Venous Ulcers

Question 1

What veins have the most valves?

Answer 1

Deep veins

Question 2

What accompanies the deep veins?

Answer 2

Arteries

Question 3

What are all the deep veins in the leg?

Answer 3

• posterior tibial v.
• anterior tibial v.
• fibular v.
• popliteal v.
• femoral v.
• deep femoral v.
• external iliac v.

Question 4

What is the superficial veins also known as?

Answer 4

Saphenous system

Question 5

What are the two major vessels in the superficial vein system?

Answer 5

Greater saphenous vein and lesser saphenous vein

Question 6

What is the longest vein in the body?

Answer 6

Greater saphenous vein (most problems and where DVT in medial malleolus is)

Question 7

True/False: the superficial veins are located just below the superficial fascia?

Answer 7

True

Question 8

Where are superficial vein valves more abundant and why?

Answer 8

Lower leg (versus the thigh) because it doesn’t have the force from the heart to move it and gravity creates more pressure distally

Question 9

What connects the superficial and deep vein systems?

Answer 9

Perforator veins

Question 10

How many perforator veins are there?

Answer 10

Varies!
200 below the knee
20 above the knee

Question 11

What do perforators pass through and what do they join to?

Answer 11

Pass through openings in deep fascia to join directly with deep veins of the calf or thigh

Question 12

What plays a vital role in normal blood flow?

Answer 12

Valves

Question 13

What do valves prevent specifically?

Answer 13

Valves prevent back flow of blood from high-pressure deep system to the low-pressure superficial system

Question 14

Where are there more valves?

Answer 14

Deep veins

Question 15

What kind of valves are found in 50-60% of patients with venous ulcers?

Answer 15

Incompetent venous valves in perforating and superficial vessels

Question 16

What do healthy vein valves do?

Answer 16

Close with pressure and prevent blood from reflexing or pooling

Question 17

What are the 3 major mechanisms to help return blood to the heart through the venous system?

Answer 17

1. Smooth muscle tone in vessel walls
2. Contraction of calf muscle
3. Negative intrathoracic pressure created during inspiration

Question 18

What is the most important mechanism in returning venous blood?

Answer 18

Muscle pump, pushes blood out of the deep veins and into central circulation

Question 19

What does respiration cause?

Answer 19

Negative pressure in the chest that assists the return of blood from the legs to the heart

Question 20

What is it called when there sustained high pressure in low pressure veins caused by retrograde flow from incompetent veins?

Answer 20

ambulatory venous hypertension

-causes a vicious cycle of distended veins and damaged valve leaflets

Question 21

What happens to unidirectional blood flow during ambulatory venous hypertension?

Answer 21

Becomes bidirectional

Question 22

Why does edema build up during ambulatory venous hypertension?

Answer 22

Congested superficial veins and capillaries

Question 23

When ambulatory venous hypertension happens and the deep veins are not completely emptied out, what happens next?

Answer 23

Increased pressure within the deep system that creates a resistance to blood draining from superficial veins.
-this creates more congestion and distention in superficial and perforating veins causing more valves to be compromised

Question 24

What does improper functioning of the venous system lead to?

Answer 24

Chronic venous insufficiency (CVI)

Question 25

What does chronic venous insufficiency impair and cause?

Answer 25

- impairs nutrient and oxygen supply to involved tissue of lower leg - lack of nutrients cause tissue damage - tissue damage worsens and the dies

Question 26

What are the 2 possible mechanisms for chronic venous insufficiency?

Answer 26

1. Fibrin cuff theory | 2. White blood cell trapping hypothesis

Question 27

Veins in the lower leg include what?

Answer 27

Deep veins, superficial veins and perforator veins

Question 28

What else escapes into the interstitial space with large macromolecules during the fibrin cuff theory?

Answer 28

Fibrinogens

Question 29

In the fibrin cuff theory what causes widening of the capillary pores?

Answer 29

Venous hypertension that is transmitted to the superficial veins in the subcutaneous tissue and overlying skin (dilated long saphenous vein)

Question 30

What happens in the fibrin cuff theory after large macromolecules escape into the interstitial space?

Answer 30

- edema forms in the leg because of pooling of fluid in dermis - fibrin accumulates in dermis and cause "fibrin cuff" of hard, non-pitting edema - the fibrin cuff forms a mechanical border and lessens the delivery of oxygen and other nutrients to the skin

Question 31

Describe the white blood cell-trapping hypothesis

Answer 31

- transient elevation in venous pressures decrease capillary blood flow, resulting in trapping of WBC at the capillary level - the trapping plugs the capillary loops which results in areas of localized ischemia

Question 32

What does ischemia and possible WBC release that aid in? (During WBC-trapping hypothesis)

Answer 32

Release proteolytic enzymes that aid in cell death

Question 33

Where are the tissue problems most frequently at and why?

Answer 33

Medial malleolus because the great saphenous vein is most superficial and has its greatest curvature there

Question 34

Why else can someone get an ulcer by the medial malleolus?

Answer 34

- trauma to involved area | - infection

Question 35

What are the clinical indicators for CVI? (9)

Answer 35

1. Localized limb pain (dec pain with elevation and inc with leg dependency) 2. Pain with deep pressure or palpation 3. Pedal pulse are present 4. Inc temp around wound 5. Indistinct, irregular wound edges 6. Lower extremity edema 7. Shallow, fibrous covered wound bed 8. Hemosiderin staining 9. Lipodermatosclerotic changes

Question 36

What are the risk factors for CVI? (19.....)

Answer 36

- obesity - Prego - leg trauma - sedentary lifestyle - advanced age - altered/shuffling gait - dec AROM of ankle - tobacco use - malnutrition - diabetes - unplanned weight loss - meds - thrombophlebitis (DVT, PE) - cardiac disease - prolonged sitting - heart failure - previous ulcer - response to txt of previous ulcers

Question 37

What is used as a clinical prediction rule to assess the probability of a DVT in patients?

Answer 37

Wells Score

Question 38

What are the different scores for the Wells Score and what do they tell you?

Answer 38

>1 = indicates high clinical probability of DVT (28% chance of DVT)

Question 39

What is hemosiderin staining?

Answer 39

Red blood cells can lead out of dilated vessels, then iron-containing hemosiderin and stimulated melanin get trapped in the skin around the problematic areas -this causes a darkening of surrounding tissues

Question 40

What is the result of inflammation of subcutaneous adipose tissue called?

Answer 40

Lipodermatosclerosis

Question 41

How does the skin look when lipodermatosclerosis happens?

Answer 41

Thick, hard and contracted with the inverted champagne-bottle appearance -the tissue becomes sclerotic over time