Disorder of venous

circulation of
extremities
Classification of venous system diseases.
(A.A. Spridonov and L.I. Clioner, 1989)

The superior vena cava and its tributaries.

Traumatic injury;
Occlusion;
Padget-Shreter's syndrome (thrombosis of
profound veins of extremity) and
postthrombophlebiti\c syndrome of upper
extremities;
Syndrome of superior vena cava.
Congenital diseases (angiodysplasia)
 Classification of venous system diseases.
(A.A. Spridonov and L.I. Clioner, 1989)

Inferior vena cava Postthrombophlebitic

Acute thrombophlebitis: syndrome:
superficial veins of lower superficial veins;
extremities; profound veins of lower
profound veins of lower extremities;
extremities; ileofemoral veins;
ileofemoral veins; the trunk of inferior vena
venous gangrene (blue cava.
phlegmasia); Primary varicose dialtion of
the trunk of inferior vena superficial veins of lower
cava: extremities;
embolism of pulmonary Congenital diseases
artery.
(angiodysplasia)
Chronic venous insufficiency is
mainly caused diseases:

varicose disease of lower

extremities
postthrombophlebitic disease
angiodysplasia
 Varicose disease
Varicose disease of subcutaneous
veins is their irreversible dilation
and elongation occurring due to
crude pathological change of
venous walls and valvular
apparatus.
Postthrombophlebitic disease

Postthrombophlebitic disease
a complex of symptoms
developing due to thrombosis
of profound veins.
Pathogenesis chronic venous
insufficiency
 Stages of chronic venous
insufficiency
(Expert meeting in Moscow, 2000.)

0 - no symptoms;
1 - heavy feet syndrome;
2 - intermittent edema;
3 - persistent edema, hyper- or
hypopigmentation, lipodermatosclerosis,
eczema;
4 - venous ulcer.
 Complain
of fatigue,
the heavy feeling and enlargement
of feet,
spasms of gastrocnemius muscle,
paresthesia,
edema of shins and feet.
 Dilated varicose veins
1.

2.
1. interskin swollen
plexuses
2. dilated varicose veins
Edema
Edema usually
develops by
nighttime after
walking or
prolonged standing
and disappears
after a night's rest.
Hemosiderosis skin
Skin pigmentation
develops in the lower
third of the shin; it is
more pronounced
above the inner ankle;
the skin is less elastic,
it becomes dry, shiny,
vulnerable, fused with
sclerotically
degenerated fat.
 a
Trophic ulcer
Ulcers caused by venous
circulation disorder typically
develop on the inner surface of
lower third of shin, above the
ankle.
The ulcers are usually single,
flat, with an even bottom; their
borders are irregular, abrupt;
the discharge is scarce, serous
or purulent.
If infection develops, ulcers
become painful.
Around the ulcer hemosiderosis
and induration of subcutaneous
fat develop.
Main symptoms of thrombophlebitis
of profound veins
Edema of the extremity
The pains are localised in the
gastrocnemius muscles as a rule, along
the course of vascular bundles
The skin of the extremity becomes
cyanotic.
Main symptoms of thrombophlebitis
of superficial veins
Pains along the course of thrombotised
vein.
Examination of the thrombotic region
reveals hyperemia, edema of skin.
Palpation along the course of the vein
reveals a consolidation distinctly separate
from the surrounding tissues.
Classification of functional tests
1. Test enable one to judge the
condition of valvular apparatus
Trendelenburg-Trojanov's
tests
Hackenbruch's
2. Test enable of insufficient
perforating veins
Pratt's test II
Scheins' test
Thalmann's test
3. Test enable the patency of
profound veins
Delbe-Pertez test (marching
test)
Pratt-I test
Trendelenburg-Trojanov's
The patient lyingtest.
on his
back raises one leg. When
blood has drained from
superficial veins, the
greater subcutaneous vein
is compressed in the place
where it joins the femoral
vein and keeping the finger
there the patient is asked to
rise. If venous trunks swell
quickly when the finger is
removed, we can conclude
that the ostial valve is
incompetent.
Hackenbruch's test.

Place your hand on

the thigh where the
greater subcutaneous
vein joins the femoral
vein and ask the
patient to cough. You
can feel throbs over
the vein which points
to incompetence of
ostial valve.
Pratt's test II.
After draining of subcutaneous
veins the lying patient's leg is
bandaged with elastic bandage
which compresses superficial
veins. A tourniquet is applied on
the thigh under the poupart fold.
When the patient rises, another
elastic bandage is applied under
the thigh. Then the first bandage
is removed loop after loop
circling the leg with the utmost
loop. The distance between the
bandages should 5-6 cm. Quick
filling of veins between the
bandages points to an
incompetent communicant vein
in this place.
Scheins' test.

The patient is placed on the back, his legs are raised.

