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Peripheral Venous Disease
Terms in this set (81)
This is defined as the following:
1) Spectrum of disorders typically characterized by abnormal venous dilatation ranging from varicose veins to venous stasis and ulceration
2) Occasionally associated with a discrete etiology (i.e. large LE DVT that irreversibly damages the venous structure)
3) Most cases are related to the progressive degenerative changes in venous structure and function with aging
Peripheral Venous Disease
What is included in Peripheral Venous Disease?
1) Deep Vein Thrombosis (DVT)
2) Superficial thrombophlebitis
3) Varicose Veins
4) Chronic Venous Insufficiency (CVI)
This is defined as the following:
The presence of a thrombus and subsequent inflammatory response in a superficial or deep vein
Deep Vein Thrombosis (DVT)
IN DVT, Thrombi propagate in the direction of blood flow. What is the most common location?
Where are DVTs most common?
Significantly more common in lower extremities
What is the most important sequelae regarding a DVT?
1) Pulmonary embolism (50%) of untreated cases
2) Chronic venous insufficiency
What is Virchow's Triad regarding a DVT?
1) Endothelial/vascular damage
- Decreased inhibition of coagulation
- Local fibrinolysis
2) Venous Stasis
- Post MI, CHF, Stroke, Post operative and/or long travel
What are the inherited forms of hyper coagulability?
- Activated protein C Resistance (Factor V Leiden)
- Prothrombin gene mutation G20210A
- Protein C and Protein S Deficiency
- Antithrombin III Deficiency
- Antiphospholipid antibody syndrome
What are the acquired forms of hyper coagulability?
1) Age (increased with age)
2) Surgery (esp. ortho, GI, GU)
3) Trauma (esp. fractures of spine, pelvis, femur, or tibia)
4) Neoplasms (esp. lung, pancreas, colon, rectum, kidney, prostate)
5) Blood dyscrasias (myeloproliferative disorders)
6) Hyperviscosity (Multiple myeloma, polycythemia, leukemia, sickle cell)
7) Prolonged immobilization (as above)
8) Hormone related (pregnancy, OCP, HRT)
9) Antiphospholipid syndrome
11) Heart failure
12) Family History (Lupus anticoagulant,
13) Antiphospholipid antibodies)*can be on both lists
This type of DVT is described as thrombi confined to deep calf veins
Distal (calf) vein thrombosis
This type of DVT is described as a thrombus that involves popliteal, femoral, or iliac veins
Proximal vein thrombosis
Of the distal (calf) vein thrombosis and the proximal vein thrombosis, which one is more commonly associated with the development of pulmonary emboli
Proximal vein thrombosis (maybe because it has a shorter distance to go to the lungs)
What are the clinical features of a DVT?
1) Absence of physical findings does not rule out disease
2) Unilateral leg edema, erythema, warmth and tenderness
3) Palpable venous cord (thrombosed vein)
4) Phlegmasia cerulea dolens (cyanotic hue)
5_ Phlegmasia alba dolens (pallor associated with massive edema)
6) Homan's sign (pain with foot dorsiflexion)
Phlegmasia cerulea dolens
Phlegmasia alba dolens
pallor associated with massive edema
(pain with foot dorsiflexion)
What should be in your differential diagnosis for a DVT?
1) Muscle strain/tear
3) Lymphatic obstruction
4) Venous valvular insufficiency
5) Ruptured popliteal cyst
7) Arterial occlusive disease
Ultrasonography and D-dimer tests for DVT are most useful when the results are combined with an assessment of pretest probability of DVT. What is often times measure we use?
What is the lob workup for a DVT?
1) D-dimer, do not order unless low suspicion
2) CBC with platelets
3) Coagulation studies PT & PTT
4) Renal Functions
What is the most useful to assess for a DVT?
What provides the definitive diagnosis for a DVT but is invasive?
Patients with a low probability Wells score and a negative D-dimer are unlikely to have DVT, so what should be done?
No further testing. Send them home
What should I do with patients with a "moderate" or "high" probability Wells score?
