The Vein Forum: Comprehensive Venous Management For The Practicing Clinician

MPFF has been shown to decrease the time to ulcer healing in patients with chronic venous disease (CVD). This means that MPFF can help promote the healing of ulcers that are associated with CVD. It is not effective in decreasing the diameter of existing varicosities, reducing the number of visible varicose veins, or preventing the formation of new varicosities.

Horse chestnut extract (HCE) has been shown to reduce leg edema, which makes it beneficial for those with arterial insufficiency. Arterial insufficiency refers to a condition where there is inadequate blood flow to the legs, leading to symptoms like leg pain, ulcers, and edema. HCE helps in improving blood circulation and reducing inflammation, which can alleviate the symptoms of arterial insufficiency. Therefore, those with arterial insufficiency would benefit the most from using horse chestnut extract.

A Baker's Cyst is a fluid-filled sac that forms in the popliteal fossa, which is the hollow space located at the back of the knee. It is also connected with the joint, as it is formed as a result of excess fluid accumulation in the knee joint. Therefore, the correct answer is A and C.

Laser light in venous ablation procedures is absorbed by the targeted tissue, reflected off the surrounding structures, and scattered in different directions. This combination of absorption, reflection, and scattering allows the laser energy to effectively treat the venous condition.

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The use of an optional/retrievable filter would be most appropriate for the 62 y.o. male with a prior history of deep venous thrombosis, known Factor V Leiden mutation, who is on chronic anticoagulation and is scheduled for elective total hip arthroplasty. This patient has multiple risk factors for developing deep venous thrombosis, including a previous history of the condition and a known genetic mutation. The elective surgery further increases the risk of thromboembolism. The use of a retrievable filter can provide temporary protection against pulmonary embolism during the perioperative period and can be removed once the risk has decreased.

Cessation of anticoagulation is not a preparatory step to IVC filter retrieval because anticoagulation should be continued during the retrieval procedure to prevent the formation of blood clots. Anticoagulation helps to keep the blood thin and reduces the risk of clot formation during the removal process. Therefore, stopping anticoagulation would not be a recommended step for IVC filter retrieval.

The ideal features in an IVC filter design include low impedance to flow, conical geometry, and high filtering efficiency. However, having two trapping levels is not considered an ideal feature in IVC filter design. This is because having multiple trapping levels can increase the risk of filter migration, fracture, or perforation. Therefore, the presence of two trapping levels is not recommended in an ideal IVC filter design.

The PREPIC study, which randomized patients with DVT +/- PE to receive or not receive an IVC filter in addition to anticoagulation, found that at 8 years, patients with IVC filters had a significant decrease in pulmonary embolism. This suggests that the use of IVC filters can effectively reduce the risk of pulmonary embolism in patients with DVT.

The correct answer is Kerlex gauze wrap and long stretch elastic bandage (ACE). Kerlex gauze wrap and ACE bandage provide low compression pressures and are not suitable for supporting venous ulcer healing. Compression therapy is essential for venous ulcer healing as it helps improve blood flow, reduce edema, and promote wound healing. Class II knee high compression hosiery, Unna's paste boot and Coban wrap, and Profore multilayer elastic compression system are all effective methods for providing adequate compression pressures to support venous ulcer healing.

Intermittent pneumatic compression therapy is the most likely treatment modality to achieve improved edema control in this situation. This is because the patient has difficulty applying compression hosiery and bandages consistently, which are the standard treatments for edema. Intermittent pneumatic compression therapy uses a device that applies intermittent pressure to the affected limb, helping to improve circulation and reduce edema. This therapy would be more effective for the patient compared to diuretic therapy or inelastic compression therapy. Lympho-venous bypass is not a commonly used treatment for edema and is not the most appropriate option in this case.

When managing patient expectations of cosmetic sclerotherapy, it is important to mention that a follow-up visit is frequently needed. This visit serves two purposes: to assess the need for more sclerotherapy if the veins are not completely obliterated after the initial treatment, and to assess for intra-luminal thrombus, which may require micro-thrombectomy for optimal results. This highlights the importance of ongoing assessment and potential additional treatments to achieve the desired outcome.

IVUS stands for Intravascular Ultrasound, which is a medical imaging technique that uses sound waves to produce images of blood vessels from inside the body. In this case, the question is asking about the best method to evaluate the IVC (inferior vena cava) and iliac venous system for underlying stenosis (narrowing of the blood vessels). The correct answer is IVUS with a 15 MHz catheter. This is because a 15 MHz catheter provides a good balance between image resolution and depth penetration, making it suitable for visualizing and assessing the blood vessels in this particular scenario.

