SYNDROME OF SYNDROME OF EDEMAEDEMA

Surgical department of TMA Surgical department of TMA for general practitionersfor general practitioners

edema is an increasing of the contents of a liquid in tissues. Thus volume in space which is not belonging to vessels. To establish edema it is possible by infringement skin fold between fingers. Thus is felt pastrylike tissue, and at taking off fingers on a skin are visible pits on a place of compression. edema can be general and local.

Lower extrem

ity anatomy

Thigh veinsThigh veins

Lower extrem

ity veins

Classification of edemas

By aetiology distinguished   1. Nephrotic syndrome edemas:   • glomerulonephritis,   • kidney amiloidosis,   • diabetic glomerulosclerosis,   • preeclampsia,   • rheumatoid polyarthritis,   • serum sickness,   • LEN,   • lymphatic leukemia,   • lymphogranulemathosis.

Classification of edemas (continuation)

2. As a result of circulatory deficiency:   • valvular defect,   • cardiosclerosis,   • decompensated cor pulmonare.   3. orthostatic hydrops.   4. pregnancy edemas.   5. edemas of joints:   • deforming arthrosis,   • infectious arthritis,   • reactive arthritis.   6. venous pathology edemas:   • deep veins acute thrombosis,   •Chronic venous insufficiency.   7.lymphedemas.   8. mixed edemas.

ChVIChVI Venous Venous trombostrombosisis

LELE NephrotNephrotic ic edemaedema

Cardiac Cardiac edemaedema

OrthostOrthostatic atic edemaedema

artralartral PregnanPregnancy cy edemasedemas

Often Often bilaterallbilaterallyy

unilaterunilateralal

primaryprimary – – bilaterabilaterall; ; secondasecondaryry – – often often unilaterunilateralal

Always Always bilaterabilaterall

Always Always bilaterabilaterall

Always Always bilaterabilaterall

Often Often bilaterabilaterall

bilaterabilaterall

Differential diagnosis of lover limb edemas

Obesity, no edema

Decompensated cardiac edema

Gonarthrosis on the right side

Venous thrombosis

Skin pigmentation on the chronic venous insufficiency

Differential diagnosis of chronic venous Differential diagnosis of chronic venous and arterial insufficiencyand arterial insufficiency

signssigns Chronic arterial Chronic arterial insufficiencyinsufficiency ( (late phaselate phase))

Chronic venous Chronic venous insufficiencyinsufficiency ( (late late phasephase))

painpain intermittent intermittent claudication claudication [Charcot's] [Charcot's] syndromesyndrome, later , later pain at restpain at rest

Absent or nagging pain Absent or nagging pain on upright positionon upright position

PsPs Weak or absentWeak or absent. . Normal, but Normal, but determining would be determining would be little bit difficult little bit difficult because of edema because of edema

Skin colourSkin colour pale skin, at hanging pale skin, at hanging becomes dark redbecomes dark red

Normal, at upright Normal, at upright position becomes position becomes cyanoticcyanotic

TemperaturTemperaturee

lowlow normalnormal

continuationcontinuation

edemaedema Absence or weakAbsence or weak.. Presence often Presence often substantalsubstantal..

Trophic Trophic changeschanges

Atrophic, nail Atrophic, nail deformationsdeformations..

Often on ankles, Often on ankles, stagnant dermatitis, stagnant dermatitis, pigmentationspigmentations

soressores Often on fingersOften on fingers.. On ankles, often on On ankles, often on medial surfacemedial surface

gangrenegangrene High riskHigh risk.. absenceabsence

Varicose dilation of lower Varicose dilation of lower extremity veinsextremity veins

Varicose expansion of veins is Varicose expansion of veins is disease, accompanying by increase disease, accompanying by increase of length and presence coiled of length and presence coiled subcutaneous veins, by saccular subcutaneous veins, by saccular expansion of their lumen expansion of their lumen

statisticsstatistics

Is observed at 17-25 % of the Is observed at 17-25 % of the populationpopulation

Patients by vein expansion Patients by vein expansion makes 2-3,3 % from makes 2-3,3 % from general( number of the surgical general( number of the surgical patientspatients

The women are fall ill 3 times The women are fall ill 3 times more often, than manmore often, than man

Varicose disease

а б

Posttrombophlebitic syndrome

acuteacute thrombophlebitisthrombophlebitis of of SUPERFICIAL SUPERFICIAL veinsveins

This is an inflammation of a vein This is an inflammation of a vein wall , accompanying by formation wall , accompanying by formation of a blood clot in its lumenof a blood clot in its lumen

pathogenesispathogenesis

1) venous wall 1) venous wall disturbanciesdisturbancies; 2) ; 2) circulatory decelerationcirculatory deceleration 3) 3) hypercoagulationhypercoagulation

signssigns

Pain upon veinPain upon vein;; Hyperemia and skin swellingHyperemia and skin swelling;; Tenderness Tenderness ;; Subfebrile temperatureSubfebrile temperature;;

TreatmentTreatment: : anticoagulantsanticoagulants;; Medicines improves rheologyMedicines improves rheology NSAIDNSAID;; Desensitizing medicines Desensitizing medicines ;; heparin containing ointmentsheparin containing ointments

treatmenttreatment

bandagingbandaging;; Measured walkingMeasured walking;; Operative interventionsOperative interventions. .

