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Venous and Lymphatic Disease
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VENOUS AND LYMPHATIC DISEASE
VENOUS FLOW: FACTORS
Upright position Left ventricular force
( gravity ) ( vis a tergo )
High volume, low Calf muscles
pressure circu- Venous valves in
lation lower extremities
Intra-abdominal Smooth muscles in
pressure superficial veins
THE VASCULAR CONSULTATION
• Painful extremity
• Swollen extremity
• Ulcerated leg
THE PAINFUL LOWER EXTREMITY
• No characteristic pain in venous
disease
• Aggravated by standing
• Relieved by elevating leg and foot
PAIN
• Varicose veins discomfort
Pulling Burning
Pricking Tingling
• Superficial Thrombophlebitis
inflammation
Tenderness Warmth
Redness Induration
PAIN
• Venous thrombosis
- little or no pain
- moderate aching discomfort or
sensation of heaviness
- “bursting” pain uncommon
venous claudication
THE SWOLLEN LEG
• High venous pressure
• Cardiac
intrinsic
• Venous obstruction
extrinsic
• Gravitational pressure
- effect on incompetent valves
THE SWOLLEN LEG
• Pressure
• Protein
• Permeability
• Paresis
• Pendency
EDEMA
• Central / systemic
Pitting; no skin changes
• Peripheral venous
Does not pit readily
Chronic brawny dermatitis
stasis dermatitis
gaiter distribution
EDEMA
• Lymphedema
Diffuse
Spongy
Hypertrophic skin Elephantiasis
THE ULCERATED LEG
• Stasis ulcer
• Gaiter area – around medial
malleolus
• Mild pain relieved by elevation
• Venous bleeding / oozing
• Stasis dermatitis
• Shallow, irregular with granulating
base
SUPERFICIAL THROMBOPHLEBITIS
• Local inflammatory process
• Usually aseptic
• Etiology: acidic fluid infusion
prolonged cannulation
contrast injection
varicose veins
• Treatment: bed rest, elevation
local heat
support hose / stockings
DEEP VENOUS THROMBOSIS
• Virchow 1856
1. Stasis
2. Endothelial damage
3. Hypercoagulability
DEEP VENOUS THROMBOSIS: RISK FACTORS
• Pregnancy
• Obesity
• Malignancy
• Trauma
• Sepsis
• Major surgery
• Other disease states – DIC, Poly-
cythemia, Dysfibrinogenemia,
Anti-thrombin III deficiency
ORIGIN OF DVT
• Usually from the lower extremity, starting at the calf level going proximally; source of 80-90% of pulmonary emboli
• Pelvic veins
• Renal veins
• Inferior vena cava
• Ovarian veins
• Upper extremity and neck veins
• Right atrium
DVT: CLINICAL MANIFESTATIONS
• Classic clinical syndrome Calf or thigh pain Edema Tenderness (+)Homan’s sign • Nonspecific; associated with veno- graphically proven DVT in only 50% • Conversely, 50% of those with DVT have no associated physical findings
DEEP VENOUS THROMBOSIS
• Pulmonary embolism is a common
presenting symptom in many patients
• Need to rule out the presence of arterial insufficiency
LOWER EXTREMITY DVT: CLINICAL MANIFESTATIONS
• Phlegmasia alba dolens
pain, pitting edema, blanching
pregnancy-related
• Phlegmasia cerulea dolens
loss of sensory and motor function
cessation of arterial flow
venous gangrene
DEEP VENOUS THROMBOSIS: DIAGNOSIS
• Radioactive-labelled fibrinogen
• Doppler ultrasound
• Impedance plethysmography
• Venography
• Venous duplex scan
TREATMENT OF DVT
• PREVENTION !
