Peripheral Venous & Lymphatic Vessel Disease Flashcards
(51 cards)
1
Q
Dilated, tortuous superficial veins in the legs
Asymptomatic or aching discomfort/pain
Often hereditary
Increased frequency after pregnancy
these are indicative of which dx?
A
Varicose Veins
2
Q
Varicose veins develop in the lower extremities due to ?
A
periods of high venous pressure
3
Q
contributing factors of varicose veins
A
Postpartum women (highest incidence)
Prolonged standing
Heavy lifting
Varicosities develop in over 20% of all adults
4
Q
what is the hallmark of chronic venous disease
A
Combination of progressive venous reflux and venous hypertension
5
Q
venous valve does not close appropriately leading to backward blood flow into lower extremities
A
Venous reflux
6
Q
increased venous pressure as a result of reflux
A
Venous hypertension
7
Q
varicose veins MC affects which vein
A
great saphenous and its tributaries
Short saphenous vein in posterior leg may also be affected
8
Q
Distention of the veins further prevents valve leaflet closure resulting in ?
A
valve incompetence and reflux
Vein segments below the defective valves distend and progressively fail as well
9
Q
secondary varicosities may result from obstructive changes and valve damage in the deep venous system following ?
A
thrombophlebitis
10
Q
causes of secondary varicosities
A
- 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
11
Q
presentation of varicose vein
A
- 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
12
Q
dx eval for varicose veins
A
- 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
13
Q
management for varicose veins
A
- 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 - sclerotherapy
- endovenous laser therapy (EVLA)
- endovenous radiofrequency ablation (EVRFA)
- vein stripping (last resort)
14
Q
what is sclerotherapy
A
- 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
15
Q
what is Endovenous Laser Therapy (EVLA)
A
- Performed with local anesthesia
- The laser heats up the small vein and destroys it
- Could result in heat-induced thrombosis, requiring prolonged anticoagulation
16
Q
which intervention is better for significant varicose veins with signs of venous insufficiency or for long varicosities
A
Endovenous Radiofrequency Ablation (EVRFA)
17
Q
what is vein stripping
A
last resort
Involves removing the part of the vein that is torturous
18
Q
- 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?
A
Chronic Venous Insufficiency
19
Q
A severe manifestation of venous hypertension
A
Chronic Venous Insufficiency
20
Q
causes of Chronic Venous Insufficiency
A
- 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
21
Q
what is a complicating factor for patients with chronic venous insufficiency
A
obesity
22
Q
how does chornic venous insufficiency happen and its result?
A
- Insufficiency → valve leaflets do not close bc they are thickened and scarred (post-thrombotic syndrome) or are functionally inadequate due to vein dilation
- Chronic thrombus/scarring = proximal venous obstruction, worsening the problem
- Venous reflux ensues leading to blood back up in the lower leg/foot
- The leg develops venous HTN and an abnormally high hydrostatic force is transmitted to the subcutaneous veins and tissues of the lower leg
- result = edema
23
Q
pathologic changes of chronic venous insufficiency
A
- Muscle bx: interstitial space changes
- Enlargement and fibrosis - High levels of fibrinogen and fibrin
- Edema and inflammation = local hypoxia and malnutrition - Increase in the number of capillaries in the subcutaneous tissue
- Peri-capillary fibrosis - subcutaneous thickening and induration
- Hemosiderin deposits resulting from erythrocyte lysis
24
Q
clinical manifestations of chronic venous insufficiency
A
- 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
25
leg is described having
Skin induration
Increased pigmentation
Swelling
Redness
“Inverted champagne bottle” or “bowling pin” appearance
what could this be?
Lipodermatosclerosis
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?
Atrophie Blanche
27
Characterized by abnormally dilated veins around the ankle
what is this sign
Corona Phlebectatica
28
dx eval for chornic venous insufficiency
* **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; $$
29
tx for chronic venous insufficiency
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
30
Defined as inflammation of a superficial vein, which typically results in a clot
MC a result of a recent venous catheter placement (IV)
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
31
MC pathogen of SVT
staph
32
SVT typically affects mainly where but can also develop in other sites such as?
* lower extremities - great saphenous vein
* penis, breast
33
presentation of SVT
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
34
complications of SVT
* 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**
35
complications of suppurative phlebitis
Metastatic abscess formation
Septicemia
Septic emboli
36
dx eval for SVT
* **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
37
mangement for SVT
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**
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
Lymphangitis
39
MC pathogen of lymphangitis
MC cutaneous inoculation of **hemolytic streptococci or S. aureus** that invades lymphatic vessels and spread toward regional LN
40
pathogenesis of lymphangitis
* **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
41
painful or painless nodular subcutaneous swellings along the course of the lymphatic channels
Nodular lymphangitis
42
Lymphangitis can occur in the setting of ____ (neoplastic lymphangitis or lymphangitis carcinomatosa)
malignancy
Breast, lung, stomach, pancreas, rectal, and prostate cancers are the most common tumors
43
presentation of lymphangitis
* 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**
44
diagnostic eval/work-up for lymphangitis
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
45
management for lympahngitis
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
46
what is the primary form of lymphedema
congenital hypoplastic or hyperplastic proximal or distal lymphatics
Pelvic or lumbar lymph channel and node obstruction present when the disease is extensive and progressive
47
what is the secondary form of lymphedema
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
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
secondary dilation of the lymphatics
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?
lymphedema
50
how to dx lymphedema
* **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
51
management for lymphedema
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)
