Venous and Lymphatic Disorders

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1 Venous and Lymphatic Disorders. ก.

2 Venous and Lymphatic Disorders Varicose Veins Deep Vein Thrombosis (DVT) Lymphedema

3 What Is Varicose Veins? Latin: Varicose = Varix = twisted Abnormal venous dilatation diameter > 3 mm

4 What Is Varicose Veins?

5 What Is Varicose Veins?

6 Normal venous circulation of lower extremities

7 Normal venous circulation of lower extremities

8 Direction of venous blood flow

9 Direction of venous blood flow

10 Direction of venous blood flow One way circulation

11 Most common cause of varicose veins: Valvular Reflux ก

12 Reflux (sapheno-femoral incompetence)

13 Pathogenesis Varicose veins Genetic Hormonal Pregnancy Position Progesterone > Estrogen 2 nd -half of menstrual period blood volume uterus size (obstruct venous return) hormone Cross-leg Tight pants

14 Varicose veins Pathophysiology Primary Reflux (valvular incompetence): most common

15 Incompetent saphenofemoral junction/ saphenous vein Most common cause

16 Varicose veins Pathophysiology Primary Reflux (valvular incompetence): most common Perforator incompetence

17 Incompetent perforators

18 Varicose veins Pathophysiology Primary Secondary Reflux (valvular incompetence): most common Perforator incompetence Obstruction (in deep vein) Deep vein thrombosis Pelvic tumors May-Thurner syndrome

19 Obstruction (in deep vein)

20

21 Varicose veins Symptoms 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 size

22 Varicose veins Trendelenberg Test Perthes test

23 Varicose veins CEAP classification C Clinical classification E Etiology A Anatomy P Pathology

24 Varicose veins CEAP classification C-0 Normal C-1 Spider veins, telangiectasias C-2 Varicose veins C-3 Varicose veins + edema C-4 Skin changes C-5 Skin changes w healed ulcer C-6 Skin changes w active ulcer

25 C-1 Spider veins, telangiectasias C-1 C-1

26 C-2 Varicose veins C-3 Varicose veins + edema C-2 C-2-3

27 C-4 Skin changes Hyperpigmentation Venous eczema C-4 Lipodermatosclerosis

28 C-5 Skin changes w healed ulcer C-5

29 C-6 Skin changes w active ulcer C-6

30 Varicose veins Treatment Sclerotherapy Saphenous vein ablation Stripping Endovenous surgery

31 ก ก (sclerotherapy) 1% Aethoxysclerol

32 ก ก (sclerotherapy) ก ( 30) 70-90% 7-14 ก

33 Sclerotherapy

34 Sclerotherapy

35 ก ก (sclerotherapy)

36 Varicose veins Treatment Saphenous vein ablation Stripping Endovenous surgery

37 Venous stripping

38 ก ก ก (venous stripping)

39 ก ก ก (venous stripping)

40 ก ก ก (venous stripping) Spinal block OR time 1-2 hrs Hospital stay 2 3 days Minor procedures?

41 Endo-venous surgery

42 ก ก Chronic venous ulcer 4-layer bandage

43 ก ก

44

45

46 ก ก ก ก / กก ก ก ก ( ) ก 3

47 ก ก

48 ก ก ก (compression stockings)

49 ก (compression stockings)

50 ก ก ก (compression stockings) mmhg mmhg ก ก mmhg

51 Deep Vein Thrombosis Prophylaxis and Management

52 Deep Vein Thrombosis

53

54

55 Deep Vein Thrombosis Risk factors Prevention Management

56 Risk factors: Virchow s triad Hypercoagulability Congenital hypercoagulability Malignancy Oral contraceptives Polycythemia Thrombocytosis Venous stasis Immobility Varicose veins Advanced age Congestive heart failure Obesity Endothelial Injury Trauma Recent surgery Severe infection

57 Risk factors Patient Group DVT Prevalence (%) Medical patients General surgery Major gynecologic surgery Major urologic surgery Neurosurgery Stroke Hip or knee arthroplasty, hip fracture surgery Major trauma Spinal cord injury Critical are patients 10 80

58 Deep Vein Thrombosis Prevention Graduated compression stockings Intermittent leg compression Anticoagulation

59 Prophylaxis Compression techniques Graduated compression stockings (GCS)

60 Prophylaxis Compression techniques Intermittent pneumatic compression (IPC) Flow velocities in femoral and pelvic veins Effective, up to 24 hr

61 Prophylaxis General Surgery: Risk factors Type and duration of surgery Traditional risk factors: cancer, previous DVT, obesity, varicose veins, estrogen use Type of anesthesia: spinal/epidural < general General perioperative care: degree of mobilization, fluid status, transfusion

62 Recommendation: Anticoagulation Unfractioanated heparin: 5,000 units sc bid / tid or LMWH (Enoxaparin): 40 units sc daily Decrease risk of DVT > 60% Bleeding complication - same Advantage of LMWH once-daily administration Lower risk of heparin-induced thrombocytopenia (HIT) 7 th ACCP conferences on Antithrombotic and Thrombolytic Therapy 2004

