Venous insufficiency

Disorder of venous circulation of extremities

Classification of venous system diseases. (A.A. Spridonov and L.I. Clioner, 1989)

• The superior vena cava and its tributaries.• Traumatic injury;• Occlusion;• Padget-Shreter's syndrome (thrombosis of

profound veins of extremity) and postthrombophlebiti\c syndrome of upper extremities;

• Syndrome of superior vena cava.• Congenital diseases (angiodysplasia)

Classification of venous system diseases. (A.A. Spridonov and L.I. Clioner, 1989)

• Inferior vena cava• Acute thrombophlebitis:

– superficial veins of lower extremities;

– profound veins of lower extremities;

– ileofemoral veins;– venous gangrene (blue

phlegmasia);

• the trunk of inferior vena cava:– embolism of pulmonary

artery.

• Postthrombophlebitic syndrome:• superficial veins;• profound veins of lower

extremities;• ileofemoral veins;• the trunk of inferior vena

cava.• Primary varicose dialtion of

superficial veins of lower extremities;

• Congenital diseases (angiodysplasia)

• Traumatic injury.

Chronic venous insufficiency is mainly caused diseases:

• varicose disease of lower extremities

• postthrombophlebitic disease• angiodysplasia

Varicose disease

• Varicose disease of subcutaneous veins is their irreversible dilation and elongation occurring due to crude pathological change of venous walls and valvular apparatus.

Postthrombophlebitic disease

• Postthrombophlebitic disease a complex of symptoms developing due to thrombosis of profound veins.

Pathogenesis chronic venous insufficiency

Stages of chronic venous insufficiency

(Expert meeting in Moscow, 2000.)

• 0 - no symptoms;• 1 - heavy feet syndrome;• 2 - intermittent edema;• 3 - persistent edema, hyper- or

hypopigmentation, lipodermatosclerosis, eczema;

• 4 - venous ulcer.

Complain

• of fatigue, • the heavy feeling and enlargement

of feet, • spasms of gastrocnemius muscle, • paresthesia, • edema of shins and feet.

Dilated varicose veins

1. interskin swollen plexuses

2. dilated varicose veins

1.

2.

Edema

• Edema usually develops by nighttime after walking or prolonged standing and disappears after a night's rest.

Hemosiderosis skin• Skin pigmentation

develops in the lower third of the shin; it is more pronounced above the inner ankle; the skin is less elastic, it becomes dry, shiny, vulnerable, fused with sclerotically degenerated fat.

• экземa

Trophic ulcer • Ulcers caused by venous

circulation disorder typically develop on the inner surface of lower third of shin, above the ankle.

• The ulcers are usually single, flat, with an even bottom; their borders are irregular, abrupt; the discharge is scarce, serous or purulent.

• If infection develops, ulcers become painful.

• Around the ulcer hemosiderosis and induration of subcutaneous fat develop.

Main symptoms of thrombophlebitis of profound veins

• Edema of the extremity • The pains are localised in the

gastrocnemius muscles as a rule, along the course of vascular bundles

• The skin of the extremity becomes cyanotic.

Main symptoms of thrombophlebitis of superficial veins

• Pains along the course of thrombotised vein.

• Examination of the thrombotic region reveals hyperemia, edema of skin.

• Palpation along the course of the vein reveals a consolidation distinctly separate from the surrounding tissues.

Classification of functional tests

1. Test enable one to judge the condition of valvular apparatus

– Trendelenburg-Trojanov's tests

– Hackenbruch's 2. Test enable of insufficient

perforating veins – Pratt's test II– Scheins' test – Thalmann's test

3. Test enable the patency of profound veins

– Delbe-Pertez test (marching test)

– Pratt-I test

Trendelenburg-Trojanov's test. • The patient lying on his

back raises one leg. When blood has drained from superficial veins, the greater subcutaneous vein is compressed in the place where it joins the femoral vein and keeping the finger there the patient is asked to rise. If venous trunks swell quickly when the finger is removed, we can conclude that the ostial valve is incompetent.

Hackenbruch's test. • Place your hand on

the thigh where the greater subcutaneous vein joins the femoral vein and ask the patient to cough. You can feel throbs over the vein which points to incompetence of ostial valve.

Pratt's test II. • After draining of subcutaneous

veins the lying patient's leg is bandaged with elastic bandage which compresses superficial veins. A tourniquet is applied on the thigh under the poupart fold. When the patient rises, another elastic bandage is applied under the thigh. Then the first bandage is removed loop after loop circling the leg with the utmost loop. The distance between the bandages should 5-6 cm. Quick filling of veins between the bandages points to an incompetent communicant vein in this place.

Scheins' test. • The patient is placed on

the back, his legs are raised. After draining of superficial veins three tourniquets are applied. The patient is asked to rise. A quick swelling of the veins between the tourniquets points to an incompetent perforating vein in this place.

