Surgery 6th year, Tutorial (Dr. Aram Baram)


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Dec. 17th, 2011

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Surgery 6th year, Tutorial (Dr. Aram Baram)

  1. 1. Venous Disorders Dr Aram Baram MD, MRCSEd
  2. 2. Introduction <ul><li>The lower limb is the most common site of venous disorders. </li></ul><ul><li>More than 5% of the population have varicose veins and 1% have, or have had, venous ulceration. </li></ul><ul><li>At any one time, up to 200 000 people in the UK have active venous ulceration. </li></ul>
  3. 3. ANATOMY
  4. 4. Anatomy
  5. 5. Venous Disorders <ul><li>To understand: </li></ul><ul><li>1) Venous anatomy and the physiology of venous return </li></ul><ul><li>2) The pathophysiology of venous disease </li></ul><ul><li>3) Superficial thrombophlebitis </li></ul><ul><li>4) The clinical significance of varicose veins </li></ul><ul><li>5) Deep venous thrombosis </li></ul><ul><li>6) Venous insufficiency and venous ulceration and post thrombotic syndrom </li></ul>
  6. 6. Superficial thrombophlebitis <ul><li>Inflammation or thrombosis of a superficial veins. </li></ul><ul><li>Usually due to septic complication of an intravascular cannula or other intra vascular devices that remained in its position for more then 72 hrs. </li></ul><ul><li>Pulmonary embolism rarely complicate superficial thrombophlebitis. </li></ul><ul><li>Clinical presentation : </li></ul><ul><li>A tender, palpable cord along the course of a superficial vein , red, warm, indurated vein. </li></ul><ul><li>May be a source of fever in the postoperative period. </li></ul>
  7. 7. Superficial thrombophlebitis : <ul><li>Treatment </li></ul><ul><li>Remove the infected cannula (Always change the site of the peripheral intra-venous cannula every 72 hrs to avoid this complication). </li></ul><ul><li>2) Bed rest and elevation of the extremity </li></ul><ul><li>3) Local application of heat for relief of pain </li></ul><ul><li>4) Support hose worn both during the period of </li></ul><ul><li>inflammation and for prophylaxis. </li></ul><ul><li>5) NSAID </li></ul><ul><li>6) Antibiotics could be prescribed. </li></ul>
  8. 8. Varicose Veins Definition <ul><li>Abnormally dilated and tortuous subcutaneous superficial venous networks in territory of either long or short saphenous veins or the perforators. </li></ul><ul><li>This is in response to a pathological increase in the vein’s intra-luminal pressure & valvular incompetence of the deep, superficial of perforator systems. </li></ul>
  9. 9. 2) Varicose Veins
  10. 10. 2) Varicose Veins Aetiology: <ul><li>1) Primary </li></ul><ul><li>Cause not known; often familial Probably a weakness of </li></ul><ul><li>vein wall that permits valve ring dilatation </li></ul><ul><li>2) Secondary </li></ul><ul><li>Obstruction to venous outflow : </li></ul><ul><li>Repeated pregnancy, fibroids,ovarian cyst ,abdominal lymphadenopathy, pelvic cancer (cervix, uterus, ovary, rectum) ,ascites , iliac vein thrombosis, retroperitoneal fibrosis. </li></ul><ul><li>Valve destruction </li></ul><ul><li>Deep vein thrombosis </li></ul><ul><li>High flow and pressure </li></ul><ul><li>Arteriovenous fistula (especially the acquired traumatic variety) </li></ul><ul><li>3) Congenital: </li></ul><ul><li>Due to absence of valves: Kippel-Trenaunay syndrome. </li></ul>
  11. 11. 2) Varicose Veins <ul><li>Clinical features: </li></ul><ul><li>May either give no symptoms or cause aching & discomfort in legs. </li></ul><ul><li>Often there are no specific symptoms but the cosmetic appearance is unsatisfactory. </li></ul><ul><li>Symptoms of itch and & skin thickening , bleeding, phlebitis, lipodermatosclerosis, eczema , ulceration may be present. </li></ul><ul><li>Diagnosis : </li></ul><ul><li>1) Clinical (Tourniquet test or Trendelenburg </li></ul><ul><li>test). </li></ul><ul><li>2) Doppler ultrasound & Duplex imaging </li></ul><ul><li>3) Ascending venography ( rarely performed) </li></ul>
  12. 12. 2) Varicose Veins <ul><li>Complications of varicose veins: </li></ul><ul><li>1) Venous eczema </li></ul><ul><li>2) Venous pigmentations </li></ul><ul><li>3) Lipodermatosclerosis </li></ul><ul><li>4) Superfecial therombophlebitis </li></ul><ul><li>5) Venous ulceration </li></ul>
  13. 13. 2) Varicose Veins Treatment of varicose veins <ul><li>1) Compression stocking & venotonics administration. </li></ul><ul><li>2) Injection sclerotherapy of irritant solution of sodium tetradecyl (STD). </li></ul><ul><li>3) Surgical treatment of varicose veins: The aim of surgery is two-fold: </li></ul><ul><li>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. </li></ul><ul><li>Secondarily :to remove damaged/dilated superficial varicosities (Multiple phlebectomies with ligation of the perforators ). </li></ul>
  14. 15. 3) Deep vein thrombosis <ul><li>Definition: </li></ul><ul><li>Is thrombosis of a part or all of the deep venous system in an extremity </li></ul><ul><li>Its a serious life threatening condition that may lead to sudden death in the short term or to long-term morbidity. </li></ul><ul><li>The most frequent location of deep vein thrombosis is in the lower limbs. </li></ul><ul><li>The exact incidence is not well defined but it may be up to 30% after major surgeries. </li></ul>
