eMentorSurgery

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VENOUS DISORDERS

 PATHOPHYSIOLOGY

•VENOUS BLOOD IN THE LEG HAS A PRESSURE OF 20MMHG

•BLOOD FROM THE MUSCLES IN THE LEGS RETURNS VIA THE DEEP VENOUS SYSTEM

•BLOOD FROM THE SUPERFICIAL AND TISSUES AND SKIN RETURNS EXTERNAL TO THE DEEP FASCIA  VIA THE LONG OR SHORT SAPHENOUS VEINS

•BLOOD FROM THE SUPERFICIAL AND TISSUES AND SKIN RETURNS EXTERNAL TO THE DEEP FASCIA  VIA THE LONG OR SHORT SAPHENOUS VEINS

•FROM THESE VEINS THERE ARE COMMUNICATING VEINS TO THE DEEP VEINS

•VALVES ENSURE FLOW IS TOWARDS THE HEART AND FROM SUPERFICIAL INTO THE DEEP SYSTEM

•THERE ARE A SERIES OF MUSCLE PUMPS  ACTING AS PERIPHERAL HEARTS 

•THESEI NCLUDE CALF  MUSCLES AND THE MUSCLES INTHE FOOT

•THESE MUSCLE AND THEIR CONTRACTION ENSURES BLOOD FLOW TOWARDS THE HEART

•THIS IS BECAUSE THE PRESSURE WITHIN THE VEINS RISES TO 300MMHG FROM 20MMHG DURING CONTRACTION-WALKING

•CONTRACTION   ALTERNATES WITH RELAXATION -THE PRESSURE  IN MUSCLE THE FALLS TO A LOW LEVEL

•ANDBLOOD FLOWS FROM SUPERFICIAL VEINS TO DEEP VEINS VIA THE PERFORATORS

•FACTORS THAT DETERMINE THAT MAINTAIN BLOOD FLOW TOWARDS THE HEART THEREFORE ARE

1.COMPETENCE OF THE VALVES

2.COMPETENCE OF THE COMMUNICATING PERFORATORS AND THEIR VALVES

•3. ABILITY OF THE MUSCLE PUMP TO RELAX THEREFORE DROPPING THE VENOUS PRESSURE  ENSURING BLOOD IS DIRECTED FROM SAPHENOUS TO DEEP

4. COMPETENCE OF THE     DEEP SYSTEM

VARICOSE VEINS

•DEFINITION : ABNORMAL DILATATION, ELONGATION AND TORTUOSITY OF THE SUPERFICIAL VENOUS SYSTEM OF  THE LOWER LIMB

•CAN AFFECT LONG AND SHORT SAPHENOUS VEIN

ETIOLOGY

•PRIMARY

•IDIOPATHIC.

