Transcript Presentation

SYNDROME OF
EDEMA
Surgical department of TMA for
general practitioners
edema is an increasing of the contents
of a liquid in tissues. Thus volume in
space which is not belonging to
vessels. To establish edema it is
possible by infringement skin fold
between fingers. Thus is felt pastrylike
tissue, and at taking off fingers on a
skin are visible pits on a place of
compression. edema can be general
and local.
Lower extremity anatomy
Thigh veins
Lower extremity veins
Classification of edemas
By aetiology distinguished
1. Nephrotic syndrome edemas:
• glomerulonephritis,
• kidney amiloidosis,
• diabetic glomerulosclerosis,
• preeclampsia,
• rheumatoid polyarthritis,
• serum sickness,
• LEN,
• lymphatic leukemia,
• lymphogranulemathosis.
Classification of edemas (continuation)
2. As a result of circulatory deficiency:
• valvular defect,
• cardiosclerosis,
• decompensated cor pulmonare.
3. orthostatic hydrops.
4. pregnancy edemas.
5. edemas of joints:
• deforming arthrosis,
• infectious arthritis,
• reactive arthritis.
6. venous pathology edemas:
• deep veins acute thrombosis,
•Chronic venous insufficiency.
7.lymphedemas.
8. mixed edemas.
Differential diagnosis of lover limb edemas
ChVI
Venous LE
trombos
is
Often
unilater
bilaterall al
y
Nephrot Cardiac Orthost
edema
ic
atic
edema
edema
primary Always
–
bilatera
bilatera l
l;
seconda
ry
–
often
unilater
al
Always
bilatera
l
Always
bilatera
l
artral
Pregnan
cy
edemas
Often
bilatera
l
bilatera
l
Obesity, no edema
Decompensated
cardiac edema
Gonarthrosis on the right side
Venous thrombosis
Skin pigmentation on the chronic venous insufficiency
Differential diagnosis of chronic venous and arterial
insufficiency
signs
Chronic arterial insufficiency (late Chronic venous insufficiency
phase)
(late phase)
pain
intermittent claudication
[Charcot's] syndrome, later
pain at rest
Absent or nagging pain on
upright position
Ps
Weak or absent.
Normal, but determining would
be little bit difficult because of
edema
Skin colour
pale skin, at hanging becomes dark
red
Normal, at upright position
becomes cyanotic
Temperature
low
normal
continuation
edema
Absence or weak.
Presence often substantal.
Trophic
changes
Atrophic, nail deformations.
Often on ankles, stagnant
dermatitis, pigmentations
sores
Often on fingers.
On ankles, often on medial
surface
gangrene
High risk.
absence
Varicose dilation of lower extremity
veins
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Varicose expansion of veins is disease,
accompanying by increase of length and
presence coiled subcutaneous veins, by saccular
expansion of their lumen
statistics
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Is observed at 17-25 % of the population
Patients by vein expansion makes 2-3,3 %
from general( number of the surgical
patients
The women are fall ill 3 times more often,
than man
а
б
Varicose disease
Posttrombophlebitic syndrome
acute thrombophlebitis of
SUPERFICIAL veins
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This is an inflammation of a vein wall ,
accompanying by formation of a blood clot
in its lumen
pathogenesis
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venous wall disturbancies; 2)
circulatory deceleration 3)
hypercoagulation
signs
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Pain upon vein;
Hyperemia and skin swelling;
Tenderness ;
Subfebrile temperature;
Treatment:
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anticoagulants;
Medicines improves rheology
NSAID;
Desensitizing medicines ;
heparin containing ointments
treatment
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bandaging;
Measured walking;
Operative interventions.
phlebothrombosis
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phlebothrombosis - obstruction of a vein by a
blood clot, without preceding inflammation of its
wall. It is most common within the deep veins of
the calf of the leg (deep vein thrombosis, DVT).
The affected leg may become swollen and tender
and the clot may become detached and give rise to
pulmonary embolism. Prolonged immobility, heart
failure, pregnancy, injury, and surgery predispose
to thrombosis by encouraging sluggish blood flow.
Thrombophlebitis
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Thrombophlebitis is phlebitis (vein
inflammation) related to a thrombus (blood
clot). When it occurs repeatedly in different
locations, it is known as "Thrombophlebitis
migrans" or "migrating thrombophlebitis".
