Venous Disease Lecture Notes PDF

VENOUSE DISEASE DR.Jabbar Jasim Altai Consultant cardiovascular Surgeon LEARNING OBJECTIVES To understand: Venous anatomy and the physiology of venous return The pathophysiology of venous disease The clinical significance and management of varicose veins Deep venous...

VENOUSE DISEASE DR.Jabbar Jasim Altai Consultant cardiovascular Surgeon LEARNING OBJECTIVES To understand: Venous anatomy and the physiology of venous return The pathophysiology of venous disease The clinical significance and management of varicose veins Deep venous thrombosis Venous insufficiency and venous ulceration VARICOSE VEINS dilated tortuous, subcutaneous veins ≥3 mm in diameter with demonstrable reflux. Epidemiology 25–30 per cent in women and 15 per cent in men. Factors affecting prevalence include : gender women more than men.. age: increases with age ethnicity: body mass and height: pregnancy: family history: occupation and lifestyle factors Etiologic classification : primary (congenital). : secondary (post-thrombotic) Anatomical classification : superficial veins : perforator veins : deep veins Pathophysiological classification : reflux : obstruction : reflux and obstruction Clinical features Symptoms Aching or heaviness, which typically increases throughout the day or with prolonged standing and is relieved by elevation or compression hosiery. Other less common symptoms include ankle swelling and itching while complications (bleeding, superficial thrombophlebitis, eczema, Signs Tortous dilated subcutaneous veins are usually clinically obvious. These are confined to the long and lesser saphenous systems in approximately 60 and 20 per cent of cases, respectively. Investigation.Tourniquet tests. Duplex ultrasound scanning The aim of the duplex scan in patients with varicose veins is to establish:. 1. which saphenous junctions are incompetent and their locations; the extent of reflux in the saphenous veins and their diameters; the number, location and diameter of incompetent perforating Management Patients who have asymptomatic varicose veins can simply be reassured. Indications for referral to a vascular surgeon include bleeding, superficial thrombophlebitis or symptoms which are impairing quality of life, 1.. Compression hosiery 2. Ultrasound-guided foam sclerotherapy 3. Endo venous laser ablation(E V LA) REDIO FREQUNCY ABLATION(RFA).4  SUERGERY.5 SAPHENOFIMERAL LIGATION AND STREPING PERFORATOR LIGATION SAPHENO POPLEATAL JUNCTION LIGATION AND LESSER SAPHENOUS STRIPPING Phlebectomy Complications of standard varicose vein surgery Complications (minor and major) are reported in up to 20 per cent of patients. Wound infections(MINOR) Nerve injury(MAJOR) ❑ The incidence of saphenous nerve neuralgia is up to 7 percent. ❑ The incidence of sural nerve neuropraxia and common peroneal nerve injury 20 and 4 per cent, respectively, Thromboembolic complications is approximately 0.5 per cent ,.  VENOUS LEG ULCER Venous disease is responsible for around 85% of all chronic lower limb ulcers in resource-rich countries. Community based prevalence is 0.1–0.3% in adults (2–4% in the elderly). Couses of venous leg ulcer ❑.Venous disease: superficial incompetence, deep incompetence or obstruction. ❑ arterial ischemic ulcers; ❑ vasculitis ulcers; ❑ traumatic ulcers; ❑ neuropathic ulcers; ❑ neoplastic ulcers; ❑ infections, especially in resource-poor countries Clinical features Must be carefully examined Has a gently sloping edge and the floor contains granulation tissue covered by a variable amount of slough and exudate. Develops in the area between the muscles of the calf and the ankle. The majority of ulcers develop on the medial side of the calf, but ulcers associated with SSV incompetence may develop on the lateral side. Develop on any part of the calf in patients with post-thrombotic syndrome Surrounding hemosiderosis (seen as pigmentation). the more chronic ulcers develop lipodermatosclerosis with associated fibrosis of the subcutaneous tissue. INVESTEGATION ❖ a full blood count, polycythemia rare couse. ❖ Blood glucose. ❖ Erythrocyte sedimentation rate (ESR) or ❖ C-reactive protein (CRP) and ❖ Sickle cell test. Anemia can cause ulcers (e.g. sickle cell and pernicious anemia) ❖ Anti antibody screen if the ulcer appears ‘atypical’ or there is any suggestion of joint disease (e.g. rheumatoid arthritis) ❖ Biopsies are indicated if malignancy is suspected and it is important to remember that a Marjolin’s type of ulcer (a squamous cell or basal cell carcinoma) can develop in a chronic long-standing venous ulcer A Marjolijn's ulcer (a squamous cell cancer arising in a chronic venous ulcer)  Management COMPRESSION SUPERFICIAL VENOUS ABLATION OR SURGERY ✔ PELVIC CONGESTION SYNDROME ❑Chronic pelvic pain. ❑ Multiparous women aged 20–45 years. ❑ Severe dull aching pelvic pain. ❑ Dysmenorrhea, menorrhagia, rectal discomfort or urinary frequency. Signs may include tenderness over the uterus/ ovaries, Dignosis PCS is often a long and laborious one, usually only made following extensive investigations to exclude other more common causes of pelvic pain. Abdominal, pelvic and transvaginal duplex examination (MR) venography Diagnostic venography.. Medical treatments psychotherapy, progestins, danazol, gonadotrophin receptor agonists and hormonal replacement therapy. Surgical treatment: 1.Exrtapertonal resection of ovarian vein 2.Percutnouse pelvic vein embolization Diagnosis The most common presentation of a DVT is pain and swelling, especially in the calf, usually in one leg DVT must be differentiated from other causes of systemic oedema signs of a pulmonary embolus, cellulitis cyanosis: phlegmasia alba dolens and phlegmasia cerulea dolens (Figure 57.32). This indicates venous pressures that are so high that they are impeding tissue perfusion. Patients who present with venous gangrene (Figure 57.33) often have an underlying neoplasm Clinical examination for DVT is unreliable. Physical signs may also be absent. Mild pitting oedema of the ankle, dilated surface veins, a stiff calf and tenderness over the course of the deep veins should be sought. Leg pain occurs in about 50%. Homans’ sign – resistance (not pain) of the calf muscles to forcible  Investigation Venous duplex ultrasound MRI venography CT pulmonary angiography Prophylaxis Mechanical Pharmacological Treatment ❑ Anticoagulated with a ‘treatment dose’ of subcutaneous LMWH. Patients with significant renal impairment should be commenced on intravenous unfractionated heparin. Patients who have a sensitivity towards heparinoids, such as those with heparin-induced thrombocytopenia, should commence on another anticoagulant, such as fondaparinux, rivaroxaban and apixaban (an indirect factor Xa inhibitor) or bivalirudin (a direct thrombin inhibitor ). ❑ Typically, warfarin for at least 3 months ❑ temporary inferior vena cava filter