management of varicose veins and lymphedema

8/9/2019 Management of Varicose Veins and Lymphedema

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Management of Varicose

Veins and Lymphedema


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Venous Anatomy


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The venous system in the lower limbs is

made up of a number of complex

anatomical structures, including

principally:

! The deep venous system

"! The superficial venous system

#! $erforating veins


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Deep Venous System

The deep venous system, located in the

central axis of the leg, follows the arteries

and is surrounded by muscles and

aponeurosis! %The veins have the same

names as the arteries that they run

alongside: iliac, femoral, popliteal, fibular,

tibial veins&


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'uperficial Venous 'ystem

The superficial venous system varies greatly from one

person to another! This networ( of veins is located

primarily in the subcutaneous adipose layer, between

the wall of the s(in and the aponeurosis encasing the

muscles! The main two components of the superficial

venous system are :

) The great saphenous %or greater saphenous& vein, which

runs up the inner surface of the calf and thigh before *oining

the femoral vein,) The small saphenous %or lesser saphenous& vein, located on

the posterior surface of the calf and draining into the

popliteal vein!


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$erforating Veins

Cross the aponeurosis to link deepand superfcial veins


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$hysiology of Venous 'ystem

The main purpose of the venous system within

the general circulation, is to carry oxygen+

depleted blood rich in cell metabolism waste

bac( to the heart!t is within the legs that the stresses are the

greatest and the specific characteristics of the

venous system are the most important,

since the venous system must move blood

against the force of gravity in the standing

position !


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A combination of two main actions ensures

venous return in the lower limbs:

) -irstly, the presence of mobile anti+reflux

valves and the resistance of the vein wallsallowing the blood to move in one direction

only : from the superficial to towards the deep

venous system and from the feet to the heart!

) 'econdly, a pump mechanism which activates

and maintains the blood flow through the veins!


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The anti+reflux valves allow fluid to circulate in

one direction only, ma(ing it possible to

maintain the normal direction of venous blood

flow, even in the absence of pressure ) or inthe event of negative pressure ) and thereby

prevent bac(flow of the blood!

.ormal blood flow is directed from the

superficial towards the deep system and from

the most distal part of the body towards the

heart!


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The pump mechanism mainly results

from a combination of different forces:

The stimulation of the venous system of the foot

The muscle pump, more specifically, the

muscles of the calf %leading to alternate opening

and closing of the valves&: which is the maindriving force behind the pump mechanism,

The beating of the heart and the negative

pressure due to the phenomenon of aspiration

from the abdominal cavity that occurs during

deep breathing!


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$athophysiology of /hronic

Venous 0iseases


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! Valve nsufficiency

This may be 1uantitative or 1ualitative

) 2uantitave in the event of congenital

insufficiency in terms of valve numbers or

massive destruction due to venousthrombosis

) 2ualitative as a result of a valve being torn or

due to permeability of the valve


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"! Venous 3all 0amage

0amage to the venous wall seems to be more common than valve damage! The wall

becomes thinner at the level of the valve! The vein is dilated and pushes the valve

cusps apart, compromising their impermeability! This wall damage may be related to

damage to the innermost layer of the vein: the endothelium!

)4ereditary factors, sedentary lifestyle, age,

)0eficiency of the muscle and *oint pump

)-emale sex hormones, en5ymatic factors,

)'e1uestration of leu(ocytes and their adhesion to the endothelium

)Microcirculatory problems

)0efective vasoconstriction in the standing position

)4ypercoagulability of blood in the event of a thrombosis

0amage to valves and the venous wall under the influence of one or more of the above

factors will lead to impairment of the venous networ( of the lower limbs! t causes venous

hypertension which can lead to a chronic venous disease with tissue decompensation:

chronic venous insufficiency!


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#! Venous 4ypertension

n the supine position, the venous pressure at the an(le is 6 7mm4g and

in the sitting position, 6 77mm4g!

n the standing position, the venous pressure at the an(le, which is around

89 mm4g in a healthy individual, can exceed 99 mm4g in an individual

suffering from severe /V %chronic venous insufficiency&!

3hen wal(ing, the dynamic anatomical structures which control venousreturn are activated and the venous pressure at the an(le falls gradually

with each step until it levels out at around "9+"7 mm4g for a healthy

individual!

n the event of /V0, the venous pressure at the an(le does not fall to such

low values due to stagnation of fluid, inducing venous hypertension! n theevent of severe /V0, pressure on wal(ing can be significantly higher than

normal, reaching a value of 9 mm4g, reflecting mar(ed venous

hypertension!