phlebothrombosisphlebothrombosis phlebothrombosis phlebothrombosis -- obstruction of a vein obstruction of a vein

by a blood clot, without preceding by a blood clot, without preceding inflammation of its wall. It is most inflammation of its wall. It is most common within the deep veins of the calf common within the deep veins of the calf of the leg (deep vein thrombosis, DVT). of the leg (deep vein thrombosis, DVT). The affected leg may become swollen and The affected leg may become swollen and tender and the clot may become detached tender and the clot may become detached and give rise to pulmonary embolism. and give rise to pulmonary embolism. Prolonged immobility, heart failure, Prolonged immobility, heart failure, pregnancy, injury, and surgery predispose pregnancy, injury, and surgery predispose to thrombosis by encouraging sluggish to thrombosis by encouraging sluggish blood flow.blood flow.

ThrombophlebitisThrombophlebitis

ThrombophlebitisThrombophlebitis is is phlebitisphlebitis (vein (vein inflammationinflammation) related to a ) related to a thrombusthrombus (blood clot). When it occurs (blood clot). When it occurs repeatedly in different locations, it is repeatedly in different locations, it is known as "Thrombophlebitis known as "Thrombophlebitis migrans" or "migrating migrans" or "migrating thrombophlebitis". thrombophlebitis".

Signs and symptomesSigns and symptomes

The following symptoms are often The following symptoms are often (but not always) associated with (but not always) associated with thrombophlebitis:thrombophlebitis:

pain in the part of the body affected pain in the part of the body affected skin redness or inflammation (not skin redness or inflammation (not

always present) always present) swelling (swelling (edemaedema) of the extremities ) of the extremities

(ankle and foot) (ankle and foot)

PreventionPrevention

Routine changing of intravenous (IV) Routine changing of intravenous (IV) lines helps to prevent phlebitis lines helps to prevent phlebitis related to IV lines. See the specific related to IV lines. See the specific disorders associated with disorders associated with thrombophlebitis for other thrombophlebitis for other preventive measures. preventive measures.

treatmenttreatment For more specific recommendations, see the particular condition. In For more specific recommendations, see the particular condition. In

general, treatment may include the following:general, treatment may include the following: analgesics (pain medications) analgesics (pain medications) anticoagulants e.g. warfarin or heparin to prevent new clot formation anticoagulants e.g. warfarin or heparin to prevent new clot formation thrombolytics to dissolve an existing clot such as intravenous thrombolytics to dissolve an existing clot such as intravenous

streptokinase. streptokinase. nonsteroidal anti-inflammatory medications (NSAIDS) such as nonsteroidal anti-inflammatory medications (NSAIDS) such as

ibuprofen to reduce pain and inflammation ibuprofen to reduce pain and inflammation antibiotics (if infection is present) selection will usually depend with antibiotics (if infection is present) selection will usually depend with

the causative agent. the causative agent. Support stockings and wraps to reduce discomfort Support stockings and wraps to reduce discomfort The patient may be advised to do the following:The patient may be advised to do the following:

Elevate the affected area to reduce swelling. Elevate the affected area to reduce swelling. Keep pressure off of the area to reduce pain and decrease the risk of Keep pressure off of the area to reduce pain and decrease the risk of

further damage. further damage. Apply moist heat to reduce inflammation and pain. Apply moist heat to reduce inflammation and pain. Surgical removal, stripping, or bypass of the vein is rarely needed but Surgical removal, stripping, or bypass of the vein is rarely needed but

may be recommended in some situations. may be recommended in some situations.

Chronic venous insufficiency or CVI is a Chronic venous insufficiency or CVI is a medical condition where the veins medical condition where the veins cannot pump enough oxygen-poor blood cannot pump enough oxygen-poor blood back to the heart. It is sometimes back to the heart. It is sometimes referred to as an "impaired referred to as an "impaired musculovenous pump", this is due to musculovenous pump", this is due to damaged or "incompetent" valves as may damaged or "incompetent" valves as may occur after occur after deepdeep veinvein thrombosisthrombosis (when (when the disease is called the disease is called postthromboticpostthrombotic syndromesyndrome) or ) or phlebitisphlebitis. Paratroopers, . Paratroopers, utility pole linemen, and men with leg utility pole linemen, and men with leg injuries can suffer from damaged leg injuries can suffer from damaged leg vein valves and develop this condition. vein valves and develop this condition. Ordinarily, women make up the largest Ordinarily, women make up the largest demographic for this problem.demographic for this problem.

Chronic venous insufficiencyChronic venous insufficiency

What are the symptoms of What are the symptoms of chronic venous insufficiency?chronic venous insufficiency?

The seriousness of CVI, along with the complexities of The seriousness of CVI, along with the complexities of treatment, increase as the disease progresses. That’s why treatment, increase as the disease progresses. That’s why it is very important to see your doctor if you have any of it is very important to see your doctor if you have any of the symptoms of CVI. The problem will not go away if you the symptoms of CVI. The problem will not go away if you wait, and the earlier it is diagnosed and treated, the better wait, and the earlier it is diagnosed and treated, the better your chances of preventing serious complications.your chances of preventing serious complications.

