Venous & Lymphatic Flashcards
1
Q
What is the definition of varicose veins?
A
Subcutaneous veins that dilate >= 3 mm when upright
2
Q
What pressure compression stockings should you prescribe for venous ulcers?
A
30-40mm Hg (ESCHAR trial)
3
Q
Which artery runs between the GSV and deep femoral vein?
A
External pudental artery
4
Q
What was the main conclusion of the ESCHAR trial?
A
Surgical group had same rate of healing as medical group but lower venous ulcer recurrence
5
Q
What is the recurrence rate of SSV reflux after surgery?
A
Up to 60%
6
Q
When is ligation and stripping indicated over EVLT?
A
Chronic thrombophlebitis w synechia, too superficial/extrafascial vein, acute superificial venous thrombosis, very tortuous, aneurysmal > 2.5 cm GSV
7
Q
What are 5 indications for varicose vein surgery/intervention?
A
Symptomatic, reflux > 1 s + varicosity > 4mm, venous ulcer, significant hemorrhage, lipadermotasclerosis, failure of 6 month trial of compression
8
Q
What is the caprini score?
A
Risk factor calculations for VTE - most widely used in US 2005
9
Q
Name 10 risk factors for VTE?
A
1 - Older age (rare in children)
2 - Trauma
3 - Malignancy (20% of first time VTE)
4 - Immobility
5 - Surgery
6 - Travel (unclear actual risk - WHO)
7 - Previous hx of VTE (25% of acute DVT has previous hx)
8 - A Blood group
9 - Compression (May thurner/popliteal entrapment)
10 - SLE
10
Q
What types of malignancies have the highest rates of VTE?
A
pancreatic - then kidney, ovary, lung, stomach
11
Q
How do cancer cells initiate thrombus formation (3)
A
1 - via tissue factor - not normal present in resting endothelium but is activated by tumour cells. This binds factors 7 and 7a which activates 10 and 11 and eventually thrombin.
2- cancer procoagulant - direct X activator
3 - cytokines (e.g. VEGF, TNF alpha, IL-1) activate tissue factor
12
Q
What are the most common coag abnormalities in patients with malignancy?
A
increased fibrinogen and thrombocytosis
13
Q
Name 5 ways in which chemotherapy can increase risk of VTE
A
1 - use of central venous catheters
2 - tumour cell lysis
3 - direct endothelial injury
4 - induces hypercoagulable state
5 - reduced fibrinolytic activity
14
Q
What type of surgical procedures are at highest risk of DVT?
A
ortho - hip/knee surgery up to 50% vs gen surg 20%
15
Q
Where do pregnant women typically develop VTE?
A
Left leg (97%!) - uterine compression
16
Q
Which coag factors are increased when pregnant women are in a transient hypercoag state?
A
2, 7, 8, 10, vWF, fibrinogen
17
Q
What risk factors make women prone to getting DVT during pregnancy?
A
advanced age, thrombophiia history, suppression of lactation, assisted delivery
18
Q
How does estrogen cause DVT e.g. OCP?
A
increases blood viscosity, fibrinogen, platelet activation and adherence, factors 7 and 10
19
Q
Which blood type is higher risk of VTE?
A
A highest risk, O lowest
20
Q
Does varicose veins increase risk of DVT?
A
Yes - depending on age. Young are at higher risk, old no difference. Varicose veins may be markers of previous DVT
21
Q
What is May Thurner syndrome?
A
Left iliac vein compression by right iliac artery leading to venous outflow obstruction/venous hypertension
22
Q
What is the recurrence rate of vte at 2, 5 and 10 years?
A
15%, 25%, 30%
23
Q
What is the rate of post thrombotic syndrome after acute proximal DVT?
A
~50% within 2 years with CDT or anticoagulation (ATTRACT)
24
Q
What did ESCHAR trial show?
A
No difference in ulcer healing with GSV stripping vs. compression stockings. Lower recurrence with stripping.
25
What percentage of leg thrombi resolve spontaneously? What percentage extend more proximally?
50%, 20%
26
When would you expect a DVT to recanalize?
Greatest changes first 3 months - 50% thrombus burden reduction
27
What are risk factors for developing post thrombotic syndrome?
Ipsilateral recurrent DVT is most important risk factor Also multisegment disease, proximal disease - iliac involvement, popliteal vein involvement
28
What are 5 symptoms on the Villalta score?
1- Pain
2 - heavyness
3- pruritis
4-cramps
5-paresthesias
29
What are the 7 clinical signs on the villalta score?
1-pretibial edema,
2 - skin induration
3 - venous ulcer present
4 - pain on calf compression
5 - redness
6 - venous ectasia
7 - Hyperpigmentation
30
What is the theoretical benefit of thrombolysis vs anticoagulation for acute DVT?
successful thrombolysis preserves endothelial function and valve competence in animal studies. worst post thrombotic syndrome results from obstruction and valve reflux.
31
What is the difference between primary and secondary upper arm DVT?
Primary - idiopathic or effort thrombosis e.g. Paget Schrotter
Secondary - cancer or indwelling catheter
32
What is the RIETE registry?
Largest prospective registry of all patients with DVT (upper and lower)
33
What is phlegmasia?