After draining of superficial veins three tourniquets are
applied. The patient is asked to rise. A quick swelling
of the veins between the tourniquets points to an
incompetent perforating vein in this place.
Delbe-Pertez test (marching test)
A tourniquet compressing
only superficial veins is
applied to the standing
patient's thigh whose
subcutaneous veins are
maximally full. Then the
patient is asked to walk in
one spot for 3-5 min. If
the veins deflate it means
that profound veins are
patent; if the veins do not
deflate or swell, it means
that profound veins are
obliterated.
Pratt-I test
Measure the circumference
of the patient's shin, ask him
to lie on his back, drain the
veins by stroking them along
their course. Apply elastic
bandage to the legs. The
patient is asked to walk for
10 min. If pains develop, it
points to affection of
profound veins. Enlarged
circumference of the shin
after walking points to
impatency of profound veins.
Loevenberg's test

The cuff of Rivarocci

machine is applied to the
lower third of shin and air
is slowly pumped into it.
If sharp pains develop
when the pressure in the
cuff rises to 150 mm Hg,
it is characteristic of
thrombophlebitis of
profound veins.
 Homans' sign

Pains in gastrocnemius muscle upon dorsal flexing of the foot is characteristic of thrombophlebitis

of profound veins of the extremity.

 Moses' sign

Pains in the shin upon anterior-

posterior compression
 Instrumental methods of
examination

ultrasound diagnostics
contrast-dye radiophlebography
Duplex scanning
Contrast-dye radiophlebography

In distal phlebography the

radiopaque substance is
injected into the dorsal
vein of foot while a
tourniquet is applied to
the lower third of shin. In
proximal phlebography
the radiopaque substance
is injected directly into
the femoral vein by
puncturing.
 Principles of conservative treatment
for chronic venous insufficiency
0 stage: elastic compression (preventive
or therapeutic hosiery of class I);
1 stage of chronic venous insufficiency:
elastic compression (therapeutic hosiery
of compression of class I-II);
occasional courses of
monopharmacotherapy.
Principles of conservative treatment
for chronic venous insufficiency
2 stage of chronic venous insufficiency:
elastic compression (therapeutic hosiery
of compression of class II);
repeated courses of
monopharmacotherapy;
physiotherapy and balneology.
Principles of conservative treatment
for chronic venous insufficiency
3-4 stage of chronic venous
insufficiency:
elastic compression (therapeutic hosiery
of compression of class II-III);
continuous combined pharmacotherapy;
local treatment;
physiotherapy.
 The therapeutic effect of compression
treatment is determined by the following
mechanism of action:
decrease of pathologic venous "capacity" of
lower extremities;
functional improvement of the insufficient
valvular apparatus;
increased resorbtion of tissue fluid in the venous
part of capillary; its decreased filtration in the
arterial part;
increased fibrinolytic activity of blood.
 hlebotropic drugs
detralex,
ginkor-fort,
troxevasin,
escusan,
calcium dobesilan (doxium).
Rheologic hemocorrectors
acetylcalicylic acid,
dipiridamol,
pentoxyphylline,
low-molecular dextranes
(rheopolyglucine, rheomacrodex,
rheogluman and so on)
 Principles of anticoagulant therapy.
The initial dose of non-fractionated heparin is determined in
this way: the patient's weight is multiplied by 450 then the
resulting figure is divided by the amount of injections.
Thus, for fractional intravenous administration of heparin
the amount of injections is 8 (every 3 hours), for
intramuscular administration it is 6 (every 4 hours), for
subcutaneous administration it is 3 (every 8 hours).
Afterwards the dose of heparin is chosen individually
according to the reaction of hemostasis. Blood-clotting time
should increase 2-2.5 times.
The duration of heparin therapy does not usually exceed 10-
12 days. The drug is cancelled gradually by decreasing the
dose.
Two days before the end of heparin therapy patients start
receiving indirect anticoagulants.
 Indirect anticoagulants.
This category includes derivatives of coumarine
and fenindione. They do not affect coagulation
upon direct connection with blood; they decrease
blood clotting by inhibiting the synthesis of
vitamin K-dependent procoagulants (factors II,
VII, IX, X). The initial dose of feniline
(fenindione derivative) is 0.12-0.18 g (3 times a
day), on the second day the dose is 0.09-0.15 g,
and afterwards - 0.03-0.06 g a day depending on
the prothrombin level in blood. The effectiveness
of treatment is checked with the help of
prothrombin index which should decrease to
50%.
Phlebosclerosing treatment

This method consists in introduction of sclerosing

substances (fibrovein, thrombovar, etoxisclerol) into

the varicose veins.

 The principles of surgical treatment
in chronic venous insufficiency are:
eliminating pathological reflux of from
the profound veins into superficial ones;
removal of varicosely dilated
subcutaneous veins;
preservation of unchanged segments of
the greater and lesser subcutaneous veins.
The surgery for varicose disease is a
combined surgical intervention

Trendelenburg-
Trojanov-Dieterich's
surgery is paraostial
ligation of the greater
subcutaneous vein and
its accessory branches
where it joins the
femora vein.
The surgery for varicose disease is a
combined surgical intervention
The surgery for varicose disease is a
combined surgical intervention

Narat's surgery is
removal of
varicosely dilated
subcutaneous
veins from
separate incisions
by tunneling.
The surgery for varicose disease is a
combined surgical intervention

Babcock's surgery is removal of great

trunks of subcutaneous veins with the help
of a vein sound.
Cocket's surgery is suprafascial ligation of
communicant veins.
Felder-Linton's surgery is subfascial ligaton
of communicant veins.
Thrombectomy from femoral vein