Venous DisordersVenous Disorders

Venous returnVenous return

►Muscle pump ( peripheral Muscle pump ( peripheral hearts)hearts)

►- ve intra thoracic pressure- ve intra thoracic pressure►Arterial pulsationArterial pulsation►Vise at ergoVise at ergo

Varicose VeinsVaricose Veins

►Dilated, elongated & Dilated, elongated & tortuous vein of the LLtortuous vein of the LL

►problem comes from problem comes from incompetent calve. incompetent calve.

►10 -20 % of worlds 10 -20 % of worlds population have varicose population have varicose veins. veins.

Causes of varicos veins in Causes of varicos veins in lower limbslower limbs..

►

SecondarySecondary Obstruction of venous outflow.Obstruction of venous outflow.

► Pregnancy. Pregnancy. ► Fibroids Fibroids ► Ovarian cysts. Ovarian cysts. ► Abdominal lymphadenopathy Abdominal lymphadenopathy ► Pelvic cancer (cervical, uterus, ovary, rectum) Pelvic cancer (cervical, uterus, ovary, rectum) ► Ascites Ascites ► Illiac vein thrombosis. Illiac vein thrombosis. ► Retroperitoneal fibrosis Retroperitoneal fibrosis

Valve destructionValve destruction. . ► DVT DVT

High flow and pressureHigh flow and pressure: : ► Arteriovenous fistula ( esp the aquired traumatic variety)eg.Klippel-Arteriovenous fistula ( esp the aquired traumatic variety)eg.Klippel-

Trenaunay syndrome (which is one form of congenital AV Trenaunay syndrome (which is one form of congenital AV malformation syndrome) malformation syndrome)

► Primary:Primary: Cause not known. Often familial.Probably weakness of vein wall Cause not known. Often familial.Probably weakness of vein wall

that permits valve ring to dilate. that permits valve ring to dilate. Congenital abscence of valves very rare.Congenital abscence of valves very rare.

Varicose Veins (Etiology)Varicose Veins (Etiology)

►PrimaryPrimary

HereditaryHereditary OccupationalOccupational PregnancyPregnancy obesityobesity

►SecondarySecondary

Venous Venous obstructionobstruction

Venous Venous compressioncompression

A/V fistulaA/V fistula

Varicose Veins (Etiology)Varicose Veins (Etiology)► Obstruction of venous outflow.Obstruction of venous outflow.

Pregnancy. Pregnancy. Fibroids Fibroids Ovarian cysts. Ovarian cysts. Abdominal lymphadenopathy Abdominal lymphadenopathy Pelvic cancer (cervical, uterus, ovary, Pelvic cancer (cervical, uterus, ovary,

rectum) rectum) Ascites Ascites Illiac vein thrombosis. Illiac vein thrombosis. Retroperitoneal fibrosis Retroperitoneal fibrosis

► Valve destructionValve destruction. . DVT DVT

► High flow and pressureHigh flow and pressure: : Arteriovenous fistula ( esp the aquired Arteriovenous fistula ( esp the aquired

traumatic variety)traumatic variety) Klippel-Trenaunay syndrome (which is one Klippel-Trenaunay syndrome (which is one

form of congenital AV malformation form of congenital AV malformation syndromesyndrome

Varicose VeinsVaricose VeinsPrimary V VPrimary V V► History:History:

young and middle young and middle aged womenaged women most most commonly commonly affected.1:10 affected.1:10 men :women men :women

Aggrevating factorsAggrevating factors associated with associated with increased incidence increased incidence of varicose veins:of varicose veins:

► female sex, female sex, ► parity, parity, ► clothing,clothing,► prolonged standing,prolonged standing,► marked obesity, marked obesity,

Secondary V VSecondary V V► History:History:

Any ageAny age most most commonly affect commonly affect men men

Aggrevating factorsAggrevating factors associated with associated with increased incidence increased incidence of varicose veins:of varicose veins:

► DVTDVT► TraumaTrauma► CompressionCompression► fracturefracture

Varicose Veins (symptoms)Varicose Veins (symptoms)► Disfiguring effectsDisfiguring effects of the of the

veins usually principle veins usually principle complaintcomplaint

► PainPain, , dull ache, and heaviness dull ache, and heaviness felt in calves and lower leg felt in calves and lower leg worse during day esp. on worse during day esp. on

standing up,standing up, relieved by lying down for relieved by lying down for

15-30 min. 15-30 min. ► Edema (swelling around Edema (swelling around

ankle)ankle) Aggregated by standingAggregated by standing Relived by recumbencyRelived by recumbency

► night crampsnight cramps

► Disfiguring effectsDisfiguring effects of the of the veins usually principle veins usually principle complaintcomplaint

► PainPain, , dull ache, and heaviness dull ache, and heaviness felt in calves and lower leg felt in calves and lower leg worse during day esp. on worse during day esp. on

standing up and walkingstanding up and walking relieved by lying down for relieved by lying down for

15-30 min. 15-30 min. ► Edema (swelling around Edema (swelling around

ankle)ankle) Aggregated by standingAggregated by standing Relived by recumbencyRelived by recumbency

► night crampsnight cramps► Post phlebitic syndromePost phlebitic syndrome

dilated veins, venous stars, dilated veins, venous stars, pigmentation, eczema and pigmentation, eczema and ulceration. ulceration.

