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Cardio Exam 5 > Venous Disease > Flashcards

Venous Disease Flashcards

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1
Q

Venous Diagnostic Assessments

A

a. D-Dimer
b. Venous Ultrasound
c. Venography

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2
Q

Fibrin D-Dimer

A

● Fibrin is formed from fibrinogen during blood
clotting and forms a fibrous mesh
● D-Dimer is a degradation products of
Fibrinolysis (breakdown of fibrin in blood clots)
● Fibrin is formed from fibrinogen during blood
clotting and forms a fibrous mesh.
● Presence of D-Dimer indicates recent or ongoing coagulation and fibrinolysis

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3
Q

Presence of D-Dimer indicates ______

A

recent or ongoing coagulation and fibrinolysis

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4
Q

D-Dimer can be elevated due to any significant clotting activity such as:

A

○ Myocardial Infarction or Stroke
○ Deep vein thrombosis (DVT) or Pulmonary Embolism (PE)
○ Disseminated Intravascular Coagulation (DIC)
○ Severe Infections (like COVID) and Sepsis

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5
Q

In patients with with a low or moderate pre-test probability (PTP) for
thrombosis, a negative D-Dimer ______

A

rules out a VTE and PE

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6
Q

______ does not confirm or diagnose VTE, but raises suspicion and indicates that further testing is required.

A

A positive D-Dimer

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7
Q

Venous Ultrasound

A

● Evaluation of a vein with and without compression can further aid evaluation
○ Loss of vein compressibility is the primary criterion for DVT.
○ Normal veins readily collapse with gentle manual pressure from the US
transducer creating a “wink” (normal wink = not likely a DVT)

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8
Q

Imaging of choice for venous disease.

A

Venous Ultrasound

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9
Q

CT Venography

A

○ CT Angio of the lungs is an important imaging option for suspected PE.
■ Since you are already injecting contrast, imaging the deep veins with CT
immediately after imaging the thorax for a PE can demonstrate the presence or
absence of DVT
○ Considered a highly accurate diagnostic test.
○ Reveals complex anatomy and pathology, such as superficial and femoral vein (which
are not as easily visualized on US).
○ Expensive, radiation exposure, and iodinated contrast is used

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10
Q

MR Venography-

A

○ High accuracy, although less accurate when performed on the calves.
○ Used more often than CT venography in pregnancy, with Gadolinium used as contrast.

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11
Q

______: inflammation of a vein, caused by any insult to the blood vessel wall, impaired venous flow, or coagulation abnormality. Rarely this can be caused by infection in the area

A

Phlebitis

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12
Q

_______: formation of a blood clot associated with phlebitis.

A

Thrombophlebitis

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13
Q

______: Rarely, a clot can form in the deeper
superficial veins without significant inflammation

A

Superficial Vein Thrombosis

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14
Q

Phlebitis

A

Inflammation of the walls of a superficial
vein, with NO associated thrombus

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15
Q

Thrombophlebitis

A

Inflammation of the walls of a superficial
vein, WITH an associated thrombus

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16
Q

Phlebitis / Thrombophlebitis of the LE

A

● Phlebitis and thrombosis of the lower
extremity superficial veins can be very
painful, but are generally benign and
self-limited
● If axial veins are involved (eg saphenous
veins), a thrombus can pass into the
deep vein system and cause a DVT or
even pulmonary embolism

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17
Q

Phlebitis / Thrombophlebitis of the UE

A

● Phlebitis and thrombosis involving
upper extremity veins most often occur
due to venous catheter use.
● These are also usually self limiting, but
can also lead to DVT or PE.

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18
Q

Risk Factors/Etiology for Phlebitis / Thrombophlebitis

A

● Generally related to conditions that increase the risk of clotting, including
decreased blood flow, increased venous pooling, and hypercoagulable states.
○ Varicose veins: A factor in up to 90% of LE thrombophlebitis
○ Venous Catheterization: Most common cause of UE thrombophlebitis.
Due to the combination of endothelial injury and venous stasis

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19
Q

Local risk factors of Phlebitis / Thrombophlebitis

A

○ Post vein excision/ablation
○ Trauma
○ Occult DVT
○ IV Drug use

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20
Q

Systemic risk factors of Phlebitis / Thrombophlebitis

A

○ Systemic hypercoagulability
○ Pregnancy or estrogen therapy
○ Buerger disease
○ Malignancy (ex, Trousseau
syndrome)
○ Immobilization (post-op, trauma)

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21
Q

Signs and Symptoms of Phlebitis / Thrombophlebitis

A

● Typical findings along the course of the vein include:
○ Induration
○ Erythema
○ Tenderness
○ Dull pain
● Often, a palpable, sometimes nodular cord, can be felt within the affected
vein due to thrombus
● Low-grade fever may be present in uncomplicated disease
● Significant swelling of the extremity is generally not seen.

