Download Document

VARICOUS DISEASE OF THE
LOWER EXTREMITIES
The cathedra of the faculty and hospital surgery of the treatment
faculty of the Tashkent medical academy
VARICOUS DISEASE
IS
CONSTANT, NOT REGRESSIVE
EXTENSION AND LENGTHENING OF THE
VEINS AS A RESULT OF ROUGH
PATHOLOGIC CHANGES IN THE VENOUS
WALL AND VALVE APPARATE.
Remote results of the VDV of the l/e
VDVLE is the chronic progressive disease and
brings to the development of the CVI without
adequate therapy
VDLE
CVI 2-nd stage
TDV
Trophic ulcers
Veins of the lower extremity
Superficicial veins
Deep
veins
10-15%
85-90%
Perforative
veins
Veins of the foot
Deep
1. Deep plantar venous arc
2. Medial veins
3. Lateral veins.
Superficial
1. Rear venous arc
2. Marginal veins
3. Anterior vein of the shank
Veins of the
shank
Superficial veins
1. Big subcutaneus vein
2. Small subcutaneus vein
Deep veins
1. anterior tibialis veins
2. posterior tibialis veins
3. fibialis veins
Big subcutaneus vein
Fossa ovale
Big subcutaneus vein
Upper third
Middle third
Lower third
Deep venous system

