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

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 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 labor Clinic: 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 )