Академический Документы
Профессиональный Документы
Культура Документы
In A Surgeon's Gown (Good) Physicians May Make Some Progress Incidence Age Sex Geography Genetics Predisposing factors Macroscopic appearance Microscopic appearance Spread Prognosis: mortality and complications
Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025. Coon WW, Willis PW III, Keller JB. Venous thromboembolism and other venous disease in the Tecumseh community health study. Circulation 1973; 48: 839846. Franks PJ, Wright DD, Moffatt CJ, Stirling J, Fletcher AE, Bulpitt CJ et al. Prevalence of venous disease: a community study in west London. Eur J Surg 1992; 158: 143147. Bradbury A, Evans C, Allan P, Lee A, Ruckley CV, Fowkes FG. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ 1999; 318: 353356
History of thromboembolic disease Number of pregnancies Activity (prolonged sitting or standing) Unskilled work Exercise less than once a week Height Obesity
Cornu-Thenard A, Boivin P, Baud MM, et al: Importance of the familial factor in varicose disease: Clinical study of 134 families. J Derm Surg Oncol 20:318-326, 1994 Patrick H. Carpentier, Hildegard R. Maricq, Christine Biro, Claire O. Poncot-Makinen, Alain Franco, Prevalence, risk factors, and clinical patterns of chronic venous disorders of lower limbs: A population-based study in France, Journal of Vascular Surgery, Volume 40, Issue 4, October 2004, Pages 650-659, ISSN 0741-5214, DOI: 10.1016/j.jvs.2004.07.025.
Dilated, tortuous, elongated superficial veins Possible venous eczema possible venous ulcers
Venous eczema
Superficial veins
Long saphenous (LSV) Short saphenous (SSV)
It was previously thought that axial destruction of venous valves led to transmission of ambulatory venous hypertension, causing reflux and varix formation. However, Labropoulos and associates reported that the most common location for initial varicose vein formation was in the below-knee great saphenous vein (GSV) and its tributaries, followed by the above-knee GSV, and the saphenofemoral junction. Their study clearly indicates that vein wall degeneration with subsequent varix formation can occur in any segment of the superficial and deep systems at any time and suggests a genetic component to the disease.
Labropoulos N, Giannoukas AD, Delis K, et al: Where does the venous reflux start? J Vasc Surg 26:736-742, 1997.
Asymptomatic Unsightly cutaneous veins Itching Corona phlebectatica (ankle/malleolar flare) Lipodermatosclerosis Atrophie blanche Varicose eczema Edema Hemorrhage Chronic ulceration
claudication, Itching
Risk factors
Female, age, ethnicity, occupation, pregnancy, obesity,
smoking ASK about history of abdominal complaints/cancer, DVT, previous & other venous complaints
ICEPP
Wash hands before examining the patient Cover and thank patient, present findings
Look at the legs whilst patient is standing Examine around the medial malleolus gaiter area VVV LAPS
Varicose veins distribution (LSV, SSV) Venous ulcers/eczema Venous stars Lipodermatosclerosis Atrophy blanche Pitting oedema Scars
Venous ulcers/eczema
Atrophy blanche
Ulceration: active and healed Leaves a white patch
Pitting oedema
1.
Lipodermatosclerosis
Literally "scarring of the skin and fat A slow process that occurs over a number of years and has 2 phases:
Acute
Venous pooling chronic venous hypertension RBC forced into surrounding tissue Haemoglobin broken down into brown haemosiderin Chronic haemosiderin formation leads to fibrin deposition Skin becomes thickened and shiny Skin around ankle constricts and the inverted champagne-bottle shape is seen
2.
Chronic
Temperature
Feel with back of hand,
Tap Test
Place finger at any point along the
Cough impulse
Locate the
varicose vein Tap the vein proximally (above the finger) Incompetent valves allow the transmission of a fluid thrill to the finger below
Direction Test
Empty a short section of the vein (place
saphenofemoral junction (SFJ) Feel for the smooth swelling and palpable thrill of a saphena varix (cause of groin lump) If present, cough test +ve
one finger on the vein and slide another finger firmly upwards). If the valves are incompetent, the vein will refill when you release the top finger.
Auscultation
Over a large group of veins may indicate a
Used to assess the competence of SFJ Patient lies flat Elevate the leg and gently empty the veins Palpate the SFJ and ask the patient to stand whilst maintaining pressure Findings: If the veins do not refill SFJ is incompetent If the veins do refill SFJ may or may not be incompetent, presence of distal incompetent perforators
2. Tourniquet test
Uses a tourniquet to control the junction rather than fingers Advantage of moving the tourniquet lower (mid-thigh region) Test is unreliable below the knee
3. Perthes Test
Empty the vein as above, place a tourniquet around the thigh, stand the patient up. Ask them to rapidly stand up and down on their toes filling of the veins indicated deep venous incompetence. This is a painful and rarely used test.
Examine the abdomen for masses (+ DRE) to ascertain whether the varicose veins are primary or secondary Complete a peripheral vascular exam for arterial supply of the lower limb, including ABPI
Conservative/Medical
Graded compression
Surgical
bandaging, Compression hosiery Paste Gauze (Unna) Boots Diuretics? Zinc? Phlebotrophic/Hemorheologi c agents? Aspirin/NSAIDs etc
Robert B. Rutherford (editor). Vascular surgery 6th ed. 2005. Elsevier Saunders. ISBN 0-7216-0299-1 (set) J. A. Michaels, J. E. Brazier, W. B. Campbell, J. B.MacIntyre, S. J. Palfreyman and J. Ratcliffe. Randomized clinical trial comparing surgery with conservative treatment for uncomplicated varicose veins. British Journal of Surgery 2006; 93: 175181
Ankle-to-groin saphenous vein stripping (with stab avulsion) Segmental saphenous vein stripping (with stab avulsion) Saphenous vein ligation: high, low, or both Saphenous vein ligation and sclerotherapy Saphenous vein ligation (with stab avulsion) Stab avulsion of varices without saphenous vein stripping (phlebectomy) Endoluminal occlusion of the saphenous vein by radiofrequency (RF) or laser energy
Day case procedure Oral paracetamol as analgesia Elastic bandaging for 2-3 days Mobilization: Walking for 2-3 miles daily (ideally for 5 minutes every hour) Compression stockings?
J.P. Houtermans-Auckel a, E. van Rossum b, J.A.W. Teijink c, A.A.H.R. Dahlmans a, E.F.B. Eussen a, S.P.A. Nicolaa, R.J.Th.J. Welten. To Wear or not to Wear Compression Stockings after Varicose Vein Stripping: A Randomised Controlled Trial. Eur J Vasc Endovasc Surg (2009) 38, 387-391
Any Questions?