Symptoms include: Symptoms include: Swelling in the lower legs and ankles, especially after Swelling in the lower legs and ankles, especially after

extended periods of standing extended periods of standing Aching or tiredness in the legs Aching or tiredness in the legs New varicose veins New varicose veins Leathery-looking skin on the legs Leathery-looking skin on the legs Flaking or itching skin on the legs or feet Flaking or itching skin on the legs or feet Stasis ulcers (or venous stasis ulcers) Stasis ulcers (or venous stasis ulcers)

If CVI is not treated, the pressure and swelling increase If CVI is not treated, the pressure and swelling increase until the tiniest blood vessels in the legs (capillaries) burst. until the tiniest blood vessels in the legs (capillaries) burst. When this happens, the overlying skin takes on a reddish-When this happens, the overlying skin takes on a reddish-brown color and is very sensitive to being broken if brown color and is very sensitive to being broken if bumped or scratched.bumped or scratched.

At the least, burst capillaries can cause local tissue At the least, burst capillaries can cause local tissue inflammation and internal tissue damage. At worst, this inflammation and internal tissue damage. At worst, this leads to ulcers, open sores on the skin surface. These leads to ulcers, open sores on the skin surface. These venous stasis ulcers can be difficult to heal and can become venous stasis ulcers can be difficult to heal and can become infected. When the infection is not controlled, it can spread infected. When the infection is not controlled, it can spread to surrounding tissue, a condition known as cellulitis.to surrounding tissue, a condition known as cellulitis.

CVI is often associated with varicose veins, which are CVI is often associated with varicose veins, which are twisted, enlarged veins close to the surface of the skin. twisted, enlarged veins close to the surface of the skin. They can occur almost anywhere, but most commonly They can occur almost anywhere, but most commonly occur in the legs.occur in the legs.

What are the risk factors for What are the risk factors for chronic venous insufficiency?chronic venous insufficiency?

If you have risk factors for CVI, you are more If you have risk factors for CVI, you are more likely than other people to develop the disease. likely than other people to develop the disease. The most important risk factors are: The most important risk factors are:

Deep vein thrombosis (DVT) Deep vein thrombosis (DVT) Varicose veins or a family history of varicose Varicose veins or a family history of varicose

veins veins Obesity Obesity Pregnancy Pregnancy Inactivity Inactivity Smoking Smoking Extended periods of standing or sitting Extended periods of standing or sitting Female sex Female sex Age over 50 Age over 50

As functional venous valves are required to As functional venous valves are required to provide for efficient blood return from the provide for efficient blood return from the lower extremities, CVI often occurs in the veins lower extremities, CVI often occurs in the veins of the legs. Itching (pruritis) is sometimes a of the legs. Itching (pruritis) is sometimes a symptom, along with hyperpigmentation of the symptom, along with hyperpigmentation of the legs. Symptoms of CVI include phlebetic legs. Symptoms of CVI include phlebetic lymphedema and chronic swelling of the legs lymphedema and chronic swelling of the legs and ankles. The skin may react with and ankles. The skin may react with varicosevaricose eczemaeczema, local inflammation, discoloration, , local inflammation, discoloration, thickening, and an increased risk of thickening, and an increased risk of ulcersulcers and and cellulitiscellulitis. The condition has been known since . The condition has been known since ancient times and Hippocrates used bandaging ancient times and Hippocrates used bandaging to treat it. It is better described as to treat it. It is better described as chronic chronic peripheral venous insufficiencyperipheral venous insufficiency

Venous valve incompetence is treated conservatively Venous valve incompetence is treated conservatively with manual compression lymphatic massage with manual compression lymphatic massage therapy, skin lubrication, sequential compression therapy, skin lubrication, sequential compression pump, ankle pump, compression stockings, blood pump, ankle pump, compression stockings, blood pressure medicine, frequent periods of rest elevating pressure medicine, frequent periods of rest elevating the legs above the heart level and using a 7-inch bed the legs above the heart level and using a 7-inch bed wedge during sleep. Surgical treatments include the wedge during sleep. Surgical treatments include the old old LintonLinton proceduresprocedures and the newer and the newer subfascialsubfascial endoscopicendoscopic perforatorperforator veinvein surgerysurgery. Some . Some experimental valve repair or valve transposition experimental valve repair or valve transposition procedures as well as some hemodynamic surgeries procedures as well as some hemodynamic surgeries are being pursued. This whole field of medicine are being pursued. This whole field of medicine while ancient is still filled with complications e.g. while ancient is still filled with complications e.g. Sometimes an artery can strangulate a vein or Sometimes an artery can strangulate a vein or sometimes an arteriovenous fistula (an abnormal sometimes an arteriovenous fistula (an abnormal connection or passageway between an artery and a connection or passageway between an artery and a vein) may be causing the apparent poor venous vein) may be causing the apparent poor venous return. return.