•CONGENITAL WEAKNESS OF THE VEIN WALL

•ABSENCE OF VALVES – VERYRARE

•SECONDARY

•DEEP VEIN THROMBOSIS

•TRAUMA TO VEIN WALL

•DECREASED BLOOD FLOW IN THE VEIN

•INCREASED CAOGUBALITY

ETIOLOGY

•INCOMPETENCE OF THE PERFORATORS

•DESTRUCTION BY THROMBOSIS

•TRAUMA

•SURGERY

C).       OBSTRUCTIONTO VENOUS     OUTFLOW

•PREGNANCY

•OVARIAN TUMORS/ FIBROIDS

•ABDOMINAL TUMOR

•ILIAC VEIN THROMBOSIS

•ATERIOVENOUS FISTULA

•OCCUPATIONS WHICH INVOLVE PROLONGED STANDING PREDISPOSE TO THE ILLNESS AND ARE RISK FACTORS

SYMPTOMS

•ASYMPTOMATIC

•PAIN AND ACHE-

•USUALLY LOWER LEG – CALFAREA

•AGGRAVATED ON  PROLONGED STANDING

•BURSTING TYPE  AGGRAVATED ON WALKING

•THE PAIN IS RELIVED ON LYING DOWN AND ELEVATION OF THE LIMB

•MUSCULARCRAMPS SEEN USUALLY AT NIGHT

•LOWER LIMB EDEMA

•EDEMA IS  MORE ON PROLONGED STANDING

•BEGINSAROUND THE ANKLE

•PIGMENTATION-BROWNISH DEPOSITION OF HAEMOSIDERIN-RBCS ARE FORCED OUT OF CAPILLARIES  INTO SUPERFICIAL  AREAs

•HEREHEMOGLOBIN BREAKS DOWN TO HAEMOSIDERIN

•PRURITIS – BECAUSE  OF IRRITATION BY PRESENCE OF HAEMOSIDERIN

•LIPODERMATOSCLEROSIS-

•GAITER AREA JUST ABOVE MALLEOLI

•EDEMA, INFLAMMATION,FIBROSIS, PIGMENTATION, ECZEMA

•CHAMPAGNE  BOTTLE LEG

•ATROPIE BLANCHE

•WHITE PATCHES  ALL OVER THE SKIN OF LOWER LIMB

SIGNS

•EARLY CASES PITTING EDEMA

•THEN BECOMES INDURATED

•INSPECTION:

