بسم الله الرحمن الرحيم
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بسم الله الرحمن الرحيم. دكتر مرتض ی خوانين زاده گروه جراح ی دانشگاه علوم پزشکی ایران. ب ي مار ی ها ی وريد ی.

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بسم الله الرحمن الرحيم

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بسم الله الرحمن الرحيم

دكتر مرتضی خوانين زاده

گروه جراحی

دانشگاه علوم پزشکی ایران

بيماری های وريدی

A 35-year-old female presented with complaints of achingdiscomfort and a sense of fatigue in her right leg, whichdeveloped after a vein in her right leg started to enlarge.She believed that one vein in her left leg had also becomemore apparent and unsightly. Her symptoms had lastedfor a few months and seemed to worsen with her menstrualperiods and at the end of the day. They improved bylying down with the legs elevated. She stated that hermother had a leg ulcer and her sister had had a vein stripping.On physical examination, she appeared to be healthywithout abdominal or pelvic masses. No inguinal lymphadenopathy was present.

The right greater saphenous vein was elongated and dilated in its entire length. Severalcollaterals originating from the greater saphenous veinwere also dilated in both the medial aspect of the thighand calf where some weak spots were palpated in the superficial fascia. No bruits or thrills were felt over the mainvaricosities, and no areas of dermatitis or signs of previousulceration were found over the medial malleolus. The leftleg appeared normal with a minimally dilated greater saphenous vein. With the patient standing, a Valsalva maneuver was performed, and an obvious transmitted impulsewas felt below the fossa ovalis bilaterally. Similarly, aTrendelenburg’s test was positive and a Perthe’s test wasnegative in both extremities. No further testing was done


she was advised to have a vein stripping

on the rightleg and to wear an elastic stocking

on the left leg.

آناتومی وريدهای اندام تحتانی

  • وريدهای سطحی

  • وريدهای عمقی

  • وريدهای سوراخ كننده

  • دريچه های وريدی


  • Deep veins

  • Superficial veins

  • Perforating veins

  • Reticular veins

  • Epidermal veins (spider veins)

From: Gray, H. Anatomy of the Human Body 20th ed. 2000

آناتومی وريدهای اندامفوقانی

  • وريدهای سطحی

  • وريدهای عمقی

  • وريدهای سوراخ كننده

  • دريچه های وريدی

From: Gray, H. Anatomy of the Human Body 20th ed. 2000

From: Gray, H. Anatomy of the Human Body 20th ed. 2000

From: Gray, H. Anatomy of the Human Body 20th ed. 2000



  • فشارهای وريدی

Varicose Veins


  • Varicose vein plague over 2000 years

  • Votive tablet found near the Acropolis in the sanctuary of Dr. Amynos in the 4th century

  • Multiple treatment modalities


  • 10%-20% of Western & European adults:

    15% of male over 18

    30% of female over 18

  • Females are effected twice as frequently

    Progesterone and estrogens cause dilation of varicosities increase symptoms prior to menstruation.

  • Genetic play a role in up to 70% of cases

  • Risk factors: Prolonged standing, prior blood clots, pregnancy.


  • Failing venous pump mechanism

  • Perforation veins

  • Dilation of superficial veins

Venous pump mechanismNormal veins

Venous pump mechanismfailing veins











تظاهرات بالينی

معاينه فيزيكی

وريدهای واريسی

Elevate the patients limb & empty the L.L. veins

Apply the tourniquet below the saphenous opening



The site of incompetent perforator is suspected by a palpable fascial defect, multiple tourniquet & confirmed by Duplex

As the patient stands, the V.V. fill rapidly from above.

This means that the incompetent connection between the deep & superficial system is NOT the sap-fem junction (which is controlled by the tourniquet), but it is below it.



Example of “Trendelenburg” Test

Localize the site of saphenous opening:

4cm below & lateral to the pubic tubercle

Treatment of varicose veins

  • Part One

    • Get rid of the reflux

  • Part Two

    • Get rid of the varicose veins

Treatment Varicose Veins

  • Compression stockings

  • Surgical, vein stripping

  • Endoluminal

    • Laser

    • Radiofrequency ablation

  • Subfascial Endoscopic Perforator vein Surgery (SEPS)

