Peripheral Vascular System Lecture PDF

Peripheral Vascular System Part 2 Venous Disorders Jacqueline Gil, MS, PA-C Clinical Coordinator Touro College PA Program https://www.youtube.com/watch?v=itn_MRGqaY8 1 Venous Disease  Thrombophlebitis – Superficial / Deep  DVT  Chronic Venous Insufficiency  Varicose Veins 2 Small sapheno...

Peripheral Vascular System Part 2 Venous Disorders Jacqueline Gil, MS, PA-C Clinical Coordinator Touro College PA Program https://www.youtube.com/watch?v=itn_MRGqaY8 1 Venous Disease  Thrombophlebitis – Superficial / Deep  DVT  Chronic Venous Insufficiency  Varicose Veins 2 Small saphenous vein and its tributaries 3 Valves in veins prevent backflow Normal Vs Varicosed 4 Vascular web Examination for Venous Insufficiency Inspection  Edema  Size / Symmetry  Discoloration  Stasis dermatitis  Skin texture Palpation  Warmth  Tenderness  Pitting  Cord  Varicosities  Ulcers 5 Special Tests for Venous Insufficiency  Test for incompetent Saphenous Veins • (venous mapping)  Test for Retrograde filling  Trendelenburg Test  Positive-positive = rapid filling with compression and sudden additional venous filling after removal of compression https://www.youtube.com/watch?v=RM0u0s0D_p4 6 Thrombophlebitis  Partial or complete occlusion of a vein by thrombus with inflammatory changes in superficial OR deep veins  SUPERFICIAL:  Tender palpable cord with warmth and erythema and swelling…….. + / - Fever  Commonly from IV insertion  Treat with warm compresses, elevate limb, NSAID’s and ABX if infection develops  DEEP:  Unilateral swelling, erythema, tenderness, pain, warmth and tenderness foot and /or calf; (5% are in subclavian vein) Symptoms often lacking or minimal in deep DVT 7 Phlebitis DEEP SUPERFICIAL 8 Acute Deep Venous Thrombosis (DVT)  1 -2/ 1000 per year in US  1 – 5% die from DVT/Pulm Emb (60-100,000/yr)  10-30% wihtin 1st month of DX  50% will have long-term complications  MC affects the lower extremity and pelvis  80% occurs in the Calf (tibial veins and soleal sinuses)  Most Calf DVT will not cause PE Most PE from popliteal veins and above 9 https://www.cdc.gov/ncbddd/dvt/data.html 10 Risk Factors DVT  Inherited  Acquired  Hereditary, Environmental or Idiopathic Most common cause is hospitalization or recent surgery 11 Inherited Risks DVT  Factor V Leiden mutation >> Hypercoagulability  Prothrombin gene mutation (G20210A)  Prothrombin protein, Factor II, helps blood to clot  Excess of this protein can lead to hypercoagulation  Antithrombin III deficiency  Thrombin cleaves fibrinogen to fibrin which helps form clot  Deficiency antithrombin III >>>excessive clotting  Protein C, S deficiency  Activated protein C is a natural anticoagulant by cleaving and degrading factor V 12 http://www.aafp .org/afp/2012/1 115/p913.pdf 13 http://www.aafp.org/afp/2012/1115/p913.pdf 14 Hereditary, Environmental or Idiopathic Risks DVT  Hyperhomocysteinemia  Family history DVT  Elevated levels Factor VIII, IX or XI 15 Acute Deep Venous Thrombosis (DVT) Virchow’s Triad  Venous Stasis- (rate of flow)  Endothelial damage -Trauma (quality of vessel wall)  Hypercoagulable state- Coagulopathies (consistency of flow) 16 17 Symptoms and Signs Acute DVT Symptoms     Slow onset calf pain Tight feeling in calf Difficulty ambulating Classical symptoms : (if occur)  Unilateral pain, swelling and redness of the leg and dilation of the surface veins Signs  Swelling of calf – pitting edema  Slight fever or tachycardia  Pain with dorsiflexion with leg fully extended (Homan’s Sign)  Squeezing calf elicits pain (Pratt’s sign) 18 Well’s Criteria  Diagnosis of DVT relies heavily on the use of objective tests because signs and symptoms are NOT specific.”  Clinical features can be used to classify symptomatic patients with suspected DVT as having a high or low probability for DVT before diagnostic testing.” http://cardiopt.org/csm2015/CSM-2015_DVT.pdf 19 http://www.mdcalc.com/wells-criteria-dvt/ 20 21 Diagnosis Acute DVT  Venous Duplex Ultrasonography – Gold standard for diagnosing DVT above the knee  Venogram- RARELY USED (check for allergy to contrast dye and renal function)  D- Dimer Test  Fibrin-degradation product indicative of thrombosis  Often used to R/O Pulmonary Embolus 22 http://www.aafp .org/afp/2012/1 115/p913.pdf 23 Management Acute DVT Anticoagulation  Heparin and  Coumadin (3-6 months)…….…..or lifetime  Rivaroxaban (Xarelto), Eliquis (apixaban) (Xa blockers)  Reduces risk of PE and thrombophlebitis by 80%  Compression stockings after initial anticoagulation 1 year post thrombosis  Inferior Vena Cava Filter  If anticoagulation contraindicated  Recurrent PE while on anticoagulation 24 Greenfield filter Greenfield filter is placed in the IVC to trap potentially lethal (large) emboli 25 AXR of Greenfield filter at L4-5 level GFF is usually placed below the renal veins 26 Prevention DVT in Hospital patients IMP’T  Prophylactic anticoagulation hospital patients  Intermittent pneumatic compression stockings  Early ambulation post-operatively 27 28 DVT Risk Assessment http://venousdisease.com/documents/caprini-dvt-risk-assessment.pdf Total Risk = 29 Etiology CHRONIC Venous Insufficiency  Changes from deep thrombophlebitis  Valves of deep venous channels are incompetent  History of leg trauma  Venous occlusion  May also be associated with varicose veins or