TataKelola dan KamSiber Kecerdasan Buatan v022.pdf
Lecture 8 CVD.pptx
1. Venous Venous Insufficiency (CVI)
Varicose Veins
Painful varicose veins
Superficial phlebitis
Superficial phlebothrombosis
Deep vein phlebitis
Deep vein thrombophlebitis
2.
3. (chronic venous insufficiency “CVI”; post-
phlebitic syndrome; stasis edema; stasis
dermatitis; stasis ulceration; or stasis
induration)
definition- a long-standing incompetence of
the perforating veins of the lower extremity;
the perforating veins drain the superficial
saphenous system through one-way valves
into the deep system (which drains 90% of
the blood from the LE);
4. Greatest number of perforators are located
posterior to the medial malleolus over the
posterior tibial veins;
the middle perforators are located just
proximal (and extend 7-10 cm) above the
medial malleolus; e.g. location of the stasis
ulceration
5.
6. definition- abnormal dilated and
valvular incompetance of the
superficial venous system due to
incompetence of the
saphenofemoral valve; usually
(75%) of hereditary etiology;
may be post- traumatic;
7.
8. Varicose veins are present in 25-33% of female
and 10-20 % of male adults (Coon, 1973).
The presentation of edema and cutaneous
changes, such as stasis dermatitis and
hyperpigmentation varies from 3.0% to 11% of
the population (DaSilva, 1974).
It has been estimated that venous stasis
ulceration, occurs in 1% of the population with
overall annual costs of CVD are 3 billion dollars
in the US;
Over 11 million men and 22 million women
between the ages of 40 and 80 years have
varicose veins
9. 1. edema (first sign- soft or “pitting” relieved with rest or
elevation; occurs just above the shoe-line;
2. venous dilation- ankle-flare sign is dilation of the small
veins underneath the medial malleolus;
3. stasis(stagnation of venous blood)
4. leg pain- heaviness or ache; venous claudication
(associated with DVT)
Heaviness of the legs; muscle weakness and fatigue;
restless leg symptoms
5. pruritis;
6. dermatitis,
7. hyperpigmentation- RBC death and brownish
hemosiderin deposition
Ulceration
10.
11. Superficial veins- lie
on top of the deep
fascia (unsupported
in the saphenous
compartment) can
dilate for increased
capacitance and
contain valves even
microscopic
14. the anterior accessory and
posterior accessory saphenous
veins;
Vein of Giacomini–
Inter-saphenous
communicating vein connecting
GSV to SSV
15.
16. Perforators- pass between the
compartments from the superficial to
deep;
connecting superficial veins of the
foot to the deep posterior tibial veins
when these become incompetent the
term “IPV” is used.
17. Inferior Cockett 1 perforators are direct
perforating veins located posterior to the
medial malleolus.
Middle Cockett 2 perforating veins about
7-10 cm on the lower medial leg, the
most common site of ulceration
Superior Cockett 3- medial perforators is
located in the upper third of the calf,
posterior to the tibia.
18.
19. encased in a tight muscle-
fascial envelope; drain
muscles and function in the
calf-muscle pump; eg the
soleal sinusoids
20. relationship of the phasic muscle
contraction of the calf muscles
during gait and - eg. like cardiac
ventricles; during contraction, the calf
muscles compresses the blood
contained within the venous sinuses
and deep calf veins, thereby pumping
the blood toward the heart. Valves in
the perforators, close and prevent
retrograde flow back into the superficial
system.
21.
22.
23. deep venous pressure
and incompetence of
valves within the
perforators, net effect is
retrograde flow of blood
from the deep system;
peripheral pooling
backing up into the skin
and subcutaneous
tissue
24. resulting in the following
clinical manifestations
(AKA venous
hypertension);
Pathologic = ≥3.5mm in
size, outward flow >500
ms duration and located
beneath
25. an altered ratio between type I and III collagen and
altered function of dermal fibroblasts.
Skin biopsy in patients with VV demonstrates
inflammation with activation of leukocytes, higher
levels of transforming growth factor-β1 (TGF-β-1),
fibroblasts, and matrix metaloproteinases (MMPs) and
lower levels of tissue inhibitors of
metaloproteinases(TIMPs).
It has been suggested that this MMP/TIMP imbalance
may result in a degradation of elastin and collagen
resulting in valve destruction (Michiels, 2002).