Varicose Veins (signs)Varicose Veins (signs)► Dilated elongated Dilated elongated

tortuous veinstortuous veins► Types of varicesTypes of varices

Tubular with dilated LSV Tubular with dilated LSV or SSVor SSV

Saccular incompetent Saccular incompetent perforator ( blow out)perforator ( blow out)

► Signs of PPS - veSigns of PPS - ve► Special testesSpecial testes

Modified perthe’sModified perthe’s Cough impulseCough impulse Trendelenburg’s testTrendelenburg’s test Multiple tourniquet testMultiple tourniquet test Shwartz testShwartz test

► Dilated elongated Dilated elongated tortuous veinstortuous veins

► Types of varicesTypes of varices Serpintine dilated Serpintine dilated

tributeriestributeries Spider indicate A/ V Spider indicate A/ V

fistulafistula

► Signs of PPS + veSigns of PPS + ve► Special testesSpecial testes

Modified perthe’sModified perthe’s Cough impulseCough impulse Trendelenburg’s testTrendelenburg’s test Multiple tourniquet testMultiple tourniquet test Shwartz testShwartz test

LSVLSV

LSV behind the kneeLSV behind the knee

Vein of Vein of LeonardoLeonardo

( post arch ( post arch vein )vein )

LSV behind the kneeLSV behind the knee

Vein of LeonardoVein of Leonardo ( post arch vein )( post arch vein )

LSV in front of medial LSV in front of medial malleolusmalleolus

Communicator just below kneeCommunicator just below knee

LSVLSV

Vein of LeonardoVein of Leonardo ( post arch vein )( post arch vein )

LSV behind the kneeLSV behind the knee

Vein of LeonardoVein of Leonardo ( post arch vein )( post arch vein )

LSV starting at mid thighLSV starting at mid thighCommunicator and passCommunicator and pass

behind the kneebehind the knee

Antromedial and calfAntromedial and calfGroup of tributariesGroup of tributaries

Antromedial and Antromedial and calfcalf

Group of tributariesGroup of tributaries

mid thighmid thighCommunicatCommunicat

oror

Examination:Examination:► Inspection: Inspection:

ask patient to ask patient to stand upstand up. . look for abnormal visible look for abnormal visible

subcutaneous veinssubcutaneous veins. if dilated and . if dilated and tortuous=varicose veins. tortuous=varicose veins.

record record size and shape of the veinssize and shape of the veins. . venous starsvenous stars (minute veins radiating (minute veins radiating

from a single feeding vein from a single feeding vein oedema oedema inspect skin espinspect skin esp. lower medial 1/3 . lower medial 1/3

for pigmentation, eczema, for pigmentation, eczema, ulceration.ulceration.

Examination:Examination:►Palpation: Palpation:

feel along the course of the veinsfeel along the course of the veins and feel and feel the tension in the veins the tension in the veins

feel saphenofemoral and saphenopopliteal feel saphenofemoral and saphenopopliteal junctionsjunctions and ask patient to cough, a strong and ask patient to cough, a strong cough impulse indicates incompetent valves. cough impulse indicates incompetent valves.

feel along feel along medialmedial side of lower leg side of lower leg for tender for tender defects in deep facia with patient standing defects in deep facia with patient standing and lying, these are sites of incompetent and lying, these are sites of incompetent valves. valves.

look for pitting look for pitting oedemaoedema, thickening, and , thickening, and tenderness. tenderness.

brown pigmentation , eczema and ulcerationbrown pigmentation , eczema and ulceration. .

ExaminationExamination►   Tourniquet tests.Tourniquet tests.

to check for the site of the incompetent to check for the site of the incompetent valves. valves.

Lie patient flat and elevate one leg Lie patient flat and elevate one leg place tourniquet along upper 1/3 of thigh place tourniquet along upper 1/3 of thigh ask patient to stand up ask patient to stand up if veins fill above tourniquet the if veins fill above tourniquet the

incompetence above. incompetence above. ►Trendelenburgs test.Trendelenburgs test.

direct digital pressure on long saphenous direct digital pressure on long saphenous vein valve. vein valve.

patient first lying with leg up patient first lying with leg up stand up patient stand up patient

ExaminationExamination►   Percussion: Percussion:

transmission of percussion waves transmission of percussion waves downward implies incompetent valves downward implies incompetent valves ( Shwartz test). ( Shwartz test).

Place fingers of one hand on lower limit of Place fingers of one hand on lower limit of visible vein and tap top. visible vein and tap top.

