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الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

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الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا. كلية الطب البشري قسم الجـراحـ ة الدكــتـور عاصم قبطان MD – FRCS www.surgi-guide.com 1 st lecture. Peripheral Vascular Disease. Continue. Continue. Continue. Continue. Contraceptive hormonal therapy. Continue. Clinical Features.

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الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

كلية الطب البشري

قسم الجـراحـة

الدكــتـور عاصم قبطان

MD – FRCS

www.surgi-guide.com

1st lecture

M.A.Kubtan

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Contraceptive hormonal therapy

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clinical features
Clinical Features

VVs 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 .

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Eczema

Lipodermatosclerosis

Lipodermatosclerosis

Ulceration

Ulceration

Eczema

Ulceration

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signs of varicose veins
Signs of varicose veins
  • The 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 ( saphenavarix ) may be visible .
  • Gentle palpation during coughing may elicite a cough thrill .

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saphena varix
Saphenavarix

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a torniquet test
A torniquet test

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Trendilenburg test

investigation
Investigation
  • Tourniquet test .
  • Standareddoppler examination .
  • Duplex ultrasound imaging .
  • Varicography .
  • Venography .

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varicogram
Varicogram

Perforator joining long SV to deep veins

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VVs connecting long and short SV

venogram
Venogram

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management of patients with varicose veins
Management of patients with varicose veins
  • Prevention ( 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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avulsion
Avulsion

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alternative technique
Alternative technique
  • Radiofrequency ablation ( using radiofrequency to destroy the endothelial lining ).
  • Laser to cause endothelial damage .
  • Endovenous laser ablation .

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complication of vvs surgery
Complication of VVs surgery
  • Bruising .
  • Sensory nerve injury ( saphenous nerve , sural nerve ).
  • Recurrence .

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الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

كلية الطب البشري

قسم الجـراحـة

الدكــتـور عاصم قبطان

MD – FRCS

www.surgi-guide.com

2nd lecture

M.A.Kubtan

venous thrombus
Venous thrombus
  • Is 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.Kubtan

aetiology
Aetiology

Virchow triad

  • Changes in the vessel wall ( endothelial damage ) .
  • Stasis, which diminished blood flow through the veins .
  • Coagulability of blood ( thrombophilia ) .

M.A.Kubtan

risk factors for venous thromboembolisim
Risk 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.Kubtan

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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 .

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Other risk factors

  • Inflammatory bowel disease .
  • Nephrotic syndrome.
  • Polycythemia .
  • Paroxismal nocturnal haemoglobinuria antibody or Lupus
  • Anticoagulant .
  • Behcet,s disease .
  • Homocystinaemia.

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clinical pathology
Clinical Pathology

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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.

methode of propagation in phlebothrombosis
Methode of propagation in phlebothrombosis

With thrombus formation at each entering tributary.

Clotting mass in an extensive length of vein propagated clot .

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pulmonary embolism
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 .

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clinical symptoms of dvt
Clinical Symptoms of DVT

The 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%

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clinical signs of iliac femoral vein thrombosis
Clinical signs of Iliac femoral vein thrombosis
  • Swelling involving the whole length of lower limb .
  • Phlegmasia alba dolens .
  • Phlegmasiaceruliadolens .
  • Venous gangrene .

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phlegmasia alba dolens pad
Phlegmasia alba dolens PAD
  • When 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.

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phlegmasia cerulia dolens pcd
Phlegmasiaceruliadolens PCD
  • The 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.

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physical signs of dvt
Physical 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 .

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A 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 .

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investigation1
Early Diagnosis of DVT

D-dimer is a fibrin degradation product (FDP ) .

D-dimeris a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis.

D-dimermeasurment 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 ) .

Investigation

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slide57
An ascending venogram of DVT seen as filling defects ( arrows ) with contrast passing around the thrombus

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

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slide60
Ventilation – perfusion lung scan showing unmatched filling defects on the perfusion scan .(a) Ventilation , (b) Perfusion .

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slide62
MR

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the differential diagnosis of dvt
The differential diagnosis of DVT
  • Ruptured Baker,s cyst .
  • Calf muscle haematoma .
  • Ruptured plantaris muscle .
  • Thrombosedpopliteal aneurysm .
  • Arterial ischaemia .

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classification of risky patients
Classification 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 ) .

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prevention and prophylaxis
Prevention and prophylaxis
  • Mechanical approach .
  • Pharmacological approach .

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mechanical approach
Mechanical approach
  • Lower limbs elevation .
  • Graduated elastic compression stockings .
  • External pneumatic compression pump .

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slide68
Anti – embolism thigh compression stockings

Anti embolic knee compression stockings

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pharmacological approach
Pharmacological approach
  • More 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 .

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treatment of a deep vein thrombosis
Treatment of a deep vein thrombosis
  • Intravenous 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 .

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thrombolysis of dvt
Thrombolysis 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 .

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invasive approach to dvt
Invasive 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 phlegmasiaceruliadolen .
  • 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.Kubtan

treatment of pulmonary embolus
Treatment of pulmonary embolus
  • Multiple 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.Kubtan

superfacial thrombophlebitis
Superfacialthrombophlebitis
  • Implies a major inflammatory component .
  • Common causes include external trauma especially to VVs .
  • Venopuncture and infusion of hyperosmolor solution and drugs .
  • Thromboangitisobliterance ( Buerger disease)

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الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

كلية الطب البشري

قسم الجـراحـة

الدكــتـور عاصم قبطان

MD – FRCS

www.surgi-guide.com

3rd lecture

M.A.Kubtan

leg ulceration
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.Kubtan

aetiology of ulceration
Aetiology 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.

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clinical features1
Clinical features
  • A 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 .

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  • The 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 suroundinglipodermatosclerosis .

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slide82
Venous ulcer at the gaiter area

Marjolin ulcer arising from venous ulcer

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investigation2
Investigation
  • Duplex scan .
  • Full blood count .
  • ESR .
  • CRP .
  • Sickle cell test .
  • Bipedal ascending phlebography ( detection of DVT ) .

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management
Management
  • Elevation of legs .
  • Bandaging ( Elastic compression bandage ) .
  • Excision and grafting .
  • Biological dressing .( amniotic membrane ) .
  • Skin graft .

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congenital anomalies
Congenital anomalies
  • Aplasia .
  • Hypoplasia .
  • Duplication.
  • Persistance of vestigeal vessels.

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