Noninvasive testing for DVT (Doppler ultrasound)
What is is the noninvasive approach of choice for the diagnosis of patients with a first episode of suspected DVT?
What is the treatment of a DVT?
1) Prevent further clot extension
2) Prevention of acute PE
3) Reduce risk of recurrent thrombosis
4) Treatment of massive iliofemoral thrombosis with acute lower limb ischemia and or venous gangrene
5) Limit development of late complications
- Post-phlebitic syndrome
- Chronic venous insufficiency
- Chronic thromboembolic pulmonary HTN
What is the initial therapy for a DVT?
1) Low Weight Molecular Heparin (LWMH) or
2) Unfractionated Heparin
4) Fibrinolytics are reserved for:
- Limb/life threatening thrombosis
- Very recent symptoms
- Low bleeding risk
What is the inpatient treatment of DVT?
Low-molecular-weight heparin (LMWH)
- LMWH is superior to unfractionated heparin for the initial treatment of DVT because it reduces mortality rates and the risk of major bleeding during initial therapy.
- Unfractionated heparin or LMWH is appropriate for the initial treatment of patients with pulmonary embolism.
What is the outpatient treatment of a DVT?
In stable patients for whom the required support services are in place, outpatient treatment of VTE with LMWH is as safe as inpatient treatment and is cost-effective
- 4000-6500 daltons MW means:
- Very high bioavailability
- Longer half-life
- Less interindividual variation
- Given as outpt, *
Is LMWH interchangeable?
What are the LMWH that we used?
1) Enoxaparin (Lovenox)
2) Dalteparin (Fragmin)
3) Tinzaparin (Innohep)
What is the most popular LMWH?
What is the standard treatment of a DVT?
1) Lovenox, start at 1mg/kg Q12h
2) Coumadin, start at 5mg daily
- Continue Lovenox until INR is between 2 & 3
o Average 7 days
o Minimum 5 days
3) Continue coumadin for at least 6 months
o Coumadin > 6 months, bleeding curve goes up
Who should continue on Coumadin therapy past the minimum 6 months?
In cancer patients or pregnancy
When should I use a IVC Filter (Greenfield)?
1) Use with anticoagulant contraindications
2 )Recurrent thromboembolism with anticoagulation
3) Recurrent embolism with PH
4) Urgent surgery without time for anticoagulation
What is used for DVT prophylaxis?
3) Compression Stockings
4) Intermittent external pneumatic compression
This is a Benign disorder that is described as:
Erythema, induration, and tenderness along a superficial vein, usually spontaneous, but can follow venous cannulation
What is the etiology of Superficial Thrombophlebitis?
1) Suppurative phlebitis
- Complication of intravenous cannulation
- Varicose veins
- Buerger's disease
- Systemic lupus
- Migratory superficial thrombophlebitis
- Polycythemia Vera
- Occult malignancy (pancreas)
o Trousseau syndrome - recurrent migratory superficial thrombophlebitis
What vessel is most commonly affected by Superficial Thrombophlebitis?
Describe the clinical features in Superficial Thrombophlebitis?
1) Pain and cord like swelling along course of vein
2) Areas of induration, erythema, and tenderness correspond to dilated and often thrombosed superficial veins
What are the complications of Superficial Thrombophlebitis?
1) Simultaneous DVT (20-40%)
2) Pulmonary embolus (only if DVT)*
3) Recurrent superficial thrombophlebitis
What is the work-up for Superficial Thrombophlebitis?
1) Clinical diagnosis
2) Doppler to rule out DVT
What is the conservative treatment for superficial thrombophlebitis?
1) Bed rest and elevation of limb
2) Moist heat
7) Ambulation as tolerated
When is surgical treatment (Excision of involved vein) considered for superficial thrombophlebitis?
1) Failure of conservative treatment
2) Symptoms > 2 weeks
3) Suppurative Thrombophlebitis
In combination with broad spectrum IV antibiotics
This distention of tortuous superficial veins resulting from incompetent valves in the deep, superficial, or perforator systems
What are Varicose Veins in the esophagus called?