►Auscultation:Auscultation: listen over clusters of veins especially if listen over clusters of veins especially if

they remain distended when patient lies they remain distended when patient lies down may be arteriovenous fistula. down may be arteriovenous fistula.

ExaminationExamination

►General examination:General examination: examine abdomenexamine abdomen, incl rectal and vaginal , incl rectal and vaginal

examination. examination. men: palpate testes, testicular tumoursmen: palpate testes, testicular tumours can can

be small but cause massive enlargement of be small but cause massive enlargement of the abdominal nodes with vena caval the abdominal nodes with vena caval obstruction. obstruction.

look for look for dilated collateral veins on abdomendilated collateral veins on abdomen. . direction of flow: Harvey's testdirection of flow: Harvey's test (emty veins (emty veins

with 2 fingers and see where it fills from) with 2 fingers and see where it fills from)

Congenital A/V fistula with Congenital A/V fistula with secondary V Vsecondary V V

Traumatic A/V fistula with Traumatic A/V fistula with secondary V Vsecondary V V

InvestigationInvestigation

► Routine Lab mainly Routine Lab mainly BSLBSL

► Hand held DopplerHand held Doppler

Continuous wave Continuous wave Doppler (CWD)Doppler (CWD)

(phono-angiography)(phono-angiography)

InvestigationInvestigation

► Doppler USDoppler US

InvestigationInvestigation

Duplex US gold Duplex US gold standard standard

► (B mode ultrasound (B mode ultrasound and a coupled and a coupled doppler probe) doppler probe)

► allows direct allows direct visualiastion of visualiastion of veins, direction of veins, direction of flow can be flow can be recorded recorded

InvestigationInvestigation

►Plethysmography and Venography are Plethysmography and Venography are obsoleteobsolete

►Venous pressureVenous pressure►Radio-active isotope scanningRadio-active isotope scanning►Arteriograpgy if A/V fistulaArteriograpgy if A/V fistula

Complications:Complications:

► Haemorrhage Haemorrhage ► OedemaOedema► Skin pigmentationSkin pigmentation► LipodermatosclerosisLipodermatosclerosis► Varicose eczema Varicose eczema ► Venous ulcerationVenous ulceration► Thrombophlebitis Thrombophlebitis ► Atrophie blancheAtrophie blanche► Marjolin ulcerMarjolin ulcer► Equinous deformity Equinous deformity

►

ThrombophelbitisThrombophelbitisVaricose eczemaVaricose eczema

Treatment Treatment ►A. Non- operative management. A. Non- operative management.

walking should be encouraged walking should be encouraged and prolonged sitting and and prolonged sitting and standing should be forbidden standing should be forbidden

patient should elevate leg as patient should elevate leg as frequently as possible to reduce frequently as possible to reduce venous pressure. venous pressure.

elastic stockings. extending from elastic stockings. extending from distal metatarsals to just below distal metatarsals to just below the knee the knee

TreatmentTreatment

Compression Compression sclerotherapysclerotherapy. . permanent permanent fibrotic fibrotic

occlusion of collapsed occlusion of collapsed veinsveins. .

patient is recumbent patient is recumbent and veins collapsed, and veins collapsed,

a small amout of 0.5 a small amout of 0.5 ml of sclerosing ml of sclerosing solution (3% sodium solution (3% sodium tetradecyl sulfate) is tetradecyl sulfate) is injected into each injected into each varix varix

Compression sclerotherapyCompression sclerotherapy. . continuous continuous pressure is maintained for 1-2 pressure is maintained for 1-2

weeksweeks with elastic stockings. with elastic stockings. much less expensive than surgery much less expensive than surgery if successful it gives the best cosmetic if successful it gives the best cosmetic

result. result. long term results are worse than surgery. long term results are worse than surgery. best for small unsightly veins, dilated best for small unsightly veins, dilated

superficial veins, lower leg perforators, and superficial veins, lower leg perforators, and recurrent or persistant veins after surgery recurrent or persistant veins after surgery

unsatisfactory at or above the kneeunsatisfactory at or above the knee

Endo-venous laserEndo-venous laser

► Peri-venous LAPeri-venous LA► 810 nm diode810 nm diode► Time consumingTime consuming► Less painfulLess painful

Radiofrequency ablationRadiofrequency ablation

► Peri-venous LA/ Peri-venous LA/ regional regional anaesthesiaanaesthesia

► Pode expansion in Pode expansion in CFVCFV

► Cook at 85Cook at 85ooCC► Time consumingTime consuming

TreatmentTreatmentSurgical therapySurgical therapy. .

IndicationsIndications: : ►severe symptoms severe symptoms ►very large varices very large varices ►attacks of superficial phlebitis attacks of superficial phlebitis ►haemorrhage from rupturd haemorrhage from rupturd varices. varices.

►ulceration from venous stasis. ulceration from venous stasis. ►cosmetic reasons. cosmetic reasons.

