Peripheral Vascular Disease(3)

Guo Xueli ( 郭学利 )

Dept. Vascular Surgery, First Affiliated
Hospital
 Veins
The most important disease processes
affecting veins are two:
varicosity and thrombosis
Varicose vein
A varicose vein
---dilated, lengthened and tortuous
It’s reason---increased pressure in the lumen of the vein,
which stretches the vein wall.
Stretching in the transverse axis
---dilatation of the vein
Stretching in the longitudinal direction
---to become tortuous in order to
accommodate its additional length
The causes of the increased pressure
in the lumen of the vein:
the aetiology differs--- according to the site and
underlying pathology
Vein in the submucosa of the lower end of the
oesophagus(oesophageal varices)
---increased pressure in the portal venous
system, due to cirrhosis etc.
Vein in the lower limbs---their valves
become functionless (incompetent)
The incompetent valve
---commonly at the termination of
the long saphenous vein.
---sometimes at a site lower down
the limb
Varicose vein in the lower limbs

#an extremely common condition in

European and American
#uncommon in the Eastern countries
---the most likely explanation:
the inhabitants have better veins.
Aetiology
the most common lesion
---an incompetent (functionless) valve
such cases---primary varicose vein, and constitute
the vast majority of cases.
secondary varicose vein---any causes of venous
obstruction, e.g. tumour or pregnancy, and
thrombosis of the deep veins.
varicose veins in children and adolescents
---due to a congenital arteriovenous fistula
or an extensive cavernous haemangioma.
Pathology of primary varicose vein
In the upright position:
1.With each muscle contraction, blood is
bumped upward and prevented from returning
by the valves in the veins.
2.the pressure in the deep vein---reduced
3.blood in the superficial veins to empty into
---the deep vein, ready to be pumped upwards
with the the next muscle contraction.
The valves in the superficial veins ensure that
1.only a short segment---empty through the
corresponding perforating vein
2.widespread transfer of blood from superficial to
deep vein---is prevented
Extensive incompetence in the superficial valves
blood to spill over from deep veins---at high level
down the superficial veins
Finally to enter the deep vein---at lower level
these vein fall slack after muscle contraction
Such a retrograde circuit---based on an
incompetent long or short saphenous vein.
its upper end ---the source
its main stem and branches---the pathway of
incompetence
one or more perforating vein---reentry points
#removal of the source and the pathway of
incompetence
#enlarged reentry points(the perforators)---to be
closed off
The main valves:
1.the termination of the long saphenous vein
into the femoral vein.
2. the termination of the short saphenous vein
into the popliteal vein.
3.the mid-thigh
4.on either side of the tibia and fibula where
there are communication (perforators)
passing through openings in the deep fascia
above the ankle.
Symptoms
#a tired and aching sensation
---in the leg, specially the calf,
towards the evening.
#itching of the skin over the varices
Examination
The varicosities
---most commonly distributed along the
course of the long saphenous vein
---less often, the short saphenous vein
Identifying the location of the incompetent
valve
to identify the exact location ---ligation at
exact sites, to abolish the retrograde
flow of blood.
Selective occlusion (Trendelenberg) test
(Valves functional test)
1.lies down and the limb is elevated to empty the
veins.
2.the suspected pathway of incompetence is
selectively occluded by compression with
fingertips.
3.stands up and the varicose is observed. After a
few seconds the compression is removed.
The vein fills promptly only at this stage
---the varicose vein fills by down flow
So its valves---incompetent, the test---positive