- Identify risk factors
- Prophylaxis
Early ambulation
Anticoagulation heparin
Intermittent pneumatic
compression
TREATMENT OF DVT
• Treatment
- Anticoagulation
Heparin Warfarin
Low molecular weight heparin
- Fibrinolysis
Urokinase / streptokinase
TPA
- Operative
OPERATIVE TREATMENT OF DVT
• Thrombectomy
• Vena caval interruption
Greenfield filter
PULMONARY EMBOLISM
• Obstruction to blood flow in the pulmonary arterial system due to thromboemboli pulmonary hypertension, decreased cardiac output, impaired gas exchange / oxygenation, sudden death
• One of MOST COMMON CAUSES OF SUDDEN DEATH in hospitalized patients
PULMONARY EMBOLISM
• Only around 10% are diagnosed PREMORTEM
• > 90% of deaths occur within 2 hours of the onset of symptoms
• Associated with DVT in up to 40%; around 30% have no symptoms of DVT
PULMONARY EMBOLISM: RISK FACTORS
• Pregnancy
• Estrogen therapy
• Obesity
• Heart disease
• Malignancy
• Major trauma
• Previous episode of PE
• Varicose veins
• Advanced age
PULMONARY EMBOLISM: SYMPTOMS
• Classic signs – only in 25%
Hemoptysis
Pleural friction rub
Gallop rhythm
Cyanosis
• Common findings: tachycardia, tachypnea, dyspnea; arrythmias; pulmonary effusion or infiltration (infarction); hypoxemia on ABGs
Massive pulmonary embolism
Pulmonary infarction
CHF
Shock
PULMONARY EMBOLISM: DIAGNOSIS
• Pulmonary radio-isotope scanning
Perfusion scan
Ventilation scan
Ventilation / perfusion scan
• Pulmonary arteriography
Gold standard
PULMONARY EMBOLISM: MANAGEMENT
• Cardiovascular support / critical care
• Anticoagulation
• Thrombolytic therapy
• Pulmonary embolectomy
ANTICOAGULATION THERAPY: COMPLICATIONS
• Major hemorrhage
• Heparin-induced thrombocytopenia
Hemorrhage
Necrosis
• Recurrent pulmonary embolism
VARICOSE VEINS
• Primary
Familial
Favorable prognosis with medical or
surgical treatment
• Secondary
Due to deep venous disease
Stasis dermatitis or ulceration
VARICOSE VEINS
• Local pain and edema
Nonspecific ache or heaviness
Relieved by elevation of leg
• Local inflammation
• Local hemorrhage into surrounding tissues
• Dilated superficial veins
• Positive Trendelenburg test
VARICOSE VEINS
• Diagnostic aids
Doppler ultrasound / duplex scan
Venous reflux plethysmography
VARICOSE VEINS: TREATMENT
• Conservative unless:
Venous stasis
Dermatitis
Bleeding
Thrombosis / phlebitis
Superficial ulceration
• Injection sclerotherapy
• Surgery – vein stripping
• Endovenous procedures
Laser ablation
Radiofrequency ablation
CHRONIC VENOUS INSUFFICIENCY
Deep venous thrombosis
Post-thrombotic syndrome
Recanalization
Valve damage
Valve incompetence
CHRONIC VENOUS INSUFFICIENCY
• Fluid, protein extravasation
• Thickened, sclerotic subcutaneous tissues ( Brawny edema )
• Hemosiderin pigmentation
• Skin atrophy, necrosis, stasis ulceration
• Dermatitis, cellulitis
• If no recanalization venous claudication
CHRONIC VENOUS INSUFFICIENCY
• Compression tests
Trendeleburg
Perthes
Ochsner-Mahorner
• Laboratory
Plethysmography
Duplex scanning
TREATMENT OF CVI
• Supportive – elastic stockings
frequent leg elevation
avoid prolonged
standing or sitting
• Operative – perforator vein ligation
venous reconstruction
LYMPHEDEMA
• Swelling of one or more extremities caused by lymphatic obstruction or insufficiency
• Primary vs secondary
PRIMARY LYMPHEDEMA
• Congenital – present at birth
10% of cases
hereditary – Milroy’s
disease
• Lymphedema praecox – from puberty;
most common type
• Lymphedema tarda – after 30s
SECONDARY LYMPHEDEMA
• Malignancy
• Radiation
• Trauma
• Inflammatory
• Parasitic elephantiasis ( Wuchereria bancrofti )
LYMPHEDEMA
• Diagnosis – confirmed by lymphangiogrphy
• Treatment
- limb elevation, weight reduction,
salt restriction
- compressive stockings
- surgery: dermal flap
omental transposition
microsurgical anastomosis