Venous and Lymphatic Disease

VENOUS AND LYMPHATIC DISEASE

VENOUS FLOW: FACTORS

Upright position Left ventricular force

( gravity ) ( vis a tergo )

High volume, low Calf muscles

pressure circu- Venous valves in

lation lower extremities

Intra-abdominal Smooth muscles in

pressure superficial veins

THE VASCULAR CONSULTATION

• Painful extremity

• Swollen extremity

• Ulcerated leg

THE PAINFUL LOWER EXTREMITY

• No characteristic pain in venous

disease

• Aggravated by standing

• Relieved by elevating leg and foot

PAIN

• Varicose veins discomfort

Pulling Burning

Pricking Tingling

• Superficial Thrombophlebitis

inflammation

Tenderness Warmth

Redness Induration

PAIN

• Venous thrombosis

- little or no pain

- moderate aching discomfort or

sensation of heaviness

- “bursting” pain uncommon

venous claudication

THE SWOLLEN LEG

• High venous pressure

• Cardiac

intrinsic

• Venous obstruction

extrinsic

• Gravitational pressure

- effect on incompetent valves

THE SWOLLEN LEG

• Pressure

• Protein

• Permeability

• Paresis

• Pendency

EDEMA

• Central / systemic

Pitting; no skin changes

• Peripheral venous

Does not pit readily

Chronic brawny dermatitis

stasis dermatitis

gaiter distribution

EDEMA

• Lymphedema

Diffuse

Spongy

Hypertrophic skin Elephantiasis

THE ULCERATED LEG

• Stasis ulcer

• Gaiter area – around medial

malleolus

• Mild pain relieved by elevation

• Venous bleeding / oozing

• Stasis dermatitis

• Shallow, irregular with granulating

base

SUPERFICIAL THROMBOPHLEBITIS

• Local inflammatory process

• Usually aseptic

• Etiology: acidic fluid infusion

prolonged cannulation

contrast injection

varicose veins

• Treatment: bed rest, elevation

local heat

support hose / stockings

DEEP VENOUS THROMBOSIS

• Virchow 1856

1. Stasis

2. Endothelial damage

3. Hypercoagulability

DEEP VENOUS THROMBOSIS: RISK FACTORS

• Pregnancy

• Obesity

• Malignancy

• Trauma

• Sepsis

• Major surgery

• Other disease states – DIC, Poly-

cythemia, Dysfibrinogenemia,

Anti-thrombin III deficiency

ORIGIN OF DVT

• Usually from the lower extremity, starting at the calf level going proximally; source of 80-90% of pulmonary emboli

• Pelvic veins

• Renal veins

• Inferior vena cava

• Ovarian veins

• Upper extremity and neck veins

• Right atrium

DVT: CLINICAL MANIFESTATIONS

• Classic clinical syndrome Calf or thigh pain Edema Tenderness (+)Homan’s sign • Nonspecific; associated with veno- graphically proven DVT in only 50% • Conversely, 50% of those with DVT have no associated physical findings

DEEP VENOUS THROMBOSIS

• Pulmonary embolism is a common

presenting symptom in many patients

• Need to rule out the presence of arterial insufficiency

LOWER EXTREMITY DVT: CLINICAL MANIFESTATIONS

• Phlegmasia alba dolens

pain, pitting edema, blanching

pregnancy-related

• Phlegmasia cerulea dolens

loss of sensory and motor function

cessation of arterial flow

venous gangrene

DEEP VENOUS THROMBOSIS: DIAGNOSIS

• Radioactive-labelled fibrinogen

• Doppler ultrasound

• Impedance plethysmography

• Venography

• Venous duplex scan

TREATMENT OF DVT

• PREVENTION !