Patients are often encouraged to walk Patients are often encouraged to walk while wearing the prescribed medical while wearing the prescribed medical stockings and to sleep in a 6 degree stockings and to sleep in a 6 degree TrendelenburgTrendelenburg positionposition.[] Obese or .[] Obese or pregnant patients might be advised by pregnant patients might be advised by their physicians to forgo the tilted bed.their physicians to forgo the tilted bed.

Surprisingly, leech therapy long ago Surprisingly, leech therapy long ago abandoned by medicine, can actually be abandoned by medicine, can actually be beneficial treatment.[] The leeches draw beneficial treatment.[] The leeches draw out the excess venous blood that has out the excess venous blood that has CO2 and metabolic wastes in a CO2 and metabolic wastes in a measured amount with little danger of measured amount with little danger of dropping the blood volume.[]dropping the blood volume.[]

May-Thurner syndromeMay-Thurner syndrome

May-Thurner syndrome is a rare May-Thurner syndrome is a rare condition in which blood clots, called condition in which blood clots, called deepdeep venousvenous thrombosisthrombosis (DVT), occur in (DVT), occur in the iliofemoral vein due to the iliofemoral vein due to compression of the blood vessels in the compression of the blood vessels in the leg. The specific problem is leg. The specific problem is compression of the left common iliac compression of the left common iliac vein by the overlying right common vein by the overlying right common iliac artery.[] This leads to pooling or iliac artery.[] This leads to pooling or stasis of blood, predisposing the stasis of blood, predisposing the individual to the formation of blood individual to the formation of blood clots.clots.

How is chronic venous How is chronic venous insufficiency treated or insufficiency treated or

managed?managed? Like any disease, CVI is most treatable in its earliest stages. Like any disease, CVI is most treatable in its earliest stages.

Vascular medicine or vascular surgery specialists typically Vascular medicine or vascular surgery specialists typically recommend a combination of treatments for people with CVI. recommend a combination of treatments for people with CVI. Some of the basic treatment strategies include: Some of the basic treatment strategies include:

Avoid long periods of standing or sittingAvoid long periods of standing or sitting: If you must take a : If you must take a long trip and will be sitting for a long time, flex and extend your long trip and will be sitting for a long time, flex and extend your legs, feet, and ankles about 10 times every 30 minutes to keep the legs, feet, and ankles about 10 times every 30 minutes to keep the blood flowing in the leg veins. If you need to stand for long blood flowing in the leg veins. If you need to stand for long periods of time, take frequent breaks to sit down and elevate your periods of time, take frequent breaks to sit down and elevate your feet. feet.

Exercise regularly.Exercise regularly. Walking is especially beneficial. Walking is especially beneficial. Lose weightLose weight if you are overweight. if you are overweight. Elevate your legsElevate your legs while sitting and lying down, with your legs while sitting and lying down, with your legs

elevated above the level of your heart. elevated above the level of your heart. Wear compression stockings. Wear compression stockings. Take antibiotics as needed to treat skin infections. Take antibiotics as needed to treat skin infections. Practice good skin hygiene. Practice good skin hygiene. The goals of treatment are to reduce the pooling of blood and The goals of treatment are to reduce the pooling of blood and

prevent leg ulcers. prevent leg ulcers.

ChVI on the right side Primary lymphedema

Varicose disease complicated by trophic disordes

Varicose disease, skin pigmentation

Acute indurative cellulitis on VD

Circulatory trophic disorders Skin white atrophy

А. А. Arterial insufficiencyArterial insufficiency..Б. Б. Venous insufficiencyVenous insufficiency..

А Б

Arterial trophic ulcer

Trophic disorders on diabetis

Malignant ulcer on the shin.

Pyogen ulcer.

Hypertonic trophic ulcer.

Nonsurgical TreatmentNonsurgical TreatmentNonsurgical treatments include sclerotherapy and endovenous thermal Nonsurgical treatments include sclerotherapy and endovenous thermal

ablation. ablation. SclerotherapySclerotherapy involves the injection of a solution directly into spider involves the injection of a solution directly into spider

veins or small varicose veins that causes them to collapse and disappear. veins or small varicose veins that causes them to collapse and disappear. Several sclerotherapy treatments are usually required to achieve the Several sclerotherapy treatments are usually required to achieve the desired results. Sclerotherapy is simple, relatively inexpensive, and can desired results. Sclerotherapy is simple, relatively inexpensive, and can be performed in the doctor’s office. Sclerotherapy can eliminate the pain be performed in the doctor’s office. Sclerotherapy can eliminate the pain and discomfort of these veins and helps prevent complications such as and discomfort of these veins and helps prevent complications such as venous hemorrhage and ulceration. It is also frequently performed for venous hemorrhage and ulceration. It is also frequently performed for cosmetic reasons.cosmetic reasons.

Endovenous thermal ablationEndovenous thermal ablation is a newer technique that uses a laser or is a newer technique that uses a laser or high-frequency radio waves to create intense local heat in the affected high-frequency radio waves to create intense local heat in the affected vein. The technology is different with each energy source, but both forms vein. The technology is different with each energy source, but both forms of local heat close up the targeted vessel. This treatment closes off the of local heat close up the targeted vessel. This treatment closes off the problem veins but leaves them in place so there is minimal bleeding and problem veins but leaves them in place so there is minimal bleeding and bruising. Compared with ligation and stripping, endovenous thermal bruising. Compared with ligation and stripping, endovenous thermal ablation results in less pain and a faster return to normal activities, with ablation results in less pain and a faster return to normal activities, with similar cosmetic results.similar cosmetic results.