neoplastic obstruction of the pelvic veins 30 SIGNS / Symptoms Chronic Venous Insufficiency  Diffuse aching of the legs…..worse as day wears on  Itching  Progressive edema of lower extremity  Ankle edema is first sign  Followed by secondary changes in the skin and subcutaneous tissue  Thin shinny atrophic skin with brownish pigmentation +/- varicose veins (hemosiderin in subcutaneous tissue)  Possible ulceration ( at malleolus) 31 Venous stasis dermatitis 32 Severe Chronic Venous Insufficiency Medial malleolus; ulcer doe not penetrate the fascia 33 34 Treatment Chronic Venous Insufficiency  Intermittent elevation of the legs especially at night  Avoid long periods of standing (> 2 hrs)  Elastic/ support stocking during the day  Unna boot to treat ulceration 35 Varicose Veins  Dilated superficial veins of the lower extremity  Usually asymptomatic but may cause fatigue, aching discomfort, bleeding or pain  Risk factors :  Female gender, Pregnancy  Family history  Prolonged standing jobs  History of phlebitis 36 Stasis dermatitis and superficial varicosities 37 Treatment Varicose Veins  Non Surgical  Knee high/ support stockings  periodic elevation  Weight control / diet  Exercise  Surgical  Sclerotherapy/Microsclerotherapy/Laser therapy/Endovenous ablation therapy/endoscopic vein surgery  Phlebectomy/Vein stripping and ligation  Indications for surgical intervention  Persistent or disabling pain  Recurrent superficial thrombophlebitis  Erosion of overlying skin with bleeding https://www.nhlbi.nih.gov/health/healt h-topics/topics/vv/treatment 38 Sclerotherapy Injects a hypertonic saline into varicose veins The hypertonic saline irritates and scars the veins from the inside out 39 Ablation  Ablation uses a thin, flexible tube called a catheter inserted into a varicose vein. Tiny electrodes at the tip of the catheter heat the walls of the varicose vein and destroy the vein tissue. 40 Vein Stripping Provided by the Society for Vascular Surgery in collaboration with 41 NorthPoint Domain 72 y/o female after Proximal saphenous vein ligation and distal micro-vein extractions 42 56 year old male ligated the leaking vein high up the leg at the groin Rest of the diseased veins were micro-extracted with the ambulatory Phlebectomy procedure 43 Spider Veins around the ankles are very hard to cover up. After 3 treatments of injection Sclerotherapy this patient was no longer embarrassed to wear sandals or walk on the beach. 44 Diseases of LYMPHATIC Channels Lymphedema Lymphangitis Lymphadenopathy 45 Lymphedema  Painless edema of one or both lower extremities, often NON pitting  Ulcerations, varicosities and stasis pigmentation do not occur  Usually have episodes of lymphangitis and cellulitis  Due to impairment of lymph flow from extremity  May be from trauma, lymph node resection, malignant disease or infection  Stasis of protein rich fluid causes fibrosis and skin thickening 46 Treatment Lymphedema  Intermittent elevation  Elastic stockings  Avoid cellulitis with good hygiene  Intermittent diuretics 47 Elephantiasis: Most commonly caused by a parasitic disease known as lymphatic filariasis Aedes aegypti mosquito Wuchereria bancrofti in thick blood smear stained with Giemsa 48 A 67-year-old man was admitted to the hospital with a 12-year history of swelling of his left leg 49 A full-term infant born to a woman (gravida 1, para 1) with a history of gestational diabetes presented with edema of the right leg (Panel A) At four and a half months of age, her right calf and foot were debulked with softtissue reconstruction 50 Lymphangitis  Usually bacterial due to staph aureus or strep pyogenes  Red streaks from area of cellulitis toward regional lymph nodes (ascending)  Arms or legs  No palpable cord  ‘Draining Basin’ Nodes are usually enlarged and tender  Chills, fever and malaise may be present  Mimics: acute cellulitis, erythema nodosum Treatment  Warm soaks, elevation, analgesics and Antibiotics (may have to administers HIGH doses) 51 52 Telangiectasia  widened venules  “spider veins” because of their fine and weblike 53 Telangiectasia – venous HTN and venous insufficiency  Age  Pregnancy  Lifestyle/occupation  Varicosities  Cirrhosis  CHF/pulmonary edema 54 What’s my Diagnosis? 55 Question A patient you are seeing complains of a sore on his lower leg that does not seem to get better. Based on examination findings, you suspect venous insufficiency. Which of the clinical findings below would suggest venous insufficiency as the cause of his problem? a. Leg discomfort is exacerbated by dependency b. Hyperpigmentation is present around the lower calf area c. Ulceration is present on the medial side of the ankle d. Affected leg feels warm to the touch e. All the above Question A patient you are seeing complains of severe pain in her right foot. Based on examination findings, you suspect arterial insufficiency. Which of the clinical findings below would suggest arterial insufficiency as the cause of her problem? a. Brisk posterior tibial and dorsalis pedis pulses b. Pallor of the foot upon elevation c. Pitting edema of the lower leg d. Warmth of the right foot PVS Write -Up  “Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric.”  No palpabale epitrochlear, axillary or inguinal adenopathy 58 Thank you for your attention! https://www.youtube.com/watch?v=itn_MRGqaY8 59