  • Sclerotherapy

    • Ultrasound guided

    • Catheter delivered

  • Compression

    Vein Stripping

    • Typically requires general anesthesia

    • Two incisions are need

    • Can be painful post-operatively

    • Requires 4-7 days off work

    EndoVenous treatment

    • Laser ablation

      810 nm

      940 nm


    • Radio-Frequency ablation

    Laser Ablation

    Radiofrequency Ablation

    Catheter Directed Foam Sclerotherapy

    Subfascial Endoscopic Perforator vein Surgery (SEPS)

    Part TwoRemoval of Varicosities

    • Stab phlebectomy and avulsion

    • Suction phlebectomy


    • Sodium Tetradecyl (STS) 1%-3%

    • Polidocanol 0.5%-1%

    • Hypertonic Saline

    • Part One

      • Get rid of the reflux

    • Part Two

      • Get rid of the varicose veins

    U/S Guided Sclerotherapy

    Transilluminated power Phlebectomy

    Spider veins

    • Sclerotherapy

      • Sodium Tetradecyl (STS) 1%-3%

      • Polidocanol 0.5%-1%

      • Hypertonic Saline

  • Laser

  • long pulse Nd : Yag 1064nm >5o ms

    Spray cooling

  • Common Location of Spiders

    Injection of Reticular Veins

    Complications, varicose veins

    • Wound infection

    • Hematoma

    • DVT

    • Skin burns

    Complication, Spider veins

    • Skin staining (tattooing, hyperpigmentation, lighting)

    • Ulcerations

    • Anaphylactic reaction

    • Recurrence is not a complication


    • Know the cause

    • Know what you’re treatment options

    • Know who’s doing it & what training they have

    • Stop suffering

    Deep Vein Thrombosis

    ترومبوز وريدهای عمقی

    • اختلالات جريان خون(سكون خون)

      نارسائی وريدینارسائی شديد قلبیاستراحت طولاني

    • آسيب ديواره عروقی

      هيپوكسيك(ترومای مستقيم-فشار-كانولاسيونبيوشيميائی(انفوزيون-فلبيت)

    • افزايش قابليت انعقاد خون

      سابقه قوی خانوادگی

      ترومبوفلبيت خودبخود در سنين پائين

      ترومبو آمبولی های مكرر ريوی

    Risk Factors for the development of D.V.T

    • Venous Stasis

      Immobility or paraplegia :

      more than 3 days of bed rest

      Hospitalization within the previous 3 months

      Varicose Veins/superficial thrombophlebitis

      Advanced Age

      Congestive Heart Failure



    Risk Factors for the development of D.V.T

    • Endothelial injury


      Recent Surgery (within 4 weeks)

      Severe Infection

    Risk Factors for the development of D.V.T

    • Hypercoagulability

      Congenital Hypercoagulability

      (family history of DVT)


      Oral contraceptives (hormones)



    Diagnosis: clinical

    • Pain

    • Swelling

      Thigh and calf

      Calf more than 3 cm

    • Tenderness

      Along the deep vein

      Unilateral pitting edema

      Dilated superficial veins erythema

      Blanching cyanotic

    • Idiopathic DVT & younger than age 50

    • A family history of thrombosis

    • Thrombosis in an unusual site

      Cerebral-mesentric-portal ,….

    • Recurrent DVT

    • Recurrent loss

    • Thrombosis with pregnancy or hormonal therapy

    اسكن فيبرينوژن نشاندار


    ونوگرافی با ماده حاجب

    MR Venography

    تظاهرات بالينی(محل انسداد)فلگمازيا سرولا دولنس

    فلگمازيا البا دولنس

    معاينه فيزيكی

    سونوگرافی دوپلكس

    يافته های تشخيصی


    • Phlebography (ascending Venograph)

    • Duplex Ultrasonography

    • I125 labeled fibrinogen scanning

    • Plethysmography

    • MRI Venography

    • D-Dimer

    Standard Laboratory TestFactor

    • Thrombin Time

    • Factor vLeaden (APC resistance)