Can chronic venous Can chronic venous insufficiency be prevented?insufficiency be prevented?

To reduce your risk of developing CVI, To reduce your risk of developing CVI, follow these guidelines:follow these guidelines:

Eat a healthy balanced diet. Eat a healthy balanced diet. Quit smoking. Quit smoking. Exercise regularly. Exercise regularly. Avoid wearing restrictive clothing Avoid wearing restrictive clothing

such as tight girdles or belts. such as tight girdles or belts. Lose weight if you are overweight. Lose weight if you are overweight. Avoid prolonged sitting or standing. Avoid prolonged sitting or standing.

Septic pelvic Septic pelvic thrombophlebitisthrombophlebitis

Septic pelvic thrombophlebitis and septic ovarian vein Septic pelvic thrombophlebitis and septic ovarian vein thrombophlebitis are seen principally as complications of thrombophlebitis are seen principally as complications of puerperal infections and of septic abortions. It occurs puerperal infections and of septic abortions. It occurs approximately 1 in 3,000 vaginal deliveries and 1 in 2000 approximately 1 in 3,000 vaginal deliveries and 1 in 2000 times Caesarean sections. Factors contributing to the times Caesarean sections. Factors contributing to the pathogenesis of gonadal vein thrombophlebitis include stasis pathogenesis of gonadal vein thrombophlebitis include stasis of blood, increased levels of procoagulants, and endothelial of blood, increased levels of procoagulants, and endothelial damage. damage. Gonadal vein thrombophlebitis can also be seen after Gonadal vein thrombophlebitis can also be seen after gynaecological surgery or pelvic inflammatory disease. gynaecological surgery or pelvic inflammatory disease. Anaerobic bacteria are often involved, resulting in septic Anaerobic bacteria are often involved, resulting in septic pelvic thrombophlebitis. Bacterial organisms spread within pelvic thrombophlebitis. Bacterial organisms spread within thrombosed veins. Intermittent septicaemia results in septic thrombosed veins. Intermittent septicaemia results in septic pulmonary emboli and metastatic abscesses. pulmonary emboli and metastatic abscesses.

Clinically, the patient with septic pelvic thrombophlebitis Clinically, the patient with septic pelvic thrombophlebitis most present with fever of unknown origin in the postpartum most present with fever of unknown origin in the postpartum period. Once the diagnosis is suspected, the administration of period. Once the diagnosis is suspected, the administration of heparin quickly reduces the fever. Traditionally, resolution of heparin quickly reduces the fever. Traditionally, resolution of the fever within 24 hours of heparin administration confirms the fever within 24 hours of heparin administration confirms the diagnosis thrombophlebitis.the diagnosis thrombophlebitis.

Perineal varicose

Laparoscopy. Varicose of left ovarian veins

Pathologies associated with Pathologies associated with IVCIVC

Health problems attributed to the IVC are most often Health problems attributed to the IVC are most often associated with it being compressed (ruptures are rare associated with it being compressed (ruptures are rare because it has a low intraluminal because it has a low intraluminal pressurepressure). Typical ). Typical sources of external pressure are an enlarged sources of external pressure are an enlarged aortaaorta ( (abdominalabdominal aorticaortic aneurysmaneurysm), the ), the gravidgravid uterusuterus ( (aortocavalaortocaval compressioncompression syndromesyndrome) and abdominal maligancies, ) and abdominal maligancies, such as such as colorectalcolorectal cancercancer, , renalrenal cellcell carcinomacarcinoma and and ovarianovarian cancercancer. Since the inferior vena cava is primarily a . Since the inferior vena cava is primarily a right-sided structure, unconscious pregnant females right-sided structure, unconscious pregnant females should be turned on to their left side (the should be turned on to their left side (the recoveryrecovery positionposition), to relieve pressure on it and facilitate venous ), to relieve pressure on it and facilitate venous return. In rare cases, straining associated with return. In rare cases, straining associated with defecationdefecation can lead to restricted blood flow through the can lead to restricted blood flow through the IVC and result in IVC and result in syncopesyncope (fainting). (fainting).33

Occlusion of the IVC is rare, but considered life-Occlusion of the IVC is rare, but considered life-threatening and is an emergency. It is associated with threatening and is an emergency. It is associated with deepdeep veinvein thrombosisthrombosis, , IVC IVC filtersfilters, , liverliver transplantationtransplantation and and instrumentation (e.g. instrumentation (e.g. cathetercatheter in the in the femoralfemoral veinvein).).44

Collaterals at Collaterals at v.cava thrombosisv.cava thrombosis::

1.1. V. V. thoracoepigastrica;thoracoepigastrica;

2.2. V. circumflexa V. circumflexa ileum superfacialis;ileum superfacialis;

3.3. V. cutanea V. cutanea abdominis.abdominis.

1

2

3

ThromboThromboemboly emboly consequences consequences

Inferior vena cava thrombosis is Inferior vena cava thrombosis is usually a side effect of IVC filters. If usually a side effect of IVC filters. If the thrombosis is left untreated the the thrombosis is left untreated the IVC may shrivel away and become IVC may shrivel away and become atretic. This can make the problem atretic. This can make the problem even worse and prevent treatment. even worse and prevent treatment. Inferior vena cava thrombosis can Inferior vena cava thrombosis can cause the IVC syndrome. cause the IVC syndrome.

vena cava thrombosis can vena cava thrombosis can cause the IVC syndrome.cause the IVC syndrome.

