Diseases of The Veins &

Lymphatics
 Venous Anatomy
 VARICOSE VEINS
 SUPERFICIAL THROMBOPHLEBITIS
 DEEP VEIN THROMBOSIS
 AXILLARY-SUBCLAVIAN VENOUS THROMBOSIS
 CHRONIC VENOUS INSUFFICIENCY
 LYMPHEDEMA
 LYMPHANGITIS
Saphenous.v
VENOUS ANATOMY
 superficial and deep systems Femoral +popliteal +iliac

 venous perforators Between superficial and deep system //that perforate the fascia

 The saphenofemoral junction branches of the greater

saphenous vein:
 the superficial circumflex iliac vein,
 the external pudendal vein,
 the superficial epigastric vein,
 the medial and lateral accessory saphenous veins.
There’s junction between sup + deep vein

= saphenofemoral junction

Clear about anatomy of it

There’s also branches =

• inf.epigastric.v
• Pudendal.v
• Lateral.circumflex.v
•
 Blood flow is directed from superficial to deep veins of
the leg via valved perforating veins.

 Perforators are located

 below the medial malleolus (inframalleolar perforator),
 in the medial calf (Cockett perforators),
 at the level of the adductor canal (hunterian perforator),
 and just above (Dodd's perforator) and below (Boyd's
perforator) the knee.
 There are valves between veins allow flow in one direction

 bicuspid venous valves prevent reflux and direct the

flow of blood from the foot and leg toward the heart.
 Valves are more numerous in the distal part of the
extremity, decrease in number proximally, and are
virtually absent in the IVC.
 There are nerves associated with superficial veins
• saphenous.n —great saphenous.v
• Sural.n —short saphenous.v

Nerves related to sup. veins

Veins of the upper extremity
Brachiocephalia
Trunk

deepuperfacial
 VARICOSE VEINS
Essentials of Diagnosis
 Dilated, tortuous superficial veins
 Usually bilateral in the lower limbs Can be degrees
From high to low
 reticular veins, telangiectasias, and spider veins degrees like = spider
and reticular
 asymptomatic
 Symptomatic
 localized pain
 nocturnal cramps
 aching discomfort and "heaviness" with prolonged standing.
 bleeding,
 The most common complaint
 Varicose veins are very common, 10-20% of the world's
population.
 risk factors
 female sex,
 pregnancy,
 family history,
 prolonged standing,
 history of phlebitis.
 Defect in :

· vein itself
or

& - wall
·
values

Primary varicose veins

due to genetic or developmental defects in the vein
wall that cause diminished elasticity and valvular
incompetence.
Secondary varicose veins
 Secondary to Deep venous insufficiency
 Arise from destruction or dysfunction of valves caused
by deep venous thrombosis, arteriovenous fistula,
trauma, or proximal venous obstruction (pregnancy,
pelvic tumor)
varicose veins
 May be along the
course
great.saphenous.vein

= dorsal venous arch

- anterior to medial
melluols - medial
aspect of leg
-post.medial aspect
of knee —thigh -
medial -anteriomedial
- anterior to the
saphenofemoral
junction

The course of short

saphenous.vein
• posteriorly from popliteal
fossa
• Descend laterally
• Connect with great
saphenous at
(Dorsal.venous arch)
Secondary varicose veins are assosiated with symptoms
characteristic of chronic venous insufficiency,
 edema, Signs of severity

 hyperpigmentation,
 scaling dermatitis,
 and venous ulcerations.
Lipodermato sclerosis
 So by history = complaint
Physical examination = u notice the veins / compressible / erythema /changes at lower leg

And make the test below

 The Brodie- Trendelenburg test ‫ للدكتور رائد‬intro ‫مرجعه محاضرة ال‬

Ask the pt to raise his legs

To emptying of veins
• build up the tourniquet
• ask pt to stand
• The veins may filing rapidly or slowly
• So u can know the source of reflux ( saphenofemoral junction/perforators)
• Repeat the process at different levels at thigh and leg
Nonsurgical Treatment
 Elastic stocking ‫جرابات مطاطية‬

 Periodic leg elevation,

 regular exercise
 Discourage Prolonged sitting and standing.

