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Venous + Lymph short note by S.

Wichien (SNG KKU)


Anatomy 2 primary Fxn 1.transport blood to heart 2.serving as reservoir ,prevent intravascular volume oveload Venous intima -nonthrombogenic endo -endo.derived relaxing factor,PGI2 Venous valve -2 thin cusps -unidirectional blood flow -below knee--more valve -proximal vein--less valve PV,IVC,common illiac,cranial sinus => no valve 1.Lower ext 1.superficial v -GSV-->FV--at 4cm inf+lat to pubic T -SSV-->PV -prox extend of SSV (v of Giacomini) -->connect FV/GSV 2.deep v -ant TV,post TV,peroneal v--pair -PV,FV 3.perferator v -cockett--medial lower leg--post TV -boyd--10 cm BK, 2 cm medial tibia Venous sinus -thin wall,large vein -locate in soleus,gastroc m -valveless -large amount of blood can stored 2.upper ext 1.superficial v -cephalic v--lat surface-->axilla v -basilic v--medial-->deep brachial v 2.deep v -brachial v-->axilla v-->subclavian v Evaluation 1.Clinical evaluation Possible sign of superfi v.abnor 1.tortuosity 2.varicosity 3.venous saccule 4.corona phlebectatica :distend subdermal venule 5.spider angiomata :distend intradermal venule 6.superfi thrombophlebritis :warm,red,tender CVI 1.venous reflux + 2.venous obstruc -excess proteinaceous capi exudate -deposite of capi fibrin cuff -wbc trapping in skin microcircu -microvas congest + thrombosis -lipodermatosclerosis :fibrosis,chronic inflam,fat necrosis -skin pigmentation :exudate of rbc,hemosiderin deposit -ulceration :longstanding v HT Trendelenberg test -supine+elevate leg 45 -occlude GSV-->stand-->1st observe -release occlude-->2nd observe Negative result -no reflux -gradual filling Positive result -1st +ve-->bad deep+perforate v -2nd +ve-->bad GSV 2.noninvasive evaluation duplex US -std for infrainguinal DVT -valvular reflux 3.invasive evaluation Venography -adjunct for pecu/operative Tx :evaluate iliofemoral v :can't by duplex US

Venous + Lymph short note by S.Wichien (SNG KKU)


CVI -leg fatigue,discomfort,heaviness -varicose vein,pigmentation lipodermatosclerosis,venous ulcer Dx 1.Ambulatory V Pressure : AVP Venous Recovery Time : VRT -needle insert into dorsal foot v -reflect P in deep vein -10 tiptoe exercise -hi AVP--venous HT 2.plethysmography 3.duplex us Non sx Tx 1.compression tx -elastic comp stocking paste gauze boots (Unna boot) multilayer elastic wrap pneumatic compression device -below knee--30-40 mmhg -dec edema,promote ulcer healing 2.skin substitute Apligraf -commercial bilayer living skin -approximate human skin Sx Tx 1.perforator v ligation MIS -subfas.endo.perforater v sx--SEPS -pre op DUS--identify perforator v -2 incision--prox medial leg -trocar--subfascial dissection -touniquet prevent air embolism -clip perforator v -EB 5 days 2.venous reconstruction -valve transplantation :replace by axillary/brachial v -internal suture repair Venous ulcer Pathophysio 1.venous HT 2.pericapillary fibrin cuff formation 3.leucocyte adhesion+activation 4.valve+vein wall change Clinical -Hx of DVT (post thrombotic synd) :edema by position :relief by elevate -Hx of AVF -Gaiter area ulcer -eczema -hyperpigmentation -lipodermatosclerosis Ix 1.continuous wave doppler u/s -venous patency -venous reflex 2.duplex doppler u/s (B mode+pulse doppler flow) C/p -osteomyelitis -malignant ulcer Tx 1.compression -elastic bandage or -graduate compression stocking (30-40 mmhg) 2.local wound care -DB -silver sulfadiazine cream -occlusive dressing 3.Sx A.high ligation/ superficial venous stripping/ endovenous therapy:laser/RFA :sapheno-femoral/popliteal incompe B.subfascial perforating v.interrupt :perforating v.incompetence C.skin graft/free flap coverage D.venous valve reconstruction/ venous valve transfer,bypass/ endovascular stenting 4.medication -pentoxifylline 400 mg tid -micronize and purified flavinoid fraction / sulodexid

Venous + Lymph short note by S.Wichien (SNG KKU)


