Venous diseases Zsolt Pécsvárady [email protected] Pécs.
-
Upload
dorcas-golden -
Category
Documents
-
view
217 -
download
0
Transcript of Venous diseases Zsolt Pécsvárady [email protected] Pécs.
VV. saphaena maga. saphaena magaVV. saphaena parva. saphaena parva
Main Main perforaperforatorstors
Deep veinsDeep veins
I. Superficial thrombophlebitis
II. Deep venous thrombosis and pulmonal embolisation
III. Chronic venous insufficiency CVI
- Varicophlebitis / -thrombosis- Septic thrombophlebitis- Catether phlebitis- Flebitis migrans: Unknown origin in different location. Together with cancer, autoimmun or Buerger diseases.- Mondor disease: Unknown origin with spontaneous healing. associate with pancreas diseases.
I. Superficial thrombophlebitis
Hard, palpable veins. As these veins are not not flexible: stretching is painful
It is a painful but not dangerous disease with quick recovery.
II. Sign and symptoms of deep venous thrombosis
- Oedema of dependent leg- Pain- Cyanosis- Shining skin- Superficial collateral veins- Acut developement of the symptoms- Pain to press of deep veins, muscles around them- „Cord” feeling of thrombotic vein- Dorsalflexion of calf can cause pain in the gastrocnemic muscles ( Homans-sign ) - Inflate of the BP meter (on both calves) can cause pain in the dependent leg (Lowenberg jel)
Probability of DVT based on medical history and physical exmination
Clinical condition Score • active cancer 1 • plegia, plaster in the near past 1 • immobility or maior operation in the near past 1 • pressure sensitivity in the location of deep veins 1 • swelling of the whole leg 1 • >3 cm difference between the diameter of calves 1 • oedema 1 • collateral superficial veins 1 probability of other diagnosis -2
High probability >3; medium probability 1-2; Low probability 0
(Wels és munkatársai Lancet 1997; 350-1795)
Non invasive diagnosis of DVT
CUS= compression ultrasound test
Negative predictive value for proximal DVT is 98%
for distal DVT is just 40%
Low probability medium probability high probability 3-10% 15-30% >70% CUS negativ CUS negativ -D-dimer + D-dimer + D-dimer DVT can exclude DVT p value 3-5% DVT p value 20-30% without CUS
repeat CUS repeat CUS
Risk factors for DVT I.
• major orthopedic surgery ( hip, knee )
• malignant disease
• trauma, postoperative condition
• DVT or PE in medical history
• immobilization
• heart attack, heart failure
• stroke or paralysis
• infections, sepsis
Risk factors for DVT II.
• Age older than 40 yrs
• Obesity
• Varicositas
• Oral contraceptive, oestrogen treatment, gravidity
• Thrombophylia
APC resistency, Protein C and S, antithrombin III. insufficiency.
fibrin és plasminogen disturbances, myeloproliferatíve diseases
• Other serious diseases ( heart, lung, inflammatory bowel disease etc. )
Etiology of Primary Insufficiency
Heredity: most important risk factor
„ Varicose veins are the result of poorly selecting one’s grandparents” Sir William Osler MD
CVICVI = v = venous hypertensionenous hypertension
Causes:- reflux ( insufficiency of valves )- occlusion ( thrombosis )- disturbed lymphatic circulation- disturbed muscle pump function
Physiology of Venous Return
PumpCalf muscles provide the forceSinusoidal veins as chambers
ValvesMaintain unidirectional flow
Foot to heartSuperficial to deep
CEAP Clinical State
0 – No visible venous disease1 – Teleangiectasia or reticular veins2 – Varicose veins3 – Edema4 – Skin changes5 – Healed ulcer6 – Active ulcer
PathoPathopysiologypysiology ( PR, PO, PRO )( PR, PO, PRO )
reflux (PR) 81 %,occlusion ( PO) 2 %,
combination of these 17 %, ** 3.5x risk ** of signs
Patterns of Reflux
1. Truncal reflux saphenous related
up to 5/6 of varicose veins2. Non-truncal Reflux
at least 1/6 of varicose veins3. Deep and perforator reflux
Not common alone but increases with severity of disease
Venous tests:
- Percussion test ( reflux )- Trendelenburg test ( reflux )
- Perthes test ( occlusio )
Continous wave (Continous wave ( CW ) Doppler CW ) Doppler inin venous diagnosisvenous diagnosis
Proximalis “A Proximalis “A soundsound”” Distalis “A Distalis “A soundsound””NormNormaal l venous flowvenous flow 0 0 ++RefluxReflux ++ ++Distal occlusioDistal occlusionn 00 00 animáció
Conclusions
- CVI results from venous hypertension usually related to primary reflux in the superficial veins- Heredity is primary risk factor
Multiparity increases chance of its expression- Stigmata can vary
Depends on veins involvedCosmetic to limb threateningMost patiens have symptoms
- Disease occurs in patternsCategorization most important first step