anterior tibialis
veins
 posterior tibialis
veins
 Fibialis veins
Deep
femoral
vein
Femoral vein
Posterior
view
Internal view
V. Poplitea
Vv. Tibiales ant.
Vv. Peroneae
V. Saphena parva
V. Tibiales post.
V. Saphena magna
Venensinus
des M. Soleus
Vv. Communicantes
Anatomy of the lower extremity
Venous valves
Venous valves
Opening
moment
Closing
moment
Depending of the arterial pressure
РН-15
РО-25
РН-30
РО-25
РН-30
РО-25
РН-28
РО-25
РН-8
РО-10
А
Б
Transmitted pulsation
А
V
А
V
Venous-muscular pump
Pump function of the diaphragm
Spreading of the varicous disease of the
lower extremities
 15-18% of the country people
 20-25% of the urban people
 Women suffer more often than men in 6 times
 Depend on the profession
 Usually suffer high and fat people
 Seldom suffer representatives of mongoloid and
negroid race.
 genetic predisposing;
 hormonal
dependings
admition of the estrogens);
 Gender (women);
 constitution;
 race;
 profession;
(pregnancy,
Obesity
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
18 кг/м2
27 кг/м2
34 кг/м2
 Increasing of the index of the mass of body over 27
kg/m2 increases the risk of development of the disease on
33%
Pathogenesis of the VDVLE
Degradation of the smooth muscular and elastic fibers
of the subcutaneus veins and perforantesa
Extension of the veins
Insufficiency of the velves
Venous reflux
Vertical
Horisontal
Phenomena of the leucocytar
aggression
Activation of the leucocytes
Infiltration of the intima and media of the vein
Lisosomal ferments
Collagen fibers extend and separate
The vein losses the fullness of the framework
Extension of the vein
Valve apparatus defeates seldom
Changes of the valve apparatus begin from the deepness
of the comissures and gradual increasing of the space
between the septums. At this stage their hanging with the
bulboform extension of the free borders marks.
Phlebohypertension
Change of the
endothelium
Increased
filtration
Clinic picture
Of th chronic diseases of the venous system is variable
Х
В
Н
ДО
Х
В
Н
Х
В
Н
Initial signs of the varicous disease of thee
lower extremities
The beginning of the disease – not
significant varicous disease of the veins,
soft, the skin isn’t changed.
teleangioectasions
Vaticous extended
subcutaneus veins
Classification of the CVI
Е.Н.Яблоков, 2000
Degree
Main syptoms
0
1
Aabsence.
Syndrome of the “grave legs”, regressive
hypostasis of the lower extremity.
Constant hypostasis, hypo- or
hyperpigmentation, lipodermatosclerosis,
exema.
Venous trophic ulcer (open or close).
2
3
0 degree
No significant defeats of the venous flow, the patients
come because of cosmetic defect.
1 degree
Pain in the shank
Hypostasis at the genus
joint
Dyscomfort
Weakness in the l/e
Gravity in the legs
2 degree
Significant
varicous
extended veins
hypoor
hyperpigmentation of
the skin
lipodermatosclerosis,
exema,
Constant hypostasis
Skin scratching
3 degree
Venous trophic ulcer (open
or close).
Clinic forms of the CVI of the
l/e
Descending form
Because
of
insufficiency of the ostial
valve
Ascending form
Without insufficiency
of the ostial valve
Delbe-Peters’s test
Sheynise’s test
Talman’s test
Troyanov-Tredelenburg test
At the doubtful or negative results of the tests it is
necessary to carry out the instrumental researches.
The main among them is duplex scanning
Duplex scanning allows define the passibility of the valve
apparatus and find out the presence of the horisontal and vertical
reflux.
Phlebotonometry
Norma
Valve insufficiency of the velve apparatus
Obliteration of the deep veins
А- valsalva’s test
Б- muscular effort
В- come bach to the initial level
Local radiometry
Phlebography
Doesn’t use at present time
Methods of phlebography
Phlebography
Phlebogrammes
Differential diagnosis
 Postthrombophlebitic
syndromeболезнью
 Traumatic and innate arterio-vein
fistulas
 Kleppel-Grenone’s syndrome
Parx-Veber-Rubashov’s syndrome
Innate dysplasia, conditioned with the presence of plural arteio-vein
shunts, through which the evacuation of the arterial blood is
carrying out to the veins.
At the Parx-Veber syndrome
mark:
Hypertrophy and lengthening of the
extremity
hypertrichosis
Pulsation of the extended veins
Systolo-dyastolic noise at the projection
of the extended veins
Vascular maculas
Contrasting of the veins at the
angiography
Reduced arterio-venous defference from
15% to 2-3%.
Klippel-Trenone’s syndrome
Vascular maculas at the
lower extremity,
Rough extended veins of
the lower extremity by the
lateral surface,
Increasing of the volume
and length of the extremity
Negative test
Complications
of the varicous
disease
 Trophic ulcers of the shank
 Acute varicophlebitis
 Bleedind from the vericous veins
Clinic diagnostic
 Gravity in the shanks
 Cricks of the shanks
 Fever, scratching
 Maculas
 Orange skin
 White atrophy of the skin
 Typical view and localization of the ulcer
 Depending on the CVI
Acute vericophlebitis
 Sudden begining
 Trauma in anamnesis
 Pain by the way of veins
 Hyperemia and hyperthermia of the skin
 Defeat of the function of the extremity
Ascending varicophlebitis
Diagnostic
 Clinic symptoms
 US duplex angioscanning
 Analyses of blood
Lymphangoitis
 Bright diffuse





hyperemia
2-3 red stretches
Hypostasis
Regional
lymphadenitis
Wound
Fever
Erysipelas
 Acute begining
 Intoxication symptoms
 Eerytema with the borders
 Hypostasis
 Pain
 Ascending
thrombophlebitis of
the big and small
subcutaneus veins
 Threat of TEPA
Troyanov-Tredelnburg’s
operation
(crossectomy)
TroyanovTredelnburg’s
operation
(crossectomy)
LIGATION OF THE LONG SAPHENOUS
VEIN AT THE SAPHENO-FEMORAL
JUNCTION
Falciform
margin
Femoral
vein
Correctly placed
ligature
Inferior external
pudendal artery
Long saphenous
vein
Bleeding from the varicous
veins
 The breakup may occur even after
the not significant traumas.
 Blood flows strong from the breaked
node.
Treatment
 Taut bandaging
 Conservative methods
of haemostasis
 Surgical treatment




Principles of treatment
of the VD
Elastic compression
Drug-therapy
Sclerotherapy
Surgical treatment
Drug-therapy of the VD
 Phlebotonics
 Desagregants
 Rheological drugs
Phlebectomy by Bebkokk-Narat
Linton’s operation
Kokket’s operation