Varicose vein -10% of population Findings -dilated and tortous v. -telangiectasia -fine reticular varicosities Risk -obesity -female -inactivity -fam hx Primary -intrinsic abnormality of venous wall Secondary -deep/superficial venous insuff Symptom -aching -heaviness -early fatigue of affected leg -mild edema -worsen c prolong standing/sitting -relief by elevate leg above heart -thrombophlebitis -hyperpigmentation -lipodermatosclerosis -ulceration -bleeding CEAP C=clinical severity E=etiology A=anatomy P=pathophysiology Grading 0=no 1=superficial v 2=varicose v 3=ankle edema 4=lipodermatosclerosis 5=heal venous ulcer 6=open venous ulcer Treatment Elastic compression stocking -20-30 mmhg Injection sclerotherapy -<3mm diameter/telangiectasia vv -destroy venous endothelium Telangiectasia hypertonic saline 11.7-23.4% Na tetradecyl sulfate 0.125-0.25% polidocanol 0.5% Larger varicose v. Hypertonic saline 23.4% Na tetradecyl sulfate 0.5-0.75% Polidocanol 0.75-1% -wrap EB post injection 3-5 d to produce apposition of inflam vein and prevent thrombus -after remove EB,used elastic compression stocking>=3wk -c/p:allergic rxn,thrombophlebitis, pigmentation,DVT,skin necrosis Symptomatic GSV/SSV reflux (endovenous ablation technic vs sx) 1.Endovenous laser and RFA 2.saphenous v ligatipon/stripping -for large diameter or >2 cm -removed GSV -small incision--1.groin 2.just BK -c/p=ecchymosis,lymphocele,infect, numbness along saphenous n 3.Stap avulsion technique -larger varicose v -2mm incision over branch varicose -varicose is dissected from subcu

Venous + Lymph short note by S.Wichien (SNG KKU)


SVT -superficial v thrombophlebritis -c/p of catheter -hidden visceral malignancy :thrombophlebritis migran Clinical -redness,warm,tenderness -palpable cord -suppurative SVT--fever,leukocytosis Ix DUS -confirm dx + access DVT -f/u SVT in 5-7 d :SVT prox GSV can progerss to DVT Tx >1cm of SF jxn -compression -anti-inflam--indomethacin -suppurative SVT--excise vein <1cm of SF jxn -can extent into common FV :anti coag 6 mo -GSV ligation :prevent thrombus extend DVT VTE Rudolf Virchow 1.stasis of blood flow--2nd DVT 2.endo.damage --2nd DVT 3.hypercoagulability--spon DVT Dx 1.Clinical -phlegmasia alba dolen :block major deep v, spare collateral :pain,edema,blanching -phlegmasia cerulea dolens :extend to collateral :extreme pain,edema,cyanosis :compartment synd 2.duplex US -sen/spec >95% in sym pt -normal=biphasic :inspiration -- dec :iexpiration -- inc DVT -lack of compressible -lack of spon flow -loss of respi flow variation -venous distention 3.impedence plethysmography -IPG -2 electrodes 3.iodine 125 fibrinogen uptake -uptake in fibrin clot 4.venography -most definite test / gold std -fail to fill deep vein VTE prophylaxis 1.Low risk -minor sx in mobilet -risk <10% Tx--early and aggressive ambulate 2.mod risk -open gyne,uro,gen sx -risk 10-40% Tx--LMWH,mech.thromboprophylaxis 3.hi risk -hip/knee arthroplasty,hip fx -risk 40-80% Tx--LMWH, VKA (INR 2-3), mech.thromboprophylaxis Mech.thromboprophylaxis -intermittent pneumatic comp,IPC -graduate comp stocking

Venous + Lymph short note by S.Wichien (SNG KKU)