63 Patient Types Medical patients with restricted mobility Hip-replacement patients Extended prophylaxis in hip-replacement patients Knee-replacement patients Dosage 40 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) 40 mg SC once a day 30 mg q12 h SC (initiated 12 to 24 hours post op) Dosing Adjustment for Severe Renal Impairment (creatinine clearance <30 ml/min) 30 mg SC once a day 30 mg SC once a day 30 mg SC once a day 30 mg SC once a day

64 Patient Types Abdominal surgery patients Unstable angina/non- Q-wave MI patients Outpatient treatment for acute DVT without PE Inpatient treatment for acute DVT with or without PE Dosage 40 mg SC once a day (initiated 2 hours preop) 1 mg/kg q 12 h SC (when concurrently administered with aspirin) 1 mg/kg q 12 h SC (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) Dosing Adjustment for Severe Renal Impairment (creatinine clearance <30 ml/min) 30 mg SC once a day 1 mg/kg SC once a day (when concurrently administered with aspirin) 1 mg/kg SC once a day (in conjunction with warfarin sodium therapy) 1 mg/kg SC once a day (in conjunction with warfarin sodium therapy)

65 Recommendation High Risk Surgery Brief procedures of < 30 min for benign disease: No need for prophylaxis Laparoscopic procedures + additional risk factors: IV heparin / LMWH / IPC / GCS All major abdomional surgery: Need for thromboprophylaxis 7 th ACCP conferences on Antithrombotic and Thrombolytic Therapy 2004

66 Wells clinical probability score 2 points = High probability of having DVT

67 Deep Vein Thrombosis Investigation D-dimer (> 500 ng/ml) Duplex Ultrasound

68 D-dimer

69 Probability of DVT Using clinical score + D-dimer Clinical score 2 points > 2 points D-dimer Negative 1% 20% D-dimer Positive 15% 80%

70 ก Deep Vein Thrombosis Assess Clinical Probability score 2 > 2 D-dimer - + Exclude DVT Ultrasound

71 Ilio-femoral DVT Acute DVT IV heparin / SC heparin / LMWH At least 5 days + Warfarin Suspicious of DVT Treatment while waiting for the test

72 Ilio-femoral DVT Unfractionated heparin IV Heparin SC Heparin 80 u/kg IV bolus 18 u/kg/h 5,000 units IV bolus 17,500 u sc bid PTT prolongation

73 Ilio-femoral DVT Low molecular weight heparin Enoxaparin 1 mg/kg sc q 12 hr 1.5mg/kg sc OD

74 Ilio-femoral DVT Warfarin : target PT-INR First episode DVT: reversible risk factor 3 months First episode DVT: idiopathic At least 6-12 months? indefinite

75 Ilio-femoral DVT Warfarin : target PT-INR Recurrent DVT Indefinite DVT with cancer Indefinite or cancer is resolved

76 Complications Acute Chronic Pulmonary Embolism Post-thrombotic Syndrome

77

78 Pulmonary emboli Sudden chest pain & dyspnea

79 Pulmonary emboli

80 Pulmonary emboli Uegently need ACLS (Oxygen,? Intubation) EKG Chest x-ray Arterial blood gas Respiratory alkalosis po 2 pco 2

81 Wells clinical probability score 4 points = High probability of having PE

82 Probability of PE Using clinical score + D-dimer Clinical score 4 points > 4 points D-dimer Negative D-dimer Positive 1.6% 11% 56%

83 ก Pulmonary Emboli Assess Clinical Probability score 4 > 4 D-dimer - + Exclude PE CT Chest

84 Treatment = DVT Pulmonary emboli IV heparin or LMWH Massive PE with hemodynamic unstable IV thrombolytic therapy Against catheter and surgical embolectomy

85 Caval filter

86 Venatech Gunther-tulip OptEase

87 Indications Caval filter Contraindication for anticoagulant treatment Complication of anticoagulant treatment Failure of anticoagulant treatment

88 Deep Vein Thrombosis Treatments Absolute bed rest 5 days Leg elevation Anticoagulation Heparin (IV = LMWH), check platelets + Warfarin (PT-INR 2-3) Compression stockings

89 Post-phlebitic syndrome

90 Post-thrombotic syndrome No treatment leg edema At 2 years: 50% developed PTS 24% severe GCS, mmhg At 2 years: 24% developed PTS <5% severe

91 Deep Vein Thrombosis Prophylaxis (?) Diagnosis - Ultrasound Management bed rest enoxaparin + warfarin Warfarin indefinite (?) GCS at leat 2 years

92 Lymphedema Clinical presentation Edema slow, progressive, painless swelling Skin changes peau d orange, pigskin ulcerations are rare

93 Causes Primary - congenital Lymphedema Secondary Filariasis Lymph node excision ± radiation Tumor invasion Trauma Infection

94

95

96

97

98 Thank you

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