الجامعة السورية الدولية
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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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6729560

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






Continue
Continue

M.A.Kubtan






Continue1
Continue

M.A.Kubtan




Continue2
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M.A.Kubtan



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Contraceptive hormonal therapy

M.A.Kubtan


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Continue

M.A.Kubtan




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 .

M.A.Kubtan


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 .

M.A.Kubtan



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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6729560

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 thrombosis
Venous thrombosis

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 .

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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 .

M.A.Kubtan


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Other risk factors

  • Inflammatory bowel disease .

  • Nephrotic syndrome.

  • Polycythemia .

  • Paroxismal nocturnal haemoglobinuria antibody or Lupus

  • Anticoagulant .

  • Behcet,s disease .

  • Homocystinaemia.

M.A.Kubtan


Clinical pathology
Clinical Pathology

M.A.Kubtan

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 .

M.A.Kubtan



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 .

M.A.Kubtan


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%

M.A.Kubtan


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 .

M.A.Kubtan


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.

M.A.Kubtan


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.

M.A.Kubtan


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 .

M.A.Kubtan



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

M.A.Kubtan



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An ascending thrombus 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 thrombus

  • Ventilation-perfusion scanning , which mismatched defect .

  • Computerised tomography CT .

  • Pulmonary angiography ( rarely required ).

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MAK thrombus


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

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MR pulmonary artery.

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M.A.Kubtan pulmonary artery.


The differential diagnosis of dvt
The differential diagnosis of DVT pulmonary artery.

  • Ruptured Baker,s cyst .

  • Calf muscle haematoma .

  • Ruptured plantaris muscle .

  • Thrombosedpopliteal aneurysm .

  • Arterial ischaemia .

M.A.Kubtan


Classification of risky patients
Classification of risky patients pulmonary artery.

  • 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 ) .

M.A.Kubtan


Prevention and prophylaxis
Prevention and prophylaxis pulmonary artery.

  • Mechanical approach .

  • Pharmacological approach .

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Mechanical approach
Mechanical approach pulmonary artery.

  • Lower limbs elevation .

  • Graduated elastic compression stockings .

  • External pneumatic compression pump .

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Anti – embolism thigh compression stockings pulmonary artery.

Anti embolic knee compression stockings

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External pneumatic compression
External pneumatic compression pulmonary artery.

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Pharmacological approach
Pharmacological approach pulmonary artery.

  • 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 .

M.A.Kubtan


Treatment of a deep vein thrombosis
Treatment of a deep vein thrombosis pulmonary artery.

  • 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 .

M.A.Kubtan


Thrombolysis of dvt
Thrombolysis pulmonary artery. 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 .

M.A.Kubtan


Invasive approach to dvt
Invasive approach to DVT pulmonary artery.

  • 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


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MAK pulmonary artery.


Treatment of pulmonary embolus
Treatment of pulmonary embolus pulmonary artery.

  • 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
Superfacial pulmonary artery. thrombophlebitis

  • Implies a major inflammatory component .

  • Common causes include external trauma especially to VVs .

  • Venopuncture and infusion of hyperosmolor solution and drugs .

  • Thromboangitisobliterance ( Buerger disease)

M.A.Kubtan


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الجامعة السورية الدولية pulmonary artery. 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 pulmonary artery.

  • 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 pulmonary artery. 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.

M.A.Kubtan


Clinical features1
Clinical features pulmonary artery.

  • 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 .

M.A.Kubtan


Continue7
Continue pulmonary artery.

  • 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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Venous ulcer at the gaiter area pulmonary artery.

Marjolin ulcer arising from venous ulcer

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Investigation2
Investigation pulmonary artery.

  • Duplex scan .

  • Full blood count .

  • ESR .

  • CRP .

  • Sickle cell test .

  • Bipedal ascending phlebography ( detection of DVT ) .

M.A.Kubtan


Management
Management pulmonary artery.

  • Elevation of legs .

  • Bandaging ( Elastic compression bandage ) .

  • Excision and grafting .

  • Biological dressing .( amniotic membrane ) .

  • Skin graft .

M.A.Kubtan


Congenital anomalies
Congenital anomalies pulmonary artery.

  • Aplasia .

  • Hypoplasia .

  • Duplication.

  • Persistance of vestigeal vessels.

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M.A.Kubtan pulmonary artery.


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M.A.Kubtan pulmonary artery.


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M.A.Kubtan pulmonary artery.


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M.A.Kubtan pulmonary artery.


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M.A.Kubtan pulmonary artery.


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