TreatmentTreatmentSurgical therapySurgical therapy. .

identify all perforating and superficial identify all perforating and superficial veins preoperativelyveins preoperatively and mark them. and mark them.

results depend on thoroughness of results depend on thoroughness of the procedure. the procedure.

postoperatively leg is supported with postoperatively leg is supported with elastic bandageselastic bandages for approximately 6 for approximately 6 weeks. weeks.

elevation of leg in bed minimizes elevation of leg in bed minimizes postop swelling. postop swelling.

recurrens rate of about 10%.recurrens rate of about 10%. most most common cause is failure to ligate all common cause is failure to ligate all the tributaries, and incompetent the tributaries, and incompetent perforatorsperforators. .

External valvular stentExternal valvular stent

Adjustable gore-tex/ Adjustable gore-tex/ dacron cuffdacron cuff

?physiological?physiological

Deep Vein ThrombosisDeep Vein Thrombosis ► Only 1/3 of DVT's cause symptoms and signs. Only 1/3 of DVT's cause symptoms and signs. ► predisposition to thrombosis is predicted predisposition to thrombosis is predicted

with with Virchow's triad.Virchow's triad. Change in vessel wallChange in vessel wall; distention, injury, ; distention, injury,

inflammation, trauma. inflammation, trauma. Diminished rate of blood flowDiminished rate of blood flow; during and ; during and

after operations (postop rare before 40years, after operations (postop rare before 40years, most common operations;obesity, operations for most common operations;obesity, operations for cancer,prostate and hip), debilitating diseases cancer,prostate and hip), debilitating diseases

Increased coagulability of the bloodIncreased coagulability of the blood;; infections, after haemorrhage, visceral infections, after haemorrhage, visceral cancers,during pregnancy, hypercoagulable cancers,during pregnancy, hypercoagulable states( congenital abnormalities of protein C and states( congenital abnormalities of protein C and S, antithrombin III), deficiencies in the fibrinolytic S, antithrombin III), deficiencies in the fibrinolytic systemsystem

Increased Increased coagulabilitycoagulability

Change in vessel wallChange in vessel wall

Diminished rate Diminished rate of blood flow of blood flow

(Stasis)(Stasis)

Deep Vein ThrombosisDeep Vein Thrombosis► History: History:

pain and swellingpain and swelling in the calf or whole leg of sudden in the calf or whole leg of sudden onset and severe onset and severe

walking may be difficultwalking may be difficult if PEif PE pleuritic pain, dyspnea, haemoptysis, collapse. pleuritic pain, dyspnea, haemoptysis, collapse.

► Examination. Examination. Swelling Swelling muscles muscles containing the thrombus may be hard and containing the thrombus may be hard and

tender. tender. Homan's signHoman's sign (pain in calf when foot is plantar (pain in calf when foot is plantar

flexed) flexed) If thrombosis obstructes communicating veins then If thrombosis obstructes communicating veins then

superficial veins may dilate and leg feel hot. superficial veins may dilate and leg feel hot. phlegmasia alba dolensphlegmasia alba dolens (white leg or milky leg) (white leg or milky leg) Phlegmasia cerulea dolensPhlegmasia cerulea dolens (venous thrombosis (venous thrombosis

blocks all main veins and leg becomes congested blocks all main veins and leg becomes congested and blue)and blue)

Deep Vein ThrombosisDeep Vein ThrombosisMajor criteriaMajor criteria►History of DVT or family historyHistory of DVT or family history►MalignancyMalignancy►Paralyzed or recent plaster Paralyzed or recent plaster

immobilizationimmobilization►Recent bed ridden > 3 daysRecent bed ridden > 3 days►Operated < 4 weeksOperated < 4 weeks►Thigh and calf sweelingThigh and calf sweeling►Calf swelling > 3 cmCalf swelling > 3 cm

Deep Vein ThrombosisDeep Vein ThrombosisMinor criteriaMinor criteria►Trauma to the leg < 60 dayTrauma to the leg < 60 day►Hospitalization in last 6 monthsHospitalization in last 6 months►Unilateral oedemaUnilateral oedema►Unilateral erythemaUnilateral erythema►Unilateral dilated veinsUnilateral dilated veins

Deep Vein ThrombosisDeep Vein ThrombosisHigh possibility 85 %High possibility 85 %

> 3 major> 3 major > 2 major > + 2 minor > 2 major > + 2 minor

Moderate possibility 33 %Moderate possibility 33 % 1 major + > 2 minor1 major + > 2 minor > 3 major> 3 major

Low possibility 5 %Low possibility 5 %►othersothers

DVTDVT

SwellingSwelling muscles

muscles hard and

hard and

tender

tender..

