Venous Disease: Peripheral and Embolic

Venous Disease: Peripheral and Embolic

Dr. D. W. Daugherty

Department of Surgery

* All material presented has been referenced from Schwartz, Textbook of Surgery (Unless otherwise cited on the slide)

The Venous System• To return blood to the heart, against

the force of gravity. This takes a very dynamic system.

• To act as a reservoir to prevent intra-arterial volume overload.

• Gravity, uni-directional valves, cardiac and respiratory cycles, blood volume, and the ‘calf muscle pump’ are all major factors in venous flow.

The Anatomy of a Vein

• Thin walled, highly distensible, and collapsible

• Intima is composed of a nonthrombogenic endothelium with an unerlying basement membrane and an elastic lamina

• Circumferential rings of elastic tissue and smooth muscle located in the media allow for changes in caliber, limiting changes in pressure.

The Anatomy of a Vein

• Uni-directional valves are composed of two thin cusps consisting of a fine connective tissue lattice and covered with endothelium

• The IVC, common iliacs, portal, and cranial sinuses are valveless

Copyright ©2005 American Heart Association

Eberhardt, R. T. et al. Circulation 2005;111:2398-2409

Illustrative ambulatory venous pressure measurements


Nicolaides, A. N. Circulation 2000;102:e126-e163

Diagrammatic representation of typical recording of volume changes during standard sequence of postural changes and exercise. a, Patient in supine position with leg elevated 45 degrees. b, Patient standing with weight on nonexamined leg. c, Single tiptoe movement. d, Ten tiptoe movements. e,

Return to resting standing position as in b. Reproduced with permission from Nicolaides and Sumner

Lower Extremity Venous System

• Lower extremity is divided into superficial, deep, and perforating veins


• Superficial system lies above the uppermost fascial layer of the leg and thigh: great saphenous (GSV) and small saphenous veins (SSV) and their tributaries

• The GSV originates from the dorsal pedal venous arch, anterior to the medial malleolus.

• The GSV drains into the common femoral vein at approximately 4cm inferior and lateral to the pubic tubercle


• The SSV originates from the lateral side of the dorsal pedal arch and courses posteriorly along the calf

• The SSV course is highly variable. Usually enters the popliteal fossa and joins the popliteal vein.

• The surreal nerve accompanies the SSV along its course, providing sensation to the lateral malleolar region.



• The deep veins follow the course of the major arteries in the lower extremity.

• In the leg, paired veins course with the anterior tibial, posterior tibial, and peroneal arteries. These join at the knee to form the popliteal vein.

• Multiple perforator veins transverse the deep fascia to connect the superficial and deep systems.


• The Cockett perforators are relatively consistent and drain the medial lower leg.

• The Boyd perforator veins connect the GSV to the deep system at apx 10cm below the knee and 2cm medial to the tibia.

• Venous sinuses are thin-walled, valveless, large veins located in the soleus and gastrocnemius muscles.

• Small venous channels, with valves, connect the sinuses to the main system.

Upper Extremity Venous System

• The Upper extremity has deep and superficial venous systems.

• Deep veins are paired and follow the artery of the same name.

• The superficial veins are the basilic and cephalic and their tributaries.


• The cephalic vein originates at the lateral wrist and courses on the ventral surface of the arm. It terminates in the infraclavicular fossa, where it joins the axillary vein.

• The basilic vein runs medially along the forearm and penetrates the deep fascia at the elbow.

• The basilic vein joins the deep brachial veins in the upper arm to become the axillary vein.


• The axillary vein becomes the subclavian vein at the lateral boarder of the 1st rib.

• At the medial boarder of the anterior scalene muscle, the SCV (courses anterior to the anterior scalene) joins with the internal jugular vein to become the brachiocephalic vein.

• The left and right brachiocephalic veins join to form the SVC, which then drains into the right atrium.



Chronic Venous Insufficiency

AKA: Post-thrombotic or post-phlebitic syndrome

History of significant DVT is the largest risk factor


Pathophysiology:

recanalization of the deep system with resultant incompetance of the valves

high venous pressure results and subsequently promotes fluid and protein loss into the subcutaneous tissues

resultant impairment of oxygenation and metabolism lead to subcutaneous fibrosis, called liposclerosis.