Extremes of age, such as being 79 years old, are considered a relative contraindication for thrombolysis in the given scenario. This means that while thrombolysis may still be considered as a treatment option, caution should be exercised due to the patient's age. Thrombolysis involves the use of medications like TPA to dissolve blood clots, but in older patients, there may be an increased risk of complications. Therefore, the decision to proceed with thrombolysis should be carefully weighed against the potential benefits and risks, taking into account the patient's individual circumstances and overall health.

In cases where there is severe obstruction of the left renal vein or iliac veins, it is important to treat this obstruction before performing pelvic venous embolization. This is because the obstruction can interfere with the effectiveness of the embolization procedure. By treating the obstruction first, the pelvic venous congestion can be better managed and the desired outcome of the embolization can be achieved.

The correct answer is "Reflux > 500 ms, size > 3.5 mm, CEAP 5 or 6, near an open or healed ulcer". This answer meets all the criteria for the diagnosis of a pathologic perforator. Reflux greater than 500 ms indicates abnormal blood flow, a size greater than 3.5 mm indicates a larger perforator, and a CEAP score of 5 or 6 indicates advanced venous disease. Additionally, the proximity to an open or healed ulcer suggests that the perforator is contributing to the ulceration.

The ideal position to perform a venous reflux examination in a leg is standing with the index leg weighted. This position allows for the most accurate assessment of venous reflux, as it puts the leg in a more natural and weight-bearing position. When the leg is weighted, it increases the venous pressure, making it easier to detect any reflux or backward flow of blood in the veins. The standing position also mimics the conditions that may exacerbate venous reflux in daily activities, providing a more realistic evaluation.

Apligraf is a bioengineered skin substitute that contains living cells and proteins that promote wound healing. Applying Apligraf to the wound, along with continued high strength compression bandaging, is likely to result in an increased likelihood of healing the ulcer in the next 6 months. This treatment approach addresses both the underlying venous insufficiency with compression bandaging and provides additional cellular support for wound healing with Apligraf. High ligation and stripping of the great saphenous vein and endovenous laser ablation of the great saphenous vein may be indicated in cases where the reflux of blood is contributing to the ulcer, but in this case, the duplex studies revealed a normal deep venous system and an incompetent great saphenous vein, suggesting that these procedures may not be necessary.

Warfarin is not indicated for the initial treatment of acute deep venous thrombosis. Unfractionated heparin, low molecular weight heparin, and fondaparinux are recommended as initial therapy for acute deep venous thrombosis. Warfarin is typically used for long-term treatment and prevention of thromboembolic events, but it takes time to reach therapeutic levels and requires frequent monitoring of the international normalized ratio (INR). Therefore, it is not recommended as the initial therapy for acute deep venous thrombosis.

The next appropriate step for treatment of this patient would be the treatment of the incompetent perforator veins. This is because the patient has venous ulcers, popliteal vein reflux, and refluxing medial calf perforating veins. Treating the incompetent perforator veins can help improve the venous circulation and alleviate the symptoms associated with venous insufficiency. It is the most suitable option for this patient, regardless of their history of deep vein thrombosis or the presence of edema and varicose veins.

The most common pathologic thigh varicosity is the Anterior Accessory Saphenous Vein. This vein is a common site for varicose veins in the thigh area. Varicose veins occur when the veins become enlarged, twisted, and swollen, usually due to weak or damaged valves in the veins. The Anterior Accessory Saphenous Vein is often affected by this condition, leading to the development of varicosities in the thigh.

The correct answer is 'B' mode. In duplex ultrasound, 'B' mode refers to the brightness mode which produces a two-dimensional image of the scanned area. It uses grayscale to display the intensity of the reflected ultrasound waves, allowing visualization of the internal structures and organs. This mode is commonly used in diagnostic imaging to examine the anatomy, detect abnormalities, and guide various medical procedures.

Duplex ultrasound combines Doppler and 'B' mode. Doppler ultrasound measures the speed and direction of blood flow, while 'B' mode (brightness mode) produces a two-dimensional image of the scanned area. By combining these two modes, duplex ultrasound can provide both anatomical information and real-time visualization of blood flow, making it a valuable tool in diagnosing and monitoring various vascular conditions.

Great Saphenous Vein Duplication occurs in the thigh. This means that there can be more than one great saphenous vein present in the thigh region. The great saphenous vein is a large superficial vein in the lower limb, and duplication of this vein can occur due to developmental variations. It is important to note that this duplication does not occur in the calf or only in the left leg, but specifically in the thigh.

