VENOUS THROMBOSIS

A. VAYDA

department of surgery with urology and anesthesiology

The venous thrombosis - is the acute disease, characterized by formation of the thrombus in the vein with associative inflammation and disturbances of the venous outflow

VENOUS THROMBOSES

ETIOLOGY OF THROMBOSES

•Injury of the vascular wall•Changes of the blood rheology•Decrease of blood velosity

Etiology of superficial thrombophlebitis

•Varicosity•Trauma•Pregnancy•Operations and postoperative period•Undercooling •Bloodloss•Stroke with paralysis•Sensibilization of the organism, autointoxication, allergic reactions (immunization, antibiotics, blood transfusion, flu, rheumatic diseases, complications of varicosity: eczema, cellulitis)•Infection (trophic ulcers)

Clinic of superficial thrombophlebitis

Painfull infiltrate, heperemia, local increase of temperature along the varicose vein

No edema!No cyanosis!

•Anamnesis •Objective examination •General blood analyses •Coagulogram •Dopplerography •Colour-flow duplex imaging•US of retroperitoneal space

Diagnostic of deep venous thrombosis

• Ascending thrombophlebitis - the thrombotic lesion located in the site of sapheno-femoral or sapheno-popliteal junction

• Migrating thrombophlebitis - the multiple appearance in location and time sites of thrombotic lesion along the superficial vein

Special forms of superficial thrombophlebitis

•Anamnesis •Objective examination •General blood analyses •Coagulogram •Dopplerography •Colour-flow duplex imaging

Diagnostic of superficial thrombophlebitis

•Deep vein thrombosis•Lymphangiitis•Nodular erythema•Erysipelas

Differential diagnosis of superficial thrombophlebitis

In preoperative period:•Phlebotonics (detralex, phlebodia, hincor-forte)•Antiinflammatory therapy (diclofenac Na, mesulid, naclofen)•Local therapy (heparin or antiinflammatory ointments)•Antibiotic therapy in case of systemic response (increased temperature, leucocytosis)

•Saphenectomy •Urgent saphenectomy for ascending thrombophlebitis!

Treatment of superficial thrombophlebitis

Treatment of superficial thrombophlebitis

•Crossectomy for urgent situations (urgent surgical or gynecologic operations, labor).

Etiology of deep venous thrombosis

•Thrombophlebitis•Trauma•Pregnancy•Operations and postoperative period•Prolonged bed regimen•Stroke with paralysis•Sensitization of the organism, autointoxication, allergic reactions (immunization, antibiotics, blood transfusion, flu, rheumatic diseases, complications of varicosity: eczema, cellulitis)•Infection (trophic ulcers)

Clinic of deep venous thrombosis

•Arching pain of the leg•Edema of the leg•Cyanotic skin•Painful muscle palpation of the leg•Homans’ sign - tibial muscle pain after maximal dorsiflexion of foot. •Lowenberg’s test - tibial muscle pain under the pressures of 80-100 mm Hg by imposing on the leg a cuff of sphygmomanometer.

Iliofemoral venous thrombosis

Etiology:•Thrombosis of the leg veins•Anatomic predispose factors (septa and membranes in iliac veins)•Inflammatory processes and tumours in small pelvis•Pregnancy and laborClinic:•Clinic of deep venous thrombosis•Edema of the whole leg (the edema of thigh is the sign of

iliofemoral venous thrombosis •Concomitant signs of lymph insufficiency.

• White phlegmasia - associated arterial spasm in response to venous block

Special forms of iliofemoral venous thrombosis

• Blue phlegmasia - the total thrombosis of deep, superficial and pelvic veins which can result in venous gangrene.

•Thrombosis of a distal segment (below renal veins). The clinic of one-side iliofemoral thrombosis slight edema on the contrlateral leg due to compensatory properties of collateral circulation by azygos and hemiazygos veins.

•Thrombosis of a renal segment. The signs of renal failure

•Thrombosis of a hepatic segment. Clinic of Badd-Chiary’s syndrome

Vena cava inferior thrombosis

Paget-Schrotter syndrome

Etiology:•Compressing of subclavial vein by anatomic structures•Subclavial vein catheterization•Permanent pacemakers implantation•Postmastectomy syndrome

Clinic:•Arching pain of the arm•Edema of the arm•Cyanotic skin•Painful muscle palpation of the arm

•Anamnesis •Objective examination •General blood analyses •Coagulogram •Dopplerography •Colour-flow duplex imaging•US of retroperitoneal space

Diagnostic of deep venous thrombosis

Treatment of deep venous thrombosis

•Bed regimen•Anticoagulant therapy (heparin, low-molecular, indirrect)•Antiaggregants (aspirin, ticlides, pentoxiphyllin)•Thrombolytics therapy (streptokinase, actilise)•Correction of a blood rheology and microcirculation (rheopolyglucin, rheosorbilact)•Improving of the venous wall nutrition and venous outflow (elastic bandage, venotonics)•Antiinflammatory therapy (diclofenac Na, mesulid, naclofen)

Prophylaxis of venous thrombosis

•Active regimen in pre- and postoperative period•Treatment of varicosity•Good anesthesia and minimal traumatization of tissues during operation•Restore of the volume of circulating blood, hemodilution•Prophylaxis of infection and inflammatory complications•Low-molecular heparoids (klexan, fraxiparin, fragmin)

Pathogenesis of postthrombotic syndrome

Clinic of postthrombotic syndrome

•“Heavy sensation” sign•Edema •Hyperpigmentation•Lipodermatosclerosis (indurative cellulitis)•Eczema •Trophic ulcer

І stage – heavy sensation; ІI stage – transitory or persistent edema,

lipodermatosclerosis, hyperpigmentation; ІII stage – trophic ulcer (open or healed).

Classification of venous insufficiency

Treatment of postthrombotic syndrome

•Elastic bandage•Correction of microcirculation, rheology and lymph outflow (phlebodia, detralex – double doses, enzymes)•Antiinflammatory therapy (diclofenac Na, mesulid, naclofen) •Physiotherapy (darsonvalization, ultraviolet insolation in suberythematous doses, laser therapy)•Local therapy (antiseptics, curiosin)•Surgical treatment (subfascial ligation of perforative veins by Linton, endoscopic subfascial clipping of perforative veins )