Page 1373 - TNFlipTest

Toronto Notes 2019 Peripheral Venous Disease Vascular Surgery VS9 Peripheral Venous Disease
Deep Venous Thromboembolism
• seeHematology,H35
Chronic Venous Insufficiency
Definition
• widespectrumofchronicvenousdiseasewithadvancingsymptomsofedema,skinchanges,varicosities or leg ulcers
Epidemiology
• primaryvenousinsufficiencyisthemostcommonvenousdisorderoflowerextremity • 65%ofNorthAmericanadultpopulationdevelopssomedegreeofvenousinsufficiency
Etiology
• spectrumofchronicvenousdiseaseinvolvingdeepandsuperficiallowerextremityveinscausedby calf muscle pump dysfunction, venous obstruction, and chronic valvular incompetence (reflux) due to phlebitis, varicosities or DVT
• finalcommonpathwayisdevelopmentofvenoushypertension,leadingtohistologicandphysiologic inflammatory changes
• primary(99%ofcases)varicosities:venousvalveincompetenceorobstruction
■ risk factors: increasing age, systemic hormonal contraceptive use, prolonged standing, pregnancy,
obesity
• secondaryvaricosities:DVT,malignantpelvictumourswithvenouscompression,congenitalanomalies,
arteriovenous fistulae, trauma
Clinical Features & Complications
• pain(mostcommon)describedasfullness/tightnessandaching;worstatnight
• ankleandcalfedema;relievedbyfootelevation
• pruritus, eczema, burning, aching, fullness/tightness, nocturnal cramping
• stasisdermatitis,brownishhyperpigmentation(hemosiderindeposits),subcutaneousfibrosisifchronic
(lipodermatosclerosis)
• ulceration:shallow,abovemedialmalleolus(gaitorarea),weeping(wet),painless,irregularoutline
• varicoseveins:visible,long,dilatedandtortuoussuperficialveins(greatorsmallsaphenousveinsand
tributaries) resulting from incompetent valves in the deep, superficial, or perforator systems; • signsofrecurrentsuperficialthrombophlebitisandDVT
• bleedingorhematomaofvaricositiessecondarytotrauma
Investigations
• ABI(pre-compressiontoensurenoarterialdisease) • venousduplexU/S
Treatment
• indicationsforsurgery:failureofconservativetreatment,symptomaticvarix(pain,bleeding,recurrent thrombophlebitis), tissue changes (hyperpigmentation, ulceration), cosmetic
• 10yearpost-operativerecurrenceof20%
• conservative
■ elastic compression stockings, ambulation, periodic rest-elevation, avoid prolonged standing ■ ulcers: wound care using multilayer compression bandage +/- antibiotics +/- debridement prn ■ medical treatments are variable eg. pentoxifylline, horse chestnut oils, etc
• surgical
■ if conservative measures fail, or once ulcers heal to reduce the risk of recurrence
■ surgical excision: destruction of vein with partial or complete removal; techniques include vein
ligation/stripping, phlebectomy, perforator ligation
• endovenous:lasertherapy,radiofrequencyablation(RFA),foam/liquid/gluesclerotherapy(oftenonly
for residual varicosities following GSV/LSV treatment)