Vascular Technology Lecture 24: Venous Testing (Signs, Symptoms, Mechanisms of Disease) HHHoldorf

Venous Testing It is important to obtain pertinent clinical history and lab values, findings of physical examination and appropriate indication for testing prior to performing the study

Signs and Symptoms 1. Acute Deep venous thrombosis (DVT): clinical diagnosis based on medical history and physical exam

Most common findings of DVT: Swelling Pain Redness Warmth

Differential Diagnosis Include: Muscle strain Direct injury to the leg Muscle tear Baker’s cyst Cellulitis Lymphangitis Heart failure Extrinsic compression

2. Chronic Venous Obstruction Most common findings: Chronic Venous Disease Swelling Heaviness Discoloration Ulcers varicosities

3. Skin Changes Induration of tissue (edema) fluid accumulation Redness (erythema): Inflammatory process, e.g., cellulitis Brownish discoloration (brawny): venous stasis usually in lower leg-to-ankle (gaiter zone) Whiteness (pallor): arterial spasms secondary to extensive, acute iliofemoral thrombosis; Limb threatening; called phlegmasia alba (whitish) dolens Bluish discoloration (cyanosis): severely reduced venous outflow from iliofemoral thrombosis reduces arterial inflow: limb threatening; called phlegmasia cerulea (blueish) dolens

4. Venous Ulcers vs. arterial ulceration Characteristics Venous Ulcers Arterial ulcers Location Often near medial malleolus Tibial area, toes, bony prominences Appearance Shallow, irregular shape Deep, regular shape, “punched out” appearance Skin Changes Stasis Changes: Inflammation, infection, brawny discoloration, presence of varicosities, lipodermatosclerosis Trophic changes; Dryness, scaly, atrophy, shiny skin, loss of hair, thickened toenails Pain Mild Severe Bleeding Venous ooze Little

Edema: body tissue contains an excessive amount of fluid ‘Pitting’ edema: Fluid in subcutaneous tissue Depression of skin surface with manual pressure Can be related to many conditions (e. g., fluid retention, congestive heart failure, or elevated venous pressure).

6. Lymphedema Normally, lymphatic system drains excess fluid from tissue. Fluid accumulates when lymph nodes and or lymph vessels are removed or damaged Frequently seen after many types of cancer surgery Non-pitting edema (firm/hard)

Mechanisms of Disease Risk factors: Trauma to the vessel or endothelial damage: Peripherally inserted central catheter (PICC line) A form of intravenous access that can be used for a prolonged period of time (e.g., for long chemotherapy regimens, extended antibiotic therapy, or total parenteral nutrition)

Know your anatomy: A PICC line is a line inserted into the cephalic vein and will be advanced into the subclavian vein, then to the innominate V, and then to the SVC. Problems include Thrombosis: usually occur in the most proximal portion of the PICC line

More Risk Factors: Mechanisms of venous disease Venous stasis, e.g., immobility, chronic obstructive pulmonary disease, obesity, pregnancy, previous DVT, extrinsic compression Surgery Surgery is a risk factor for DVT. May be due to alteration in endothelial cell function. Hypercoagulability, e. g., certain protein deficiencies, pregnancy, cancer, hormones, i.e., estrogen intake

Acute Thrombosis Intraluminal thrombi frequently begin at valve cusps or in soleal sinuses secondary to stagnation. Thrombi resulting from trauma occur at any site

Soleal veins

Consequences of Acute Thrombosis Chronic venous insufficiency Stretching of walls results in damage to valves Increased venous pressure causes flow changes Post – phlebitis syndrome Chronic flow changes result in persistent edema, stasis changes and pain May also lead to ulceration Pulmonary embolism Thrombus breaks loose Travels into pulmonary circulation CT of chest and pulmonary angiography are currently the definitive diagnostic Tools (US helps determine the source Can be life-threatening

Valvular Incompetence Valves no longer maintain unidirectional flow Calf muscle pump on longer forces blood cephalad towards heart or from superficial system to deep

Results of Valvular Incompetence Increased pressure/venous hypertension Ambulatory venous hypertension: increasing pressure when patient stands or walks Precipitates varicosities Fluid, red blood cells, and fibrinogen may leak into surrounding tissue; breakdown of stagnant red blood cells cause brawny discoloration Breakdown of other substances prevents proper tissue nutrition and oxygenation, leading to ulceration

Varicose Veins Primary: Secondary: Dilated veins secondary to valvular incompetence of superficial system: Deep System intact Secondary: Dilated veins caused by incompetence of the superficial system, resulting from a deep venous obstruction: deep system not intact.

Portal Hypertension Elevated venous pressure results from obstruction of blood flow; may result in reverse (hepato-fugal) flow in the portal vein and increased portal venous pressure that impedes blood flow into the liver Usually related to some form of advanced chronic liver disease e.g., hepatitis, C; cirrhosis

Miscellaneous Congenital venous disease Avalvular (valveless vein(s) Arteriovenous malformations (AVM) Syndromes: Klipple-Trenaunary: Can include multiple varicosities of the superficial system and hypoplastic or absent deep veins Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disorder in which a limb may be affected by port wine stains (red-purple birthmarks involving blood vessels), varicose veins, and/or too much bone and soft tissue growth. The limb may be larger, longer, and/or warmer than normal. The cause is unknown.

IVC Tumor Renal cell carcinoma is the most common solid renal mass in the adult The most common cause of an IVC tumor is renal cell carcinoma

Additional Notes Most common finding of ACUTE DVT Swelling Pain Redness Warmth

Skin changes Fluid accumulation Edema Redness Erythema Brownish discoloration Brawny Whiteness Pallor Bluish discoloration Cyanosis

Phlegmasia alba dolens vs. Phlegmasia cerulea dolens Alba = white Cerulea = blue Lymphedema is related to the lymphatic system, and not the venous system. Frequently seen after many types of cancer surgery (for cancer treatment)

Paget-Schroetter Syndrome Young athletes Venous compression of the TOS Example: young pitchers

Upper extremity venous flow is continuous Not phasic, like the lower extremity.

PICC Line Peripherally Inserted Central Catheter Used to form an intravenous access that can be used for a prolonged period of time (Chemotherapy-antibiotic therapy). Start at the cephalic vein and ends in the distal SVC. Know the pathway of a PICC line. ANSWER ME THIS…Insert the PICC line into the cephalic vein…then where does it go? Varicosities = varicose veins

Homework Textbook: Chapter 26: Testing Conditions, Patient History, Mechanisms of Disease and Physical Examination Pages: 281 – 292 SDMS Assignments