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

2. 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

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

4. Most common findings of DVT:
Swelling
Pain
Redness
Warmth

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

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

7. 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

8. 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

9. 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).

10. 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)

11. 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)

12. 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

13. 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

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

15. Soleal veins

16. 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

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

18. 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

19. 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.

21. 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

22. 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.

23. 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

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

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

26. 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)

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

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

29. 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

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