Venous and Lymphatic
Disorders
Venous and Lymphatic
Disorders
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Varicose VeinsVaricose Veins
Deep Vein Thrombosis (DVT)Deep Vein Thrombosis (DVT)
LymphedemaLymphedema
Venous and Lymphatic
Disorders
Venous and Lymphatic
Disorders
What Is Varicose Veins?What Is Varicose Veins?
Abnormal venous dilatation
diameter > 3 mm
Abnormal venous dilatation
diameter > 3 mm
Latin: Varicose = Varix = twistedLatin: Varicose = Varix = twisted
What Is Varicose Veins?What Is Varicose Veins?
What Is Varicose Veins?What Is Varicose Veins?
Normal venous circulationof lower extremities
Normal venous circulationof lower extremities
Normal venous circulationof lower extremities
Normal venous circulationof lower extremities
Direction of venous blood flowDirection of venous blood flow
Direction of venous blood flowDirection of venous blood flow
Direction of venous blood flow“One way circulation”
Direction of venous blood flow“One way circulation”
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Most common cause of varicose veins:“Valvular Reflux”
Most common cause of varicose veins:“Valvular Reflux”
Reflux (sapheno-femoral incompetence)Reflux (sapheno-femoral incompetence)
Varicose veinsVaricose veinsPathogenesisPathogenesis
GeneticHormonal Progesterone > Estrogen
2nd-half of menstrual period
Pregnancy ↑ blood volume
↑ uterus size (obstruct venous return)
↑ hormone
Position Cross-leg
Tight pants
GeneticHormonal Progesterone > Estrogen
2nd-half of menstrual period
Pregnancy ↑ blood volume
↑ uterus size (obstruct venous return)
↑ hormone
Position Cross-leg
Tight pants
Varicose veinsVaricose veins
PathophysiologyPathophysiology
PrimaryPrimary
Reflux (valvular incompetence): most commonReflux (valvular incompetence): most common
Incompetent saphenofemoral junction/
saphenous vein
Most common cause
Incompetent saphenofemoral junction/
saphenous vein
Most common cause
Varicose veinsVaricose veins
PathophysiologyPathophysiology
PrimaryPrimary
Reflux (valvular incompetence): most commonReflux (valvular incompetence): most common
Perforator incompetencePerforator incompetence
Incompetent perforatorsIncompetent perforators
Varicose veinsVaricose veins
PathophysiologyPathophysiology
PrimaryPrimary
Reflux (valvular incompetence): most commonReflux (valvular incompetence): most common
Perforator incompetencePerforator incompetence
SecondarySecondary
Obstruction (in deep vein)
Deep vein thrombosis
Pelvic tumorsMay-Thurner syndrome
Obstruction (in deep vein)
Deep vein thrombosis
Pelvic tumorsMay-Thurner syndrome
Obstruction (in deep vein)Obstruction (in deep vein)
Varicose veinsVaricose veins
SymptomsSymptoms General appearance
Aching pain
Leg heaviness
Easy to fatigue
Superficial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Venous ulcer
General appearance
Aching pain
Leg heaviness
Easy to fatigue
Superficial thrombophlebitis
External bleeding
Ankle hyperpigmentation
Lipodermatosclerosis
Venous ulcer
Symptoms are not related to varicose veins sizeSymptoms are not related to varicose veins size
Trendelenberg TestTrendelenberg Test
Varicose veinsVaricose veins
Perthes testPerthes test
Varicose veinsVaricose veins
CEAP classificationCEAP classification
C – Clinical classificationC – Clinical classification
E – EtiologyE – Etiology
A – AnatomyA – Anatomy
P – PathologyP – Pathology
Varicose veinsVaricose veins
CEAP classificationCEAP classification
C-0 – NormalC-0 – Normal
C-1 – Spider veins, telangiectasiasC-1 – Spider veins, telangiectasias
C-2 – Varicose veinsC-2 – Varicose veins
C-3 – Varicose veins + edemaC-3 – Varicose veins + edema
C-4 – Skin changesC-4 – Skin changes
C-5 – Skin changes w healed ulcerC-5 – Skin changes w healed ulcer
C-6 – Skin changes w active ulcerC-6 – Skin changes w active ulcer
C-1C-1 C-1C-1
C-1 – Spider veins, telangiectasiasC-1 – Spider veins, telangiectasias
C-2C-2 C-2-3C-2-3
C-2 – Varicose veinsC-2 – Varicose veins
C-3 – Varicose veins + edemaC-3 – Varicose veins + edema
LipodermatosclerosisVenous eczemaHyperpigmentation
C-4C-4
C-4 – Skin changesC-4 – Skin changes
C-5C-5
C-5 – Skin changes w healed ulcerC-5 – Skin changes w healed ulcer
C-6C-6
C-6 – Skin changes w active ulcerC-6 – Skin changes w active ulcer
Varicose veinsVaricose veins
TreatmentTreatment
Saphenous vein ablationSaphenous vein ablation
StrippingStripping
Endovenous surgeryEndovenous surgery
SclerotherapySclerotherapy
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SclerotherapySclerotherapy
SclerotherapySclerotherapy
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Varicose veinsVaricose veins
TreatmentTreatment
Saphenous vein ablationSaphenous vein ablation
StrippingStripping
Endovenous surgeryEndovenous surgery
Venous strippingVenous stripping
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Spinal blockSpinal block
OR time 1-2 hrsOR time 1-2 hrs
Hospital stay 2 – 3 daysHospital stay 2 – 3 days
Minor procedures?Minor procedures?
