Vascular - Test 3 (Jo's & Mine)

brachial and basilic veins combine to form what?

axillary vein

axillary vein and cephalic vein form what?

subclavian vein

lateral and medial veins are connected by what?

median cubital vein

transmural pressure

the difference between intraluminal (inside) pressure and interstitial (outside) pressure

• determines cross sectional shape of the vessel

interstitial pressure

the pressure surrounding tissue

hydrostatic pressure

equivalent to the weight of a column of blood extending from the heart to the level where the pressure is being measured

when you do valsalva, what should happen?

you should not see flow on spectral doppler because the whole venous system stops

what does it mean if you see flow on spectral doppler during valsalva?

venous reflux/insufficiency

varicose veins

palpable, distended veins that are > 4 mm in diameter

phlegmasia alba dolens

rare complication of DVT during pregnancy where leg turns milky white

phlegmasia cerulea dolens

similar condition to “alba” except this is when severely reduced venous flow markedly reduces arterial inflow and the leg becomes cyanotic and has a bluish discoloration

May-Thurner syndrome (MTS)

a condition in which compression of the common venous outflow tract of the left lower extremity MAY cause discomfort, swelling, pain or blood clots (DVT) in the iliofemoral veins

how many valves does GSV have?

10-12

how many valves does LSV have?

6-12

how many valves does soleal sinuses have?

none

how many valves do the perforators have?

1 each

how many valves do the calf veins have?

9-12 each

how many valves do the popliteal and SFV have?

1-3 each

how many valves does the CF have?

1

how many valves does the external iliac vein have?

has them 25% of the time

how many valves do the common and internal iliac veins have?

none

how many valves does the IVC have?

none

how many valves does the IJV have?

1

paired posterior tibial veins

empty the back of the leg and carry blood to the tibioperoneal trunk

paired anterior tibial veins

empty the front of the leg and join the tibioperoneal trunk just below the knee to form the popliteal vein

popliteal vein

becomes the superficial femoral vein at the adductor canal, turning into the common femoral vein at the inguinal ligament

lower extremity deep veins

• paired posterior tibial

• paired anterior tibial 

• popliteal

leg veins

perforators

veins that connect superficial veins to the deep veins

perforators

contain one-way valves to direct blood from superficial to deep, but never deep to superficial

perforators

• Cockett

• Boyd’s

• Dodd’s

• Hunterian

Boyd’s perforators

• connect GSV to posterior tibial vein

• common sites for primary varicose veins

Hunterian perforators

connect GSV to the superficial femoral vein

perforators to know

upper extremity veins

clinical findings for DVT

swelling, pain, redness (erythema), skin warmth

acute venous clinical findings

swelling, pain, redness, warmth

chronic venous clinical findings

swelling, heaviness, discoloration/ulcerations, and varicosities

Virchow’s triad

1. trauma to the vessel

2. venous stasis

3. hypercoagulability

the development of venous thrombosis can be summarized based on three factors known as:

Virchow’s Triad

hypercoagulability (blood chemistry) »

Hemaglide Vitamin E & C

vessel injury (trauma) »

Hemaglide Quercetin

venous stasis (blood flow) » 

Hemaglide Nattokinase, Raspberry extract

know this

examples for hypercoagulable state

• malignancy

• pregnancy and peri-partum period

• oestrogen therapy

• trauma or surgery of lower extremity, hip, abdomen or pelvis

• inflammatory bowel disease

• nephrotic syndrome

• sepsis

• thrombophilia

vascular wall injury examples

• trauma or surgery

• venepuncture

• chemical irritation

• heart valve disease or replacement

• atherosclerosis

• indwelling catheters

examples of circulatory stasis

• atrial fibrillation

• left ventricle dysfunction

• immobility or paralysis

• venous insufficiency or varicose veins

• venous obstruction from tumor, obesity or pregnancy

venous ulcers

• location: near medial malleolus

• pain: none to mild

• appearance: shallow, irregular

• bleeding: ooze

• other: brawney color, presence of variosities

arterial ulcers

• location: tibial area, toes, bony structures

• pain: severe

• appearance: deep, regular

• bleeding: little

• other: shiny skin, loss of hair, thickened toenails

what causes phlegmasia alba dolens?

unclear, but edema may increase soft tissue pressure leading to ischemia and wet gangrene

phlegmasia cerulea dolens

severe form of DVT where there’s a massive iliofemoral venous thrombosis that causes almost total venous occlusion

what is phlegmasia cerulea dolens characterized by?

• ischemia

• marked limb swelling

• extreme pain

• cyanotic

VENOUS GANGRENE IF LEFT UNTREATED

what primarily triggers phlegmasia cerulea dolens?

• malignancy

• CFV catheterization

• heparin-induced thrombocytopenia

• antiphospholipid syndrome

• surgery

• heart failure

• pregnancy

may-thurner syndrome

also known as the iliac vein compression syndrome

MTS

veins

highly compliant, explanding and contracting according to intraluminal pressure changes

when a person is supine, what is their transmural pressure?

low » a vein assumes a dumbell shape

when a person is supine, what is their hydrostatic pressure?

around 15 mmHg » rises to around 100 mmHg when patient stands

What is plethysmography?

Volume flow studies

What is venous photoplethysmography (PPG)?

