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Integumentary > Lesson 3: Venous Insufficiency > Flashcards

Lesson 3: Venous Insufficiency Flashcards

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1
Q

Prevalence of chronic venous insufficiency:

A

9.4%

70–90% of leg ulcers are due to VI

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2
Q

Who is at risk for VI:

A

Women have 3x greater risk

Risk of VI ulcer is 7.5x greater after age 65

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3
Q

Recurrence rate of VI:

A

13–81%

Recurrence correlated with nonadherence

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4
Q

According to research, who is most likely to develop VI?

A

Patients > 60 years old, with history of blindness, cataracts, renal insufficiency, or a history of pressure ulcers

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5
Q

How much blood does the venous system store?

A

70-80% of total blood volume

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6
Q

Anatomy of Leg Veins

A

Deep system
Superficial System
Perforators

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7
Q

Deep Vein Function

A

Lay beneath the muscle fascia
Responsible for 80- 90% of the venous return
Drain the lower extremity musculature
Typically paired with an artery (femoral, popliteal, tibial)

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8
Q

Superficial Vein Function

A

Lay above the deep fascia
Drain the cutaneous microcirculation
Great and small saphenous veins lay between the muscle fascia and the saphenous fascia
Reticular veins lay between the saphenous fascia and the dermis

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9
Q

What do superficial veins assist with?

A

temperature regulation

Carry about 10% of the venous return

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10
Q

Perforators Vein Function

A

Penetrate the deep fascia
Connect the Superficial and deep systems
An average of 64 perforators between the ankle and the groin
1 to 3 valves to direct flow from superficial to deep

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11
Q

What does the intimal layer excrete?

A

antithrombogenics

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12
Q

What does the medial layer contain?

A

3 thin layers of smooth muscle adrenergically innervated muscle weaker than that in arteries

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13
Q

Adventitial layer-

A

thick outer wall rendering veins stiffer than arteries aiding in calf pump

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14
Q

Proximal flow of venous blood relies on

A

Respiratory pump
Calf muscle pump
Valves

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15
Q

Calf Pump

A

Most efficient of the venous pumps (foot, calf, and thigh)

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16
Q

What does calf pump use?

A

crural fascia and extensive valves to generate 65% ejection fraction.

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17
Q

Pressure in venous system:

A

As blood is pushed from deep veins, venous pressure decreases allowing veins to refill from the superficial system through the perforators

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18
Q

Vein Bicuspid Valves

A

Formed from folds of vein endothelium
More numerous distally, lessen toward the hip
Insure flow from superficial to deep and from caudal to cephalad
Close when pressure gradient is reversed, <0.5 second reflux/delay is normal

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19
Q

Common causes of venous insufficiency

A

Vein dysfunction

Calf muscle pump failure

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20
Q

Ulceration Pathophysiology

A

Venous hypertension causes leakage into interstitial space of fluid and white blood cells
Edema and blood products cause inflammation
Inflammation leads to skin failure

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21
Q

Risk factors contributing to VI ulcers

A 
Vein dysfunction
Calf muscle pump failure
Trauma
Previous VI ulcer
Advanced Age
Diabetes
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22
Q

Vein Dysfunction

A 
Venous hypertension
Valve damage
Degeneration
Scarring
Inflammation
Clot sequelae
Varicosity
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23
Q

Calf muscle pump function:

A

Calf weakness/paralysis
Decreased dorsiflexion
Prolonged standing
Incompetent valves

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24
Q

Trauma

A

Benign trauma to venous-insufficient leg may result in ulceration due to edema-induced local tissue hypoxia

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25
Previous VI Ulcer:
Recurrence rate as high as 81% Local tissue hypoxia and malnutrition Scar tissue from prior ulcer increases risk of skin breakdown Precipitating factors/wound etiology not successfully addressed
26
Advanced Age:
Anatomical and functional changes that occur with aging Valve degeneration
27
Diabetes:
Increased microvascular disease Impaired immune response Impairs all 3 phases of wound healing
28
PT Tests and Measures for VI
Clinical Assessment for DVT Ankle-Brachial Index Trendelenburg Test Venous Filling Time
29
What is the gold standard for DVT:
venogram
30
Trendelenburg Test
Supine, leg in 45° elevation for 1 minute Note venous distension Tourniquet to distal thigh Stand upright Note time for superficial venous distention Release tourniquet
31
Trendelenburg Test indications:
To differentiate deep or perforating vein incompetence from superficial vein incompetence
32
Brodie-Trendelenburg Test
Differentiates between perforator and GSV incompetence Legs elevated to 45 degrees and tourniquet placed at groin Patient stands and tourniquet is removed Vein re-filling determines level of incompetence
33
Tendelenburg test time to venous distention greater than 20 seconds, tourniquet on:
deep or perforator vein incompentence
34
Tendelenburg test time to venous distention greater than 10 seconds, tourniquet off
superificial vein incompetence
35
Perthes Test
Tourniquet placed below knee and 10 heel raises performed If varicose veins empty, site of reflux is cranial to the tourniquet in the SFJ, SPJ, or thigh perforators If varicose veins remain distended, site of reflux caudal to the tourniquet in calf perforators Pain with heel raising indicates possible of deep venous obstruction
36
Indications of venous filling time:
Unable to tolerate ABI ABI > 1.1 History of diabetes or vessel calcification Suspected concomitant arterial insufficiency
37
Venous Filling Time
Predictor for arterial insufficiency Patient supine, note superficial veins on dorsal foot Elevate the limb 60° for 1 minute or until veins are drained by gravity Lower limb to dependent position, note time for veins to refill
38
Doppler Ultrasound
``` Gold standard for venous system More subjective than arterial Doppler Resting test Augmentation test Reflux test ```
39
Indications for Doppler Ultrasound:
``` Gold standard for venous system More subjective than arterial Doppler Resting test Augmentation test Reflux test ```
40
CO
asymptomatic
41
CI
telangiactasias or spider veins <3mm
42
C2
varicose veins>/= 3mm
43
C3
leg edema
44
C4
skin and subcutaneou tissue change
45
C4A:
hemosideran deposition
46
C4B:
lipodermatosclerosis
47
C5
healed venous ulcer
48
C6
current venous ulcer
49
Telangiectasis and Reticular Veins
Treated for cosmesis Indicate early stages of chronic venous insufficiency Dilation of surface veins causes vein prominence
50
Telangiectaisis/spider veins-
0.5 to 1 mm diameter
51
Reticular veins-
bluish discoloration- 1-3 mm diameter
52
Varicosities
Present in 10-15% of men and 20-25% women in Western population Dilated >4mm in diameter Mainly occur in great and short saphenous veins
53
Hemosiderin Staining
Venous dilatation allows passage of red blood cells through the endothelium into the interstitium Breakdown converts hemoglobin to hemosiderin Brown pigment stain usually occurs on the lower medial third of the leg Darkens over time
54
Lipodermatosclerosis
Inflammation of the layer of fat under the skin
55
Lipodermatosclerosis results in:
``` Pain Hardening of skin Redness Swelling Tapering of the legs above the ankles (champagne bottle deformity) ```
56
VI etiology:
Impaired venous return > increased hydrostatic pressure> Stasis hypertension > dermal ulceration
57
Venous signs:
Eschar or slough, wet, yellow fibrous Moderate to heavy exudate Tortuous veins Edematous leg
58
Wound edges in VI:
Shallow wounds | Irregular wound edges
59
Location of VI insufficiency:
Superior to Malleoli, usually medial | Surrounding skin dry and scaly
60
Pulses with VI:
present
61
Pain with VI ulcers:
Pain in dependent position, decreased with elevation, usually minimal dull ache or heaviness
62
What is pain in VI ulcers caused by?
Caused by valvular incompetence, obstruction of deep venous system, or congenital absence or malformation of venous valves Foot warm, ABI >.8
63
Periwound and Structural Changes | Venous ulcer:
Edema Cellulitis, dermatitis Hemosideran deposition Lipodermatosclerosis
64
Temperature in VI:
normal to mild warth
65
Healing time for full-thickness venous ulcers with appropriate interventions
Average eight weeks Smaller ulcers 5–7 weeks Larger ulcers 10–16 weeks
66
VI ulcers with good healing:
``` Small size Decrease in size in first 2–3 wks of treatment No deep vein involvement Adherence with compression ```
67
VI ulcers with poor healing:
``` Large size Increase in size over 4 wks of treatment Concomitant PAD Older age, higher BMI ```
68
Not Predictive of CVI Healing
Gender Race Skin condition Presence of infection
69
Patient/Client-Related Instruction
Educate about etiology Explain link between disease process and interventions for wound healing Inform of risk factors for re-ulceration Identify patient and caregivers’ beliefs about treatment to maximize adherence and outcomes
70
Provide guidelines
``` Control swelling Protect your feet and legs Live healthy Know when to call clinician Inform patients of proper positioning and exercises to enhance venous return ```
71
Request for Further Medical Testing
Patients scoring 3 or more on DVT clinical prediction guidelines Wounds that fail to progress Wound culture and sensitivity if suspect infection Bone scan/X-rays if exposed capsule or bone Wounds that do not present with typical VI ulcer characteristics
72
Keys to Local Wound Care
Protect surrounding skin Address wound bed Enhance venous return Educate patient/caregiver
73
Protect Surrounding Skin
Moisturize dry, scaling skin Use topical steroids to decrease inflammation or weeping Use topical agents prudently to avoid sensitization
74
Intervention Goals
Non adherent dressings to protect delicate skin Gentle debridement- enzymatic or autolytic due to severe tenderness Compression to promote venous return- 4-layer wraps, short stretch wraps, compression stockings Elevation Exercise to promote venous return
75
Effects of Compression
``` enhances calf muscle pump improves venous return decreases peripheral edema reduces venous distention increases tissue oxygenation softens lipdodermtosclerosis protects limb from trauma limits need for prolonged elevation/bed rest ```
76
Compression Parameters
30–40 mm Hg at ankle 10 mm Hg at infrapatellar notch If severe VI, can increase to 40–50 mm Hg If mild AI, can decrease to 20–30 mm Hg
77
Contraindications to Compression
``` ABI < 0.7 Acute infection Pulmonary edema Uncontrolled or severe congestive heart failure Active DVT Claustrophobia (relative) ```
78
Therapeutic Exercise
Range of motion exercise Aerobic exercise Gait and mobility training Focus on Calf pump!!!!
79
Stripping and Ligation of the Great Saphenous Vein
A Saphenectomy strips the vein from the SFJ to the popliteal fossa Stripping into the calf can be complicated by Saphenous nerve injury Skeletonization or ligating and disconnection of each saphenous tributary in the groin contributes
80
Varicose Vein Ligation
In the 70’s-80’s segmental ligation of visible varicosities utilizing multiple incisions was performed but missed affected veins not visible Research shows venous insufficiency must be addressed at its point of highest reflux
81
Microphlebectomy
May be performed alone or in combination with other vein procedures Hooks are used to pick up the vein and bring it through the incision where it is transected Used to remove visible varicose saphenous tributaries or clusters are associated with incompetent perforating veins
82
Endovenous Vein Obliteration
Radiofrequency (RF) or laser thermal energy used to destroy the vein endovascularly Mostly used to treat great and small saphenous veins Preoperative vein mapping with duplex ultrasound to determine location to be treated Need to perform at least 2 cm distal from the SFJ to prevent femoral vein DVT
83
Sclerotherapy
Non-surgical option for ablation Injection of a special chemical (sclerosant) damages and scars the inside lining of the vein causing the vein to close. May cause staining visible through the skin
84
Liton’s Procedure
1950s technique Surgical ligation of subfascial perforators through three long calf incisions Abandoned because of wound complications Later modified using smaller incisions and skin grafts but complications still common
85
Phlebotome Device
Introduced through a small incision just below the knee and is advanced subfascially toward the medial malleolus Disrupts the perforators blindly as it is advanced
86
SEPS | Subfascial Endoscopic Perforator Surgery
Instruments are introduced into the subfascial space through two small incisions Each perforator is identified and clipped Often combined with saphenous vein ablation
87
Valvuloplasty
most frequent procedure used for primary deep reflux Good result in 70% of cases in freedom of ulcer recurrence and the reduction of pain, valve competence and hemodynamic improvement 5 years post External transmural valvuloplasty not as reliable as internal valvuloplasty in providing long-term valve competence or ulcer free-survival

Integumentary (18 decks)

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