Lecture 18: PVD Flashcards by Enoch Koo

What are the essentials of diagnosis of varicose veins?

Dilated, tortuous, superficial veins in the leg
Asymptomatic or aching discomfort/pain
Often hereditary
Increased frequency post pregnancy

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What are the main contributing factors to varicose veins?

Postpartum women (MC)
Prolonged standing
Heavy lifting

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What are the two underlying mechanisms that contribute to varicose veins?

Poor venous reflux (valves causing backflow)
Venous Hypertension

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What vein is MC affected as a varicose vein?

Great saphenous vein (medial leg)

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What are some possible causes of secondary varicosities?

Thrombophlebitis
Proximal venous occlusion (rare)
Congential/AV malformations

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What is the MC complaint for varicose veins?

Dull, aching heaviness after periods of standing.

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What secondary symptom may occur over varicose veins?

Itching due to venous eczema

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Does the # or size of varicosities correlate with symptoms?

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What is the chronic condition that may result with long-standing varicose veins?

Chronic venous insufficiency

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What characterizes chronic venous insufficiency?

Ankle edema
Brownish skin pigmentation
Chronic skin induration or fibrosis

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How are varicose veins diagnosed?

Clinically, but duplex sonography can be ordered as the imaging of choice for planning surgery

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What is the nonsurgical tx for varicose veins?

Compression stockings (20-30 mm Hg)
Leg elevation

You only wear stockings during waking hours

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What is sclerotherapy?

Direct injection of a sclerosing agent to cause permanent fibrosis.

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What is endovenous laser therapy?

EVLA requires local anesthesia and a laser to destroy the small vein.

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When is endovenous radiofrequency ablation a preferred procedure?

For significant varicose veins with signs of venous insufficiency or long varicosities

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When is vein stripping used?

Removing part of the vein that is tortuous

LAST RESORT

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What are the essentials of diagnosis of chronic venous insufficiency?

History of DVT or leg injury
Edema, brawny skin pigmentation, or subcutaneous lipodermatosclerosis in lower legs
Ulcerations at or above medial ankle

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What is the MC etiology of chronic venous insufficiency?

Prior deep venous thrombophlebitis

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What is a major complicating factor for patients with chronic venous insufficiency?

Obesity

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What exactly does venous insufficiency lead to in the vein itself?

Failure of the valve leaflets to close due to scarring and thickening

Ultimately leads to edema

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If a muscle biopsy were taken of someone with chronic venous insufficiency, what might be seen?

Interstitial space changes
Enlargement and fibrosis (elevated fibrinogen and fibrin)
Edema and inflammation

Leads to more capillaries

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What is peri-capillary fibrosis?

Subcutaneous thickening and induration

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What results from erythrocyte lysis in chronic venous insufficiency?

Hemosiderin deposits => brownish skin

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What is the primary symptom of someone with chronic venous insufficiency?

Progressive, pitting edema of the lower leg.

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What are the secondary conditions that may occur in chronic venous insufficiency?

* Stasis dermatitis * Lymphedema

What does chronic venous insufficiency look like?

* **Taut, shiny skin** at the ankle * Hemosiderin staining => **brownish skin pigmentation** * Loss of skin integrity => secondary cellulitis

What is lipodermatosclerosis?

* Panniculitis subtype * **Inverted champagne bottle/bowling pin appearance**

What is atrophie blanche?

Star-shaped, ivory white atropic plaque

What is corona phlebectatia?

Abnormally dilated veins around the ankles

How is chronic venous insufficiency diagnosed?

Clinically

What is the imaging test of choice for planning therapy in regards to chronic venous insufficiency?

Duplex ultrasonography

What is the backup imaging for chronic venous insufficiency?

MDCT venography or MR venography, but requires dye | Only used if doppler was nondiagnostic

What are the mainstays of treating chronic venous insufficiency?

* Compression stockings * Avoid sitting a long time * Pneumatic compression for **refractory cases**

What is an unna boot and what is it for?

Paste gauze compression dressing used for both compression and topical therapy | Weekly changed

If a patient develops an ulcer in chronic venous insufficiency, what do they need?