Chronic Venous InsufficiencyPathophysiology:

edema is characteristic of early post-phlebitic syndrome

chronic microscopic hemorrhages lead to deposition of hemosiderin and the characteristic brown pigmentation



Manifestations of CVI


Pathophysiology:

ulceration frequently occurs and is characteristically located medially (above the medial malleolus)

chronic edema predisposes the patient to recurrent bouts of cellulitis


Treatment:

Compression Stockings

Elevation

Una Boots

Surgical ligation of perforating veins

Surgical venous reconstruction



A simplified overview for the diagnosis and treatment of CVI based on pathophysiological mechanisms

Varicose Veins

Superficial Thrombophlebitis

• Aseptic thrombosis of the superficial veins

• Upper Extremities: almost always associated with an indwelling catheter (IV).– Treatment consists of removing the IV catheter and anti-

inflammatory agents (most often NSAIDs)

• Lower Extremities: usually associated with varicose veins, can occur as a result of minor trauma, dangerous only if it propagates to the femoral vein.– Therapy is supportive: Bed rest, elevation, warm compresses,

anti-inflammatory agents.– Surgical excision is only indicated when the process becomes

infective and purulent.

Superficial Thrombophlebitis

Deep Vein Thrombosis

Virchow’s Triad:

Endothelial damage

hypercoagulability

stasis


Endothelial Damage: Most commonly immune vasculitis associated. e.g. SLE, Buerger’s Disease, Giant Cell Arteritis, Takayasu Disease, Anti-cardiolipin antibodies.

Hypercoagulability: APC resistance, Anti-phospholipid syndrome, Antithrombin III deficiency, Protein C and S deficiencies, Dysfibrinogenemia.

Stasis: CHF, Hyperviscosity, Prolonged Immobility, Neurologic Disorders causeing loss of muscle pump.

Copyright ©2004 American Society of Hematology. Copyright restrictions may apply.

Lopez, J. A. et al. Hematology 2004;2004:439-456

Figure 1. Model for venous thrombosis


Venous thrombi are almost always redish and are always composed primarily of fibrin and RBC’s

Clinical diagnosis is notoriously innacurate

Objective testing is the cornerstone of diagnosis

Contrast Phlebography is the gold standard

Duplex Ultrasound is very accurate

A-C, Management algorithms for patients with suspected DVT.

Fraser J D , Anderson D R Radiology 1999;211:9-24

©1999 by Radiological Society of North America


Duplex Ultrasound:

Highly sensitive and specific for femoral segment thrombosis

Loses sensitivity for isolated thrombi of the calf veins or iliac veins

Isolated iliac vein thrombis is extremely rare

US images of acute proximal DVT.



Case of a 34-year-old woman who presented early in the postpartum period with buttock, groin, and upper thigh pain.



US images of acute proximal DVT.



Appearance of chronic DVT.



Copyright © 2007 by the American Roentgen Ray Society

Garg, K. et al. Am. J. Roentgenol. 2001;177:319-323

--Chronic deep venous thrombosis in 74-year-old man undergoing dialysis because of chronic renal failure

Appearance of chronic DVT.



Figure 10b. Myeloma, chest pain, and leg swelling in a 72-year-old woman.

Katz D S et al. Radiographics 2002;22:S3-S19



Prophylaxis:

High Risk Category: Recent major surgery, malignancy, major trauma, paralysis, and history of previous DVT.

Prophylactic Treatment Options:

Compression stockings

Intermittent pneumatic compression devices

LMWH

Low dose SQ heparin

Warfarin anticoagulation (major joint replacement)


Treatment:

Depends on location

Isolated calf sinus thrombi: No anticoagulation

Distal thrombi (leg): Anticoagulation

Proximal thrombi (thigh): Anticoagulation +/- IVC Filter




Figure 2. A staged approach to selecting duration of anticoagulant therapy based on assessment of risk factors for recurrent venous thromboembolism (VTE)

Deep Vein ThrombosisIV therapy with a heparin gtt is the initial treatment

The goal is an aPTT of double the normal (60-90)

Oral therapy with Warfarin can be initiated concomitantly with the start of heparinization

