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M.A.Kubtan1 MD FRCSwww.surgi-guide.com

1st lecture

Peripheral Vascular Disease

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ContinueContraceptive hormonal therapyM.A.Kubtan16

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Clinical FeaturesVVs rarely cause sever symptoms .Aching in the veins at the end of the day after prolonged standing .Ankle swelling .Itching .Bleeding .Superficial thrombophlebitis .Eczema .Lipodermatosclerosis .Ulceration .M.A.Kubtan20M.A.Kubtan21

LipodermatosclerosisEczema Eczema UlcerationUlcerationLipodermatosclerosis

UlcerationSigns of varicose veinsThe termination of long and short saphenous veins must be palpated .The presence of dilated trunk can be rolled back and forth .Percussion over the VVs may elicit an impulse tap by the fingers .A large VVs in the groin ( saphena varix ) may be visible .Gentle palpation during coughing may elicite a cough thrill . M.A.Kubtan22M.A.Kubtan23Saphena varix

M.A.Kubtan24A torniquet testTrendilenburg test

InvestigationTourniquet test .Standared doppler examination .Duplex ultrasound imaging .Varicography .Venography .M.A.Kubtan25M.A.Kubtan26Duplex ultrasound imaging

M.A.Kubtan27VVs connecting long and short SVVaricogram

Perforator joining long SV to deep veinsM.A.Kubtan28Venogram

Management of patients with varicose veinsPrevention ( avoid lengthy standing ).Supportive measures (encourage exercises) .Elastic stockings ( lower pressure 30 , higher pressure 12 ).Sclerotherapy . Ultrasound-guided foam sclerotherapy.Surgery ( stripping of long or short saphenous vein ,avulsion of varicose tributaries , ligation of perforators ) .

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M.A.Kubtan32Avulsion

Alternative technique Radiofrequency ablation ( using radiofrequency to destroy the endothelial lining ).Laser to cause endothelial damage .Endovenous laser ablation .M.A.Kubtan33M.A.Kubtan34

Radiofrequency ablation M.A.Kubtan35Laser treatment for spider veins

Complication of VVs surgeryBruising .Sensory nerve injury ( saphenous nerve , sural nerve ).Recurrence .M.A.Kubtan36 M.A.Kubtan37 MD FRCSwww.surgi-guide.com

2nd lecture

M.A.Kubtan38Venous thrombosisVenous thrombusIs the formation of a semi-solid coagulum within flowing blood in the venous system .Venous thrombosis of the deep veins of the legs is complicated by the immediate risk of pulmonary embolus and sudden death. Subsequently , patients are at risk of developing a post thrombotic limb and venous ulceration .M.A.Kubtan39Aetiology Virchow triad Changes in the vessel wall ( endothelial damage ) .Stasis, which diminished blood flow through the veins .Coagulability of blood ( thrombophilia ) .M.A.Kubtan40Risk factors for venous thromboembolisim Patients factors :Age .Obesity .Varicose veins .Immobility .Pregnancy .Puerperium .High-dose oestrogen therapy .Previous deep vein thrombosis .Pulmonary embolism .Thrombophilia .M.A.Kubtan41Continue Disease or surgical procedure :Trauma or surgery of pelvis, hip and lower limb .Malignancy , pelvic and abdominal metastasis Heart failure .Recent myocardial infarction .Paralysis of lower limb(s).Infection .Dehydration .

M.A.Kubtan42Continue Other risk factors Inflammatory bowel disease .Nephrotic syndrome.Polycythemia .Paroxismal nocturnal haemoglobinuria antibody or Lupus Anticoagulant .Behcet,s disease .Homocystinaemia.M.A.Kubtan43M.A.Kubtan44 Clinical Pathology A thrombus often develops in the soleal veins of the calf .Initially as a primary platelet thrombus ( aggregate ). Coralline thrombus . Occluding thrombus .Consecutive clot to the next venous tributary.

