Clinical aspects of vein Presented by: ANKITA MISHRA 16
Clinical anatomy of vein Anatomy of the venous system of the legDEEP VEINSPOSTERIOR TIBIALANTERIOR TIBIALPERONEAL `SOLEALGASTROC NEMIUSPOPLITEALFEMORALILIACSUPERFICIAL VEINSLONG SAPHENOUS (LSV)SHORT SAPHENOUS (SSV)
PHYSIOLOGY OF VENOUS BLOOD FLOW VENOUS RETURN FROM LEG IS GOVERNED BY:Arterial pressureCalf musculovenous pumpGravityThoracic pumpVis a tergo of adjoining musclesValves in veins
MUSCULOVENOUS PUMPFoot and calf muscles act tosqueeze blood out of deepveins.One way valve allow onlyupward and inward flow.During muscle relaxationblood is drawn inward thruperforating veins.
Vein DisordersVenous Thrombosis (Superficial and Deep VeinThrombosis),ThrombophlebitisChronic Venous InsufficiencyVaricose Veins
Chronic Venous InsufficiencyResults from obstruction of venous valves in legs orreflux of blood back through valvesVenous ulceration is serious complicationPharmacological therapy is antibiotics for infectionsDebridement to promote healingTopical Therapy may be used with cleansing anddebridement
Stages of chronic venous insufficiency0 - no symptoms;1 - heavy feet syndrome;2 - intermittent edema;3 - persistent edema, hyper- or hypopigmentation,lipodermatosclerosis, eczema;4 - venous ulcer.
CausesPrimaryTheories of Aetiology:• Weak wall theory• Congenital valvular incompetenceAggravating factors:• Female sex• High parity• Occupation requiring prolonged standing• Marked obesity• Constricting clothes• Estrogen intake• Deep venous thrombosis
SecondaryAnything that raises intra-abdominal pressure or raises pressure in superficial/deep venous system so…: •Pregnancy •Abdominal/pelvic mass •Ascites •obesity •constipation •thrombosis of leg veins (DVT) •AV fistula •Vena cava thrombose •Large liver cysts
Varicose disease Varicose disease of subcutaneous veins is their irreversibledilation and elongationoccurring due to crudepathological change of venous walls and valvular apparatus.
ANY RISK FACTOR INCREASED VENOUS PRESSURE DILATION OF VEIN WALLS STRECHING OF VALVES-VALVULAR INCOMPETENCE REVERSAL OF BLOOD FLOW FAILURE OF MUSCLES TO PUMP BLOODVEINS DISTEND,ELONGATE,TORTOUS,POUCHED,INELASTIC AND FRIABLE
Surgical InterventionINDICATED OR DONE FOR PREVENTION OR RELIEF OF EDEMA, FORRECURRENT LEG ULCERS OR PAIN OR FOR COSMETIC PURPOSESVEIN LIGATION AND STRIPPINGTHE GREAT SAPHENEOUS VEIN IS LIGATED (TIED) CLOSE TO THEFEMORAL JUNCTIONTHE VEINS ARE STRIPPED OUT THROUGH SMALL INCISIONS AT THEGROIN, ABOVE & BELOW THE KNEE AND AT THE ANKLES.STERILE DRESSING ARE PLACED OVER THE INCISIONS AND ANELASTIC BANDAGE EXTENDING FROM THE FOOT TO THE GROIN ISFIRMLY APPLIED
NURSING CARE AFTER VEIN LIGATION & STRIPPINGKeep pt. flat on bed for first 4 hrs. after surgery,elevate leg to promote venous return when lying or sittingMedicate 30 mins. before ambulation and assist patientKeep elastic bandage snug and intact, do not removebandageMonitor for signs of bleeding, esp. on 1st post-op dayif there is bleeding, elevate the leg, apply pressure overthe wound and notify the surgeon
RISK FACTORS Age Gender Height left>right Heredity Pregnancy Obesity and overweight Posture
25-50% of adult women 15-30% of adult men Is it an industrialized country disease?UK: 45 000 hospital admissions per year
