Term
Define lower extremity venous disease
3 primary symptoms |
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Definition
Presence of chronic changes in structure and fx of the venous system resulting from physiologic changes like edema, hyperpigmentation, SQ fibrosis and ulcer formation
Telangiectasias
Varicose veins
Venous ulcers |
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Term
| Most common cause of leg ulcer |
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Definition
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Term
Describe fibrin cuff theory of venous ulcers
Describe the trap hypothesis
Describe the WBC activation hypothesis
What do all of these share? |
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Definition
The fibrin cuff theory involves the accumulation of fluid containing fibrin into the pericapillary space. This cuff with impaired fibrinolysis is speculated to increase the diffusion barrier, inhibit the repair process, and maintain the inflammatory process.
Trapping of growth factor by fibrin and other macromolecules, making them unavailable to facilitate healing.
Trapping of white blood cells in the capillaries or postcapillary venules. The adhesion of white blood cells with activation releases inflammatory mediators and proteolytic enzymes with endothelial damage that may increase permeability or impede flow leading to occlusion.
All involve occlusion of interface b/w artery and vein |
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Term
Note re: venous ulcer recurrence
When do most recur (percentages)
3 complications of venous ulcers |
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Definition
Can persist from weeks to severeal years and have a high recurrence rate
A quarter reoccur in first year, three quarters reoccur w/in 3-5 years
Cellulitis
Osteomyelitis
Malignant changes |
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Term
Kind of CA recurring venous ulcers can cause
What to consider if ulcers are changing
Why these ulcers often recur |
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Definition
Squamous cell CA
Biopsy
Wearing compression stockings prevents them, but they are uncomfortable and people will often stop wearing them |
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Term
| Some reasons that venous ulcers can lead to social isolation |
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Definition
Wounds drain and smell
Shower less with compression stockings
Going to clinic often
Inability to work |
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Term
Function of deep veins
Superficial veins
Perforating veins |
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Definition
Return blood to the heart; found deep in muscles
Drains blood from the skin and sub-Q tissues
Drains blood from superficial veins to keep veins; found in faschia |
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Term
Describe normal vein valves
What they prevent |
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Definition
Are bicuspid valves dispersed along veins that allow for one-way flow
Prevents reflux to low pressure superficial veins |
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Term
Calf pump:
What calf contraction does
What calf relaxation does |
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Definition
Propels blood toward the heart
Draws blood from the superficial and lower deep veins |
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Term
2 steps of how veins become incompetent
What can cause first step
Vein types seen with each step |
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Definition
1) Damaged valves: valves become stretched, allowing blood to flow back
2) Valvular reflex: increasing pressure, thinning walls, engorged veins
Caused by injury, trauma
Spider veins seen with damage; varicose seen in valvular reflux |
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Term
| 8 risk factors for venous disease |
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Definition
Varicose veins
Pregnancy
Thrombotic conditions
DVT/phlebitis/PE
Trauma/surgery/fractures
Obesity
Sedentary lifestyle
Advance age |
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Term
| Some other causes of venous insuff |
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Definition
| PAD, CHF, renal disease, radiculopathy, lymphedema, rheumatoid arthritis, infection, tumor, dermatitis |
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Term
Two things that increase pain in venous ulcer patients
One thing that improves pain in venous ulcer pts
Describe venous ulcer pain |
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Definition
Increased with standing
Increased when seated w/ feet in dependent position
Improves w/ limb elevation and walking
Localized pain, does not radiate |
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Term
Coloring found in venous stasis ulcer pt LEs
Two kinds of abnormal veins found |
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Definition
Telangiectasia
Varicose veins
Hemosiderin staining |
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Term
| How LE edema in venous ulcer pts increases and decreases |
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Definition
| Increases with prolonged standing, decreases with elevation |
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Term
| 6 major things found with LE venous ulceration physical assessment |
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Definition
Leg edema
Telangiectasia
Varicose veins
Hemosiderin staining
Stasis dermatitis
Skin ulcers |
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Term
| 6 differentials to distinguish from LE venous ulcers |
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Definition
LEVD
Lymphedema
Vesculitis
Mixed disease
Cellulitis
DVT |
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Term
Main diagnostic imaging test for venous ulceration
4 things it does |
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Definition
Duplex US
Assesses venous obstruction
Assesses valvular incompetence
Assesses extent of reflux in the venous system
Differentiates acute DVT from chronic venous changes |
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Term
Why do ankle-brachial index?
Normal ratio
Decrease flow
Severe decrease in flow |
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Definition
Assesses perfusion status and r/o arterial insufficiency
Normal: 0.96-1.2
Decreased: 0.40-0.80
Severe: <0.04 |
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Term
| Circumstance in which ABI is >1 |
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Definition
| In diabetics d/t calcified vessels |
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Term
When to do the toe brachial index
How to do it
TBI ratio that is diagnostic for PAD |
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Definition
When ABI values are not possible d/t non-compressible pedial pulses (diabetic calcification?)
