بسم الله الرحمن الرحيم. دكتر مرتض ی خوانين زاده گروه جراح ی دانشگاه علوم پزشکی ایران. ب ي مار ی ها ی وريد ی.
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.
15% of male over 18
30% of female over 18
Progesterone and estrogens cause dilation of varicosities increase symptoms prior to menstruation.
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.
4Example of “Trendelenburg” Test
Localize the site of saphenous opening:
4cm below & lateral to the pubic tubercle
نارسائی وريدینارسائی شديد قلبیاستراحت طولاني
سابقه قوی خانوادگی
ترومبوفلبيت خودبخود در سنين پائين
ترومبو آمبولی های مكرر ريوی
Immobility or paraplegia :
more than 3 days of bed rest
Hospitalization within the previous 3 months
Varicose Veins/superficial thrombophlebitis
Congestive Heart Failure
Recent Surgery (within 4 weeks)
(family history of DVT)
Oral contraceptives (hormones)
Thigh and calf
Calf more than 3 cm
Along the deep vein
Unilateral pitting edema
Dilated superficial veins erythema
PTT<35 80-4 PTT 35-45 40-2
PTT 45-70 INR 2-3 continues for 4-5 days
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
Fasciotomy of the calf compartment
Venography from other side
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
Arteriovenus Fistula(6W) angiograph AVF ligation
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.
WITH A LEG ULCER
No further tests were done and considering
her surgical risks,
conservative treatment was advised.An Unna boot bandage was applied.
نارسائی مزمن قلبی