Venous Disease

Superficial thrombophlebitis-

inflammation and confirmed thrombosis within a venous tributary ●Not considered a DVT...clot of superficial vein with exceptions to greater saphenous vein

T wave

inversions in precordial leads (V1-V4) and +/- inferior leads Indicative of right heart strain secondary to PE

Superficial phlebitis-

is inflammation of vein without thrombus

AVMs in bone cause

pathologic fractures

Physical exam may denote

pulsatile mass if superficial or bruits.

Management is either

surgical removal or endovascular embolization (unclear if asymptomatic AVMs should be treated)

Echo:

to evaluate for right heart strain and right ventricular dilation Would be done inpatient, but possibly at the bedside by trained ER provider

Treatment approach for PE classification High risk(Massive) PE

●Have right heart strain with abnormal vitals ●If there are no contraindications to thrombolytic therapy HOLD anticoagulants and administer Systemic tPA if too unstable for catheter directed tPA ●If there is a contraindication to tPA then consult surgery for embolectomy ●Unfractionated Heparin can be initiated 24 hours after systemic tPA has been given. ●ICU admit ●Once stable for discharge to appropriate long term anticoagulant for outpatient treatment.

Early, common signs of chronic venous insufficiency

●Heaviness/leg pain that gets worse with prolonged standing ●Not really in the AM ●Burning/pruritus ●Leg edema- Dependant

Classification of PE Intermediate risk (Submassive) PE

●Hemodynamically stable ●Nml vitals or near nml ●Right ventricle dysfunction

Classification of PE High risk (massive) PE

●Hemodynamically unstable ●Hypotension with a systolic <90 mmHg or a drop in systolic of > or equal to 40 from baseline ●Will have right ventricular dysfunction ●Massive does not describe/mean the size of the PE

Chest XR findings Hampton Hump

●Hump shaped or wedge shaped opacity in the periphery of the lung against plural surface. ●Due to lung infarction

In the work up of a pregnant patient for PE you can start with US:

●If positive and your diagnosis for PE made ●If negative does not r/o a PE. ●D-dimer not typically done

Study looks for a miss-match in ventilation and perfusion

●In the case of a PE: ●Decreased perfusion ●No change in ventilation

Venous Thromboembolism: Long Term Tx Recurrent

●Indefinite anticoagulation

Chronic Venous Insufficiently: Stasis Dermatitis Inflammatory process that looks like eczema rash

●Itching ●Erythema ●Scaling ●Weeping ●Erosions ●crusting

Locations of PE Segmental

●Lobar arteries branch into segmental

Classification of PE Low-risk PE

●No evidence of right ventricle strain ●Stable vitals

Wells risk score interpretations 2 to 6 points: moderate risk (27.8%)

●Obtain a sensitive D-dimer if greater than or equal 500 obtain a CTA or VQ

Once history obtained you can use two clinical prediction tools to determine if a D-dimer or more advnaced imaging should be done (assuming they are hemodynamically stable):

●PERC ●Wells

Modified Wells Score Modifies Wells score >4 PE is likely

●Proceed to a CTA

Advanced Imaging -VQ scan Preferred test for:

●Renal disease ●IV contrast allergy

Patient who typically do not get CTAs:

●Renal failure patients ●CR elevated or GFR low ●Allergy to iodinated contrast ●Unable to lie flat

Time injected contrast that allows visualization of the vessels and any defect secondary to clot burden

●Results won't be affected if they have other pulmonary conditions like pneumonia

With proximal progression risk of embolism increases:

●Risk of PE increases from 10% to 50% ●PE occurs when a DVT breaks loose and travels to the lungs

Venous Insufficiency: Diagnosis Venous Duplex US

●Show retrograde flow of >0.5 sec in duration ●evaluate the nature and extent of venous reflux ●Evaluates combination of superficial and deep insufficiency ●Excludes or includes other diagnoses too

Later findings:

●Skin changes (Stasis dermatitis) ●Ulceration (venous stasis ulcers)

Lets review PE work-up in Pregnancy with or without leg symptoms If there is clinical suspicion:

●Skip the D-Dimer ●Obtain a chest x-ray ●You have a DDx and want to rule out other causes of her SOB, CP,... ●Start with US of both legs even if they don't have symptoms such as pain and leg swelling. ●Some patients will be asymptomatic with their DVTs ●If US + for DVT pt is treated for their PE ●If US - then you do need to do additional imaging and you proceed to a CTA/VQ scan

Three basic theory explaining the pathogenesis of venous thromboembolism

●Stasis of blood or alterations in blood flow ●Endothelial injury ●Hypercoagulable state (inherited or acquired)

Treatment approach for PE classification Intermediate risk(Submassive)PE

●Symptomatic with evidence of right heart strain, but have normal vitals ●Admit telemetry vs ICU ●Initiate Unfractionated Heparin ●Consult for catheter directed tPA ●EkoSonic Endovascular system or EKOS is an example ●Once D/C transition to long term anticoagulant.