Endo-venous surgeryEndo-venous surgery
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.�������8��� ���.�������8��� ���15-20 mmHg15-20 mmHg
20-30 mmHg20-30 mmHg
30-40 mmHg30-40 mmHg
Deep Vein ThrombosisDeep Vein Thrombosis
Prophylaxis and
Management
Prophylaxis and
Management
Deep Vein ThrombosisDeep Vein Thrombosis
Risk factorsRisk factors
PreventionPrevention
ManagementManagement
Deep Vein ThrombosisDeep Vein Thrombosis
Risk factors: Virchow’s triadRisk factors: Virchow’s triad
HypercoagulabilityHypercoagulability
Congenital hypercoagulabilityCongenital hypercoagulability
MalignancyMalignancy
Oral contraceptivesOral contraceptives
PolycythemiaPolycythemia
ThrombocytosisThrombocytosis
Venous stasisVenous stasis
ImmobilityImmobility
Varicose veinsVaricose veins
Advanced ageAdvanced age
Congestive heart failureCongestive heart failure
ObesityObesity
Endothelial InjuryEndothelial Injury
TraumaTrauma
Recent surgeryRecent surgery
Severe infectionSevere infection
Patient GroupPatient Group
Medical patients 10 – 20 Medical patients 10 – 20
General surgery 15 – 40General surgery 15 – 40
Major gynecologic surgery 15 – 40Major gynecologic surgery 15 – 40
Major urologic surgery 15 – 40Major urologic surgery 15 – 40
Risk factorsRisk factors
DVT Prevalence (%)DVT Prevalence (%)
Neurosurgery 15 – 40Neurosurgery 15 – 40
Stroke 20 – 50 Stroke 20 – 50
Hip or knee arthroplasty, hip fracture surgery 40 – 60 Hip or knee arthroplasty, hip fracture surgery 40 – 60
Major trauma 40 – 80 Major trauma 40 – 80
Spinal cord injury 60 – 80 Spinal cord injury 60 – 80
Critical are patients 10 – 80 Critical are patients 10 – 80
Deep Vein ThrombosisDeep Vein Thrombosis
PreventionPrevention
AnticoagulationAnticoagulation
Intermittent leg compressionIntermittent leg compression
Graduated compression stockingsGraduated compression stockings
ProphylaxisProphylaxis
Compression techniquesCompression techniques
Graduated compression stockings (GCS)Graduated compression stockings (GCS)
Intermittent pneumatic compression (IPC)Intermittent pneumatic compression (IPC)
↑ Flow velocities in femoral and pelvic veins
↑ Flow velocities in femoral and pelvic veins
Effective, up to 24 hr Effective, up to 24 hr
ProphylaxisProphylaxis
Compression techniquesCompression techniques
ProphylaxisProphylaxis
General Surgery:General Surgery: Risk factorsRisk factors
Type and duration of surgeryType and duration of surgery
Traditional risk factors: cancer, previous DVT,
obesity, varicose veins, estrogen use
Traditional risk factors: cancer, previous DVT,
obesity, varicose veins, estrogen use
Type of anesthesia: spinal/epidural < generalType of anesthesia: spinal/epidural < general
General perioperative care: degree of mobilization,
fluid status, transfusion
General perioperative care: degree of mobilization,
fluid status, transfusion
Recommendation:
Anticoagulation
Recommendation:
Anticoagulation
7th ACCP conferences on Antithrombotic and Thrombolytic Therapy 20047th ACCP conferences on Antithrombotic and Thrombolytic Therapy 2004
Unfractioanated heparin: 5,000 units sc bid / tidUnfractioanated heparin: 5,000 units sc bid / tid
LMWH (Enoxaparin): 40 units sc dailyLMWH (Enoxaparin): 40 units sc daily
oror
Bleeding complication - sameBleeding complication - same
Decrease risk of DVT > 60%Decrease risk of DVT > 60%
Advantage of LMWH – once-daily administration
Lower risk of heparin-induced thrombocytopenia (HIT)
Advantage of LMWH – once-daily administration
Lower risk of heparin-induced thrombocytopenia (HIT)