Homan's signHoman's sign

Phlegmasia cerula DolensPhlegmasia cerula Dolens

Common Iliac occlusion With Common Iliac occlusion With phlegmasia Cerula dolensphlegmasia Cerula dolens

IVC occlusionIVC occlusion

Prevention of DVTPrevention of DVT► Before operationBefore operation:: Stop pill ( if possible 6 Stop pill ( if possible 6

weeks before), grossly overweight patients weeks before), grossly overweight patients should reduce weight, those over 40 should should reduce weight, those over 40 should have increased activity 2-3 weeks at home, low have increased activity 2-3 weeks at home, low dose heparin dose heparin

► During operationDuring operation: : prevent pressure on prevent pressure on venous system(elevate leg on sand bag), venous system(elevate leg on sand bag), graduated compression stocking or intermittent graduated compression stocking or intermittent pneumatic compression, after operation pneumatic compression, after operation elevate and massage the leg. elevate and massage the leg.

► After operationAfter operation:: Massage, leg movements, Massage, leg movements, graduated stockings (TED stockings), low dose graduated stockings (TED stockings), low dose heparin, adequate hydration, early ambulation, heparin, adequate hydration, early ambulation, Patients should not sit with their legs Patients should not sit with their legs dependant often better to have in bed then dependant often better to have in bed then sitting in a chair.sitting in a chair.

Prevention of DVTPrevention of DVTMethods of prevention:Methods of prevention: ► Mechanical:Mechanical: assisting venous return by; Graduated assisting venous return by; Graduated

static compression elastic stockings (Kendall's Thrombo static compression elastic stockings (Kendall's Thrombo Embolic Deterrent-TED) may reduce incidence of DVT Embolic Deterrent-TED) may reduce incidence of DVT to below 10% (20% in hip surgery), electronic to below 10% (20% in hip surgery), electronic stimulation of calf muscles, Pneumatic compression. stimulation of calf muscles, Pneumatic compression.

► Low dose heparin 5000 units subcutaneouslyLow dose heparin 5000 units subcutaneously 2h before 2h before operation and continued twice daily until patient is fully operation and continued twice daily until patient is fully ambulating, avoid if operation will leave bleeding areas ambulating, avoid if operation will leave bleeding areas or if bleeding in cosed space may be disastrous. or if bleeding in cosed space may be disastrous.

► Low molecular weight heparinsLow molecular weight heparins; reduced risk of ; reduced risk of bleeding but as effective. bleeding but as effective.

► (Dextran '70(Dextran '70'. inhibits platelet adhesion 500ml iv during '. inhibits platelet adhesion 500ml iv during operation and 500 ml following 24 h)operation and 500 ml following 24 h)

►accurate diagnosis using doppler accurate diagnosis using doppler ultrasound (or venography).ultrasound (or venography).

►Anticoagulation Anticoagulation (Aim of treatment is to prevent (Aim of treatment is to prevent

proximal propagation of thrombus) proximal propagation of thrombus) before anticoagulation collect before anticoagulation collect

blood for APTT, INR and platelet blood for APTT, INR and platelet count. count.

Treatment of DVTTreatment of DVT

HeparinHeparin 5000 units IV as loading dose 5000 units IV as loading dose followed by initially 1250 units/hour followed by initially 1250 units/hour

then adjust according to APTT. then adjust according to APTT. Measure APTT every 4hours and Measure APTT every 4hours and

adjust dose accordingly 60-85 adjust dose accordingly 60-85 seconds is the considered seconds is the considered therapeutic dose. therapeutic dose.

When dose is in the therapeutic When dose is in the therapeutic range check APTT daily. range check APTT daily.

Check platelets 3/week for heparin Check platelets 3/week for heparin induced thrombocytopenia.(rare) induced thrombocytopenia.(rare)

Treatment of DVTTreatment of DVT

►cease heparin when cease heparin when warfarinwarfarin is is established with a therapeutic INR established with a therapeutic INR 2< for 2days. 2< for 2days.

►initial Warfarin 10mg orally, once initial Warfarin 10mg orally, once daily for 2 days, on 3 day warfarin daily for 2 days, on 3 day warfarin should be adjusted according to should be adjusted according to INR. INR.

►continue for 3-6 month.continue for 3-6 month.►check INR on 3 day, then daily, for check INR on 3 day, then daily, for

first week, then weekly first week, then weekly

Treatment of DVTTreatment of DVT

Treatment of DVTTreatment of DVT

► ThrombectomyThrombectomy; rarely indicated ; rarely indicated ► Fibrinolytic treatmentFibrinolytic treatment: :

streptokinase, urokinase or combination of streptokinase, urokinase or combination of streptokinase with tissue plasminogen activator streptokinase with tissue plasminogen activator (TPA). (TPA).

consider in young people with extensive thrombosis consider in young people with extensive thrombosis ► ThrombolysisThrombolysis

likelihood of substantial likelihood of substantial thrombolysisthrombolysis is below 50% is below 50% there is only limited evidence of long term benefit. there is only limited evidence of long term benefit. carries an increased risk of major bleeding.carries an increased risk of major bleeding.