Who is at risk?
-prolonged standing :‫ا;درس‬+ :‫ق‬8‫الح‬+‫عمال الشاورما‬
Surgical Treatment
Indications include (primary varicose veins)
 Cosmotic
 Persistent or disabling pain,
 Recurrent superficial thrombophlebitis,
 Bleeding
Surgical procedures
 High ligation of junction

 Stripping Complete excision of the veins

 Multiple Stab-avulsions of Tributaries

Sclerotherapy
 Visual liquid sclerotherapy
 telangiectasias, spider veins,
and small varicosities
 Ethanolamine oleate
Polidocanol injection
 Complications,
This is most common use in nowadays
 allergic reactions
 Thrombophlebitis
 neoangiogenesis,
 skin necrosis
 hyperpigmentation
New methods of treatment
 Foam sclerotherapy
 sodium tetradecyl sulfate or polidocanol
 Transcutaneous laser therapy
 Endovenous Ablation
 Laser or radiofrequency ablation
Klippel-Trenaunay syndrome
 The classic triad is varicose veins, limb hypertrophy,
and a cutaneous birthmark (port wine stain or venous
malformation).
 the deep veins are often anomalous or absent
 saphenous vein stripping can be hazardous.
 extensive varicose veins are encountered in a young
patient—especially if unilateral and in an atypical
distribution (lateral leg)
Klippel-Trenaunay syndrome
SUPERFICIAL THROMBOPHLEBITIS
 Erythema, induration, and tenderness along the
superficial vein.
 Secondary to venous cannulation. (upper limbs)
 spontaneous (lower limbs)
 varicose veins,
 pregnant or postpartum women,
 Estrogen therapy
 Behcet's disease
 Hypercoagulable states
 Malignancy
 The most common vein affected is the greater
saphenous vein and its branches.
 In up to 20% of cases, a simultaneous deep venous
thrombosis exists.
 Areas of induration, erythema, and tenderness
correspond to dilated and thrombosed superficial
veins.
 a firm cord may develop.
 The presence of fever and shaking chills suggests
septic or suppurative phlebitis, which occurs most
commonly as a complication of intravenous
cannulation.
Differential Diagnosis
 ascending lymphangitis,
 cellulitis,
 erythema nodosum,
 erythema induratum,
 and panniculitis.
Treatment
 nonsteroidal anti-inflammatory drugs,
 local heat,
 elevation,
 and support stockings
 In most cases, symptoms will resolve within
7-10 days.
 Septic thrombophlebitis requires treatment with
broad-spectrum intravenous antibiotics.
 Excision of the involved vein is recommended for
symptoms that persist over 2 weeks despite treatment
or for recurrent phlebitis in the same vein segment
 In progressive proximal extension with involvement of
the saphenofemoral junction .
 Anticoagulation
 ligation and resection of the vein at the junction.
 DEEP VEIN THROMBOSIS
 Virchow's triad (stasis, vascular injury, and
hypercoagulability)
 Provoked vs non provoked
&
inknown
known cause
cause
unkown reason
.

* provoked by
* Fracture
or

Truma

post
*
surgery
 Stasis can occur with
 venous insufficiency,
 severe heart failure,
 prolonged bed rest or immobility of an extremity
following coma, prolonged ventilatory support, pelvic or
limb fracture, paralysis,
 extended airplane travel,
 lengthy operation.
 Endothelial injury can result from
 direct trauma (severed vein, venous cannulation, or
transvenous pacing)
 or local irritation secondary to infusion of
chemotherapy,
 previous deep venous thrombosis,
 or phlebitis.
Hypercoagulable state
 Malignancy
 antithrombin 3 and proteins C and S deficiency may be
inherited or may result from nephrotic syndrome,DIC,
or liver failure
 Increased homocysteine,
 factor V Leiden mutation,
Other risk factors
 advanced age,
 type A blood group,
 obesity,
 history of previous deep venous thromboses,
 multiparity,
 use of oral contraceptives,
 inflammatory bowel disease,
 and systemic lupus erythematosus.
 Distal
swelling in
Leg
=

+ pain

Clinical Findings
->
↓
-
& massive & Thigh= proximal
e
kema
2
Asymptomatic
 Distal DVT dull ache or pain in the calf or leg
associated with mild edema.
 Proximal DVT, massive edema, cyanosis,warmness
and dilated superficial collateral veins .
 Iliofemoral venous thrombosis can result in
 phlegmasia cerulea dolens, characterized by
cyanosis of the limb due to venous outflow
obstruction.
 phlegmasia alba dolens, the leg is pulseless, pale,
and cool due to concomitant arterial spasm.
Potential complications
 PE
 As many as 40% of patients have silent PE when
symptomatic DVT is diagnosed[5]
 Recurrent DVT
 Postthrombotic syndrome (PTS)
 Paradoxic emboli (rare)
 Venous gangrene
 -if O No DVT
Lab
:

May
if Q :
not DUT
-> may

 D-Dimer Testing
 high sensitivity (up to 97%);
 relatively poor specificity (as low as 35%) should only be
used to rule out DVT, not to confirm the diagnosis of
DVT.
 Other causes of raised D-Dimer
 recent surgery, trauma, infection, heart disease, liver disease.
 Coagulation Profile 6
if -it
2

DUI or not

-
DS
Imaging Studies
 Duplex ultrasound
 less accurate in detection of calf thromboses and is
highly operator-dependent.
 Sensitivity
 below knee <50%
 Above knee 80 – 90 %
 Venography
 CT venography
 MRI venography
Differential Diagnosis

