Venous Insufficiency/PPG/APG/Non-Atherosclerotic Pathologies

Anterior Accessory Vein

Runs parallel and anterior to femoral vein

GSV

Saphenous Eye

Between facial layers

GSV in Calf

Angle Sign

Triangular form between gastrocnemius muscle and tibial bone

Tributary

Outside fascial plane

Perforator

Pass through muscular fascia layers - connect deep system to superficial system

Primary Valvular Insufficiency

Congenital absence of veins

Secondary Valvular Insufficiency

Damaged valves caused by thrombotic events

Chronic Venous Insufficiency

Obstruction & valve insufficiency

Arterial Ulcers

Found in tibial area/bony areas

Severe pain

Deep, regular shape

Little bleeding

Shiny skin, hair loss, thickened toe nails

Venous Ulcers

Found near medial malleolus

Minimal pain

Shallow, irregular shape

Oozing/Odor

Stasis dermatitis/brown discoloration/varicosities

Normal Physiologic Reflux

Small amount of flow in the opposite channel is normal

Deep System Reflux

≥ 1 sec

Superficial System Reflux

≥ 0.5 sec

Reflux Photoplethysmography (PPG)

Evaluates venous valve competency

Easy & reliable results

Positive findings must be confirmed with other studies

PPG Testing Protocol

Relaxed limb - normal baseline

Dorsiflex foot 5-6x - to empty calf veins

Venous refilling time - time from when exercise stops to stabilization period of ≥ 5 seconds

Normal PPG

Refill time/time to baseline > 20 seconds

Abnormal PPG

Does not return to baseline

PPG - Tourniquet Test

Differentiates superficial from deep system

GSV Reflux PPG

Refill time < 20 sec

Normalizes with tourniquet above knee

SSV Reflux PPG

Refill time < 20 sec

Normalizes with tourniquet below knee

Incompetent Deep Valves PPG

Consistent reflux < 20 sec

Air Plethysmography (APG)

Recommended for chronic venous insufficiency

Cuff inflated to 10 mmHg

Leg is elevated

Patient quickly stands - bearing weight on non-tested leg

Distribute weight evenly

1 toe raise

10 toe raises

Return to supine and elevate tested leg

Filling Time

How long to accumulate blood in calf to 90% venous volume

NL = > 25 seconds

Ejection Fraction

After one toe

> 60% = normal

Venous Filling Index

Blood accumulated per unit time

NL = < 2 mL/s

Residual Volume

Percentage of venous volume

How much volume is pumped from calf after 10 toe raises

NL = < 20 - 35%

Baker's Cyst

Leaking synovial fluid into joint space

Connect to knee joint in medial popliteal fossa

Rupture looks like rat tail

Popliteal Entrapment

Exercise ABI decreases 30-50%

Pain or cramping in calf during exercise

Discoloration

Swelling

Numbness

Untreated = ischemia or arterial damage

Nutcracker Syndrome

Left renal vein compressed by SMA

May-Thurner/Iliac Vein Compression Syndrome

Iliac vein is compressed between iliac artery and vertebral body

More common on left side

Can present as iliofemoral DVT or lower extremity edema/insufficiency

Treated by stent/balloon

Acute Compartment Syndrome

Increased intracompartmental pressure - > 30 mmHg

Diminishes vascular flow and tissue viability

Most commonly caused by fractures

Pain

Pareshthesia

Pallor

Paralysis

Pulselessness

Poikothermia (cold)

Giant Cell Arteritis

Inflammatory immune system disorder

Affects temporal & carotid arteries

Visual & neurological symptoms

Polymyalgia Rheumuatica

Takayasu's Arteritis

Inflammatory disease

Pulselessness of aorta, carotid, & branches

Narrowing & blockages

Macaroni sign

Buerger's Disease (Thromboangitis Obliterans)

Bilateral inflammatory disease of digital arteries in hands and feet

Always related to tobacco use

Fixed occlusive disease process

Ulcerations/gangrene - ¾ limb involvement common

Decreased distal pulses

Iatrogenic Injury/Pseudoaneurysm

Due to percutaneous arterial catheterization, penetrating trauma, or graft anastomosis "blowout"

Treated by compression, surgical repair, or thrombin injection