Cardiology: Venous diseases

what are varicose veins?

dilated torturous superficial veins mostly affecting long saphenous and its tributaries in the LE

what are the RF of varicose veins?

pregnancy, women >50, obesity, FH, menopause, prolonged standing, heavy lifting, chronic constipation, tumor

what is the patho of varicose veins?

dysfunction of the valves within veins leading to blood pooling and vein dilation

what are the SS of varicose veins?

dull, aching discomfort or pain that worsens with prolonged standing, itching, burning, fatiguability of legs

what does edema, pigmentation, and ulcerations on the leg indicate?

venous insufficiency

what does long standing varicose veins lead to?

chronic venous insufficiency

How do you make the dx of varicose veins?

clinical

when do you dx varicose veins using a duplex ultrasound?

surgical planning

what is the nonsurgical tx for varicose veins?

compression therapy, elevation of legs, exercise, avoid long periods of straining/standing, weight loss, phlebotonics

what are phlebotonics?

drugs that improve venous tone, decrease inflammation, enhance lymphatic drainage

what is the first line tx of varicose veins in pregnant women?

compression therapy

what are the indications of non-cosmetic surgery for varicose veins?

symptomatic varicosities, recurrent thrombophlebitis, bleeding, tx for venous HTN after the onset of skin and subcutaneous tissue changes

what is thrombophlebitis?

Inflammation of a vein with formation of a clot

what is mechanical surgical ablation therapy for varicose veins?

excision and ligation of varicosities

what is chemical surgical ablation therapy for varicose veins?

scleropathy of fibrous vein

what is scleropathy?

injection of liquid, foam, or glue that irritates the lining of the vein, causing it to collapse, seal shut, and eventually be reabsorbed by the body

what is thermal surgical ablation therapy for varicose veins?

external or endovenous lasers

what is endovenous vein therapy or reconstruction for varicose veins?

vein stenting or valve repair

what is superficial venous thrombophlebitis?

Thrombus formation in a superficial vein

what is the MC vein for development of superficial venous thrombophlebitis?

great saphenous

what is superficial venous thrombophlebitis usually caused by?

short term peripheral venous catherization and PICC lines

what are the RF for superficial venous thrombophlebitis?

IV catheter, trauma to leg, immobilization, pregnancy/post-partum, high dose estrogen therapy, obesity, steroid use, smoking, carcinoma, hx of venous disease, >60 yo

what are 20% of superficial venous thrombophlebitis cases caused by?

DVT

what are the SS of superficial venous thrombophlebitis?

dull pain, palpable cord that is red, swollen, thickened, and edema of extremity which is uncommon

How is the dx of superficial venous thrombophlebitis?

venous duplex ultrasound

what is the tx for superficial venous thrombophlebitis that is well localized NOT near saphenofemoral junction?

warm compress, bed rest, leg elevation, NSAIDs

what is important to tell pts with superficial venous thrombophlebitis about the tx for well localized NOT near SF junction?

should resolve in 1-2 weeks, palpable cord may persist for months

what is the tx for superficial venous thrombophlebitis that is very extensive OR progresses upward to SF junction?

ligation and division of saphenous vein

when is full anticoagulation indicated for superficial venous thrombophlebitis?

if disease rapidly progresses or extension into deeper tissue

when should you prophylactically tx superficial venous thrombophlebitis with anticoags?

5 cm or longer

what should you use to prophylactically tx superficial venous thrombophlebitis when it is 5cm or longer?

UFH/LMWH

when is anticoagulation therapy not indicated for superficial venous thrombophlebitis?

focal processes

what are focal processes?

localized inflammatory and thrombotic events within a specific segment of a superficial vein

what is pain, fever, and chills indicative of?

septic phlebitis

what is the most common pathogen for septic phlebitis?

staph aureus

what is chronic venous insufficiency?

dysfunction of venous wall or valve in leg veins making is difficult to return blood to the heart

what are the RF for chronic venous insufficiency?

