Term
| What is the risk factor for VV if both parents have the disease? |
|
Definition
|
|
Term
What is the risk factor for developing VV if one parent has the disease? Men Women |
|
Definition
|
|
Term
| What is the risk factor for developing VV if neither parent has the disease? |
|
Definition
|
|
Term
Describe the valve status of the IVC Common iliac veins external iliac vein |
|
Definition
IVC valveless Common iliac vein valveless external iliac usually only one but can be valveless |
|
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Term
| What is the overall incidence in the general population of VV in women? men? |
|
Definition
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|
Term
What percentage of patients with venous thromboembolism have a recurrence within 10 years? When is the highest incidence of recurrence? |
|
Definition
|
|
Term
| Try to list as many independent predictors of recurrent venous thromboembolism |
|
Definition
male gender increasing patient age body mass neurological disease with paresis active malignancy |
|
|
Term
What is the 20 year incidence of venous stasis disease after venous thromboembolism? After proximal deep venous thrombosis? |
|
Definition
|
|
Term
What two major "groups" of patients account for the highest incidence of venous thromboembolism? What % of the overall incidence? |
|
Definition
Hospitalized patients 60% Active cancer patients 20% |
|
|
Term
| Is superficial thrombophlebitis an independent risk factor for deep venous thrombosis? Y or N |
|
Definition
|
|
Term
What is the incidence of venous thromboembolism in the USA per 1000 population? What % present as DVT PE |
|
Definition
1/1000 2/3's as DVT 1/3 as PE |
|
|
Term
| What % of DVT patients are suspected of having silent PE |
|
Definition
|
|
Term
What is another name for detergent sclerosing solutions? By what "mechanism" do they function and describe their action |
|
Definition
Fatty acids and alcohols They work by denaturation or protein theft stealing away protein essential proteins from the cell membrane |
|
|
Term
| What type of hemolysis do detergent sclerosing agensts cause? |
|
Definition
|
|
Term
| What is CMC concerning detergent sclerosing agents and explain it? |
|
Definition
Critical micellar concentration When the concentration of thedetergent sclerosing agents reachs a threshold that all further molecules of the solution enter into micelles |
|
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Term
What are micelles? What is the advantage of detergent sclerosing solutions? |
|
Definition
Lipid bilayer There are threshold concentrations where that are not toxic to the vascular endothelium |
|
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Term
How does temperature effect solubility of detergent sclerosing agents? Use polidocanol as an example and how that effects it efficacy. At what temp is polidocanol more effective? |
|
Definition
They are more soluble in cold solutions and dissolved molecules are ineffective. Therefore polidocanol works better in warm temperatures |
|
|
Term
| What are the two variables in detergent micellar formation? |
|
Definition
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|
Term
Name 4 detergent sclerosing agents Which two are exempt from FDA approval |
|
Definition
Polidocanol Sodium tetradecyl Sodium morrhuate Ehanolamine oleate The last two |
|
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Term
What is sodium morrhuate chemically? Where does it come from? Why is it a disadvantage? What are its two major complications |
|
Definition
Fatty acid Cod fish oil It is a biological compound not synthetic skin necrosis and allergic reactions |
|
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Term
Where is ethanolamine most used? Principal disadvatage? Advantage? Main complications involving what system? |
|
Definition
Esophageal varices causes mural necrosis It's high viscosity Does not cause allergic reactions Pulmonary |
|
|
Term
Sodium tetradecyl is what chemically? What is it used for industrially? 3 disadvantages? |
|