Inferior vena cava filter with thrombus Inferior vena cava filter with thrombus that extends above, but mainly below. that extends above, but mainly below. Notice clot burden in the IVC below the Notice clot burden in the IVC below the filterfilter

Inferior vena cava thrombosis Inferior vena cava thrombosis consequencesconsequences

Thrombosis of the IVC is usually symptomatic. Thrombosis of the IVC is usually symptomatic. The IVC syndrome is not subtle. People suffer The IVC syndrome is not subtle. People suffer from from swollenswollen legslegs, heaviness and pain. A severe , heaviness and pain. A severe form of the post-phlebitic syndrome can occur.form of the post-phlebitic syndrome can occur.

A rare A rare consequenceconsequence ofof inferiorinferior venavena cavacava thrombosisthrombosis isis caudacauda equinaequina syndromesyndrome. The . The thrombus can extend from the IVC into the thrombus can extend from the IVC into the lumbar veins. This may cause elevated pressure lumbar veins. This may cause elevated pressure on the spinal cord and paralysis. Patients with on the spinal cord and paralysis. Patients with lumbar vein thrombosis can have difficulty lumbar vein thrombosis can have difficulty walking and problems with bowel control.walking and problems with bowel control.

Treatment of inferior vena Treatment of inferior vena cava thrombosiscava thrombosis

The best treatment for inferior vena cava thrombosis The best treatment for inferior vena cava thrombosis is prevention. is prevention. IVC IVC filtersfilters areare thethe mainmain causecause forfor thisthis conditioncondition. Therefore . Therefore IVC IVC filtersfilters should only be used should only be used for proper indications. If an IVC filter is inserted it for proper indications. If an IVC filter is inserted it should be a retrievable one. The filter needs to come should be a retrievable one. The filter needs to come out as soon as possible. If the filter cannot be out as soon as possible. If the filter cannot be removed, anticoagulation should be given indefinitely.removed, anticoagulation should be given indefinitely.

Inferior vena cava thrombosis can also be treated by Inferior vena cava thrombosis can also be treated by endovascular techniques. Catheter directed endovascular techniques. Catheter directed techniques can remove the clot. This uses mechanical techniques can remove the clot. This uses mechanical thrombectomy and pharmacological thrombolysis. thrombectomy and pharmacological thrombolysis. Success rate is limited as there is often much clot to Success rate is limited as there is often much clot to cross. Sometimes stents are placed in the IVC after cross. Sometimes stents are placed in the IVC after the procedure. This is not a simple procedure and the procedure. This is not a simple procedure and patients should be chosen carefully. On the other patients should be chosen carefully. On the other hand, if the procedure is successful, results can be hand, if the procedure is successful, results can be astounding.astounding.

Mondor's diseaseMondor's disease Mondor's diseaseMondor's disease (also known as "Mondor's syndrome of (also known as "Mondor's syndrome of

superficial thrombophlebitis"superficial thrombophlebitis"11) is a rare condition which involves ) is a rare condition which involves thrombophlebitisthrombophlebitis of the superficial of the superficial veinsveins of the of the breastbreast and and anterior chest wall. It sometimes occurs in the anterior chest wall. It sometimes occurs in the armarm or or penispenis..

Patients with this disease often have abrupt onset of superficial Patients with this disease often have abrupt onset of superficial pain, with possible swelling and redness of a limited area of their pain, with possible swelling and redness of a limited area of their anterior chest wall or breast. There is usually a lump present, anterior chest wall or breast. There is usually a lump present, which may be somewhat linear and tender. Because of the which may be somewhat linear and tender. Because of the possibility of the lump being from another cause, patients are possibility of the lump being from another cause, patients are often referred for often referred for mammogrammammogram and/or breast and/or breast

Mondor's disease is self limiting and generally benign. A cause is Mondor's disease is self limiting and generally benign. A cause is often not identified, but when found include trauma, surgery, or often not identified, but when found include trauma, surgery, or inflammation such as infection. There have been occasional cases inflammation such as infection. There have been occasional cases of associated malignancy. Management is with warm compresses of associated malignancy. Management is with warm compresses and pain relievers, most commonly and pain relievers, most commonly NSAIDSNSAIDS such as such as ibuprofenibuprofen..

