الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا

1. الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD – FRCS www.surgi-guide.com 1st lecture M.A.Kubtan

2. Peripheral Vascular Disease M.A.Kubtan

3. M.A.Kubtan

4. M.A.Kubtan

5. M.A.Kubtan

6. Continue M.A.Kubtan

7. M.A.Kubtan

8. M.A.Kubtan

9. M.A.Kubtan

10. M.A.Kubtan

11. Continue M.A.Kubtan

12. M.A.Kubtan

13. M.A.Kubtan

14. Continue M.A.Kubtan

15. M.A.Kubtan

16. Continue Contraceptive hormonal therapy M.A.Kubtan

17. Continue M.A.Kubtan

18. M.A.Kubtan

19. M.A.Kubtan

20. Clinical Features VVs rarely cause sever symptoms . • Aching in the veins at the end of the day after prolonged standing . • Ankle swelling . • Itching . • Bleeding . • Superficial thrombophlebitis . • Eczema . • Lipodermatosclerosis . • Ulceration . M.A.Kubtan

21. Eczema Lipodermatosclerosis Lipodermatosclerosis Ulceration Ulceration Eczema Ulceration M.A.Kubtan

22. Signs of varicose veins • The termination of long and short saphenous veins must be palpated . • The presence of dilated trunk can be rolled back and forth . • Percussion over the VVs may elicit an impulse tap by the fingers . • A large VVs in the groin ( saphenavarix ) may be visible . • Gentle palpation during coughing may elicite a cough thrill . M.A.Kubtan

23. Saphenavarix M.A.Kubtan

24. A torniquet test M.A.Kubtan Trendilenburg test

25. Investigation • Tourniquet test . • Standareddoppler examination . • Duplex ultrasound imaging . • Varicography . • Venography . M.A.Kubtan

26. Duplex ultrasound imaging M.A.Kubtan

27. Varicogram Perforator joining long SV to deep veins M.A.Kubtan VVs connecting long and short SV

28. Venogram M.A.Kubtan

29. Management of patients with varicose veins • Prevention ( avoid lengthy standing ). • Supportive measures (encourage exercises) . • Elastic stockings ( lower pressure 30 , higher pressure 12 ). • Sclerotherapy . • Ultrasound-guided foam sclerotherapy. • Surgery ( stripping of long or short saphenous vein ,avulsion of varicose tributaries , ligation of perforators ) . M.A.Kubtan

30. M.A.Kubtan

31. M.A.Kubtan

32. Avulsion M.A.Kubtan

33. Alternative technique • Radiofrequency ablation ( using radiofrequency to destroy the endothelial lining ). • Laser to cause endothelial damage . • Endovenous laser ablation . M.A.Kubtan

34. Radiofrequency ablation M.A.Kubtan

35. Laser treatment for spider veins M.A.Kubtan

36. Complication of VVs surgery • Bruising . • Sensory nerve injury ( saphenous nerve , sural nerve ). • Recurrence . M.A.Kubtan

37. الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD – FRCS www.surgi-guide.com 2nd lecture M.A.Kubtan

38. Venous thrombosis M.A.Kubtan

39. Venous thrombus • Is the formation of a semi-solid coagulum within flowing blood in the venous system . • Venous thrombosis of the deep veins of the legs is complicated by the immediate risk of pulmonary embolus and sudden death. • Subsequently , patients are at risk of developing a post thrombotic limb and venous ulceration . M.A.Kubtan

40. Aetiology Virchow triad • Changes in the vessel wall ( endothelial damage ) . • Stasis, which diminished blood flow through the veins . • Coagulability of blood ( thrombophilia ) . M.A.Kubtan

41. Risk factors for venous thromboembolisim Patients factors : • Age . • Obesity . • Varicose veins . • Immobility . • Pregnancy . • Puerperium . • High-dose oestrogen therapy . • Previous deep vein thrombosis . • Pulmonary embolism . • Thrombophilia . M.A.Kubtan

42. Continue Disease or surgical procedure : • Trauma or surgery of pelvis, hip and lower limb . • Malignancy , pelvic and abdominal metastasis • Heart failure . • Recent myocardial infarction . • Paralysis of lower limb(s). • Infection . • Dehydration . M.A.Kubtan

43. Continue Other risk factors • Inflammatory bowel disease . • Nephrotic syndrome. • Polycythemia . • Paroxismal nocturnal haemoglobinuria antibody or Lupus • Anticoagulant . • Behcet,s disease . • Homocystinaemia. M.A.Kubtan

44. Clinical Pathology M.A.Kubtan A thrombus often develops in the soleal veins of the calf . Initially as a primary platelet thrombus ( aggregate ). Coralline thrombus . Occluding thrombus . Consecutive clot to the next venous tributary.

45. Methode of propagation in phlebothrombosis With thrombus formation at each entering tributary. Clotting mass in an extensive length of vein propagated clot . M.A.Kubtan

46. M.A.Kubtan

47. Pulmonary embolism • The embolus arising from the lower leg veins becomes detached , passes through the large veins of the limb and vena cava . • Through the right heart ( heart occlusion ) . • Lodges in the pulmonary arteries . • Massive pulmonary embolus (total occlusion of pulmonary trunk) . • Partial pulmonary embolus affecting Rt or Lt pulmonary arteries . • Recurrent micro emboli . • Pyramidal shape infarcts . M.A.Kubtan

48. Clinical Symptoms of DVT The most common presentation of DVT is : • No symptoms . • Pain in the calf muscles . • Swelling in the calf muscles . • May present with sudden symptoms of pulmonary embolism (pleuritic chest pain , haemoptysis , shortness of breath ) . • Bilateral DVT are relatively common occurring in 30% M.A.Kubtan

49. Clinical signs of Iliac femoral vein thrombosis • Swelling involving the whole length of lower limb . • Phlegmasia alba dolens . • Phlegmasiaceruliadolens . • Venous gangrene . M.A.Kubtan

50. Phlegmasia alba dolens PAD • When the thrombosis involves only major deep venous channels of the extremity sparing collateral veins . • The venous drainage is decreased but still present . • These phases are reversible if proper measures are taken. M.A.Kubtan