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Vasc disenglindian

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  • 1. Chronic Venous Insufficiency
  • 2. C hronic Venous Insufficiency
    • Has been recognized since ancient times
    • By Greek physicians (Hyppocrates 460-377 B.C.)
    • By Roman physicians (centuries later)
    • These disease entities continue to defy understanding.
  • 3. C hronic Venous Insufficiency (CVI) of the Legs
    • C ommon and progressive disorder
    • found in many parts of the world
    • a condition with ambulatory venous hypertension
    • affects approximately 5% to 15% of the adult population. One percent develop venous ulcers
    • CVI consumes 1-2% of the healthcare budget of the European countries
  • 4. C hronic Venous Insufficiency
    • has a major impact on health economics :
    • in Germany leg ulcers caused >1.2 million hospitalisation days, for a cost of 1.5 billion EURO
    • In France CVI amounted to 2.25 billion EURO
    • in UK costs associated with leg ulcers went up to 230-400 millions Sterling Pounds
  • 5. CVI
    • T he term CVI is used to describe signs and symptoms of chronic venous hypertension in the lower limbs
    • This condition is generally considered as the pathophysiological trigger of skin changes, the most serious of which is ulceration
  • 6. CVI
    • T he clinical hallmark of CVI is distal venous hypertension, which follows the development of valvular incompetence, reflux, and/or venous obstruction.
    • At the cellular level there is abnormal metabolism of the connective tissue matrix of the vein wall with a marked increase in fibrouse tissue and abnormal deposition of collagen in both the vein wall and the skin.
  • 7. CVI-classifications
    • W idmer’s Classification
    • It is based exclusively on objective signs
    • 3 stages:
    • 1. Corona phlebectatica paraplantaris, edema
    • 2. Trophic lesions (lipodermatosclerosis, atrophie blanche, dermatitis).
    • 3. Active or healed leg ulcer
  • 8. CVI-classifications
    • CEAP Classification
    • C : Clinical
    • E : Etiology
    • A : Anatomy
    • P : Pathophysiology
  • 9. CEAP classification
    • T he clinical part (C) is based on objective clinical signs of chronic venous disease according to 7 classes:
    • 0 = No visible or palpable signs of venous disease
    • 1 = Telangiectasia or reticular veins
    • 2 = Varicose veins
    • 3 = Edema
    • 4 = Skin changes (pigmentation, venous eczema, lipodermatosclerosis)
    • 5 = Skin changes as defined above with healed ulcer
    • 6 = Skin changes as defined above with active ulceration
  • 10. Subjective Symptoms and Objective Signs
    • Pain - weak or absent
    • Heavy legs
    • Cramps at night
    • Paresthesias or burning sensation
    • Localized itch without skin changes
    • Edema
  • 11. Skin Changes at CVI
    • G ravitational dermatitis
    • Hyperpigmentation
    • Lipodermatosclerosis
    • Their presence mirrors microcirculatory disorders
  • 12. Lipodermatosclerosis
    • T here is a proliferation of the dermal capillaries and fibrosis on subcutaneous tissue
    • It is a combination of:
    • induration
    • pigmentation
    • inflammation
  • 13. VENOUS LEG ULCERS Large scale studies suggest that about 1% of the population develop a chronic leg ulcer at some point in their live. Most of the ulcers have chronic venous origin. Venous disease is identified as the most common predisposing risk factor.
  • 14. VENOUS LEG ULCERS
    • Venous ulcers are approximately 80% of all leg ulcerations and they are also known to have the highest recurring rates.
    • Venous ulcers are not generally as painful, do not lead to amputation, do not require surgical intervention as often as ulcers caused by arterial insufficiency.
  • 15. VENOUS LEG ULCERS
    • However, their chronic course, unpredictable behavior, morbidity, the associated economic burden have to led to a renewed interest in the development of new approaches to improve the speed of healing, the quality of live and work productivity.
  • 16. Venous Ulcer
    • D efinition :
    • An ulcer in the lower leg due to CVI
    • Clinical Findings :
    • The sites of predilection is the inner aspect of the distal third of the leg
    • Shape - rounded, elongated or very large like a cuff (so-called gaiter ulcer)
  • 17. Venous Ulcer
    • Clinical Findings:
    • base - flat, covered with fibrous plough
    • margins - sharp or rolled border
  • 18. CLINICAL CHARACTERISTIC
    • Venous ulcers are usually located over the medial malleolus where the long saphenous vein is more superficial and the pressure is greatest.
  • 19. CLINICAL CHARACTERISTIC
    • Trauma or infection may localize ulcers more proximal or laterally. Ulcers above the mid calf or on the foot commonly suggest another cause.
  • 20. CLINICAL CHARACTERISTIC
    • Venous ulcers are shallow, they generally have borders with irregular margins that are either flat or with a slight steep elevation. The ulcer bed is covered initially by yellow fibrinous slough.
    • Healing is very slow, often from months to years.
