Peripheral Venous & Lymphatic Vessel Disease

Question 1

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

these are indicative of which dx?

Answer 1

Varicose Veins

Question 2

Varicose veins develop in the lower extremities due to ?

Answer 2

periods of high venous pressure

Question 3

contributing factors of varicose veins

Answer 3

Postpartum women (highest incidence)
Prolonged standing
Heavy lifting

Varicosities develop in over 20% of all adults

Question 4

what is the hallmark of chronic venous disease

Answer 4

Combination of progressive venous reflux and venous hypertension

Question 5

venous valve does not close appropriately leading to backward blood flow into lower extremities

Answer 5

Venous reflux

Question 6

increased venous pressure as a result of reflux

Answer 6

Venous hypertension

Question 7

varicose veins MC affects which vein

Answer 7

great saphenous and its tributaries
Short saphenous vein in posterior leg may also be affected

Question 8

Distention of the veins further prevents valve leaflet closure resulting in ?

Answer 8

valve incompetence and reflux

Vein segments below the defective valves distend and progressively fail as well

Question 9

secondary varicosities may result from obstructive changes and valve damage in the deep venous system following ?

Answer 9

thrombophlebitis

Question 10

causes of secondary varicosities

Answer 10

• Rarely a result of proximal venous occlusion due to neoplasm or fibrosis
• congenital or acquired arteriovenous fistulas or venous malformations, especially if present in young patients

Question 11

presentation of varicose vein

Answer 11

• Dull, aching heaviness or a feeling of fatigue of the legs following periods of standing is MC complaint
• Itching from venous eczema may occur either above the ankle or directly overlying large varicosities
• severity not correlated with the number and size of the varicosities - may have no pain but numerous varicosities
• Dilated, tortuous veins of the thigh and calf are visible and palpable - esp when standing
• Long standing varicose veins may progress to chronic venous insufficiency - ankle edema, brownish skin hyperpigmentation, and chronic skin induration or fibrosis

Question 12

dx eval for varicose veins

Answer 12

• No diagnostic testing needed for the diagnosis of varicose veins
• If there is a suspected obstruction, imaging warranted
• If surgical intervention is planned, imaging is a necessary aid - Duplex ultrasonography is the test of choice for planning therapy

Question 13

management for varicose veins

Answer 13

1. nonsurgical - compression stockings (20-30 mmHg pressure), leg elevation (PM)
   - Effective for sx management
   - Should be worn during waking hours
   - Helpful for elderly or wishing to avoid surgery
2. sclerotherapy
3. endovenous laser therapy (EVLA)
4. endovenous radiofrequency ablation (EVRFA)
5. vein stripping (last resort)

Question 14

what is sclerotherapy

Answer 14

• Direct injection of a sclerosing agent → permanent fibrosis and obliteration of the target veins
• Recurrence rate >50% if underlying reflux is not managed
• Complications: phlebitis, tissue necrosis, or infection may occur

Question 15

what is Endovenous Laser Therapy (EVLA)

Answer 15

• Performed with local anesthesia
• The laser heats up the small vein and destroys it
• Could result in heat-induced thrombosis, requiring prolonged anticoagulation

Question 16

which intervention is better for significant varicose veins with signs of venous insufficiency or for long varicosities

Answer 16

Endovenous Radiofrequency Ablation (EVRFA)

Question 17

what is vein stripping

Answer 17

last resort
Involves removing the part of the vein that is torturous

Question 18

• History of prior DVT or leg injury
• Edema, (brawny) skin hyperpigmentation, subcutaneous lipodermatosclerosis in the lower leg
• Venous ulcers characterized by ulcerations at or above the medial ankle

what is this dx?

Answer 18

Chronic Venous Insufficiency

Question 19

A severe manifestation of venous hypertension

Answer 19

Chronic Venous Insufficiency

Question 20

causes of Chronic Venous Insufficiency

Answer 20

• Prior deep venous thrombophlebitis (MC)
• Progressive superficial venous reflux
• History of leg trauma or surgery
• Other: congenital or neoplastic obstruction of the pelvic veins or a congenital or acquired arteriovenous fistula

Question 21

what is a complicating factor for patients with chronic venous insufficiency

Answer 21

obesity

Question 22

how does chornic venous insufficiency happen and its result?

