CH 31-33: alternative diagnostic tests, medical therapies, surgical and endovascular therapies

Alternative diagnostic tests related to venous diseases fall into 2 main categories.

What are they?

• Diagnostic tests for possible venous thrombosis or venous reflux

• Evaluation for a pulmonary embolism (PE)

Which 2 factors are considered when ruling out a venous thrombosis and/or reflux?

• D-dimer

• Contrast venography

D-dimer is a…

Lab value

What does ‘PE’ stand for?

Pulmonary embolism

Describe what ‘D-dimer’ is.

Protein fragment that is produced when a blood clot dissolves in the body

Name the lab:

“Protein fragment produced when a blood clot dissolves in the body”

D-dimer

D-dimer is normally __________ in the blood.

Undetectable

When is D-dimer measurable?

When a clot is breaking down

When there is an increase in clot breakdown, what can that result in?

Rise in D-dimer levels in the blood

High levels of D-Dimer can suggest what?

Presence of a thrombus

A high level of which lab can suggest the presence of a thrombus?

D-Dimer

Positive D-Dimer lab results have little (1)__________, but points to the need for (2)_____________________.

1. Specificity

2. Additional testing

Because D-Dimer does not specify if there is a (1)______, what can it be an indicator for instead(2)?

1. Clot

2. Extra testing

Which 2 factors does D-Dimer lack?

• Specificity

• Positive Predictive Value (PPV)

What does ‘PPV’ stand for?

Positive predictive value

List the 5 conditions/pathologies/procedures that D-Dimer elevation will be seen in.

• Pregnancy

• Liver disease

• Renal disease

• Cancer/Any thrombotic processes

• Recent surgery

A positive D-Dimer result is consistent with which 2 pathologies?

• Lysis

• Breakdown of thrombus

A negative D-Dimer will imply, but not be conclusive, for what pathology?

Absence of a thrombus process

What imaging modality is considered the gold standard in regards to DVTs/Venous Testing?

Ultrasound

Which procedure’s use has decreased due to the accuracy of venous ultrasound exams?

Contrast venography

Which imaging modality is seen here?

Contrast venography

Contrast venography is capable of…

1. Helping in the evaluation of ___________.

2. Evaluates congenital _________ disease and/or __________.

3. Assists in the evaluation of ________________ changes.

4. Can detect and quantify _________________.

1. Acute DVT

2. Venous, Anomalies

3. Chronic venous

4. Reversed flow

Reversed flow is essentially…

Reflux

List the 2 types of venograms that are performed.

• Ascending

• Descending

Ascending venograms images veins from _________ to _________.

Distal to Proximal

Descending venograms images veins from _________ to _________.

Proximal to Distal

Which venogram images veins from distal to proximal?

Ascending

Which venogram images veins from proximal to distal?

Descending

An ascending venogram detects which 2 abnormalities?

• Venous abnormalities

• DVT

A descending venogram assesses which 2 factors?

• Valve function

• Venous reflux

Which venogram detects venous abnormalities, including a DVT?

Ascending

Which venogram assesses valve function and venous reflux?

Descending

Which venogram requires contrast to be injected into a distal superficial vein and directed into the deep system?

Ascending

An ascending venogram requires contrast to be injected into a (1)_______________________ and directed into the (2)_______________.

1. Distal superficial vein

2. Deep system

If contrast is injected into the lower extremity for an ascending venogram, which vein is used?

A vein on the dorsum of the foot

If contrast is injected into the upper extremity for an ascending venogram, which 2 veins can be used?

• Basilic vein

• Cephalic vein

Label which arrow is ascending and descending.

Purple = Ascending

Blue = Descending

Which venogram only evaluates the lower extremity?

Descending

If contrast is injected into the lower extremity for an descending venogram, which vein is it usually injected into?

Common femoral vein (CFV)

Any deviation of normal is evidence of ___________ as seen on ascending venography.

Obstruction

On an ascending venogram, a filling defect can indicate the (1)____________ of contrast material by (2)_________.