Consequence of severe DVT with venous outflow obstruction to the point of limb ischemia +/- limb loss
34
What is phlegmasia alba vs. cerulean? What's worse?
Alba = milk leg - swollen white
Cerulean = cyanotic, worse than alba
35
How do catheter related DVTs present? Common presentations and rare?
1 - asymptomatic, on imaging
2 - common: red, pain, swelling of neck/chest/arm
3 - rare: tremendous engorgement of chest wall veins, phlegmasia
36
What percentage of patients with upper extremity DVT go on to have a PE?
5-20%
37
What type of patients are at higher risk of getting a PE after upper extremity DVT?
Cancer patients
38
Should you anticoagulate all patients with central venous catheters?
Even though at higher risk of DVT, no support for anticoagulation
39
What are 3 catheter-related risk factors (not patient related) for developing a DVT with indwelling catheter?
1 - duration of use
2 - multiple punctures required
3 - large diameter catheter
40
What are 4 patient related (not catheter related) risk factors for developing a DVT from indwelling catheter?
1 - infection
2-malignancy
3-inherited thrombotic disorder
4-previous DVT
41
What central line catheter tip position is recommended to reduce the risk of subsequent DVT?
Junction of right atrium and SVC (French guidelines)
42
What percentage of PICCs result in DVT?
3%
43
What central line access has highest risk of DVT? (IJ, subclavian, femoral)
Femoral. IJ=Subclavian equivalent thrombotic risk.
44
What do chest guidelines recommend with respect to catheter related upper extremity DVT?
3-6 months of anticoagulation and removal of the catheter
45
Which patients with upper extremity DVT may benefit from thrombectomy/thrombolysis (6 patient characteristics)?
Chest 2016 guidelines:
1- phlegmasia
2- severe symptoms,
3- thrombus in axillary or subclavian,
4- good functional status,
5- low risk of bleeding,
6 -life expectancy \> 1 year
46
How many valves does the GSV have?
7-10
47
What percentage of patients have a duplicate GSV
15% (anterior accessory GSV most common)
48
What is a major tributairy to the small saphenous vein?
intersaphenous vein
49
What are 2 differences between telengectasias and reticular veins?
1) size - reticular 1-3mm, telengectasia 0.1-1mm
2) appearance - telengectasia are red or blue depending on origin, reticular veins involve lateral aspect of the leg (lateral subdermic venous system)
50
What CEAP class?
C0
51
What CEAP class?
C1 - telengectasias or reticular veins
52
What CEAP class?
C2 varicose veins \> 3mm
53
What CEAP class?
C3 edema
54
What CEAP class?
C4a - pigmentation or eczema
55
What CEAP class?
C4 lipadodermatosclerosis
56
What CEAP class?
C5 healed venous ulcer
57
What CEAP class?
C6 active venous ulcer
58
What do the SVS and American Venous Forum recommend for treating chronic venous disease?
EVLT or RFA - similar efficacy, better than surgery in terms of recovery, morbidity and pain. Also better than foam sclerotherapy in terms of efficacy
59
How should you treat telengectasia and reticular veins?
Liquid or foam sclerotherapy
60
Which endovenous treatment involves destroying the endothelium, contraction of vein and collagen/thrombus formation?
RFA
61
What are 5 contraindications to RFA of veins?
1-SVT
2- DVT
3- ABI \< 0.9
4 - venous aneurysm
5- pacemaker (not a strict contraindication)
62
Where should you park your RFA catheter?
2.5 cm distal to SFJ to avoid endothermal heat induced thrombosis or extension of thrombus to CFV.
63
What is tumescent anesthesia composed of?
50 mL lidocaine w epi, 450 mL saline, 10 mL or sodium bicarb
64
Why is tumsecenet anesthesia used for endovenous procedures? (2)
1 - pain relief
2 - buffer around the vein to protect the surrounding tissue
65
How much tumescent anesthesia can be used safely?
35 mg/kg
66
What are your 3 post-op instructions for the patient after RFA endovenous treatment?
1 - Wear compression stocking 30-40 mm Hg for 1 week
2 - Come back in 72 h for a duplex ultrasound to confirm no CFV thrombus extension
3 - ambulate to help seal the vein
67
What are 9 potential complications of endovenous treatment with RFA?
1-vessel perf
2 - thrombosis
3 - PE
4 - phlebitis
5- thrombus of CFV
6 - infection
7 - nerve injury
8 - skin discolouration
9 - skin burns
68
What wavelength range are available for EVLT?
810 to 1470 nm
69
What are the potential benefits of a high wavelength EVLT laser?
Less pain and bruising
70
What are the potential benefits of a jacket tibbed fiber compared with bare tipped fiber for EVLT?
less pain and bruising
71
What energy of EVLT are typically used?
50-80 J/cm
72
What are the advantages of higher energy LEED (linear endovenous energy density)? Disadvantages?
Pro: Better treatment effect.
Cons: More parasthesia and pain post-op
73
What is the risk of DVT following EVLT?
0-5%
74
What is the risk of skin burns with EVLT?
\< 1%
75
What is the risk of superficial thrombophlebitis with EVLT
0-25%
76
What are 6 relative contraindications to sclerotherapy?