26. 1. CEAP
2. VCSS(venous clinical
Severity score)
3. VDS [venous disability
score- includes quality of Life
(QOL) issues]
27. Consists of 4 components
Clinical
Etiologic
Anatomic
Pathophysiologic
28. C1 Telangiectases or reticular veins
C2 Varicose veins
C3 Edema
C4a Pigmentation (stasis
hyperpigmentation) or eczema
(stasis dermatitis)
C4b Lipodermatosclerosis or
atrophie blanche
C5 Healed venous ulcer
C6 Active venous ulcer
29.
30.
31.
32. E in CEAP: Etiologic
Congenital
Primary
Secondary
Present since birth
Undetermined
• Post-thrombotic
A in CEAP: Anatomic Distribution (where is the problem)
Superficial
Deep
Perforator
Great and small saphenous veins
Cava, iliac, gonadal,
femoral, profunda,
popliteal, tibial
Thigh and leg
perforating veins
33. P in CEAP: Pathophysiological
Reflux
Obstruction
Combination
Axial and perforating veins
Acute and chronic Valvular dysfunction and
thrombus
34. In 2000 the American Venous Forum (AVF)
developed the three-part Venous Severity
Score: Venous Clinical Severity Score
(VCSS), Venous Segmental Disease Score
(VSDS), and Venous Disability Score (VDS) -
a modification of the original CEAP disability
score. It has been reported in literature to be
"easy and useful both in research and in the
daily practice."
35. Four grades: 0= absent, 1= mild, 2= moderate,
3= severe (see appendix to this lecture)
Pain
Varicose Vein
Venous Edema
Pigmentation
Inflammation
Induration
Active Ulcers
Ulceration Duration
Active Ulcer Size
Compressive Therapy
36.
37. physical exam on weight bearing,
Perthes test; Trendelenberg test
Venous Ultrasound Examination- must obtain the
following:
ANNA Compression test
Presence/absence reflux in the GSV
dilation of the vein
reflux time
Presence/absence reflux in the SSV
Presence of perforators
Competence of deep venous
38. 1. Venous Doppler 80-85% accurate; (B mode
imaging); color flow imaging- Doppler
Venous Doppler: Using a handheld Doppler:
augmented sound with compression
“ANNA” Compression Test with a hand-held
Doppler on the posterior tibial veins; this is a easy
test to determine venous reflux and venous outflow.
The Doppler remains in place over the PT veins and
go through the following maneuvers:
39. 1. apply distal compression
to the foot (apply continued pressure to the sole of the
foot) the venous flow will be
A- augmented sound (increased sound) on distal
compression of the veins
means there in increased venous flow passed
the Doppler and no proximal
obstruction such as DVT; this is normal
N- no augmented sound (does not get louder) on
distal compression
means there in is no increased venous flow
passed the Doppler possibly due to
proximal obstruction; this is abnormal
40. 2. Apply proximal compression (e.g. to the calve
or thigh) the venous should be
No augmentation of sound (i.e. no flow reversal
with good valves) then release the compression
and there should be
Augmented sound (i.e. increased venous outflow
due to the build up of venous pressure and
release of the compression, if there is no prox
obstruction such as DVT).
41. Venous Doppler: Using a handheld Doppler:
augmented sound with compression
Watch this you tube link:
https://youtu.be/pXvvbWaL9Ts
42. goal: reduction of venous hypertension
CBR; foot elevation; regular ambulation and exercise;
decrease BMI;
sleep in Trendelenberg position;
resolve edema (compression wraps-
eg. Ace or elastic) and stockings;
Intermittent pneumatic compression pumps;
treat ulceration (wet to dry dressings; antiseptic
scrubs; oral antibiotic);
Unna paste boot ”soft cast”;
43. Recommends compression therapy for patients with
CVI (Class C3-C6)
Primary therapy to aid in healing venous ulcers
Adjuvant therapy to superficial vein ablation to prevent
ulcer recurrence.
Contraindications to Compression therapy:
Severe arterial insufficiency
Cutaneous infections
Hypodermatitis in the acute phase
Wet dermatoses
Non-ambulatory uses
Diabetic microangiopathy
Congestive heart failure
44. Bandages may be inelastic and
stiff such as the zinc
impregnated Unna Boot or
elastic stretch bandages.
