Tuesday, 18 February 2020

VENOUS AND LYMPHATIC DISEASE

CLINICAL EVALUATION

- most common location of venous

ulceration is approximately 3 cm
proximal to the medial malleolus,
frequently referred to the “gaiter”
region

TREATMENT

- IV or subcutaneous (SC) unfractionated heparin (initial IV bolus of 80 units/kg) or SC

low molecular weight heparin

• monitored every 6 hours using the activated partial thromboplastin time (aPTT)

• anticoagulation may be reversed with protamine sulfate

• Heparin-induced thrombocytopenia (complication)

- due to anti platelet antibodies

- occurs most frequently in the second week of therapy

- Fondaparinux, a synthetic pentasaccharide, is sometimes also used as an alternative

to heparin to initiate therapy

- goal: (INR) ≥2 for 24 hours

- minimum of 5 days of heparin or fondaparinux therapy

- Low molecular weight heparins

• have increased bioavailability (>90% after SC injection), longer half-lives

(approximately 4 to 6 hours), and more predictable elimination rates

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• can be reversed partially by protamine sulfate
- Direct thrombin inhibitors

• reserved for (a) patients in whom there is a high clinical suspicion or confirmation
of HIT, and (b) patients who have a history of HIT or test positive for
heparin-associated antibodies

• should be administered for at least 7 days

- Warfarin

• steady-state concentration is usually not reached for 4 to 5 days

• INR is monitored
- contraindications to thrombolytic therapy

• history of ischemic or hemorrhagic stroke within 3 months, head trauma within 3

months, neurologic surgery within 6 months, known intracranial neoplasm, internal
bleeding within 6 weeks, active or known bleeding disorder, traumatic
cardiopulmonary resuscitation within 3 weeks or suspected aortic dissection

- IVC filter

• lower extremity VTE and absolute contraindications to anticoagulation, have a

bleeding complication from anticoagulation therapy of acute VTE, or those
who develop recurrent DVT or PE despite adequate anticoagulation therapy and for
patients with severe pulmonary hypertension

• be placed only if a proximal DVT is present and anticoagulation therapy is

contraindicated

CHRONIC VENOUS INSUFFICIENCY

- usually due to venous reflux, although most severe cases tend to have an obstructive
etiology as well

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- compression stockings: 20 to 60 mmHg

- pneumatic compression therapy: 30 to 60 mmHg, 4-6 hrs a day