The correct answer is "Is within the saphenous fascia." The saphenous fascia is a layer of connective tissue that surrounds the Great Saphenous Vein. This helps to protect and support the vein, keeping it in place within the body. Being within the saphenous fascia also helps to prevent the vein from bulging or becoming enlarged.

The small saphenous vein is deep to the fascia in the upper calf. This means that it is located beneath the layer of connective tissue known as the fascia in the upper part of the calf muscle. This positioning is important to note as it can affect the accessibility and potential complications during surgical procedures or interventions involving this vein.

The Great Saphenous Vein is not always confined within the saphenous fascia and has the ability to exit the fascia. This means that it can sometimes be found outside of the fascia. The other statements are not necessarily true as the vein may not always be singular and its size can vary in patients with varicose veins.

The Great Saphenous Vein can be normal with varicose veins. This means that even if a person has varicose veins, the Great Saphenous Vein may still be functioning normally. Varicose veins are enlarged and twisted veins that usually occur in the legs and can be caused by weakened valves or increased pressure in the veins. However, the presence of varicose veins does not necessarily mean that the Great Saphenous Vein is always affected or abnormal.

The "Mickey Mouse" sign refers to the saphenofemoral junction. This term is used to describe the appearance of the junction between the saphenous vein and the femoral vein when viewed with an ultrasound probe held longitudinally. The junction appears like the ears of Mickey Mouse, with the saphenous vein representing the head and the femoral vein representing the two ears. This sign is commonly used in the field of vascular ultrasound to identify and assess the saphenofemoral junction.

The femoral vein can be absent in certain patients and can also be duplicated. This means that some individuals may not have a femoral vein, while others may have more than one femoral vein. This variability in the presence and number of femoral veins is a normal anatomical variation that can occur in the human body.

Continuous non-phasic flow in the common femoral vein is a characteristic of US evaluation of iliofemoral vein obstruction. This means that there is a constant and steady flow of blood in the common femoral vein, without any variation or pulsatility. This is in contrast to normal phasic flow, which is characterized by variations in flow with respiration. The presence of continuous non-phasic flow suggests a blockage or obstruction in the iliofemoral vein, leading to a disruption in the normal flow patterns.

Partial compressibility is a characteristic on ultrasound (US) of chronic deep vein thrombosis (DVT) in the femoral vein. Chronic DVT refers to a long-standing blood clot, and on US, the vein may appear dilated. However, the key characteristic is the partial compressibility of the vein, which means that the vein can still be compressed by external pressure. This is in contrast to acute DVT, where the vein is typically non-compressible. The presence of partial compressibility suggests that the thrombus is organized and has undergone some degree of fibrosis, indicating a chronic process.

The given statement suggests that the use of four layer compression wraps is more effective than three layer wraps in the management of venous stasis ulcers. This implies that the four layer compression wraps provide better outcomes in terms of wound healing and symptom improvement compared to the three layer wraps. The effectiveness of the four layer wraps may be attributed to their ability to provide more pressure and support to the affected area, leading to improved venous return and reduction in edema.

Foam sclerotherapy is more effective than liquid sclerotherapy for obliteration of venous malformations. This is because foam has a larger surface area and greater contact with the vein walls, allowing for better distribution and penetration of the sclerosant. The foam also displaces blood in the vein, ensuring that the sclerosant comes into direct contact with the vein wall. This leads to improved efficacy in obliterating the malformations compared to liquid sclerotherapy.

The correct answer is "Visualization of the renal veins is adequate." This means that using IVUS (Intravascular Ultrasound) to place a bedside IVC (Inferior Vena Cava) filter in the ICU allows for clear visualization of the renal veins. This is important because the renal veins are the blood vessels that carry blood away from the kidneys. By having adequate visualization, the physician can ensure accurate placement of the IVC filter and minimize the risk of complications.

The correct answer is "A patient with an iliofemoral DVT with an extension into the IVC." This is because pharmacomechanical thrombolysis (PMT) is a treatment option for iliofemoral deep vein thrombosis (DVT), especially when it extends into the inferior vena cava (IVC). In this case, an IVC filter placement should be considered prior to PMT to prevent the dislodgement of thrombus during the procedure, which can potentially cause a pulmonary embolism (PE).

The correct answer is "Macroscopic, anechoic spaces without doppler flow." This is because lymphatic malformations (LM) typically appear as large, anechoic (black) spaces on ultrasound imaging. These spaces do not show any flow on Doppler ultrasound, indicating that they are not vascular structures. The absence of Doppler flow helps differentiate LM from other vascular malformations or tumors.