The goal is an INR of 2.0

IV Heparin may be discontinued once the INR stabilizes at a therapeutic level of 2.0 – 2.5

Alternative treatment with LMWH is an option

Administered SQ daily

Dose of 1mg/kg is based on multiple level I data



Figure 2. A staged approach to selecting duration of anticoagulant therapy based on assessment of risk factors for recurrent venous thromboembolism (VTE)


Hirsh, J. et al. Circulation 1996;93:2212-2245

Cumulative incidence of recurrent venous thromboembolism after the first episode of symptomatic deep vein thrombosis

Inferior Vena Cava Interruption• Goal is to prevent pulmonary emboli

• Percutaneous procedure• A cage-style filter is inserted into the IVC

– Access is almost always via the femoral vein– Internal jugular vein or cephalic vein access are

alternative options– Fluoroscopy is used for visualization– The filter is placed just below the most inferior renal

vein

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Inferior Vena Cava Interruption• Goal is to prevent pulmonary emboli

• Percutaneous procedure with very low risk

• A cage-style filter is inserted into the IVC – Access is almost always via the femoral vein– Internal jugular vein or cephalic vein access are

alternative options– Fluoroscopy is used for visualization– The filter is placed just below the most inferior renal

vein49

Inferior Vena Cava Interruption• Absolute Indications:

1. The presence of a proximal DVT, select patients with distal DVT, and:

• An absolute contraindication to anticoagulation• Uncorrected coagulopathy• Intraventricular monitor or epidural catheter• History of heparin induced thrombocytopenia• Patelet count < 50,000• Need for major surgical procedure within 2 weeks

2. The development of a pulmonary embolus despite being on therapeutic anticoagulation therapy.

• Relative Indications: Proximal thrombus in iliacs or common femoral veins, on medical therapy for known DVT but needs major surgery, high risk trauma patients, and high risk patients who require surgery

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Inferior Vena Cava Interruption

• Relative Indications: – Proximal thrombus in iliacs or common femoral veins– Currently on therapy for known DVT but needs major surgery,– High risk trauma pts (spinal cord injury, GCS < 8, long bone Fx– High risk pts requiring surgery (morbidly obese, metastatic CA)

• Timing of placement:– Many reports of PE occurrence in first 24-48 hrs following injury– Incidence reaches statistical significance at 72 hrs after insult– Appropriate planning for placement should aim for the first 72

hrs following injury (ideally in first 24 hrs)

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– Non-retrievable: Permanent. For patients with high risk of future DVT or PE. Older and elderly patients.

– Retrievable : Can be removed. Use in patients who received IVCF secondary to a prophylactic indication or a temporary contraindication to anticoagulation. Also advisable in very young patients requiring IVCF placement.

• Most often removed via right internal jugular approach

• Recommended retrieval within 30 days of placement• The Bard Recovery G2 Filter is approved for

retrieval up to 150 days 52


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Hirsh, J. et al. Circulation 1996;93:2212-2245

Diagnostic approach when pulmonary embolism is suspected

Pulmonary Thromboembolism

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Management algorithm for patients with suspected pulmonary embolism (PE).




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Kluge, A. et al. Am. J. Roentgenol. 2006;186:1686-1696

--59-year-old woman with SOB

Figure 7b. Shortness of breath in an 89-year-old woman.

Katz D S et al. Radiographics 2002;22:S3-S19




--48-year-old man with SOB



--64-year-old woman with pulmonary embolism. source image of MR angiography show large embolus in left pulmonary artery

Superior Vena Cava Syndrome

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Lanciego, C. et al. Am. J. Roentgenol. 2009;193:549-558

--68-year-old man with small cell carcinoma and severe stenosis of superior vena cava (SVC) with marked development of collateral veins



--65-year-old man with non-small cell lung carcinoma already treated on previous occasions (4 and 2 months earlier) with stents to resolve superior vena cava (SVC) syndrome



--65-year-old man with non-small cell lung carcinoma already treated on previous occasions (4 and 2 months earlier) with stents to resolve superior vena cava (SVC) syndrome



-Kaplan-Meier curves

Questions?

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Health & Medicine

Venous Disease: Peripheral and Embolic