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AXILLARY-SUBCLAVIAN VENOUS
THROMBOSIS
 less than 5% of all cases of deep vein thrombosis.
 Only 12% result in pulmonary thromboembolism,
upper ‫ ممكن يصير بال‬DVT ‫ال‬
limb but less chance

occurs when a blood vessel in your upper

arm gets compressed by a nearby rib or
muscle and blood clots develop
 PSS:
effort-induced thrombosis of the axillary and
subclavian veins associated with compression of
the subclavian vein at the thoracic outlet.

 Primary axillary-subclavian thrombosis Due to :

 (Paget-Schrotter syndrome) ‫ اللي بستخدمها‬limb ‫ بال‬DVT ‫مثل عازف الكمان فممكن يصير عنده‬
 hypercoagulable states.
Most commonly due to central line
 Secondary subclavian vein thrombosis results
from venous injury by indwelling central venous
catheters, external trauma, or pacemaker wires.
A central venous catheter, also known as a central line, is a tube that doctors place in a
large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do
medical tests quickly.
Clinical Findings Swelling,pain, Cyanosis in
upper limb
 aching pain most severe in the axilla,
 edema and cyanosis of the upper extremity.
 Significant superficial venous distention
 Duplex ultrasound
Imaging Studies D-Dimer Testing

 Chest x-ray to exclude the presence of cervical rib

 Upper extremity venous duplex ultrasound a test that uses high frequency sound
waves to look at the speed of blood flow

 Upper extremity venography x-ray exam

 MRV
Magnetic resonance venography (MRV) is an imaging test that is used to visualize
veins in the body
Treatment
 remove indwelling central venous lines or pacemaker
wires
 Arm elevation,
 pain control,
 Anticoagulation
 Catheter directed thrombolysis
 Surgery for thoracic outlet syndrome
compression of nerves or blood vessels in the area between the neck and shoulder


CHRONIC VENOUS INSUFFICIENCY
Due to reflux or obstruction

 The basic physiologic abnormality is chronic elevation

of venous pressure
 calf muscle pump dysfunction
 valvular reflux, due to valve incompetence most commonly
 proximal obstruction due to chronic DVT
 Main bridge in chronic venous insufficiency is the venous hypertension

Pressure in
venous
system very
high

‫ للدم )الدم بكون متجمع (بزيد ال‬congestion ‫ا يكون واقف بصير‬9 ‫الشخص‬
pressure
pressure ‫ للدم فبقل ال‬pump‫ا تمشي بصير‬9

During exercise venous pressure decrease due to pumping of blood

pain ‫ بصير عنده‬pressure ‫ ما بقل ال‬venous insufficiency ‫ريض اللي عنده‬4‫با‬

Hemodynamic charting of (a) healthy patients, (b) patients with only varicose veins,
(c) patients with incompetent perforator veins, and (d) patients with deep and
perforator incompetence.
 "venous claudication" as the deep venous system fills
with blood during exercise. The leg becomes painful,
swollen, and heavy, mimicking arterial insufficiency.
Clinical Findings
 ankle and calf edema worst at the end of the day and
improves with leg elevation
 stasis dermatitis,
 hyperpigmentation,
Chronic swelling
 brawny induration,
 Lipodermatosclerosis on gaiter area
 ulceration.
 Venous stasis ulcers are large, painless, and irregular in
outline.
 They have a shallow, moist granulation bed,
 occur in the gaiter area on the medial or lateral
aspects of the ankle
 the "gaiter areas" around the ankles.
 the location of the commonly affected perforator veins
 a region with sparse soft tissue support to withstand
elevated venous pressures.
 Brawny edema
 extravasation of plasma fluid, red blood cells, and plasma
proteins.
 Lysis of red blood cells results in deposition of hemosiderin,
which creates a brownish discoloration.
 inflammatory response
 Leukocytes become sequestered in the microcirculation,
leading to capillary occlusion and release of superoxide
radicals, proteolytic enzymes, and growth factors.
 Macrophages and T lymphocytes are primary mediators of
this inflammatory response which results in fibroblast
activation and scarring and fibrosis of the subcutaneous
tissues.
 compromised skin perfusion and ulceration.
Bilateral
Venous ulcer
Diagnostic Studies
 Duplex ultrasound More sufficient

 air plethysmography, ‫ردن‬$‫مش متوفره عنا با‬

 venous reflux (by the venous filling index),
 calf muscle pump function (by the ejection fraction),
 overall venous function (by residual volume function)
 Venography ----outflow obstruction
Treatment
Most commonly conservative
 conservative treatment program
 intermittent leg elevation,
 regular exercise,
 the use of surgical elastic graduated compression
stockings
 local wound care
 phlebotonic drugs
 ‫ ممكن‬IVC ‫ او بال‬iliac ‫ بال‬proximal venous occlusion *‫اذا عنده مث‬
bypass surgery ‫ او‬Endovascular ‫ او‬surgery ‫ينفع معه‬