1 - asthma
2 - DM
3- hypercoagulable states
4 - leg edema
5 - advanced PAD
6 - Chronic renal insufficiency
77
What are 8 absolute contraindications to sclerotherapy?
1. allergy
2. acute cellulitis
3. acute resp or skin disease
4. severe systemic disease
5. phlebitis migrans
6. pregnancy
7. hyperthyroid
8. bedridden
78
What are 3 types of sclerosing agents?
1-osmotics
2-alcohols
3-detergents
79
What is the strongest and weakest types of sclerosing agents?
Strongest - detergent (sotradecol), weakest - alcohol (glycerin)
80
What type of sclerotherapy do you use for larger reticular veins and varicose veins?
Foam - bubbles have increased surface area and stay in contact with endothelium longer
81
How do you calculate the volume of foam to inject into veins?
V = π x (D/2) x L
V=volume
D = diameter
L = length
82
What type of sclerosing agents are the most painful to inject?
Hypertonic saline
83
Name 3 conditions associated with venous gangrene
1. Cancer
2. HITT
3. Warfarin induced protein c deficiency
84
What does D-dimer measure?
DD is a product of proteolysis by plasmin, elevated levels signify fibrinolysis is occurring (e.g. response to injury)
85
What conditions other than DVT may elevate D dimer (4)
1. Recent surgery/trauma
2. Pregnancy
3. Cancer
4. Thrombotic disorders
86
When does the thrombus become adherent to vein wall? Why does this matter?
7-10 days, lower efficacy of systemic thrombolysis or thrombectomy
87
How should you treat an acute DVT associated with cancer?
3 months of anticoagulation with LMWH (better than vitamin K antagonist) - 2016 Chest guidelines
88
How long should you bridge warfarin with UFH for treating dvt? why do you need to?
4-5 days. Natural anticoagulants protein c & s are also inhibited by warfarin and have a shorter half life than other factors therefore warfarin is procoagulant for the first 3 days.
89
Which DOAC has less renal clearance and does not require renal dose adjustment for treating VTE?
Apixaban
90
What is the 4 year patency of iliac veins after venous thrombectomy with av fistula?
80%
91
What are 1 point items on the Caprini score (name at least 5)?
1. Age 40-60
2. Minor surgery
3. Major surgery \< 1 mo ago
4. Varicose veins
5. CHF
6. Obesity
7. Swollen
8. Lung disease
9. COPD
10. Pregnant
92
What are risk factors worth 2 points on Caprini score?
1. Age 60-75
2. Arthroscopic surgery
3. Malignancy
4. Major surgery
5. Laparoscopic surgery
6. Confined to bed
7. Immobilizing cast
8. Central venous access
93
Name 5 risk factors on the Caprini score that are worth 3 points
1. Age \> 75
2. Previous DVT
3. Family history of VTE
4. Factor V leiden
5. SLE
6. HIT
7. Elevated homocysteine
94
Apart from improving venous hemodynamics, which factors do intermittent pneumatic compression stockings stimulate to protect from VTE?
tpA, prostacyclin, tissue factor pathway inhibitor
95
How does ASA work as a blood thinner (molecular)?
Acetylates irreversibly COX-1 which then inhibits platelet derived thromboxane A2
96
What is the mechanism of action of unfractionatedheparin?
Inactivates thrombin and factor Xa and reduces thrombin induced platelet activation
97
What is the mechanism of action of LMWH?
Xa inhibitor, also inhibits thrombin but to a lesser extent
98
What is virchow's triad?
Factors that contribute to thrombosis: 1. Stasis 2. Endothelial injury 3. Hypercoagulable state
99
What is a normal standing resting venous pressure (mm Hg)
60-80 mm Hg
100
How much (in mm Hg) can you increase compression stocking strength before occluding lower extremity veins?
60 mm Hg
101
What are the four strengths (as in mm Hg) for compression stockings? Which strength do you need a prescription?
1. 10-20 mm Hg (over the counter)
2. 20-30 (prescription)
3. 30-40 (prescription)
4. 40-50 (prescription)
102
Name 5 medications that have been tried for treating chronic venous insufficiency. Do any of them work?
1. Diuretics - controversial
2. Pentoxyfiline
3. Phlebotropic (Flavonoids) - best evidence that there may be benefit but not enough for formal recommendation
4. Zinc
5. Prostaglandins
103
What are 6 indications to treat incompetent perforator veins
Evidence about IPV role is lacking. Described indications include:
1) venous hypertension
2) prevention of advancement of CVI
3) symptomatic varicose veins
4) varicose vein recurrence
5) promotion of venous ulcer healing
6) preventing venous ulcer recurrence
104
What are 6 classes of perforating veins?
1. PV of foot
2. ankle
3. calf
4. knee
5. thigh
6. gluteal
105
Name 4 important perforators
A. Cockett 2 (post tibial vein to post arch vein
B. Cockett 3 (another connection between post tib veins and arch veins
C. "24 cm vein" (post tib vein to paratibial vein)
D. more proximal paratibial veins (post tib to paratibial vein where it comes off of GSV
106
What is meant by a "pathologic perforating vein" in the AVF/SVS guidelines?
