Lecture 16

Question 1

What are the different classifications of the veins?

Answer 1

Deep veins: underneath deep fascia/through muscles
Superficial veins: in subcutaneous tissue
Connected by perforating veins, from superficial in subcutaneous tissues into deep veins, and sent back to heart

Question 2

What is the divisions of the deep vein?

Answer 2

• inferior vena cava
• common iliac
• external/internal iliac
• external iliac branches to femoral (which branches into deep femoral and superficial femoral)
• superficial femoral turns into the popliteal vein behind knee
• popliteal branches into anterior and posterior tibial veins and the peroneal vein

Question 3

What are the classifications of the superficial veins?

Answer 3

Long saphenous vein- runs medially down inside of leg from the femoral vein via perforators

Short saphenous vein- connects through perforators at popliteal vein, at the back of the calf

Question 4

Where is the long saphenous vein?

Answer 4

Runs medially along leg, and along front of medial malleolus

Used to be the site where IV’s were cannulated

Question 5

What is the calf muscle pump?

Answer 5

‘Peripheral heart’

• soleus and gastrocnemius push blood against gravity back towards heart (push blood from superficial veins, through perforating veins, into deep veins)
• valves open:blood pushed through, valves closed: prevent retrograde movement

Question 6

What happens to the venous pressure in the foot during exercise?

Answer 6

Venous pressure is reduced

-as blood is no longer pooling in the feet, it is being pumped back towards right side of heart

Question 7

What is peripheral venous disease?

Answer 7

Varicose veins

• more common in older ages/females
• valves ineffective, blood movement is slow/reversed
• saphenous veins common site (superficial)
• walls of veins weaken (valve cusps separate and varicosities form), causing the veins to become incompetent, can get pooling

Question 8

What are some symptoms associated with varicose veins?

Answer 8

• heavy/ache/muscle cramps/throbbing
• thin, itchy skin along affected veins
• haemorrhage: in shower, venous pooling and heat causing vasodilation=bleeding out of legs
• varicose eczema
• superficial vein thrombophlebitis (inflammatory process resulting in a clot in the vein= these put you at a greater risk of a DVT)
• chronic venous insufficiency

Question 9

What is an example of haemosiderin staining?

Answer 9

-venous eczema/ulceration

Question 10

Why does the calf muscle pump fail?

Answer 10

Need to be using the calf muscles-plantarflexion of ankle joint during walking
-if not using muscles, leads to retrograde flow

Question 11

Who is at risk of venous hypertension/calf muscle pump not working?

Answer 11

• elderly, obese, injured (immobile)

- Parkinson’s: shuffling- not plantarflexing properly

Question 12

What does calf muscle pump failure cause?

Answer 12

• deep vein incompetence (retrograde flow)

- superficial vein incompetence (retrograde flow back down through perforators into superficial veins)

Question 13

What is the most common cause of arterial thrombosis?

Answer 13

Atheroma

-platelet rich aggregate, plug damaged vessel

Question 14

What is Virchow’s triad?

Answer 14

• vessel wall damage
• stasis (flow)
• hypercoagulability

Question 15

What is a venous thrombosis like?

Answer 15

Little platelet component, fibrin rich

Often due to slow flow:stasis-trauma, dehydration, chemo, pregnancy

Question 16

What factors can cause venous thrombosis?

Answer 16

• trauma
• chemo
• pregnancy
• inflammatory conditions

Question 17

What is a DVT?

Answer 17

Clotting of blood in a deep vein (common in calf)

• impaired venous return
• inflammatory component: redness/swelling following thrombosis

Question 18

Who is risk at a DVT?

Answer 18

• ambulatory patients
• long flight
• post surgery patients

Question 19

What are some symptoms of DVT?

Answer 19

• calf tenderness
• warm
• distended/visible superficial veins
• oedema
• pyrexia with no other cause (if a patient post-op have pyrexia with no other cause it could be a DVT)
• asymmetry

Question 20

Why do DVT’s occur?

Answer 20

Stasis-no calf muscle pump
-prothrombotic/hypercoagulability state following malignancy/pregnancy/before or after surgery

=promote mobility soon after surgery

Question 21

What is a fatal consequence of a DVT?

Answer 21

Pulmonary embolism

Question 22

How do you treat a DVT?

Answer 22

Prophylaxis

Anticoagulant agents

Question 23

How do you limit incidence of acute ischaemia/stenosis of major vessel?

Answer 23

Collateral circulation 
(Knee/shoulder/hip/stenosed arteries- around joints, as vessels could be occluded while flexing or around stenosis)

Question 24

What is acute limb ischameia?

