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Vasc disenglindian
 

Vasc disenglindian

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    Vasc disenglindian Vasc disenglindian Presentation Transcript

    • Chronic Venous Insufficiency
    • 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.
    • 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
    • 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
    • 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
    • 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.
    • 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
    • CVI-classifications
      • CEAP Classification
      • C : Clinical
      • E : Etiology
      • A : Anatomy
      • P : Pathophysiology
    • 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
    • Subjective Symptoms and Objective Signs
      • Pain - weak or absent
      • Heavy legs
      • Cramps at night
      • Paresthesias or burning sensation
      • Localized itch without skin changes
      • Edema
    • Skin Changes at CVI
      • G ravitational dermatitis
      • Hyperpigmentation
      • Lipodermatosclerosis
      • Their presence mirrors microcirculatory disorders
    • Lipodermatosclerosis
      • T here is a proliferation of the dermal capillaries and fibrosis on subcutaneous tissue
      • It is a combination of:
      • induration
      • pigmentation
      • inflammation
    • 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.
    • 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.
    • 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.
    • 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)
    • Venous Ulcer
      • Clinical Findings:
      • base - flat, covered with fibrous plough
      • margins - sharp or rolled border
    • CLINICAL CHARACTERISTIC
      • Venous ulcers are usually located over the medial malleolus where the long saphenous vein is more superficial and the pressure is greatest.
    • 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.
    • 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.
    • Venous Ulcer
      • Complications:
      • superinfection
      • contact allergy
      • squamous cell carcinoma (Marjolin ulcer) on the basis of a long standing ulcer
    • 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
    • Venous Ulcer
      • Differential Diagnosis
      • Arterial leg ulcers :
      • Arteriosclerosis
      • Diabetic angiopathy
      • Polyarteritis nodosa
      • Cutaneous polyarteritis nodosa
      • Ulcus cruris hypertonicum Martorell
    • Venous Ulcer
      • Differential Diagnosis
      • Crural leg ulcer in some dermatoses:
      • Sclerodermia progressiva
      • Lupus erythematosus profundus
      • Necrobiosis lipoidica
      • Fasciitis necroticans
    • Venous Ulcer
      • Differential Diagnosis
      • Neoplastic leg ulcers:
      • Basal cell carcinoma
      • Squamous cell carcinoma
      • Malignant melanoma
    •  
    • 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
    •  
    •  
    •  
    • 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
    • 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
    • Periarteriitis nodosa cutanea benigna
    • Diseases of the Microcirculation
            • Ulcus hypertonicum Martorell
              • an example of microcirculatory disorder leading to leg ulcer
              • extremely rare condition
    • 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
    • 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
    • Ulcus Hypertonicum Martorell
    • 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
    • T reatment of CVI
      • 1 . Graduated compression bandaging
      • - elastic compression bandages
      • - compression stockings
    • 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
    • T reatment of CVI
      • 2. Local treatment
      • - cleansing of the ulcer base (proteolytic enzyme preparations, mechanically )
      • - stimulation of wound granulation and epithelialization
    • Local Treatment Venous ulcer Ulcer cleaning Granulation Epithelialization
    • 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.
    • DEBRIDEMENT
      • The removal of dead tissue speeds ulcer healing.
      • The main options are:
        • Enzymatic treatment
        • Mechanical debridement (curette, scissors)
    • NEXT LINE TREATMENT
      • Promotion of healthy granulation tissue
      • Stimulation of epithelialization
    • 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
    • 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
    • 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
    • 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
    • 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.