\> 3.5 mm, outward flow \< 500 ms.
107
When should you treat incompetent perforators
When they are pathologic ( \> 3.5mm \> 500 ms of outward flow) in patients where perforators are:
Adjacent to healed (C5) or open (C6) ulcers or skin changes suggestive of an impending venous ulcer (C4b).
108
What is a SEPS procedure?
subfascial endoscopic perforator surgery
109
How does SEPS compare with conservative treatment of venous ulcers? RCT?
Dutch SEPS trial - no difference in healing rate or recurrence
110
What size of perforator veins can you treat with sclerotherapy?
4-7mm
111
Approximately how many perforators are in the lower extremity?
60
112
What are 5 contraindications to treating perforator veins with sclerotherapy
1. pregnancy
2. lactating
3. allergy
4. active vasculitis
5. severe arterial occlusive disease (because you may injure the accompanying perforator artery and can cause skin necrosis)
113
What do you do if you accidentally puncture a perforating artery when trying to sclerose perforating veins?
1 - procaine
2 - cooling
3 - heparinization
4 - infusion of LMW dextran
114
How long of reversed flow is considered "reflux" in femoropopliteal veins? what about deep femoral and tibial veins?
femoropopliteal - \> 1 s
tibial/profunda - \> 500 ms.
115
How many valves are in the:
1) paired tibial or peroneal veins?
2) popliteal vein?
3) femoral vein?
4) common femoral vein?
1) paired tibial or peroneal veins: 3 - 12
2) popliteal vein: 1-3
3) femoral vein: 1-5
4) common femoral vein: 0-1
116
Name 5 causes of venous occlusion
1 - DVT
2 - Malignancy
3 - external compression (retroperitoneal fibrosis, may thurner)
4 - cysts
5 - aneurysms
117
Name 2 condiions associated with iliofem and caval thrombosis
1. membranous occlusion of suprahepatic IVC with or w/o thrombosis of hepatic veins (Budd Chiari)
2. aplasia, hypplasia of iliofem veins in KTS
118
What is budd chiari syndrome?
Classic triad of: 1. abdo pain 2. ascites 3. liver enlargement associated with hepatic vein occlusion.
(Classes: fulminant, acute, chronic or asymptomatic)
119
Identify vein 13
buttock veins
120
Identify vein 12
cystic and vaginal veins
121
Identify vein 11
internal pudental vein
122
Identify vein 10
vulvar varicosity
123
Identify vein 9
Sciatic vein
124
Identify vein 8
Varicosity of posteromedial aspect of the thigh
125
Identify vein 7
Varicosity of anteromedial aspect of the thigh
126
Identify vein 6
Great saphenous vein
127
Identify vein 5
External pudental vein
128
Identify vein 4
Obturator vein
129
Identify vein 3
Uterine vein
130
Identify vein 2
Internal iliac vein
131
Identify vein 1
Ovarian vein (drains into IVC on right and left renal vein on left)
132
What are 3 causes for pelvlic varicose veins?
1. Reflux secondary to genital (ovarian) vein incompetence
2. Secondary to obstruction of outflow (May Thurner, nutcracker, left renal vein thrombosis, Budd Chiari)
3. Secondary to local compression - endometriosis, tumours, post-traumatic, infection.
133
Which medications treat symptoms of pelvic congestion syndrome?
1. Medroxyprogesterone (provera)
2. Micronized purified flavonoid fraction (daflon)
Only effective while taking them to control symptoms, symptoms return when meds are discontinued.
134
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151
What are the 7 (Class 0-6) clinical categories of the CEAP class?
0. Asymptomatic
1. Telengectasia/reticular
2. Varicosity
3. Edema, no skin change
4. Skin changes
5. Healed ulcer
6. Active ulcer
152
What are the 3 etiologies in CEAP classification?
EC Congenital
EP Primary (undetermined cause)
ES Secondary (known cause, e.g. post-thrombotic)
153
What are the pathologic classifications in the CEAP?
PR Reflux
PO Obstruction
PR,O Reflux and Obstruction
154
What are the 10 attributes of the Venous Clinical Severity Score?
All scored from 0 - 3 (absent, mild, mod, severe)
1. Pain
2. Varicose vein
3. Edema
4. Skin pigmentation
5. Inflammation
6. Induration
7. Number of acute ulcers
8. Active ulceration
9. Active ulcer size
10. Compressive therapy compliance
155
What is the differential diagnosis for bilateral leg swelling?
Conditions related to fluid overload
1. CHF
2. Renal impairment
3. Cirrhosis
156
What is the differential diagnosis for unilateral leg swelling? (6 including DVT)
1. DVT
2. Cellulitis
3. Muscular strain/tear
4. Baker's cyst
5. Hematoma
6. Dermatitis.
157
What percentage of patients with superficial thrombophlebitis of the GSV progress to a DVT of the common femoral vein?
10%
158
Where are the pain features of ischemic vs. neurotrophic vs. venous stasis ulcers?
1. Ischemic: severe pain, worse at night, relieved by dependency
2. Neurotrophic: none
3. Venous: mild, relieved by elevation
159
What are lesion characteristics associated with ischemic vs. neurotrophic vs. venous stasis ulcers?