30 mg SC once a day40 mg SC once a dayMedical patients with restricted mobility†
30 mg SC once a day
40 mg SC once a day (initiated 12 (± 3) hours preop) or 30 mg q 12 h SC (initiated 12 to 24 hours post op)
Hip-replacement patients
30 mg SC once a day40 mg SC once a dayExtended prophylaxis in hip-replacement patients
30 mg SC once a day30 mg q12 h SC (initiated 12 to 24 hours post op)
Knee-replacement patients
Patient TypesPatient Types DosageDosageDosing Adjustment for Severe Renal Impairment (creatinine clearance <30 mL/min)
Dosing Adjustment for
Severe Renal Impairment (creatinine clearance <30 mL/min)
30 mg SC once a day40 mg SC once a day (initiated 2 hours preop)
Abdominal surgery patients
1 mg/kg SC once a day (when concurrently
administered with aspirin)
1 mg/kg q 12 h SC (when
concurrently administered
with aspirin)
Unstable angina/non-Q-wave MI patients
1 mg/kg SC once a day (in conjunction with
warfarin sodium therapy)
1 mg/kg q 12 h SC (in
conjunction with warfarin
sodium therapy)
Outpatient treatment for acute DVT without PE
1 mg/kg SC once a day (in conjunction with
warfarin sodium therapy)
1.5 mg/kg SC once a day or 1 mg/kg q 12 h SC (both in conjunction
with warfarin sodium
therapy)
Inpatient treatment for acute DVT with or without PE
Patient TypesPatient Types DosageDosageDosing Adjustment for Severe Renal Impairment (creatinine clearance <30 mL/min)
Dosing Adjustment for
Severe Renal Impairment (creatinine clearance <30 mL/min)
RecommendationHigh Risk Surgery
RecommendationHigh Risk Surgery
� Brief procedures of < 30 min for benign disease:
No need for prophylaxis
� Brief procedures of < 30 min for benign disease:
No need for prophylaxis
� Laparoscopic procedures + additional risk factors:
IV heparin / LMWH / IPC / GCS
� Laparoscopic procedures + additional risk factors:
IV heparin / LMWH / IPC / GCS
� All major abdomional surgery:
Need for thromboprophylaxis
� All major abdomional surgery:
Need for thromboprophylaxis
7th ACCP conferences on Antithrombotic and Thrombolytic Therapy 20047th ACCP conferences on Antithrombotic and Thrombolytic Therapy 2004
≥ 2 points = High probability of having DVT ≥ 2 points = High probability of having DVT
Wells’ clinical probability scoreWells’ clinical probability score
Deep Vein ThrombosisDeep Vein Thrombosis
InvestigationInvestigation
Duplex UltrasoundDuplex Ultrasound
D-dimer (> 500 ng/ml)D-dimer (> 500 ng/ml)
D-dimerD-dimer
80%20%> 2 points
15%1%≤ 2 points
D-dimer PositiveD-dimer NegativeClinical score
Probability of DVT
Using clinical score + D-dimer
Probability of DVT
Using clinical score + D-dimer
D-dimer
Exclude DVT Ultrasound
≤≤≤≤ 2 ����� > 2 .:4��
Assess Clinical Probability score
4����,�������*���%W��X����8�,���Deep Vein Thrombosis
+-
Acute DVTAcute DVT
IV heparin / SC heparin / LMWHAt least 5 days+ Warfarin
IV heparin / SC heparin / LMWHAt least 5 days+ Warfarin
Suspicious of DVTSuspicious of DVT
Treatment while waiting for the test Treatment while waiting for the test
Ilio-femoral DVTIlio-femoral DVT
IV Heparin 80 u/Kg IV bolus18 u/Kg/h
SC Heparin 5,000 units IV bolus17,500 u sc bid
PTT 1.5 – 2.5 prolongation
Unfractionated heparinUnfractionated heparin
Ilio-femoral DVTIlio-femoral DVT
Low molecular weight heparinLow molecular weight heparin
Enoxaparin 1 mg/Kg sc q 12 hr
1.5mg/kg sc OD
Ilio-femoral DVTIlio-femoral DVT
Warfarin : target PT-INR 2.0-3.0Warfarin : target PT-INR 2.0-3.0
First episode DVT: reversible risk factorFirst episode DVT: reversible risk factor
3 months3 months
First episode DVT: idiopathicFirst episode DVT: idiopathic