    • Protein C

    • Protein S

    • Antithrombin

    • Antiphospholipid Antibodies

    • Homocysteine

    به حداقل رساندن خطر

    آمبولی ريوی

    محدود كردن ادامه تشكيل لخته

    تسهيل در انحلال لخته های موجود

    وريدهای واريسی

    نازسائی مزمن وريدی

    عود بيماری

    آمبولی ريوی

    عوارض بيماری و اهداف درمان

    كيست بيكر

    توده رتروپريتوئن

    نارسائی قلب–كبد-كليه

    بسته شدن IVC

    فشردگی يا كشيدگی عضلات

    پارگی تاندون آشيل


    لنف ادم

    تشخيص افتراقی ها


    ترومبكتومی جراحی

    مسدود كردن وريد اجوف تحتانی


    فيلترگذاری ازراه پوست

    بستری شدن

    بالا نگه داشتن اندام

    درمان ضد انعقادی



    Anticoagulation therapy

    • HeparinHct & Platelet 24hours aptt/6h>1,5

      80u/kgIV 18u/kg/h

      PTT<35 80-4 PTT 35-45 40-2

      PTT 45-70 INR 2-3 continues for 4-5 days

    • Wrfarin 2days after

      24hours PTT 5 unit above the normal

      10mg daily for 2 days

      5mg daily INR 2-3 Daly stabilizes

      Twice/weekly for first few weeks stabilizes

      Once weekly for next several months

      Once monthly

    Surgical Treatment

    Fasciotomy of the calf compartment

    Venography from other side

    V/P Scan

    Longitudinal venotomy in CFV <7 days

    Embolectomyof IVC 10-15 cm h2o peep

    Manual removal distal rubber elastic wrap

    Femoral vein ligation Cannot be extract

    Transperitoneal IVC approach

    Intraoperative venogram mandatory

    Intraoperative Angioplasty

    Arteriovenus Fistula(6W) angiograph AVF ligation


    • Older than 40 years with Major surgery

    • Older than 60 years with Minor surgery

    • Obese patient

    • Malignant disease

    • Paralysis

    • Prior DVT or PE

    • Long complicated operation

    جورابهای فشارنده

    فشار خارجی متناوب بر روی پا

    بالا نگه داشتن اندام

    حركت دادن زود هنگام بيمار

    پروفيلاكسی داروئی

    AVC filter

    DVT پروفيلاكسی

    • UFHeparin 5000 IU/SQ BiD

    • LMW Heparin enoxaparin 30mg SQ BiD

    • Dextran 10ml/kg

    • External pneumatic compression

    • Gradient elastic stocking

    • Wrapping the legs with elastic bandages

    • Warfarin

    • IVC filter

    Contraindication to anticoagulation

    Recurrent thrombosis despite anticoagulation

    Complication of anticoagulation

    Trauma with cerebral or Spinal injury



    IVC erosion

    IVC obstruction

    IVC Filter

    تشخيص افتراقی




    پيش آگهی




    ترومبوفلبيت سطحی


    دوپلكس سونوگرافی


    گرافی قفسه سينه



    داروهای ضدانعقادی

    ترومبوليز با كاتتر

    برداشتن فشار خارجی


    ناهنجاری آناتوميك دهانه خروجی قفسه سينه

    قرار دادن كاتتر

    افزايش انعقاد پذيری

    ترومبوز ناشی از تلاش

    علائم بالينی

    ترومبوز وريد ساب كلاوين و آگزيلاری



    CT Scan




    تومور IVC

    تومور رتروپريتوئن

    هيپر نفروما

    ترومبوز وريد اجوف تحتانی

    A 68-year-old retired with a history of diabetes and unstable angina attended the vascular clinic complainingof heaviness on ambulation and left ankle edema with achronic ulcer over the medial malleolus. She stated thatsome years previously, her left leg became acutely swollenand some “blood thinner tablets” were prescribed. Onphysical examination she had a normal greater saphenousvein, a swollen ankle, a large area of induration, and marked brown skin pigmentation over the medial malleolus.

    At its center, a 1 ´ 2-cm superficial ulcer with a moist base and extensive granulation was present. Trendelenburg’s test was positive, and a Perthe’s test was negative. A duplex study was done that revealed a competent saphenofemoral junction and patent femoral veins. However, the popliteal vein showed reversal of flow with the Valsalva maneuver and the Doppler probe revealed reflux in Cockett’s perforators at the calf.



    No further tests were done and considering

    her surgical risks,

    conservative treatment was advised.An Unna boot bandage was applied.

    علائم بالينی









    اتيولوژی :

    بالا بودن فشار مزمن وريدی

    كار آمد نبودن عضلات

    نارسائی دريچه ها



    نارسائي مزمن وريدي


    غير جراحی


    بستن پرفوراتورها

    بازسازی وريدی


    تشخيص افتراقی:

    نارسائی مزمن قلبی

    نارسائی كبدی

    نارسائی كليوی

    لنف ادم

    نارسائی شريانی

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