1. Ischemic: irregular edge, poor granulation tissue
2. Neurotrophic: punched out, deep sinus
3. Venous: shallow, irregular shape, granulating base, rounded edges
160
How much bleeding with manipulation occurs with ischemic vs. neurotrophic vs. venous stasis ulcers?
1. Ischemic: little to none
2. Neurotrophic: may be brisk
3. Venous: venous ooze
161
Where are the usual locations of ischemic vs. neurotrophic vs. venous stasis ulcers?
1. Ischemic: distal on dorsum of foot or toes
2. Neurotrophic: Under calluses or pressure points
3. Venous: Gaiter area (classically medial malleolus)
162
What is the trendelenburg test?
Patient is supine, manual compression or tourniquet used to occlude proximal gsv, pt then stands upright.
Superficial varicosities should slowly fill over 20 seconds. Otherwise it indicates significant deep venous insufficiency or perforator incompetence
163
What is the Perthe's test?
Tourniquet is used to occlude proximal superficial veins. As patient ambulates, varicosities will enlarge if there are incompetent perforating veins.
164
How is lymphedema classified?
**1. Primary Lymphedema**
A Congenital (before 1 year of age): familial (Millroy's disease), non-familial
B Praecox (1 - 35 year old): familial (Meige disease), non-familial
C Tarda (\> 35 year old):
**Secondary:**
A Filiriasis
B LN excision/rads
C Tumour invasion
D Infection
E Trauma
F Other
165
What is the most common form of lymphedema?
Lymphedema praecox (1-35 year old), accounts for over 80% of all patients with lymphedema
166
What is Stemmer's sign?
Inability to punch and lift the dorsal skin of the foot between the 1st and 2nd toes is indicative of lymphedema.
Lymphedema rarely spares the toes and differentiates it from other conditions like lipedema.
167
What are the clinical stages of lymphedema?
Grade 1: Early pitting, reduces with elevation, no fibrotic skin thickening
Grade 2: Skin thickened and fibrotic pitting only to deep pressure, no reduction with elevation overnight
Grade 3: Skin fibrotic and slerotic, verrucal development, permanent changes
168
Name 4 ways of reconstructing the PV and SMV in the context of pancreaticoduodenectomy for cancer
1. Lateral venorrhaphy (if tumour luminal narrowing will be \< 30%)
2. Patch angioplasty (if tumour involves 30-50% of circumference)
3. Primary end-to-end (luminal narrowing \> 30% and length of involved vein \< 2 cm)
4. Interposition graft using autologous vein or prosthetic (luminal narrowing \> 30% and length of involved vein \> 2 cm)
169
What are the 3 morphologic classifications of lymphedema?
1. Aplasia
2. Hypoplasia
3. Numerical Hyperplasia
4. Hyperplasia
170
What is the most common cause of secondary lymphedema in third world countries?
Filiarasis
171
Name 3 organisms associated with filiriasis
1. Wuchereria bancrofti
2. Brugia malayi
3. Brugia timori
172
What are the clinical grades/stages of lymphedema?
Latent phase: excess fluid accumulates, fibrosis occurs, but no edema apparent clinically
Grade 1: edema pits on pressure, reduced by elevation, no clinical evidence of fibrosis
Grade 2: edema does not pit on pressure, not reduced by elevation, moderate to severe fibrosis
Grade 3: edema is irreversible and develops from repeated inflammatory attacks, fibrosis and sclerosis of the skin and subcutaneous tissues. This is the stage of elephantitis.
173
Name 6 skin changes associated with lymphedema
1. Lichenification
2. Peau d'orange
3. Hyperkeratosis
4. Recurrent chronic eczema
5. Yellow nails
6. Verrucae which frequently drain clear lymph
174
Name 5 tumours that appear with increased frequency in lymphedematous limbs
1. Lymphangiosarcoma
2. Kaposi's sarcoma
3. Squamous cell carcinoma
4. Malignant lymphoma
5. Melanoma
175
Name 8 imaging methods to evaluate lymphedema
1. Isotopic lymphoscintigraphy
2. Near infrared fluorescent lymphatic imaging
3. Indirect and direct lymphography
4. Lymphatic capillaroscopy
5. MRI
6. CT
7. U/S
8. Direct lymphography (rarely used - only for pts who will undergo lymphatic surgery
176
What are typical abnormalities observed in lymphedema in lymphoscintgraphy?
1. Dermal backflow
2. Absent or delayed transport of tracer
3. Crossover filling with retrograde backflow
4. Absent or delayed visualization of lymphnodes
177
What are typical scitigraphic findings in lymphangiectasia?
Dilated lymph channelwith only mild or no delay in lymph transport
178
How can you tell lymphedema apart from venous edema on CT or MRI?
Lymphedema - honeycomb distribution within epifascial structures along with thickening of the skin
Venous edema - Both epifascial and subfascial compartments are affected
Lipema - Fat accumulation without fluid
179
How can you tell the difference between lipedema and lymphedema clinically?
Lipedema has feet sparing
180
Administration of what drug significantly decreased lymphatic filariasis in undeveloped contries?
