Peripheral Venous Disease

Question 1

most common chronic venous diseases include

Answer 1

varicose veins and chronic venous insufficiency

Question 2

what leads to chronic venous disease explain the pathophys?

Answer 2

blood flows backwards’, and leads to dilated veins

due to valve insufficiency/dysfunction in the veins

Question 3

risk factor for chronic vascular disease

Answer 3

family history of venous disease
prolonged standing or sedentary lifestyle
increased age
female sex
obesity
smoking
high estrogen states, pregnancy
hereditary, klippel trenauny syndrome

Question 4

varicose veins

Answer 4

dilated superficial veins greater than (> 3mm) in diameter due to increased venous pressure

Question 5

which vein is most commonly affected with varicose veins

Answer 5

the great saphenous vein is most commonly affected

Question 6

other signs of venous dysfunction

Answer 6

reticular veins, blushed subdermal veins

telangiectasia, spider veins

corona phlebectatica, fan shaped, telangiectasia,

Question 7

patho phys of varicose veins

Answer 7

weak valves, cause back flow into veins

cause veins to become dilated and tortuous, due to increase venous hypertension

Question 8

clinical manifestations of varicose veins

Answer 8

can be symptomatic or asymptomatic

symptoms, develop after standing for long periods and are relieved with rest

long-standing varicose veins lead to chronic venous insufficiency, which lead to skin changes, and can lead to ulcers.

Question 9

complication of varicose veins

Answer 9

superficial venous thrombophlebitis
dvt
bleeding

Question 10

what is chronic venous insufficiency

Answer 10

loss of venous wall tension or valves are dysfunctional in the legs , which allow blood to go backward, and pool. causing venous dilation of wall

Reflux, ➡️stasis➡️hypertension, leads to edema
cause swelling, edema, and stasis dermatitis, pigment changes, and ulcers, over time

Question 11

chronic venous insufficiency causes what signs

Answer 11

skin changes due to chronic edema

skin pigmentation changes- (reddish brownish brawny appearance)

stasis dermatitis (itchy/ dry/ scaling skin)
lipodermatosclerosis (hardening) champagne leg,

complications, include ulcers , typically near medial malleolus

cellulitis common caused by strep or staph

symptoms, pt will have increased pain and cramping while standing, or prolonged sitting. pain relief with walking or with elevation.

Question 12

test of choice for chronic venous disease (varicose veins and for CVI)

If pt has ulcer what other test?

Answer 12

duplex ultrasound,

can do CT or MRI if no duplex ultrasound is available

CBC, microbiology

Question 13

mainstay tx for cvd (varicose and chronic venous insufficiency)

non surgical
1. varicose veins and edema what compression sizing will u want to use?

2. for skin changes and ulcers what mmhm compression sizing will u want to use?

what else would u recommend for patients

Answer 13

need compression

1. c2-c3, 20-30 mmHG
2. c4-c6 if skin changes and ulcer is present need more compression
   30-40

avoiding long periods of sitting and standing

elevate legs throughout the day, and sleep with legs elevated

lifestyle changes
- management of obesity
- avoid smoking
- proper skin care

Question 14

compression bandaging systems such as the Unna boot is used when? and what does the unna boot consist of ?

Answer 14

unna boot is a rolled paste bandage that contain combination of calamine, zinc oxide

changed every 3-7 days

used for treatment of venous ulcers

Question 15

if conservative therapy (use of compression therapy, elevation of legs, reduce smoking) all fail what is your next treatment

Answer 15

surgical, ablation (using a laser), and with conservative measure continued,

Question 16

superficial venous thrombophlebitis is what

Answer 16

clot forms in the superficial veins

increases risk for vet (dvt and a pe)

Question 17

risk for superficial thrombophlebitis includes (UPPER EXTREMITY)

Answer 17

most common cause is a indwelling catheter, (IV)
- short term venous catheter,
- long term PICC line
- iv administration with irritating solution

Question 18

risk for superficial thrombophlebitis LOWER EXTREMITY)

Answer 18

varicose veins

Question 19

virchow triad include

Answer 19

venous stasis, reduced blood flow

injury, surgery,

hypercoag state, ibd, pregnancy, blood clot disorder

Question 20

symptoms of superficial venous thrombophlebitis

septic thrombophlebitis

Answer 20

pain, redness, localized to the site of a superficial vein, often with a palpable cord

palpable cord (firm, thickened vein)

septic thrombophlebitis,
- high fever
- purulent drainage

Question 21

ddx for superficial venous thrombophlembitis

Answer 21

cellulitis
dvt, will have redness and pain,
lymphedema, swelling, no palpable cord seen

Question 22

workup for superficial venous thrombophlebitis

Answer 22

compression duplex ultrasonography

with or without doppler

Question 23

what will duplex ultrasonography show for superficial venous thrombosis?

Answer 23

non-compressible superficial vein

Question 24

treatment for superficial venous thrombophlebitis

Answer 24

initial management is supportive
elevation
warm and hot compress

nsaids, low risk pt

Question 25

when to consider anticoagulation for superficial venous thrombophlebitis

Answer 25

based on length, if >5 cm location, close, to the deep venous system, near saphenopopliteal, or saphenofemoral junction of the leg risk factor for dvt, Virchow triad

Question 26

low risk for VTE (anticoagulation not needed when?)

