Venous Disease and Thrombosis

Varicose Veins & Anatomy - Leggy Lumps

• Anatomy:
  • Superficial: GSV, SSV.
  • Deep: Femoral, Popliteal, Tibial.
  • Perforators: Connect superficial to deep.
• Varicose Veins: Dilated, tortuous superficial veins.
  • Primary: Valvular incompetence.
  • Secondary: Post-DVT, AV fistula.
  • Risk Factors: Family Hx, Age, Female, Obesity, Prolonged standing, Pregnancy. 📌 FAME (Family Hx, Age, More women, ↑Venous pressure).
  • Pathophysiology: Valve failure → venous reflux → ↑venous pressure → dilation.
• Clinical: Tortuous veins, aching, heaviness, edema, cramps.
• Complications: Bleeding, thrombophlebitis, skin changes (lipodermatosclerosis), ulceration (medial malleolus).

⭐ Saphenofemoral junction incompetence is the most common cause of primary varicose veins.

Deep Vein Thrombosis - Clot Calamity

Deep Vein Thrombosis (DVT): Blood clot in a deep vein, most commonly in the leg. 📌 VIRCHOW Mnemonic: Vascular damage, Increased coagulability, Reduced blood flow - Stasis, Clot Hx, OCP/HRT, Wt (obesity), Old age, W immobilization.

Virchow's Triad:

• Inherited: Factor V Leiden, Prothrombin gene mutation, Protein C/S deficiency, ATIII deficiency.
• Acquired: Surgery, trauma, malignancy, OCPs/HRT, pregnancy, immobilization, Antiphospholipid Syndrome (APLS), age > 60.

⭐ Factor V Leiden mutation is the most common inherited thrombophilia predisposing to DVT.

Clinical Features: Often asymptomatic. Leg pain, swelling, warmth, tenderness. Homan's sign (unreliable).

Diagnosis:

• Compression Ultrasound (CUS): Gold standard.

Complications: Pulmonary Embolism (PE), Post-Thrombotic Syndrome (PTS), Phlegmasia Cerulea Dolens (painful blue leg).

Pulmonary Embolism - Lung Blockers

• Def: Obstruction of pulmonary artery/branches.
• Source: >90% DVT (lower limbs).
• Pathophysio: V/Q mismatch → hypoxemia; ↑pulm. vascular resistance → pulm. HTN → RV strain.
• Types: Thrombus (most common), fat, air, amniotic fluid, tumor, septic.
• Clinical: Sudden dyspnea, pleuritic chest pain, cough, hemoptysis. Tachycardia, tachypnea. Severe: syncope.
  • 📌 PE: Pleuritic pain, Expectoration (hemoptysis)
• Diagnosis:
  • Scores: Wells score for PE, revised Geneva score.
  • D-dimer: Rules out PE if low probability & negative D-dimer.
  • CT Pulmonary Angiography (CTPA): Gold standard.
  • V/Q Scan: If CTPA contraindicated/inconclusive.
  • ECG: S1Q3T3 (classic but uncommon), sinus tachycardia.
  • Echo: RV dysfunction (e.g., McConnell's sign).
• Lines of Zahn:

  ⭐ Lines of Zahn (alternating layers of platelets/fibrin & RBCs) indicate a thrombus formed in flowing blood (pre-mortem).

• Severity:
  • Massive PE: Sustained hypotension (SBP <90 mmHg).
  • Submassive PE: RV dysfunction or myocardial necrosis (biomarkers) without systemic hypotension.

Other Venous Conditions & CVI - Vein Vexations

• Superficial Thrombophlebitis: Superficial vein inflammation/thrombosis, often varicose.

• Migratory Thrombophlebitis (Trousseau Syndrome): Malignancy-assoc. (pancreatic Ca). 📌 TROUSSEAU: Tumour Related OUtflow Stasis, Superficial Emboli, Adenocarcinoma Underlying.

  ⭐ Trousseau syndrome (migratory thrombophlebitis) is a paraneoplastic sign strongly associated with visceral adenocarcinomas, particularly pancreatic cancer.

• SVC & IVC Syndromes:

  Feature	SVC Syndrome	IVC Syndrome
  Causes	Lung cancer, lymphoma	Tumor, thrombus
  Signs	Face/arm swell, dyspnea, plethora	Leg edema, ascites, caput medusae

• Chronic Venous Insufficiency (CVI):

  • Patho: Venous HTN, valve damage, post-thrombotic.
  • Features: Edema, skin changes (pigment, lipodermatosclerosis), medial malleolus ulcer.

High‑Yield Points - ⚡ Biggest Takeaways

• Deep Vein Thrombosis (DVT) commonly affects leg veins; pulmonary embolism (PE) is its most feared complication.
• Virchow's triad (stasis, hypercoagulability, endothelial injury) is fundamental to venous thrombogenesis.
• Factor V Leiden mutation is the most common inherited cause of hypercoagulability, predisposing to DVT.
• Antiphospholipid syndrome (APS) is a significant acquired cause of recurrent venous or arterial thrombosis.
• Elevated D-dimer has high sensitivity but low specificity; primarily used to rule out DVT/PE.
• Trousseau syndrome (migratory thrombophlebitis) is often a paraneoplastic sign of visceral malignancy.
• Chronic venous insufficiency can follow DVT, causing edema, stasis dermatitis, and ulceration.