Vasc Le Venous By Sr

Front 1

What are the functions of veins?

Back 1

carry waste product for cellular activity, not completely passive, they will vasoconstrict and vasodialate from sympathetic inervation.

Front 2

What are the 3 layers of veins?

Back 2

Adventitia, media, intimal

Hint 2

Adventitial and medial layers contains vasovasorum

Front 3

Describe veins in comparison to arteries.

Back 3

Thin walled low pressure vessels that can hold a much larger volume and have significantly less smooth muscle compared to arteries, This is related to the fact that blood in the veins has less pressure than blood in the arteries. They are considered capacitance vessels that hold about 70% of normal blood volume. Veins are thinner and less rigid than arteries.

Front 4

What factors contribute to venous blood flow?

Back 4

•Venous valves - continuation of intimal layer, Valves are bicuspid and point toward the heart
•Calf muscle pump
•Respiration – during inspiration venous blood from upper extremities rushes intot he thorax, during expiration, abdominal pressure decreases and venous blood from the lower extremities rushes into the abdomen

Front 5

Why do veins have valves?

Back 5

Because the blood return through veins is mainly due to the skeletal muscle and respiratory pumping, they require valves to keep blood from flowing retrograde.

Front 6

Venous return =

Back 6

cardiac output

Front 7

Hydrostatic pressure in veins?

Back 7

( when standing the highest hydrostatic pressure is in the legs)

Front 8

Normal venous pressure

Back 8

is around 15mmHg

Front 9

....a measure of expandability

Back 9

Veins are compliant

Front 10

Respiratory Flow Changes

Back 10

1.Inspiration decreases intrathoracic pressure but increases intraabdominal pressure as the diaphragm descends. The decrease in intrathoracic pressure increases the inflow of the blood from the arm and head veins. The increase in intraabdominal pressure reduces the outflow of blood from the peripheral veins of the lower extremity.
2.Expiration increases venous flow from the lower extremities, while halting flow from the upper extremities.

Front 11

Understand the anatomy and purpose of vein valves.
What are the valves made from?

Back 11

The venous valves are just a continuation of the intimal layer.
Valves are bicuspid and point toward the heart

Front 12

Where are the most valves located?

Back 12

More valves exist distally. So you have very few valves in the ivc, you may have one or two between common iliacs down to fem bifurcation. Alot more below the knee because of hydrostatic pressure trying to move blood flow up.

Front 13

Blood flow to the tissues in the extremities is dependent on ______

Back 13

Blood flow to the tissues in the extremities is dependent on cardiac output - bad output can cause cyanotic digits, congenial heart defects (clubbing of digets) due to low perfusion - mixed content from the shunt.

Front 14

What would be a cause for bad perfusion in the extremities?

Back 14

People with really poor cardiac output will have bad perfusion to the extremities

Front 15

What is the difference between interstitial and interlumenal pressure called?

Back 15

Intermural pressure

Front 16

What effect does intermural pressure have on a vein?

Back 16

determines the shape of the vein. If you have a lot of pressure inside the vein it is going to expand the walls. If the pressure is really low and tissue pressure is high, your veins will have all kinds of shapes.

Front 17

What effect does body position have on a vein?

Back 17

Body position will affect shape of veins because of the hydrostatic pressure change associated with position.

Front 18

What effect does peripheral resistance have on perfusion?

Back 18

Peripheral resistance in the capillary bed can keep the extremities from being well perfused

Front 19

Interlumenal high vs low pressure results?

Back 19

Intralumenal blood pressure, very high is going to push oxygenated blood out.Llow pressure won’t push as much.

Front 20

which veins are paired

Back 20

Veins are usually paired below the knee

Front 21

which veins have corresponding arteries

Back 21

Usually veins course adjacent to major arteries and have the same name. The trick is if you are having a problem telling the difference between the deep and superficial veins, the deep veins have adjacent arteries

Front 22

Veins of the lower extremity consist of .... (two systems)

Back 22

deep and superficial systems. There are more deep veins in the legs. There are perforators, soleosinuses (muscle tributaries).

Front 23

Which type of vein is the primary drainage route of the lower extremities? And how does that affect visability?

Back 23

deep veins drain the LE - That means it is usually easier to see the deep veins in the lower extremity because they have the bulk of the blood flow

Front 24

Which type of vein is the primary drainage route of the upper extremities?