Calculated by dividing toe pressure gy the higher of the two brachial pressures
TBI |
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Term
Compression therapy in venous ulcer disorder: note
Limb elevation note
2 exercises to do
Movements to avoid
Another thing to avoid
Weight |
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Definition
Lifelong compression therapy: apply in the morning
Elevate limb above heart for 20 minutes/day
Walk 30 mins/day
Calf muscle exercises
Avoid crossing legs, prolonged sitting or standing
Avoid trauma to legs
Manage wt |
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Term
4 kids of compression stockings by:
Class
Description
Ankle pressure
Indication |
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Definition
Class 1: light support. 20-30 mm Hg. Indicated for varicose veins
Class 2: medium support. Gives 30-40mm Hg. Treatment/prevention of LEVD.
Class 3: strong support. 40-50 mmHg. Treatment of LEVD
Class 4: very strong support. 50-60 mm Hg. Treatment of LEVD. |
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Term
What compression stocking type is covered by insurance.
How often to replace compression stockings.
How much pressure anti-embolism stockings provide
Note re: cohesive/ACE bandages
Alternative to compression stockings and how they work |
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Definition
Insurance covers 30-40 mmHg only
Replace every 3 mos
Anti-embolism stockings provide only 8-18 mm Hg compression
These do not provide sustained compression and are not adequate for LEVD management; can't really even measure actual pressure
Circade: is Velcro and easier to apply |
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Term
How stasis dermatitis looks (in r/t LEVD)
Temp in stasis dermatitis
How to tx |
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Definition
Itching, weeping skin surrounding by scaly/ crusting skin
No warmth
Topical steroids: eg Triamcinolone 0.1%, short term low dose 1-2X/day for 1-2 weeks |
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Term
Describe surgery for LEVD
Describe sclerotherapy for LEVD |
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Definition
Provides more symptomatic relief and improvement in quality of life compared to lifestyle modifications and compression hosiery in pts w/ uncomplicated varicose veins
Injection of a chemical into a vein to irritate the lining of the vessel, causes it to swell and stick together, eventually turning into scar tissue and fades from view |
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Term
| Main complication of varicose veins |
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Definition
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Term
Describe radiofrequency ablation for LEVD
Describe endovenous laser ablation for LEVD |
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Definition
Under US guidance, a radiofrequency catheter is inserted into the abnormal vein and the vessel treated with radio-energy, resulting in closure of the involved vein
An optical fiber is inserted into the vein to be treated, an infrared laster light is shone into the interior of the vein causing it to contract as the optical fiber is slowly withdrawn |
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Term
Describe excision/stab therapy for LEVD
Describe SEPS |
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Definition
Small incisions are made directly over the large varicose veins, and the vein is removed in specific sections
Minimally invasive surgical technique to tx chronic venous ulcers caused by perforating veins that may have been damaged d/t DVT or chronic venous insuff |
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Term
Describe cellulitis of LE
How it appears
Associated symptoms
Tx |
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Definition
Soft tissue infection of the dermis and sub-q tissue
Painful, erythema, indurated tissue, bullae
Fever, malaise, chills, elevated WBCs
Antibiotics |
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Term
Typical location of venous leg ulcers
Typical pain
Exudate description |
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Definition
Lower leg/ankle, at or above medial malleolus
Pain can be mild to severe
Exudate can be moderate to heavy, larger with edema |
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Term
Note re: debriding in LEVD
What to use for ambulatory pts
How often to change dressing |
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Definition
Debride necrotic tissue
Unna boot
1-2X/wk |
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Term
LEVD debridement agent to use, and how to apply it
How this cream works |
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Definition
Santyl: apply nickel thick. Is OK if on normal tissue.
Is hypertonic and pulls moisture from wound bed |
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Term
| Describe wrapping layers for LEVD leg |
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Definition
First layer: mesh contact to prevent sticking to wound
Absorbent layer: like aquacel. Will macerate healthy skin if exudate not removed.
Cast layer: like cast material, very fluffy and absorbs drainage
Stocking: stocking material, stretchy
Next: compression bandage. Can pull rectangle into square and have fifty percent coverage |
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Term
How to wrap the LEVD leg with bandages
What to do with wrapping when wounds have healed
What required to maintain healing
Is single or double wrapping better? |
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Definition
Wrap with 50% overlap at a 45 degree angle
Got from wrappings to stockings after healing
Lifelong compression is required after wounds have healed
Multilayer bandaging is superior to single |
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Term
| 3 pharmacological agents to use in LEVD |
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Definition
Horse chestnut extract
Rutoside
Pentoxyfilline |
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Term
What horse chestnut extract is good for in LEVD
Dose of horse chestnut extract used
What rutoside does in LEVD
Dose
Problem with rutoside |
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Definition
Effective to decrease edema, pain and itching
300 mg BID
Improves ulcer healing rate
250-300 mg BID
Moderate drug interaction with warfarin |
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Term
What pentoxyfilline does in LEVD
Note re: efficacy
Dose note |
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Definition
Effective in accelerating healing of leg ulcers when added to compression therapy
Reported efficacy is variable, benefit is generally small
In studies, higher doses of 800g TID was more effective that at lower doses, increased doses assoc w/ GI upset |
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