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22
Q

Suppurative Thrombophlebitis

A
  • Infection within or originating from the vein
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23
Q

Symptoms of Suppurative Thrombophlebitis

Study These Flashcards
A

● Symptoms include high fever, chills, fluctuance, and/or purulent drainage
● Suspect when erythema extends significantly beyond the margin of the vein.
● Generally only occurs after venous cannulation
(ie, venipuncture or catheterization).
● Can lead to septic phlebitis
● S. aureus is the most common pathogen.

24
Q

Difference between Phlebitis / Thrombophlebitis and cellulitis?

Study These Flashcards
A

○ Cellulitis is usually circular or circumferential
○ Cellulitis generally extends into the deeper tissue

Remember, thrombophlebitis
follows the course of a
superficial vein.

25
Phlebitis / Thrombophlebitis Diagnosis
● Diagnosis is usually clinically apparent based upon symptoms and physical exam, especially in patients with known risk factors. Further workup is based on multiple factors: ● Dx test of choice: Duplex US of the deep and superficial axial veins ● CT venography- ○ Only used if ultrasound is equivocal
26
Patients with spontaneous thrombophlebitis WITHOUT a previous IV catheter or other precipitating cause/risk factors (like blunt trauma) should be considered for ______
evaluation for a hypercoagulable state.
27
Treatment of Uncomplicated Phlebitis / Thrombophlebitis
● Extremity elevation (ie, waist level) ● Local heat (warm compresses) ● NSAIDs ● Compression therapy as tolerated ● Anticoagulation is suggested for patients at increased risk for DVT ● Surgery - Only in severe cases to prevent propagation. Includes ligation of the vein or vein excision
28
Treatment of Septic Thrombophlebitis
● Antibiotic Therapy: Often IV vancomycin +/- ceftriaxone (rocephin). Obtain culture and susceptibility data. ● Anticoagulation: Heparin often used, especially if persistent manifestations of infection or significant thrombus. ● Remove offending catheter (if present). ● If persistent, may warrant incision and drainage or excision of the affected vein
29
Varicose Veins
➔ Dilated, tortuous, superficial veins of the lower extremity. ➔ May be asymptomatic or associated with aching and heaviness. ➔ Often hereditary. ➔ ↑↑ frequency after pregnancy
30
Varicose veins are surface evidence of _____
reversed venous flow
31
Pathophysiology of Varicose veins
● In healthy veins, one-way valves usually direct the flow of venous blood upward and inward. ● Exposure to high pressures causes superficial veins to become dilated and tortuous.
32
Risk factors are situations that ↑↑↑ venous pressure
○ Prolonged standing ○ Heavy lifting ○ Pregnancy
33
Signs and Symptoms of Varicose Veins
● Patient can be asymptomatic or symptomatic: ○ Dull, aching heaviness in the affected limb ○ Leg fatigue triggered by time on feet ○ Thrombophlebitis of the affected vein ○ Burning sensation ○ Restlessness ○ Night cramping ○ Paresthesias ○ Skin changes
34
Diagnostic Testing of varicose veins
● Dx test of choice: Duplex ultrasound ● In most cases, reflux will arise from the greater saphenous vein.
35
The risk of DVT or embolization with varicose veins is _____
extremely low
36
Treatment of Varicose Veins
● Compression stockings are considered first line Tx ● Sclerotherapy is an option if not responding to compression stockings ● Surgical procedures can remove or ablate the vein. ○ Endovenous thermal ablation (with either radiofrequency or laser) ○ Open surgical resection (not common)
37
Sclerotherapy
○ Direct injection of a sclerosing agent induces permanent fibrosis and obliteration of the target veins ○ Expensive, often considered cosmetic and not covered by insurance
38
Deep Venous Thrombosis
