Clinical aspects of vein

Presented by:

ANKITA MISHRA

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Clinical anatomy of vein

DEEP VEINS

POSTERIOR TIBIAL

ANTERIOR TIBIAL

PERONEAL

SOLEAL

GASTROC NEMIUS

POPLITEAL

FEMORAL

ILIAC

SUPERFICIAL VEINS

LONG SAPHENOUS (LSV)

SHORT SAPHENOUS (SSV)

Anatomy of the venous system of the leg

PHYSIOLOGY OF VENOUS BLOOD FLOW

Arterial pressure

Calf musculovenous pump

Gravity

Thoracic pump

Vis a tergo of adjoining muscles

Valves in veins

VENOUS RETURN FROM LEG IS GOVERNED BY:

Foot and calf muscles act to squeeze blood out of deep veins.

One way valve allow only upward and inward flow.

During muscle relaxation blood is drawn inward thru perforating veins.

MUSCULOVENOUS PUMP

VALVE LEAFLETS ALLOW UNIDIRECTIONAL FLOW UPWARD OR INWARD.

“NONREFLUXING OF VALVES”

MAJOR VALVES-OSTIAL VALVE

PRETERMINAL VALVE

VENOUS VALVULAR FUNCTION

PATHOPHYSIOLOGY

Primary muscle pump failure

Venous obstruction

Venous valvular incompetance:

1.perforator incompetence-hydrodynamic reflux

2.sup.vein incompetence- hydrostatic reflux

3.deep vein incompetence- isolated/2°

Vein Disorders

Venous Thrombosis (Superficial and Deep Vein Thrombosis),

Thrombophlebitis

Chronic Venous Insufficiency

Varicose Veins

Chronic Venous Insufficiency

Results from obstruction of venous valves in legs or reflux of blood back through valves

Venous ulceration is serious complication

Pharmacological therapy is antibiotics for infections

Debridement to promote healing

Topical Therapy may be used with cleansing and debridement

Stages of chronic venous insufficiency

0 - no symptoms;

1 - heavy feet syndrome;

2 - intermittent edema;

3 - persistent edema, hyper- or hypopigmentation, lipodermatosclerosis, eczema;

4 - venous ulcer.

Causes

Primary

Theories of Aetiology:• Weak wall theory• Congenital valvular incompetence

Aggravating factors:• Female sex• High parity • Occupation requiring prolonged standing• Marked obesity• Constricting clothes• Estrogen intake• Deep venous thrombosis

SecondaryAnything that raises intra-abdominal pressure or raises

pressure in superficial/deep venous system

so…:

•Pregnancy

•Abdominal/pelvic mass

•Ascites

•obesity

•constipation

•thrombosis of leg veins (DVT)

•AV fistula

•Vena cava thrombose

•Large liver cysts

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.

ANY RISK FACTOR INCREASED VENOUS PRESSURE

DILATION OF VEIN WALLS

STRECHING OF VALVES-VALVULAR INCOMPETENCE

REVERSAL OF BLOOD FLOW

FAILURE OF MUSCLES TO PUMP BLOOD

VEINS DISTEND,ELONGATE,TORTOUS,POUCHED,INELASTIC AND FRIABLE

Surgical Intervention

INDICATED OR DONE FOR PREVENTION OR RELIEF OF EDEMA, FOR RECURRENT LEG ULCERS OR PAIN OR FOR COSMETIC PURPOSES

VEIN LIGATION AND STRIPPING

THE GREAT SAPHENEOUS VEIN IS LIGATED (TIED) CLOSE TO THE FEMORAL JUNCTION

THE VEINS ARE STRIPPED OUT THROUGH SMALL INCISIONS AT THE GROIN, ABOVE & BELOW THE KNEE AND AT THE ANKLES.

