Vascular - Venous

Front 1

What do the Digital Veins make up?

Back 1

Metatarsal Veins

Front 2

What do the Metatarsal Veins make up?

Back 2

Deep venous arches

Front 3

May-Thurner Syndrome

Back 3

The left CIV passes beneath the right CIA to empty into the IVC. This pressure point is recognized by some to account for the increased incidence of left lower extremity DVT.

Front 4

Where is the confluence of the CIV to form the IVC?

Back 4

Level of the 5th lumbar

Front 5

What vessels form the GSV?

Back 5

Digital Veins

Front 6

Each perforator has at least ____ valves to maintain unidirectional flow.

Back 6

1

Front 7

What is the branch of the GSV below the knee?

Back 7

Posterior Arch Vein

Front 8

Where are the 3 Cockett Perforators located?

Back 8

3 ankle perforating veins
Importance with venous stasis ulcers.

Front 9

Where is Boyd's Perforator?

Back 9

At the Knee

Front 10

Where is Dodd's Perforator?

Back 10

Distal thigh

Front 11

Where is the Hunter's Perforator?

Back 11

Mid Thigh

Front 12

What are the venous sinuses of the legs?

Back 12

Soleal & Gastrocnemius veins.

Front 13

Which veins form the Palmar Arches?

Back 13

Deep Digital Veins

Front 14

Portal Vein

Back 14

Formed by the Superior Mesenteric and Splenic Veins, carry blood into the sinusoids of the liver. Portal Vein is the predominant source of blood flow into the liver (80%).

Front 15

What is Flow into the liver?

Back 15

Hepatopetal

Front 16

Where does the Hepatic Vein carry blood from?

Back 16

Carries blood from the liver into the IVC

Front 17

What is Flow away from the liver called?

Back 17

Hepatofugal

Front 18

Veins expand in response to what?

Back 18

Transmural Pressure aka Distention Pressure

Front 19

Venomotor Tone

Back 19

Veins element of reactivity when smooth muscle cells contract with temp, exercise, stress and trauma

Front 20

What is the Tunica Intima made up of?

Back 20

Single layer of endothelial cells

Front 21

What is the Tunica Media made up of?

Back 21

Thicker layer of smooth muscles and collagenous fiber

Front 22

What is the Tunica Adventitia made up of?

Back 22

Fibrous layer surrounding elastic tissue. Contains the Vasa Vasorum

Front 23

What kind of valves are in the venous system?

Back 23

Bicuspid Valves

Front 24

Which veins have valves?

Back 24

GSV, SSV, Perforators, Infrapop, Pop, Fem, EIV (25%), CFV, IJV, Ax, Cephalic and Basilic

Front 25

Which veins do not have valves?

Back 25

Soleal, EIV (75%), IIV, CIV, IVC, SubcV, Innominate Veins, and SVC

Front 26

Are veins compliant or not?

Back 26

Highly compliant
As intraluminal pressure increases the veins expands
As intraluminal pressure decreases - "dumbbell"

Front 27

Transmural Pressure

Back 27

The differences between pressures within (intraluminal) and outside (interstitial) of the veins.
The higher the intraluminal pressure the higher the Transmural Pressure.

Front 28

Due to the flattened shape of veins most of the time, are veins high or low resistance?

Back 28

Low Resistance

Front 29

Hydrostatic Pressure

Back 29

Equivalent to the weight of a column of blood extending from the heart to the level being measured.

Supine - 0mmHg
Standing at ankle - 100mmHg
Standing, above heart - pressure decreases

Front 30

What are the calf muscles also known as

Back 30

"Venous Heart"

Front 31

Where does blood flow during muscle contraction and relaxation?

Back 31

Contraction: Deep system toward the heart
Relaxation: Superficial into Deep via perforators

Front 32

What happens during Inspiration?

Back 32

Increase in intraabdominal pressure, decrease in intrathoracic pressure

Increases blood flow from arm and head veins
Decreases blood outflow from peripheral veins and lower extremity

Front 33

What happens during Expiration?