Dietylcarbamazine + ivermectin
181
Name 8 measures lymphedema patients can take to prevent edema
1. Skin hygiene
2. Clothing - avoid synthetics, loose fitting
3. Avoid trauma
4. Fungal infection control with topical antifungals
5. Limb elevation
6. Diet: low salt, high protein, weight loss
7. Exercise
8. Compression stockings
182
What are the 4 components of complex decongestive therapy (1st line treatment for stage 2/3 lymphedema)
1. Manual lymphatic drainage
2. Compression bandages
3. Compression garments
4. Compression devices
183
What pressure should you use for lymphedema patients with recalcitrant chronic lymphedema?
184
What pressure do upper extremity compression garments provide?
185
What pressure chronic venous insufficiency or lymphedema garments provide?
186
What pressure anti embolism garments provide?
187
What pressure does over the counter garments provide?
188
Name 7 contraindications to wearing compression garments
1. Arterial insufficiency
2. Acute cardiac failure
3. Extreme limb shape distortion
4. Very deep skin folds
5. Extensive skin ulceration
6. Severe peripheral neuropathy
7. Lymphorrhea
189
Name 4 contraindications for using intermittent pneumatic compression devices
1. Local or proximal malignancy
2. DVT
3. Infection of limb
4. Anticoagulation medication
190
What type of compression garment should you prescribe to treat lymphedema patients (in addition to complex decongestive therapy)?
60-70 mm Hg non-elastic graduated compression stocking
191
Name 4 conditions associated with migratory thrombophlebitis
1. Carcinoma (Trousseau syndrome)
2. Behcet
3. Buerger
4. Polyarteritis nodosa
192
What is mondor disease?
Thrombophlebitis of the thoracoepigastric vein of the breast and chest wall.
193
How do you treat patients with SVT?
LMWH seems to provide the best outcomes for treatment of SVT with the least complications.
194
Name 6 differential diagnoses for tachnypnea/tachycardia/dyspnea/chest pain other than pulmonary embolism.
1. Acute coronary syndromes
2. Aortic dissection
3. Pericardial tamponade
4. New onset arrythmia
5. Pneumonia
6. Pneumothorax
195
Name 6 CXR findings associated with PE.
CXR Not sensitive or specific for PE - useful for R/O other diagnoses like pneumothorax.
1. Atelectasis
2. Pleural effusion
3. Fleischner sign (enlarged pulmonary artery)
4. Hampton hump (peripheral wedge of airspace opacity/lung infarction
5. Westermarck sign (regional olegemia)
6. Knuckle sign (abrupt tapering or cutoff of pulmonary artery).
196
What percentage of patients with a PE will have lower extremity DVT?
30-50%
197
When suspecting PE, when should you use VQ scans?
Only if pregnant or severe renal dysfunction. Can also consider MRA.
198
What are the components and associated score of the Wells score? When is PE likely?
1. Previous PE/DVT = 1
2. HR \> 100 = 1
3. Surgery/immobilization within 4 weeks = 1
4. Hemoptysis = 1
5. Active cancer = 1
6. Clinical signs of DVT = 1
7. Alternate diagnosis less likely than PE = 1
PE unlikely = 0-1
PE likely = \>2
199
What is a high risk pulmonary embolism and associated mortality?
- Hemodynamically unstable, sustained shock or sBP \< 90
- Mortality - 15 - 30%
200
What is an intermediate risk pulmonary embolism and associated mortality?
- Normotensive
- Imaging evidence of RV dysfunction or elevated cardiac biomarkers
- Mortality - 3-15%
201
What is a low risk pulmonary embolism and associated mortality?
- Normotensive
- No imaging evidence of RV dysfunction
- No elevated cardiac biomarkers
- Mortality - 1-2%
202
How do you work up a patient who you suspect PE and is hemodynamically unstable and CTPA is not immediately available?
Echo to look for RV overload, if patient has RV overload and is stabilized can do CTPA but if not can go straight to reperfusion treatment if necessary.
203
How do you work up a patient who you suspect PE and is hemodynamically stable?
Wells or Geneva Score.
If PE unlikely - do D Dimer.
If PE likely do CTPA
204
What are components of the simplified PESI score?
Pulmonary embolism risk stratiication based on Pulmonary Embolism Severity Index
1. Age \> 80 = 1
2 .Cancer = 1
3. CHF = 1
4. Pulse \> 110 = 1
5. sBP \< 100 = 1
6. Saturation \< 90%
0 = very low risk, 1 + = intermediate or more risk.
205
What is your initial management for a patient with a suspected PE?
1. Airway breathing circ assessment
2. O2 supplementation to maintian sat \> 90%. If mechanical ventilation required, careful with PEEP because it may decrease venous return and worsen RV failure in patients with massive PE
3. IV access - if hypotensive give fluids in small volumes to avoid stretching an already overstretched RV. If fluid challenge fails - give norepinephrine
4. Empiric initiation of anticoagulation - IV UFH
206
What are the indications for an IVC filter?
Patients with acute PE with absolute contraindications to anticoagulation drugs and in patients with objectively confirmed recurrent PE despite adequate anticoagulation.