Test that measures capillary volume and can evaluate presence and severity of venous reflux or insufficiency

How does photoplethysmography (PPG) work?

Photocell sensor transmits infrared light into tissues to be reflected back to sensor and converted into waveforms or analog

What is the photoplethysmography (PPG) technique?

1. Sensor applied above medial malleolus

2. Patient completes 20-25 dorsiflexions to empty veins

3. VRT calculated to determine need for further testing

What is a VRT?

Venous refill time

What is a normal value for VRT?

> 20 seconds

Identify this image.

Normal PPG as VRT > 20 seconds

Identify this image.

Abnormal PPG as VRT < 20 seconds

What is the photoplethysmography (PPG) technique used if the initial VRT is abnormal?

1. BP cuff below knee to test LSV: VRT NORMALIZES to > 20 secs with inflated cuff below knee is consistent with reflux (retrograde flow) of LSV

2. BP cuff above knee to test GSV: VRT NORMALIZES to > 20 secs with inflated cuff above knee is consistent with reflux (retrograde flow) of GSV

3. Both systems: VRT < 20 seconds with AND without inflated BP cuffs is consistent with insufficiency of deep and superficial venous systems

4. Thigh: VRT < 20 seconds with a cuff in place on thigh indicates deep venous insufficiency or reflux

What is duplex imaging?

Combination of b-mode and PW Doppler to create images and measure blood flow

What are the advantages of duplex imaging?

1. Rule out or identify thrombus

2. Identify thrombus type (acute, subacute, etc)

3. Diagnose venous incompetence

Which venous characteristics should be checked when using duplex imaging for a lower extremity examination?

1. Compressibility: Normal veins compress

2. Spontaneity: Normal flow is audible and consistent

3. Phasicity: Normal flow is phasic with respiration

4. Augmentation

5. Valsalva Maneuver

6. Pulsatility

Identify this image.

Abnormal aphasic flow due to undiagnosed occlusion

What is the normal venous response with augmentation?

1. Normal distal augmentation: Visual and audible signal

2. Normal proximal augmentation: NO visual and audible signal (augmentation during proximal compression is consistent with venous reflux)

Identify this image.

Normal LEV augmentation

What is the normal venous response with valsalva maneuver?

1. Normal: Venous flow augmented following maneuver

2. Abnormal: Augmentation during maneuver is consistent with reflux

When might pulsatility be present in veins?

1. Fluid overload

2. CHF

3. Right heart failure

What position should the patient be in for duplex imaging of the lower extremity?

Reverse Trendelenburg’s or Semi-Fowler’s position with head higher than heart

What is reflux evaluation?

Test used to assess for DVT complications

What is the technique used for a reflux evaluation?

1. Rule out chronic venous outflow obstruction by assessing compressibility, phasicity, and augmentation

2. Evaluate vessels for reflux

Which vessels are used to evaluate for venous reflux?

1. CFV

2. Proximal femoral vein

3. Popliteal vein

What is the sonographic appearance of venous reflux?

Retrograde flow following augmentation seen as change in color Doppler

What is the normal response to venous reflux testing?

1. Cessation of flow with proximal compression

2. Returning flow upon release

What is the reflux duration criteria that indicates venous reflux?

1. Deep veins: ≥ 1 second

2. GSV and SSV ≥ 0.5 seconds

3. Perforating veins ≥ 0.35 seconds

(T/F) Longer reflux durations are seen in those in the supine position.

True

Identify this image.

Abnormal study seen as venous reflux

What is vein mapping?

Exam performed to determine if GSV or radial vein is suitable for CABG procedure

What is the criteria assessed when performing a vein mapping procedure?

1. Suitability

2. Presence or location

3. Patency

4. Size

What is the required vein diameter in order to be used in a CABG procedure?

2.5 mm

What is the gold standard of venous exams?

Contrast venography

What is contrast venography?

Invasive test that consists of injecting contrast into veins and x-ray shows any filling defects

(T/F) Heparin dissolves clots.

False; Heparin PREVENTS GROWTH of clots

What is radiofrequency ablation?

Minimally invasive procedure that uses catheter-based techniques to heat and destroy varicose veins

What is vein stripping?

Invasive procedure performed under general anesthesia in which small incisions allow removal of individual varicose vein clusters

What is sclerotherapy?

Minimally invasive procedure performed while patient is standing in which a salty solution is injected into varicose veins to scar and close them

What is a thrombectomy?

Procedure that removes a blood clot or thrombus from a vessel by using a catheter-based device and a stent to restore blood flow

Which conditions could a thrombectomy resolve?

1. Acute cerebral ischemic stroke

2. Pulmonary embolism (PE)

3. Acute myocardial infarction (MI)

What is endovenous ablation therapy?

Non-surgical procedure that uses heat, chemicals, glue, or a wire to damage and close off varicose veins

What is laser light therapy (EVLA)?

Procedure used to compliment or replace vein stripping that uses a light beam on varicose vein to seal it off, causing vein to dissolve from heat

What is laser therapy?

Procedure in which a laser fiber is inserted through skin, directly into
varicose vein to damage, collapse, shrink, and reabsorb it back into body

What is a microphlebectomy?

Minimally invasive procedure in conjunction with sclerotherapy to remove varicose veins

The venous puncture for introducing contrast in venography to assess for deep venous thrombosis is done at what level?

Dorsal vein on foot