
LMWH for 6 months if proven malignancy
What should INR be
2-3
What do you do for idiopathic clot
Stay on for longer as higher risk of another as prone Hx and exam CXR FBC, Ca, LFT, urine dip Do all of these
Consider
CT CAP / mammogram etc
Haematology for thrombophilia screen
What do you do for massive PE
Thrombolyse = 1st line
Vena cava filter if recurrent / active bleeding
What are complications
Pulmonary haemorrhage / infarction = pleural rub and pleuritic pain
Hypertension
RHF
What are ECG changes
Sinus tachy
RH strain - RBBB, V1+V2, T wave inversion
S1,Q3, T3
Deep S, pathological Q and inverted T
When are DOAC CI
When is LMWH CI
Pregnant
Breast fed
Malignancy
LMWH CI if already on warfarin / DOAC / active bleeding
Why are you SOB in PE
V/Q mismatch
Shunt created
What is varicose veins and what causes varicose veins
Dilated torturous superficial veins
Valves to prevent back flow = damaged
Proximal obstruction or weakness damages valves
Blood flows back from deep veins into superficial veins which become dilated and engorged leading to more damage and increased pressure
DUE TO INCREASED PRESSURE
Occurs at sapheno-famoral and sapheno-popliteal junction
What are the symptoms and complications
Discomfort Burning Nocturnal cramps Swelling Tightness Discolouration Haemorrhage as fragile skin over veins Superficial thrombophlebitis Pruritus Spider veins - no Rx Haemosiderin, lipodermatosclerosis, venous eczema Venous ulcers Non-pitting oedema
Increased risk of infection, ulcers, and DVT
What are RF / 2 causes
2 obstruction - DVT / pregnancy / pelvic tumour
AV malformation
Congenital valve absence = rare
RF = increase pressure Standing Twins Multiple pregnancy Pelvic tumour Prengnacy Previous DVT OCP Trauma FH
How do you investigate
Duplex USS to look for site
Check deep venous system competent before removal - if DVT = incompetent
+Ve Trendelenburg
ABPI to exclude PAD
How do you treat
Conservative
- Lose weight
- Education e.g. avoid standing
- Graduated compression stockings
- Skin care
Surgery
Endovenous = 1st line (cannulate vein pass catheter and heat + laser to fibrose)
USS guided sclerotherapy = 2nd line
Open Surgery - strip vein under Ga = 3rd line
Compression stockings if pregnant
When is open surgery CI
DVT as need deep venous to compensate Pregnancy Comorbid Arterial insuffiency Obesity
When is intervention indicated
Superficial thrombophlebitis Symptomatic varicose veins Chronic venous insuffieincy Superficial vein thrombosis Leg ulcer Bleeding Anxiety Cosmesis
What are complications of surgery
Haemorrhage Thrombophlebitis Wound Saphenous nerve damage DVT
What does chronic venous insufficiency affect
Deep veins
What causes chronic venous insufficiency
Venous hypertension creates back pressure
Due to failure of muscle pump
or Obstruction
What causes failure of muscle pump
Venous reflux Obstruction - DVT Neuromuscular Obesity Inactive
Superficial vein
Varicose
Deep vein
DVT
What are symptoms of chronic venous insufficiency
Ankle oedema as veins leaky and blood leaks out
Telangtasia
Venous eczema as skin becomes dry and inflamed
Hemosiderin pigmentation - brown (HB breaks down and deposited)
Hyperpigmentation
Lipodermatosclerosis as skin becomes tight and fibrotic
Venous ulceration >4 weeks
Warm
How do you Dx chronic venous insufficiency
History and examination
ABPI - calculate as if arterial compression would damage
Duplex to check flow of vein = 1st line
How do you treat
Elevate Manual drainage Compression stockings or bandage Naproxen = 1st line for superficial thrombophlebitis Dressing Eczema creams Physio/ OT Exclude DVT
What do you not give in chronic venous insufficiency
Diuretic
What causes lymph oedema
Inadequate drainage of lymphatic system Congenital - presents in first 3 decades Malignancy Surgery - after LN clearance RT Infection Post DVT
How do you treat
Prone to infection / ulcers / venous failure Massage Elevation Manual drainage Compression
What causes venous ulcers
Hypertension 2 to chronic venous insufficiency
What are the symptoms
Painless Large and irregular Other features of insufficiency Above ankle Affect gaiter region Shallow ulceration
How do you Dx
Duplex USS
ABPI to exclude arterial
Biopsy if non-healing to exclude malignancy / Marlins ulcer
How do you Rx
Refer to venous ulcer clinic Managed by district nurses Good wound care - debride, clean, dress Manage RF Best rest and elevation Compression after excluding PAD Tissue viability nurse Plastic surgery Refer if >12 weeks or >10cm for skin graft
Arterial ulcers
Toes and heels Painful Gangrene Cold No pulse Pain at night when legs elevated Tend to be smaller with more regular border Low ABPI
Neuropathic ulcers
Plantar surface of metatarsal and hallux
Due to pressure
Shoes to prevent
Pyoderma gangrenosum and what is Rx
IBD / RA
Erythematous nodules or pustules which ulcerate
Rx = steroid
Marjolin’s ulcer
SCC at site of chronic inflammation e.g. OM / burns after 10-20 years
Mainly lower limb
Vein anatomy
IVC Common iliac Internal iliac External iliac Femoral Popliteal Arterial and posterior tibial Long saphenous (superficial) -> femoral (arise dorsal venous arch and travel anterior to medial malleolus) Short saphenous -> popliteal (arise plantar venous arch and posterior to lateral malleolus)
What nerve close to superficial veins
Sural
Do superficial veins have muscle pump
No only deep veins
Deep veins are within muscle so can withstand higher pressure
What are the 3 tests to Dx chronic venous insufficiency
Tap test
Hand held doppler
Trendelenburg
What is the tap test
One hand on saphenofemoral junction
One on long saphenous above knee
Tap junction
If transmits =.incompetence
What is the hand held doppler
Put your hand over junction
Squeeze calf
Single whoosh if competent
Double if reflux back
What is the trendelenburg test
Drain superficial by lying flat and raising legs
Apply pressure over junction
Stand up
If don’t dilate = vein competent
If dilate even with pressure = incompetent
What are veins that you can remove without affecting patient
Renal as collateral adrenal and gonadal tae over
IVC
Facial - transected in carotid endarectomy
How could a DVT cause systemic ischaemia
If DVT passes into heart and patient has a VSD allowing blood clot to move into L side of heart and into systemic circulation
COMMON EXAM
What should everyone in hospital get
VTE risk assessment
If increased risk what do they get
LMWH
Caution in renal failure
If CI i.e. due to risk of bleed = compression stockings
When does great saphenous join deep system (femoral vein)
3cm below and lateral to pubic tubercle
Where does small saphenous join deep (popliteal)
Popliteal fossa
