Vascular I - Test 2 Review

Purpose of compressions in venous tests

To check for blood clots/DVTs

How do you compress during venous tests?

Apply pressure with probe periodically

How will a normal vs. abnormal vein look like during compression?

Normal = compressible

Abnormal = non compressible (clot)

Purpose of augmentation in venous tests

To check valve competency

How do you augment in venous tests?

Squeeze the leg to push blood towards heart

What does a normal vs. abnormal vein look like during augmentation?

Normal = spike in Doppler during augment

Abnormal = no spike during augment

What is the Valsalva maneuver?

Patient holds breath in & bears down

Purpose of Valsalva maneuver

Tests valve competence in veins near upper body & groin

Examples of differential diagnoses aside from a DVT?

Muscle strain/tear

Baker’s cyst

Cellulitis

Lymphedema

Heart failure

Extrinsic compression

Complications with CVI

What happens to venous flow in UE & LE during INSPIRATION?

UE venous flow increases

LE venous flow decreases

What happens to venous flow in UE & LE during EXPIRATION?

LE venous flow increases

UE venous flow decreases

Signs of normal LE venous flow

Phasic with respiration

Non pulsatile

Signs of abnormal venous flow

Continuous flow (non Phasic)

Pulsatile

What venous flow is normally seen in UE (close to the heart)? Why?

Pulsatile because they’re close to the heart

What’s a pulmonary embolism?

Blood clot that detaches & travels to lungs

What artery does a pulmonary embolism block?

Pulmonary artery

Name the deep calf veins

Anterior tibial veins

Posterior tibial veins

Peroneal (Fibular) veins

Soleal veins

Gastrocnemius veins

Name the superficial calf veins

Great saphenous vein

Small saphenous vein

Name the perforating veins

Cockett perforators

Boyd perforators

Name the paired veins in calf

Anterior tibial veins

Posterior tibial veins

Peroneal veins

Gastrocnemius veins

What is an IVC filter?

Device placed in IVC to capture blood clots (so it doesn’t reach the lungs or heart)

What would pulsatile flow in LE veins indicate?

CHF/right sided heart failure

When would you see continuous flow in LE?

Abnormal

Indicates potential clot

What is May-Thurner Syndrome?

Right iliac artery compresses the left iliac vein

Blocks blood flow

What is SVC syndrome?

Obstruction of SVC

Long term effects of DVT in lower extremity

Damage to vein valves, edema, recurring DVTs

What is a venogram (venography)?

Test for DVT by injecting contrast agent into the vein

Used to be considered gold standard for DVT diagnosis

How is conventional venography assessed?

Using fluoroscopy (X Ray)

What are the 2 types of venography?

Ascending and descending

What does Ascending Venography assess?

Deep vein patency

(Observed ascending up the leg)

Where is the contrast injected for ascending Venography?

Foot

What does Descending Venography assess?

Valvular incompetence

Where is the contrast injected for Descending Venography?

At CFV

(Observed descending down the leg)

What is Ventilation Perfusion (VQ) Lung Scan?

Nuclear medicine to detect the probability of pulmonary embolism

In VQ scans, what type of contrast is injected into the arm?

Radioactive contrast

What is currently the “gold standard” for PE detection?

VQ (ventilation perfusion) lung scans

Tells you high, medium, or low probability of PE

What does it mean when venous flow is spontaneous?

Once you put your probe on the vessel, you can easily find blood flow

(The blood moves on its own without any extra pressure/compression)

What do you see on the ultrasound during distal augmentation? What does it represent?

Spike on Doppler representing surge of blood flow past the probe

What happens to venous pressure when lying down?

Decreases

What happens to venous pressure when standing up?

Increases

Characteristics of the superficial venous system

No associated artery & runs alone

Lies immediately beneath skin surface

Characteristics of the deep venous system

Parallel to an artery

Lies deep within fascia

What are the different types of tests for DVT?

Duplex Ultrasound, venography, MRV, & D-Dimer

What is MRV?

Magnetic Resonance Venography

Purpose of MRV

Diagnostic test, checks for DVT in abdominal veins

What technology does MRV use?

MRI technology

What is the most reliable symptom for Acute DVT?

Unilateral LE edema

What is Homan’s Sign?

Dorsiflexion of the foot at ankles

Knee is flexed 90 degrees

Is Homan’s sign an accurate test?

No

What are reliable symptoms of upper extremity DVT?

Unilateral, painful

Non-pitting edema

Cyanosis or redness

What is the D-Dimer test?

Blood test that indicates breakdown of fibrin

How accurate is the D-Dimer test?

Not accurate

Many people may have a positive D-Dimer without a DVT (i.e., menstruating women)

What are signs of IVC or iliac vein thrombosis?

• Entire leg swollen with no evident thrombus in LE

• Unilateral, continuous flow in CFV

What are symptoms of pulmonary embolism?

Unexplained shortness of breath

Chest pain (worse when inhaling)

Rapid heart rate

Unexplained coughing

Coughing up blood

What are anticoagulants?

Blood thinners

Name anticoagulant medications

Heparin

Lovenox

Warfarin (AKA Coumadin)

How does Heparin help with blood clots?

Interferes with clot formation, but does not dissolve clot

How is Heparin administered?

IV injection over 5-10 days

How is Lovenox administered?

Subcutaneous injection

What’s another name for Warfarin?

Coumadin

How does Warfarin help with blood clots?

Interferes with Vitamin K synthesis

How is Warfarin administered?

Long term oral therapy

What are two acquired disorders associated with blood clots?

Antiphospholipid antibody syndrome (lupus)

Trousseau syndrome (associated with malignancies)

What inherited protein deficiencies are associated with blood clots?

Protein S

Protein C

Antithrombin III

What genetic disorders are associated with blood clots?

Factor V Leiden

Factor II Prothrombin

What’s the most common hereditary blood disorder in the U.S.?

Factor V

What are predisposing conditions/risk factors for DVT?

Immobility

Recent surgery

Injury or trauma

Genetics

Pregnancy

Cancer

Female

Over age 40

Hormone medication

Over 6’1”, etc.

What are risk factors specifically to upper extremities?

Intimal injury (catheter or pacer)

IV drug use

Vein puncture

Compression of thoracic outlet

What does it mean when a vein has high transmural pressure?

Pressure inside the vein is higher than the pressure outside the vein

What does it mean when a vein has low transmural pressure?

Pressure inside the vein is equal to or less than the pressure outside the vein

Is transmural pressure higher or lower when standing?

Higher

Is transmural pressure higher or lower in supine position?

Lower

What is lymphedema?

Chronic swelling due to blockage

If a patient has incompetent LE valves, what would you see on the ultrasound?

Retrograde flow

What is currently the gold standard test for DVTs?

Duplex ultrasound

What is the function of soleal veins?

Deep calf veins that act as blood reservoirs

What’s the function of gastrocnemius veins?

Deep, paired calf veins that drains blood from the gastrocnemius muscles

What does normal spectral Doppler flow look like?

Spontaneous, Phasic, non-pulsatile

Should blood flow cease with Valsalva maneuver?

Yes, that is a sign of normal flow!

Should Doppler signal augment with distal compression?

Yes, that is a sign of normal flow!

What does “no distal augmentation” suggest?

Distal DVT or extrinsic compression distally

What does non-spontaneous venous flow in CFV, FV, or Pop V suggest?

Distal DVT or extrinsic compression distally

What does continuous flow in LE veins suggest?

Proximal DVT or extrinsic compressional proximally

Should there be spontaneous flow in calf veins? Why or why not?

No, because they’re very small and far from the heart