Vasc disenglindian


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Vasc disenglindian

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