207
When is thrombolysis used to treat PE?
Reserved for high risk and selected cases of intermediate risk PE. Greatest benefit within 48 h but can be useful in patients who have had symptoms for up to 14 days.
208
How is thrombolysis for PE administered?
Usually peripheral IV but now catheter directed lytic administration directly into pulmonary arterial tree is becoming more frequent.
209
How do you treat a patient with a suspected PE and sustained hypotension (sBP \< 90)
Systemic thrombolysis if no contraindication. Low dose protocol of systemic thrombolysis or catheter intervention with or without lytics if there is a contraindication (multidisciplinary decision)
210
How do you treat air embolism?
High oxygen concentration, volume expansion, aspiration with central catheter, place patient in left lateral decubitus position to prevent RV outflow obstruction by airlock.
211
What is the definition of CTEPH (chronic thromboembolic pulmonary hypertension)
Mean pulmonary artery pressure \> 25 mm Hg that persists 6 months after PE event
212
A relative expanded indication for vena cava filters is documented VTE in patients with high risk of complications with anticoagulation - give 6 examples of such patients
1. Major operation
2. Intracranial hemorrhage
3. Solid intra-abdominal organ injury
4. Pelvic or retroperitoneal hematoma
5. Ocular injury
6. Medical problems (cirrhosis, ESRD, PUD, meds, coag disorder)
213
A relative expanded indication for vena cava filters is VTE prophylaxis in high risk patients - give 7 examples of such patients
1. Critically ill
2. Previous DVT
3. FHx of DVT
4. Malignancy
5. Morbid obesity
6. Known hypercoagulable state
7. Prolonged immobility.
214
Name 5 trauma situations where you might consider vena cava filtration for prophylaxis
1. Multiple injuries
2. Spinal cord injury
3. Closed head injury
4. Complex pelvic fractures
5. Multiple long bone fractures.
215
Name 9 relative expanded indications for vena cava filter placement
1. Poor anticoagulation compliance
2. Free floating iliocaval thrombus
3. Renal cell carcinoma with renal vein extension
4. Venous thrombolysis/thromboembolectomy
5. Documented VTE + limited cardiopulmonary reserve
6. Documented VTE + high risk for anticoagulation complications
7. Recurrent PE complicated by pulmonary hypertension
8. Documented VTE - cancer patient, burn patient, pregnancy
9. VTE prophylaxis: high risk surgical pts, trauma patients, high risk medical conditions
216
Name 5 contraindications to placing a vena cava filter
1. Chronically occluded vena cava
2. Vena cava anomalies
3. Inability to access the vena cava
4. Vena cava compression
5. No location in vena cava available for placement.
217
Name 8 complications of vena cava filters
1. PE (2%–5%), fatal PE (0.7%)
2. death linked to filter insertion (0.12%)
3. venous access site thrombosis (2%–28%)
4. filter migration (3%–69%)
5. vena cava penetration (9%–24%)
6. vena cava obstruction (6%–30%)
7. venous insufficiency (5%–59%)
8. filter fracture (1%)
9. guide wire entrapment (1%)
218
What is the PREPIC trial and what was its main findings?
Prevention of recurrent PE with vena cava interruption - 2x2 RCT comparing filter vs no filter and UFH vs enoxaparin.
Filters significantly reduced PE during first 12 days (1% vs 5%) but increased incidence of recurrent DVT at 2 years (21% vs 11%). At 8 years findings persisted. No diff in post-thrombotic venous insufficiency or survival.
219
When should you use retrievable IVC filters?
1. No indication for permanent filter
2. Risk of clinically significant PE is acceptably low
3. Return to high risk for VTE is not anticipated
4. Life expectancy long enough to realize benefit of removal
5. Filter can be removed safely or converted.
220
When might you place a vena cava filter supra-renal?
1. Pregnancy
2. IVC thrombus
3. Malpositioning of an infrarenal IVC filter
4. Duplicate IVC
5. Ovarian vein thrombosis
221
What is the risk of PE with UE DVT?
5-10%
222
Why shouldn't you perform fasciotomies for swelling associated with extensive venous disease?
Venous thrombectomy is the most effective way of relieving venous hypertension and improving symptoms. Fasciotomies are not effective. Intact fascia may also be required long term to preserve calf muscle pump function.
223
Name 7 causes for SVC syndrome
**Malignant - most common (60%):**
1. Lung cancer
2. Mediastinal cancers (thyroid, teratoma, synovial cell carcinoma)
**Benign:**
3. Pacemakers
4. Central venous catheters
**Others:**
5. Previous radiotherapy to mediastinum
6. Retrosternal goiter
7. Aortic dissection
224
What is this depicting?
Type 4 venographic pattern of SVC syndrome:
Extensive occlusion of SVC, innominate and azygous veins with collaterals from chest wall and epigastric veins.
225
What is this depicting?
Type 3 venographic pattern of SVC syndrome:
Occlusion of SVC with retrograde flow in the azygous and hemiazygous veins.
226
What is this depicting?
Type 2 venographic pattern of SVC syndrome:
Occlusion or near occlusion of SVC but still has normal flow direction in azygous vein.
227
What is this depicting?