Answer 24

Major occlusion of an arterial in lower limb
(Occurs in mins/days= acute)
-no collateral circulation can develop in this time

Question 25

What are the 6 P’s in leg ischameia?

Answer 25

``` Pain Pallor (can become cyanotic and necrotic, can become hyperkalaemic) Perishing with cold Pulseless Paraesthesia Paralysis/reduced power ```

Question 26

What is chronic peripheral arterial disease?

Answer 26

Intermittent claudication in limb-occurs over a period of time - caused by atherosclerosis: oxygen supply/demand ratio is not balanced - cramping in leg: exercise induced (pain goes away when resting)

Question 27

How do you manage chronic peripheral arterial disease?

Answer 27

- exercise: increase collateral circulation - smoking cessation - antiplatelet drugs - angioplasty - bypass graft

Question 28

What is critical ischaemia?

Answer 28

Rest pain: poor blood supply so pain at rest (Get pain when sleeping, and relieve it when they stick their leg out of the bed- last attempt to try and get blood to lower limbs) -at rest oxygen supply/demand ratio is not sufficient (Like unstable angina- chest pain at rest)

Question 29

What can untreated critical ischameia lead to?

Answer 29

-ulceration -gangrene (dry) (Viability of limb is compromised) -requires referral to vascular surgical unit immediately

Question 30

What are the different classifications of claudication?

Answer 30

-mild -moderate -severe -rest pain Where stenosis is, dictates what pulses you will be able to feel

Question 31

What are the difference pulses of lower limbs?

Answer 31

- femoral pulse: mid-inguinal point, midway between anterior superior iliac spine and pubic symphysis ) (if can’t palpate= urgent as this pulse is high up) - popliteal pulse: deep in popliteal fossa - dorsalis pedis pulse: lateral to extensor hallucis longus tendon - posterior tibial pulse: behind medial malleolus

Question 32

What is ultrasonography and its uses?

Answer 32

Sonogram using ultrasound and Doppler effector measure flow/velocity - used to record flow/velocity of blood: disrupted in occlusion - used in echocardiogram - used in distal vessels - echoes produced from moving blood are detected and computed into flow direction and velocity

Question 33

What is the ankle-brachial pressure index?

Answer 33

ABPI - measure pressure in brachial artery - measurement of BP in dorsalis pedis, posterior tibial arteries - if the BP in the ankle is less than in the brachial = peripheral artery disease DIVIDE ANKLE SYSTOLIC BY BRACHIAL SYSTOLIC ABPI <0.9 indicated peripheral artery disease

Question 34

What do varicose veins look like?

Answer 34

Tortuous/twisted

Question 34

What is haemosiderin staining?

Answer 34

Venule pressure is high, RBC’s leak out, macrophages oxidise RBC’s and haem converted to ferrous > ferric -staining in tissues

Question 34

What is lipodermatosclerosis?

Answer 34

Inflammation and thickening of fat layer under skin | =chronic venous insufficiency

Question 35

What can eczema lead to?

Answer 35

Chronic/itchy/red skin can lead to lipodermatosclerosis (hard to the touch)

Question 36

Where does venous eczema and ulceration usually present?

Answer 36

Hard modular areas e.g. medial malleolus

Question 37

What is chronic venous insufficiency and what can it cause?

Answer 37

Venous wall/valves in leg aren’t working properly making it difficult for blood to return back to the heart =stasis Causes: - venous hypertension - oedema - haemosiderin staining - lipodermatosclerosis - venous ulceration

Question 38

In what patients is the development of chronic venous deficiency common?

Answer 38

50% of DVT patients

Question 39

How do you treat venous ulceration?

Answer 39

Ligation/vein stripping perforating vein (stop retrograde blood flow back into superficial veins)

Question 40

What is Virchow’s triad?

Answer 40

- vessel wall damage - stasis - hypercoagulability

Question 41

What are some diagnosis you should consider when diagnosing a DVT?

Answer 41

- soft tissue trauma - cellulitis - lymphatic obstruction

Question 42

What is the Well’s score?

Answer 42

Pre-test probability -give different numbers to different risk factors, overall number dictates whether you should be considering a DVT as prognosis

Question 43

What are the most common causes for acute limb ischaemia?

Answer 43

- trauma | - leg embolism

Question 44

What is the most common presentation of claudication?

Answer 44

Atheroma | -atherosclerosis of superficial femoral artery

Question 45

What is an atheroma?

Answer 45

Degeneration of walls of arteries caused by accumulation of fatty deposits