 Surgery is indicated for a small percentage of patients

with nonhealing ulcers or disabling symptoms
refractory to conservative management
 Perforating vein ligation
 venous reconstructive surgery
 ‫ جايه‬perforator reflux ‫ وفيه‬proximal reflux (‫اذا واحد كان عنده مث‬
‫ عند ال‬perforator ‫ بت(قي هناك فيه‬ultrasound ‫ اذا بتعمل‬ulcer ‫عند ال‬
‫ او من خ(ل‬laparoscope ‫شكله فممكن من خ(ل ال‬C‫ هوه عامل ا‬ulcer
‫ بس هاد‬ulcer ‫ وتربطه فبخف ال‬vein‫ انك تفتح ع هاد ال‬open surgery
if there’s failar of compression therapy ‫الحل نلجأ اله‬

 Perforating vein ligation reverse the local wound

complication of venous ulceration and does nothing to
change the underlying deep venous hemodynamics of the
leg
 venous reconstructive surgery indicated for
 (1) venous reflux not amenable to a conservative
treatment regimen,
 (2) failure to relieve symptoms after perforator ligation,
 (3) intractable disabling venous claudication associated
with venous outflow obstruction.
 CEAP Classification
Classifi venous system
standardization of the venous
disease
 CEAP Classification
 consistent communication with specific descriptors,
 Allows standardization of CVD into classes,
 Guide treatment and assess prognosis.
 tissue swelling caused by an accumulation of
protein-rich fluid that's usually drained through
the body's lymphatic system

LYMPHEDEMA ‫ او‬primary ‫ممكن تكون‬

‫ او‬secondary
‫ او‬developmental
acquired
 Can be developmental or acquired.
 Painless edema of one or both lower extremities,
usually involving the ankle, the dorsum of the foot,
and the toes.
 Edema is usually pitting at first and then becomes
firm, rubbery, and nonpitting due to fibrosis.
 Frequent episodes of lymphangitis and cellulitis may
occur.
 Primary lymphedema
 caused by abnormal lymphatic development—most
often hypoplasia resulting in severe reduction in the
number of lymphatics and the lymphatic diameters.
 It is classified by age at onset of the disease.
swelling in lower limb ‫ عنده‬male ‫بالعاده بكون‬
 Congenital lymphedema develops before 1 year of
age, is usually bilateral, and affects males more than
females; if familial, it is known as Milroy's disease.
‫ بكون‬swelling ‫ صار عندها‬female 16 or 17 years old suddenly ‫بالعاده بتكون‬
persistent swelling of the lower limb
 Lymphedema praecox develops during adolescence
(and is unilateral; there is a 3.5:1 female predominance.
 lymphedema tarda occurring after age 35
Female 35 years old ‫فما فوق وبلش يصير عندها‬
persistent swelling
 Due to other cause
such as malignancy
surgery
Secondary lymphedema radiotherapy
chemotherapy
filariasis
Results from disease processes that cause obstruction
to the lymphatic system.
 surgical excision and radiation to the axillary or
inguinal lymph nodes as part of the treatment cancer.
 bacterial and fungal infections,
 trauma,
 lymphoproliferative diseases.
 filariasis Wuchereria bancrofti, Brugia malayi, and
Brugia timori.
 other causes of‫ بشيك عال‬swelling ‫طبعا اول شي واحد عنده‬
kidney function test ‫ بطلبله‬swelling
Cardiac echo
Liver function test
Imaging Studies Duplex

 Lymphangiography is rarely used now, as it can

further damage the lymphatics and is unnecessary to
establish the diagnosis.
 Lymphoscintigraphy is a specialized test used for the
detection of lymph node metastasis and does not play
a significant role in the diagnosis of lymphedema
though it may confirm the diagnosis in ambiguous
cases.
Differential Diagnosis
 bilateral lower extremity edema—
 congestive heart failure,
 chronic renal or hepatic insufficiency,
 hypoproteinemia.
 unilateral leg edema,
 chronic venous insufficiency.
 congenital vascular malformations,
 Conservative

Treatment
 Lymphedema is a chronic disease for which there is no
complete cure.
 A variety of conservative measures can substantially
reduce the risk of further complications and disability.
 Use of benzopyrones (coumarins) and steroid
injections to increase lymphatic transport has not
shown consistent benefit
 external compression
 meticulous skin care.
 frequent leg elevation,
 manual lymphatic drainage massage,
 low-stretch wrapping techniques,
 intermittent pneumatic compression
 Operation may be considered in rare cases of severe
functional impairment and recurrent lymphangitis.
 ablative techniques (excision of excess tissue)
 (lymphatic reconstruction).
 infection on lymphedema
along the course of the
lymphatic vessels

LYMPHANGITIS tenderness on lymph node ‫بصير‬

 hemolytic streptococcal or staphylococcal

 Multiple long red streaks can be seen coursing toward
the regional lymph nodes.
 Regional lymph nodes are often enlarged and tender
 systemic manifestations include tachycardia, fever,
chills, and malaise
 ‫رضى اللي عندهم‬-‫؟؟ با‬elevation ‫متى ما بنعمل‬
ischemia

improve drainage and conditions of the

patients
 The extremity should be elevated and warm
compresses applied.
 Analgesics
 intravenous antibiotics
 Local Wound care