Signs and symptomes
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The following symptoms are often (but not
always) associated with thrombophlebitis:
pain in the part of the body affected
skin redness or inflammation (not always
present)
swelling (edema) of the extremities (ankle and
foot)
Prevention
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Routine changing of intravenous (IV) lines helps
to prevent phlebitis related to IV lines. See the
specific disorders associated with
thrombophlebitis for other preventive measures.
treatment
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For more specific recommendations, see the particular condition. In general, treatment
may include the following:
analgesics (pain medications)
anticoagulants e.g. warfarin or heparin to prevent new clot formation
thrombolytics to dissolve an existing clot such as intravenous streptokinase.
nonsteroidal anti-inflammatory medications (NSAIDS) such as ibuprofen to reduce
pain and inflammation
antibiotics (if infection is present) selection will usually depend with the causative
agent.
Support stockings and wraps to reduce discomfort
The patient may be advised to do the following:
Elevate the affected area to reduce swelling.
Keep pressure off of the area to reduce pain and decrease the risk of further damage.
Apply moist heat to reduce inflammation and pain.
Surgical removal, stripping, or bypass of the vein is rarely needed but may be
recommended in some situations.
Chronic venous insufficiency
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Chronic venous insufficiency or CVI is a
medical condition where the veins cannot
pump enough oxygen-poor blood back to the
heart. It is sometimes referred to as an
"impaired musculovenous pump", this is due
to damaged or "incompetent" valves as may
occur after deep vein thrombosis (when the
disease is called postthrombotic syndrome) or
phlebitis. Paratroopers, utility pole linemen,
and men with leg injuries can suffer from
damaged leg vein valves and develop this
condition. Ordinarily, women make up the
largest demographic for this problem.
What are the symptoms of chronic
venous insufficiency?
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The seriousness of CVI, along with the complexities of treatment, increase as
the disease progresses. That’s why it is very important to see your doctor if
you have any of the symptoms of CVI. The problem will not go away if you
wait, and the earlier it is diagnosed and treated, the better your chances of
preventing serious complications.
Symptoms include:
Swelling in the lower legs and ankles, especially after extended periods of
standing
Aching or tiredness in the legs
New varicose veins
Leathery-looking skin on the legs
Flaking or itching skin on the legs or feet
Stasis ulcers (or venous stasis ulcers)
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If CVI is not treated, the pressure and swelling increase until the
tiniest blood vessels in the legs (capillaries) burst. When this
happens, the overlying skin takes on a reddish-brown color and
is very sensitive to being broken if bumped or scratched.
At the least, burst capillaries can cause local tissue inflammation
and internal tissue damage. At worst, this leads to ulcers, open
sores on the skin surface. These venous stasis ulcers can be
difficult to heal and can become infected. When the infection is
not controlled, it can spread to surrounding tissue, a condition
known as cellulitis.
CVI is often associated with varicose veins, which are twisted,
enlarged veins close to the surface of the skin. They can occur
almost anywhere, but most commonly occur in the legs.
What are the risk factors for chronic
venous insufficiency?
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If you have risk factors for CVI, you are more likely than other
people to develop the disease. The most important risk factors
are:
Deep vein thrombosis (DVT)
Varicose veins or a family history of varicose veins
Obesity
Pregnancy
Inactivity
Smoking
Extended periods of standing or sitting
Female sex
Age over 50
As functional venous valves are required to provide for
efficient blood return from the lower extremities, CVI
often occurs in the veins of the legs. Itching (pruritis) is
sometimes a symptom, along with hyperpigmentation of
the legs. Symptoms of CVI include phlebetic
lymphedema and chronic swelling of the legs and
ankles. The skin may react with varicose eczema, local
inflammation, discoloration, thickening, and an
increased risk of ulcers and cellulitis. The condition has
been known since ancient times and Hippocrates used
bandaging to treat it. It is better described as chronic
peripheral venous insufficiency
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Venous valve incompetence is treated conservatively
with manual compression lymphatic massage therapy,
skin lubrication, sequential compression pump, ankle
pump, compression stockings, blood pressure
medicine, frequent periods of rest elevating the legs
above the heart level and using a 7-inch bed wedge
during sleep. Surgical treatments include the old
Linton procedures and the newer subfascial
endoscopic perforator vein surgery. Some
experimental valve repair or valve transposition
procedures as well as some hemodynamic surgeries
are being pursued. This whole field of medicine while
ancient is still filled with complications e.g. Sometimes
an artery can strangulate a vein or sometimes an
arteriovenous fistula (an abnormal connection or
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Patients are often encouraged to walk while
wearing the prescribed medical stockings and to
sleep in a 6 degree Trendelenburg position.[]
Obese or pregnant patients might be advised by
their physicians to forgo the tilted bed.