Answer 22

1. Insufficiency → valve leaflets do not close bc they are thickened and scarred (post-thrombotic syndrome) or are functionally inadequate due to vein dilation
2. Chronic thrombus/scarring = proximal venous obstruction, worsening the problem
3. Venous reflux ensues leading to blood back up in the lower leg/foot
4. The leg develops venous HTN and an abnormally high hydrostatic force is transmitted to the subcutaneous veins and tissues of the lower leg
5. result = edema

Question 23

pathologic changes of chronic venous insufficiency

Answer 23

1. Muscle bx: interstitial space changes
   - Enlargement and fibrosis - High levels of fibrinogen and fibrin
   - Edema and inflammation = local hypoxia and malnutrition
2. Increase in the number of capillaries in the subcutaneous tissue
3. Peri-capillary fibrosis - subcutaneous thickening and induration
4. Hemosiderin deposits resulting from erythrocyte lysis

Question 24

clinical manifestations of chronic venous insufficiency

Answer 24

• Primary sx: progressive pitting edema of the lower leg
• Secondary changes in the skin and subcutaneous tissues develop over time - Stasis dermatitis
• Other common sx: itching, a dull discomfort made worse by periods of standing, and pain if an ulceration is present
• Secondary lymphedema - Progressive sclerosis of lymph channels
• Taut, shiny skin at ankle - edema
• hemosiderin staining
• loss of skin integrity with ulceration - secondary cellulitis - dx by blanching erythema with pain
• fixation of the ankle joint secondary to tissue fibrosis
• Lipodermatosclerosis (panniculitis)
• Atrophie Blanche
• Corona Phlebectatica
• Venous Ulcers

Question 25

leg is described having Skin induration Increased pigmentation Swelling Redness “Inverted champagne bottle” or “bowling pin” appearance what could this be?

Answer 25

Lipodermatosclerosis

Question 26

Star-shaped or polyangular, ivory-white depressed atrophic plaques Prominent red dots within the scar due to enlarged capillary blood vessels Surrounding hyperpigmentation what is this sign?

Answer 26

Atrophie Blanche

Question 27

Characterized by abnormally dilated veins around the ankle what is this sign

Answer 27

Corona Phlebectatica

Question 28

dx eval for chornic venous insufficiency

Answer 28

* **No diagnostic testing needed** for dx * If suspected obstruction = imaging * If surgery planned, imaging is a necessary - **Duplex US** * Multidetector computed tomographic (MDCT) **venography** and magnetic resonance (MR) venography could be considered - Used if doppler US nondiagnostic; Requires injection of IV dye; $$

Question 29

tx for chronic venous insufficiency

Answer 29

1. _1st line_ - Fitted, graduated **compression stockings** (20–30 mm Hg pressure or higher) from foot to just below knee during AM and PM 2. Patient education - Avoidance of long periods of sitting or standing - Intermittent elevations of the involved leg - Sleeping with the legs elevated 3. pneumatic compression for refractory cases 4. Unna Boot - Provides both compression and topical therapy; 3 layer dressing, changed weekly 5. vein tx - significant saphenous reflux - ablation - ulcers - monitored by wound care team

Question 30

Defined as inflammation of a superficial vein, which typically results in a clot MC a result of a recent venous catheter placement (IV)

Answer 30

Superficial Venous Thrombophlebitis * IV sites should be evaluated daily for signs and should be removed if present * May lead to thrombotic or septic complications if ignored * Other causes: Varicose veins, Spontaneous in pregnant or postpartum women, Trauma, Hypercoagulable states

Question 31

MC pathogen of SVT

Answer 31

staph

Question 32

SVT typically affects mainly where but can also develop in other sites such as?

Answer 32

* lower extremities - great saphenous vein * penis, breast

Question 33

presentation of SVT

Answer 33

1. Localized redness, induration, and tenderness **along a superficial vein** 1. pain, fever, and chills 1. If spontaneous, MC involves great saphenous vein 1. A **palpable cord** may be present for several weeks, even after initial inflammatory reaction is past

Question 34

complications of SVT

Answer 34

* Extension into the deep venous system * Hyperpigmentation over the affected vein * Persistent, firm nodule in subcutaneous tissues at the site of the affected vein * **suppurative thrombophlebitis**

Question 35

complications of suppurative phlebitis

Answer 35

Metastatic abscess formation Septicemia Septic emboli

Question 36

dx eval for SVT

Answer 36

* **clinical dx** requiring no testing - hypercoagulable state testing if spontaneous thrombophlebitis * **elevated WBC** - * _Venous doppler US_ - *_only_* if involves proximal LE or if pt has mixed picture

Question 37

mangement for SVT

Answer 37

1. _Mild, localized_: **mild analgesics (ASA/NSAIDs) + elastic support** - Patients are encouraged to continue their usual daily activities 2. _More severe, larger:_ **elevate extremity + hot, wet compresses** - _>5 cm_: **prophylactic Fondaparinux/LMWH/ Rivaroxaban x 45 d** - Rapidly progressing or extension into deep system → full dose anticoagulation 3. _cannula/catheter:_ **device removed and cx** 4. _septic state:_ **Vanc + Ceftriaxone + Heparin/Fondaparinux**