M.A.Kubtan45Methode of propagation in phlebothrombosisWith thrombus formation at each entering tributary.Clotting mass in an extensive length of vein propagated clot .

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Pulmonary embolism The embolus arising from the lower leg veins becomes detached , passes through the large veins of the limb and vena cava . Through the right heart ( heart occlusion ) . Lodges in the pulmonary arteries . Massive pulmonary embolus (total occlusion of pulmonary trunk) . Partial pulmonary embolus affecting Rt or Lt pulmonary arteries .Recurrent micro emboli . Pyramidal shape infarcts . M.A.Kubtan47Clinical Symptoms of DVTThe most common presentation of DVT is :No symptoms .Pain in the calf muscles .Swelling in the calf muscles .May present with sudden symptoms of pulmonary embolism (pleuritic chest pain , haemoptysis , shortness of breath ) .Bilateral DVT are relatively common occurring in 30% M.A.Kubtan48Clinical signs of Iliac femoral vein thrombosis Swelling involving the whole length of lower limb .Phlegmasia alba dolens .Phlegmasia cerulia dolens .Venous gangrene . M.A.Kubtan49Phlegmasia alba dolens PADWhen the thrombosis involves only major deep venous channels of the extremity sparing collateral veins . The venous drainage is decreased but still present .These phases are reversible if proper measures are taken.

M.A.Kubtan50Phlegmasia cerulia dolens PCDThe thrombosis extends to collateral veins, resulting in venous congestions with massive fluid sequestration and more significant edema .Without established gangrene .These phases are reversible if proper measures are taken.M.A.Kubtan51Physical signs of DVT May be absent or ephermeral .Mild pitting oedema of the ankle .Dilated surface veins .Stiff calf and tenderness over the course of deep veins .Homans sign ( resistance of calf muscles to forcible dorsiflexion ) might be misleading .Low grade pyrexia may be present , especially in a patient who is having repeated pulmonary emboli.Patient may develop signs of cyanosis and dyspnoea , raised neck veins , split second heart sound , pleural rub in PE . M.A.Kubtan52A foot with venous gangrene . The gangrene is symmetrical involving all the toes .There is no clear cut edge and there is marked oedema of the foot . M.A.Kubtan53

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InvestigationM.A.Kubtan55 Early Diagnosis of DVTD-dimer is a fibrin degradation product (FDP ) .D-dimer is a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.D-dimer measurment if withen normal range it rules out the diagnosis of DVT or Pulmonary embolus and there is no indication for further investigation .If raised , a duplex ultrasound examination of the DVT .Ascending venography ( now rarely required ) .

Transverse section of duplex scan of vein containing a thrombus M.A.Kubtan56

An ascending venogram of DVT seen as filling defects ( arrows ) with contrast passing around the thrombusM.A.Kubtan57

Diagnosis of pulmonary embolus Ventilation-perfusion scanning , which mismatched defect .Computerised tomography CT .Pulmonary angiography ( rarely required ).M.A.Kubtan58MAK59

Ventilation perfusion lung scan showing unmatched filling defects on the perfusion scan .(a) Ventilation , (b) Perfusion .M.A.Kubtan60

CT scan showing pulmonary emboli as a filling defects in the pulmonary artery. M.A.Kubtan61

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M.A.KubtanThe differential diagnosis of DVTRuptured Baker,s cyst .Calf muscle haematoma .Ruptured plantaris muscle .Thrombosed popliteal aneurysm .Arterial ischaemia .M.A.Kubtan6464Classification of risky patients Low risk : young , minor illnesses , who are to undergo 30 min or less surgery .Moderate risk : over the age of 40 ,or those with debilitating illness who are to undergo major surgery .High risk : those who are over the age of 40 , who have serious accompanying medical condition ( stroke , MI , past history of DVT , known malignant disease ) .M.A.Kubtan65Prevention and prophylaxis Mechanical approach .Pharmacological approach .M.A.Kubtan66Mechanical approach Lower limbs elevation .Graduated elastic compression stockings .External pneumatic compression pump .M.A.Kubtan67M.A.Kubtan68Anti embolism thigh compression stockings Anti embolic knee compression stockings