Back 33

Increase venous flow from lower extremities
Decreases flow from upper extremities

Front 34

Is the Portal Vein effected during respiration?

Back 34

This is almost no variation with respiration. Flow of an adult is minimally phasic.

Front 35

What should happen during a normal Valsalva Maneuver?

Back 35

Augmentation of venous signal should be evident as the patient releases and stops bearing down.

Front 36

What should happen during an abnormal Valsalva Maneuver?

Back 36

A venous signal is augmented as the patient bears down

Front 37

What are the 4 main Acute DVT findings?

Back 37

Swelling
Pain
Redness or erythema
Warmth

Front 38

4 things seen with Chronic venous disease

Back 38

Swelling
Heaviness
Discoloration or ulcerations
Varicosities

Front 39

What 3 things make up Virchow's Triad?

Back 39

Trauma
Venous Stasis
Hypercoagulability

Front 40

What is intraluminal thrombi made up of?
Where is it commonly found?

Back 40

Predominately composed of RBC trapped within a fibrin web

Commonly found at the cusps or valves or in the soleal sinuses because of stagnation

Front 41

Paget-Schreotter Syndrome

Back 41

aka Stress or Effort Thrombosis

Involves thrombosis of the subclavian or axillary vein secondary to intense, repetitive activity.

Venous component of Thoracic Outlet Syndrome

Front 42

May-Thurner Syndrome

Back 42

Compression of the left common iliac vein by the right common iliac artery as the artery crosses over it. Sometimes there is enough compression to thicken the vein wall as well as alter flow to the point of thrombosis

Front 43

Superior Vena Cava (SVC) Syndrome

Back 43

An obstruction of the SVC, usually by a malignant lesion.

Dyspnea (difficultly breathing) is most common, but also facial and extremity swelling may be seen.

Front 44

Where is the Gaiter Zone?

Back 44

Distal calf-to-ankle area

Front 45

What is Post-Thrombotic or
Postphlebitic Syndrome?

Back 45

Combination of chronic swelling, brawny discoloration and ulcer formation in the gaiter zone.

Related to a previous DVT

Front 46

What are 4 congenital venous diseases?

Back 46

Avalvular (valveless) veins
Incompetent valves
Arteriovenous Malformations (AVM)
Klippel-Trenaunay Syndrome

Front 47

Klippel-Trenaunay Syndrome

Back 47

Hypoplastic or absent deep veins

(absent iliacs with varicosities of the superficial system resulting in an enlarged limb)

Front 48

Portal Hypertension

Back 48

Often the result of an obstruction of blood flow, while usually related to chronic liver disease like cirrhosis, it can also be caused by severe CHF or proximal venous occlusion of hepatic veins or IVC. Elevated pressure results in a reverse pressure gradient that causes portal venous flow away from the liver (hepatofugal)

Front 49

Primary Varicose Veins

Back 49

Dilated, tortuous veins that may be hereditary.
From congenital absence or one or more valves.
Unrelated to DVTs

Front 50

Secondary Varicose Veins

Back 50

Cause by obstructive condition like DVT, pregnancy or obesity

Front 51

Brawny discoloration

Back 51

Increased venous pressure causes fluid, RBC and fibrinogen to leak into the surrounding tissue. The breakdown of RBC creates a hemosiderin deposit that give the brawny discoloration.

Represents venous insufficiency

Front 52

Lipodermatosclerosis

Back 52

Thickening and hardening of the skin and can be found in patients with chronic venous insufficiency.

