Presentation on theme: "Jessie Stewart Morning Report July 09"— Presentation transcript:
1Jessie Stewart Morning Report July 09 VENOUS INSUFFICIENCYJessie StewartMorning ReportJuly 09
2Vasodilatory EdemaBiggest culprit drugs are arteriolar smooth muscle relaxers.Minoxidil (7%): opens K channels, preventing smooth muscle contraction.Hydralazine (?%): prevents Ca accumulation, may protect nitric oxide.
3CCB also guiltyAmlodipine (2-15%, dose related). Blocks calcium transport.NEJM Volume 341: November 4, Calcium-Antagonist Drugs. Darrell R. Abernethy, M.D., Ph.D., and Janice B. Schwartz, M.D.
4Vasodilatory edema caused by: 1. Increased intracapillary pressure.2. Activation of the Renin-Angiotensin SystemCan diminish edema by concomitant use of ACE inhibitor.Image at:
5Venous Insufficiency 7 million Americans with VI. 1 in 1000 with a venous ulcerInternists, vascular surgeons, plastic surgeons, dermatologists.$1 billion/ year in USA.$40,000 per person
6Veins: Hold 75% of the blood volume Are organized into superficial and deep veins connected by perforating veinsHave valves for unidirectional flowAre low pressure systems (10-15mmHg)Have thin walls (superficial veins have thicker walls than deep veins.)
7Venous Insufficiency is… Valvular incompetence and venous obstruction.Symptoms worsen as more sites are involved.Iliac veins as especially susceptible.Injured by crossing arteriesVenous hypertension leads to ?Dilation of capillary beds, fibrinogen leak, formation of a fibrin cuff that then stops delivery oxygen, nutrients, growth factors.WBC entrapment in the capillary wall, setting up an inflammatory reaction, injuring the vein and valves.
8Risk factors? Age Obesity Family history Pregnancy Female Gender Heart failure, hypertension, renal diseaseH/o Leg injury (fx, burn, crush, penetrating injury), phlebitis, DVTPrevious varicose vein surgeryLong hours standing, or sitting.
9Symptoms and Signs Nocturnal pain, restless legs Orthostatic pain Edema, Varicosity, Hyperpigmentation, ulceration
13Lipodermatosclerosis (LDS) Induration, Fibrosis, the shape of an inverted bottle
14Venous Ulcer Medial Malleolus Shallow Irregular borders Base with granulation tissueSurrounding white scar (atrophie blanche)Surrounding hemosiderin depositionSurrounding Edema80% of LE ulcers$40,000Venous Ulcer. A. Khachemoune & C. L. Kauffman : Diagnosis Of Leg Ulcers . The Internet Journal of Dermatology Volume 1 Number 2
15Clinical Aspects of the Most Common Types of Ulcers of the Lower Limbs de Araujo, T. et. al. Ann Intern Med 2003;138:
20CEAPA patient has painful swelling of the leg, and varicose veins, lipodermatosclerosis, and active ulceration. Duplex scanning on May 17, 2004, showed axial reflux of the great saphenous vein above and below the knee, incompetent calf perforator veins, and axial reflux in the femoral and popliteal veins. There are no signs of postthrombotic obstruction.Classification according to basic CEAP: C6,S, Ep,As,p,d, Pr.Classification according to advanced CEAP: C2,3,4b,6,S, Ep,As,p,d, Pr2,3,18,13,14 ( , L II).Revision of the CEAP classification for chronic venous disorders: Consensus statement. Journal of Vascular Surgery Volume 40, Issue 6, December 2004, Pages
21Treatment Compression is the cornerstone of treatment. At least 40mmHg at the ankle is the goal.Range of 10-60mmHg (TED hose 18mmHg)Knee-High as good as Thigh-High.Open or closed toe per pt preference.Either graduated stockings and wrapsCaution with CHF, invasive infection, arterial insufficiency.Compliance very difficult.Replace every 6 months.Size S, M, L, XL based on ankle, calf circum.
23Compression Plus…Leg Elevation. Above heart-level for 30 minutes 3 times per day.Diuretics. May help but can’t do much alone.Pentoxifylline. May improve oxygen delivery, inhibit WBC activation. Shown to accelerate ulcer healing mg tid.Aspirin may help some.
25Other ReferencesManaging the Patient with Venous Ulcers. Tami de Araujo, MD; Isabel Valencia, MD; Daniel G. Federman, MD; and Robert S. Kirsner, MD. 18 February 2003 | Volume 138 Issue 4 | PagesState-of-the-Art Treatment of Chronic Venous Disease. Michael S. Weingarten. Clinical Infectious Diseases, Vol. 32, No. 6 (Mar. 15, 2001), ppJull AB, Waters J, Arroll B. Pentoxifylline for treating venous leg ulcers. Cochrane Database Syst RevWiersema-Bryant LA. Management of edema. In: Sussman C, Bates-Jensen BM, eds. Wound Care: A Collaborative Practice Manual for Physical Therapists and Nurses. Gaithersburg, MD: Aspen; 1998: