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Vascular > Module 4 : Acute Venous Pathology > Flashcards

Module 4 : Acute Venous Pathology Flashcards

1
Q

venous system characteristics

A
  • low pressure system
  • spontaneous flow
  • demonstrate changes with respiration and augmentation/compression
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2
Q

Deep Venous Thrombosis (DVT)

A
  • occur when there is an alteration of the normal hemodynamics or architecture of the venous system
  • most common reason for a vein exam
    + 50% clinically diagnosed
  • complication
    + pulmonary embolism
    + 80% originate in LE
    + 30% mortality
  • chronic venous problems = valves
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3
Q

Virchows triad

A
  • stasis
  • hyper coagulability
  • intimal injury
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4
Q

venous stasis

A
  • MOST COMMON FACTOR
  • caused by
    + immobility
    + myocardial infarction
    + congestive heart failure
    + chronic obstructive pulmonary disease
    + obesity
    + pregnancy
    + previous DVT
    + surgery
    + paraplegia
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5
Q

hypercoagulability

A
  • clotting ability of blood increased
  • caused by
    + pregnancy
    + cancer
    + estrogen intake
    + genetic blood factors (deficiency in protein C & S anticoagulants)
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6
Q

indications for lower extremity vascular US

A
  • suspicion of DVT
  • suspicion of pulmonary embolism
  • incompetent valves and mass causing symptoms
  • edema/swelling especially unilateral
  • limb pain and tenderness
  • ulceration shallow and round
  • discolouration in gaiter area
  • varicose veins
  • hypercoagulable state
  • pallor
  • cyanosis
  • positive D-dimer test (increase in fibrin strands in blood)
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7
Q

indications for upper extremity venous US

A
  • suspicion of DVT
  • history of catheter lines or drug abuse
  • head or neck swelling/edema
  • limb redness
  • suspected injury after venous puncture (IJV)
  • symptoms of PE
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8
Q

patient history for LE DVT

A
  • acute onset of leg pain
  • acute onset of swelling
  • persistent leg calf swelling
  • redness
  • warm skin
  • symptoms of PE
  • previous DVT
  • clotting issues
  • trauma
  • surgery
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9
Q

symptoms of PE

A
  • shortness of breath SOB
  • chest pain
  • hemoptysis
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10
Q

thrombus formation

A
  • starts in sole sinus and or calf veins a valve cusps
  • predominantly due to stasis
  • formation begins as aggrgations of red cells near valve cusps due to stasis and eddy currents
  • stabilized by fibrin, thrombi become adherent to endothelium and propagation occurs
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11
Q

Acute DVT

A
  • days to 1-2 weeks old
  • dilation of the veins along with lack of compressibility
  • echogenic or isoechoic material
  • total or partial obstruction
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12
Q

disease location

A 
- although any venous site can develop thrombus, common origins include
   \+ gastrocnemius and solar sinus
   \+ valve sites
   \+ venous confluence 
   \+ deep venous system
   \+ superficial venous system
   \+ perforators 
* superficial - deep
  calf veins - proximal
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13
Q

sonographic findings of acute DVT

A
  • enlarged vein with isoechoic or slightly echogenic
  • vein will not coapt
  • may not adhere well to wall and appear to float or wave within the lumen
  • collateralization may occur rapidly
  • retrograde flow
  • incompetent valves reverse flow in response to valsalva or compression proximal to site of valve
  • continuous venous flow with respiratory phasicity is abnormal and suggest proximal disease
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14
Q

sub acute thrombus

A
  • 1 to 2 months old
  • changes show increasing echogenicity and decreasing venous diameter
  • some resumption of flow through recanaliztion and formation of collaterals
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15
Q

chronic thrombus

A
  • chronic thrombotic scarring months to years after the initial event
  • moderate to high echogenicity and may be isoechoic to surrounding tissue and making it difficult to assess the vein
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16
Q

sonographic findings of chronic DVT

A
  • echogenic thrombus
  • vein smaller than artery
  • presence of collaterals
  • recanalization
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17
Q

diagnostic criteria for venous duplex - normal

A
  • complete compression of vein walls with light probe pressure
  • absent intraluminal thrombus
  • color flow fills lumen completely
  • normal venous doppler spontaneity, phasicity and augmentation
  • no venous dilation
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18
Q

diagnostic criteria for venous duplex - abnormal

A
  • lack of complete vein compression
  • intraluminal echoes present
  • decrease or absence of color flow
  • abnormal venous doppler spontaneity phasicity or augmentation
  • dilated or contracted veins noted
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19
Q

thrombosis descriptions and characteristics - acute

A
  • light to medium echogenic or anechoic
  • spongy lecture on compression
  • poorly attaches or free floating
  • dilated vein
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20
Q

thrombosis descriptions and characteristics - chronic

A
  • bright heterogenous echoes
  • irregular texture
  • attached
  • same size as artery or vein is contracted
  • collateral vein may be seen
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21
Q

can veins be partially or completely incompressible in the two acute and chronic

A

yes

22
Q

can DVT be both acute and chronic

A
  • yes

0 acute on top of chronic thrombosis

23
Q

can we determine age of thrombus

A
  • no
24
Q

calf vein DVT

A
  • solar sinus most common site of formation
  • clinical importance is uncertain
  • propagation into pop vein varies widely
  • current treatments
    + surveillance with duplex US to check propagation into larger veins
    + therapeutic anticoagulation for 6 weeks
25
Q

iliac DVT

A
  • difficulty in imagingiliac veins with ultrasound
  • indirect assessment with doppler signal
  • confirmation of diagnosis with venography
  • compare bilateral CFV waveforms to rule out iliac obstruction
26
Q

monophonic CFV flow

A
  • steady continues flow suggest proximal DVT or extrinsic compression
27
Q

axiallosubclavian veins

A
  • use of centra venous catheters is causing increase in DVT of upper extremity
  • patient history of mediastinal lymphoma, previous radiation therapy, trauma or surgery can predispose them to thrombus formation
  • spontaneous thrombosis
28
Q

acute disease facts and perspectives

A
  • originates at cusps of valves
  • disease mechanism
  • superficial venous thrombosis is benign and usually diagnosed clinically
  • deep venous thrombosis is common and potentially fatal
  • 90% of PE originates from lower extremity
  • 60% of patient with DVT for on to have chronic venous insufficiency
  • thrombus anywhere is life threatening
  • calf vein DVT may cause PE but thrombus to little to be lethal
29
Q

acute disease treatment - medical treatment

A
  • anticoagulation = 3-6 months on heparin or warfarin prevents clot propagation does not dissolve thrombus
    + STANDARD TREATMENT
  • thrombolytic agent = injected to dissolve thrombus
  • control risk factors = not lots of rest, compression socks, check hyper coagulability
30
Q

acute disease treatment - surgical treatment

A
  • IVC filter = patients who can’t be anti coagulated
  • venous thrombectomy = patient with impending limb loss if thrombolytic agent does not work
  • bypass grafting = caval occlusion
31
Q

endovascular treatment

A
  • catheter directed thrombolysis ( acute DVT)
  • balloon venoplasty and stenting (chronic iliofemoral DVT)
  • mechanical thrombectomy (acute DVT)
32
Q

venography

A
  • contrast injected into small veins of the foot
  • x ray taken of entire leg to demonstrate any disease that may be present
  • ascending acute disease
  • descending valve disorders
  • complete thrombus seems as lack of filing with contrast in expected location
  • can be painful = chemical phlebitis
  • differentiation between chronic and acute is hard
  • GOLD STANDARD
33
Q

pulmonary angiogram

A
  • radiographic test using contrast to evaluate the lungs for PE
34
Q

VQ scan (ventilation quotient) / lung scan

A
  • nuke med
  • involves inhaling radioactive gs to demonstrate PE
  • indicates perfusion and ventilation of lungs
  • doppler stiff can be negative with positive VQ scan
  • VQ scan reported as high probability normal or non high
35
Q

isotope venographer

A
  • nuke med
  • requires I-125 injection to evaluate peripheral and pulmonary veins
  • not utilized often in case of suspected acute thrombus because takes 24 hours fro isotope to tag thrombus
36
Q

D- dimer assay

A
  • lab test to detect formation of acute thrombus indication probably presence of absence of DVT
  • results are reported as negative (<500 ug/L) or positive (>500ug/l)
  • d-dimer show positive in majority of patients with recent surgery trauma pregnancy and active malignancy
    + not ordered as primary test
37
Q

Wells Score (DVT probability)

A
  • estimate probability of DVT
  • patient suspected of having DVT given a Wells score
  • done by assessing the clinical history and signs the patient has giving each positive finding a point
  • reported as
    + low probability (0)
    + intermediate probability (1-2)
    + high probability (3)
  • low or moderate then a D-Dimer assay next step
  • high then patient goes directly to get ultrasound
38
Q

wells score factors - DVT

A
  • malignancy
  • limb immobalization
  • patient immobilization
  • localized tenderness
  • entire leg swollen
  • calf swelling
  • pitting edema
  • collateral superficial ceils dilated
  • alternative diagnosis more likely than DVt
39
Q

PE probability

A
  • estimate probability of pulmonary embolism patient assessed clinically and each positive criterion given a number value
  • low probability (<2)
  • intermediate (2-6)
  • high (>6)
  • low to moderate wells score = D -Dimer test next step
  • high wells score = VQ scan directly
40
Q

wells score factors - PE

A
  • signs and symptoms of DVT
  • pulse > 100bpm
  • immobilization
  • previous DVt or PE
  • hemoptysis
  • malignancy
  • PE most likely over other diagnosis
41
Q

phlegmasia alba dolens

A
  • white leg
  • decreases venous drainage due to thrombosis of extremity deep veins without collateral drainage
  • extensive edema obscures capillary circulation
  • arterial spasms
  • can progress to phlegmasia cerulea dolens
42
Q

phlegmasia cerulea dolens

A
  • massive venous occlusion due to multisegment thrombosis
  • obstruction of venous outflow reduces arterial inflow causing arterial vasoconstriction
  • venous congestion causes a blue discolouration to skin
  • massive thigh and calf swelling
  • acute onset starting with hypoxia leading to gangrene
  • surgical emergency
43
Q

may-thurner syndrome

A
  • compression of left CIV by right CIA and spine

- increase risk for DVT and can result in left CIV stenosis and left leg swelling

44
Q

Paget-schroetter syndrome (effort thrombosis)

A
  • most common axillosubclavian thrombosis in ambulatory healthy people
  • men more commonly affected
  • caused by anatomical variations of muscle and bone in thoraces inlet
  • occurs when thrombosis of axillary/subclavian vein at thoracic inlet
  • more common in dominant arm
45
Q

thrombophlebitis

A
  • diagnosed clinically - hard cord
  • inflammation with thrombus formation
  • ultrasound used to delineate extent of thrombus particularly at major confluences into the deep system
  • approximately 20% of superficial thrombosis has concurrent DVT
  • treatment is ambulation and compression therapy along with anti inflammatory drug administration
46
Q

congestive heart failure

A
  • bilateral lower extremity edema from increased hydrostatic pressure
  • leg edema and dyspnea
  • increased pulsatility
  • may have (-) d - dimer
  • come to rule out DVT
47
Q

hematomas

A
  • accumulation of blood within tissue
  • due to trauma, anticoagulation, therapy, vigorous exercise
  • hypoechous mass with ill defined borders, contained within muscle tissues
48
Q

abcesss & cellulitis

A
  • result of bacterial infection
  • access = and enclosed collection of pus
  • cellulitis = diffuse collection of fluid within the subcutaneous
  • swelling erthema, pain tenderness resemble signs of DVT
  • confirm that the Venous system is patent
49
Q

bakers cyst

A
  • dilation of bursa communicate with knee joint
  • degenerative joint disease and rheumatoid arthritis
  • as cyst enlarges they extend into muscle planes accusing pain tenderness and swelling
  • usually medial to knee joint
  • usually anechoic but may contain debris and have septation
  • no flow with color doppler
  • ruptures cysts
  • may dissect into calf muscles and intramuscular septums
  • rule out hematoma by demonstrating communication with joint space
50
Q

tumors

A
  • benign or malignant may be encountered with routine US
  • usually solid may have necrosis
  • may resemble other benign pathologies important to demonstrate blood flow in solid portion
51
Q

enlarged lymph nodes (adenopathy)

A
  • can be mistakes for thromboses vein

- may cause limb swelling compression of veins

52
Q

popliteal aneurysm

A
  • considered when patient present with a lump or pain behind knee
  • color flow seen with aneurysm providing it is patent

Vascular (7 decks)

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