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;! Visible Morphological /hanges

As a result of this excessive pressure anddefective peripheral vasoconstriction, the

venous wall gradually stretches! Varicose

veins appear!


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7! Tissue /hanges

4aemodynamically, /V0 is manifested by stagnation or stasis of

fluids leading to an increase in venous pressure %more mar(ed

distally than proximally&, combined with a reduction in venous wall

resistance and dilation of the vein diameter! All this leads to the

valve cusps being moved further apart, causing them to become

incompetent!

The increase in venous pressure is passed on to the capillaries,

causing tissue oedema and extravasation of blood elements, which

participate in the release of inflammation mediators!


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n addition, interstitial flooding creates conditionsfavourable to the formation of local tissue

ischaemia and trophic problems: atrophie

blanche, varicose ec5ema, pigmented purpuric

dermatitis, etc!


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Varicose Veins

Long, tortuousand dilatedvein

of the superficial varicose system


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$athophysiology


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'igns and 'ymptoms

Aching, heavy legs %often worse at night and after exercise&!

Appearance of spider veins %telangiectasia& in the affected leg!

An(le swelling, especially in evening!

A brownish+yellow shiny s(in discoloration near the affected

veins!

>edness, dryness, and itchiness of areas of s(in, termed

stasis dermatitis or venous ec5ema, because of waste

products building up in the leg!

/ramps may develop especially when ma(ing a sudden moveas standing up!

Minor in*uries to the area may bleed more than normal or ta(e

a long time to heal!


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4istory

4istory of venous insufficiency %eg, date of onset of visible abnormal vessels, date ofonset of any symptoms, any (nown prior venous diagnoses, any history of pregnancy+

related varices&

$resence or absence of predisposing factors %eg, heredity, trauma to the legs,

occupational prolonged standing, sports participation&

4istory of edema %eg, date of onset, predisposing factors, site, intensity, hardness,

modification after a night?s rest&

4istory of any prior evaluation of or treatment for venous disease %eg, medications,

in*ections, surgery, compression&

4istory of superficial or deep thrombophlebitis %eg, date of onset, site, predisposingfactors, se1uelae&

4istory of any other vascular disease %eg, peripheral arterial disease, coronary artery

disease, lymphedema, lymphangitis&

-amily history of vascular disease of any type


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$hysical @xamination

'urgical scars from prior intervention

$igmentations and s(in changes %lipodermatosclerosis&

Varicose veins

lcers of the medial an(le


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$alpate the saphenofemoral *unction %'-=&! t is best

palpated " fingerbreadths below the inguinal ligament

and *ust medial to the femoral artery! f reflux is present,

a forced coughing maneuver may produce a palpable

thrill or sudden expansion at this level!

The posterior surface of the calf is the territory of theshort saphenous vein! This may be palpable in the

popliteal fossa in some slender patients!

$alpation of an area of leg pain or tenderness may

reveal a firm, thic(ened, thrombosed vein! 3ith the patient in a standing position, a vein segment is

percussed at one position while an examining hand feels

for a Bpulse waveB at another position!


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'pecial Test

Trendeleburg Test

This can sometimes distinguish patients with superficial venous

reflux from those with incompetent deep venous valves!

The patient should lie flat with the leg elevated, allowing the veins

to empty! A tourni1uet is applied to the thigh at the saphenousopening! f the valve is competent, the vein should fill from below!

f the valve is incompetent, the vein will fill from above on removal

of the tourni1uet!

The test can be repeated with the tourni1uet at different levels to

further pinpoint the level of valvular incompetence:) above the (nee + to assess the mid+thigh perforators

) below the (nee + to assess incompetence between the short

saphenous vein and the popliteal vein!


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Perthes Test

This manoeuvre is used to distinguish antegrade flow

from retrograde flow in superficial varicosities!

A tourni1uet is applied to a varicose leg in such a way

that the superficial veins are compressed without

pressure being applied to the deep vessels! The patient

is then as(ed to stand repeatedly on tiptoe, activating the

calf muscles! .ormally this would empty the varicosities

but, in the presence of deep vein obstruction, they wouldparadoxically become congested!

management of varicose veins and lymphedema

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