  15. 16. 3) Deep vein thrombosis RISK FACTORS <ul><li>I.Secondary DVT occurring in the setting of a recognized risk factor. </li></ul><ul><li>II. Primary or idiopathic absence of risk factors. </li></ul><ul><li>The changes described by Virchow lead to clotting in the veins: </li></ul><ul><li>1) Changes in the vessel wall with damage to the endothelium due to injury or inflammation, this is known to happen following previous deep vein thrombosis. </li></ul><ul><li>2) Diminished rate of blood flow in the veins. </li></ul><ul><li>In modern medical practice this occurs during and after operations, and in debil­itating conditions such as strokes and myocardial infarction. </li></ul>
  16. 17. 3) Deep vein thrombosis RISK FACTORS <ul><li>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. </li></ul><ul><li>Immobility remains one of the most important risk factors. </li></ul><ul><li>Recently, the term 'ethrombosis' has been used to describe blood clots occurring in people sitting at their computer for prolonged periods of time. </li></ul>
  17. 18. 3) Deep vein thrombosis Clinical presentations: <ul><li>The most significant findings are tenderness in the calf and oedema at the ankle. </li></ul><ul><li>(Homans' sign) Pain in the calf on dorsiflexion of the toes </li></ul><ul><li>( It should no longer be used). </li></ul><ul><li>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: </li></ul><ul><li>• Swelling </li></ul><ul><li>• Pain </li></ul><ul><li>• Redness or no apparent signs and symptoms </li></ul><ul><li>• Dilated superficial veins </li></ul><ul><li>• Calf tenderness </li></ul><ul><li>• Low-grade pyrexia </li></ul><ul><li>50% of the patients are asymptomatic </li></ul>
  18. 19. 3) Deep vein thrombosis Diagnosis: <ul><li>General investigations and screening for Thrombophilia. </li></ul><ul><li>2) Doppler ultrasound and duplex imaging is most useful diagnostic tool have sensitivity a specifity up to 90%. </li></ul><ul><li>About 20% of patients with clinical signs and symptoms of a deep vein thrombosis have normal deep veins. </li></ul><ul><li>3) If this is not available, then ascending phlebography should be undertaken. </li></ul><ul><li>4) For diagnosis of pulmonary embolism, enhanced helical computerised tomography (CT) scanning is considered the standard test and is replacing isotope imaging studies. </li></ul>
  19. 20. 3) Deep vein thrombosis Differential diagnosis : <ul><li>Ruptured Baker's cyst, </li></ul><ul><li>Superficial thrombophlebitis, </li></ul><ul><li>Calf muscle haematomas and </li></ul><ul><li>Ruptured plantaris tendon. </li></ul><ul><li>All of these diagnoses can be demonstrated on ultrasonography . </li></ul>
  20. 21. 3) Deep vein thrombosis Treatment: <ul><li>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. </li></ul><ul><li>The duration of heparin treatment should be at least 5 days . </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul><ul><li>Warfarin dosage is controlled by measuring the international normalised ratio (INR) . </li></ul><ul><li>The INR should be prolonged to between 2.5 and 3.5 times the control value. </li></ul><ul><li>Patients with recurrent venous thromboembolic problems should be anticoagulated for life. </li></ul>
  21. 22. 3) Deep vein thrombosis Treatment: <ul><li>2) Subcutaneous injections of low-molecular-weight heparin (LMWH) for the treatment of deep vein thrombosis is an alternative method of anticoagulation. </li></ul><ul><li>The dose is based on the patient's </li></ul><ul><li>(100 IU/kg) weight and treatment given without blood tests to control the dose. </li></ul>
  22. 23. 3) Deep vein thrombosis Treatment: <ul><li>3) Venous thrombectomy : Occasionally, massive venous thrombosis in the lower limb leads to severe impairment in the blood supply to the limb, leading to ischaemia and, eventually, gangrene. </li></ul><ul><li>This is a surgical emergency and requires rapid relief of the venous obstruction. </li></ul>
  23. 24. 3) Deep vein thrombosis Treatment: <ul><li>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. </li></ul>
  24. 25. 3) Deep vein thrombosis Prevention of deep vein thrombosis: <ul><li>Low risk patents : </li></ul><ul><li>Young patients, minor illnesses, operations lasting for less than 30 minutes with no additional risk factors; needs no specific prophylactic measure. </li></ul><ul><li>2) Moderate risk. </li></ul><ul><li>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: </li></ul><ul><ul><li>Graduated compression stockings (TED stockings) </li></ul></ul><ul><ul><li>Heparin 5000 iu s/c bd or LMWH. </li></ul></ul><ul><ul><li>Continued regimen until full mobilisation. </li></ul></ul><ul><li>3) High risk: </li></ul><ul><li>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 . </li></ul><ul><li>They need: </li></ul><ul><ul><li>Graduated compression stockings (TED stockings) </li></ul></ul><ul><ul><li>Heparin 5000 iu s/c tds or LMWH. </li></ul></ul><ul><ul><li>+/- Intra-operative pneumatic calf compression device use. </li></ul></ul><ul><ul><li>Continued regimen until full mobilisation. </li></ul></ul>
  25. 26. 3) Deep vein thrombosis Complications of DVT: <ul><li>1) Systemic complications : pulmonary embolism , pulmonary hypertension . </li></ul><ul><li>2) Local complications : </li></ul><ul><li>Post-phlebitic limb , </li></ul><ul><li>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. </li></ul>