Treatment approach for PE classification Low risk PE:

●They have symptoms, but nml vitals and no heart strain ●Depending on the clinical scenario they may be discharged home or admitted to telemetry ●A Pulmonary embolisms severity index (PESI) can help determine low-risk patients who can be treated as out-patient ●This rarely occurs ●Initiate anticoagulation

Locations of PE Saddle

●Thrombus that straddles the bifurcation of main pulmonary artery and usually extending into main right and left pulmonary arteries

●Thrombus

●Usually from a deep vein thrombosis (DVT) that breaks loose and travels ultimately settling in the lungs. ●Lower extremity DVT above the knee are likely to travel vs below the knee stay ●Tumor ●Fat ●Air

Wells risk score interpretations > 6 points: high risk (78.4%)

●Will need to do advanced imaging such as a CTA or VQ scan ●Don't need to do a D-dimer

AVM in brain may cause seizures, neurologic deficits or even

hemorrhage

Virchow's triad- Endothelial injury

Trauma Long term use of lines such as PICC, Central, Ports/catheters Chronic inflammation Smoking

These vessels become dilated secondary to elevated pressure and this can weaken the vessel leading them more prone to

hemorrhage.

Venous Insufficiency: Risk Factors

**Family History...#1 ***Female gender ●Elevated estrogen (hormone replacement, pregnancy, oral contraceptives) ***Advanced age ***Obesity/sedentary lifestyle ***Prolonged standing DVT ●Post-thrombotic syndrome Smoking Trauma AVM

Clinical exam finding with PE

**Tachypnea (about half) **Calf swelling, erythema, edema, tenderness or palpable cord ●Homans sign...unreliable **Tachycardia (~ 24%) **Hypotension Decreased breath sounds Splinting Fever that can mimic pneumonia (~3%) **Associated with Right heart strains: *●Rales ●Accentuated or split second heart sound ●JVD

AVMs

Abnormal communication between artery and vein resulting in shunting blood from arterial system directly into venous system (bypassing capillaries).

Venous Stasis Ulcer

Usually located low on medial ankle over the smaller saphenous veins Never above the knee Shallow, exudative ulcer with a granulation base Can extend circumferentially borders are irregular Painful assuming no neuropathy

What patient education/instructions should you give when discharging a patient with a DVT on an anticoagulant?

-Avoid falls -compliant with meds -educate to back if they fall

Varicose Veins

Varicose veins are dilated, tortuous veins of the lower extremity Common (15% incidence in adults) Gradually develops and becomes painful Hereditary component Increase in frequency after pregnancy

Pathogenesis of VTE is called

Virchow's Triad

Venous Insufficiency: Tx Surgical tx:

Wound debridement of devitalized tissue in ulcers Vein ablation

Moderate/High Venous Doppler Ultrasound of lower extremities

95% Sensitivity, Specificity CT in cases where a DVT within the abdomen is a concern

Treatment - Anticoagulation contraindication

Allergy Bleeding issue such as GI Hemorrhagic stroke history Spinal cord/intracranial tumors

______ is cornerstone of treatment

Anticoagulation

Embolus travels through right heart to pulmonary artery ending in lung 2

As heart struggles to push against increased resistance patient can develop increased right heart strain

Venous Insufficiency: H&P

Asymptomatic in mild disease

D-Dimer

Bi-product of fibrin degradation If D-dimer is +, its not specific to a PE, but will warrant advanced imaging to rule out a PE If D-dimer is negative, because it is so sensitive, you can rule out a PE. ●No further testing warranted This number can be adjusted by patients age Not typically done in pregnancy as it is usually elevated

Locations of PE

Bilateral vs unilateral

Work up: Labs

CBC BMP Troponin ●Can be elevated in PE secondary to right heart strain BNP ●If elevated concern for right heart strain +/- D-dimer Tox screen Pregnancy test if of reproductive age Consider LFT and lipase if upper abd pain

Advanced Imaging- CTA

CT pulmonary angiography (CTA)-Gold Standard

Deep Vein thrombosis: S&S Patient complains of:

Calf pain Calf/leg edema Maybe redness

PE: Pathophysiology

DVT breaks off section causing embolus

This occurs by one of the below mechanisms:

Damaged or incompetent venous bicuspid valves in lower extremities result in failure of venous segments resulting in pooling of blood in lower extremity. This results in further damage of the bicuspid valves and dilated tortuous veins. Inadequate muscle pump function Obstruction

Venous Insufficiency: Diagnosis

Clinical Exam/Hx

Venous Thromboembolism: Pathogenesis DVT

Commonly originated in the calf, but can be in upper extremities too 15-30% progress proximally

Wells Clinical Prediction rule for PE

Criteria Score Clinical signs and symptoms of DVT 3 PE is #1 diagnosis or equally likely 3 HR > 100 1.5 Immobilization at least 3 days, or Surgery in the last 4 weeks 1.5 Previous diagnosed PE 1.5 Hemoptysis 1 Malignancy with treatment within 6 months 1

Venous Thromboembolism

Deep vein thrombosis and Pulmonary embolism Common occurrence This is either acquired or inherited

Low probability ●D-Dimer

Degradation product of fibrin (i.e. clot) If elevated perform Ultrasound If normal DVT ruled out

AVMs dx

Diagnostic Radiographic Studies CTA MRA

Deep Vein thrombosis: S&S PE

Dilated superficial veins Unilateral leg edema Warmth/tenderness/palpable cord (most DVT will not have palpable cord because they are DEEP) Homan's sign (pain in calf with dorsiflexion of foot)

Work Up

EKG Chest XR Doppler US of LE ECHO Consider Arterial blood gas (ABG) in unstable patient

Treatment-Anticoagulants: Fast Acting Low-molecular wt heparin (LMWH)

Enoxaprin (lovenox) Given SQ 1mk/kg Q 12 hours if GFR > 30 and Q 24 hours if GFR < 30 Lower chance of HITS Used as a bridge till Warfarin is therapeutic. LMWH would be taken simultaneously with warfarin for 4-5 days till INR is therapeutic for at least 24 hours. Can be sent home on this Treatment of choice in pregnancy Used in more stable pt Renal failure: avoid in late-stage CKD IV or V

Venous Thromboembolism: Long Term Anticoagulation

For a first time unprovoked thrombotic event, treat patients for 3-12 months then reassess.

Long Term Venous Thromboembolism Anticoagulant Summary

For patients who are NOT pregnant, have severe renal insufficiency or have active cancer, an oral factor Xa(Xarelto/Eliquis) is appropriate. For pregnant patients LMW heparin is preferred with active VTE For cancer patients without risk of bleeding oral factor Xa and LMWH are preferred.

Treatment-Anticoagulants: Fast Acting Heparin unfractionated:

Given IV Starts immediately with a bolus followed by drip Can cause HITS Can be used for high risk (unstable) and intermediate risk PE pts Can use in renal failure

DVT: Disposition and Treatment Outpatient management:

Hemodynamically stable Low risk of bleeding No renal insufficiency Social support at home

Can be seen in several syndromes:

Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome)

PE : ED Treatment If hemodynamically unstable

ICU admit ●mechanical ventilation ●Pressor for BP support such as Dopamine

TPA - Absolute contraindications

Intracranial hemorrhage Ischemic stroke within 3 months Suspect aortic dissection Active bleeding Recent head/face injury with radiology evidence bony fx or brains injury Recent surgery on brain or involving spinal canal Known malignant neoplasm of brain/spinal cord

Superficial phlebitis / Thrombophlebitis RF

Intravenous catheter use (IV sites) Medications IV Potassium Phenergan Varicose veins-due to venous stasis Hypercoagulable Conditions Pregnancy Malignancy Exogenous estrogen use Thrombophlebitis migrans (Trousseau Syndrome)

Venous Insufficiency: Primary Care Tx Conservative tx:

Lifestyle modifications-avoid prolonged standing/sitting, wt loss Leg elevation-when able Exercise Discuss proper skin care ●Prevention of dryness and developing fissures ●Don't itch/scratch to prevent development of ulcers. Compression therapy/stockings ●This is assuming no ulcer

Duplex Doppler US

Looks to see if vessels compress. ●If they are not compressible this is secondary to a clot

DVT: Disposition and Treatment Inpatient management:

Massive DVT (iliofemoral DVT Presents with a PE as well Other comorbid conditions that warrant in-hospital care

Thrombophlebitis migrans (Trousseau Syndrome)

Migrating thrombophlebitis due to thrombosis of superficial veins in multiple areas of the body at the same time.

EKG

Most common finding is sinus tachycardia! EKG could be normal! S1Q3T3 (also indicative of right heart strain) Not so specific or sensitive but can be seen in pts with a PE New incomplete or complete RBBB

Venous Insufficiency

Normal function required adequate muscle contraction and competent venous valves.