1. Displacement

2. Thrombus

On descending venography…

1. What pathology is evidence of reflux?

2. It is evidence of reflux in what vessels?

1. Retrograde filling

2. Common femoral vein (CFV) / Femoral vein (FV)

What pathology is seen here?

Varicose veins

1. Does this vein look normal or abnormal?

2. If abnormal, what pathology would it be?

1. Normal

1. Does this vein look normal or abnormal?

2. If abnormal, what pathology would it be?

1. Abnormal

2. Varicose veins

List the 3 procedures used to evaluate pulmonary embolisms.

• Lung ventilation / Perfusion scan / V/Q scan

• Pulmonary angiography

• Computed tomographic angiography (CTA) of the chest

What does ‘V/Q’ stand for?

Ventilation quotient

Lung ventilation / perfusion scan / V/Q scan is from what imaging modality?

Nuclear medicine

Lung ventilation / perfusion scan / V/Q scan measures for which 2 factors in the lungs?

• Air

• Blood flow

Lung ventilation / perfusion scan / V/Q scan is a screening test for the detection of _________ defects of the lungs.

Perfusion

Which procedure measures air and blood flow in the lungs?

Lung ventilation / perfusion scan / V/Q scan

Which procedure is a screening test for the detection of perfusion defects in the lungs?

Lung ventilation / perfusion scan / V/Q scan

Pulmonary angiography is from what imaging modality?

Flouroscopy

Pulmonary angiography is used to evaluate the (1)__________ arteries for a (2)____________________.

1. Pulmonary

2. Pulmonary embolism

Which procedure is used to evaluate the pulmonary arteries for pulmonary embolism?

Pulmonary angiography

Which procedure is the study of choice to evaluate pulmonary embolisms?

Computed tomographic angiography (CTA)

1. Which imaging modality is used for this image?

2. This modality can be used to look for what pathology?

1. Computer tomographic angiography (CTA)

2. Pulmonary embolism

1. List the 3 causes of venous thrombosis.

2. What is the name of all 3 factors combined?

1. • Venous stasis

   • Trauma

   • Hypercoagulability

2. Virchow’s Triad

Which 2 factors decrease the chance of venous stasis?

• Limit long periods of inactivity / bed rest

• Promote venous drainage when patient is inactive

List 4 techniques that helps promote venous drainage/decreases venous stasis.

• Leg elevation

• Support stockings

• Pneumatic compression devices

• Weight management

How can trauma be controlled before becoming a venous thrombosis?

By preventing injury or infection of the extremity

To prevent venous thrombosis, the sonographer should be aware of hypercoagulability ______/______.

States/Factors

Virchow’s triad is associated with which pathology?

Venous thrombosis

1. What is seen in this image?

2. What can this promote?

3. What can it help prevent?

1. Support stockings

2. Promotes venous drainage

3. Venous stasis (Venous thrombosis)

What treatment is used to decrease the risk of venous thrombosis in a high risk population?

Medications

Anticoagulation therapy can be used for what 3 pathologies?

• Disease

• Acute DVT

• Pulmonary embolism

What kind of medication is Lovenox?

Low molecular weight heparin

What kind of medication is Arixtra?

Low molecular weight heparin

Which 2 medications are used to decrease the risk of venous thrombosis in high risk populations?

• Unfractioned heparin

• Low molecular weight heparin

List the 2 types of low molecular weight heparin that are commonly in use today.

• Lovenox

• Arixtra

When using heparin to treat acute DVT and pulmonary embolism, continuous (1)________ until oral (2)____________ is deemed (3)_________, usually in (4)__-__ days.

1. Infusion

2. Anticoagulation

3. Therapeutic

4. 4-5

List the 2 anticoagulation therapies used to treat acute DVT and pulmonary embolisms.

• Heparin

• Oral anticoagulation (Warfarin/Coumadin)

What is the brand name of Coumadin that is typically administered?

Warfarin

Dosage of Warfarin/Coumadin is regulated to ensure that the patient’s (1)_____________ is (2)____-____ times more normal.