Definition
Long chain fatty acid Synthetic soap Hyperpigmentation Cutaneous necrosis Allergic reactions |
|
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Term
Polidocanol is what chemically? |
|
Definition
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|
Term
What category is glycerin as a sclerosing agent? How strong is it compared to polidocanol? In what form is it sold for sclerosis? Advantages-2 Necrosis yes, no rare? Two major disadvantages? Main systemic complication? |
|
Definition
Chemical irritant 1/4 the strength As a chromated solution 72% Rarely causes hyperpigmentation or matting rare necrosis extremely viscous painful to inject with lidocaine Ureteral colic and hematuria |
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|
Term
What is the other class of sclerosing solutions other than detergent sclerosing agents? How are they thought to work? |
|
Definition
Osmotic sclerosants Cause hemolysis but also cause denaturation of cellular proteins in diluted concentrations |
|
|
Term
| Name three generic osmotic sclerosing solutions |
|
Definition
Hypertonic saline Saline and dextrose Iodine |
|
|
Term
What is the combination of dextrose and saline trade name? In what concentrations are they? Name the three major side effects |
|
Definition
Sclerodex Dextrose 25% and sodium chloride 10% Painful, epidermal necrosis whenever extravastion occurs and pain |
|
|
Term
Name negative actions of hypertonic saline and its side effects What concentration is it used as a sclerosing agent? What is Heparsol? |
|
Definition
Salt overload and red blood cell hemolysis Causes leg cramping, considerable staining, pain,skin necrosis 20 or 23.4% Hypertonic saline mixed with heparin and procaine |
|
|
Term
| What are 5 factors make a sclerosing solution effective? |
|
Definition
Concentration Volume mixing patient positioning temperature |
|
|
Term
What is the incidence of VTE in the US? What % manifest themselves as DVT? PE? |
|
Definition
|
|
Term
Match generic with trade enoxaparin Innohep fondaparinux Lovenox tinzaparin Arixtra dalteparin Fragmin |
|
Definition
Lovenox enoxaparin Fragmin dalteparin Innohep tinzaprin Arixtra fondaparinux |
|
|
Term
What is the incidence of HIT in UF heparin Low molecular wgt heparin? |
|
Definition
|
|
Term
Randomized trials have shown what benefit in LMWH prophylaxis in reducing risk of
VTE? |
|
Definition
14.9% placebo vs 5.5% in Lovenox 5% vs 2.8% 10.5%vs 5.5% Approx 1/2 in studies |
|
|
Term
ACCP supports use of UFH and LMWH in at risk medical pts for prophylaxis Define at risk |
|
Definition
Acutely ill patients CHF, severe respiratory disease, or confined to bed with one or more risk factor: active CA, preevious VTE, sepsis, acute neurological disease, Inflammatory bowel disease All pts admitted to ICU should be evaluated for risk |
|
|
Term
| What does the ACCP recommend in patients with acute nonmassive PE in terms of therapy? |
|
Definition
|
|
Term
|
Definition
watts x sec joules per second |
|
|
Term
| Which wave lasers are absorbed by hemoglobin? |
|
Definition
Diode lasers: 810 Diomed Angiodynamics Elves Vascular solutions 940 Dornier
980 Angiodynamics Elves Solid state 1064 NdYag |
|
|
Term
Diode lasers are damage vein walls by what type of energy? What is the primary mechanism? Secondary and to what degree? |
|
Definition
Convective Heating of steam bubbles Direct contact with vein wall but only 40% injury to the media can be achieved in only 40% of the circumference |
|
|
Term
|
Definition
| Linear endovenous energy delivery |
|
|
Term
What energy variable is vein wall shrinkage dependent upon with EVLT? What are its units? |
|
Definition
Linear endovenous energy delivery defined in joules per cm |
|
|
Term
Diode laser achieve vein wall shrinkage as their mechanism of action. What is the average shrinkage achieved at what energies? How is the remainder of vein wall closure achieved? |
|
Definition
LEED 80 joules/cm approx 30% 150 joules/cm 50% The remainder of the vein is closed by endovascular clot formation |
|
|
Term
