Vascular Surgery
Lec : 3
Venous System :
Varicose Veins :-
defined as tortuous dilated veins which affect
5% of adult population. M > F but most Pt.s seek for Rx. Are F.
there is +ve family history for inheritance through FOXC2 gene.
V.V develops due to defect in connective tissue and smooth
muscles in vein wall leading to secondary incompetence in the
valves , other predisposing factors are: -
1.DVT 2.Pregnancy 3.Pelvic tumors 4.Age
5.Weight and Hight- heavy weight and tall pts. are more liable.
6.Diet – Low fiber diet leads to chronic constipation which → V.Vs
7.side - left > right 8. Occupation with long standing period.
C.F :- 1. Ache in the vein after prolonged standing.
2. Ankle swelling , itching , bleeding , superficial thrombophlibitis,
ulceration. 3.Tortous dilated veins in the subcutaneous tissue
4. varicosities in the thigh are indicative of long SV incompetence
while varicosities on the back of the leg are suggestive of short SV
incompetance
5. Cough thrill –a vibration can be felt by gentle palpation through
the fingers over sapheno-femoral junction while the pt. is
coughing caused by turbulent backflow with in the varicosity.
6. Torniquet test – when tourniquet is applied round the upper
thigh after elevation of the limb and emptying of the veins can
control all lower limb varicosities indicating sapheno-femoral
junction incompetence , release of tourniquet leads to rapid refill
of varicosities confirm the Dx. Greater SV varicosity represent 80%
of cases.
Test for Lessor SV. By tourniquet placed below Knee to test
Sapheno-popliteal junction incompetence.
Duplex u/s imaging – the probe of Duplex scanner contains
multiple emitting and receiving crystals , this allow the vein to be
seen as a black void in subcutaneous and deep tissues. Directional
flow can be seen as a coulor image super-imposed on grey scale
image of the vessel , visible venous flow can be seen when
augmented by calf squeeze , the duplex image allow the vein to
be traced to its termination while compression and relaxation can
demonstrate the presence of retrograde flow( reflux).
Mx – indication for intervention /
1.cosmotic appearance esp. for female. 2.Reccurent episode of
bleeding. 3.development of skin changes.
a.if varicose vein is secondary to DVT or elderly Pt. who doesnot
not seek surgery Rx. done By use of below Knee Class 2 Elastic
compression stockings with Ankle pressuer 30mm Hg decrease to
15 mm Hg at knee level.
b. Injection seclerotherapy using Sodium Tetredecyl Sulphate is
injected directly into the superficial veins to destroy the lipid
memberane of endothelial cells which will shed leading to fibrosis
and obliteration of vein with local compression on injected veins ,
it is useful for minor varicosities and recurrent cases in calf and
lower leg.
c. Surgery – done by ligation of the communication point i.e
sapheno-femoral or Saphenopopliteal junctions and remove the
major part of incompetent trunk using Babcocks intraluminal
stripper then small tributaries are removed individually by making
minor cut downs and avulse them out from under the skin.
D.V
.
T :-
is the formation of semisolid coagulum with in the
flowing blood in the venous system , it carries high risk of
Pulmonary Embolism and Sudden death.
Etiology - 1. Change in vessel wall ( endothelial damge).
2. Stasis leads to decrease blood flow through the vein.
3. increase blood viscosity
Risk factors for DVT- 1. Pt. factors a. age b.obesity
c.varicosity d.immobility e.pregnancy f.puerperium
g.high dose Estrogene Rx h.previous DVT.
2. Disease or surgery- a.Trauma or surgery esp. pelvic , hip.
b. Malignancy eps. Pelvic or abdominal. C. Heart failure
d. Recent MI e. Lower limb paralysis f. infection
Pathology :- the thrombus usually develop in the soleal veins of
calf initially as platelet aggregate then fibrin and red cells form a
mesh until the lumen of the vein occludes , the thrombus extend
up to next large vein branch and may break off and pass through
the large veins of lower limb and IVC and through the right side of
the heart and embolise to the pulmonary arteries of the lung as
P.E. , this may totally occlude perfusion to all or part of one or
both lungs leading to acute right side heart failure with sudden
collapse and death.
Dx : –
1. Pain and Swelling in the calf of one lower limb .
2. pt. may present from start with ss of P.E e.g Dyspnea ,
hemoptasis , pleuretic chest pain.
O/E – 1. Mild pitting edema of ankle 2. Dilated superficial veins.
3. stiff calf 4.Low grade fever. 5. Tenderness over the course of
deep veins.
heart sound
nd
1.cyanosis 2. Dyspnea 3.fixed splitting of 2
-
P.E
4.pleural rub.
DVT Dx confirmed by Duplex U/S imaging which shows filling
defects in the flow and lack of copressibility.
P.E Dx confirmed by CT scan of Chest which shows filling defect in
the pulmonary arteries.
DDx of DVT is :- 1.ruptuerd backers cyst 2.calf muscle hematoma
3. thrombosed popliteal aneurysm 4.arterial ischemia.
Prophylaxis
:- pt. who are being admitted for surgery are classified to
Low , moderate and high risk group.
1.Low risk pt.- are young with minor illness who will undergo opt. which
last 30 min or less.
2. Moderate risk pt. - age >40 yr. or have debilitating illness and will
undergo major surgery.
3. High risk pt. – age >40 yr , have serious medical illness e.g CVA or MI ,
undergo major surgery with previous Hx of thromboembolism or
malignant disease.
Prophylactic methods which can be used are as following
1.good post-opt I.V hydration is simple method as the pt. will stay fasting
for about 8 hours pre-opt together with internal body response which
increase blood coagulability post-opt. and the inability of pt. to drink oral
fluid in immediate post-opt. period all this will increase blood viscosity and
make the pt highly susceptible to develop thromboembolism , therefore ;
good I.V fluid Mx is very important and it breaks the vicious circle of stasis
and increase blood viscosity
2.encourage the pt. to move his or her feet in the bed aginst some
resistance this will make the calf muscles to contract and squeeze the
blood from the venous sinusoids preventing clot formation
3. for pt.s who cannot move post-opt. e.g limb fracture we can use
graduated elastic compression stockings and external pneumatic
compression devices
4.Low-molecular weight heparin can be given subcutaneously 50 mg/Kg
body Wt. as single or in 2 divided doses
Heparin I.V infusion 1000U/hr. together with oral Warfarine
start with
–
Rx
three days then heparin stopped and Pt. kept on warfarine whose
st
for 1
dose adjusted according to PT , INR ratio which must be between 2-3 , the
pt must be kept in bed with minimum movement for 1 Wk to prevent clot
detachment since the clot inside the vein is loosely adherent to vein wall
wk and easily can detach and cause pulmonary Embolism.
st
in the 1
P.E requires 1. Thrombolytic Rx 2.Cardiac support 3.I.V fluid
4. Pulmonary Embolectomy Through Median Sternotomy and
Cardiopulmonary bypass.
