Chapter 157 - Chronic venous disorder - nonoperative

Question 1

Percentage of CVD that develop ulcers

Answer 1

20%

Question 2

Micronized purified flavonoid fraction uses

Answer 2

treatment of large and long standing ulcers from venous disease

Question 3

Lifestyle modifications for CVD

Answer 3

1) exercise

2) leg elevation (30 cm above heart)

Question 4

Normal standing resting venous pressure

Answer 4

60-80 mmHg

Question 5

Highest pressure safety limit for compression stocking

Answer 5

60 mmHg

Question 6

Benefit of compression therapy

Answer 6

1) improve venous pump function
2) enhance venous flow velocity
3) improve cutaneous microcirculation?
4) Decreased TNFalpha and VEGF

Question 7

Types of compression garments

Answer 7

1) gradient elastic stockings
2) circaid garment
3) Unnaboot (paste gauze boot
4) layered elastic and nonelastic compression bandages
5) intermittent pneumatic compression

Question 8

Gradient elastic stockings developed in

Answer 8

1950’s

Question 9

4 strengths of gradient compression stockings

Answer 9

Class 1: 10-15 mmHg
Class 2: 20-30
Class 3: 30-40
Class 3 high compression: 40-50

Question 10

Timing to replace compression garments

Answer 10

6-9 months

Question 11

Measuring compression stockings at levels in the leg

Answer 11

1) thigh
2) midcalf
3) ankle

Question 12

People that benefit from Class 1 compression

Answer 12

1) symptom control in CEAP 1
2) varicose vein in pregnancy
3) prevention of leg edema related prolonged standing/sitting
4) prevention of VTE in non-ambulation

Question 13

Evidence on class 2 compression in varicose vein prevention and treatment

Answer 13

weak evidence overall

Question 14

REACTIV trial key points

Answer 14

Randomised clinical trial, observational study and assessment of cost-effectiveness of treatment of varicose veins

Three groups
group 1: minor VV, conservative vs sclero
Group 2: moderate varicose with reflux, conservative vs surgery
Group 3: severe varicose: conservative vs surgery

Surgery provided better symptom relief and QOL and pt satisfaction
Sclerotherapy not really

Question 15

Gradient compression type for C4-6 disease

Answer 15

Class 3 stockings

Compliance is poorer however than Class 2

Question 16

SOX trial

Answer 16

Compression stocking to prevent PTS after DVT
410 patients
Class 3 vs placebo
no difference

Question 17

CircAid garment

Answer 17

1) non elastic compression with multiple Velcro bands

2) Adjustable for limb size and improved comfort

Question 18

Unna boot

Answer 18

1) developed by Paul Gerson Unna 19th century end
2) multi layer compression dressing
3) gauze with calamine, zinc oxide, glycerin, sorbitol, gelatin and magnesium aluminum oxide, elastic wrap
4) stiff with drying
5) pressure 50-60 mmHg
6) change weekly depending on drainage amount

Better healing than polyurethane dressing

Question 19

Dressing classes

Answer 19

1) Hydrocolloid: mild exudating ulcers
2) Foam dressing: heavy exudating ulcer, painful ulcer
3) Alginate: infected ulcer, hemorrhagic and exudating ulcer
4) Hydrogel: necrotic ulcer/dry ulcer
5) Hydrofibers (Aquacel): infected ulcer, heavy exudate
6) Impregnated mesh dressing (adaptic, mepitel): mild exudate
7) Hyaluronic acid based dressing: mild exudate
8) Charcoal dressing: foul smelling ulcers
9) Silver dressing (Acticoat, aquacel Ag): infected exudating
10) Protease modulating: hard to heal ulcer
11) Paraffin/petroleum gauze (jelonet)

Question 20

Elastic and non-elastic bandages

Answer 20

ELASTIC - easier to apply but uncomfortable

1) Ace
2) sure press
3) perfecta

NONELASTIC - may lose pressure over time as swelling down

4) putter
5) comprilan
6) coban

Question 21

Intermitten pneumatic compression dressing evidence

Answer 21

helps with reducing edema

ulcer healing evidence poor

Question 22

ACTitouch device

Answer 22

Adaptive pressure multichamber system

50 mmHg at foot/ankle
45 mmHg at midcalf
40 mmHg at knee

improved QOL, ease of use, skin protection but no change in ulcer healing

Question 23

ESCHAR study

Answer 23

Effect of surgery and compression on healing and recurrence

500 patients
compression vs compression + surgery

Healing rates similar
recurrence rate 2 year better in surgery

Question 24

Function of zinc in body

Answer 24

1) cofactor for enzyme process

2) humoral and cell mediated immunity response and wound healing

Question 25

Pharmacologic treatment of CVD that have no evidence

Answer 25

No evidence for diuretic, zinc, fibrinolytic, horse chestnut (prostaglandin F), aspirin, ifetrobane (thromboxane A2 antagonist)

Question 26

Pentoxifylline function

Answer 26

1) competitive non-selective adenylate cyclas inhibitor
2) increase intracellular cAMP
3) activate protein kinase A
4) inhibit TNF
5) promote leukotriene synthesis

Red blood cell deformity and inhibit platelet aggregation and thrombus formation
Antiinflammatory effect

Question 27

Evidence on pentoxifylline in ulcer healing

Answer 27

overall more effective with pentoxifylline

there’s some controversy

Question 28

Phlebotropic agent definition

Answer 28

medication with multiple pharmacologic microcirculatory activities

Question 29

Micronized purified flavonoid fraction component

Answer 29

90% micronized diosmin

10% flavonoids

Question 30

Action of MPFF

Answer 30

1) inhibit granulocyte and macrophage infiltration

2) phleotropism prevent apoptosis of endothelial and prevent valve degeneration

Question 31

MPFF effect with studies

Answer 31

1) reduce edema

2) improve ulcer healing

Question 32

Prostaglandin E1 effect

Answer 32

Attenuate WBC activation

improve ulcer healing

Question 33

Calcium dobesilate

Answer 33

Reduce capillary permeability
improve edema

no effect on ulcer healing