This test ---great diagnostic value

Positive---accurately identify simple(primary)
varicose veins
Negative --- to look for the real source of
incompetence
Testing for patency of the deep venous system
before any surgical treatment---to know whether
or not the deep venous system is patent.
Selective perthes’ test
1.stands up so that the vein are well filled
2.the suspected pathway of incompetence---
compressed with fingertips or a tourniquet .
3.the patient asked to rise on his toes---10 times.
The veins---visibly less prominent and soft
The test---positive
the deep vein pumping mechanism---functioning satisfactorily,
fault--- in the superficial vein.
Directional Doppler flowmetry
---to found the downflow
Photoplethysmography
---to determine the venous refilling time
incompetent valves---shortened
Ultrasonography---to found the downflow
Venography---to found the downflow
Treatment
Varicose veins without venotensive changes
treatment---cosmetic, symptomatic or definitive
cosmetic method
varicose veins---appropriate make-up or elastic
support stockings
Symptomatic method
heaviness or tiredness---relieved by elastic
stockings and elevation of the limbs whenever
Definitive method
---sclerotherapy or surgery
Compression sclerotherapy
only a few minor varicosities
---by injecting a sclerosing agent in solution,
which causes thrombosis
The resultant fibrosis---the vein to shrink down
in size, or even get obliterated.
Surgical treatment
the first necessary --- to know the sites of the
incompetent superficial valves
---to know whether the deep
vein are patent or not
1.the deep vein---patent, the deep valves and
perforators---competent
surgical results---very good
2. the deep vein---patent, the deep valves---
competent, but perforators---incompetent
surgical results---reasonable
3. the deep vein---obstruction
superficial venous ligation and stripping
---not be carried out
because a marked worsening of the situation
---usually occurs
#The basic principle of the operative treatment is
the ligation
1.incompetence at the sapheno-femoral junction---
ligation at this site, the termination of long
saphenous vein.
2.saphenopopliteal ligation, the termination of short
saphenous vein.
3.incompetence perforating veins are individually
located by tourniquet tests and marked;next
isolated by dissection and ligated.
Not to damage or destroy normal competent
saphenous veins---for coronary bypass operation
#Stripping
Apart from ligation, the varicose vein---may by
excised.
Complications of varicose vein:
Thrombophlebitis ---red and tender.
elastic bandage ---applied over foam rubber pads.
Eczema ---the patient scratches the skin which
itches. An ointment containing hydrocortisone
or zinc oxide and coal tar
Haemorrhage---a varicose vein may rupture and
bleed furiously.
#Press the bleeding point.
#A bandage to be applied over a sterile gauze pad.
#The leg should be elevated over 1 or 2 pillows.
to elevate the leg without compressing the
bleeding point---dangerous; air can enter the
vein---air embolism
Venous ulcer(Gravitational ulcer,Varicose ulcer)
---chronic, tend to recur, and cause considerable
disability
---follow either varicose veins or deep thrombosis
The cause---venous stasis, results in---local anoxia
and oedema.
---signs:dermatitis, brown discoloration,
thickening of skin and oedema.
---the site:lies on the anteromedial surface of the
tibia just above the medial malleolus.
Syphilis---must be excluded by serological tests
Atherosclerotic ischaemia---by checking the
peripheral pulses
The Doppler ultrasound---may be employed
Malignant change---a long-standing ulcer
(Marjolin’s ulcer)
The pathophysiology---not fully understood
In a patient--- the high venous pressure in the deep
vein transmitted to the superficial venous system
---extravasation of plasma and blood cell, the
subcutaneous tissue---firm with a leathery feel.
Venous ulcer heal promptly---after ambulatory
treatment or ligation operations
Post-thrombotic ulcers---to be refractory to
treatment---require bed-rest and skin grafting
The bisgaard method---
The limb is elevated, passive and active movements.
A firm elastic bandage is next applied from the base
of the toes to the knee and the patient encouraged to
walk.
Movements in walking alternatively stretch and relax
the bandage and produce a venous pumping effect.
The treatment of incompetent perforators
subfascial ligation---ligation under the deep
fascia, a theoretically sound procedure.
---employed by some
abandoned by others
Thrombosis
The main factors:
1.Change in the vessel wall, usually damage
to the endothelium, as in injury or
inflammation.
2.Diminished rate of blood flow, as after