| By what mechanism does the 1320nm ablate veins and what is its target? |
|
Definition
| Cooltouch targets water heating vein wall without perforations |
|
|
Term
What adverse event is unaffected by change in laser wavelength? What is the average reported incidence? |
|
Definition
|
|
Term
What year did the FDA approve EVLT for varicose veins? Define the term LASER What type of particles are emitted with laser? |
|
Definition
2002 Light Amplification Stimulated Emission of Radiation Photons In what units is laser energy measured |
|
|
Term
| What are the three components of a laser and what are their roles? |
|
Definition
Laser medium emits photons when excited. It can be solid liquid or gas pump source provides the energy that excites the medium eg electrical discharge optical resonator is a mirror or system of mirrors that intensifies and amplifies light |
|
|
Term
| What type of lasers are used in EVLT and what are the two types? |
|
Definition
Solid state lasers Diode and Nd:Yag |
|
|
Term
What is the pump source and medium of diode lasers? What does the medium consist of? What is the space between the medium called? |
|
Definition
PS is electrical current Medium is a semiconductor of two layered wafers of semiconductor eg silicon P-n junction |
|
|
Term
What does Nd:Yag an acronym for? What is the medium? Pump source? What are the two wavelengths of Nd:Yag lasers used in EVLT |
|
Definition
neodymium doped yttrium aluminum garnet medium is a rod of NdYag PS is a diode laser or a flash lamp 1320 1064 |
|
|
Term
What type of light do lasers emit? What is a chromophore? How is a chromophore important in the function of a laser What is the chromophore(s) of the 810 laser 940 980 1320 |
|
Definition
Infrared It is the target molecule of the laser that absorbs that particular lasers light wavelength The chromophore absorbs light energy and emits heat to generate a thermal reaction 810 (Hgb) 940, 980(Hgb and h2o) 1320 H2O |
|
|
Term
| What are the average power settings and LEED of the diode and NdYag lasers? |
|
Definition
Diode: 10-15 watts 50-80 j/cm (ed comment prob higher Nd: 5-7 watts 50-70 j/cm |
|
|
Term
| What parameters are associated with successful endovenous occlusion according to a study by Proebstle? |
|
Definition
Higher fluence j/cm2 Higher LEED Shorter distance from thrombus in vessel at day 1 to SFJ Smaller vein caliber Longer total energy time |
|
|
Term
What type of energy does RF utilize? What type of heating occurs and what anatomical structure is affected? What creates the impedance to RF energy? |
|
Definition
Electromagnetic Resistive heating denuding the endothelium Impedance in the vein wall to RF emergy causes heat destruction |
|
|
Term
| In a randomized study, what are the advantages of RF ablation? |
|
Definition
Shorter convalescence Less postop pain Lower economic costs |
|
|
Term
| Name 3 absolute exclusion criteria for the RF procedure |
|
Definition
Deep venous obstruction Arteriovenous malformations Restricted ambulation |
|
|
Term
Which nerve may be injured if RF is used below the knee Describe the location of symptoms from the injury, the incidence and its course |
|
Definition
Saphenous nerve Limited to distal thigh, 1-16% Short lived |
|
|
Term
Name two factors found to be associated with incomplete RF ablation according to Morrison study? What role does age/ size of vessel play in incomplete ablation? |
|
Definition
Preop deep venous reflux Presence of perforators or large tributaries None |
|
|
Term
| What is the name of the venous network often responsible for telangiectasias of the thigh? |
|
Definition
| Lateral subdermic venous system |
|
|
Term
| Which sclerosing agent causes the least pigmentation and matting? |
|
Definition
|
|
Term
What percent of patients in sclerotherapy will clear to their satisfaction after their first course(series) of treatment? What is the incidence of pigmentation persisting after one following sclerotherapy?Where anatomically is it most common? |
|
Definition
|
|
Term
| Which laser has shown some improvement in recalcitrant post sclerotherapy pigmentation? |
|
Definition