What are Varicose Veins in the Anorectum?
What are Varicose Veins in Scrotum?
What are Varicose Veins in the leg?
Greater saphenous vein
What is the "main" factor for varicose veins?
Structural weakness of vessel wall or valves
What are primary "contributing factors" to varicose veins?
1) Increasing age
2) Female gender
3) OCP use
4) Prolonged standing
What are the secondary etiologies for varicose veins?
1) Deep venous valvular insufficiency
2) Incompetent perforating veins
3) Malignant pelvic tumors with venous compression
4) Congenital anomalies ~ AV Fistula
What is the most common form of venous disorder of the lower extremity?
What are the clinical features of varicose veins?
Visible long, dilated, tortuous superficial veins along thigh and leg
- Diffuse aching
- Nocturnal cramping
What are varicose veins aggravated by?
1) Prolonged standing (end of day)
What medical conditions are varicose veins associated with?
What are the complications of varicose veins?
1) Recurrent superficial thrombophlebitis
T or F. Varicose Veins are largely a cosmetic problem?
What is the conservative treatment of varicose veins?
1) Elevation of leg
2) Elastic stockings
What is the surgical treatment of varicose veins?
1) High ligation
2) Stripping of saphenous vein
4) Endovenous laser therapy
What prognosis of varicose veins?
1) Benign, slow and with predictable course
2) Almost 100% symptomatic relief for primary varicosities
3) Good cosmetic results with treatment
4) Significant post operative recurrence
- Greatest with sclerotherapy
Chronic elevation of deep venous pressure and blood pooling in lower extremities
Chronic Venous Insufficiency
What is the etiology of Chronic Venous Insufficiency?
1) Calf muscle pump dysfunction
2) Valvular incompetence
- Reflux secondary to:
3) Venous obstruction
4) AV fistulas
5) Venous malformations
What are the clinical features of Chronic Venous Insufficiency?
2) Ankle and calf edema
- Relieved by foot elevation
5) Stasis dermatitis
- Above medial malleolus
- Weeping (wet)
- Irregular outline
8) Varicose veins
What is the "gold standard" in working up Chronic venous insufficiency?
Ambulatory venous pressure measurement
What is most commonly used for Chronic venous insufficiency?
What other random study can be used for chronic venous insufficiency?
What is the conservative treatment of chronic venous insufficiency?
1) Elastic compression stockings
2) Leg elevation
3) Avoid prolonged standing/sitting
How are the ulcers treated in chronic venous insufficiency?
1) Zinc oxide wraps
2) Split thickness skin grafts
What is the surgical treatment of venous insufficiency?
1) For failures of conservative therapy
2) For large or recurrent ulcers
3) Surgical ligation of perforators in region of ulcer
4) Greater saphenous vein stripping
5) Venous bypass if short segment obstruction
This is obstruction of lymphatic drainage resulting in edema with high protein content
What is primary Lymphedema?
Hereditary congenital lymphedema
What is secondary Lymphedema?
What is the most common cause of Lymphedema caused by infection "worldwide"?
What other other causes of secondary Lymphedema due to infection?
1) Post operative
2) Malignant infiltration
What is the most common cause of Lymphedema in the United States?
Radiation/surgery (axillary or groin lymph node removal)
What are the clinical feature of Lymphedema?
1) Classically non-pitting edema
2) Impaired limb mobility
3) Discomfort and pain
4) Psychological distress
What does Stage I Lymphedema look like?
What does Stage II Lymphedema look like?
What is the treatment of Lymphedema?
1) Avoid limb injury (can precipitate or worsen lymphedema)
2) Skin hygiene
3) External support
- Intensive: compression bandages
- Maintenance: lymphedema sleeve
- Gentle daily exercise of affected limb
o Gradually increase ROM
- Must wear a sleeve/bandage when doing exercise
5) Massage and manual lymph drainage therapy
What happens if Lymphedema is left untreated?
1) It becomes resistant to treatment due to subcutaneous fibrosis
2) Cellulitis causes rapid increase in swelling and
can lead to sepsis and death
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