1. Venous Diseases

2. Anatomy: Superficial and deep systems All are valved
Important perforators
Sinusoids.

3. Anatomy:

4. Physiology: Venous pressure on standing 100 mmHg
Single calf muscle contraction empties 60% of pooled blood
Ambulatory venous
pressure 40 mmHg

5. Deep Vein Thrombosis (DVT)
Etiology:
According to Virchow’s Triad
Changes in the vessel wall (endothelial damage);
Changes in the blood flow (stasis);
Changes in the blood composition (hypercoagulability).

6. Risk factors: Patients factors: Age Obesity Varicose veins Immobility
Pregnancy
Puerperium
Oral contraceptive pills
Previous deep vein thrombosis or pulmonary embolism
Disease or surgical factors:
Trauma or surgery,
Malignancy,
Heart failure
Recent myocardial infarction
Paralysis of lower limb(s)
Infection
Inflammatory bowel disease
Nephrotic syndrome
Polycythaemia
Paraproteinaemia

7. Pathology:
Occlusive thrombus
Non occlusive thrombus

8. Pulmonary
embolism

9. Fate of DVT: Complete resolution of thrombus
Incomplete resolution  Post phlebotic syndrome and chronic venous insufficiency
Organization of thrombus
Embolization.

10. Clinical presentation:
Pain and swelling
Bilateral in 30%
Asymptomatic
Chest pain, dyspnea and hemoptysis (pulmonary embolism)
Phlegmasia alba dolens (white leg)
Phlegmasia cerulea dolens

11. On examination: Pitting oedema of the ankle, Dilated surface veins,
A larger stiff calf
Tenderness
Hotness
Homans’ sign – resistance (not pain) of the calf muscles to forcible dorsiflexion
A low-grade pyrexia may be present
Signs of pulmonary embolism or pulmonary hypertension

13. Inestigations: Duplex ultrasound Venography D-dimer
If pulmonary embolism suspected:
Ventilation / perfusion scan
CT scan
Pulmonary angiography

14. Differential diagnosis:
Ruptured Baker’s cyst,
A calf muscle haematoma,
A ruptured plantaris muscle,
Thrombosed popliteal aneurysm
Arterial ischemia

15. Prophylaxis:
Low risk: young, with minor illnesses, who are to undergo operations lasting 30 min or less.
Moderate risk: over 40 or with a debilitating illness who are to undergo major surgery.
High risk: over 40 who have serious medical conditions, or undergoing major surgery with an additional risk factor.

16. Methods of prophylaxis:
Mechanical methods:
graduated elastic compression stockings
external pneumatic compression
passive foot movement (foot paddling machine)
simple limb elevation
Pharmaceutical methods:
low molecular weight heparin
unfractionated heparin
warfarin

17. Medical treatment: Admission to hospital and bed rest
Anticoagulant therapy (heparin and warfarin)
Leg elevation
Elastic compressive bandage from the toes to the upper thigh
Patients with phlegmasia cerulea dolens need thrombolytic therapy

18. Surgical treatment: Venous thrombectomy: Inferior vena cava filter:
Phlegmasia cerulea dolens with contraindication to thrombolytics
Inferior vena cava filter:
Recurrent thromboembolism despite adequate anticoagulation
Progressing thromboembolism despite adequate anticoagulation
Complication of anticoagulants
Contraindication to anticoagulants

19. Varicose Vein Introduction: Dilated tortuous veins
5% of adult population
Equal gender prevalence
Family history

20. Pathology: Incompetence of the venous valves
Primary venous incompetence
Secondary venous incompetence

21. Clinical manifestations:
Unsightly appearance
Discomfort and aching at the end of the day
Ankle swelling towards the end of the day
Complications:
Itching and eczema
Lipodermatosclerosis
Venous ulceration

22. Venous Eczema (stasis dermatitis):

23. Lipodermatosclerosis:

24. Venous Ulcer:

25. On examination: Great or small saphenous vein
Incompetent saphenofemoral junction or incompetent perforators
Exclude DVT or deep vein incompetence

26. Investigations: Usually diagnosed clinically
Investigations done to confirm and exclude
Duplex ultrasound
Venography
Abdominal and/or pelvic imaging

27. I- Conservative Treatment:
Reassurance
Elastic compression stockings
Avoid prolong standing and change of occupation may be required
Periodic elevation of the feet

28. II- Injection sclerotherapy:
Sodium tetradecyl sulfate (STD)

29. III- Surgical Treatment:
Indications for surgery:
Symptomatic varicose veins
Complicated or bleeding varicose veins
Large varicose veins
Cosmetic purposes
Surgical options include:
Ligation and stripping of the saphenous vein
Multiple subfacial perforator ligation
Combination of both.
Complications of varicose vein surgery:
Nerve injury (saphenous nerve and sural nerve)
Recurrence

30. Deep Vein Incompetence
Pathology:

31. Clinical presentation
Leg swelling,
Discomfort on walking,
Edema,
Varicose veins (which may not be present),
Ankle flare (small varices),
Lipodermatosclerosis
Ulceration

32. Post Phlebetic syndrome:

33. Investigations:
Duplex ultrasound
Venography.

34. I- Conservative Treatment:
Elastic compression stockings
Avoid prolong standing and change of occupation may be required
Periodic elevation of the feet
Exercise of the calf muscles

35. II- Surgical Treatment:
Venous bypass procedures (e.g. Palma procedure)
Venous valve reconstruction
Venous valve transposition

36. Differential diagnosis of leg ulcers:
Venous Ulceration
Differential diagnosis of leg ulcers:
Venous disease: deep vein incompetence
Arterial ischemia
Rheumatoid ulcer
Traumatic ulcer
Neuropathic ulcer (diabetic)
Neoplastic ulcer (squamous cell carcinoma and basal cell carcinoma).

37. Etiolgy: Not fully understood Ambulatory venous hypertension
Due to valve incompetence:
Incompetent superficial veins
Incompetent perforator veins
Incompetent or obstructed deep veins

38. Clinical examination Site: gaiter region (between calf and ankle)
Size: usually large
Depth: usually superficial
Edges: gently sloping edges
Base: granulation tissue + slough and exudates
Discharge: pus occasionally blood
Surrounding tissue: features of chronic venous disease
Local lymph nodes: enlarged (superadded infection)
Movement of ankle joint: restricted due to pain

39. Venous Ulcer:

40. Investigations: Swab and culture from the ulcer Duplex ultrasound
Venography

41. I- conservative Treatment:
multilayered elastic compression bandaging system,
avoid prolong standing,
periodic leg elevation

42. II- Surgical Treatment:
Surgery for the cause of the venous ulcer (varicose vein, DVT or chronic venous insufficiency)
Perforator vein subfacial ligation
Skin graft to the ulcer after dealing with the underlying cause

43. Superficial Thrombophlebitis
Etiology:
External trauma,
Venepunctures and infusions of hyperosmolar solutions and drugs.
Intravenous cannula
Some systemic diseases: buerger’s disease, and malignancy,
Coagulation disorders: polycythaemia, thrombocytosis and sickle cell disease

44. Examination: Treatment:: Overlying skin erythematous
Palpable and tender superficial vein
Treatment::
Reassurance
NSAIDs
Warm massage

45. Superficial thrombophlebitis

46. Thank You