Delbe-Pertez test (marching test) • A tourniquet compressing

only superficial veins is applied to the standing patient's thigh whose subcutaneous veins are maximally full. Then the patient is asked to walk in one spot for 3-5 min. If the veins deflate it means that profound veins are patent; if the veins do not deflate or swell, it means that profound veins are obliterated.

Pratt-I test • Measure the circumference

of the patient's shin, ask him to lie on his back, drain the veins by stroking them along their course. Apply elastic bandage to the legs. The patient is asked to walk for 10 min. If pains develop, it points to affection of profound veins. Enlarged circumference of the shin after walking points to impatency of profound veins.

Loevenberg's test • The cuff of Rivarocci

machine is applied to the lower third of shin and air is slowly pumped into it. If sharp pains develop when the pressure in the cuff rises to 150 mm Hg, it is characteristic of thrombophlebitis of profound veins.

Homans' sign

• Pains in gastrocnemius muscle upon dorsal flexing of the foot is characteristic of thrombophlebitis of profound veins of the extremity.

Moses' sign

• Pains in the shin upon anterior-posterior compression

Instrumental methods of examination

• ultrasound diagnostics • contrast-dye radiophlebography

Duplex scanning

Contrast-dye radiophlebography • In distal phlebography the

radiopaque substance is injected into the dorsal vein of foot while a tourniquet is applied to the lower third of shin. In proximal phlebography the radiopaque substance is injected directly into the femoral vein by puncturing.

Principles of conservative treatment for chronic venous insufficiency

• 0 stage: elastic compression (preventive or therapeutic hosiery of class I);

• 1 stage of chronic venous insufficiency:• elastic compression (therapeutic hosiery

of compression of class I-II);• occasional courses of

monopharmacotherapy.


• 2 stage of chronic venous insufficiency:• elastic compression (therapeutic hosiery

of compression of class II);• repeated courses of

monopharmacotherapy;• physiotherapy and balneology.


• 3-4 stage of chronic venous insufficiency:

• elastic compression (therapeutic hosiery of compression of class II-III);

• continuous combined pharmacotherapy;• local treatment;• physiotherapy.

The therapeutic effect of compression treatment is determined by the following

mechanism of action: • decrease of pathologic venous "capacity" of

lower extremities;• functional improvement of the insufficient

valvular apparatus;• increased resorbtion of tissue fluid in the venous

part of capillary; its decreased filtration in the arterial part;

• increased fibrinolytic activity of blood.

Рhlebotropic drugs

• detralex, • ginkor-fort, • troxevasin, • escusan, • calcium dobesilan (doxium).

Rheologic hemocorrectors

• acetylcalicylic acid, • dipiridamol, • pentoxyphylline, • low-molecular dextranes

(rheopolyglucine, rheomacrodex, rheogluman and so on)

Principles of anticoagulant therapy. • The initial dose of non-fractionated heparin is determined in

this way: the patient's weight is multiplied by 450 then the resulting figure is divided by the amount of injections.

• Thus, for fractional intravenous administration of heparin the amount of injections is 8 (every 3 hours), for intramuscular administration it is 6 (every 4 hours), for subcutaneous administration it is 3 (every 8 hours).

• Afterwards the dose of heparin is chosen individually according to the reaction of hemostasis. Blood-clotting time should increase 2-2.5 times.

• The duration of heparin therapy does not usually exceed 10-12 days. The drug is cancelled gradually by decreasing the dose.

• Two days before the end of heparin therapy patients start receiving indirect anticoagulants.

Indirect anticoagulants. • This category includes derivatives of coumarine

and fenindione. They do not affect coagulation upon direct connection with blood; they decrease blood clotting by inhibiting the synthesis of vitamin K-dependent procoagulants (factors II, VII, IX, X). The initial dose of feniline (fenindione derivative) is 0.12-0.18 g (3 times a day), on the second day the dose is 0.09-0.15 g, and afterwards - 0.03-0.06 g a day depending on the prothrombin level in blood. The effectiveness of treatment is checked with the help of prothrombin index which should decrease to 50%.

Phlebosclerosing treatment

• This method consists in introduction of sclerosing substances (fibrovein, thrombovar, etoxisclerol) into the varicose veins.

The principles of surgical treatment in chronic venous insufficiency are:

• eliminating pathological reflux of from the profound veins into superficial ones;

• removal of varicosely dilated subcutaneous veins;

• preservation of unchanged segments of the greater and lesser subcutaneous veins.

The surgery for varicose disease is a combined surgical intervention

• Trendelenburg-Trojanov-Dieterich's surgery is paraostial ligation of the greater subcutaneous vein and its accessory branches where it joins the femora vein.



• Narat's surgery is removal of varicosely dilated subcutaneous veins from separate incisions by tunneling.


• Babcock's surgery is removal of great trunks of subcutaneous veins with the help of a vein sound.

• Cocket's surgery is suprafascial ligation of communicant veins.

• Felder-Linton's surgery is subfascial ligaton of communicant veins.

Thrombectomy from femoral vein

Health & Medicine

Venous insufficiency