VENE
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Transcript of VENE
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VENE
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Anatomie• Vene profundeVene profunde( omonime arterelor)
• Vene de legaturaVene de legatura
- anastomotice intre vene profunde
intre tr safene(v Giacomini)
pe aceeasi vena
- comunicante directe
indirecte
- plonjante Delater
• Vene superficialeVene superficiale
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• In cazul venelor de legatura rol important vene :
1.ComunicanteComunicante
- safeno femural
- hunterian( Sherman)
- safeno popliteu( Linton Dodd)
- punct solear
- triceps sural
- 1/3 infero intern al gambei( Cockett)
2.Plonjante DelaterPlonjante Delater
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Fiziologie
• 2 functii
- circulatie de intoarcere
- rezervor de sange
• viteza de circulatie 10cm/s
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Fiziologie
• Factori favorizanti
1. Pres sist reziduala( vis a tergo)
2. Contractia musculara
3. Joc valvular
4. Aspir.toracica( vis a fronte)
5. Venomotricitatea
• Factori defavorizanti
1. Forta gravitationala
2. Vascozitatea
3. Presa abdominala
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Fiziologie
• 80-90% din sangele venos prin sist profund• in repaus pres in 1/3 gamba este 90 cm H2O
in miscare scade la 20 cm H2O si creste dupa 1-2 min
• repaus valve intredeschise este masurata inaltimea coloanei de sange
• in miscare valvele sunt eficiente si nu lasa singele sa cada
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Etiologie
I. Varice secundare( castigate)
- compresiune tumori abdominale
- trombozelor profunde
- traumatisme
1. Valvei ostiale
2. Fistule a-v posttraumatice
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Etiologie
II. Primitive
1. Congenitale1. Congenitale
- sdr Klippel Trenaunay creste in lungime
varice importante
nevi vasculari
- sdr Parkes Weber fistula a-v
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Etiologie
2. Castigate2. Castigate
- graviditate
- obezitate
- ortostatism
- caldura
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Patogenie
• Varice secundare
- compresiune creste presiunea venoasa
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- traumatisme distructie valvulara
- tromboza profunda- creste pres
- repermeabilizari
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Patogenie
• Varice primitive exista 3 teorii
- Mecanica anatomia venelor fara suport muscular
forta gravitationala
- Anatomopatologica lez parietale
- Hidrostatica cresterea presiunii venoase
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Anatomie patologica
• MacroscopicMacroscopic
modif de calibru
alungirea venei
hipertrofie
in final se subtiaza
neregulata dilatata
calcificari
periflebita
• MicroscopicMicroscopic
hiperplazie endoteliu inlocuit de colagen
tunica mijlocie hipertrof musculara
adventice lez nervoase si vasa vasorum
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Anatomie patologica
• Initial dezv tunicii musculare si cele circulare
• zone de atrofie scleroasa
• astfel dispare progresiv tunica medie si interna sunt inlocuite de tracturi fibroase
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Anatomie patologica
• Leziuni asociateLeziuni asociate
- tegumente sclerozeaza, keratinizare
- vene aderente de derm
- scleroza vaselor limfatice, arteriole, nervi
- alterarea limfaticelor agraveaza edemul
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FiziopatologieVARICE• Stagnarea sangelui in venele dilatate• insuf valvulara flux retrograd= cerc vicios• staza in sist superficial= efort in sist profund• munca suplimentara cu 10-20%• vene profunde se dilata devin insuficiente• comunicante insuficiente tulb trofice
INSUFICIENTA VENOASA CRONICA
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Fiziopatologie
SINDROM POSTTROMBOTIC
• Sist profund afectat de la inceput
• Distructii valvulare
• Recanalizari uni-plurivanalare
• Creste presiunea in sist profund explicata prin manometrie
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Fiziopatologie Manometrie
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Tablou clinic
• Stadiul de debut
- greutate in gamba
- accentuare in ortostatism
• Varice constituite
- greutate
- varice constituite
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Tablou clinic
• Interogatoriu
- evolutie
- eventuala tromboflebita in antecedente
• Examenul obiectiv
- inspectia
- palpare semnul Schwartz
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Tablou clinic
• Metode de explorare
- Proba Brodie Trendelenburg reflux ostial
- Proba celor 3 garouri Mahorner-Ochsner
- Proba Perthes
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Paraclinic• Neinvaziv
- Doppler
- Duplex
- Fotopletismografia