Surprisingly, leech therapy long ago abandoned
by medicine, can actually be beneficial
treatment.[] The leeches draw out the excess
venous blood that has CO2 and metabolic
wastes in a measured amount with little danger
of dropping the blood volume.[]
May-Thurner syndrome
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May-Thurner syndrome is a rare condition
in which blood clots, called deep venous
thrombosis (DVT), occur in the iliofemoral
vein due to compression of the blood vessels
in the leg. The specific problem is
compression of the left common iliac vein
by the overlying right common iliac artery.[]
This leads to pooling or stasis of blood,
predisposing the individual to the formation
of blood clots.
How is chronic venous insufficiency
treated or managed?
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Like any disease, CVI is most treatable in its earliest stages. Vascular medicine or
vascular surgery specialists typically recommend a combination of treatments for
people with CVI. Some of the basic treatment strategies include:
Avoid long periods of standing or sitting: If you must take a long trip and will be
sitting for a long time, flex and extend your legs, feet, and ankles about 10 times every
30 minutes to keep the blood flowing in the leg veins. If you need to stand for long
periods of time, take frequent breaks to sit down and elevate your feet.
Exercise regularly. Walking is especially beneficial.
Lose weight if you are overweight.
Elevate your legs while sitting and lying down, with your legs elevated above the level
of your heart.
Wear compression stockings.
Take antibiotics as needed to treat skin infections.
Practice good skin hygiene.
The goals of treatment are to reduce the pooling of blood and prevent leg ulcers.
ChVI on the right side
Primary lymphedema
Varicose disease complicated by trophic disordes
Varicose disease, skin
pigmentation
Acute indurative cellulitis on
VD
Skin white atrophy
Circulatory trophic
disorders
А
А. Arterial insufficiency.
Б. Venous insufficiency.
Б
Trophic disorders on diabetis
Arterial trophic
ulcer
Pyogen ulcer.
Hypertonic trophic ulcer.
Malignant ulcer on the shin.
Nonsurgical Treatment
Nonsurgical treatments include sclerotherapy and endovenous thermal ablation.
 Sclerotherapy involves the injection of a solution directly into spider veins or
small varicose veins that causes them to collapse and disappear. Several
sclerotherapy treatments are usually required to achieve the desired results.
Sclerotherapy is simple, relatively inexpensive, and can be performed in the
doctor’s office. Sclerotherapy can eliminate the pain and discomfort of these
veins and helps prevent complications such as venous hemorrhage and
ulceration. It is also frequently performed for cosmetic reasons.
 Endovenous thermal ablation is a newer technique that uses a laser or highfrequency radio waves to create intense local heat in the affected vein. The
technology is different with each energy source, but both forms of local heat
close up the targeted vessel. This treatment closes off the problem veins but
leaves them in place so there is minimal bleeding and bruising. Compared
with ligation and stripping, endovenous thermal ablation results in less pain
and a faster return to normal activities, with similar cosmetic results.
Can chronic venous insufficiency be
prevented?
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To reduce your risk of developing CVI, follow these
guidelines:
 Eat a healthy balanced diet.
 Quit smoking.
 Exercise regularly.
 Avoid wearing restrictive clothing such as tight
girdles or belts.
 Lose weight if you are overweight.
 Avoid prolonged sitting or standing.
Septic pelvic thrombophlebitis

Septic pelvic thrombophlebitis and septic ovarian vein
thrombophlebitis are seen principally as complications of puerperal
infections and of septic abortions. It occurs approximately 1 in 3,000
vaginal deliveries and 1 in 2000 times Caesarean sections. Factors
contributing to the pathogenesis of gonadal vein thrombophlebitis
include stasis of blood, increased levels of procoagulants, and
endothelial damage.
Gonadal vein thrombophlebitis can also be seen after gynaecological
surgery or pelvic inflammatory disease. Anaerobic bacteria are often
involved, resulting in septic pelvic thrombophlebitis. Bacterial
organisms spread within thrombosed veins. Intermittent septicaemia
results in septic pulmonary emboli and metastatic abscesses.
Clinically, the patient with septic pelvic thrombophlebitis most present
with fever of unknown origin in the postpartum period. Once the
diagnosis is suspected, the administration of heparin quickly reduces
the fever. Traditionally, resolution of the fever within 24 hours of
heparin administration confirms the diagnosis thrombophlebitis.
Perineal varicose
Laparoscopy. Varicose of left ovarian veins
Pathologies associated with IVC
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Health problems attributed to the IVC are most often associated
with it being compressed (ruptures are rare because it has a low
intraluminal pressure). Typical sources of external pressure are an
enlarged aorta (abdominal aortic aneurysm), the gravid uterus
(aortocaval compression syndrome) and abdominal maligancies,
such as colorectal cancer, renal cell carcinoma and ovarian cancer.