FH/hx of venous disease, obesity, pregnancy, hx of leg trauma or surgery, smoking, women, >50 yo

what is the patho of chronic venous insufficiency?

valve leaflet do not bridge dt thickening, scarring or dilation of vessel causing venous insufficiency, venous HTN and increased hydrostatic pressure resulting in edema and skin changes

what are the SS of chronic venous insufficiency?

progressive pitting edema, aching/tiredness of legs, new varicose veins, leathery looking skin on legs, flaking/itching on feet/legs, stasis ulcers

How is the dx of chronic venous insufficiency made?

clinical or duplex ultrasound

what is the conservative tx for chronic venous insufficiency?

leg elevation, avoidance of long periods of sitting/standing, exercise, compression stockings

what is the stasis dermatitis tx for chronic venous insufficiency?

wet compresses 1 hr 4xday, compression stockings, local corticosteroids

what is the recalcitrant stasis dermatitis tx for chronic venous insufficiency?

systemic corticosteroids, pneumatic compression device

what is the ulceration tx for chronic venous insufficiency?

debridement, compresses of saline solution, semi-rigid gauze boot made with unna paste, skin grafting

what is the infection tx for chronic venous insufficiency?

systemic abx

what is the surgical tx for chronic venous insufficiency?

stenting

what is the prevention of chronic venous insufficiency?

early and aggressive anticoag tx for DVT, compression stockings if edematous after DVT, avoid prolonged standing, straining and heavy lifting

what is a deep vein thrombosis?

thrombus in deep veins that return blood to heart

what are the most common veins affected?

femoral, popliteal, iliofemoral, in pregnancy pelvic veins

what are upper extremity DVTs associated with?

presence of central line or maligancy

what are the RF for deep vein thrombosis?

male, african american/caucasian, factor V leiden mutation, prolonged immobility >48 hrs, trauma to long bones, smoking, meds, maligancy, CKD, nephrotic syndrome

what is the patho of deep vein thrombosis?

thrombus forms in venous valves leading to hypoxia dt decreases blood flow

what is virchows triad?

venous stasis, endothelial injury, hypercoagulability

what is venous stasis in regards to a deep vein thrombis?

Stoppage of the normal venous blood flow dt blood clot

what is the patho of endothelial injury in regards to a deep vein thrombus?

trauma or inflammation cause exposure to tissue factor in which prothrombin --> thrombin and fibrinogen --> fibrin leading to clot formation

what is hypercoagulability in regards to a deep vein thrombus?

increased clotting synthesis and PLT adhesion

what are the RF for venous stasis?

post-surgical, immobility, venous insufficiency

what are the RF for hypercoagulability?

Factor V Leiden, cancer, OCP + smoking, pregnancy

what are the RF for endothelial injury?

trauma, surgery

what are the SS of deep vein thrombosis?

unilateral leg pain, swelling, warmth, and erythema

what is the wells criteria used for?

probability of a DVT

what is the wells criteria for a DVT and what is high, mod and low risk?

1) Active Cancer (tx within 6 months, or palliation) -1

2) Paralysis, paresis, or immobilization of lower extremity -1

3) Bedridden for > days secondary to surgery (within 4 weeks) -1

4) Localized tenderness W/I the deep vein distribution -1

5) Entire leg swollen - 1

6) Unilateral calf swelling of > 3 cm (below the tibial tuberosity) - 1

7) Unilateral pitting edema - 1

8) Collateral superficial veins - 1

9) Alternative dx as liklely or more likely than DVT - 2

High = 3

Moderate = 1-2

Low = <1

how can the dx of deep vein thrombosis be made?

D-Dimer >500, compression of ultrasound with doppler, contrast venography, CT/RI

what is the diagnostic test of choice for a deep vein thrombosis?

compression of ultrasound with doppler

why is a contrast venography rarely used in diagnosing deep vein thrombosis?

expensive

what is the short term tx for deep vein thrombosis?

heparin with warfarin or DOAC at least 3 months

what is a CI of anticoags?

ICV filter

what is the indication for long term tx for deep vein thrombosis?

recurrent DVTs, multiple RF, severe anticlotting factor deficiencies

what are the SS of phlegmasia cerulea dolens?

Severe pain, swelling, cyanosis, edema, gangrene, and compartment syndrome, can result in death if not treated

what is the tx of phlegmasia cerulea dolens?

IV UFH; Consideration catheter-directed thrombectomy or mechanical thrombectomy

What is phlegmasia cerulea dolens?

Venous gangrene, iliofemoral DVT that obstructs venous drainag

what are the CIs of an IVC filter for deep vein thrombosis?

anticoags, bleeding risk too high, poor cardiopulmonary reserve, prox DVT

If a pt has an IVC filter and the risk of bleeding is now acceptable what should you do?

begin anticoag and remove filter

What is the prevention for deep vein thrombosis?

anticoags, compression stockings, exercise, elevate LE, avoid prolonged sitting especially with sitting, etc