Diseases of the veins

MUDr. Nina Benáková

Dermatovenerologická klinika

1. LF UK Praha

Importance

medical, social, pharmacoeconomic• epidemiology, demography• interdisciplinary collaboration, teamwork• Centers for wound healing:

Leg ulcersDiabetic footDecubites

VaricesChronic venous incompetence

deep + superficial venous system + perforators

Physiologic blood stream from surface to profundity and proximal

venous valves – direction, inhibition of reflux

Clinical examination

History and physical examination =

fundamental• NO: circumstances of origin and duration• OA: internal diseases, risk factors• FA, GA, SA+PA• RA: venous diseases

aspection- standing: edema, colour, trophic changes, varices palpation- lying: temperature, edema, pain subjective complains, alleviation manoeuvres

history+ clinical picture → determination of etiology→ determination of etiology knowledge of patgogenesis, diagnostic examinations and

therapeutic possibilities → adequate therapy→ adequate therapy

Functional and scanning examinations

Supportive, confirmative• Historical – turnstile tests

Trendelenburg´s a Perthes´s test

• Modern – instrumental dopplerimetry and duplex dopplerimetry plethysmography: PPG, LRR

• Scanning phlebography, scintigraphy CT, MR

Varicous veins

dilatation, elongation, meander like shape• epidemiology - race, sex, age, genetics

population < 40 yrs. ≈ 30%, > 70 yrs. 10x ↑

• classification - ethiologyprimarysecondary

• classification - lumenstar burst < 2 mm reticular 2-4 mmstem > 4 mm

Posttromboticsyndroma

→ incompetence of perforators

and superficial veins

→ secondaryvarices

stem varicesstarburst varices

Complications of varicouse veins

• bleeding

• trombophlebitisin 1/3 cases + deep thrombosis

• phlebothrombosis trias of symptoms

in 50% inappparent Diff. dg.

• phlebitis migrans recidivans - symptom

Therapy of varicous veins

• ProphylaxisProphylaxis “regime measures“

• therapy of phlebotrombosis – trombolysis

• Compression bandages Compression bandages - correct application!

• Pharmacotherapy: venotonics, rheologics, oedema-protectives,

anticoagulation agents – supportive

• Sclerotisation

• Surgical therapy

Chronical venous incompetence

Functional defect of venous segment

ethio: PTS obstruction 75% / varices 25%→ valve incompetence

→ venous hypertension

→ CVI = trophic and inflammatory skin changes

• epidemiology ≈ 5%, ♀ 2-3x ↑, ulcera ≈ 1,5%• progressive character > 60 yrs. 4%

Pathogenesis of CVI

changes in macrocirculation → stasis, reflux, hypertension → variceschanges in microcirculation→ capillaries, lymphatics, interstitium

valves incompetence → hypertension

capillary dilatation↑permeability

fluid, proteins, fibrinogen

↓blood flow adhesion + migration leukocytesenzymes, ROS, MMP, cytokines

chronic inflammationedema, hypoxia, malnutrition

trophical changesdestruction of vessels and subcutaneous tissue

Classification of CVI

I. varices, reversible edema

II. varices, permanent edema + trophic changes

III. varices, edema+ trophic changes + ulcus

(scar)

Trophical changes:

• hyperpigmentations• hypodermitis → dermosclerosis• stasis dermatitis → eczema• verrucous hyperplasia• white atrophy

CVI ≠ varices

CVI grade IIStasis dermatitis =Dermatitis varicosa

corona phlebectatica

papillomatosis = verrucous hyperplasia

white atrophy

hemosiderin hyperpigmentations

arterial ulcer diabeticgangrene

diabetic ulcerations

kalosities

neuro - trophic ulcer

Dif. dg. algorithm

ETIO Local Shape Puls Perception

/ painVENOUSVENOUS

♀maleol

medial

bisar + +

leg downARTERIALARTERIAL

♂frontal

leg

round

cutted

0 ,

±

+

elevationMETABOLICMETABOLIC

NEUROPATNEUROPATacral round

necrosis

± ±

permanent

Complications of CVI

• Contact allergic eczema• Contact irritative dermatitis• Microbial eczema

≈ 80 %

• Erysipelas

• Spinocellular cancer ulcus Marjolin

Contact iritative or allergic dermatitis ?

erysipelas cellulitis, dermatolymfangiodermatitis

spinocellular cancer

Therapy of leg ulcers

• Complex I

biological – psychological – social

• Complex II - medical therapy of al patient´s disease

and general health statusprophylaxis: regime measures, pressotherapy

causal therapy + skin symptoms:

Topical therapy of leg ulcer

correlates with phases of wound healing

Chronic wound = no spontaneous healing> 6 weeks despite therapy

1. cleanance – necrosis, fibrin, detritus2. reduction of inflammation and infection

microbial film, exudation, inflammation3. granulation and epitelisation

+ care of surrounding skin, compression

nekrotic

black

infection fibrin

yelow

epitelisating

pink

granulating

red

Ulcer description

Wound assessment

Wound dressing

1. Classical : dressing gauze + ointment

2. Modern : „wet wound healing“

= special materials:• humidity, • exchange of gases and vapours, • inpermeable for microorganisms, • antiseptic

Modern dressing - overview

• Hydrocoloids• Alginates• Hydropolymers• Polyuretan foams• Polyacrylates

exudate absorption, antisepsis

• Hydrogels• Silicon foams• Polyuretan films

wet dressing.

antisepsis

Insufficient healing

• General factors:age, immunity, internal diseases, abusus; non - compliance

• Local factors:intensity and extent of vessel disease, ulcer localisation and size, infection.

If impossible to eliminate/ reduce the cause = not healable → ensure acceptable QoL

to be continued …

Lymphedema

chronic solid edema = consequence of lymfatic system dysfunction

• lymphostasis + high proteins → edema• chronic inflammation + fibrosis → solid

• complications: erysipelas, lymfangiosarcoma• examination: sonography, lymphangioscintigraphy

papillomatosis = verrucous hyperplasia

Classification

Ethiology primary vessel dysplasia secondary non-/inflammatory obstruction

Phases of edema:

I. latent

II. reversible

III. ireversible

IV. elephantiasis nostras

Erysipelas in lymphedema

Therapy of lymphedema

Symptomatic, prevent progresssionmust be started early

• Decongestion manual lymphodrainage Instrumental compressive bandages therapeutic exercices

• Skin care, infection prophylaxis• Systemic• Surgical lymfovenous shunts, lymfo-liposuction, ablative