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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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slide2
دكتر مرتضی خوانين زاده

گروه جراحی

دانشگاه علوم پزشکی ایران

بيماری های وريدی
slide3

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.

slide4

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

slide5

SYMPTOMATIC VARICOSE VEINS

she was advised to have a vein stripping

on the rightleg and to wear an elastic stocking

on the left leg.

slide6
آناتومی وريدهای اندام تحتانی
  • وريدهای سطحی
  • وريدهای عمقی
  • وريدهای سوراخ كننده
  • دريچه های وريدی
anatomy
Anatomy
  • Deep veins
  • Superficial veins
  • Perforating veins
  • Reticular veins
  • Epidermal veins (spider veins)
slide15
آناتومی وريدهای اندامفوقانی
  • وريدهای سطحی
  • وريدهای عمقی
  • وريدهای سوراخ كننده
  • دريچه های وريدی
slide20
فيزيولوژی
  • فشارهای وريدی
history
History
  • 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
etiology
Etiology
  • 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.
pathophysiology
Pathophysiology
  • Failing venous pump mechanism
  • Perforation veins
  • Dilation of superficial veins
slide34
تشخيص

داپلر

ونوگرافي

درمان

طبی

جراحی

اسكلروتراپی

اتيولوژی

اوليه

ثانويه

تظاهرات بالينی

معاينه فيزيكی

وريدهای واريسی
example of trendelenburg test

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

Apply the tourniquet below the saphenous opening

2

3

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.

5

4

Example of “Trendelenburg” Test

Localize the site of saphenous opening:

4cm below & lateral to the pubic tubercle

treatment of varicose veins
Treatment of varicose veins
  • Part One
    • Get rid of the reflux
  • Part Two
    • Get rid of the varicose veins
treatment 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
vein stripping
Vein Stripping
  • Typically requires general anesthesia
  • Two incisions are need
  • Can be painful post-operatively
  • Requires 4-7 days off work
endovenous treatment
EndoVenous treatment
  • Laser ablation

810 nm

940 nm

980nm

  • Radio-Frequency ablation
part two removal of varicosities
Part TwoRemoval of Varicosities
  • Stab phlebectomy and avulsion
  • Suction phlebectomy
sclerotherapy
Sclerotherapy
  • 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
spider veins
Spider veins
  • Sclerotherapy
      • Sodium Tetradecyl (STS) 1%-3%
      • Polidocanol 0.5%-1%
      • Hypertonic Saline
  • Laser
  • long pulse Nd : Yag 1064nm >5o ms

Spray cooling

complications varicose veins
Complications, varicose veins
  • Wound infection
  • Hematoma
  • DVT
  • Skin burns
complication spider veins
Complication, Spider veins
  • Skin staining (tattooing, hyperpigmentation, lighting)
  • Ulcerations
  • Anaphylactic reaction
  • Recurrence is not a complication
conclusions
Conclusions
  • Know the cause
  • Know what you’re treatment options
  • Know who’s doing it & what training they have
  • Stop suffering
slide70
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
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

Obesity

pregnancy

risk factors for the development of d v t1
Risk Factors for the development of D.V.T
  • Endothelial injury

Trauma

Recent Surgery (within 4 weeks)

Severe Infection

risk factors for the development of d v t2
Risk Factors for the development of D.V.T
  • Hypercoagulability

Congenital Hypercoagulability

(family history of DVT)

Malignancy

Oral contraceptives (hormones)

Polycythemia

Thrombocytosis

diagnosis clinical
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

slide75
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
slide76
اسكن فيبرينوژن نشاندار

پلتيسموگرافی

ونوگرافی با ماده حاجب

MR Venography

تظاهرات بالينی(محل انسداد)فلگمازيا سرولا دولنس

فلگمازيا البا دولنس

معاينه فيزيكی

سونوگرافی دوپلكس

يافته های تشخيصی
diagnosis
Diagnosis
  • Phlebography (ascending Venograph)
  • Duplex Ultrasonography
  • I125 labeled fibrinogen scanning
  • Plethysmography
  • MRI Venography
  • D-Dimer
standard laboratory test factor
Standard Laboratory TestFactor
  • Thrombin Time
  • Factor vLeaden (APC resistance)
  • Protein C
  • Protein S
  • Antithrombin
  • Antiphospholipid Antibodies
  • Homocysteine
slide80
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
slide81
كيست بيكر

توده رتروپريتوئن

نارسائی قلب–كبد-كليه

بسته شدن IVC

فشردگی يا كشيدگی عضلات

پارگی تاندون آشيل

سلوليت

لنف ادم

تشخيص افتراقی ها
slide82
ترومبوليز

ترومبكتومی جراحی

مسدود كردن وريد اجوف تحتانی

جراحی

فيلترگذاری ازراه پوست

بستری شدن

بالا نگه داشتن اندام

درمان ضد انعقادی

هپارينوارفارين

درمان
anticoagulation therapy
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
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

prophylaxis
Prophylaxis
  • 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
slide88
جورابهای فشارنده

فشار خارجی متناوب بر روی پا

بالا نگه داشتن اندام

حركت دادن زود هنگام بيمار

پروفيلاكسی داروئی

AVC filter

DVT پروفيلاكسی
slide89
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
ivc filter
Contraindication to anticoagulation

Recurrent thrombosis despite anticoagulation

Complication of anticoagulation

Trauma with cerebral or Spinal injury

Thrombosis

Migration

IVC erosion

IVC obstruction

IVC Filter
slide91
تشخيص افتراقی

درمان

طبی

جراحی

پيش آگهی

اتيولوژی

علائم

تشخيص

ترومبوفلبيت سطحی
slide92
تشخيص

دوپلكس سونوگرافی

ونوگرافی

گرافی قفسه سينه

درمان

طبی

داروهای ضدانعقادی

ترومبوليز با كاتتر

برداشتن فشار خارجی

اتيولوژی

ناهنجاری آناتوميك دهانه خروجی قفسه سينه

قرار دادن كاتتر

افزايش انعقاد پذيری

ترومبوز ناشی از تلاش

علائم بالينی

ترومبوز وريد ساب كلاوين و آگزيلاری
slide93
تشخيص

MRI

CT Scan

Venography

Sonography

اتيولوژی

تومور IVC

تومور رتروپريتوئن

هيپر نفروما

ترومبوز وريد اجوف تحتانی
slide94

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.

slide95

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.

slide96

DEEP VEIN INSUFFICIENCY

WITH A LEG ULCER

No further tests were done and considering

her surgical risks,

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

slide97
علائم بالينی

ادم

درماتيت

زخم

هيپرپيگمانتاسيون

تشخيص

داپلر

پلتيسموگرافی

ونوگرافی

اتيولوژی :

بالا بودن فشار مزمن وريدی

كار آمد نبودن عضلات

نارسائی دريچه ها

مادرزادی

اكتسابی

نارسائي مزمن وريدي
slide99
درمان

غير جراحی

جراحی

بستن پرفوراتورها

بازسازی وريدی

Bypass

تشخيص افتراقی:

نارسائی مزمن قلبی

نارسائی كبدی

نارسائی كليوی

لنف ادم

نارسائی شريانی

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