When skin and fat under the skin has been inflamed for years, the tissue becomes hard. Over time the tissue can become depressed, changing shape, "bottle-neck deficiency"

Front 53

Phlegmasia alba dolens

Back 53

Limb threatening condition results from arterial spasms that occur secondary to extensive, acute iliofemoral vein thrombosis

Limb is very swollen, pallor (pale) and painful

Front 54

Phlegmasia cerulea dolens

Back 54

Limb threatening complication of an acute iliofemoral vein thrombosis. The severely reduced venous outflow causes a marked reduction in arterial inflow. Tissue hypoxia can develop, leading to gangrene

Limb is very swollen, cyanosis (dark blue) and painful

Front 55

Describe Venous Ulcers

Back 55

Near medial & lateral malleolus
Mild to severe pain
Shallow, irregular shape
Venous ooze
Stasis changes: Brawny, lipodermatosclerosis, varicosities

Front 56

Describe Arterial Ulcers

Back 56

Tibial area, toes, boney areas
Severe pain
Deep, regular shape
Little bleeding
Trophic changes: Shiney skin, loss of hair, thickened toenail

Front 57

What is pitting edema caused from?

Back 57

secondary to fluid retention, electrolyte imbalance, renal dysfunction, CHF or other causes of elevated venous pressure

Front 58

What is nonpitting edema caused from?

Back 58

Lymphedema, obstruction in the lymphatic system. Fluid accumulates when lymph nodes are damages or removed.

Front 59

What does Impedance Plethysmography (IPG) detect?

Back 59

Can detect thrombi in the iliac, femoral & popliteal veins.

Measures changes in resistance through the calf

Front 60

What does plethysmography measure?

Back 60

Volume changes

Front 61

DC coupling

Back 61

Direct current.
Electrical voltage that is either positive or negative with a current flowing in one direction. Very useful in evaluating the slower-flow states of the venous system.
Batteries operate in DC mode

Front 62

AC coupling

Back 62

Alternating current
Electrical voltage that reverses its polarity ( + or - voltage) 60 times a second. Used in arterial studies, requires more intense changes to produce a measurable signal
USA- standard outlets deliver 120 volts of AC current

Front 63

Describe the Impedance Plethysmography technique

Back 63

Patient supine with calves elevated about heart and heels above calfs. Electrically conductive gel applied to IPG electrodes and placed on proximal and distal portions of calf. Cuff placed on thigh and inflated to 50-60mmHg. Rapid deflate and record outflow patterns. Results based on MVC and MVO on scoring grid.

Thrombosis: reduced venous capacitance and outflow
Absence or obstruction based on values on scoring grid.

Test should be repeated several times.

Front 64

Capacitance

Back 64

The maximum filling capability of the veins as venous outflow is momentarily halted by an occluding cuff

Maximum Venous Capacitance (MVC): The maximum rise of the tracing (compared to initial baseline).

Front 65

Outflow

Back 65

The amount of venous emptying that occurs after deflation of the occluding thigh cuff. Tracing should fall to the baseline within 3 seconds of deflation.

Maximum Venous Outflow (MVO): The measured "fall" at 3 seconds is calculated and plotted on scoring grid.

Front 66

Describe Strain Gauge Plethysmography (SGP)

Back 66

Used to detect venous obstruction in large veins above the knee.
Measures changes in the circumference of the calf
Patient supine, cuff on thigh and mercury-in-Silastic gauge on largest part of calf. Cuff inflated to 50mmHg for 45 seconds and quickly deflated. MVC and MVO plotted on grid.

Increased limb volume/increased resistance = positive deflection
Decreased limb volume/decreased resistance = negative deflection

Front 67

Venous Photoplethysmography PPG

Back 67

Documents capillary blood volume, evaluates the presence and severity of venous insufficiency

Contraindicated with acute DVT

Patient sitting with limb dangling, PPG placed 5-10cm above medial malleolus. Patient does dorsiflexions to empty veins (or tourniquet or cuff applied). PPG records venous refill time (VRT)

Front 68

Venous PPG results

Back 68

If venous filling is slow if traveling the normal route, faster if there is retrograde flow.

VRT > 20sec without tourniquet = Normal

VRT< 20sec without tourniquet and >20sec with tourniquet above the knee ='s GSV reflux

VRT < 20sec without a tourniquet and >20sec with a tourniquet below the knee ='s SSV reflux

VRT <20sec with and without a tourniquet ='s insufficiency of the deep system.