| Q-switched ruby laser (694nm) |
|
|
Term
What is one theory regarding the etiology of telangiectatic matting? What are possible risk factors for TM? What can reduce the incidence of TM? Which laser has an effect on TM ? |
|
Definition
Hypoxia induced neovascularization Obesity, estrogen containing hormones, family history of TM Studies have shown longer compression results in lower incidence 532nm long pulse NdYag laser set at highest fluence and pulse duration but may cause hypopigmentation |
|
|
Term
| What is the range of intralymphatic pressures? |
|
Definition
|
|
Term
What natural substance can help lymphedema? Exactly how does it work? |
|
Definition
bioflavinoids Assist removal of accumulated protein, slow leakage from vascular system |
|
|
Term
Chemically what are bioflavinoids? Where are they found? |
|
Definition
They are the natural pigments in fruits and vegetables Most of these are the yellow pigments found in citrus fruit as well as other fruits and vegetables, these are referred to as flavonoids. |
|
|
Term
| What food substance needs to be limited in patients with lymphedema and why? |
|
Definition
| Long chained fatty acids are dependent on lymphatics to be absorbed from the intestine. The risk is retrograde flow of chyle into the lower limbs |
|
|
Term
| What are the two types of venous tumors? |
|
Definition
Hemangioendotheliomas and leiomyosarcomas |
|
|
Term
| Describe treatment for leiomyosarcomas |
|
Definition
| Preoperative chemotherapy followed by radical excision |
|
|
Term
| What was the incidence of ulceration in the Australian polidocanol study? |
|
Definition
|
|
Term
| What are the four causes of cutaneous ulceration with sclerotherapy |
|
Definition
Vasospasm Injection of an arteriole Extravasation Excessive external compression |
|
|
Term
How does arterial spasm from sclerotherapy present? What are the treatments? |
|
Definition
Porcelain white appearance at the site of injection followed by hemorrhagic bullae in two to 48 hours and then ulceration Vigorous massage 2% nitroglycerine |
|
|
Term
| How can cutaneous ulceration from extravasated NaTetradecyl be treated |
|
Definition
Hyaluronidase 150 USP u/cc Reconstitute with 0.9% saline Best rx 75units in volume of 3cc injected in several sites around infiltrated area |
|
|
Term
What is pelvic congestion syndrome? Define the syndrome Which vein is more commonly involved, to what % What are the other two causes? |
|
Definition
Venous engorgement of the pelvis due to dilitation and incompetence of one or both ovarian veins Chronic pelvic pain in the setting of pelvic venous varicosities Ovarian vein reflux in 71% of cases with L>R Saphenofemoral tributaries causing vulva varicosities 10% Internal iliac reflux alone Sgmental pelvic reflux g uterine veins, veins in round ligament |
|
|
Term
What is the incidence of vulva varicosities in pregnancy? What conditions and circumstances allow these to persist after pregnancy? |
|
Definition
2-7% Usually after 3 pregnancies some varicosities remain in the vulva, upper medial thigh perianal and gluteal regions The majority of cases are due to the enlargement of the ovarian veins draining the pregnant uterus, perhaps associated with internal iliac vein compression Perhaps after pregnancy some ovarian veins do not return to normal and the limited one or two valves at the upper end of the ovarian veins may become incompetent |
|
|
Term
| Name 3 sites of venous compression that can result in pelvic congestion |
|
Definition
L renal vein compressed by Superior mesenteric artery Retroaortic Left renal vein Compression of the L common iliac vein by the right common iliac artery producing internal iliac vein reflux |
|
|
Term
| What can be the result of large residual veins in the broad ligament after pregnancy? |
|
Definition
Pelvic symptoms can occur Pelvic escape through internal iliac tributaries namely obturator or internal pudendal or round ligament into the vulva and upper medial thigh or posteriorly into the buttock and posterior thigh |
|
|
Term
