Venous Disorders Of The

Lower Limb
Venous Thromboembolism

Deep Vein Pulmonary

Thrombosis Embolism
ENDOTHELIAL INJURY STASIS

HYPERCOAGULABILITY

VIRCHOW’S TRIAD
RISK FACTORS
STASIS HYPERCOAGULABILITY ENDOTHELIAL INJURY
• Immobility • Cancer • Surgery
• Heart failure • Obesity • Prior VTE
• Venous insufficiency • High oestrogen states (COCP, • Central line
Pregnancy) • Trauma/Fracture
• Sepsis
• Smoking
• Thrombophilia
• IBD
HISTORY
• Sudden pain and swelling at the calf
• Warmth and erythema
• Usually unilateral, but can be bilateral
• Worsening on standing or walking, relieved by
rest
• Symptoms of pulmonary embolism:
• Dyspnea
• Pleuritic chest pain
PHYSICAL EXAMINATION
• Examination of legs, abdomen and pelvis
• Look for:
• Dilated superficial veins
• Unilateral edema, warmth, tenderness, erythema
• Pain and tenderness along the course of the involved major veins
• Difference in calf or thigh diameter (Goodacre, Sutton, & Sampson, 2005)
 FBC – haematocrit, platelet
count
ESR, d-dimer
INVESTIGATION
Coagulation profile

Duplex ultrasound, CT
pulmonary angiogram
Wells Score

High probability
3-8 Points:
of DVT
Moderate
1-2 Points:
probability

-2-0 Points: Low Probability

MANAGEMENTS
• S/C LMWH, e.g: Clexane 1mg/kg BD or 1.5 mg/kg OD
• Thromoblysis, e.g: tPA, urokinase
• Stenting
• Venous thrombectomy
• Encourage patient to walk
CHRONIC VENOUS INSUFFICEINCY
• Refers to the presence of edema, skin changes or ulceration
• Most commonly associated with chronic venous reflux due to
• Obstruction of venous flow (tumour, DVT, pregnancy)
• Dysfunction of venous valve (varicose vein)
• Failure of venous pump (muscle weakness, stroke)
 Manifestation of Venous Insufficiency
Venous Dilatations Oedema - pitting
• Telangiectasia
• Reticular vein
• Varicosities

Skin changes Venous ulcer formation

• Hyperpigmentation
• Atrophic blanche
• Venous stasis eczema
• Lipodermatosclerosis
• Cellulitis
CEAP Classification of Chronic Venous Insufficiency
Investigations
• Color-flow duplex Doppler
ultrasound (GOLD)
• ABSI
Managements
• Support and compression of skin – graduated compression
stockings
• Ankle 40 mmHg, reduce upward
• Ulcer management
• Proper wound care
• Cellulitis – systemic antibiotics
• Venous surgery – superficial venous incompetence
Long-term care & Preventions

01 02 03
Continue Take care, avoid Apply moisturizer
compressive even minor trauma, to dryness or
stockings especially to the flaking of the skin.
gaiter area above
medial malleolus
Difference of Arterial & Venous Ulcers
References
• Browse, N. L. (1991). An introduction to the Symptoms and Signs of
Surgical Disease. (1991)
• https://www.uptodate.com/contents/deep-vein-thrombosis-dvt-
beyond-the-basics
• Wells PS, Anderson DR, Bormanis J, et. al. Value of assessment of
pretest probability of deep-vein thrombosis in clinical
management. Lancet. 1997 Dec 20-27;350(9094):1795-8.