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2) Injection sclerotherapy of irritant solution of sodium tetradecyl (STD).
3) Surgical treatment of varicose veins: The aim of surgery is two-fold:
Firstly : to disconnect the deep and superficial systems where there is a direct communication (i.e. saphenofemoral, saphenopopliteal junction and above-knee perforators) and followed by sttripping of the long or short saphenous veins accordingly.
Secondarily :to remove damaged/dilated superficial varicosities (Multiple phlebectomies with ligation of the perforators ).
3) Increased coagulability of the blood . This also occurs following surgery and in the presence of infection or systemic malignancy or Thrombophilia due to deficiencies of anti-thrombin III, protein C, protein S and factor V Leiden has been shown to lead to venous thrombosis in young patients, sometimes with severe or fatal consequences.
Immobility remains one of the most important risk factors.
Recently, the term 'ethrombosis' has been used to describe blood clots occurring in people sitting at their computer for prolonged periods of time.
3) Deep vein thrombosis Clinical presentations:
The most significant findings are tenderness in the calf and oedema at the ankle.
(Homans' sign) Pain in the calf on dorsiflexion of the toes
( It should no longer be used).
Some patients with deep vein thrombosis of the lower limb may have no symptoms in the leg, but present with severe dyspnoea due to pulmonary embolism:
Intravenous heparin, with the dose adjusted according to the weight of the patient and controlled by the activated partial thromboplastin time (APTT) which sould be twice of the control in first 48 hrs.
The duration of heparin treatment should be at least 5 days .
At the same time, the patient should be commenced on warfarin . The aim here is to reduce the risk of a further recurrence of venous thrombosis.
Warfarin does not remove the clot from blocked veins and the duration of treatment (usually 3-6 months) is selected to prevent further episodes of venous thrombosis.
Warfarin dosage is controlled by measuring the international normalised ratio (INR) .
The INR should be prolonged to between 2.5 and 3.5 times the control value.
Patients with recurrent venous thromboembolic problems should be anticoagulated for life.
4) Intra-venous thrombolysis , achieved by passing a catheter into the affected vein and infusing a fbrinolytic drug such as streptokinase or tissue plasminogen activator (TPA), is reducing the need for surgical thrombectomy nowadays.
3) Deep vein thrombosis Prevention of deep vein thrombosis:
Low risk patents :
Young patients, minor illnesses, operations lasting for less than 30 minutes with no additional risk factors; needs no specific prophylactic measure.
2) Moderate risk.
Patients over the age of 40 years with debilitating illnesses, undergoing major surgery but no additional risk factors; these patients have up to 40% change to develop DVT and about 1% for pulmonary embolism . They need:
Graduated compression stockings (TED stockings)
Heparin 5000 iu s/c bd or LMWH.
Continued regimen until full mobilisation.
3) High risk:
Patients over the age of 40 years with serious medical conditions, such as stroke and myocardial infarction, and undergoing major surgery with additional risk factor, such as a past history of venous thromboembolism, extensive malignant disease or obesity. These may develop DVT in 40%- 80% of the cases & 10% will complicate to pulmonary embolism .
Phlegmasia alba dolens due to obstruction of the iliofemoral vein this may progresse to Phlegmasia cerulea dolence (Venous gangrene) if not well treated by heparin, intravenous thrombolysis and even some time venous thrombectomy.