Describe the typical timing and symptoms of pelvic congestion syndrome What are the bladder symptoms and what are they due to? |
|
Definition
Pelvic heaviness or deep pelvic pain Before the menstrual period and often on day 1 and 2 Mid cycle and post coital Particularly noticeable on standing up immediately after having moring intercourse. Aching may persist for several hours through the day Rlated pervesical varicosities causing frequency or difficulty in starting the flow of urine. Also irritable bowel syndrom |
|
|
Term
Describe incidence of VTE in frequency in Age Whites vs Blacks vs Asians Men vs Women Child bearing age vs later |
|
Definition
VTE is a disease of older age The incidence is slightly higher in blacks than whites lower in Asians Higher in child bearing age in women than men Higher in men than women after 45 |
|
|
Term
| What % of PE patients is the initial presentation death? |
|
Definition
|
|
Term
What is the rate of reoccurence of VTE within 10 years? When is the highest incidence of reoccurence? How has the incidence of reoccurence been affected once anticoagulation is stopped? |
|
Definition
30% Within the first 6 - 12 months Once stopped,the duration of anticoagulation does not affect reoccurence |
|
|
Term
| Name five independent predictors of VTE reoccurence |
|
Definition
Male gender Increasing age body mass index neurological disease with paresis Active malignancy |
|
|
Term
What is the 7 day fatality rate for recurrent PE? Recurrent DVT? How does this affect the decision for anticoagulation |
|
Definition
34% 4% Prolonged anticoagulation for incident PE should be considered especially for patients with reserved cardiopulmonary capacity |
|
|
Term
What is the 20 yr incidence of of venous stasis syndrome after VTE? In proximal DVT? What is the 20 yr cumulative risk for venous ulcer in patients with VTE? How does this increase per decade of age at the incident? |
|
Definition
25% 40% 3.7% 30% per decade, the older you get a VTE, the greater the risk of a venous ulcer |
|
|
Term
What % of VTE occuring in the community is seen hospitalized or nursing home patients? In cancer patients? |
|
Definition
|
|
Term
| What % of VTE in the community is now due to central catheters? |
|
Definition
|
|
Term
Is superficial thrombophlebitis an independent risk factor for DVT? Varicose veins?? What family of medications may reduce the risk of VTE and by how much? Is cigarette smoking and COPD an independent risk factor for VTE? |
|
Definition
Yes Uncertain Statin Rx by 20-50% No |
|
|
Term
How high is the risk of VTE in pregnant vs nonpregnant women? Postpartum vs compared to pregnant What is the risk of PE in pregnant vs postpartum women |
|
Definition
Fourfold 5X higher in postpartum as compared to pregnant women Uncommon in pregant women, much more common postpartum |
|
|
Term
What is the sensitivity and specificity of vein wall compression alone for the diagnosis of DVT? When all duplex criteria are used? |
|
Definition
95% sensitive 98% specific 98% sensitiv 94% specific |
|
|
Term
How sensitive is duplex in the diagnosis of isolated calf thrombi in symptomatic patients? Asymptomatic? |
|
Definition
|
|
Term
| What percent of acute DVT's become chronic? |
|
Definition
|
|
Term
What are D dimers? How are they best used in the diagnosis of DVT considering its sensitivity and specificity? |
|
Definition
| D- dimers are degradation products from the action of plasmin on fibrin and thus are an indication of the initiation of blood clotting |
|
|
Term
What is the sensitivity and specificity of MRV in the diagnosis of DVT? It is the study of choice for what anatomical location of DVT? What are the criteria for diagnosis of DVT on MRV? |
|
Definition
97% 100% Pelvic vein Intraluminal filling defect Absence of imaging a vein |
|
|
Term
Define CCTVPA How is it used in the diagnosis of DVT and PE? How sensitive is it? |
|
Definition
Combined computerized tomography venography and pulmonary arteriography After waiting 3 -5 minutes after injecting contrast for a CTPA (computrized tomograpy pulmonary arteriography) the veins from the diaphragm to the calves can be visualized 97% sensitive 100% specific |