Chest XR findings

Normal is the most common finding Atelectasis Effusions

Advanced Imaging -VQ scan

Nuclear medicine scan that looks at perfusion and ventilation by injecting and inhalation of a nuclear material. Ideal if the chest x-ray is nml Can be used in pregnant pt.

Pulmonary Embolism (PE): Definition

Obstruction of the Pulmonary Artery or of its branches.

PE : ED Treatment During work up possible treatment options:

Oxygen - target O2 >90% IV fluids Be cautious if EKG shows signs of right heart failure Anticoagulation Thrombolytic

Venous insufficiency: Indications for Referral

PAD Nonhealing ulcers Ulcer recurrence Persistent stasis dermatitis Suspected contact dermatitis Resistant or recurrent cellulitis Diagnostic uncertainty

Modified wells

PE Likely >4 PE unlikely <4

Post-thrombotic Syndrome Prevention

PREVENTION Prevent recurrent DVTs

Signs and symptoms include:

Pain, tenderness, redness, swelling along the course of a superficial vein Vein feels like a palpable cord

Results in decreased

cerebral perfusion, shock and death

May be ____ or _____ (trauma or vascular surgery developing a AV fistula for dialysis)

congenital (AVM) acquired

Epidemiology

Per CDC it is estimated up to 900,000 every year 10-30% will die within first month Sudden death in about 25% of PEs. Males over slightly higher than females (56 vs 48 per 100,000) As age increases, women have higher incidence of >500 per 100,000 after age 75 5-8% of population carries genetic risk factor Special populations were risk is significantly higher

Venous Insufficiency-skin changes

Pigmentation changes are most prominent in medial ankle but will eventually involve lower leg and foot. Described as a Brown hyperpigmentation Secondary to hemosiderin deposition from breakdown of RBC have extravasated from the capillaries into dermis

Thrombophlebitis migrans (Trousseau Syndrome) cont

Patients have multiple superficial areas of thrombophlebitis Can sometimes be an early sign of cancer Known as Trousseau's Syndrome or Migratory thrombophlebitis

VTE Treatment- Anticoagulation Patient Education:

Prevents blood from clotting Does not dissolve clot Patients must be counseled on their risk of bleeding on these meds.

Virchow's triad- Stasis

Prolonged immobilization ●Hospitalization ●Long car ride or plane ride ●Long surgical operations ●Varicose veins

Venous Insufficiency: Tx Skin/ulcer care:

Refer to a wound care specialist or vascular surgeon Compression therapy Wound management/bandages Unna boot with zinc oxide Silver sulfadiazine Dressing Hyperbaric oxygen

Post-thrombotic Syndrome

Syndrome of venous insufficiency AFTER DVT (extends beyond resolution of thrombosis) Pain, swelling in lower extremity affected by DVT

PE : ED Treatment Majority of patients will be stable

Telemetry bed will be sufficient

Embolus travels through right heart to pulmonary artery ending in lung 1

This blocks blood flow to lung resulting in inadequate O2 exchange leading to hypoxia

Embolus travels through right heart to pulmonary artery ending in lung 3

This decreases preload to left heart heart failure, death

Post-thrombotic Syndrome tx

Treatment includes: compression stockings and pain management

Superficial phlebitis / Thrombophlebitis: Treatment

Treatment will depend on etiology NSAIDS Warn compresses Removal of catheter if possible Antibiotics ●Not indicated for uncomplicated superficial thrombophlebitis ●If infectious thrombophlebitis cover with empiric antibiotics

Treatment-Anticoagulants: slow acting Vit K. Antagonist:

Warfarin/Coumadin Acts on Factor 2,7,9,10, C and S DVT/PE tx: Start at 5 mg daily dose once INR is therapeutic (INR 2-3) LMWH can be discontinued Takes up to a week to become therapeutic This is reversible ●Vit. K ●FFP ●Prothrombin Complex Concentrate (PCC) Can be used in renal failure patients Many drug interactions Cheap!!! $4

Venous Insufficiency Patho

Will be somewhat dependent on the cause but ultimately there is reflux that leads to increased pressure in veins (venous hypertension) and affects microvasculature and leads to dependent edema of lower extremities.

Can be used in pregnant patients if

advanced imaging is needed outside of US duplex of legs

PE: Treatment-Tissue Plaminogen Activator (tPA) With massive PE and unstable consider systemic tPA.

