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Cardiovascular > Venous Insufficiency and Ulceration > Flashcards

Venous Insufficiency and Ulceration Flashcards

1
Q

What is chronic venous insufficiency?

A

Chronic elevation of deep venous pressure (venous HTN) and blood pooling in lower extremities.

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2
Q

Aetiology of chronic venous insufficiency?

A
  • Calf muscle pump dysfunction and valvular incompetence (phlebitis, varicosities or DVT)
  • Venous obstruction
  • AV fistulas, venous malformations
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3
Q

What are the clinical features of chronic venous insufficiency?

A
  • Pain, LL oedema (relieved with elevation)
  • Pruritus, haemosiderin deposits
  • Stasis dermatitis, subcutaneous fibrosis
  • Ulceration: shallow, above medial malleolus, weeping, painless, irregular outline
  • Signs of DVT/varicose veins / thrombophlebitis
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4
Q

Ix in chronic venous insufficiency?

A
  • ambulatory venous pressure measurement
  • Doppler U/S
  • photoplethysmography
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5
Q

Conservative Mx chronic venous insufficiency?

A
  • Compression stockings, elevation, avoid prolonged standing

- Ulcers: zinc oxide wraps, split thickness skin grafts, ABx, debridement

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6
Q

Surgical Mx chronic venous insufficiency?

A
  • Surgical ligation of perforators in ulcer region, greater saphenous stripping
  • venous bypass if short segment obstruction
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7
Q

Pathophysiology of venous chronic venous disease?

A
  • Blood flow superficial -> deep through unidirectional valves
  • Exercise: calf muscle pump + vein patency + competent valves decrease venous pressure 90>30mmHg.
  • Failure of any of these results in chronic venous insufficiency
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8
Q

What are the two theories of venous hypertension causing venous ulceration?

A
  1. White cell trapping hypothesis

2. Fibrin cuff hypothesis

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9
Q

What is the white cell trapping hypothesis of venous ulceration?

A
  • WBCs larger, less bendy than RBCs
  • When perfusion pressure decreased by venous hypertension, WBC plug capillaries -> RBCs congest behind
  • WBCs activated –> adhere to endothelium –> release of proteolytic enzymes and ROS
  • Endothelial and tissue damage
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10
Q

What is the fibrin cuff hypothesis of venous disease causing venous ulceration?

A
  • increased venous pressure transmitted to capillaries==> capillary elongation and increased endothelial permeability
  • fibrinogen deposited into tissues ==> fibrin
  • accumulation of fibrin barrier to oxygen ==> tissue hypoxia ==> ulceration
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11
Q

How is severity of venous disease classified?

A 
CEAP
C: clinical (i.e. severity of AFx)
E: etiology
A: anatomic classification
P: pathophysiologic classification
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12
Q

What are the major types of leg ulcers?

A
  1. Ischaemic
  2. Neuropathic (DM, EtOH, spinal cord lesions)
  3. Stasis / venous
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13
Q

CFx ischaemic leg ulcers?

A
  • Painful ulcer
  • Hx claudication
  • CV RFx
  • previous peripheral vascular surgery
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14
Q

Location of ischaemic leg ulcers?

A

-Distal periphery: dorsum of foot / pretibia

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15
Q

Appearance of ischaemic leg ulcer?

A
  • Puched out edges
  • Ulcer base: poorly developed grey granulation tissue
  • Surrounding skin pale / mottled with no sigs of inflammation
  • Little bleeding with debridement
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16
Q

Signs of chronic arterial insufficiency?

A
  • Atrophic nails / skin
  • venous guttering
  • slow capillary return
  • Absent pulses
  • Beurger’s +ve
17
Q

CFx neuropathic ulcers?

A
  • Painless

- Hx diabetes / other causes of neuropathy

18
Q

Signs of neuropathy (a/w neuropathic ulcers)?

A
  • Hypoaesthesia
  • Proprioception decreased
  • 2 point discrimination diminished
  • Vibratory perception decreased
19
Q

Location of neuropathic ulcers?

A
  • Plantar surface of MTPs
  • “Bunion” areas
  • Dorsum of IP joints
  • Base of 5th MT
  • MM or LM
  • Callused posterior rim of heel pad
20
Q

CFx venous ulcers?

A
  • Hx venous insufficiency (VVs, thrombophlebitis, DVT)

- Previous venous surgery

21
Q

Appearance venous ulcers?

A
  • Large, irregular area
  • Shallow
  • Location: over gaiter area (common = medial malleolus)
  • Moist, granulating base
  • Surrounded by zone of inflammation and stasis dermatitis
22
Q

Ix in ulcer workup?

A
  • FBE
  • UEC
  • CRP
  • BSL + HbA1C
  • Vasculitic screen
  • ESR
  • Thrombophilic screen
  • Swab MCS
  • Xray/bone scan / MRI
  • Duplex (art / venous)
  • CTA
  • Biopsy
23
Q

Treatment ulcers?

A
  • Bed rest
  • Elevation or dependency
  • IV ABx
  • Dressings
  • Debridement / split skin graft
  • Treat underlying aetiology (revascularisation, compression stockings, pressure offloading footwear)

Cardiovascular (22 decks)

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