describe venous insufficiency
- Inadequate venous drainage of the lower extremities
- CAUSE
–> clot
–> inheriteda bnormality of the veins
–> increased pressure in the venous system
- Superficial = varicose veins
- deep = chronic venous insufficiency
define thrombophlebitis
- broad term
- inflammation of vein with or without presence of a clot
- most commonly involves great saphenous vein
describe risk factors of superficial thrombophlebitis
- coagulation abnormalties
- endothelial dysfunction
- venous therapy (following vein ablation)
- malignancy and hypercoagulable states
describe clinical features of thrombophlebitis
- tenderness, induration, pain and erythema along the course of superficial vein
- palpable cord
- HIGH INDEX OF SUSPICION FOR DVT in patients with risk factors (prior DVT)
**feels like a piece of rope under skin**
describe tx of superficial thrombophlebitis
- aimed at alleviating symptoms of pain, swelling
–> NSAIDs, Warm compress, elevation
- thrombus prevention in the deep veins
- anticoagulation in patients with extensive involvement or high risk patients
define varicose veins
- dilated, elongated, tortuous
- involves superficial veins 3mm or greater in size
- affect 10-30% of population
- seen more in older patients
describe pathophysiology of varicose veins
- inadequate muscle pump
- incompetent valves leading to reflux
- venous obsturciton
**above components lead to increase venous pressure known also as venous hypertension
–> venous hypertension –> vein dilation –> skin changes –> skin ulceration
describe diagnosis/management of varicose veins
- diagnosis
–> correlates with degree of venous reflux
- identified by venous duplex ultrasound as retrograde flow of greater than .5 secs oin duration
- management
–> conservative = elevation, compression, exercise
–> ablation therapy
describe chronic venous insufficiency
- associated with structural and histologic changes
–> cappilary microcirculatory disorder
–> fibrin deposition
–> inflammation
**all of hte above impaire oxygenation of the skin and subcutaneous tissues
–> results in edema, hyperpigmentation, fibrosis and ulcer formation
TX: improve symptoms, reduce edema, healing and prevention of ulcers
describe general treatment of chronic venous insufficiency
- Leg elevation
–> level of heart or above 30 minutes 3-4 times/days
–> helps to impove microcircualtion and reduce edema
- exercise
–> walking or ankle flexion exercise to help with muscle pump
- compression therapy = choice of compression varies from patient to patient
- Skin care = emollients to lubricate dry skin
describe ulcer care
- Debridement = removes devitalized tissue
- Topical agents = enzymatic agents or silver sulfadiazine
- Growth factors = oasis, epiflex
- dressing options = hydrocolloids, absorbent dressings, occlusive dressings
- Skin grafting/skin substitues = dermagraft, apligraf, STSG
describe the divisions of DVT
- Distal = thrombus remains in the deep calf veins
- Proximal = invovles popliteal, femoral or iliac veins (at or above knee)
–> the more proximal, the more common of a pulmonary embolus
describe the risk factors of DVT
- Prolonged immobilization or bed rest
- recent surgery
- obesity
- prior thromboembolism
- lower extremity trauma
- malignancy
- oral contraceptives or hormone replacement therapy
- pregnancy or postpartum
- stoke
Describe the clinical presentation of DVT
- Palpable cord
- calf pain
- unilateral leg edema with increase in calf diameter
- warmth
- tenderness
- erythema
- hohman sign = pain in the calf during dorsiflexion
- wells score criteria
describe wells score criteria
- Risk factors involved
- used along with clinical exam
describe the diagnosis of DVT
- Compression ultrasonography (venous duplex)
–> non-invasive modality of choice
–> positive predictive value of 94%
- D-Dimer
–> negative D-Dimer as stand alone test may not be valid
–> often used in conjunction with wells score (pre-test probability)
- patient wiht low probability wells score and negative D-dimer is UNLIKELY to have DVT are said to NOT need furhter testing
- patient with moderate or high probability Wells score should be sent for ultrasound
TX of DVT
- Anticoagulation therapy - indicated in patient with symptomatic proximal DVT
–> PE is likely to occur in up to 50% of untreated patients
–> initial tx with anticoagulation should be started acutely
–> inferior vena cava filter (in case where anticoagulation is contraindicated or complicated or patient is high risk for PE
