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Flashcards in Venous disorders Deck (57):
1

Outline the venous anatomy of the leg

  • Superficial: Great saphenous, lesser saphenous, tributaries
  • Deep: Popliteal, anterior tibial, posterior tibial, fibular (located between muscle compartments, around major arteries)
  • Perforators: connect superficial and deep veins

2

Where are venous perforators located?

  • Calf Saphenopopliteal junction (lesser saphenous)
  • Saphenofemoral junction (great saphenous)
  • Mid-thigh

3

Differentiate the great and lesser saphenous veins

  • Great saphenous vein: Dorsum of foot (medial) ➔ anterior to medial malleolus ➔ medial leg and thigh ➔ saphenous opening of deep fascia of thigh ➔ saphenofemoral junction ➔ femoral vein
  • Lesser saphenous vein: Dorsum of foot (lateral) ➔ posterior to lateral malleolus ➔ deep fascia of leg ➔ saphenopopliteal junction ➔ popliteal vein

4

Define varicose veins

Tortuous, dilated, superficial leg veins, associated with valvular incompetence

5

Describe the classification of varicose veins

  • Thread: intradermal dilated veins (pink/purple)
  • Reticular: subdermal 1-2mm diameter (blue)
  • Truncal: long or short saphenous

6

How must varicose veins be assessed and why?

Patient must be standing, otherwise trunkal varicose veins will not be visible.

This is due to gravity's effect on venous blood.

7

How can the aetiology of varicose veins be grouped?

  • Congenital
  • Primary idiopathic (98%)
  • Acquired

8

Describe the pathophysiology of varicose veins

Incompetent valves in the affected vein, which result in reflux of blood and increased pressure in the vein distally.

9

Name a congenital cause of varicose veins

Klippel-Trenaunay syndrome: failure to form blood and/or lymph vessels ➔ port-wine stain, venous/lymphatic malformation, soft tissue hypertrophy

10

Name 2 acquired causes of varicose veins

  • Pelvic mass: pregnancy, tumour, uterine fibroids, ovarian mass
  • Pelvic venous abnormality: AV fistula, DVT, post-pelvic surgery, irradiation

11

Name 4 symptoms in varicose veins

Majority are asymptomatic

Symptoms are associated with trunk varices

  • Pain
  • Aching
  • Itching
  • Swelling
  • Heaviness

12

When are symptomatic varicose veins worse?

  • End of day
  • Hot weather
  • Premenstruation

13

Name 3 complications of varicose veins

  • Bleeding
  • Thrombophlebitis
  • Venous HTN:
    • Oedema
    • Aatrophy blanche, Haemosiderin
    • Venous eczema
    • Lipodermatosclerosis
    • Ulceration (commonly at gaiter region)

14

Why is it important to classify varicose veins?

Reticular and thread varicose veins are not associated with lower limb symptoms ➔ no pathological significance.

Truncal varicose veins are associated with lower limb symptoms

15

Name 3 risk factors for varicose veins

  • Genetics
  • Increasing age
  • Female
  • Pregnancy
  • Obesity
  • Occupation - long periods of standing

16

Name 1 examination and 2 investigations for varicose veins

Trendelenburg (tourniquet) test Handheld doppler - most accurate outpatient tool for Dx of primary varicose veins Colour duplex - Gold standard for defining anatomy and incompetence

17

Describe Trendelenburg (tourniquet) test for varicose veins

Whilst supine, raise leg to empty veins Apply tourniquet high in the thigh (SFJ) Ask patient to stand Look for varicose filling -If filling does not occur, release tourniquet: varicose filling after release suggests SFJ incompetence -If filling does occur: suggests incompetent perforators below level of SFJ Repeat above (mid-thigh) and below knee (SPJ)

18

Outline primary care treatment options of varicose veins

Majority just need reassurance that varicose veins are unlikely to cause complications. Varicose veins in pregnancy are common and tend to improve considerably afterwards. Lifestyle advice: Weight loss and exercise, avoid sitting/standing for long periods, elevate legs when possible. Compression stockings Referral to Vascular services - requires criteria to be met

19

How does thrombophlebitis present?

Tender, inflamed varicose vein with overlying redness and heat and which feels firm owing to the presence of thrombus within the vein

20

What is the NICE criteria for varicose vein referral to secondary care vascular services?

Symptomatic primary or recurrent varicose veins Lower limb skin changes (pigmentation or eczema etc.) due to potential chronic venous insufficiency Superficial vein thrombosis and suspected venous incompetence Venous leg ulcer ➔ 2 week referral Healed venous leg ulcer

21

Outline secondary care treatment options of varicose veins

Surgical removal or ligation Foam sclerotherapy Endothermal ablation

22

Define leg ulcer

Break in the skin below the knee Has not healed within 2 weeks

23

Name 4 vascular causes of leg ulcers

Venous (85%): venous HTN and varicose veins Arterial: atherosclerosis, AV malformation Vasculitis: SLE, RA, scleroderma, PAN, GPA Lymphatic

24

Name a neuropathic cause of leg ulcers

Diabetic neuropathy Peripheral neuropathy

25

Name a haematological cause of leg ulcers

Polycythaemia rubra vera (increased RBC mass and blood volume) Sickle cell anaemia

26

Name 2 traumatic causes of leg ulcers

Burns Cold injury Pressure sore Radiation

27

Name 2 neoplastic causes of leg ulcers

BCC SCC Melanoma Bowen's disease (In situ squamous cell carcinoma)