Since the inferior vena cava is primarily a right-sided structure,
unconscious pregnant females should be turned on to their left
side (the recovery position), to relieve pressure on it and facilitate
venous return. In rare cases, straining associated with defecation
can lead to restricted blood flow through the IVC and result in
syncope (fainting).3
Occlusion of the IVC is rare, but considered life-threatening and
is an emergency. It is associated with deep vein thrombosis, IVC
filters, liver transplantation and instrumentation (e.g. catheter in
the femoral vein).4
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1.
2.
1
3.
2
3
Collaterals at v.cava
thrombosis:
V. thoracoepigastrica;
V. circumflexa ileum
superfacialis;
V. cutanea abdominis.
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Thromboemboly
consequences
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Inferior vena cava thrombosis is usually a side
effect of IVC filters. If the thrombosis is left
untreated the IVC may shrivel away and become
atretic. This can make the problem even worse
and prevent treatment. Inferior vena cava
thrombosis can cause the IVC syndrome.
vena cava thrombosis can cause the IVC
syndrome.
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Inferior vena cava filter with thrombus that
extends above, but mainly below. Notice clot
burden in the IVC below the filter
Inferior vena cava thrombosis
consequences
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Thrombosis of the IVC is usually symptomatic. The
IVC syndrome is not subtle. People suffer from swollen
legs, heaviness and pain. A severe form of the postphlebitic syndrome can occur.
A rare consequence of inferior vena cava thrombosis is
cauda equina syndrome. The thrombus can extend
from the IVC into the lumbar veins. This may cause
elevated pressure on the spinal cord and paralysis.
Patients with lumbar vein thrombosis can have
difficulty walking and problems with bowel control.
Treatment of inferior vena cava
thrombosis
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The best treatment for inferior vena cava thrombosis is
prevention. IVC filters are the main cause for this condition.
Therefore IVC filters should only be used for proper indications.
If an IVC filter is inserted it should be a retrievable one. The
filter needs to come out as soon as possible. If the filter cannot
be removed, anticoagulation should be given indefinitely.
Inferior vena cava thrombosis can also be treated by
endovascular techniques. Catheter directed techniques can
remove the clot. This uses mechanical thrombectomy and
pharmacological thrombolysis. Success rate is limited as there is
often much clot to cross. Sometimes stents are placed in the IVC
after the procedure. This is not a simple procedure and patients
should be chosen carefully. On the other hand, if the procedure
is successful, results can be astounding.
Mondor's disease
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Mondor's disease (also known as "Mondor's syndrome of superficial
thrombophlebitis"1) is a rare condition which involves
thrombophlebitis of the superficial veins of the breast and anterior
chest wall. It sometimes occurs in the arm or penis.
Patients with this disease often have abrupt onset of superficial pain,
with possible swelling and redness of a limited area of their anterior
chest wall or breast. There is usually a lump present, which may be
somewhat linear and tender. Because of the possibility of the lump
being from another cause, patients are often referred for mammogram
and/or breast
Mondor's disease is self limiting and generally benign. A cause is often
not identified, but when found include trauma, surgery, or
inflammation such as infection. There have been occasional cases of
associated malignancy. Management is with warm compresses and pain
relievers, most commonly NSAIDS such as ibuprofen.
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Localisations of
venous
disturbancies at
Mondorsdiseases
Subclavian Vein Thrombosis
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Sir James Paget first described thrombosis of the subclavian
veins in 1875. He coined the name gouty phlebitis to describe
the spontaneous thrombosis of the veins draining the upper
extremity. He observed that the syndrome was accompanied
by pain and swelling of the affected extremity. However, he
incorrectly attributed the syndrome to vasospasm. In 1884,
von Schrötter postulated that this syndrome resulted from
occlusive thrombosis of the subclavian and axillary veins. In
recognition of the work of these pioneers, in 1949, Hughes
coined the term Paget-von Schrötter syndrome. A related
condition is thrombosis of the subclavian vein that is induced
by the presence of indwelling catheters. The incidence of this
condition has increased remarkably over the past two decades
because of the extensive use of catheters in patients with
cancer and other chronic medical conditions
Presentation
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Not all patients with subclavian vein thrombosis are
symptomatic. Those with symptoms may present with mildto-moderate nonpitting edema and mild cyanosis of the hands
and fingers on the affected side. Dilatation of subcutaneous
collateral veins may be present over the upper arm and chest.