STERILE DRESSING ARE PLACED OVER THE INCISIONS AND AN ELASTIC BANDAGE EXTENDING FROM THE FOOT TO THE GROIN IS FIRMLY APPLIED

Keep pt. flat on bed for first 4 hrs. after surgery, elevate leg to promote venous return when lying or sitting

Medicate 30 mins. before ambulation and assist patient

Keep elastic bandage snug and intact, do not remove bandage

Monitor for signs of bleeding, esp. on 1st post-op day

if there is bleeding, elevate the leg, apply pressure over the wound and notify the surgeon

NURSING CARE AFTER VEIN LIGATION & STRIPPING

Microscopic appearance

RISK FACTORS

AgeGenderHeight

left>rightHeredity

PregnancyObesity and overweight

Posture

25-50% of adult women 15-30% of adult men

Is it an industrialized country disease? UK: 45 000 hospital admissions per year

Treatment complications

Major complications following VV surgery are relatively rare

Up to 20% morbidityInfection

HematomaPain

Nerve damage Saphenous nerve (LSV surgery)

Sural, peroneal nerve (SSV surgery)Lymphatic leak - Venous thrombosis - Vascular injury

Recurrence

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Deep Vein Thrombosis (DVT)

DVT: Blood clot in a vein located deep in the muscles of

the legs, thighs, pelvis or arms

DVT is the result of 3 principle factors

1. Reduce or stagnant blood flow in deep veins

2. Injury to the blood vessels wall

3. Increase clotting activity (hyper-coagulability

or thrombophilia)

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Risk of DVT

1. Immobilization2. Recent surgery or trauma

3. The use of medication4. Inherited or acquired hypercoagulability,

Note: Approximately 75-90% of DVT have at least one established

risk factor : Inherited thrombophilias can be identified

in 24-37% of patients

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SIGN AND SYMPTOMS

Leg pain or tenderness

Leg swelling

Increase wormth of one leg,change in skin color (redness)

Homans sign positive

Medical ManagementDeep vein thrombosis

REQUIRES HOSPITALIZATIONBED REST W/ LEGS ELEVATED TO 15-20 DEGREES ABOVE HEART LEVEL ( KNEES SLIGHTLY FLEXED, TRUNK HORIZONTAL (HEAD MAY BE RAISED) TO PROMOTE VENOUS RETURN AND HELP PREVENT FURTHER EMBOLI AND PREVENT EDEMAAPPLICATION OF WARM MOIST HEAT TO REDUCE PAIN, PROMOTES VENOUS RETURNELASTIC STOCKING OR BANDAGEANTICOAGULANTS, INITIALLY WITH IV HEPARIN THEN COUMADINFIBRINOLYTIC TO RESOLVE THE THROMBUSVASODILATOR IF NEEDED TO CONTROL VESSEL SPASM AND IMPROVE CIRCULATION

Nursing Assessmentcharacteristic of the painonset & duration of symptomshistory of thrombophlebitis or venous disorderscolor & temp. of extremityedema of calf of thigh - use a tape measure, measure both legs for comparisonIdentify areas of tenderness and any thrombosis

SURGERY if the thrombus is recurrent and extensive or if the pt. is at high risk for pulmonary embolismThrombectomy – incising the common femoral vein in the groin and extracting the clotsVena caval interruption – transvenous placement of a grid or umbrella filter in the vena cava to block the passage of emboli

Thrombophlebitis inflammation of the veins caused by

thrombus or blood clotFactors assoc. with the devt. of

Thrombophlebitis venous stasis

damage to the vessel wall hypercoagulability of the blood – oral

contraceptive usecommon to hospitalized pts. , undergone

major surgery (pelvic or hip surgery), MIPathophysiology

develops in both the deep and superficial veins of the lower extremity

deep veins – femoral, popliteal, small calf veins

superficial veins – saphenous vein Thrombus – form in the veins from

accumulation of platelets, fibrin, WBC and RBC

Thrombophlebitis•Thrombosis with infammation of superfiacial veins

•Occur spontaneously/due to minor trauma

•Can occur durin injection of sclerosing fluid for treatment

Main symptoms of thrombophlebitis

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.

Medical ManagementThrombophlebitis

bed rest with legs elevated apply moist heat

NSAID’s ( Non – steroidal anti-inflammatory drugs) -

aspirin

Homans' sign

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

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.

Pratt's test II.

Hackenbruch's test.

Scheins' test.

Delbe-Pertez test (marching test)

Loevenberg's test

Thrombectomy from femoral vein

Edema

Venous ulceration

Thanks to all…..`