Type 1 venographic pattern of SVC syndrome:
Partial obstruction but still has normal flow direction in azygous vein.
Increased collateral circulation through hemiazygous and accessory hemiazygous veins
228
When does the embryogenesis of the IVC begin? What primitive structures does it develop from?
Week 6
Develops from supracardinal, subcardinal and postcardinal veins
229
One described method of maintaining patency with good inflow/outflow in the context of open venous reconstructions is to create AV fistulas. What is the major risk with that?
High output cardiac failure - fistulas would have to be ligated
230
What should you work up a patient for if they are under 30 and have an indiopathic DVT?
Congenital absence of IVC
231
What is a normal portal vein pressure? What is signficantly elevated?
Normal: 5-10 mm Hg
Significant: 10 mm Hg above systemic venous pressure
232
Name 6 causes of presinusoidal portal hypertension other than portal vein thrombosis
1. Polycythema vera
2. Billiary atresia
3. Schistosomiasis
4. Sarcoidosis
5. Wilson disease
6. Congenital hepatic fibrosis
233
Name 6 causes of extrahepatic postsinusoidal obstruction
**Hepatic vein thrombosis:**
1. Budd Chiari
2. Hepatic vein webs
3. Malignant obstruction
4. Hypercoagulable states
**Cardiac**
5. CHF
6. Constrictive pericarditis
234
What causes postsinusoidal portal hypertension?
Cirrhosis and hemachromatosis
235
What causes sinusoidal portal hypertension?
Alcoholic, viral and toxic hepatities
236
What is the most common cause of pulmonary hypertension in the Western world?
Sinusoidal and post-sinusoidal hypertension resulting in cirrhosis
237
Name 5 causes of portal vein thrombosis
1. Omphalitis (infection of umbilical stump)
2. Pancreatitis
3. Trauma
4. Malignancy
5. Hypercoagulable states
238
What is the most common cause of portal hypertension in 3rd world countries?
Schistosomiasis
239
Which vessels are most often affected by portal hypertension and become varices?
Left gastric vein arising from portal vein
Short gastric vein arising from splenic vein
240
What are signs of chronic liver disease?
ABCDEFGHIJ
Asterixis, Ascites, Ankle oedema, Atrophy of testicles
Bruising
Clubbing/ Colour change of nails (leuconychia)
Dupuytren’s contracture
Encephalopathy / palmar Erythema
Foetor hepaticus
Gynaecomastia
Hepatomegaly
Increase size of parotids
Jaundice
241
What are 3 ways of treating variceal bleeding prophylactically?
1. Nonselective beta blockers (propranolol)
2. Endoscopic variceal band ligation
3. Endoscopic sclerotherapy
242
What procedure is this showing?
Transjugular intrahepatic portosystemic shunt
243
Name 5 ways of treating acute variceal hemorrhage
1. Vasopressin
2. Octreotide/Somatostatin
3. Balloon Tamponade
4. Balloon occluded antegrade and retrograde transvenous obliteration
5. TIPS
244
Name 4 ways of treating ascites due to portal hypertension
1. Sprionolactone
2. Furosemide
3. Paracentesis
4. TIPS
245
Name 2 medications you can use to treat enecephalopathy related to liver failure
1. Lactulose (prevents ammonia absorption and increases fecal nitrogen excretion
2. Neomycin (however nephrotoxicity and ototoxicity limit its use)
246
Name 3 causes of primary venous aneurysms
1. Klippel Trenaunay
2. NF-1
2. Parkes Weber
247
248
What type of IVC aneurysm is this?
Type 1 aneurysm - suprahepatic location without obstruction in IVC
249
How would you treat this IVC aneurysm?
Type 1 aneurysms are usually observed
250
How would you treat this IVC aneurysm?
Type 1 aneurysms can usually be observed
251
What type of IVC aneurysm is this?
Type 1: aneurysm in perihepatic location with left sided IVC
252
What type of IVC aneurysm is this?
Type 2: Aneurysms located above or below the hepatic veins with obstruction - this shows suprahepatic interruption with infrarenal aneurysm
253
What type of IVC aneurysm is this?
Type 2 Aneurysms located above or below the hepatic veins with obstruction - here infrahepatic interruption of IVC and infrarenal IVC aneurysm
254
How would you treat this IVC aneurysm?
Type 2, 3, 4 aneurysms are prone to thrombosis or embolization so usually treated - surgical repair is the most common treatment with either tangential excision with venorraphy or resection with interposition grafting
255
What type of IVC aneurysm is this?
Type 2 Aneurysms located above or below the hepatic veins with obstruction
Here it shows intrahepatic interruption of IVC, infrahepatic IVC aneurysm and entry of renal veins into azygous and hemiazygous systems
256
What type of IVC aneurysm is this?
Type 3: infrarenal aneurysm without obstruction
257
What type of IVC aneurysm is this?
Type 4: miscellaneous aneurysm
This is showing aneurysm of iliac vein with left sided IVC
258
How would you treat this IVC aneurysm?
Type 1 aneurysms can usually be observed
259
What is this photo showing?
IJ aneurysm - under valsava maneuver the aneurysm becomes alarmingly large