28

Name 1 other cause of leg ulcers

Sarcoidosis Tropical ulcer Pyoderma gangrenosum

29

Describe the distribution of venous leg ulcers

Calf 5% Gaiter 87% - calf muscle pump failure ➔ venous ulcer Foot 8%

30

Outline the management of venous ulcers

*exclude arterial insufficiency and other causes Venous duplex colour scan Compression bandages -ABPI >0.8 ➔ 4-layer bandaging -ABPI >0.5 ➔ 3-layer bandaging

31

Describe preventative measures of venous ulcer recurrence

Keep mobile Varicose vein surgery - remove, ligate, or fuse Below knee class 2 (anti-emboli) compression stocking

32

Describe the pathophysiology of deep venous thrombosis

Virchow's triad -Stasis -Endothelial injury -Hypercoagulability

33

Name 3 causes of hypercoagulability

Inherited: Factor V Leiden Protein C and S deficiency ATIII deficiency Acquired: Surgery Malignancy Sepsis Polycythaemia Smoking HRT OCP Dehydration

34

Name 3 causes of stasis

Immobility and travel (esp. flying) Trauma Mass/obstruction Paralysis

35

Name 3 causes of endothelial injury

Trauma Surgery Atherosclorsis Iatrogenic - catheters, venepuncture

36

Describe clinical features of deep vein thrombosis

*May be absent Local: Swelling Pain Erythema and warmth Mild fever and tachycardia

37

Name 2 complications of deep venous thrombosis

Pulmonary embolism* - do CTPA if suspected Venous gangrene (phlegmasia caerulea dolens) - occlusion of both superficial and deep veins

38

What is the investigation of choice for DVT?

Duplex scan

39

Name 4 continuous risk factors for DVT

Previous DVT Cancer Increasing age Obesity Male Heart failure Acquired/familial thrombophilia Chronic low-grade injury to vasculature: vasculitis, hypoxia from stasis, chemotherapy etc.

40

Name 3 temporary risk factors for DVT

Immobility Significant trauma or direct trauma to vein Hormone treatment Pregnancy and postpartum period Dehydration

41

What are the typical signs of DVT?

Pain and swelling in one leg Tenderness Changes to skin colour Temperature Vein distension

42

Name 3 differential diagnoses for DVT

Physical trauma Cardiovascular disorders: superficial thrombophlebitis and post-thrombotic syndrome Ruptured baker's cyst Cellulitis

43

What is post-thrombotic syndrome?

Post-DVT development of chronic leg pain, swelling, erythema, and ulcers

44

What scoring system is used to assess DVT risk?

Two-level DVT Wells score

45

What scoring system is used to assess PE risk?

PE Wells score - original or simplified

46

Outline the two-level PE Wells score

Well's criteria for Pulmonary embolism: -PE unlikely if 4 or less -PE likely if more than 4 Clinical sign of DVT - 3 Alternative Dx is less likely than PE - 3 Previous PE or DVT - 1.5 Heart rate >100 bpm - 1.5 Surgery or immobilisation within 4 weeks - 1.5 Haemoptysis - 1 Active cancer - 1

47

Outline the two-level DVT Wells score

Following score 1 point each: -Active cancer -Bedridden recently >3d or major surgery within 4wk -Calf swelling >3cm compared to asymptomatic leg -Collateral superficial veins (non-varicose) -Entire leg swollen -Local tenderness along deep veins -Pitting oedema of symptomatic leg only -Paralysis, paresis, or recent plaster immobilisation of lower extremity -Previously documented DVT Following scores -2: -Alternative Dx at least as likely as DVT DVT unlikely: 1 or less DVT likely: 2 or more

48

Outline the initial investigation of patients with likely DVT (2+ Wells score)

  • Proximal leg vein USS within 4hr
  • Otherwise,
    • D-dimer test
    • Interim 24hr treatment dose LMWH
    • Proximal leg USS request

49

Outline the initial investigation of patients with unlikely DVT (<2 Wells score)?

D-dimer test:

  • If +ve, manage as likely DVT
  • If -ve, consider alternative Dx

50

Outline the management of confirmed DVT

  • Lifestyle
    • Walk regularly
    • Elevated affected leg when sitting
    • Refrain from extended travel and flights for at least 2wk from starting anticoagulation
  • Class 2/3 compression stockings for 2 yr
  • Maintenance oral warfarin or rivaroxaban
    • Warfarin target INR 2.5 (2.0-3.0)
    • Provoked: 3+ months
    • Unprovoked: 6+ months
    • Provoked w/ cancer: 6+ months of LMWH

 

51

What is the benefit of using Rivaroxaban over Warfarin?

Rivaroxaban (NOAC) does not require coagulation monitoring or regular dose adjustment

52

What investigations should be considered in unprovoked DVT?

  • Cancer investigations
  • Thrombophilia testing

53

Name 2 contraindications of oral anticoagulation therapy

  • Cancer
  • Pregnancy

54

Differentiate venous and arterial insufficiency

Venous: Heavy, aching Swelling esp around ulcers, and end of day Worsens when standing Improves with elevation and activity Pulses present Arterial: Sharp cramping pain Swelling is rare Tired leg/hip muscles Worsens with activity Improves with rest Pulses absent or diminished

55

What secondary care investigations may be performed in suspected PE?

  • CTPA: Likely PE (Wells score >4)
  • D-dimer: Unlikely PE (Wells score 4 or less)
  • ABG
  • CXR and ECG: exclude alternative Dx
  • Echocardiogram: Massive PE

56

Outline the initial investigation of patients with likely PE (>4 Wells score)

  • CTPA
  • If delayed,
    • Interim LMWH
    • Arrange hospital admission

57

Outline the initial investigation of patients with unlikely PE (4 or less Wells score)

D-dimer test

  • If +ve, investigate as likely PE
    • CTPA or bridge with LMWH and admit
  • If -ve, consider alternative Dx