●20% bleeding risk ●Hemodyncamically unstable pts BP, 90 mmHg for more than 15 min ●Cardiac arrest with PEA (pulseless electrical activity) ●Respiratory arrest

Chest XR findings Westermark sign

●A dilation of the pulmonary arteries proximal to embolus ●Collapse of distal vasculature ●You will see a sharp cut off on CXR

PERC Criteria If any of these criteria are positive, the PERC rule can't be used to rule out a PE in your patient. UPHEAPSS

●Age >50 years old ●Pulse >100 bpm ●SaO2 < or = 95% ●Hemoptysis ●Estrogen use ●Surgery /trauma/ hospitalization in the last 4 weeks ●Prior venous thromboembolism ●Unilateral leg swelling

Wells risk score interpretations <2 points: low risk (3.4%)

●Are they PERC negative? ●If no obtain a D-dimer ●If yes; no further testing ●Document in your medical decision making section

Work up Obtain a complete history and PE.

●Ask specific questions such as travel, surgery, family history of PE, surgery or injury, hormone etc....

Clinical symptoms Less common symptoms:

●Back pain ●Abdominal pain ●Atrial fibrillation ●Near syncope or syncope ●Hemodynamic collapse

Locations of PE Lobar

●Branch of main pulmonary artery to the lobes of lung

Locations of PE Sub-segmental

●Branches of the segmental artery

Virchow's triad- Hypercoagulable state Acquired

●Cancer ●Pregnancy ●Hormone ●hormone replacement or birth control ●testosterone ●Nephrotic syndrome (10-40% increase)

PE Treatment Embolectomy

●Clot is removed surgically or using a catheter ●Can be considered in hemodynamically UNSTABLE patients: ●Thrombolytic therapy is contraindicated ●Options in those who fail thrombolysis

Modified Wells Score Modified Wells score < 4 PE is not likely

●Consider D-dimer test and if negative work up for PE stops ●IF D-dimer Positive continue to a CTA of chest

PE: Treatment-Tissue Plaminogen Activator (tPA) Submassive PE

●Consider a catheter directed thrombosis with tPA

Doppler US of lower extremity if there is a pain, swelling or of physical exam finding suspicious for a DVT

●Consider doing this in pregnant patients if clinical concern for PE even if they don't have signs or symptoms consistent with DVT

Treatment - Factor Xa inhibitors Rivaroxaban (Xarelto):

●DVT/PE treatment: 15 mg BID for 21 days followed by 20 mg once daily with food ● If CrCL < 30 ml/min avoid use

Treatment - Factor Xa inhibitors Apixaban (Eliquis):

●DVT/PE tx: 10 mg PO BID x 7 days followed by 5 mg BID daily ●Avoid use with a CrCL <15 ml/min

Clinical symptoms Common symptoms:

●Dyspnea ●Pleuritic/chest pain/upper back pain ●Hemoptysis ●Calf/thigh pain and or swelling ●Cough ●Orthopnea

Treatment-IVC filter Used if there is a contraindication to anticoagulation

●Ex: Cancer pts with DVT or PE but is having active bleeding Filter placed in the vena cava Used when: ●Recurrent PE despite use of anticoagulant ●Absolute contraindication to anticoagulation ●Massive DVT

Virchow's triad- Hypercoagulable state Hereditary

●Factor V Leiden ●Protein C and S deficiency ●Deficiency of antithrombin III ●Prothrombin gene mutation ●Antiphospholipid syndrome

Duration of long term anti-coagulation is dependent on clinical scenario:

●First proximal DVT or Pulmonary embolism due to reversible, precipitating factor ●Minimum 3 months ●First DVT/PE unprovoked: ●3 months than reassess risk/benefit. Likely treatment will be 6-12 months

Things that are considered during reassessment:

●Gender (males have a higher risk for recurrence than females) ●Presence of a clotting disorder ●Obesity ●Chronic leg swelling ●Positive D-dimer test while patient is still on anticoagulation therapy ●Positive D-dimer test 4 weeks after discontinuing anticoagulation therapy ●Residual clot on follow up (Doppler ultrasound) ●Patients with PEs are more like to have a recurrence of future PEs. More so than patient's with DVTs.

Treatment - Factor Xa inhibitors Apixaban (Eliquis)- half life 9-14 hours or Rivaroxaban (Xeralto)- half life is 5-13 hours

●Given orally ●Fast acting(1-2 hour onset) ●Require loading dose but no-pretreatment like coumadin ●No need for INR monitoring ●Medication is costly $$$ ●DVT tx can be started in the ED then D/C home with appropriate F/U

Associated with hypercoagulability

●Glioma ●Adenocarcinoma of pancreas, lung