Localisations Localisations of venous of venous disturbancies disturbancies at at MondorsdiseaMondorsdiseasesses

Subclavian Vein Subclavian Vein Thrombosis Thrombosis 

Sir James Paget first described thrombosis of the Sir James Paget first described thrombosis of the subclavian veins in 1875subclavian veins in 1875.. He coined the name gouty He coined the name gouty phlebitis to describe the spontaneous thrombosis of phlebitis to describe the spontaneous thrombosis of the veins draining the upper extremity. He observed the veins draining the upper extremity. He observed that the syndrome was accompanied by pain and that the syndrome was accompanied by pain and swelling of the affected extremity. However, he swelling of the affected extremity. However, he incorrectly attributed the syndrome to vasospasm. In incorrectly attributed the syndrome to vasospasm. In 1884, von Schrötter postulated that this syndrome 1884, von Schrötter postulated that this syndrome resulted from occlusive thrombosis of the subclavian resulted from occlusive thrombosis of the subclavian and axillary veinsand axillary veins.. In recognition of the work of these In recognition of the work of these pioneers, in 1949, Hughes coined the term Paget-von pioneers, in 1949, Hughes coined the term Paget-von Schrötter syndrome. A related condition is Schrötter syndrome. A related condition is thrombosis of the subclavian vein that is induced by thrombosis of the subclavian vein that is induced by the presence of indwelling catheters. The incidence the presence of indwelling catheters. The incidence of this condition has increased remarkably over the of this condition has increased remarkably over the past two decades because of the extensive use of past two decades because of the extensive use of catheters in patients with cancer and other chronic catheters in patients with cancer and other chronic medical conditions medical conditions

PresentationPresentation Not all patients with subclavian vein thrombosis are Not all patients with subclavian vein thrombosis are

symptomatic. Those with symptoms may present with symptomatic. Those with symptoms may present with mild-to-moderate nonpitting edema and mild cyanosis mild-to-moderate nonpitting edema and mild cyanosis of the hands and fingers on the affected side. of the hands and fingers on the affected side. Dilatation of subcutaneous collateral veins may be Dilatation of subcutaneous collateral veins may be present over the upper arm and chest. This later sign present over the upper arm and chest. This later sign may be the only clue to ASDVT in otherwise may be the only clue to ASDVT in otherwise asymptomatic patients with catheter-related venous asymptomatic patients with catheter-related venous thrombosis. In a few cases, in which the diagnosis thrombosis. In a few cases, in which the diagnosis was missed or delayed or the patient presented late, was missed or delayed or the patient presented late, the thrombus may have extended to the superior vena the thrombus may have extended to the superior vena cava. These patients show most features of the cava. These patients show most features of the superior vena cava syndrome, including face and superior vena cava syndrome, including face and neck swelling, periorbital edema, blurred vision, and neck swelling, periorbital edema, blurred vision, and some degree of facial cyanosis. some degree of facial cyanosis.

treatmenttreatment The initial treatment of subclavian vein thrombosis is The initial treatment of subclavian vein thrombosis is

conservative management, which includes rest, conservative management, which includes rest, elevation of the limb, and application of heat or warm elevation of the limb, and application of heat or warm compresses. compresses.

In a few patients who have minimal symptoms and no In a few patients who have minimal symptoms and no anatomical defects, physical therapy is always the first anatomical defects, physical therapy is always the first goal of therapy. Structured physical therapy may help goal of therapy. Structured physical therapy may help the patient lose weight and loosens the adhesions at the patient lose weight and loosens the adhesions at the site of obstruction. Physical therapy may also the site of obstruction. Physical therapy may also improve range of motion, decrease swelling, and help improve range of motion, decrease swelling, and help decrease pain. decrease pain.

The different natural histories of Paget-von Schrötter The different natural histories of Paget-von Schrötter syndrome and catheter-induced subclavian vein syndrome and catheter-induced subclavian vein thrombosis indicate different treatment protocols. thrombosis indicate different treatment protocols. Because large series of patients with this condition are Because large series of patients with this condition are lacking, the therapeutic approach to subclavian vein lacking, the therapeutic approach to subclavian vein thrombosis is mainly anecdotal. thrombosis is mainly anecdotal.

heparinheparin Unfractionated or low molecular weight heparin (LMWH) can Unfractionated or low molecular weight heparin (LMWH) can

maintain patency of the venous collaterals and reduce the maintain patency of the venous collaterals and reduce the chance of propagation of the thrombus. In all cases, heparin chance of propagation of the thrombus. In all cases, heparin therapy is followed by warfarin therapy, with an international therapy is followed by warfarin therapy, with an international normalized ratio (INR) goal of 2-3. normalized ratio (INR) goal of 2-3.

Heparin is usually the initial therapy, followed by warfarin. Heparin is usually the initial therapy, followed by warfarin. LMWH has been used for both inpatient and outpatient LMWH has been used for both inpatient and outpatient therapy. Most studies have shown that LMWH is just as therapy. Most studies have shown that LMWH is just as effective as unfractionated heparin, but the former is effective as unfractionated heparin, but the former is associated with a significant decreased incidence of venous associated with a significant decreased incidence of venous thromboembolism. thromboembolism.