•DILATED TORTUOUSSUPERFICIAL VEINS

•PIGMENTATION OF THE SKIN OF THE INVOLVED LEG – BROWNISH

•SWELLING OF THE  LEG

•ULCER

•SAPHENA VARIX  A GROIN SELLING WITH EXPANSILE COUGH IMPULSE

• DISAPPEARS ON LYING DOWN& 4.5 CM INFERIOLATERAL TO THE PUBIC TUBERCLE

•SAPHENOFEMORAL JUNCTION

•PALPATION

•BRODIE TRENDELENBURG’STEST

•SCHWARTZ TEST

•PERTHE’S TEST

•MORRISEY’S TEST

•MULTIPLE TOURNIQUET TEST

•FEGAN’S TEST

•AUSCULTATION IS DONE ALWAYS TO RULE OUT ATERIOVENOUS FISTULA  AS AN ETIOLOGY

•REGIONAL NODES AND ARTERIAL PULSES MUST BE EXAMINED ALONG WITH DETAIL ABDOMINAL EXAMINATION

COMPLICATIONS

•THOROMBOPHLEBITIS

•ECZEMA- CHRONIC DERMATITIS

•LIPODERMATOSCLEROSIS

•HEMORRHAGE

•CALCIFICATION

•PERIOSTITIS

•OSTEOMYELITIS

•VENOUS ULCER

•TALIPES EQUINUS VARUS

VENOUS ULCER

•COMPLICATION OF VARICOSEVEINS

•PATHOPHYSIOLOGY – FIBRINCUFF HYPOTHESIS

•WHITECELL TRAPPING HYPOTHESIS

FIBRIN CUFF HYPOTHESIS

VARICOSE VEINS

VENOUS HYPERTENSION

FIBRIN CUFF HYPOTHESIS

CAPILLARY DAMAGE

HAEMOSIDERIN DEPOSITION-ECZEMA-INFLAMMATORY INFILTRATE

FIBRIN CUFF HYPOTHESIS

DEPOSITION OF COLLAGEN- FIBRIN-FIBRONECTIN

PERIVASCULAR CUFF

FIBRIN CUFF HYPOTHESIS

HYPOXIA TO SUPERFICIAL TISSUE

ULCER

WHITE CELL TRAPPING HYPOTHESIS

INFLAMMATORY CELL INFILTRATE

TRAPPING OF WHITE CELLS AND THEIR ACTIVATION

WHITE CELL TRAPPING HYPOTHESIS

WHITE CELLS RELEASE PROTEOLYTIC ENZYMES

INJURY TO CAPILLARY ENDOTHELIUM AND SKIN

CLINICAL FEATURES

•SITE  : LOWER 1/3RD OF LEG GAITER AREA  NEAR MEDIAL MALLEOLUS

•EDGES:SLOPING

CLINICAL FEATURES

•BASE : INDURATED

•SURROUNDING SKIN- PIGMENTEDAND INDURATED

•VARICOSEVEINS PRESENT

COMPLICATIONS OF AN ULCER

•PERIOSTITIS

•OSTEOMYELITIS

•MARJOLIN’S ULCER

•TALIPESEQUINUS

INVESTIGATIONS

•DETAILED CLINICAL TESTS

•DOPPLER  -BI-DIRECTIONAL PROBE – PATENCY OF DEEP VEINAND PERFORATORS – ERECT POSITION

•DUPLEX SCANNING – COLOR DOPPLER - PERFORATORS

INVESTIGATIONS

•VENOGRAM- SELDOM USED INCURRENT SURGICAL PRACTICE

•PLETHYSMOGRAPHY

TREATMENT

•NON OPERATIVE MEASURES

•OPERATIVEMEASURES

NON OPERATIVE MEASURES

•ELASTIC STOCKINGS- MILDVARICOSITY- GRADED COMPRESSION STOCKINGS

•ELASTIC BANDAGES

•CREPE BANDAGES

INJECTION SCLEROTHERAPY

•INDICATIONS

•MINOR VARICOSE VEINS

•VARICOSE VEINS BELOW THE KNEE

•RESIDUAL VARICOSE VEINS

•PEOPLE WHO REFUSE SURGERY

INJECTION SCLEROTHERAPY

•CONTRAINDICATIONS

•INFECTIVE THOROMBOPHLEBITIS

•ABOVE KNEE VARICOSE VEINS

•LARGER VARICOSITIES

•PREGNANCY

•DEEP VEIN THROMBOSIS

•PRINCIPLE

INJECTION OF SCLEROSANT

INTO THE VARICOSITIES

THE SCLEROSANT WILL

DESTROY ENDOTHELIUM

 CAUSES SCLEROSISOF THE

VEIN WHICH IS THEN

INCAPABLE OF RECANALISING

•TECHNIQUE

MARK THE AREAS TO BE

INJECTED

EMPTY THE VEIN

INJECT THE SCLEROSANT

ABOUT 0.5 ML EACH

INJECTION SCLEROTHERAPY

•TECHNIQUE

IMMEDIATE MANUAL COMPRESSION APPLICATION  OF ABANDAGE

•SCLEROSANT

•SODIUM TERADECYL -3%

•ETHONALAMINE OLEATE –5%

INJECTION SCLEROTHERAPY

•PROCEDURE  SHOULD BE DONE  EVERY 3- 6 WEEKS  AT WEEKLY INTERVALS UNTIL ALL VARICOSITIESARE TREATED

INJECTION SCLEROTHERAPY

•COMPLICATIONS

ULCERATION

PIGMENTATION

THOROMBOPHLEBITIS

DEEP VEIN THROMBOSIS

•MICROSCLEROTHERAPY

OPERATIVE TREATMENT

•PRINCIPLE

LIGATE THE SOURCE OF

VENOUS REFLUX WHICH MAY

BE SFJ OR SPJ

REMOVE  INCOMPETENT

SAPHENOUS TRUNK

OPERATIVE TREATMENT

TREAT THE COMMUNICATIONS

BETWEEN DEEP AND

SUPERFICIAL VEINS

REPAIR OF THE DEEP VEIN

VALVES

OPERATIVE TREATMENT

SAPHENOFEMORAL FLUSH

LIGATION/

SAPHENOPOPLITEAL

TRENDELENBURG'S

OPERATION

OPERATIVE TREATMENT

STRIPPING OF THE LONG

SAPHENOUS VEINS

COCKET AND DODD'S

SUBFASCIAL LIGATION OF

PERFORATOR VEINS

VALVULOPLASTY

TREATMENT OF AN VARICOSE ULCER

•BISGAARDS METHOD

MASSAGE AND ELEVATION OF

WHOLE LEG

PASSIVE MOVEMENTS OF THE

FOOT AND ANKLE BY

PHYSIOTHERAPY

•BISGAARDS METHOD

ACTIVE MOVEMENTS OF THE CALF IN ELEVATION

TEACH THE PROPER WAY OF WALKING PLACING HEEL DOWN FIRST

•BANDAGE BY GRADED ELASTIC COMPRESSION BANDAGING

•ELEVATION OF THE LIMB ONBED AT NIGHT

•IF INFECTION SYSTEMIC ANTIBIOTICS

•DAILY DRESSINGS- KEEP THE ULCER DRY