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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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

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+-

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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