External pneumatic compression M.A.Kubtan69

Pharmacological approachMore effective than mechanical method in reducing the risk of thrombosis .They carry an increased risk of bleeding .Most patients at risk should start on low molecular weight Heparin given subcutaneously .The amount of given heparin based on the patients body weight .This treatment does not require PTT monitoring ,and has reduced risk of developing thrombocytopenia.It can be given once daily and has lower risk of bleeding . M.A.Kubtan70Treatment of a deep vein thrombosisIntravenous sodium heparin by heparin pump after loading dose and PTT monitoring . Subcutaneous low molecular heparin without PTT monitoring .Rapid oral anticoagulation with warfarin .Warfarin given loading dose for 3 days after measuring prothrombin time .Complete bed rest followed by ambulation .M.A.Kubtan71Thrombolysis of DVT By using streptokinase or uorokinase .Should be considered in patients with an iliac vein thrombosis if they are seen in the early stages .When the limb is extremely swollen . M.A.Kubtan72Invasive approach to DVT Rarely carried out in Iliac and femoral vein thrombosis In case of patient with the risk of developing venous gangrene .In patient developing phlegmasia cerulia dolen .If it,s been performed it should be accopmpanid by arterio-venous fistula at the PT level . Trans venous stent deployment .Greenfield umbrella .M.A.Kubtan73MAK74

Treatment of pulmonary embolusMultiple and recurrent micro emboli's can be treated by anticoagulation and observation .Those with sever onset who develop sever heart strain and shortness of breath indicates the need for fibrinolytic treatment .Surgical pulmonary embolectomy may not save the patient from his or her fate . M.A.Kubtan75Superfacial thrombophlebitisImplies a major inflammatory component .Common causes include external trauma especially to VVs .Venopuncture and infusion of hyperosmolor solution and drugs .Thrombo angitisobliterance ( Buerger disease) M.A.Kubtan76 M.A.Kubtan77 MD FRCSwww.surgi-guide.com

3rd lecture

Leg Ulceration Venous disease is responsible for 60 70% of legs ulcers .Arterial iscaemic ulcers.Rheumatoid ulcers .Traumatic ulcers .Neuropathic ulcers ( Squamous cell carcinoma and Basal cell carcinoma ) .M.A.Kubtan78Aetiology of ulceration Ambulatory venous hypertension regarded as the cause of ulceration.The venous hypertension may be the result of primary valve incompetence .Incompetence of the perforating veins .Obstruction of deep veins. M.A.Kubtan79Clinical featuresA venous ulcer has gently sloping edge and the base contains granulation tissue .Any elevation of the ulcer edge should indicate the need for biopsy .Venous ulcer of the leg usually develop in the skin of the gaiter region , which is rich in perforators .M.A.Kubtan80ContinueThe majority ob venous ulcers develop on the medial side of the calf .Ulcers associated with lesser saphenous incompetence often develop on the lateral side of the leg .Ulcer can develop on any part of the calf skin in patients with post DVT syndrome .Venous ulcer rarely develop on the foot or into the upper calf.Almost all venous ulcers have surounding lipodermatosclerosis . M.A.Kubtan81M.A.Kubtan82Venous ulcer at the gaiter areaMarjolin ulcer arising from venous ulcer

InvestigationDuplex scan .Full blood count .ESR .CRP .Sickle cell test .Bipedal ascending phlebography ( detection of DVT ) .M.A.Kubtan83Management Elevation of legs .Bandaging ( Elastic compression bandage ) .Excision and grafting .Biological dressing .( amniotic membrane ) . Skin graft .M.A.Kubtan84Congenital anomalies Aplasia .Hypoplasia .Duplication.Persistance of vestigeal vessels.M.A.Kubtan85M.A.Kubtan86

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