Veins and Lymphatics Varicose veins Phlebothrombosis or

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Veins and Lymphatics

• Varicose veins
• Phlebothrombosis or Thrombophlebitis

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VARICOSE VEINS

• Abnormally dilated, tortuous veins produced by
  prolonged, increased intraluminal pressure and
  loss of vessel wall support
• Main sites superficial veins of the upper and
  lower leg
• At risk
• Occupations WITH PROLONED STANDING
• simple orthostatic edema
• gt50 years old, obese
• Women (pregnancy)
• familial tendency -defective venous wall
  development
• 15 to 20 of the general population

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VARICOSE VEINS
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VARICOSE VEINSMorphology

• Thrombosis
• Valvular deformities
• Microscopically
• Thickness of the vein
• Dilation hypertrophy of the smooth muscle and
  subintimal fibrosis
• Spotty calcifications media (phlebosclerosis)
• Elastic tissue degeneration

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VARICOSE VEINS Clinical Course

• venous stasis, congestion, edema, pain, and
  thrombosis
• Sequelae
• Persistent edema
• Trophic changes in the skin
• dermatitis, ulcerations
• poorly healing wounds
• infections
• varicose ulcers
• Embolism is very rare

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VARICOSE VEINS Clinical Course

• Esophageal Varices
• Cirrhosis of the liver and its attendant portal
  hypertension
• Massive upper gastrointestinal hemorrhage
• Hemorrhoids
• Hemorrhoidal plexus of veins at the anorectal
  junction
• Pregnancies
• Straining at stools

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THROMBOPHLEBITIS AND PHLEBOTHROMBOSIS

• Deep leg veins- 90 of cases of thrombophlebitis
• Important clinical predispositions
• Cardiac failure
• neoplasia
• pregnancy
• Obesity
• postoperative state
• prolonged bed rest or immobilization
• Genetic hypercoagulability

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THROMBOPHLEBITIS AND PHLEBOTHROMBOSIS

• Migratory thrombophlebitis (Trousseau syndrome)
• Adenocarcinomas of the pancreas, colon, or lung
• Hypercoagulability
• paraneoplastic syndrome
• Periprostatic venous plexus in the male
• Pelvic veins in the female
• Veins in the skull and the dural sinuses by
  bacterial infections of the meninges

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THROMBOPHLEBITIS AND PHLEBOTHROMBOSIS

• Early stages
• Edema distal to the occluded vein
• Dusky cyanosis
• dilatation of superficial veins, heat,
  tenderness, redness, swelling, and pain
• Homan sign
• Pain over affected veins on squeezing the calf
  muscles or forced dorsi -flexion of the foot

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Cinical sequel

• Pulmonary embolism
• common and serious clinical sequel
• Sometimes - first manifestation of
  thrombophlebitis

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PHLEBOTHROMBOSIS Plegmasia alba dolens

• Plegmasia alba dolens (painful white leg or milk
  leg)
• Pregnant women prior to or following delivery
• Iliofemoral venous thrombosis
• Initiators of phlebitis
• pressure of the gravid uterus
• Hypercoagulable state during pregnancy

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VENA CAVAL SYNDROMES

• Superior vena caval syndrome -SVC
• Primary bronchogenic carcinoma or mediastinal
  lymphoma
• Dusky cyanosis
• Respiratory distress
• Dilation of the veins of the head, neck, and arms

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Inferior vena caval syndrome

• Hepatocellular carcinoma and Renal cell carcinoma
• edema of the legs
• massive proteinuria
• distention of the superficial collateral veins of
  the lower abdomen

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LYMPHANGITIS AND LYMPHEDEMA

• Most common- Bacterial infections
• Group A beta-hemolytic streptococci
• Lymphangitis
• Acute lymphadenitis

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Obstructive lymphedema

• CAUSES
• Spread of malignant tumors
• Radical surgical procedures
• Flariasis
• Post inflammatory thrombosis
• Post irradiation fibrosis
• Rupture of obstructed, dilated lymphatics
• Chylous ascites, chylothorax, and chylopericardium

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Primary Lymphedema

• Simple congenital Lymphedema
• Familial Milroy disease (heredofamilial
  congenital lymphedema)
• Lymphedema praecox

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Primary LymphedemaClinical features

• Age -10 and 25 years
• Sex- females
• Cause - unknown cause
• Edema - begins in the feet
• Complications
• Disability (due to size of the limb)
• peau d'orange" appearance of the skin
• superimposed infection
• chronic ulcerations

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Raynaud phenomenon

• Definition
• paroxysmal pallor or cyanosis
• Sites
• Common - digits of the hands or feet
• Uncommon - tips of the nose or ears
• Mechanism
• vasoconstriction
• exaggeration of normal central and local
  vasomotor responses
• Stimuli
• Cold
• Emotions
• Vessels involved
• digital arteries
• precapillary arterioles
• cutaneous arteriovenous shunts

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Raynaud phenomenon

• Color changes
• white-blue-red
• prevalence
• 3-5 of population
• Median age 14 yrs
• Family history 25 of patients
• Clinical Course
• Benign
• On long standing (due to intimal thickening)
• Atrophy
• Skin
• Subcutaneous tissue
• Muscles

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Raynaud phenomenon
Types

• Primary
• Uncomplicated
• Age -14 yrs
• Mid or Benign
• No other features

• Secondary
• Due to SLE, SS, AS, Buerger's Disease
• gt30 yrs
• Severe episodes
• Skin changes other features

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Pathology of Vascular Interventions
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Balloon Angioplasty

• Percutaneous transluminal coronary angioplasty
  PTCA
• Mechanism of luminal expansion
• plaque rupture
• medial dissection
• stretching of the media of the dissected segment
• Results
• short-term
• Abrupt reclosure
• long-term
• proliferative restenosis

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Stent

• Technique
• expandable tubes of metallic mesh
• at sites of balloon angioplasty
• Advantages
• acting as a scaffold
• increase blood flow
• prevent vascular spasm
• limit elastic recoil
• Disadvantages
• Early Thrombosis
• Late - in- stent restenosis (the major
  limitation)
• Rx - irradiation or antiproliferative drugs

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VASCULAR REPLACEMENT

• Grafts
• synthetic or autologous
• replace a segment of vessel or bypass

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VASCULAR REPLACEMENT

• Types
• Large-diameter -Dacron grafts
• high-flow locations (aorta)
• small-diameter
• most widely used small vessel replacements
• autologous saphenous vein
• fabric vascular grafts (polytetrafluoroethylene )
• For periphery or coronary artery bypass

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VASCULAR REPLACEMENT

• Failure
• Common cause
• thrombotic occlusion
• intimal fibrous hyperplasia
• Occasionally
• atherosclerosis
• Healing of a vascular graft depends on
  endothelialization

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Coronary Artery Bypass Graft Surgerygrafts
Patency at 10 years

• Reversed autologous saphenous vein
• 50

• Internal mammary artery
• 90

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Trousseau
Sign or syndrome ?