The most useful initial diagnostic study in this case would be a duplex ultrasound. This non-invasive imaging technique can provide detailed information about the blood flow in the veins and can help to identify any abnormalities or malformations. In this case, the presence of distended tortuous veins and symptoms of leg fatigue and heaviness suggest a possible vascular malformation. A duplex ultrasound can effectively evaluate the veins and provide valuable information for further diagnosis and management.

The correct answer is ">0.5 seconds." This means that if the duration of reflux in perforating veins is more than 0.5 seconds, it indicates pathologic reflux. The statement "Reflux is not determined by time" is incorrect because the duration of reflux is indeed an important criterion for determining pathologic reflux. Additionally, the statement "Is measured with the leg elevated" is not relevant to the criteria for duration of reflux in perforating veins.

Tumescent anesthesia during endovenous ablations is used to protect the skin from thermal burn. This technique involves injecting a large volume of diluted local anesthetic solution into the area around the vein being treated. The tumescent solution helps to cool the skin and protect it from the heat generated during the ablation procedure, reducing the risk of thermal injury. This ensures the safety and well-being of the patient during the treatment.

Thermal endovenous ablation should not be used above the ankle because it might cause injury to the saphenous nerve.

The correct answer is 55 year old with iliofemoral DVT of less than 14 days in duration. This is because the guidelines suggest that early thrombus removal is recommended for iliofemoral DVT, which is a more severe form of DVT involving the iliac and femoral veins. Additionally, the duration of less than 14 days is specified, indicating the importance of early intervention in these cases.

Patients with diffuse chronic scar in the iliac and common femoral veins are most likely to experience recurrent Deep Vein Thrombosis (DVT). This is because the scar tissue can disrupt the normal blood flow, leading to the formation of blood clots. Chronic therapeutic anticoagulation and anticoagulation after a provoked acute DVT that resolves are both aimed at preventing DVT recurrence, while thrombolysis for acute DVT while on therapeutic rivaroxaban (xarelto) is a treatment option for acute DVT and not directly related to recurrence. Therefore, the presence of diffuse chronic scar in the iliac and common femoral veins is the most relevant indication for treating DVT and recurrence.

In acute deep vein thrombosis (DVT) in the femoral vein, a characteristic finding on ultrasound (US) is a dilated vein. This means that the affected vein appears enlarged compared to its normal size. This dilation occurs due to the presence of the blood clot within the vein, which obstructs the normal flow of blood and causes the vein to expand. This finding is important in diagnosing DVT as it helps differentiate it from other conditions and guides appropriate management.

The most appropriate agent to achieve effective vein closure with minimal side effects is 1.0% Polidocanol (PD). This concentration of Polidocanol is considered the minimum effective concentration, meaning it is sufficient to effectively close the veins while minimizing the risk of side effects. Sodium Tetradecyl Sulfate (STS) liquid at 3.0% concentration may be too strong and could potentially cause more side effects. Foam sclerotherapy and 0.5% Polidocanol (PD) liquid are not mentioned as being the most appropriate for achieving effective vein closure with minimal side effects.

Intravascular ultrasound is a diagnostic tool used to examine the blood vessels. It is particularly useful in identifying venous pathology. Vein stenosis due to extrinsic compression, venous webs, and non-occlusive "hyperechoic" vein wall changes suggestive of prior DVT are all examples of venous pathology that can be identified with intravascular ultrasound. However, venous atherosclerotic plaque is not typically identified with this imaging technique. Atherosclerotic plaque is more commonly associated with arterial disease rather than venous pathology.

B-Mode ultrasound imaging is a type of intravascular ultrasound technology used in treating deep vein disease. It involves the use of high-frequency sound waves to create a real-time, two-dimensional image of the blood vessels and surrounding tissues. This imaging technique allows healthcare professionals to visualize the structure and function of the veins, helping in the diagnosis and treatment of deep vein disease. It provides valuable information about the size, shape, and location of blood clots or blockages, allowing for accurate and targeted interventions.

The chromophore, water, is incorporated into the mechanism of action with 1470 nm laser ablation. This means that the 1470 nm laser specifically targets water molecules in the tissue, causing them to heat up and vaporize, leading to tissue ablation. Water is a common chromophore in laser ablation procedures because it absorbs light at this wavelength, making it an effective target for treatment.

The access site for endogenous ablation should be at the lowest point of reflux. This is because endogenous ablation is a procedure used to treat venous reflux, which is the backward flow of blood in the veins. The lowest point of reflux is the area where the blood is pooling and flowing in the wrong direction. By accessing this point, the procedure can effectively target and treat the reflux, restoring proper blood flow in the veins.

The correct answer is Great saphenous and small saphenous veins. The question is asking about the connection made by the intersaphenous vein. The intersaphenous vein connects the great saphenous vein and the small saphenous vein.