|
|
Term
| What percent of lower limb DVT was found to extend into the iliac veins or IVC? |
|
Definition
|
|
Term
| According to Guex, what is the formula to calculate the volume of foam needed to occlude a vein? |
|
Definition
| Volume= π(pi 3.14) x (diameter of vein/2) squared x length of vein |
|
|
Term
Based on comparative trials, foam sclerotherapy is more less equally effective in eliminating axial reflux when compared to surgery and endovenous ablation? |
|
Definition
| "results are not inferior" |
|
|
Term
| At what diameter vessel does foam no longer have an advantage? |
|
Definition
|
|
Term
| What drug has been shown to induce superficial venous thrombosis during sclerotherapy? |
|
Definition
|
|
Term
| Why are women more symptomatic from varicose veins? |
|
Definition
| Progesterone prevents veins from contracting away from nerves |
|
|
Term
What are the two types of local anesthetics? Which are more commonly used and why? Name 3 examples of the latter |
|
Definition
Esters and amides Amides are more widely used because of fewer allergic reactions Lidocaine (xylocaine) Mepivicaine Bupivacaine |
|
|
Term
| What is the component breakdown in gms of 1% xylocaine with epinephrine 1:100,000 |
|
Definition
| One gram of lidocaine to 1 mg of epinephrine per 100cc |
|
|
Term
| Name 3 CNS side effects of epinephrine and 4 CVS side effects |
|
Definition
Nervousness, headaches, tremors Palpitations, HTN, chest pain, palpitation |
|
|
Term
| What is maximum recommened dose of lidocain mg/kg body wgt and total dose |
|
Definition
| 7mg/kg body wgt not to exceed 500mg |
|
|
Term
| List the signs of toxicity of local anesthestics |
|
Definition
metal taste (copper penny) circumoral, tongue numbness Lightheadedness Visual adn auditory disturbances Slurred speech CNS excitement (restlessness and tremors) Drowsiness, loss of consciousness Convulsions Cardiac arrest |
|
|
Term
| Name some common drugs that increase the toxicity of amide local anesthestics |
|
Definition
Cipro, erythromycin Common antidepressants Tagamet Antifungals Dilantin Benzodiazepines such as xanax, valium Propanolol Calcium channel blockers Cholesterol lowering drugs eg Lipitor |
|
|
Term
| Name 3 etiologies of pelvic congestion syndrome |
|
Definition
Congential absence of ovarian vein valves Post pregnancy valvular insufficiency. Ovarian veins dilate 60x during pregnancy Compression syndromes |
|
|
Term
| What are two venographic criteria for pelvic congestion syndrome? |
|
Definition
Ovarian vein diameter > 1cm Cross pelvic collateral filling |
|
|
Term
| What % of patients with pelvic congestion syndrome will need their internal iliac veins occluded? |
|
Definition
|
|
Term
| Name 3 symptoms of Nutcracker syndrome |
|
Definition
Hematuria Flank pain Varicocele in males |
|
|
Term
| What is Paget Schroetter syndrome? |
|
Definition
| Axillary-subclavian thrombosis or effort thrombosis |
|
|
Term
What is the risk of developing VV if both parents have VV? If one parent (overall incidence) Differentiate risk between men and women Risk of VV if no parents have VV? |
|
Definition
90% 47% 62% for females 25% for males 20% if neither is affected |
|
|
Term
Is pregnancy an independent or secondary risk factor for varicose veins? Has a relationship clearly been defined between developing varicose veins and: obesity Living in an industrialized society diet Increasing age trauma |
|
Definition
Independent risk Yes to where you live and increasing age |
|
|
Term
| What two over the counter drugs may impact the development of superficial venous disease and why? |
|
Definition
NSAIDS may interfere with the inflammatory response that injures vein walls Horse chestnut seed extract contains Escin which prevents leukocyte activation, leads to increased venous tone Results in decreased leg volume ie edema |
|
|
Term
| Which leg symptom is clearly more prevalent in patients with venous disease than normal individuals? |
|
Definition
|
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