VTE Tx Goal 1.prevent mm from PE 2.prevent postphlebitic synd 1.Antithrombotic Tx -heparin 5d (INR>2)-->warfarin Unfractionated heparin -bind antithrombin -antithrombin-heparin complex -inh f.2,10 -mornitor PTT q 6 hr = 1.5-2.5x -antidote = protamine sulfate C/p 1.HIT--1-5% -heparin asso anti-plt ab (HAAbs) -stop all form heparin -give direct thrombin inh -hirudin,argatroban,bivalirudin 2.osteopenia -prolong hi-dose LMWH -bind antithrombin -no mornitoring Fondaparinux -bind antithrombin -specific inh f.10 -rare HIT Direct thrombin inhibitor (DTI) -hirudin,argatroban,bivalirudin -bind thrombin (not antithrombin) -inh fibrinogen-->fibrin -reserve for HIT pt Vit K antagonist -warfarin -inh vit k dependent f.2 7 9 10 -inh prot c,s -INR 2-3 Duration of VKA 1st episode/transient risk->3 m distal DVT/unprovoke-->3 m 1st episode/unprovoke-->at least 3 m prox DVT-->long term 2nd episode/unprovoke-->long term DVT+ancer-->until ca resolve 2.Catheter direct thrombolysis -extensive prox DVT -dec develop of post-thrombotic synd -SK,urokinase,altepase(rt-PA) -convert plasminogen-->plasmin -degradate fibrin (fibrinogenolysis) Useful in selected pt -extensive iliofemoral DVT -onset < 14d -good FC -low bleeding risk -decent life expectency 3.IVC filter I/C -develop recurrent DVT -PE despite adequate anticoagulate -pulmo HT w experience recur PE -C/I or c/p of anticoagulant C/p -insert site thrombosis -filter migration -erosion of filter into IVC -IVC thrombosis 4.Venous thrombectomy -liofemoral DVT, worsen c anticoag and impending venous gangrene -longitudinal venotomy -venous ballon embolectomy -distal thrombus--manaul pressure Extend IVC -tranperitoneal expose -control IVC below renal v -intrao venogram, if residual/stenosis -if illiac v stenosis :angioplasty + stenting -create AVF--end GSV to side SFA :maintain patency of v segment -post op heparin-->warfarin 6m PE Pulmo.thrombectomy -preterminal massive PE -fail/CI thrombolysis -posterolateral thoracotomy Percu.cath base technic -mech thrombus fragmentation -suction device

Venous + Lymph short note by S.Wichien (SNG KKU)


Lymphedema 1lymphedema 1.Congenital lymphedema -single,multiple limb,genitalia,face -edema before 2yr -asso Turner synd, Miroy synd Klippel-Trenaunay weber synd 2.lymphedema pracox -most common of 1lymph -women,childhood -foot/calf 3.lymphedema tarda -uncommon ->35 yr 2lymphedema -far common than 1lymphedema -lymphatic obstr/disruption :axilla LN dissection :XRT,trauma,malignant :infection--filariasis--most com of 2 Clinical -heaviness and fatigue limb -inc limb size--d>n -swelling dorsum of foot -toe--square off appearance -hyperkeratosis skin -fluid weeps from lymp fill vesicle -recurrent cellulitis--most com c/p Ix Lymphoscintgraphy -most common dx test -tech sulfer colloid inject subdermal -mornitor by whole gamma camera Normal -15-60 m--inguinal LN -3hr--pelvic and abdo LN Lymphedema -delay/absence transport to inguinal -inc cuta.collateral Lymphangiography -inject color dye into hand/foot -visualize lymp segment -small incision--cannulated -inject oil base dye slowly Reserve for -lymphangiectasia -lym.fistula Tx -no cure for lymphedema 1goal -minimize swelling -prevent recurrent infection 1.Compression garment -Graded compression stocking -reduce swelling -20-60 mmhg 2.bedrest, leg elevation -1st recommend intervention 3.sequestial ext pneumatic compress -intermittent pneumatic compression -adjunct 1. in supine 4.lymphatic massage 5.sx 1.excision of extra tissue -debulk redundant tissue 2Lymphaticolymphatic anas Lymphaticovenous anas -microsx

Venous + Lymph short note by S.Wichien (SNG KKU)


Upper ext thrombosis Axillary subclavian v thrombosis 1ASVT (venous thoracic outlet synd or Paget Schrotetter synd) -repetitive damage motion to subcla v -head of clavicle and 1st rib 2ASVT -more common -asso.catheter,hypecoag Tx -anticoagulation Tx--prevent PE -cath-directed thrombolytic Tx :acute symp 1ASVT -thorasic outlet syndrome :1st rib resection -residual venous stenosis :sx venous recons, ballon angiplasty Mesenteric vein thrombosis -15% of acute mesen ischemia -non specific abdo.pain,diarrhea,n/v Plain film -non specific bowel gas pattern CT -dx test of choice Tx Without peritoneal sign -adequate fluid resuscitation -bowel rest -closed observe ando.sign -heparin iv-->oral anticoag (lifelong) Peritoneal sign -urgent laparotomy -nonviable--resect,1anastomosis -if questionable--2look 24-48 hr

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