Front 69

Briefly describe Venous Air Plethysmography

Back 69

Determines the presence or absence of venous insufficiency,

Patient supine with heels above heart, Cuff applied to ankle-6mmHg, Veins emptied. Quickly standing on (nontest leg) gravitational pressure. Standing on both legs with 1-toe tip (activate calf pump). Then 1--toe tips. Measure Ejection volume (EV) and Venous Filling Time (VFT). Patient supine, leg elevated and empty the veins. If abnormal, repeat.

Front 70

Describe Venous Air Plethysmography results

Back 70

Venous Filling Index (rate of venous refilling) VFI=90%VV/VFT
Normal - VFI < 2.0
Mild-Mod - VFI > 2.0-10.0
Severe - VFI > 10.0

Ejection Fraction (EF) measures calf muscle function
EF = EV / VV x 100
Normal >60%

Residual Volume Fraction (RVF), equivalent to the ambulatory venous pressure
RVF = RV / VV
Normal <30%

Front 71

With CW Doppler, which vessels are not always clearly heard. Spontaneity

Back 71

LE: Tibial veins and GSV
UE: Radial & Ulnar

Cold vessels, they're more collapsed

Front 72

Venous Respiratory patterns/phasicity

Back 72

LE: Increase with expiration,
Decrease with inspiration

UE: Decrease with expiration
Increase with inspiration

Front 73

What happens to venous flow when the patient is in a slight Trendelenburg position?

Back 73

Venous flow is not as much related to respiration but cardiac dependent.

Front 74

What is seen in the outflow vein of a patent dialysis graft?

Back 74

Increased flow velocity and volume flow
No response to distal compression
Incompressible vessel
Collateral channels evident

Front 75

Which vessels make up the portal vein?

Back 75

Superior Mesenteric & Splenic Veins make up the Portal Vein and carry blood into the sinusoids of the liver, hepatopetal flow.

Normally phasic flow
Pulsatile flow with CHF or fluid overload.
Not usually affected with respiration.

B-mode - hyperechoic walls

Front 76

Describe the Hepatic Vein

Back 76

Carries blood from the liver to the IVC, hepatofugal flow.

Flow is minimally phasic, bidirectional or pulsatile appearing doppler signal.

B-mode - Walls are not clearly visible like the portal vein.

Front 77

Flow characteristics of the Renal Veins

Back 77

Minimally phasic, bidirectional or pulsatile appearing doppler signal.

Like the Hepatic Vein

Front 78

Flow characteristics of the IVC

Back 78

Phasic, bidirectional or pulsatile Doppler signals

Front 79

What does continuous flow indicate?

Back 79

Proximal Obstruction

Front 80

A compressible vessel with Rouleau formation may indicate what?

Back 80

Proximal obstruction, increased proximal venous pressure, or other processes such as an increase in plasma immunoglobulin.

Front 81

Synechiae

Back 81

Linear, echogenic intraluminal striations.

Form as Acute DVTs become chronic

Front 82

Budd-Chiari Syndrome

Back 82

Results from hepatic vein obstruction. Some abnormal clinical findings include hepatomegaly, abdominal pain, and sudden onset of ascites. The causes of this syndrome are many and vary with regard to the primary site of obstruction.

Front 83

D-dimer and what its levels mean

Back 83

D-dimer is a measurable product of the thrombotic process detected on a quantitative blood assay.

Positive result (increased level) - consistent with lysis or breakdown or thrombus

Negative result (normal or less than normal) - implies absence of a thrombotic process

May be elevated with pregnancy, liver disease, renal disease, cancer or resent surgery.

Should not be used on patients already being treated with anti-coagulation therapy.

Front 84

Contrast Venography

Back 84

Considered the Gold Standard of all venous tests.
2 Types:
Ascending: Injected in the dorsum of the foot. Evaluates Acute DVT, congenital venous disease, and or abnormalities, and in the evaluation of chronic venous changes

Descending: Injected in the CFV.
Used to detect and quantify reversed flow from incompetent venous valves.