- Identify risk factors

- Prophylaxis

Early ambulation

Anticoagulation heparin

Intermittent pneumatic

compression

TREATMENT OF DVT

• Treatment

- Anticoagulation

Heparin Warfarin

Low molecular weight heparin

- Fibrinolysis

Urokinase / streptokinase

TPA

- Operative

OPERATIVE TREATMENT OF DVT

• Thrombectomy

• Vena caval interruption

Greenfield filter

PULMONARY EMBOLISM

• Obstruction to blood flow in the pulmonary arterial system due to thromboemboli pulmonary hypertension, decreased cardiac output, impaired gas exchange / oxygenation, sudden death

• One of MOST COMMON CAUSES OF SUDDEN DEATH in hospitalized patients

PULMONARY EMBOLISM

• Only around 10% are diagnosed PREMORTEM

• > 90% of deaths occur within 2 hours of the onset of symptoms

• Associated with DVT in up to 40%; around 30% have no symptoms of DVT

PULMONARY EMBOLISM: RISK FACTORS

• Pregnancy

• Estrogen therapy

• Obesity

• Heart disease

• Malignancy

• Major trauma

• Previous episode of PE

• Varicose veins

• Advanced age

PULMONARY EMBOLISM: SYMPTOMS

• Classic signs – only in 25%

Hemoptysis

Pleural friction rub

Gallop rhythm

Cyanosis

• Common findings: tachycardia, tachypnea, dyspnea; arrythmias; pulmonary effusion or infiltration (infarction); hypoxemia on ABGs

Massive pulmonary embolism

Pulmonary infarction

CHF

Shock

PULMONARY EMBOLISM: DIAGNOSIS

• Pulmonary radio-isotope scanning

Perfusion scan

Ventilation scan

Ventilation / perfusion scan

• Pulmonary arteriography

Gold standard

PULMONARY EMBOLISM: MANAGEMENT

• Cardiovascular support / critical care

• Anticoagulation

• Thrombolytic therapy

• Pulmonary embolectomy

ANTICOAGULATION THERAPY: COMPLICATIONS

• Major hemorrhage

• Heparin-induced thrombocytopenia

Hemorrhage

Necrosis

• Recurrent pulmonary embolism

VARICOSE VEINS

• Primary

Familial

Favorable prognosis with medical or

surgical treatment

• Secondary

Due to deep venous disease

Stasis dermatitis or ulceration

VARICOSE VEINS

• Local pain and edema

Nonspecific ache or heaviness

Relieved by elevation of leg

• Local inflammation

• Local hemorrhage into surrounding tissues

• Dilated superficial veins

• Positive Trendelenburg test

VARICOSE VEINS

• Diagnostic aids

Doppler ultrasound / duplex scan

Venous reflux plethysmography

VARICOSE VEINS: TREATMENT

• Conservative unless:

Venous stasis

Dermatitis

Bleeding

Thrombosis / phlebitis

Superficial ulceration

• Injection sclerotherapy

• Surgery – vein stripping

• Endovenous procedures

Laser ablation

Radiofrequency ablation

CHRONIC VENOUS INSUFFICIENCY

Deep venous thrombosis

Post-thrombotic syndrome

Recanalization

Valve damage

Valve incompetence

CHRONIC VENOUS INSUFFICIENCY

• Fluid, protein extravasation

• Thickened, sclerotic subcutaneous tissues ( Brawny edema )

• Hemosiderin pigmentation

• Skin atrophy, necrosis, stasis ulceration

• Dermatitis, cellulitis

• If no recanalization venous claudication

CHRONIC VENOUS INSUFFICIENCY

• Compression tests

Trendeleburg

Perthes

Ochsner-Mahorner

• Laboratory

Plethysmography

Duplex scanning

TREATMENT OF CVI

• Supportive – elastic stockings

frequent leg elevation

avoid prolonged

standing or sitting

• Operative – perforator vein ligation

venous reconstruction

LYMPHEDEMA

• Swelling of one or more extremities caused by lymphatic obstruction or insufficiency

• Primary vs secondary

PRIMARY LYMPHEDEMA

• Congenital – present at birth

10% of cases

hereditary – Milroy’s

disease

• Lymphedema praecox – from puberty;

most common type

• Lymphedema tarda – after 30s

SECONDARY LYMPHEDEMA

• Malignancy

• Radiation

• Trauma

• Inflammatory

• Parasitic elephantiasis ( Wuchereria bancrofti )

LYMPHEDEMA

• Diagnosis – confirmed by lymphangiogrphy

• Treatment

- limb elevation, weight reduction,

salt restriction

- compressive stockings

- surgery: dermal flap

omental transposition

microsurgical anastomosis