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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5677306

بسم الله الرحمن الرحيم


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دكتر مرتضی خوانين زاده

گروه جراحی

دانشگاه علوم پزشکی ایران

بيماری های وريدی


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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.


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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


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SYMPTOMATIC VARICOSE VEINS

she was advised to have a vein stripping

on the rightleg and to wear an elastic stocking

on the left leg.


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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)


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


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آناتومی وريدهای اندامفوقانی

  • وريدهای سطحی

  • وريدهای عمقی

  • وريدهای سوراخ كننده

  • دريچه های وريدی


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


5677306

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


5677306

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


Hemodialysis catheters

Hemodialysiscatheters


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فيزيولوژی

  • فشارهای وريدی


Varicose veins

Varicose Veins


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


Venous pump mechanism normal veins

Venous pump mechanismNormal veins


Venous pump mechanism failing veins

Venous pump mechanismfailing veins


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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


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    Compression


    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


    Laser ablation

    Laser Ablation


    Radiofrequency ablation

    Radiofrequency Ablation


    Catheter directed foam sclerotherapy

    Catheter Directed Foam Sclerotherapy


    Subfascial endoscopic perforator vein surgery seps

    Subfascial Endoscopic Perforator vein Surgery (SEPS)


    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


    U s guided sclerotherapy

    U/S Guided Sclerotherapy


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    Transilluminated power Phlebectomy


    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


  • Common location of spiders

    Common Location of Spiders


    Injection of reticular veins

    Injection of Reticular Veins


    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


    Deep vein thrombosis

    Deep Vein Thrombosis


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    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


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    • 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


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    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


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    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


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    كيست بيكر

    توده رتروپريتوئن

    نارسائی قلب–كبد-كليه

    بسته شدن IVC

    فشردگی يا كشيدگی عضلات

    پارگی تاندون آشيل

    سلوليت

    لنف ادم

    تشخيص افتراقی ها


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    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


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    جورابهای فشارنده

    فشار خارجی متناوب بر روی پا

    بالا نگه داشتن اندام

    حركت دادن زود هنگام بيمار

    پروفيلاكسی داروئی

    AVC filter

    DVT پروفيلاكسی


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    • 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


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    تشخيص افتراقی

    درمان

    طبی

    جراحی

    پيش آگهی

    اتيولوژی

    علائم

    تشخيص

    ترومبوفلبيت سطحی


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    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


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    تشخيص

    MRI

    CT Scan

    Venography

    Sonography

    اتيولوژی

    تومور IVC

    تومور رتروپريتوئن

    هيپر نفروما

    ترومبوز وريد اجوف تحتانی


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    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.


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    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.


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    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.


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    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


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    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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