operation.
3.increased coagulability of blood, as in
infections and after haemorrhage.
The pathological effects of thrombosis
1.locally, the clot---dissolved and the vein---
recanalized. Alternatively, the clot---organize
into fibrous tissue.
specially the thrombus---infected, an abscess---
form, or pyaemia---occur due to systemic spread
of the infection.
in the pelvic veins a clot---calcifies, may look
like a stone.
2. Distally
the vein---remains blocked, a collateral
circulation---soon opens up, by the appearance
of tortuous superficial veins.
3. Proximally
the clot---extend into the larger veins
a portion of the thrombus---become detached---get
lodged in a branch of the pulmonary artery---
pulmonary infarction.
an infected thrombus---lodged in the portal
vein---the formation of abscesses in the liver
(pylephlebitis)
Thrombosis in the superficial veins---
commonly accompanied by inflammation
(thrombophlebitis),
while in the deep veins---no phlebothrombosis.
Superficial venous thrombosis(Thrombophlebitis)
Occur in the following:
1.in a grossly varicose vein
2.in occult malignant neoplasms
3.in local trauma
4.in a vein cannulated for infusion
5.in polycythaemia and thromboangiitis
obliterans
Clinical feature
at the site of the vein ---a painful, red and tender
cord
Treatment
thrombophlebitis---below the knee
usually self-limiting,
the risk of thromboembolism---minimal
anticoagulation---not needed
thrombophlebitis---above the knee
embolization---occur
the patients---closely observed for cephalad
progression of thrombus
Bed rest and a crepe bandage
Aspirin---relieves pain
---reduces the coagulability of the blood
An abscess---be drained, along with proximal
and distal ligation of the vein
Anticoagulation ---to prevent pulmonary
embolism
Deep vein thrombosis (Phlebothrombosis)
the thrombus---to embolize to the lungs
half the patients---no symptoms
the most common---the pelvic and calf veins
Its cause:
1.the intima is damaged(e.g. in trauma)
2.the circulation of the blood is sluggish (e.g.
major operation or debilitating illness)
3.the blood is rendered more coaguable(e.g.
operation)
More than one factor---thrombosis increased
Postoperative thrombosis
---common in middle aged and elderly person, in the
obese, and after operation on the hip and
malignancies.
The thrombosis
1.starts in a tributary of a main vein(the circulation is
sluggish)
2.extends proximally to the main vein(the faster
bloodstream)
3.break off a portion---lodges in the pulmonary
vasculature---a pulmonary embolus
‘White leg’ and ‘blue leg’
A length of deep femoral vein---thrombosed,
oedema and painful venous congestion in the
lower limb.
If the lymphatics---inflamed, a more pronounced
and persistent swelling (phlegmasia alba
dolens---‘white leg’ )
If extensive thrombosis of the iliac and pelvic
vein---infarction affect parts of the lower
limb(‘blue leg’)
Clinical findings
#half the patients---no symptoms
#a dull ache, a tight feeling, or frank pain in the calf
#slight edema and fever
The foot is passively dorsiflexed---pain in the calf
-----Homan’s sign
After extensive major operation, the calves should be
examined every day for tenderness.
Diagnostic tests
Venography ---the most specific test
Contrast medium is injected into a vein to
demonstrate the venous drainage---the
popliteal, femoral and iliac vein.
Doppler ---a practical, non-invasive method
of assessment of blood flow.
Plethysmography---useful non-invasive
technique
Magnetic resonance imaging---a reliable
method
Management of deep vein thrombosis
Prevention
Before operation:
to stop oral contraceptives---prone to develop
venous thrombosis after operation
a over-weight patient---reduce his weight
elderly patients---mobilization
heparin---subcutaneously 2hrs before operation
---be avoided in operation
During operation
the heel---be elevated on foam rubber pads
the leg---be elevated and massaged at the end of
the operation
After operation
#massage and active leg movement---be
prescribed and supervised, and dehydration
corrected.
#get onto his feet as early as possible
#low dose heparin
#dextran---inhibiting platelet adhesion
Treatment
1.the limb---be bandaged using crepe bandages
bed rest advised---until the local signs subside
2.Anticoagulation
heparin in combination with phenindione---to
prevent the propagation of the original thrombus
and the development of the new thrombi.
3.Fibrinolytics
streptokinase and recombinant tissue
plasminogen activator---lyse upto 70% of thrombi
Pulmonary embolism
Placing a Greenfield or similar filter in the
inferior vena cava---to prevent any
dislodged thrombus, allow the flow of
blood upwards through its interstices.
Thank you