Treatment complicationsMajor complications following VV surgery are relatively rare Up to 20% morbidity Infection Hematoma Pain Nerve damage Saphenous nerve (LSV surgery) Sural, peroneal nerve (SSV surgery) Lymphatic leak - Venous thrombosis - Vascular injury Recurrence
Deep Vein Thrombosis (DVT) DVT: Blood clot in a veinlocated deep in the muscles of the legs, thighs, pelvis orarms DVT is the result of 3principle factors 1. Reduce or stagnantblood flow in deep veins 2. Injury to the bloodvessels wall 3. Increase clottingactivity (hyper-coagulability 22 or thrombophilia)
Risk of DVT1. Immobilization2. Recent surgery or trauma3. The use of medication4. Inherited or acquired hypercoagulability,Note: Approximately 75-90% of DVT have at least one established risk factor : Inherited thrombophilias can be identified in 24-37% of patients 23
SIGN AND SYMPTOMSLeg pain or tendernessLeg swellingIncrease wormth of one leg,change in skin color (redness)Homans sign positive 24
Medical Management Deep vein thrombosisREQUIRES HOSPITALIZATIONBED REST W/ LEGS ELEVATED TO 15-20 DEGREES ABOVEHEART LEVEL ( KNEES SLIGHTLY FLEXED, TRUNK HORIZONTAL(HEAD MAY BE RAISED) TO PROMOTE VENOUS RETURN ANDHELP PREVENT FURTHER EMBOLI AND PREVENT EDEMAAPPLICATION OF WARM MOIST HEAT TO REDUCE PAIN,PROMOTES VENOUS RETURNELASTIC STOCKING OR BANDAGEANTICOAGULANTS, INITIALLY WITH IV HEPARIN THENCOUMADINFIBRINOLYTIC TO RESOLVE THE THROMBUSVASODILATOR IF NEEDED TO CONTROL VESSEL SPASM ANDIMPROVE CIRCULATION
Nursing Assessmentcharacteristic of the painonset & duration of symptomshistory of thrombophlebitis or venous disorderscolor & temp. of extremityedema of calf of thigh - use a tape measure,measure both legs for comparisonIdentify areas of tenderness and any thrombosisSURGERYif the thrombus is recurrent and extensive or ifthe pt. is at high risk for pulmonary embolismThrombectomy – incising the common femoral veinin the groin and extracting the clotsVena caval interruption – transvenous placementof a grid or umbrella filter in the vena cava to blockthe passage of emboli
Thrombophlebitisinflammation of the veins caused by thrombus or blood clot Factors assoc. with the devt. of Thrombophlebitis venous stasis damage to the vessel wall hypercoagulability of the blood – oral contraceptive use common to hospitalized pts. , undergone major surgery (pelvic or hip surgery), MI Pathophysiologydevelops in both the deep and superficial veins of the lower extremity deep veins – femoral, popliteal, small calf veins superficial veins – saphenous veinThrombus – form in the veins from accumulation of platelets, fibrin, WBC and RBC
Thrombophlebitis•Thrombosis with infammation of superfiacialveins•Occur spontaneously/due to minor trauma•Can occur durin injection of sclerosing fluidfor treatment
Main symptoms of thrombophlebitis 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.
Medical Management Thrombophlebitisbed rest with legs elevated apply moist heat NSAID’s ( Non – steroidal anti-inflammatory drugs) - aspirin
Homans sign• Pains in gastrocnemius muscle upon dorsal flexing of the foot is characteristic of thrombophlebitis of profound veins of the extremity.
Classification of functional tests1. Test enable one to judge the condition of valvular apparatus Trendelenburg-Trojanovs tests Hackenbruchs 2. Test enable of insufficient perforating veins Pratts test II Scheins test Thalmanns test 3. Test enable the patency of profound veins Delbe-Pertez test (marching test) Pratt-I test