Back 24

superficial veins drain the upper extremity

Front 25

What are Gastrocs?

Back 25

They come straight off the poplitieal artery and head straight into the pop vein. They are in the muscle behind the knee, vessels go in and drain and supply that muscle. Always seen in the popleteal space. Probe in that space showing vessels will be the gastrocs

Front 26

Importance of gastrocs with regards to thrombus?

Back 26

you can have throumbus in the gastrocs - vital to note, it can go into vein - bad news because all the movement in that area will easily dislodge it. Drain into the pop vein!!!

Front 27

What are Soleol Veins or soleol sinuses?

Back 27

they drain into the peronial and post tib, they are in the calf. you will probably never see them unless their is thrombus in it.

Front 28

the vena cava terminates into the ___a____ and then ___b___ and ____b____ iliac

Back 28

a) Common Iliac Vein
b) Internal and external

Front 29

internal iliac is also called ?

Back 29

the hyposgastric vein.

Front 30

The external iliac courses down through the ______ and becomes the _______

Back 30

The external iliac courses down through inguinal crease after it moves under inguinal crease then you have common femoral vein

Front 31

so when you put the probe in the inguinal crease you should see the ______

Back 31

common fem vein

Front 32

he common femoral vein divides into the _____ and _____ aka ____

Back 32

deep femoral vein (profunda femora) and the femoral vein (big long vein that goes all the way down the thigh)

Front 33

Superficial throumbus in the lower extremity is ______ an issue that needs to be treated.

Back 33

rarely needs to be treated. A deep vein thrombus does need to be treated.

Front 34

Where is the popliteal vein located?

Back 34

Popliteal vein is behind the popliteal fossa.

Front 35

Which veins drain the calf?

Back 35

anterior/posterior tibial and peroneal veins are the veins that drain the calf.

Front 36

Left common iliac thrombosis is caused by?

Back 36

Right common iliac artery sits right on top of the left iliac vein and it pushes on it enough that it makes the opening small and blood circulates slowly and has a tendency to coagulate and thrombus - happens to pregnant women

Front 37

We scan the GSV from where to where?

Back 37

we start scanning greater saphenous vein you will start at the inguinal crease and follow all the way down

Front 38

Perforators are veins that _____

Back 38

run between superficial and deep veins. The majority of them are in the calf in the lower leg. We may be able to see them in a healthy individual, they will cross through fascia.
They are numbered and not named because there was too many variation. Easy to find when problematic because they are huge.

Front 39

Blood flow between veins is from ______

Back 39

superficial to deep

Front 40

What is the importance of the perforator valves? What can happen if they become diseased?

Back 40

There are valves in the perferators, if they become incontinent all hell will break loose. Because the bulk of flow is in the venous system. Flow would go from lower to higher pressure, this is how to end up with vericosity. Vital they are spared disease.

Front 41

Veins bifurcate ______ to arterial bifurcation

Back 41

Veins bifurcate distal to arterial bifurcation

Front 42

The anterior tibial vein branches off of the

Back 42

popliteal vein

Front 43

The tibial peroneal trunk splits into the

Back 43

posterior tibial and peroneal veins.

Front 44

The posterior tibial vein drains the

Back 44

posterior medial portion of the calf

Front 45

The lesser saphenous vein is the

Back 45

first branch off the popliteal vein. It courses down the posterior portion of the calf.

Front 46

Doppler signals Interpretation:
Spontaneous

Back 46

venous flow is readily detectable. Exceptions may be the PTV and GSV due to
vasoconstriction.

Front 47

Doppler signals Interpretation:
Phasic

Back 47

venous flow waxes and wanes with respiration. It decreases with inspiration and increases with expiration due to changes in intra-abdominal pressure from the rise and fall of the diaphragm. Continuous flow with no respiratory variation suggests more proximal obstruction

Front 48

Doppler signals Interpretation:
Pulsatile flow

Back 48

is present with elevated right heart pressures (CHF or TV regurgitation), usually in the UE, abnormal to find in the LE.

Hint 48

Indicates volume overload, venous htn. Can also be AV malformation but woudl be consistent with HR.