► Venous interuptionVenous interuption extension of life treatening thrombus; consider extension of life treatening thrombus; consider

venous interuption using filtervenous interuption using filter

IVC filterIVC filter

Chronic venous insufficiencyChronic venous insufficiency

V a rico se V e ins P ig m e n ta tion U lce ra tion

In c re a sed ve n ou s p re ssu re

In e ffe c tive m u scle pu m p

In com pe te n t va lves

Chronic venous Chronic venous insufficiencyinsufficiency

Macro- circulation Macro- circulation ChangesChangesMuscle dysfunctionMuscle dysfunction ObstructionObstructionRefluxReflux

Increase AVPIncrease AVPIncrease perforatorIncrease perforator

incompetenceincompetencePrimaryPrimary PhysicalPhysical

Secondary Secondary To DVTTo DVT FunctionalFunctional

SVI 40 %SVI 40 % DVI 10 %DVI 10 %Combined SVI+Combined SVI+DVI 40%DVI 40%

Perforator Incompetence isolated in 2-4%Perforator Incompetence isolated in 2-4%

Chronic venous insufficiencyChronic venous insufficiencyMicro- circulation ChangesMicro- circulation Changes

The two most popular current explanations for this The two most popular current explanations for this process are process are

Fibrin cuff theoryFibrin cuff theory► Increase venous pressure will lead to capillary elongation Increase venous pressure will lead to capillary elongation

and widening of the pores and widening of the pores ► giving a chance to fibrinogen to escape and polymerize giving a chance to fibrinogen to escape and polymerize

creating a cuff that impedes oxygenation ~>ulceration creating a cuff that impedes oxygenation ~>ulceration

White cell trapping theoryWhite cell trapping theory► Decreased pressure gradient slow circulation down and Decreased pressure gradient slow circulation down and

trap the WBCs that marginate and block capillaries. trap the WBCs that marginate and block capillaries. ► These will liberate oxygen free radicals and proteolytic These will liberate oxygen free radicals and proteolytic

enzymes causingenzymes causing endothelial damage.endothelial damage.

Chronic venous insufficiencyChronic venous insufficiencyMicro- circulation ChangesMicro- circulation Changes

Arterio-venous communicationsArterio-venous communications Some suggest the presence arteriovenous shunts further Some suggest the presence arteriovenous shunts further

depriving the skin from oxygendepriving the skin from oxygenTrap hypothesisTrap hypothesis Some suggest that macromolecules exuded can trap Some suggest that macromolecules exuded can trap

growth factors and cells rendering them unavailable for growth factors and cells rendering them unavailable for regular tissue repairsregular tissue repairs

Tissue pressureTissue pressureThe benefit of elevation, elastic stocking and corrective The benefit of elevation, elastic stocking and corrective

venous surgery reduces the tissue pressures and heal the venous surgery reduces the tissue pressures and heal the ulcers ulcers

Cutaneous iron overloadCutaneous iron overloadThe accumulation of ferritin can induce production of oxygen The accumulation of ferritin can induce production of oxygen

free radilces causing tissue destruction.free radilces causing tissue destruction.

Chronic venous insufficiencyChronic venous insufficiency

► OedemaOedema► Skin pigmentationSkin pigmentation► LipodermatosclerosisLipodermatosclerosis► Varicose eczema Varicose eczema ► Venous ulcerationVenous ulceration► Thrombophlebitis Thrombophlebitis ► Atrophie blancheAtrophie blanche► Marjolin ulcerMarjolin ulcer► Equinous deformity Equinous deformity

Venous Ulcer Venous Ulcer ► The ulcerThe ulcer

Gaiter areaGaiter area lower leg (medial lower 1/3) lower leg (medial lower 1/3) edgeedge sloping and pale purple-blue in sloping and pale purple-blue in colourcolour. . basebase ping granulation tissue. ping granulation tissue. tendons and bones may be exposed. tendons and bones may be exposed. seropurulent dischargeseropurulent discharge, heavy infection and pus , heavy infection and pus

is not common. is not common. shallow and flat. shallow and flat. surrounding tissuessurrounding tissues show signs of venous show signs of venous

hypertension (pigmentation, warmth, redness hypertension (pigmentation, warmth, redness and tenderness) and tenderness)

scars from previous ulcersscars from previous ulcers, scar tissue may , scar tissue may interfere with movement of foot. interfere with movement of foot.

lymph nodeslymph nodes should not be enlarged. should not be enlarged.

LSV

CVICVI

Ankle flareAnkle flare

LSV

CVICVI

Ankle flareAnkle flare

DD of leg ulcerDD of leg ulcer

► Infective UlcerInfective Ulcer TBTB $$

► Ischemic ulcerIschemic ulcer► TraumaticTraumatic► MalignantMalignant

EpitheliomaEpithelioma Malignant melanomaMalignant melanoma

► Trophic ulcerTrophic ulcer

DD of leg ulcerDD of leg ulcer

Traumatic ulcer

Ecthyma

Symptomatic chronic venous insufficiency Symptomatic chronic venous insufficiency or or Impending Impending ulcerationulceration

Hand held Doppler examination

SVI only

Superficial venous surgery

?Compression therapy

Duplex scan

DVI only SVI+DVI

Functional assessment (venous pressure tracing or photoplethysmography)

Suspected DVIRecurrent varicose veinsUncertain diagnosis Short saphenous vein incompetence

Symptomatic chronic venous insufficiency Symptomatic chronic venous insufficiency or or Impending Impending ulcerationulceration

Compression therapy

Functional assessment (venous pressure tracing or photoplethysmography)

No improvement with superficial venous occlusion

Significant improvement in refilling time with superficial venous occlusion

Superficial venous surgery

Conservative TreatmentConservative Treatment

►Bisgaar methodBisgaar method: Elevation, bandaging, : Elevation, bandaging, exercises and massage. exercises and massage.