Question 38

Red streaking from wound or cellulitis towards regional lymph nodes, which are typically enlarged and tender; Inflammation of the lymphatic channels Chills, fever, malaise may be present

Answer 38

Lymphangitis

Question 39

MC pathogen of lymphangitis

Answer 39

MC cutaneous inoculation of **hemolytic streptococci or S. aureus** that invades lymphatic vessels and spread toward regional LN

Question 40

pathogenesis of lymphangitis

Answer 40

* **Pseudomonas** species * **strep pneumo** → uncommon * **Pasteurella multocida** → dog and cat bites * **G- rods, G- bacilli, and fungi** → cellulitis and resultant lymphangitis in immunocompromised * **Aeromonas hydrophila** → can contaminate wounds that occur in freshwater * **Wuchereria bancrofti** → filarial nematode; **major cause of acute lymphangitis WW**; leads to a **chronic Filariasis** resulting in subsequent lymphedema with thickening of skin and subcutaneous tissue

Question 41

painful or painless nodular subcutaneous swellings along the course of the lymphatic channels

Answer 41

Nodular lymphangitis

Question 42

Lymphangitis can occur in the setting of ____ (neoplastic lymphangitis or lymphangitis carcinomatosa)

Answer 42

malignancy Breast, lung, stomach, pancreas, rectal, and prostate cancers are the most common tumors

Question 43

presentation of lymphangitis

Answer 43

* Hx **abrasion or trauma** _distal_ to site of infection * F, chills, myalgias, and malaise, esp children * N, anorexia, and HA may also be present * erythematous and **irregular linear streaks** - tender and warm, extending from the primary infection site **toward draining regional nodes,** Primary site may be an abscess, an infected wound, or an area of cellulitis * **Swollen and tender LN** * **Febrile and tachycardic**

Question 44

diagnostic eval/work-up for lymphangitis

Answer 44

1. **_CBC w/ diff and blood cx_** 2. **Wound culture, abscess I&D** if possible 3. _Consult infectious disease_ to assist in the diagnostic workup 4. _Imaging - define anatomic abnormalities_ (rarely useful for dx of infectious etiologies) - **Lymphangiography & lymphoscintigraphy** have been used to evaluate for lymphedema and/or lymphatic obstruction

Question 45

management for lympahngitis

Answer 45

1. **abx covering for GABHS** - Dicloxacillin, Cephalexin, Cefazolin, Cefuroxime, Ceftriaxone, Clindamycin, Nafcillin, Trimethoprim and sulfamethoxazole (TMP/SMZ) are all good options 2. _Oral outpatient therapy_ - for nontoxic, are afebrile, and not immunocompromised - Otherwise, consider inpatient parenteral therapy 3. **Analgesics and/or anti-inflammatories** for pain 4. **Hot, moist compresses** 5. **Elevate & immobilize** affected areas to reduce swelling, pain, and the spread of infection if possible 6. _abscess_ - surgical drainage 7. _Nodular lymphangitis_ - surgical intervention

Question 46

what is the primary form of lymphedema

Answer 46

congenital hypoplastic or hyperplastic proximal or distal lymphatics Pelvic or lumbar lymph channel and node obstruction present when the disease is extensive and progressive

Question 47

what is the secondary form of lymphedema

Answer 47

involves **inflammatory or mechanical lymphatic obstruction** from trauma, regional lymph node resection/irradiation, or malignant disease or filariasis May occur following surgical removal of the lymph nodes in the groin or axilla

Question 48

this result can occur in both forms of lymphedema, which leads to incompetence of valve system, poor lymphatic fluid flow, and results in progressive stasis of a protein-rich fluid Can result in episodes of acute and chronic inflammation, worsening the edema

Answer 48

secondary dilation of the lymphatics

Question 49

* Painless **limb hypertrophy** - Markedly thickened and fibrotic skin and subcutaneous tissue * Pt typically _w/o ulceration, varicosities, or stasis pigmentation_ what is this dx?

Answer 49

lymphedema

Question 50

how to dx lymphedema

Answer 50

* **clinical** dx * MRI - identify lymphatics and proximal obstructing masses * Lymphangiography and radioactive isotope - identify focal defects in lymph flow but are of little value in planning therapy

Question 51

management for lymphedema

Answer 51

1. **_No cure for lymphedema_** 1. Control lymphedema and allow nml function 1. Common treatment strategies - **Edema control** - leg elevation, esp while sleeping (foot of bed elevated 15–20 degrees), Constant use of graduated elastic compression stockings, Massage toward the trunk (either by hand or with pneumatic pressure devices designed) - Referral to **wound care centers** - Stress **good hygiene** and tx of secondary infection - Intermittent use of _diuretics is rarely helpful_ - lymphangiosarcoma - Amputation (rare)