Venous Insufficiency

Question 1

Diagnosis

Answer 1

Identification of the underlying pathophys of the wound is critical to development and implementation of a POC

Question 2

Artery vs. Vein

Answer 2

Size of muscular wall is large in arteries!
Arterial system is a resistance system with more pressure in it
Veins have smaller vascular wall so less pressure associated with it

Question 3

Vein has what

Answer 3

valves - so blood moves in one direction only

Question 4

Elastin a vs. vein

Answer 4

the larger the artery, the more recoil the artery will have
veins have elastin but not as much as arteries
so arteries have blood flow into them, they contract, and as blood moves away, the elastic contracts and allows for maintenance of normal pressure on the arteries - this is less true for the veins

Question 5

Endothelial cells (inside - lumina)

Answer 5

they respond to shear stress
blood flow through the a and v is a shear force
They respond to inc in flow pressures by releasing inflammatory mediators that produce localized ifnlammation in the local areas - happens more in artery side because more pressure there
Endothelial cells also release growth factors

Question 6

Epidermis vascularization

Answer 6

NONE!!! no vascularization within it

Question 7

Basement membrane does wht

Answer 7

reduce friction between epidermis and dermis

Question 8

Beneath the basement membrane is what

Answer 8

Plexus
moves into basement membrane 
Another one between the dermis and the adipose tissue 
Another layer within subQ tissue
Each of these is larger as you go deeper

Question 9

Deep veins

Answer 9

Run along with arteries that share their name - might be more than one vein that runs along with it
Contained in the same sheath as the artery
Deep veins are thinner and less muscular than the superficial veins - they have less pressure associated with them than the superficial veins do
Because they are so deep though they have a little more pressure related to soft tissue around them

Question 10

LE venous anatomry - deep veins

Answer 10

Anterior tibial vein
Posterior tibial vein
Peroneal vein
Popliteal vein
Femoral vein
Deep femoral vein
Common femoral vein

Question 11

Perforating veins do what

Answer 11

connect superficial veins to deep veins

Question 12

Perforating vein - venous insufficiency theory

Answer 12

Thought is that it might be an issue with the valve not getting the blood to the superficial?

Question 13

Superficial veins of LE

Answer 13

Great saphenous vein

Small saphenous vein

Question 14

What happens in the ankle are

Answer 14

The blood moves directly into the deep veins and from the deep veins it moves into the superficial veins which then fills the saphenous veins and then perforating veins and then deep veins further up
This is why we often see venous insufficieicny in the medial ankle region

Question 15

Venous insufficiency ulcers

Answer 15

Chronic condition
Insidious
Venous hypertension exists!!! - this is the primary cause!

Question 16

Theories of venous insufficiency ulcers

Answer 16

Fibrin cuff theory of ulcer development
White blood cell trapping
Growth factor trapping (this is outlier of the theories)

Question 17

Theories of venous insufficiency ulcers - Fibrin cuff

Answer 17

Constant venous hypertension causes widening of capillary pores
This allows large molecules like fibrinogen to move through
Fibrin accumulates around the vascular walls and within the interstitial spaces
Mechanical barrier is built
This is an older theory

Question 18

Theories of venous insufficiency ulcers - Growth factor trapping

Answer 18

The cuff traps growth factors into its matrix decreasing its availability (of growth factors to health insult to tissue)

Question 19

Theories of venous insufficiency ulcers - White blood cell trapping AKA ischemia reperfusion injury

Answer 19

Cycling venous pressure allow an accumulation of WBCs in the capillaries
Localized ischemia occurs secondary to dec flow
WBC become activated and release lytic enzymes - other infalmmatory cytokines activate

Question 20

Skin characteristics in a CVI ulcer

Answer 20

1 Hyperprofileration of the epidermis
2 Thickening of the dermis with the dermal epidermal junction becoming convoluted
3 Dermal tissue changes may impair keratinocyte migration
All of this leads to - Lipodermatosclerosis (sclerosis, skin, fat)

Question 21

Lipodermatosclerosis

Answer 21

Heardening (sclerosis) of the skin

A form of panniculitis/inflammation of the SubQ tissue

Question 22

Risk factors

Answer 22

Calf muscle pump failure (weak, sustained standing)
Vein dysfunction - varicosities 
Age over 65 
Diabetes Mellitus
Trauma

Question 23

Differential diagnosis

Answer 23

Ischemic ulcer

Diabetic (neuropathic) ulcer

Question 24

Clinical classification - CO - class

Answer 24

No visible or palpable signs of venous disease

Question 25

Clinical classification - C6 - class

Answer 25

Skin changes are defined above with active ulceration

Question 26

Clinical classification - S - clinical presentation class

Answer 26

symptomatic - but not seeing the classic venous signs

Question 27

Clinical classification - A

Answer 27

asymtomatic

Question 28

E - etiological classification

Answer 28

Ec = congenital 
Ep = primary
Es = secondary (postthrombotic)
En = no venous causes identified

Question 29

Anatomic classification

Answer 29

As = superficial veins
Ap = perforator veins
Ad = deep veins
An = no venous location identified

Question 30

Pathophysiologic classifciation

Answer 30

Pr = reflux
Po = obstruction
Pr, O = reflux and obstruction
Pn = no venous pathophys identifiable

Question 31

Venous insufficiency ulcers -c haracterisitcs

Answer 31

1 hemosiderin deposits 
2 lipodermatosclerosis
3 generally on medial aspect of leg above medial malleolus
4 loss of subQ fat
5 dry skin surrounding wound
6 shallow wound
7 irregular wound margins
8 moderate to severe exudate
9 mild pain
10 red round bed may have fibrous yellow or white slough

Question 32

Venous insufficiency ulcers - general tx guidelines

Answer 32

1 infection prevention, measures needed
2 dec risk of trauma
3 LE exercises
4 promote healing - edema control, compression, dressing to control exxudate)
5 clean and moisturize skin
6 pt education regarding life long care

Question 33

Venous insufficiency ulcers - general tx guidelines - dressing that control exudate

Answer 33

usual semipermeable semiocclusive