Front 49

Doppler signals Interpretation:
Augmentation

Back 49

distal limb compressions should elicit and audible increase in venous flow velocity.
(3slides)

Hint 49

This augmentation correlates to a patent veins between site of the transducer and the location of the distal compression.
(3slides)

Front 50

Doppler signals Interpretation:
Competency

Back 50

assesses the effectiveness of the venous valves. If venous flow is detected in the reverse direction after release of a distal compression, the valves are considered incompetent. True reflux appears for more than ½ second

Hint 50

The longer it stays retrograde, the worese the disease is.

Front 51

Why is clinical history very important when diagnosing DVT?

Back 51

With duplex, it is sometimes difficult to determine acute versus chronic DVT,

Front 52

By duplex, acute thrombus appears_____

Back 52

By duplex, acute thrombus appears spongy homogenous and smooth and poorly attached to the wall; the vein can appear distended.

Front 53

Chronic thrombus can appear

Back 53

hyperechoic, heterogenous, well adhered to the vein wall, the vein can appear contracted and valve damage can occur.

Front 54

Flow can recanalize with what type of thrombus? Acute or Chronic, under what conditions?.

Back 54

chronic thrombus and valves are no longer obvious.

Front 55

Know the patient prep for venous duplex

Back 55

• Reverse Trendelenburg – supine head of bed elevated 30 degrees
•Room warm and patient relaxed – cold patient is vasoconstricted, flexed muscles can reduce flow

Front 56

Know the basic protocol of a venous duplex to rule out DVT

Back 56

•-from inguinal crease: image the EIV, CFV, PFV, origins of FV and GSV
•-from behind knee: image popliteal, origin of LSV and possibly image gastrocs
•-from medial ankle scanning cephalad: image PTV and distal GSV, pickup peroneals at mid calf
•Image vessels in transverse view, reasonable probe pressure should collapse vein wall to show patency of vessel. This can rule out the presence of thrombus, because the walls will not coapt when thrombus is present. SHORT AXIS IS THE BEST VIEW TO DETERMINE PATENCY because the vein may slip out of the image plane during attempted compression in long axis.
•In a long axis view of vessel, obtain color flow and pulsed spectral Doppler waveform and note response to augmentation

Front 57

Understand protocol for vein mapping

Back 57

• A duplex of the superficial veins of the upper extremity may be performed to evaluate the adequacy of superficial veins for conduit material. The cephalic and basilic veins can be harvested for bypass conduit. A tourniquet is applied to the proximal upper arm to dilate the vessels. The vessel patency is determined and diameter of the vessel is measured at multiple locations. A minimum diameter of 2.5-3mm is usually required by most labs. After assuring the viability of the vessel, marking on the patient’s skin “maps” out the location of the vessel.

Front 58

Augmentation - what feedback does it provide on doppler?

Back 58

•Manual compression of the extremity distal to the site of Doppler increases or augments venous flow. The resulting gush of blood is recorded as an abrupt increase in the spectral waveform.
•This response confirms substantial patency of the veins between the site of the Doppler examination and the site of venous compression.

Front 59

Augmentation - what does a weak augment mean?

Back 59

•A weak augment could mean patent collaterals or non occlusive thrombus.

Front 60

Augmentation - what does an absence of response to it mean?

Back 60

•The absence of this response indicates substantial obstruction distal to the site of Doppler examination.

Front 61

Know what a valvutome is

Back 61

?????

Front 62

duplex findings of venous insufficiency

Back 62

Abnormal response to distal augmentation
- Flow reversed for longer than .5 seconds after release of distal compression
• This indicates venous insufficiency/valvular incmpetence

Front 63

Understand the presentationand management of venous insufficiency

Back 63

????

Front 64

Acute DVT symptoms

Back 64

•Hot
•Unilateral
•Red
•Tender
•Swollen

Front 65

Risk factors for DVT / Virchow’s triad

Back 65

Hypercoaguable state – people with clotting disorder, chemo patients, oral contraceptive users etc.
• Injury – surgical patients s/p hip knee procedure, trauma to area
• Stasis – people who are immoblilized for extended period of time

Front 66

Chronic venous obstruction symptoms

Back 66

•Swelling
•Discoloration
•Ulcers
•Varicosites

Front 67

Skin changes for DVT

Back 67

-Induration of tissue (hardened)
-Redness / rubor (part of inflammatory process)
-Brownish discoloration (brawny) usually in gaiter zone (lower leg to ankle area); increased venous pressure causes red blood cells to leak into the surrounding tissue; the break down of the red blood cells releases hemosiderin (iron-containing pigment derived from hemoglobin) deposits which discolor the skin
-Whiteness (pallor); arterial spasms secondary to acute extensive iliofem thrombosis called phlegmasia alba dolens (only affecting deep venous system, NOT collaterals)
-Bluish discoloration (cynanosis) severely reduced venous outflow from iliofemoral thrombosis reduces arterial inflow called phlegmasia cerulean dolens (affects deep venous system AND collateral network)