►Compression bandagingCompression bandaging: : multilayer bandaging for several weeks or multilayer bandaging for several weeks or strong graduated compression stockings strong graduated compression stockings

(40mmHg at ankle), (40mmHg at ankle), compression therapy is very successful compression therapy is very successful

but ulcers may re-occure. but ulcers may re-occure.

Surgical TreatmentSurgical Treatment

► Ligation and division of incompetent perforating Ligation and division of incompetent perforating veinsveins to prevent hydrodynamic forces generated in the to prevent hydrodynamic forces generated in the

muscular compartment from reaching the skin muscular compartment from reaching the skin (surgical or endoscopic)(surgical or endoscopic)

► Stripping of incompetent main superficial systemsStripping of incompetent main superficial systems if they are contributing to the high AVP if they are contributing to the high AVP significantlysignificantly

► Plastic surgeryPlastic surgery: grafting. : grafting.

Perforator sub facial ligationPerforator sub facial ligation

Endoscopic perforator surgeryEndoscopic perforator surgery► Active or healed ulcersActive or healed ulcers► Contra-indicated inContra-indicated in

Deep venous occlusionDeep venous occlusion Infected ulcerInfected ulcer

TreatmentTreatment

Deep venous reconstructionDeep venous reconstruction► Not yet standard treatmentNot yet standard treatment► Can correct primary deep veins reflux but not post-Can correct primary deep veins reflux but not post-

thombotic reflux or obstructionthombotic reflux or obstruction► Most commonly repaired veins are femoral and Most commonly repaired veins are femoral and

popliteal popliteal ► Done from within Done from within

ValvuloplastyValvuloplasty Valve transposition or coursingValve transposition or coursing Valve transplantaton Valve transplantaton

Kistner type valve repair for Kistner type valve repair for deep vein incompetencedeep vein incompetence

Palma procedure for deep system Palma procedure for deep system obstructionobstruction

Lymphoedema.Lymphoedema.

► interstitial oedema interstitial oedema of lymphatic origin. of lymphatic origin.

► rich in protein. rich in protein. ► most common most common

cause is secondary cause is secondary lymph node lymph node disease. disease.

CausesCauses

►Primary:Primary: Congenital or acquired deficiency of the Congenital or acquired deficiency of the

lymphatics ( aplasia or Hypoplasia)lymphatics ( aplasia or Hypoplasia) Dilation and incompetence of the Dilation and incompetence of the

lymphatic (Hyperplasia). lymphatic (Hyperplasia). According to age of onsetAccording to age of onset

►Congenita since birth 10 %Congenita since birth 10 %►Precox adolescent (15- 35) 75 %Precox adolescent (15- 35) 75 %►Tarda > 35 y 15 %Tarda > 35 y 15 %

CausesCauses

► Secondary:Secondary: Neoplastic infiltration of lymph nodes.Neoplastic infiltration of lymph nodes.

► secondary carcinoma secondary carcinoma ► Primary reticuloses. Primary reticuloses.

InfectionInfection ► Filariasis (parasite Wuchereria bancrofti) found in Filariasis (parasite Wuchereria bancrofti) found in

tropical and subtropical climates.This is a cause of tropical and subtropical climates.This is a cause of severe lymphoedema (elephantiasis) severe lymphoedema (elephantiasis)

► lymphogranuloma inguinale lymphogranuloma inguinale ► TB TB ► Recurrent non-specific infection. Recurrent non-specific infection.

IatrogenicIatrogenic ► surgical excision surgical excision

irradiation of lymph nodes. irradiation of lymph nodes.

Clinical ClassificationClinical Classification

► Sub clinical with histological abnormalities Sub clinical with histological abnormalities of LN and lymphaticof LN and lymphatic

► Grade IGrade I Oedema pit on pressureOedema pit on pressure Swelling disappear on elevation or bed restSwelling disappear on elevation or bed rest

► Grade IIGrade II Oedema does not pit on pressureOedema does not pit on pressure Swelling not disappear on elevation or bed restSwelling not disappear on elevation or bed rest

► Grade IIIGrade III OedemaOedema Irreversible skin changes ( fibrosis or papillae)Irreversible skin changes ( fibrosis or papillae)

Lymphoedema.Lymphoedema.History. History.

females>males. females>males. slowly progressive swelling of the limb or slowly progressive swelling of the limb or

genitelia. genitelia. lower limb most often affected often history of lower limb most often affected often history of

trauma several years ago. trauma several years ago. not painful and no discomfort. not painful and no discomfort. commonly complicated by athlete's foot (tinea commonly complicated by athlete's foot (tinea

pedis) and episodes of cellulitis. pedis) and episodes of cellulitis. Vesicles may appear on the skin that leak clear-Vesicles may appear on the skin that leak clear-

coloured fluid. coloured fluid. symptoms of underlying cause symptoms of underlying cause very rare complication of lymphangiosarcoma. very rare complication of lymphangiosarcoma. oedema does not respond to leg elevationoedema does not respond to leg elevation. .

Examination. Examination. ► oedemaoedema

all oedema pits (clasically sayed to be non-pitting). all oedema pits (clasically sayed to be non-pitting). lymphoedema of the lower limb affect the toes lymphoedema of the lower limb affect the toes

much more than other oedemas, if it has been much more than other oedemas, if it has been present for long time the toes become squared-off.present for long time the toes become squared-off.

Examine the whole patient esp. cardia, renal and Examine the whole patient esp. cardia, renal and abdomen, as well as local (venous congestion, abdomen, as well as local (venous congestion, venous thrombosis) as diagnosis of lymphoedema venous thrombosis) as diagnosis of lymphoedema is done after everything else has been excludedis done after everything else has been excluded

► SC fibrosisSC fibrosis the skin on the dorsum of the foot can not be the skin on the dorsum of the foot can not be

pinched Stemmer’s signpinched Stemmer’s sign

Examination. Examination. ► In advanced casesIn advanced cases

Chronic eczemaChronic eczema Fungal skin infection ( Dermatophtosis)Fungal skin infection ( Dermatophtosis) Fungal nail infection ( Dermatomycosis)Fungal nail infection ( Dermatomycosis) skin gets thick and hyperkeratotic. skin gets thick and hyperkeratotic. thick scales grow outward and look like thick scales grow outward and look like

warts. warts.

►Ulceration esp if associated CVIUlceration esp if associated CVI►RareRare

Lymphangectasia ( megalymphatics)Lymphangectasia ( megalymphatics) lymphangiosarcomalymphangiosarcoma

InvestigationInvestigation►LaboratoryLaboratory►PathologyPathology►RadiologyRadiology

Contrast lymphangiographyContrast lymphangiography Isotope lymphangiographyIsotope lymphangiography CT scanCT scan MRIMRI

Management: Management:

►goals of treatment is to control goals of treatment is to control the oedema and to prevent the oedema and to prevent recurrent infection. recurrent infection.

►early treatment gives the best early treatment gives the best results before fibrosis results before fibrosis developes and health of skin developes and health of skin and subcutaneous tissues are and subcutaneous tissues are compromised.compromised.

Management: Management:

Non-operative Management:Non-operative Management: ► Physical methodsPhysical methods

reduce lymph formation; reduce lymph formation; elevation of the limbelevation of the limb. . external compressionexternal compression; custom fitted, elastic ; custom fitted, elastic

stockings worn threwout the day. stockings worn threwout the day. sequential air compression devices. sequential air compression devices.

► PharmacotherapyPharmacotherapy restrict dietary sodiumrestrict dietary sodium diuretics diuretics when oedema is being actively treated. when oedema is being actively treated. instruction about instruction about foot care and hygienefoot care and hygiene to to

prevent recurrent cellulitis. prevent recurrent cellulitis. prophylactic antibioticsprophylactic antibiotics may be recuired may be recuired AntifungalAntifungal

Management:Management:

►Surgical Treatment:Surgical Treatment: Only needed in a small number of Only needed in a small number of

patients.(16%) patients.(16%) Indications for surgery. Indications for surgery.

►impaired function. impaired function. ►pain pain ►recurrent cellulitis and lymphangitis recurrent cellulitis and lymphangitis ►lymphangiosarcoma lymphangiosarcoma ►cosmetic although the result will not be a cosmetic although the result will not be a

normal looking limb. normal looking limb.

ManagementManagementBypassBypass►Microsurgery:Microsurgery: axial pattern and axial pattern and

mycocutaneous flaps and lymphatic-mycocutaneous flaps and lymphatic-lymphatic and lymphatico-venous lymphatic and lymphatico-venous anastomoses.anastomoses.

► some procedures try to some procedures try to relieve the relieve the obstructionobstruction by transplanting lymph by transplanting lymph channels from normal areaschannels from normal areas

ManagementManagementReduction proceduresReduction procedures►excisional proceduresexcisional procedures removing skin removing skin

and lymphoedematous subcutaneous and lymphoedematous subcutaneous tissues and usually requires extensive tissues and usually requires extensive skin grafts. complications: scarring, skin grafts. complications: scarring, sensory loss, recurrent swelling. sensory loss, recurrent swelling.

►Thompson procedureThompson procedure::►SistrunkSistrunk►HomanHoman►charles charles