Numerous randomized
controlled trials give evidence
to support the use of Unna
Boots demonstrating improved
ulcer healing rates (McCulloch,
1994; Polignano 2004; Isabel,
2001).
45. Three and four layer elastic bandages such as
Profore (global.smith-nephew.com) have proven
more effective than inelastic bandages (Kumar,
2002; Davis, 2005).
Long stretch bandages extend by more than 100% of
their original length, whereas short stretch, extend
to less than 100% of their original length.
Compression bandages should be applied with a
graduated decreasing pressure gradient, with the
highest pressure placed at the ankle and 70%
decrease in counter-pressure at the knee.
46. Patient Compliance
Proper fitting
Education and reinforcement
Compressive Stockings in Patients with Varicose Veins
Marked improvement after 16 months of
therapy (70% compliance):
Pain
Swelling
Skin pigmentation
Activity
Well-being
47. Compression stockings- designed to provide strongest at
the ankle and decreasing in the proximal direction
Graduated compression hose or either OTC, Rx (for the or
custom- made;
May not be graduated compression e.g. TED anti-
embolism stockings and simply are tight support hose 8-
15 mm of pressure
Come in different lengths: BK; thigh high; panty hose; for
pregnancy; for arm (post mastectomy)
The pressure ranges are measured by determining the
force that is necessary to stretch the ankle part of the
stocking in transverse direction
48. Compression Class Pressure (mmHg)
8-15 (light) over the counter; aka TED anti-
embolism stockings
Graduated Compression Rx
I 15 – 20 (moderate) over –the-counter
II 20 – 30 (firm)
III 30 – 40 (extra firm)
IV 40+
All can be dispensed in the office
49. Basic Instructions for support
stockings:
Apply first thing in am prior to
daily gravitational edema
Wear all day especially on
prolonged weight bearing or
prolonged sedentary positions with
legs in dependency
Do not sleep with the stockings.
50. Measure in the am before gravitation or
stasis any edema exists.
For knee-highs: measure around your
ankle and calf. Then, measure the
distance from the floor to the back of
your knee.
For thigh-high and pantyhose: measure
around your ankle, calf, and upper thigh.
Then, measure the distance from the
floor to your upper thigh (bottom of your
buttocks).
52. the most effective consist
of timed multi-cell
sequentially inflated air-
filled jackets in a sleeve,
pulled over the entire lower
extremity. The intermittent
positive compression
pumps designed to “milk”
the interstitial compartment
fluid back in the venous
system and proximally up
the leg.
53. possibly added
benefit of IPC is
that it ha been
shown to activate
plasmin and
increase
endogenous
fibrinolytoic
activity(Clark,
1960).
54. A. Conservative-
Indicated for spider veins: red telangiectasia and
blue reticular
1. Injection therapy (sclerotherapy)
liquid and foam sclerosants
2. Transcutaneous or percutaneous laser-
https://youtu.be/WOiKsk46KIo
55. Conservative- Injection therapy
(sclerotherapy) and laser cautery
1. Spider Veins
Transcutaneous laser-
Video- please watch this 3 minute presentation as an
introduction; this is a simplified, video on cutaneous
spider veins using a yag laser
https://youtu.be/QC3q7Kkbqhw
https://youtu.be/jZvSFi-bBeA
56. B. Surgery--Varicose Veins
Endovenous- Radio-frequency Ablation (RFA) or
laser (EVLT) ablation-
Under local Tumescent anesthesia
Conservative- office based
Surgery ligation and stripping- oldest and invasive
SEPS-sub-fascial endoscopic procedure for stasis-
Linton- open surgical ligation of the perforators
57. Indicated only on small veins,
reticular veins and spider veins
Must be sure there is no underlying
venous hypertension or proximal
venous congestion
Thus, generally not a primary Tx;
Potentially dangerous (allergenicity)
may necessitate repeated injections;
Mechanism of action: depends on
producing an inflammatory response
Endothelial inflammation,
thrombosis, fibrosis and vein closure;
External compression is then
applied causing adherence and
fibrosis of the endothelium of the
vessel wall
58. Sclerosants:
23% saline injection;
“Sotradecol” STS (sodium tetradecyl-sulfate 1-3%)
“Monolate” (monoethanolamine oleate);
protonatesd glycerol
“Polidocanol” (Varisolve)
Technique: inject 0.5 ml. of the solution after a
test dose into each varix and apply compression;
60. Indicated for Telangiectasia:
Red spider veins
Blue (reticular veins-dpper in dermis)
Topical anesthesia applied to skin or freeing agents
Nd:yag laser hemoglobin specific photocoagulation
Expensive
https://youtu.be/WOiKsk46KIo
66. Specific wavelength of light and chromophore interaction
Intraluminal photocoagulation, vasoconstriction, endothelial
damage- “seals vessels”;
release of heat shock protein 70; TGF-BI and BII
67. This is a relatively conservative, relatively non-
invasive, percutaneous procedure to thermally
heat seal and close veins utilizing either a laser
beam or radiofrequency heat source guided
though a venous catheter. It is performed under a
locally administered local anesthestic called
Tumescent anesthesia.