 Localized muscle strain or contusion

 Achilles tendon rupture
 Cellulitis
 lymphedema,
 obstruction of the popliteal vein by Baker's cyst
 obstruction of the iliac vein by retroperitoneal mass or
idiopathic fibrosis.
 Bilateral leg edema suggests heart, liver, or kidney
failure or inferior vena cava obstruction by tumor or
pregnancy
Treatment
 Systemic anticoagulation.
 does not directly lyse thrombi but stops propagation
and allows natural fibrinolysis to occur
 Lower limb elevation
 Elastic stocking
 Heparin is initiated immediately
 Warfarin is started after therapeutic heparinization
 first episode of uncomplicated deep venous
thrombosis is 3-6 months of warfarin, maintained at a
goal international normalized ratio (INR) of 2.0-3.0
 New
with Guidlines (Rivaroxaban) >

give the
pt=Thraputic bose ->
(Discharge)

 After a second episode of deep venous thrombosis, the

usual recommendation is lifelong warfarin
 LMWHs ---lower risk of bleeding complications and
thrombocytopenia,
 Factor Xa Inhibitors (Fondaparinux, Rivaroxaban)

xaban
if the pet sever has (phleymasia)
-

<
↑ s vo

E
55 observation ins
E
+Rivaroxaban for

for the periode further mangment problem is

& Treatment COSt

=
the
Massive Proximal DVT treatment
 Fibrinolytic agents
 acute iliofemoral venous thrombosis complicated by
massive extremity edema, cyanosis, or calf compartment
syndrome
 Surgical Iliofemoral thrombectomy
 Aspiration thrombectomy
inferior vena cava filters
 Confirmed acute proximal DVT or acute PE in patients
contraindicated for anticoagulation
 Recurrent thromboembolism while on anticoagulation
 Active bleeding complications requiring termination
of anticoagulation therapy
 Duration of treatment
 Patients with a first thromboembolic event in the context of a
reversible or time-limited risk factor (eg, trauma, surgery) should be
treated for three months.
 Patients with a first idiopathic thromboembolic event should be
treated for a minimum of three months. Following this, all patients
should be evaluated for the risk/benefit ratio of long-term therapy.
 Indefinite therapy is preferred in patients with a first unprovoked
episode of proximal DVT who have a greater concern about recurrent
VTE and a relatively lower concern about the burdens of long-term
anticoagulant therapy.
 In patients with a first isolated unprovoked or provoked episode of
distal DVT, three months of anticoagulant therapy, rather than
indefinite therapy, appears to be sufficient.
 Most patients with advanced malignancy should be treated indefinitely
or until the cancer resolves.
Prevention
 Surgery increases the risk of deep venous thrombosis
21-fold.
 This disorder is a reported complication for
 20% of patients admitted for a general surgical
procedure,
 24% of those undergoing an elective neurosurgical
procedure,
 50-60% of those undergoing hip or knee arthroplasty.
Prevention
 early ambulation
 elastic stockings
 Pneumatic compression devices (PCD)
 low-dose unfractionated heparin,
 5000 units subcutaneous injection
 2 hours befor surgery ,
 2-3 times daily
 LMWH given at a prophylactic dose
 Combination therapy – LMWH or low dose UH with
PCDs
RISK FACTORS FOR VTE (One Point
Each)
Duration >1 Hour History of VTE Congestive heat failure
Pelvic Procedures Age >40 Myocardial infarction
Immobility Hormone replacement
therapy
Varicose Veins Oral Contraceptive Use
Cancer Multiparity (3)
Chronic Renal Failure Inflammatory bowel
disease
Obesity Severe infection
Peri-partum
 LEVEL OF
RECOMMENDATION/
PROCEDURE RISK FACTORS RECOMMENDATION LEVEL OF EVIDENCE
None, PCD’s, UH or
Lap Chole 0 or 1 LMWH C; II,III

Lap Chole 2 or more PCD’s, UH or LMWH C; II,III

None, PCD’s, UH or
Lap Appy 0 or 1 LMWH C; II,III

Lap Appy 2 or more PCD’s, UH or LMWH C; II,III

Diagnostic Lap 2 or more PCD’s, UH or LMWH C; II,III

Lap Inguinal H 2 or more PCD’s, UH or LMWH C; II,III

Lap Nissen 0 or 1 PCD’s, UH or LMWH B/II

PCD’s AND UH or
Lap Nissen 2 or more LMWH B/I, II

Splenectomy 0 or 1 PCD’s, UH or LMWH B/II

PCD’s AND UH or
Splenectomy 2 or more LMWH B/II

Other Major Lap

Procedures: Roux-Y, PCD’s AND UH or

etc 0 or more LMWH B/III