Answer 26

thrombus length is less than (<5 cm) not near saphenofemoral, or saphenopopliteal junction just phlebitis and no evidence of any thrombus no risk factors for VTE (recent travel, smoking, )

Question 27

intermediate risk for vte with superficial venous thrombosis factors ? what tx will u want to initiate?

Answer 27

thrombus length that is greater than 5 cm in proximity to saphenofemoral or saphenopopliteal junction, 3-5 cm above the knee NO RISK factor for vet prophylaxis, 45 days, Xarelto, arixtra enoxaparin, in pregnant pts

Question 28

elevated risk for vte what factors what treatment

Answer 28

no improvement with prophylactic treatment thrombus within 3 cm from saphenofemoral junction or saphenopopliteal junction medical risk factors for VTE DVT regimen warfarin

Question 29

what is dvt

Answer 29

clot which develops in the deep venous system primarily affects

Question 30

clinical manifestation of dvt

Answer 30

extremity swelling extremity pain increased calf circumference look for signs of pulmonary emboli chest pain, dizziness, tachycardia UNILATERAL

Question 31

wells criteria high risk probability for dvt is greater than __ intermediate probability for dvt is _____ low risk for dvt is __

Answer 31

(>3) 1-2 0 or less

Question 32

wells vs modified wells

Answer 32

modified wells, previously documented dvt

Question 33

modified wells >2 means modified wells <2 means

Answer 33

DVT is likely DVT is unlikely

Question 34

positive d dimer is _____

Answer 34

>500

Question 35

d dimer can be false positive with ______

Answer 35

sepsis, maligannayc , pregnancy

Question 36

initial test if suspect dvt (low wells score )

Answer 36

need to check a d dimer

Question 37

if wells is intermediate (1-2) or high (>3)

Answer 37

d dimer ultrasound

Question 38

if pt has a low pre test probability (low wells score) but has malignancy, sepsis, or pregnancy what to do next?

Answer 38

ultrasound

Question 39

all pt with suspect dvt what is test of choice

Answer 39

duplex ultrasound

Question 40

if negative ultrasound but pretest probability (wells score) is high what to do next

Answer 40

repeat ultrasound in 1 week

Question 41

expectant management indication

Answer 41

isolated dvt, no risk to extend

Question 42

risk for expectant management

Answer 42

elevated d dimer past history of vte close to proximal leg veins

Question 43

what is timeline for expectant management

Answer 43

ultrasound once weekly over 2 week period

Question 44

if during expectant management u note that thrombus extends into proximal veins

Answer 44

initiate anticoagulant

Question 45

anticoagulation therapy is initial, parenteral and then followed by ______

Answer 45

long term oral anticoagulant (3-6 months)

Question 46

parenteral anticoagulation _____ with oral anticoagulant (warfarin)

Answer 46

overlaps

Question 47

dabigatran and edoxoban started _____ in parenteral therapy

Answer 47

after

Question 48

initial parenteral anticoagulant (first 5-10 days)

Answer 48

1. low wt heparin (enoxaparin, SC) 2, fondaparinux (arixtra) SC 3. unfractionated heparin, inpatient (IV Bolus)

Question 49

low molecular wt heparin (enoxaparin) SC preferred medication for DVT in what conditions

Answer 49

in pt with pregnancy. liver disease, active cancer, pt with normal renal function

Question 50

fondaparinux sc is given if a patient has history of

Answer 50

HIT (heparin induced thrombocytopenia)

Question 51

unfractionated heparin is given in what setting? who is it preferred in, what patients?

Answer 51

inpatient, bolus then 18 units, kg, hour pt with renal failure, inadequate SQ , morbidly obese, high risk for a bleed, and hemodynamically unstable

Question 52

direct acting oral anticoagulants are preferred over _____, why?

Answer 52

vitamin k anticoagulant (warfarin) because associated with a lower risk of bleeding

Question 53

direct oral anticoagulant: dabigatran, and edoxaban require ___ days of parenteral anticoagulation first

Answer 53

5-10

Question 54

direct oral anticoagulant, eliquous and Xarelto start ___________

Answer 54

immediently without parenteral anticoagulant

Question 55

vitamin k anticoagulant (warfarin) is a _____ line therapy in non pregnant pt given simultaneously with parenteral anticoagulation

Answer 55

second

Question 56

dvt with cancer tx

Answer 56

initiate low weight molecular heparin, enoxaparin, and edoxaban can do Xarelto and or eliqous, at least 6 months but may be indefinite.

Question 57

pt wishes not to be on anticoagulant what will u do?

Answer 57

educate pt on risk but can recommend aspirin but Is not effective,

Question 58

infinite anticoagulant may be required in what kinds of patients

Answer 58

in a patient with an unprovoked dvt chronic risk factor, active cancer, or thrombophilia)

Question 59

catheter directed thrombolysis is considered in pt with what

Answer 59

massive iliofemoral dvt fail anticoagulation or have contraindication

Question 60

inferior vena cava filter is initiated in a pt with what

Answer 60

pt with recurrent PE, dvt despite adequate coagulation absolute contraindication to anticoagulant therapy, and cannot do thrombectomy

Question 61

A pregnant pt has a confirmed DVT what treatment would u want to do

Answer 61

Enoxaparin

Question 62

If pt has an ulcer what test next will u wanna do?

Answer 62

Ankle brachial test rule out pad