- Pletismografia
• Invaziv
- Flebografia
- Flebomanometria
- Flebo CT
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Esential pentru diagnostic
• Vene dilatate sinuoase
• Simptomatologie saraca
• Semne specifice insuf cronice
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Diagnostic diferential
• Varice primare - secundare
• Insuficienta venoasa cronica - sindrom posttrombotic
• Alte afectiuni
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Evolutie Complicatii
• Insuficienta venoasa cronica
• Tromboflebita varicoasa
• Rupturile varicelor
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HIPODERMATITA
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DERMATITA HIPERCROMA
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ULCER
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Tratament• Profilactic
- gimnastica la locul de munca
- compresiune externa• Curativ Scleroterapie
- agenti sclerozanti+compresiune externa• Chirurgical Safenectomie prin stripping (Babcock)
Safenectomie totala(Terrier-Alglave)
Operatia Linton
Modern valvuloplastii, mansonari, endochirurgia, terapie laser
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BOALA TROMBOEMBOLICA
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Cauze• Triada lui VIRCHOW
- leziunea parietala
- staza venoasa
- hipercoagulabilitatea
• Factori favorizanti
- exogeni
- endogeni
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• Varsta peste 40 ani • Sex masculin • Obezitate • Neoplazii • Istoric DVT sau de embolie • Proceduri chirurgicale Orthopedie, Neurochirurgie, Urologie; peste 2 ore • Graviditate • Contraceptive orale • Sindrom nefrotic • Lupus • Disfibrinogenemia • Deficiente cu potential genetic Proteina C Proteina S Antitrombin III Plasminogen • Abuz de droguri
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Anatomie patologica
• Tromb alb
• Tromb rosu
• Tromb mixt
• Flebotromboza embolie pulmonara
• Tromboflebita propriu zisa
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Tablou clinic
• Perioada de debut
• Perioada de stare
semne generale
semne functionale
semne de laborator
semne locale
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Tablou clinic
semne generale cr temperatura(semn Mikaelis)
accelerare de puls(puls catarator Mahler)
semne functionale durere spontana in molet neliniste, agitatie, impotenta fct.
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Tablou clinic
semne locale
- vena pretibiala dilatata semn Pratt
- semn Payr
- semn Tschmarke(compresia gambei)
- semn Homans( dorsoflexia piciorului)
- creste temperatura local
- edem dur fara godeu
- creste diametrul gambei
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Paraclinic
• Neinvaziv
- doppler, duplex
- pletismografia
• Invaziv
- flebografia
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Forme clinice• Localizare
- superficial
- profund gambiera
popliteo-femurala(phlegmatia alba dolens)
ileo-femural(phlegmatia coreulea dolens)• Particulare
- intraabdominale
- migratorie
- mbr superior(Paget-Schroetter)
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Evolutie, Complicatii
• Stadiala
• Embolia pulmonara
• Gangrena venoasa
• Sindrom posttrombotic
- org fibroconjunctiva
- repermeabilizare uni-pluricanalara
- distructie valvulara hiperpresiune
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Tratament
• Profilactic
FFI bolnavi cu risc
compresiune externa
doze mici de heparina(Kakkar) 5000U/8h s.c.
enoxaparina, calciparina, clivarin
mobilizari precoce
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Tratament• Curativ
- anticoagulant continuu 1000U/h
discontinuu 10000U bolus
5000U la 4 ore
- fibrinolitic general strepto-urochinaza
local• Chirurgical
- trombectomie cu sonda Fogarty
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Embolia pulmonara
• Mici
• Mijlocii
• Mari
• Fiziopatologic
- teorie mecanica
- teorie reflexa
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• Creste rezistenta in arterele pulmonare
• creste presiunea arteriala pulmonara
• creste lucrul inimii drepte
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Tablou clinic
• Durere toracica
• Dispnee
• Hemoptizie
• Tahicardie, tahipnee
• Cianoza
• Frecatura pleurala
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Paraclinic
• Rx normal
• Scintigrafie
• Arteriografie
• EKG inversare de unda T
aplatizare de segment ST
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Tratament• Faza acuta
- profilaxia
- medicamentos anticoagulant heparina
fibrinolitic
general urokinaza 4400U iv bolus
4400U/kg/h 12ore
streotokinaza 250000U iv 30 min
100000U/h 24ore
r-tPA 90- 100mg iv 6-7 ore
local
- chirurgical trombectomie directa
indirecta
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TratamentRecidivante
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