Venous insufficiency

Disorder of venous circulation of extremities

Classification of venous system diseases.(A.A. Spridonov and L.I. Clioner, 1989)
The superior vena cava and its tributaries.
Traumatic injury;
Occlusion;
Padget-Shreter's syndrome (thrombosis of profound veins of extremity) and postthrombophlebitic syndrome of upper extremities;
Syndrome of superior vena cava.
Congenital diseases (angiodysplasia)

Classification of venous system diseases.(A.A. Spridonov and L.I. Clioner, 1989)
Inferior vena cava
Acute thrombophlebitis:
superficial veins of lower extremities;
profound veins of lower extremities;
ileofemoral veins;
venous gangrene (blue phlegmasia);
the trunk of inferior vena cava:
embolism of pulmonary artery.
Postthrombophlebitic syndrome:
superficial veins;
profound veins of lower extremities;
ileofemoral veins;
the trunk of inferior vena cava.
Primary varicose dialtion of superficial veins of lower extremities;
Congenital diseases (angiodysplasia)
Traumatic injury.

Chronic venous insufficiency is mainly caused diseases:
varicose disease of lower extremities
postthrombophlebitic disease
angiodysplasia

Varicose disease
Varicose disease of subcutaneous veins is their irreversible dilation and elongation occurring due to crude pathological change of venous walls and valvular apparatus.

Postthrombophlebitic disease
Postthrombophlebitic disease a complex of symptoms developing due to thrombosis of profound veins.

Pathogenesis chronic venous insufficiency

Stages of chronic venous insufficiency(Expert meeting in Moscow, 2000.)
0 - no symptoms;
1 - heavy feet syndrome;
2 - intermittent edema;
3 - persistent edema, hyper- or hypopigmentation, lipodermatosclerosis, eczema;
4 - venous ulcer.

Complain
of fatigue,
the heavy feeling and enlargement of feet,
spasms of gastrocnemius muscle,
paresthesia,
edema of shins and feet.

Dilated varicose veins
interskinswollen plexuses
dilated varicose veins
1.
2.

Edema
Edema usually develops by nighttime after walking or prolonged standing and disappears after a night's rest.

Hemosiderosisskin
Skin pigmentation develops in the lower third of the shin; it is more pronounced above the inner ankle; the skin is less elastic, it becomes dry, shiny, vulnerable, fused with sclerotically degenerated fat.

экземa

Trophic ulcer
Ulcers caused by venous circulation disorder typically develop on the inner surface of lower third of shin, above the ankle.
The ulcers are usually single, flat, with an even bottom; their borders are irregular, abrupt; the discharge is scarce, serous or purulent.
If infection develops, ulcers become painful.
Around the ulcer hemosiderosis and induration of subcutaneous fat develop.

Main symptoms of thrombophlebitis of profoundveins
Edema of the extremity
The pains are localised in the gastrocnemius muscles as a rule, along the course of vascular bundles
The skin of the extremity becomes cyanotic.

Main symptoms of thrombophlebitis of superficial veins
Pains along the course of thrombotised vein.
Examination of the thrombotic region reveals hyperemia, edema of skin.
Palpation along the course of the vein reveals a consolidation distinctly separate from the surrounding tissues.

Classification offunctional tests
Test enable one to judge the condition of valvular apparatus
Trendelenburg-Trojanov's tests
Hackenbruch's
Test enable of insufficient perforating veins
Pratt's test II
Scheins' test
Thalmann's test
Test enable the patency of profound veins
Delbe-Pertez test (marching test)
Pratt-I test

Trendelenburg-Trojanov's test.
The patient lying on his back raises one leg. When blood has drained from superficial veins, the greater subcutaneous vein is compressed in the place where it joins the femoral vein and keeping the finger there the patient is asked to rise. If venous trunks swell quickly when the finger is removed, we can conclude that the ostial valve is incompetent.

Hackenbruch's test.
Place your hand on the thigh where the greater subcutaneous vein joins the femoral vein and ask the patient to cough. You can feel throbs over the vein which points to incompetence of ostial valve.

Pratt's test II.
After draining of subcutaneous veins the lying patient's leg is bandaged with elastic bandage which compresses superficial veins. A tourniquet is applied on the thigh under the poupart fold. When the patient rises, another elastic bandage is applied under the thigh. Then the first bandage is removed loop after loop circling the leg with the utmost loop. The distance between the bandages should 5-6 cm. Quick filling of veins between the bandages points to an incompetent communicant vein in this place.

Scheins' test.
The patient is placed on the back, his legs are raised. After draining of superficial veins three tourniquets are applied. The patient is asked to rise. A quick swelling of the veins between the tourniquets points to an incompetent perforating vein in this place.