Front 68

Differential diagnoses that present with classic DVT symptoms

Back 68

- Muscle tear or strain
- Direct injury to the leg
- Baker’s cyst
- Cellulitis-
- Lymphedema
– Heart failure

Front 69

Lymphedema

Back 69

Normal lymph system drains excess fluid from tissues; fluid accumulates when lymph nodes or vessels are removed or damaged; condition seen after many types of cancer surgery; usually has non pitting edema

Front 70

Cellulitis

Back 70

inflammation of cellular or connective tissue

Front 71

Mechanisms of thrombus:
What is thrombus?

Back 71

an aggregation of red blood cells and fibrin with entrapment of cellular elements.

Front 72

Mechanisms of thrombus:
Complete recanalization

Back 72

spontaneous lysis of the thrombus can occur due to the activity of the fibrinolytic system. This usally occurs within 72 hours of the thrombotic event

Front 73

Mechanisms of thrombus:
Propagation or embolization

Back 73

– in the acute phase, the thrombus may extend into the proximal veins or may embolize into pulmonary circulation

Front 74

Mechanisms of thrombus:
Partial recanalization

Back 74

flow channels are “dugout” through the existing clot and the thrombus will recanalize. This often leaves the valves “frozen”, as thrombus is likely to remain in the valve cusp sinuses

Front 75

Mechanisms of thrombus:
Complete obstruction

Back 75

thrombus will attach itself to the vessel wall. With time, a persistent thrombosis will adhere to the vessel wall and the vein will contract and become very small. Collaterals will develop around the obstructed vein to facilitate venous return.

Front 76

Thrombi frequently originate at ....

Back 76

Thrombi frequently originate at the cusps of venous valves or in the soleal sinuses because of stagnation, but can occur at any site.

Front 77

As clot propagates, flow becomes_____, pressure _____ and the vein walls _____, causing __________. Can lead to ______

Back 77

restricted, pressure increases and the vein walls stretch causing damage to valves. This can lead to chronic venous insufficiency

Front 78

An obvious danger of DVT is .....

Back 78

An obvious danger of DVT is that the clot will break loose and travel into the lungs causing a PE

Front 79

Congenital venous diseases.

Back 79

• Avalvular
•Congenital AVM
•Syndromes – Klippel-Trenaunay (VV of extremities)
•hypoplastic or absent deep veins
•May-Thurner Syndrome:

Front 80

May-Thurner Syndrome

Back 80

the right CIV and IVC lie axially on the same plane creating little angle between these 2 venous segments. The LIV joins at almost a 90 degree angle and is crossed anteriorly by the RCIA. Since the LIV lies directly above the spine and directly below the RCIA, compression of the vein may occur creating the signs and symptoms of deep venous thrombosis.

Front 81

Know the difference between primary and secondary varicose veins

Back 81

tba

Front 82

Understand what a pulmonary embolus is, symptoms, who’s at risk & testing modalities
Define: Pulmonary Embolus

Back 82

Pulmonary Embolus obstruction of the pulmonary circulation from emboli; It is usually diagnosed with a ventilation-perfusion scan.

Front 83

Symptoms of PE

Back 83

Dyspnea
Chest pain
Tachypnea
Diaphoresis
Hemoptysis

Front 84

Know what superficial thrombophlebitis is and its symptoms

Back 84

tba

Front 85

Types of thrombus
Acute thrombus

Back 85

Low level echoes
The affected veins are usually dilated
There can be free-floating appearance of the thrombus
It is soft and compliant when compressed
There is lack of collateralization
Abnormal venous Doppler signal
Filling defect on color Doppler images

Front 86

Types of thrombus
Chronic thrombus

Back 86

Hyperechoic or very bright echoes
Affected veins are contracted
Firm attachment of the tip of the thrombus to the vein wall
There is firmness or noncompliance when compressed
Evidence of collateralization
Filling defect on color Doppler images
Normal or abnormal Doppler signal depending on the extent of recanalization

Front 87

Thrombus: Pathology
Thrombophlebitis

Back 87

is venous thrombosis and inflammation in a superficial vein. It usually presents as increased skin temperature, rubor, swelling or red streak along the course of a vein. Treatment usually consists of warm moist heat, anti- inflammatory medication and Aspirin. Duplex of the deep system may be ordered to assure thrombus has not extended into the deep system.