1. Prothrombin time (PT)

2. 1.5-2

With surgical and endovascular therapies, list the 3 sonographer role and clinical preparations.

• Role of the sonographer

• Clinical information

• Informed consent

The 3 roles of the sonographer for surgical and endovascular therapies…

1. Assist physician with real time imaging guidance during _________ procedures (e.g., biopsies, vascular access, thrombin injection)

2. Optimize imaging _______ and transducer _________

3. Maintain patient _______ and ________

1. Vascular

2. Settings, Selection

3. Safety, Comfort

The 3 points of clinical information that should be taken down for surgical and endovascular therapies are…

1. Review relevant patient ________ (e.g., coagulability, allergies, prior interventions)

2. Verify procedure ______ and ___________

3. Know __________ and variations of ___________

1. History

2. Order, Indication

3. Anatomy, Anatomy

The 3 points of informed consent that should be taken down for surgical and endovascular therapies are…

1. To ensure _______________ is obtained by providers performing the procedure

2. Confirm consent is ________, _________, and includes procedure specific risks

3. Be prepared to answer basic patient ________ or refer to the provider for more detail

1. Informed

2. Signed, accurate

3. Questions

With surgical and endovascular therapies, the safety protocols and sterile techniques to keep in mind are…

1. Procedural _________

2. ______ technique

1. Time out

2. Sterile

What is performed immediately before a procedure begins?

Procedural time out

A procedural time out will include which 3 things?

• Correct patient identity

• Correct procedure

• Correct site and side

A procedural timeout must be (1)___________ and (2)________ confirmed by the team.

1. Documented

2. Verbally

List the 5 tips to keep in mind for sterile techniques? (Including PPE)

• Sterile gloves

• Sterile gel and probe cover if contacting sterile field

• Disinfect skin

• Maintain sterile field throughout procedure

• Avoid crossing over sterile field or contaminating instruments

1. Why does the probe appear this way?

2. What materials are on it?

1. To maintain sterile field

2. Probe cover and sterile gel

With surgical and endovascular therapies, list the 2 documentation and post procedure care documentations.

• Pre-procedure documentation

• Post-procedure documentation

With pre-procedure documentations, the sonographer should confirm and document…

1. Patient _______ and ________

2. Pre-procedure _________ findings

3. ___________ (if applicable)

1. Identity and consent

2. Imaging

3. Site marking

With post-procedure documentations, the sonographer should record…

1. Any ___________ or __________

2. Immediate ________ (e.g., successful access or hematoma)

3. Post-procedure _________ or ________ (if applicable)

1. Complications or observations

2. Outcomes

3. Imaging or compression

Remember, clear and accurate documentation is essential for what 3 purposes?

• Legal

• Clinical

• Quality assurance

Varicose veins are a result of…

1. Chronic _______________________

2. ____ pressure in the veins due to loss of ______ function or _________

1. Ambulatory venous hypertension

2. High, Valve, Obstruction

Which pathology is a result of chronic ambulatory venous hypertension?

Varicose veins

Which pathology is a result of high pressure in the veins due to loss of valve function or obstruction?

Varicose veins

Varicose veins are associated with what 6 risk factors?

• Pregnancy

• Heredity

• Prolonged standing

• Trauma

• Age

• Obesity

1. Are these veins normal or abnormal?

2. If abnormal, what pathology is seen here?

1. Normal

1. Are these veins normal or abnormal?

2. If abnormal, what pathology is seen here?

1. Abnormal

2. Varicose veins

Define ‘ablation.’

Destruction of a body part’s function

What procedure uses heat energy to close off the diseased vein?

Superficial venous ablation

What does superficial venous ablation use to close off the diseased vein?

Heat energy

If a superficial venous ablation cannot be performed, what other procedure can be considered?

Microphlebectomy

Define ‘microphlebectomy.’

Surgical removal of the diseased vein

What is the most common cause of varicose veins?

Incompetence of the great saphenous veins (GSV)