Warfarin is continued for 6-9 months, and an INR of 2:3 is Warfarin is continued for 6-9 months, and an INR of 2:3 is maintained. Patients who only receive inpatient heparin and maintained. Patients who only receive inpatient heparin and are no longer on warfarin therapy are at risk of recurrence are no longer on warfarin therapy are at risk of recurrence and long-term disability. Anticoagulation is required in all and long-term disability. Anticoagulation is required in all patients for a period of 6-9 months or longer, depending on patients for a period of 6-9 months or longer, depending on the cause of the thoracic outlet syndrome. In some patients the cause of the thoracic outlet syndrome. In some patients who also have hypercoagulable disorders, the treatment is who also have hypercoagulable disorders, the treatment is lifelong. lifelong.

Superior vena cava syndromeSuperior vena cava syndrome

Superior vena cava syndrome (SVCS), Superior vena cava syndrome (SVCS), or superior vena cava obstruction or superior vena cava obstruction (SVCO), is usually the result of the (SVCO), is usually the result of the direct obstruction of the direct obstruction of the superiorsuperior venavena cavacava by malignancies such as by malignancies such as compression of the vessel wall by right compression of the vessel wall by right upper lobe upper lobe tumorstumors or or thymomathymoma and/or and/or mediastinalmediastinal lymphadenopathylymphadenopathy. The most . The most common malignancies that cause SVCS common malignancies that cause SVCS is is bronchogenicbronchogenic carcinomacarcinoma. Cerebral . Cerebral edema is rare, but if it occurs it may be edema is rare, but if it occurs it may be fatal. fatal. 11

signssigns ShortnessShortness ofof breathbreath is the most common symptom, is the most common symptom,

followed by face or arm swelling.followed by face or arm swelling. Following are frequent symptoms:Following are frequent symptoms: DyspneaDyspnea HeadacheHeadache Facial Facial edemaedema Venous distention in the neck and distended veins in Venous distention in the neck and distended veins in

the upper chest and arms the upper chest and arms Upper limb edema Upper limb edema LightheadednessLightheadedness CoughCough Edema of the neck, called the Edema of the neck, called the collar of Stokescollar of Stokes Superior vena cava syndrome usually presents more Superior vena cava syndrome usually presents more

gradually with an increase in symptoms over time as gradually with an increase in symptoms over time as malignancies increase in size or invasiveness.malignancies increase in size or invasiveness.

CauseCause Approximately 90% of cases are associated Approximately 90% of cases are associated

with a cancerous tumor that is compressing with a cancerous tumor that is compressing the superior vena cava, such as the superior vena cava, such as bronchogenicbronchogenic carcinomacarcinoma including small cell and non-small including small cell and non-small cell lung carcinoma, cell lung carcinoma, BurkittBurkitt lymphomalymphoma, , lymphoblastic lymphomas, pre-lymphoblastic lymphomas, pre-T-cellT-cell lineage lineage acuteacute lymphoblasticlymphoblastic leukemialeukemia (rare), and other (rare), and other acute leukemias. acute leukemias. SyphilisSyphilis and and tuberculosistuberculosis have also been known to cause superior vena have also been known to cause superior vena cava syndrome.3cava syndrome.3 SVCS can be caused by SVCS can be caused by invasion or compression by a pathological invasion or compression by a pathological process or by thrombosis in the vein itself, process or by thrombosis in the vein itself, although this latter is less common although this latter is less common (approximately 35% due to the use of (approximately 35% due to the use of intravascular devices). intravascular devices).

DiagnosisDiagnosis

The main techniques of diagnosing SVCS are The main techniques of diagnosing SVCS are with chest with chest X-raysX-rays (CXR), (CXR), CT CT scansscans, , transbronchial needle transbronchial needle aspirationaspiration at at bronchoscopybronchoscopy and mediastinoscopy. CXRs and mediastinoscopy. CXRs provide the ability to show mediastinal provide the ability to show mediastinal widening and may show the presenting widening and may show the presenting primary cause of SVCS. CT scans should be primary cause of SVCS. CT scans should be contrast enhanced and be taken on the neck, contrast enhanced and be taken on the neck, chest, lower abdomen and pelvis. They may chest, lower abdomen and pelvis. They may also show the underlying cause and the also show the underlying cause and the extent to which the disease has progressed.extent to which the disease has progressed.

TreatmentTreatment

Several methods of treatment are Several methods of treatment are available, mainly consisting of careful drug available, mainly consisting of careful drug therapy and surgery. Glucocorticoids (such therapy and surgery. Glucocorticoids (such as prednisone or methylprednisolone) as prednisone or methylprednisolone) decrease the inflammatory response to decrease the inflammatory response to tumor invasion and edema surrounding the tumor invasion and edema surrounding the tumor. In addition, diuretics (such as tumor. In addition, diuretics (such as furosemide) are used to reduce venous furosemide) are used to reduce venous return to the heart which relieves the return to the heart which relieves the increased pressure.increased pressure.

PrognosisPrognosis

Symptoms are usually relieved with Symptoms are usually relieved with radiation therapy within one month radiation therapy within one month of treatment. However, even with of treatment. However, even with treatment, 90% of patients die treatment, 90% of patients die within two and a half years. This within two and a half years. This relates to the cancerous causes of relates to the cancerous causes of SVC that are 90% of the cases. The SVC that are 90% of the cases. The average age of onset of disease is 54 average age of onset of disease is 54 years of age years of age

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