Front 88

Thrombus: Pathology
•SVC syndrome

Back 88

•Venous inflow may be compromised with thrombosis or extrinsic compression in the SVC.

Hint 88

Flow backs up, subclavian and jugular vein
decreaced volume and velocity, continuous flow (swirling flow)

Front 89

Thrombus: Pathology
•SVC syndrome: caused by

Back 89

This is most often caused by thrombus formation around a central line.

Front 90

Thrombus: Pathology
•SVC syndrome: symptoms

Back 90

Symptoms include facial edema, dilation of neck veins and bilateral arm swelling.

Front 91

Thrombus: Pathology
Venous Thoracic Outlet /Paget von Schrotter syndrome : Cause

Back 91

Thrombosis caused by stress or spontaneous thrombosis of the subclavian or axillary vein. As the vein leaves the thoracic outlet, pressure may be applied to the subclavian vein causing thrombus to form.

Front 92

Thrombus: Pathology
Venous Thoracic Outlet /Paget von Schrotter syndrome : presentation (symptoms)

Back 92

It usually presents in a dramatic and unexpected manner in young and otherwise healthy patients. Frequent strenuous arm movements usually precipitate the syndrome. As muscle mass builds, it applies extrinsic pressure on the subclavian vein. The onset of acute pain and swelling is typically in the dominant arm and worsened with activity.

Front 93

Phlegmasia alba dolens

Back 93

tba

Front 94

Phlegmasia cerulean dole

Back 94

tba

Front 95

Describe venous valves

Back 95

continuation of intimal layer, Valves are bicuspid and point toward the heart

Front 96

What is Homan's sign?

Back 96

A sign of venous discomfort: calf discomfort on passive dorsiflexion

Front 97

What are anterior leg pains associated with?

Back 97

Nothing. Especially not DVT!

Front 98

Describe Popliteal Cyst (baker's cyst)

Back 98

kFluid filled sac, hypoechoic, always in popliteal (may look like overspaced commay, may have dots in it)

Front 99

Vein mapping procedure

Back 99

Specific vein is divided into segments, check if patent, measure diameter (size matters), need to have diameter >2.5 - 3cm to be acceptable to harvest. Preoperatively, the vein is mapped for harvest in about 6-7 segments

Front 100

Klippel-Tranaunay-Weber syndrome is characterized by:

Back 100

is characterized by a triad of port-wine stain, varicose veins, and bony and soft tissue hypertrophy involving an extremity.

Front 101

Klippel-Tranaunay-Weber syndrome: Cause

Back 101

Primary - born with it
Secondary - something causes it (valves that are damaged as a result of previous thrombophelbitis)

Front 102

Rouleaux Formation

Back 102

Sponaneous contrast

Front 103

Thrombolysis

Back 103

- In response to the presence of thrombus, the body releases plasminogent and chemically lyses throubus.
- plasminogen may completely lyse the thrombus in days to weeks but this is not common
- Residual thrombus converts to fibrous tisse that can thick the vein wall.

Front 104

Venous Reflux duplex findings

Back 104

look at doppler signal. should get a big influx of blood flow, but if blood falls back down the colunm (retrograde flow time)

Front 105

Recanilization

Back 105

the restoration of the lumen of a blood vessel following throbolitic occlusion, by restoration of the channel or by formation of new channels.

Front 106

Venous insufficiency: what is the significance of retrograde flow time?

Back 106

The longer its retrograde the worse it is.

Front 107

DVT doppler fining (re: compressability)

Back 107

Non-compressible, won't coapt.

Front 108

Swelling and vericose veins are a symptom of?

Back 108

venous insuficiency

Front 109

Phlegmasia alba

Back 109

iliac thrombosis, white = collateral flow

Front 110

Phlegmasia cerula

Back 110

blue iliac thrombosis blue = no flow

Front 111

Doppler signals Interpretation
CAPPS

Back 111

Competency, Augmentation, Pulsatile, Phasic Spontaneous.