A wound care team

What are the essentials of diagnosing superficial venous thrombophlebitis?

* Red, painful induration **along a superficial vein** * Commonly occurs at the site of a **recent IV line** * **Marked swelling** of extremity may occur

What is the MCC of superficial venous thrombophlebitis?

Recent catheter placement | Caused by staph

Where does superficial venous thrombophlebitis typically occur?

Lower extremities | MCC: Great saphenous vein

What is the lingering thing that may occur with superficial venous thrombophlebitis?

Palpable cord

What is the main complication of superficial venous thrombophlebitis?

Suppurative thrombophlebitis

How is superficial venous thrombophlebitis diagnosed?

Clinically.

What are the 3 complications of suppurative thrombophlebitis?

* Metastatic abscess formation * Septicemia * Septic emboli

When is venous doppler ultrasound indicated for superficial venous thrombophlebitis?

ONLY if **involves proximal lower extremity or mixed picture**

How do we manage superficial venous thrombophlebitis?

1. NSAIDs & compression stockings with no limitations on daily activities. 2. Larger/more painful ones may require **hot, wet compresses** and leg elevation as well.

What would indicate us to use anticoagulants for superficial venous thrombophlebitis? And what are the 3 anticoagulants?

If it is 5cm or longer. Use: arixtra/fondaparinux, LMWH, or xarelto for **45days** | Full-dose if it is rapidly progressing

If the patient ends up septic from superficial venous thrombophlebitis, what is the goto ABX combo?

**Rocephin + Vanco** + (LWMH or fondaparinux) | The goto

What are the essentials of diagnosing lymphangitis?

* **Red streaking from wound or cellulitis towards regional lymph nodes**, which are typically enlarged and tender. * Chills, fever, malaise may be present. | Ang = channels ## Footnote Extends proximally!

What is the MCC of lymphangitis and the 2 main causative organisms?

Cutaneous inoculation of **hemolytic strep or Staph**

What is lymphatic filariasis?

Lymphedema caused by a mosquito (Wuchereria bancrofti). **MC cause of acute lymphangitis worldwide previously**

What is nodular lymphangitis?

Painful or painless nodular subcutaneous swelling along lymphatic channel. | **Always consider malignancy!**

What is the MC malignancy that causes lymphangitis?

Breast cancer

How does lymphangitis typically present in the clinic?

**Trauma/abrasion DISTALLY to infection site**

How do we diagnose lymphangitis?

* **CBC w/diff and blood cultures are a MUST.** * Wound culture and I&D * Imaging for anatomic abnormalities

What imaging may be indicated for lymphangitis?

Lymphangiography and lymphoscintigraphy

What is the empiric ABX therapy for lymphangitis?

GABHS coverage: Dicloxacillin, **keflex**, ancef, rocephin, bactrim, etc

Who can undergo oral abx therapy outpatient for lymphangitis?

* Non-toxic * Non-febrile * Not immunocompromised

What kind of compresses help lymphangitis?

Hot

What kind of lymphangitis usually needs surgical intervention?

Nodular lymphangitis

What are the essentials of lymphedema?

* **Painless, persistent edema** of one or both legs, **usually young women.** * Pitting **edema w/o ulceration, varicosities, or stasis pigmentation.** * Lymphangitis and cellulitis could also develop

What is the primary form of lymphedema?

Congenital hypo/hyperplastic lymphatics. Worsening condition: pelvic or lumbar involvement.

What is the secondary form of lymphedema?

Inflammatory or mechanical lymphatic obstruction from **trauma, regional lymph node resection/irradiation, or malignancy**, often following surgical removal of the lymph nodes in the groin or axilla.

What can happen in both forms of lymphedema?

Secondary dilation of the lymphatics

How is lymphedema diagnosed?

Clinically. MRI only for identifying masses.

How is lymphedema managed?

1. Intermittent leg elevation 2. Compression stockings 3. **Massage toward the trunk** 4. Wound care 5. Good hygiene 6. **Amputation for lymphangiosarcoma**