form in the deep veins of the extremities (most often in the legs). ● Remember Virchow’s Triad: ○ Venous Stasis ○ Vessel Wall Injury ○ Hypercoagulability
39
Risk Factors for DVT
○ Acquired factors Age Male Sex Pregnancy Immobilization Estrogens ○ Inherited factors Factor V leiden Antithrombin deficiency Protein S or C deficiencies
40
Epidemiology of a DVT
● Annual occurrence is much higher in hospitalized population, occurring in about 960 people per 10,000. ● 52% of hospitalized patients are at high risk for VTE.
41
Characteristic Signs and Symptoms of DVT
○ Unilateral leg pain ○ Unilateral calf tenderness ○ Unilateral leg/ankle swelling ● Iliofemoral DVT can present with buttock or groin pain with thigh swelling. ● Upper extremity DVTs are usually secondary to PICC line with subclavian thrombosis. ○ Presents with unilateral arm swelling
42
Diagnostic Testing for DVT
● Use of a Clinical Prediction Tool is suggested (Wells Score System for DVT) ○ If low probability based on Prediction Tool: ■ Order High-Sensitivity D-Dimer (blood test) ● Negative D-Dimer rules out DVT ○ If moderate probability of DVT: ■ High-Sensitivity D-Dimer or Compression Ultrasound ○ If high probability of DVT: ■ Compression Ultrasound is diagnostic test of choice
43
______ is the diagnostic test of choice in patients with suspected DVT
Compression Ultrasonography (CUS) with Doppler
44
Treatment and Management of a DVT
○ Prevention in high-risk patients is critical! ■ Frequent ambulation is the most beneficial ○ Anticoagulation therapy for post-surgical prevention ○ Appropriate duration of treatment thereafter ● In most patients, anticoagulation should be started immediately ● If there is a high degree of concern for a PE, an Inferior Vena Cava (IVC) Filter can be placed endovascularly.
45
Inpatient treatment recommended for a DVT if:
● “Massive DVT” ● Symptomatic for Pulmonary Embolism ● High risk of bleeding with anticoagulation ● Significant comorbid conditions (uncontrolled DM or HTN, etc
46
Maintenance tx for a DVT
Oral anticoagulants are preferred for maintenance treatment. ○ DOACs - Rivaroxaban (Xarelto), Apixaban (Eliquis), Dabigatran (Pradaxa), and Edoxaban (Savaysa), are good options. ○ Low molecular weight heparin (LMWH) such as enoxaparin (Lovenox), or subcutaneous Fondaparinux (Arixtra) are options, but PO meds are preferred. ○ Warfarin was historically the 1st choice (target INR of 2-3), although the DOAC drugs are now preferred
47
How long should patients be on anticoagulation for a DVT in most cases?
3 months
48
Chronic Venous Insufficiency (CVI)
● A Severe manifestation of venous HTN History of prior DVT or leg injury is common
49
Etiologies of Venous Insufficiency
○ Progressive superficial venous reflux ○ Prior DVT (75%) ○ Obesity ○ Trauma
50
Pathophysiology of Venous Insufficiency
● Non functional valve leaflets due to: ○ Thickening or scarring ○ Dilated veins
51
Signs and Symptoms of Venous Insufficiency
● Pitting edema of lower legs ● Stasis dermatitis ● Superficial varicosities, or varicose veins ● Skin breakdown ○ Ulceration
52
Cellulitis can be difficult to differentiate from venous insufficiency, how are they different?
blanching erythema with pain is indicative of cellulitis. ● Bilateral pretibial edema and erythema consistent with stasis dermatitis (sometimes mimicking cellulitis) in CVI
53
Conditions associated with chronic ulcers:
○ Neuropathic ulcers usually from diabetes mellitus ○ Arterial insufficiency (often very painful with absent pulses) ○ Sickle Cell Crisis
54
Treatment of Venous Insufficiency
● Prevention of Complications is important ○ Early, aggressive treatment of DVT ● Compression stockings (20–30 mm Hg pressure or higher) throughout the day. ● Elevate legs. ● Avoid long periods of sitting or standing ● Ulcer treatment - Refer to wound care. ○ Edema MUST be controlled
55

Cardio Exam 5 (3 decks)

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