At least 6 - 12 months
? indefinite
At least 6 - 12 months
? indefinite
Ilio-femoral DVTIlio-femoral DVT
Recurrent DVTRecurrent DVT
IndefiniteIndefinite
Warfarin : target PT-INR 2.0-3.0Warfarin : target PT-INR 2.0-3.0
DVT with cancerDVT with cancer
Indefinite or cancer is resolvedIndefinite or cancer is resolved
Ilio-femoral DVTIlio-femoral DVT
AcuteAcute
Pulmonary EmbolismPulmonary Embolism
ChronicChronic
Post-thrombotic SyndromePost-thrombotic Syndrome
ComplicationsComplications
Pulmonary emboliPulmonary emboli
Sudden chest pain & dyspneaSudden chest pain & dyspnea
Pulmonary emboliPulmonary emboli
Pulmonary emboliPulmonary emboli
Uegently needUegently need
ACLS (Oxygen,? Intubation)
EKG
Chest x-ray
Arterial blood gas
Respiratory alkalosis
↓ pO2
↓ pCO2
ACLS (Oxygen,? Intubation)
EKG
Chest x-ray
Arterial blood gas
Respiratory alkalosis
↓ pO2
↓ pCO2
≥ 4 points = High probability of having PE ≥ 4 points = High probability of having PE
Wells’ clinical probability scoreWells’ clinical probability score
56%> 4 points
11%1.6%≤ 4 points
D-dimer PositiveD-dimer NegativeClinical score
Probability of PE
Using clinical score + D-dimer
Probability of PE
Using clinical score + D-dimer
D-dimer
Exclude PE CT Chest
≤≤≤≤ 4 ����� > 4 .:4��
Assess Clinical Probability score
4����,�������*���%W��X����8�,���Pulmonary Emboli
+-
Treatment = DVTTreatment = DVT
IV heparin or LMWHIV heparin or LMWH
Pulmonary emboliPulmonary emboli
Massive PE with hemodynamic unstableMassive PE with hemodynamic unstable
IV thrombolytic therapyIV thrombolytic therapy
Against catheter and surgical embolectomyAgainst catheter and surgical embolectomy
Caval filterCaval filter
Venatech Gunther-tulip OptEase
Caval filterCaval filter
IndicationsIndications
Contraindication for anticoagulant treatmentContraindication for anticoagulant treatment
Complication of anticoagulant treatmentComplication of anticoagulant treatment
Failure of anticoagulant treatmentFailure of anticoagulant treatment
Deep Vein ThrombosisDeep Vein Thrombosis
TreatmentsTreatments
Absolute bed rest 5 daysAbsolute bed rest 5 days
Leg elevationLeg elevation
Anticoagulation Heparin (IV = LMWH), check platelets
+ Warfarin (PT-INR 2-3)
Anticoagulation Heparin (IV = LMWH), check platelets
+ Warfarin (PT-INR 2-3)
Compression stockingsCompression stockings
Post-phlebitic syndromePost-phlebitic syndrome
Post-thrombotic syndromePost-thrombotic syndrome
No treatment leg edemaNo treatment leg edema
At 2 years: 50% developed PTS24% severe
At 2 years: 50% developed PTS24% severe
GCS, 30 – 40 mmHg GCS, 30 – 40 mmHg
At 2 years: 24% developed PTS<5% severe
At 2 years: 24% developed PTS<5% severe
Prophylaxis (?)Prophylaxis (?)
Deep Vein ThrombosisDeep Vein Thrombosis
Diagnosis - UltrasoundDiagnosis - Ultrasound
Management – bed rest
enoxaparin + warfarin
Management – bed rest
enoxaparin + warfarin
Warfarin – indefinite (?)Warfarin – indefinite (?)
GCS – at leat 2 yearsGCS – at leat 2 years
LymphedemaLymphedema
Clinical presentationClinical presentation
Edema – slow, progressive, painless swellingEdema – slow, progressive, painless swelling
Skin changes – peau d’orange, pigskin
ulcerations are rare
Skin changes – peau d’orange, pigskin
ulcerations are rare
LymphedemaLymphedema
CausesCauses
Primary - congenitalPrimary - congenital
Secondary – Filariasis
Lymph node excision ± radiationTumor invasionTraumaInfection
Secondary – Filariasis
Lymph node excision ± radiationTumor invasionTraumaInfection
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