This later sign may be the only clue to ASDVT in otherwise
asymptomatic patients with catheter-related venous
thrombosis. In a few cases, in which the diagnosis was missed
or delayed or the patient presented late, the thrombus may
have extended to the superior vena cava. These patients show
most features of the superior vena cava syndrome, including
face and neck swelling, periorbital edema, blurred vision, and
some degree of facial cyanosis.
treatment
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The initial treatment of subclavian vein thrombosis is
conservative management, which includes rest, elevation of the
limb, and application of heat or warm compresses.
In a few patients who have minimal symptoms and no
anatomical defects, physical therapy is always the first goal of
therapy. Structured physical therapy may help the patient lose
weight and loosens the adhesions at the site of obstruction.
Physical therapy may also improve range of motion, decrease
swelling, and help decrease pain.
The different natural histories of Paget-von Schrötter syndrome
and catheter-induced subclavian vein thrombosis indicate
different treatment protocols. Because large series of patients
with this condition are lacking, the therapeutic approach to
subclavian vein thrombosis is mainly anecdotal.
heparin
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Unfractionated or low molecular weight heparin (LMWH) can maintain
patency of the venous collaterals and reduce the chance of propagation of
the thrombus. In all cases, heparin therapy is followed by warfarin therapy,
with an international normalized ratio (INR) goal of 2-3.
Heparin is usually the initial therapy, followed by warfarin. LMWH has been
used for both inpatient and outpatient therapy. Most studies have shown that
LMWH is just as effective as unfractionated heparin, but the former is
associated with a significant decreased incidence of venous
thromboembolism.
Warfarin is continued for 6-9 months, and an INR of 2:3 is maintained.
Patients who only receive inpatient heparin and are no longer on warfarin
therapy are at risk of recurrence and long-term disability. Anticoagulation is
required in all patients for a period of 6-9 months or longer, depending on
the cause of the thoracic outlet syndrome. In some patients who also have
hypercoagulable disorders, the treatment is lifelong.
Superior vena cava syndrome
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Superior vena cava syndrome (SVCS), or
superior vena cava obstruction (SVCO), is
usually the result of the direct obstruction
of the superior vena cava by malignancies
such as compression of the vessel wall by
right upper lobe tumors or thymoma and/or
mediastinal lymphadenopathy. The most
common malignancies that cause SVCS is
bronchogenic carcinoma. Cerebral edema is
rare, but if it occurs it may be fatal. 1
signs
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Shortness of breath is the most common symptom, followed by face
or arm swelling.
Following are frequent symptoms:
Dyspnea
Headache
Facial edema
Venous distention in the neck and distended veins in the upper chest
and arms
Upper limb edema
Lightheadedness
Cough
Edema of the neck, called the collar of Stokes
Superior vena cava syndrome usually presents more gradually with
an increase in symptoms over time as malignancies increase in size
or invasiveness.
Cause
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Approximately 90% of cases are associated with a
cancerous tumor that is compressing the superior vena
cava, such as bronchogenic carcinoma including small
cell and non-small cell lung carcinoma, Burkitt
lymphoma, lymphoblastic lymphomas, pre-T-cell
lineage acute lymphoblastic leukemia (rare), and other
acute leukemias. Syphilis and tuberculosis have also
been known to cause superior vena cava syndrome.3
SVCS can be caused by invasion or compression by a
pathological process or by thrombosis in the vein itself,
although this latter is less common (approximately 35%
due to the use of intravascular devices).
Diagnosis
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The main techniques of diagnosing SVCS are with
chest X-rays (CXR), CT scans, transbronchial needle
aspiration at bronchoscopy and mediastinoscopy. CXRs
provide the ability to show mediastinal widening and
may show the presenting primary cause of SVCS. CT
scans should be contrast enhanced and be taken on the
neck, chest, lower abdomen and pelvis. They may also
show the underlying cause and the extent to which the
disease has progressed.
Treatment
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Several methods of treatment are available,
mainly consisting of careful drug therapy and
surgery. Glucocorticoids (such as prednisone or
methylprednisolone) decrease the inflammatory
response to tumor invasion and edema
surrounding the tumor. In addition, diuretics
(such as furosemide) are used to reduce venous
return to the heart which relieves the increased
pressure.
Prognosis
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Symptoms are usually relieved with radiation
therapy within one month of treatment.
However, even with treatment, 90% of patients
die within two and a half years. This relates to
the cancerous causes of SVC that are 90% of
the cases. The average age of onset of disease is
54 years of age
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