Delbe-Pertez test (marching test)
A tourniquet compressing only superficial veins is applied to the standing patient's thigh whose subcutaneous veins are maximally full. Then the patient is asked to walk in one spot for 3-5 min. If the veins deflate it means that profound veins are patent; if the veins do not deflate or swell, it means that profound veins are obliterated.

Pratt-I test
Measure the circumference of the patient's shin, ask him to lie on his back, drain the veins by stroking them along their course. Apply elastic bandage to the legs. The patient is asked to walk for 10 min. If pains develop, it points to affection of profound veins. Enlarged circumference of the shin after walking points to impatency of profound veins.

Loevenberg's test
The cuff of Rivarocci machine is applied to the lower third of shin and air is slowly pumped into it. If sharp pains develop when the pressure in the cuff rises to 150 mm Hg, it is characteristic of thrombophlebitis of profound veins.

Homans' sign
Pains in gastrocnemius muscle upon dorsal flexing of the foot is characteristic of thrombophlebitis of profound veins of the extremity.

Moses' sign
Pains in the shin upon anterior-posterior compression

Instrumental methods of examination
ultrasound diagnostics
contrast-dye radiophlebography

Duplex scanning

Contrast-dye radiophlebography
In distal phlebography the radiopaque substance is injected into the dorsal vein of foot while a tourniquet is applied to the lower third of shin. In proximal phlebography the radiopaque substance is injected directly into the femoral vein by puncturing.

Principles of conservative treatment for chronic venous insufficiency
0 stage: elastic compression (preventive or therapeutic hosiery of class I);
1 stage of chronic venous insufficiency:
elastic compression (therapeutic hosiery of compression of class I-II);
occasional courses of monopharmacotherapy.

2 stage of chronic venous insufficiency:
elastic compression (therapeutic hosiery of compression of class II);
repeated courses of monopharmacotherapy;
physiotherapy and balneology.

3-4 stage of chronic venous insufficiency:
elastic compression (therapeutic hosiery of compression of class II-III);
continuous combined pharmacotherapy;
local treatment;
physiotherapy.

The therapeutic effect of compression treatment is determined by the following mechanism of action:
decrease of pathologic venous "capacity" of lower extremities;
functional improvement of the insufficient valvular apparatus;
increased resorbtion of tissue fluid in the venous part of capillary; its decreased filtration in the arterial part;
increased fibrinolytic activity of blood.

Рhlebotropic drugs
detralex,
ginkor-fort,
troxevasin,
escusan,
calcium dobesilan (doxium).

Rheologic hemocorrectors
acetylcalicylic acid,
dipiridamol,
pentoxyphylline,
low-molecular dextranes (rheopolyglucine, rheomacrodex, rheogluman and so on)

Principles of anticoagulant therapy.
The initial dose of non-fractionated heparin is determined in this way: the patient's weight is multiplied by 450 then the resulting figure is divided by the amount of injections.
Thus, for fractional intravenous administration of heparin the amount of injections is 8 (every 3 hours), for intramuscular administration it is 6 (every 4 hours), for subcutaneous administration it is 3 (every 8 hours).
Afterwards the dose of heparin is chosen individually according to the reaction of hemostasis. Blood-clotting time should increase 2-2.5 times.
The duration of heparin therapy does not usually exceed 10-12 days. The drug is cancelled gradually by decreasing the dose.
Two days before the end of heparin therapy patients start receiving indirect anticoagulants.

Indirect anticoagulants.
This category includes derivatives of coumarine and fenindione. They do not affect coagulation upon direct connection with blood; they decrease blood clotting by inhibiting the synthesis of vitamin K-dependent procoagulants (factors II, VII, IX, X). The initial dose of feniline (fenindione derivative) is 0.12-0.18 g (3 times a day), on the second day the dose is 0.09-0.15 g, and afterwards - 0.03-0.06 g a day depending on the prothrombin level in blood. The effectiveness of treatment is checked with the help of prothrombin index which should decrease to 50%.

Phlebosclerosing treatment
This method consists in introduction of sclerosing substances (fibrovein, thrombovar, etoxisclerol) into the varicose veins.

The principles of surgical treatment in chronic venous insufficiency are:
eliminating pathological reflux of from the profound veins into superficial ones;
removal of varicosely dilated subcutaneous veins;
preservation of unchanged segments of the greater and lesser subcutaneous veins.

The surgery for varicose disease is a combined surgical intervention
Trendelenburg-Trojanov-Dieterich's surgery is paraostial ligation of the greater subcutaneous vein and its accessory branches where it joins the femora vein.

Narat's surgery is removal of varicosely dilated subcutaneous veins from separate incisions by tunneling.

Babcock's surgery is removal of great trunks of subcutaneous veins with the help of a vein sound.
Cocket's surgery is suprafascial ligation of communicant veins.
Felder-Linton's surgery is subfascial ligaton of communicant veins.

Thrombectomyfromfemoral vein

Venous insufficiency

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