Front 85

Lung Perfusion Scan
VQ Scan

Back 85

Lung ventilation, perfusion scan, screening test for the detection of perfusion defects of the lungs. Most commonly PE, usually from the deep system.

Other reasons: emphysema, asthma, pneumonia, cancer, CHF, liver cirrhosis, radiotherapy, multiple bood transfusions and postoperative phenomena.

Radioactive contrast medium injected.
Results: High, moderate, low probability or indeterminate of PE.

Front 86

What is the Gold Standard test for a PE?

Back 86

Pulmonary Angiography

However, sometimes a CTA is preformed.

Front 87

Anticoagulant Therapy for Prophylaxis (Prevention)

Back 87

Low dose unfractionated heparin (5,000 units) every 12 hours before and after surgery decreases the post-op risk of DVT

Low-molecular-weight heparin (Lovenox) may provide a bridge mechanism, provides anticoagulation with Coumadin must be discontinued for an invasive procedure.

Front 88

Anticoagulant Therapy for an acute DVT or PE

Back 88

Loading dose of 10,000 units of heparin followed by continuous infusion for 5-10 days.

Front 89

Heparin

Back 89

Interferes with the formation for a blood clot by slowing the conversion of prothrombin to thrombin, increasing the effect of antithrombin III, and decreasing platelet adhesiveness. It does not dissolve (lyse) and existing thrombus, but helps prevent propagation.

Front 90

While on heparin what should the patient's PTT be?

Back 90

1.5-2 times normal

Front 91

While on Coumadin, what should the patient's PT be?

Back 91

1.5-2 times normal

Front 92

What are the 2 filter devices that may be inserted in the IVC?

What vessel is used to enter through?

Back 92

Greenfield filter or a Bird's Nest filter

Jugular Vein or the Femoral Vein

Front 93

TIPSS

Back 93

Used for Portal Hypertension
Transjugular Intrahepatic Portosystemic Shunt

A catheter is inserted in the jugular vein and with fluoroscopic guidance advanced into the right hepatic vein. Inserted just a little further into the portal vein to create a bridge, supported with an endoprosthesis (stent).

Front 94

QA
Sensitivity

Back 94

The ability of a test to detect disease. The abnormal noninvasive test result is confirmed or supported by an abnormal result of the Gold Standard

How many noninvasive results were correctly called positives on the basis of Gold Standard results?

# of True + noninvasive results
-------------------------------------------------------
# of all + diagnoses by the Gold Standard

TP
----------
TP + FN

Front 95

QA
Specificity

Back 95

The ability of a test to identify normality. The normal test result is confirmed or supported by a normal Gold Standard result

Of the Gold Standard (-) how many did you correctly call (-) on the basis of the noninvasive results?

# of true (-) noninvasive diagnoses
--------------------------------------------------------
# of all (-) diagnoses by the Gold Standard

TN
---------
TN + FP

Front 96

QA
Positive Predictive Value

Back 96

% of noninvasive test results that accurately predict abnormality.

Of the + noninvasive studies, what % correctly predicted disease as supported by the Gold Standard?

# of true + noninvasive tests
---------------------------------------
# of all + noninvasive studies

TP
----------
TP + FP

Front 97

QA
Negative Predictive Value

Back 97

% of noninvasive test results that accurately predict normality

Of your (-) noninvasive studies, what % correctly predicted the absence of disease as supported by the Gold Standard?

# of true (-) noninvasive tests
-----------------------------------------
# of all (-) noninvasive studies

TN
----------
TN + FN

Front 98

Accuracy

Back 98

% of correct noninvasive diagnoses

How well does the noninvasive test both detect and rule out disease?

Total # of correct tests
-------------------------------
Total # of all studies

The value falls between Sensitivity & Specificity and Positive & Negative Predictive Values

TP + TN
------------------------------
TP + FP + FN + TN