68. The local anesthetic usually 1 % lidocaine with
epinephrine is diluted with N Saline up to 200
cc and infiltrated subcutaneously injected
along the course of the vein being treated,
using ultrasound guidance. The anesthetic
serves to provide pain relieve but also to
absorb heat and prevent thermal necrosis of the
tissues surrounding the vein.
71. Indicated for:. refluxing superficial veins,
perforators and communicators
Used either RF or lasers
Employs Tumescent anesthesia consisting of
infiltration along the course of the saphenous
system dilauted 1% lidocaine with epifor the
purpose of a heat sink and anesthesia
Techniques: a percutaneous procedure under US
guidance: IV catheter, guidewire, insertion of the
heating devise 120 degrees for 20 seconds in 7 cm
segments for the length of the saphenous system
72. Post-Op care
Catheter removed
Compression dressing applies and elastic
compression or support stockings for 48 hourss
May return tor work the same day.
No analgesia generally needed
Return in one week for follow-up US
73. Less patient pain and post-op missed work
Less patient bruising and trauma
Faster recovery times
Fewer complications
Patient Satisfaction and Referrals
74. Watch these short videos; They provide an
excellent overview of the procedure.
https://youtu.be/JwWlLTzXtdo
https://youtu.be/OjffO8J5Tgg
75. #1. High ligation and venous
stripping-
for removal of the entire GSV or SSV;
generally used for CVI and or VV
76. This is a major invasive technique, generally performed
under general anesthesia;
Involves making one or more incisions upon the desired
area (usually just distal to the femoral triangle).
The perforator is ligated and cut and the remaining
distal GSV is isolated and opened. A long steel wire
with an triangular cone shaped acorn tip is then passed
distally down the GSV. As it is passed distally, it can be
felt through the skin.
The wire is passed distal down the saphenous system to
the level of the ankle where a second incision is made.
At the distal incision, the vein is ligated around the acorn
end.
77. Under unltrasound guidance, many small incisions
are made along the course of the saphenous vein to
ligate all tributary communicating veins that drain
into the saphenous.
Then, through the proximal incision (up at the
femoral triangle) the wire is pulled proximally, and
the entire saphenous system retracted and removed
from the body at the femoral triangle.
All incisions are sutured, and pressure dressings
are applied to the incision.
78.
79. Indicated for CVI due to failure of the valves of
the perforating veins (IPV) resulting in venous
stasis disease and ulceration (generally done at
the level of the Cocketts 2 perforators)
Generally performed under spinal or general
anesthesia;
Procedure: this is an endoscopic procedure,
performed through a small proximal incision.
A 2-3 cm linear incision is made below the knee a few
cm above the perforators on the medial leg, centered
over , along- side of the GSV.
80. The incision is deepened through the skin and
subcutaneous tissue to the deep
fascia, which is underscored.
An endoscope is passed deep to the GSV and fascia
and tunneled distally, to the perforating veins
between the GSV and the tibial veins.
The veins are then clamped using multiple vascular
clips.
The endoscope with withdrawn and the wound is
closed.
82. One final procedure:
Another office based procedure.
ambulatory phlebectomy- generally performed under
local anesthesia in an office;
Indictions: performed to selective surgical excise small
varices, that are often communicating veins, that
remain after a Open surgical or RFA of a large
saphenous vein.
Procedure: minimally invasive small incisions
(1 cm) made over the prominent
varix; a hook is passed subcutaneously,
to hook and withdraw the vein.
