Low risk: young, with minor illnesses, who are to undergo operations lasting 30 min or less. Moderate risk: over 40 or with a debilitating illness who are to undergo major surgery. High risk: over 40 who have serious medical conditions, or undergoing major surgery with an additional risk factor. Prophylaxis:

Risk factors: Patients factors: 1. Age 2. Obesity 3. Varicose veins 4. Immobility 5. Pregnancy 6. Puerperium 7. Oral contraceptive pills 8. Previous deep vein thrombosis or pulmonary embolism Disease or surgical factors: 1. Trauma or surgery, 2. Malignancy, 3. Heart failure 4. Recent myocardial infarction 5. Paralysis of lower limb(s) 6. Infection 7. Inflammatory bowel disease 8. Nephrotic syndrome 9. Polycythaemia 10. Paraproteinaemia

Mechanical methods: 1. graduated elastic compression stockings 2. external pneumatic compression 3. passive foot movement (foot paddling machine) 4. simple limb elevation Pharmaceutical methods: 1. low molecular weight heparin 2. unfractionated heparin 3. warfarin Methods of prophylaxis:

Graduated elastic compressive stocking

External pneumatic compression

Foot Paddling Machine

Venous thrombectomy: Phlegmasia cerulea dolens with contraindication to thrombolytics Inferior vena cava filter: Recurrent thromboembolism despite adequate anticoagulation Progressing thromboembolism despite adequate anticoagulation Complication of anticoagulants Contraindication to anticoagulants Surgical treatment:

Venous thrombectomy

IVC filter:

Acute Lymphangitis: Infection caused by Streptococcus pyogenes or Staphylococcus aureus that spreads to the draining lymphatic vessels and lymph nodes (lymphadenitis) Treatment: Rest and elevation i.v. antibiotics Related to lymphoedema

Lymphedema: Edema due to high protein ISF secondary to defective lymphatic drainage in the presence of normal capillary filtration

Pathophysiology: Edema  high capillary filtration  normal but overwhelmed venous and lymphatic system  protein low edema Lymphedema  normal capillaries  defective lymphatics  protein rich edema Sometimes  high capillary filtration + defective lymphatics  both types of edema Lymphedema is confined to the epifascial space

Classification: Primary lymphoedema, : Congenital lymphoedema (Millroy's disease) Lymphoedema praecox (Meige's disease) Lymphoedema tarda Secondary or acquired lymphoedema, Infection (fungal, parasitic, bacterial..etc.) Exposure to foreign body material (silica particles) Malignancy (primary or metastatic) Trauma (surgery, radiotherapy, penetrating injury,…etc.) Venous disorders (DVT, thrombophlebitis, …etc.)

Clinical presentation: Lymphoedema characteristically involves the foot May spread to knee, rarely to the thigh Early it is pitting, later on it becomes non-pitting Skin problems (fungal, viral or bacterial infection) Ulceration is unusual Lymphangiomas lymphangiosarcoma

Investigations: 1. MRI 2. Lymphangiography 3. Duplex ultrasound

Treatment: 1. Pain relief 2. Skin care 3. Control of swelling (decongestive lymphatic edema therapy) 1) Manual lymphatic drainage (MLD) 2) Multilayer lymphedema bandaging (MLLB) 3) Exercise 4) Drugs 5) Surgery (lymphatic bypass procedures or limb reduction procedures)

MLD

MLLB

Sistrunk’s Procedure

Homan’s Procedure

Thompson’s Procedure

Charles Procedure