  • 21. Venous Ulcer
    • Complications:
    • superinfection
    • contact allergy
    • squamous cell carcinoma (Marjolin ulcer) on the basis of a long standing ulcer
  • 22. Venous Ulcer
    • Differential Diagnosis
    • 75-90% of all ulcers are of venous origin
    • It should always be born in mind that lower leg ulcers can have great many causes
  • 23. Venous Ulcer
    • Differential Diagnosis
    • Arterial leg ulcers :
    • Arteriosclerosis
    • Diabetic angiopathy
    • Polyarteritis nodosa
    • Cutaneous polyarteritis nodosa
    • Ulcus cruris hypertonicum Martorell
  • 24. Venous Ulcer
    • Differential Diagnosis
    • Crural leg ulcer in some dermatoses:
    • Sclerodermia progressiva
    • Lupus erythematosus profundus
    • Necrobiosis lipoidica
    • Fasciitis necroticans
  • 25. Venous Ulcer
    • Differential Diagnosis
    • Neoplastic leg ulcers:
    • Basal cell carcinoma
    • Squamous cell carcinoma
    • Malignant melanoma
  • 26.  
  • 27. Arterial Ulcers
    • Clinic
    • Are frequently pretibial or involve toes :
    • They are painful at night
    • The edges are sharply defined
    • Exudation is minimal
    • The slough is black with bare tendons or bones beneath
    • There is no pigmentation in the surrounding skin
  • 28.  
  • 29.  
  • 30.  
  • 31. Cutaneous polyarteritis nodosa
      • A benign disease, limited to the skin
      • It may be accompanied by myalgias, but without severe systemic manifestations
      • The prognosis is generally favorable
  • 32. Cutaneous polyarteritis nodosa
    • The disease primarily affects the legs and feet,
    • also the lower arms and other regions of the body
    • The clinical signs include:
      • painful subcutaneous nodules which may ulcerate
      • focal livedo reticularis
  • 33. Periarteriitis nodosa cutanea benigna
  • 34. Diseases of the Microcirculation
          • Ulcus hypertonicum Martorell
            • an example of microcirculatory disorder leading to leg ulcer
            • extremely rare condition
  • 35. U lcus Cruris Hypertonicum (Martorell 1945)
    • S ynonyms
    • Martorell Syndrome, hypertensive ischemic ulcer.
    • C linical Findings
    • The lesions usually occur in women between 40 and 60 years of age
    • With a long history o f h ypertension and raised diastolic blood pressure
    • Without evidence of arterial occlusive disease or CVI or diabetes
  • 36. Ulcus C ruris Hypertonicum
    • Clinical Findings
      • the ulcer appears bilaterally on the outher side of the leg, between the mid and lower third
      • flat
      • with a necrotic base and livid reticulate edge
      • severe pain
      • no tendency to heal
  • 37. Ulcus Hypertonicum Martorell
  • 38. U lcus C ruris Hypertonicum
    • T reatment
      • The first priority is the treatment of the hypertension
      • Alleviation of pain with non-steroidal antiinflammatory and vasodilating drugs.
      • Local treatment follows the general guidelines for the treatment of leg ulcers
  • 39. T reatment of CVI
    • 1 . Graduated compression bandaging
    • - elastic compression bandages
    • - compression stockings
  • 40. T reatment of CVI
    • The primary aims of graduated compression management ( from the toes to the knee) are:
    • -to reduce the pressure on the superficial venous system
    • -to aid venous return of blood to the heart
    • -to discourage oedema by reducing the pressure difference between the capillaries and the tissues
  • 41. T reatment of CVI
    • 2. Local treatment
    • - cleansing of the ulcer base (proteolytic enzyme preparations, mechanically )
    • - stimulation of wound granulation and epithelialization
  • 42. Local Treatment Venous ulcer Ulcer cleaning Granulation Epithelialization
  • 43. ULCER CLEANING
    • The ulcer cleaning is usually done by the use of normal saline or Ringer solution.
    • The use of irritants like chlorhexidine, iodine, hydrogen peroxide and topical antibiotics should be avoided.
  • 44. DEBRIDEMENT
    • The removal of dead tissue speeds ulcer healing.
    • The main options are:
      • Enzymatic treatment
      • Mechanical debridement (curette, scissors)
  • 45. NEXT LINE TREATMENT
    • Promotion of healthy granulation tissue
    • Stimulation of epithelialization
  • 46. T reatment of CVI
    • 3. Systemic treatment
    • venotonic drugs - a number of rutosides are widely used (Venoruton, Detralex=Daflon, Endotelon)
    • vasoactive agents - pentoxifylline: improves red cell deformability, prevents inappropriate white cell activation, enhances fibrinolysis
  • 47. POOR PROGNOSTIC INDICATORS
    • For venous ulcer healing are:
    • large size
    • long duration history of venous ligation
    • ABI of less than 0.8
    • presence of fibrin on more than 50% of the ulcer surface
  • 48. ADVERSE LOCAL CONDITIONS
    • Other local conditions that can delay
    • healing are:
    • Ulcer infection
    • Contact dermatitis/eczema
    • Excess exudate
    • Dehydration
    • Excessive use of topical antiseptics or antibiotics
  • 49. FAILURE to HEAL
    • If the ulcer fails to heal, the diagnosis has to be reevaluated and the following additional investigations should be done:
    • Biopsy
    • Autoimmune screen
    • Blood sugar level
    • X-ray
  • 50. RECURRENCE after TREATMENT
    • “ Once an ulcer patient always a potential ulcer patient”
    • Recurrence rates of venous ulcers after treatment are high. Once the patient’s ulcer is healed, careful skin care, continuous vigilance and strict use of compression therapy must be emphasized.

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