1. PERIPHERAL VEINS DISEASE Dr Nora C Hutajulu SPJP,FIHA

2. Veins Veins are capacitance vessels that contain more than 70 % of total blood volume. The sub endothelial layer of vein is thin,and the tunica media compromises fewer,smaller bundles of smooth muscle cell intermixed with reticular and elastic fibres. Whereas veins of the extremities posses intrinsic vasomotor activity,transport of blood back to the heart.

3. Veins Veins of the extremities are classified as either deep or superficial. In the lower extremity,where most peripheral venous disorders occur,the deep veins generally course along the arteries, whereas the superficial veins are located subcutaneously. The superficial vessel drain into deeper veins via a series of perforating connectors,ultimately returning blood to the heart.

6. HOW BLOOD CIRCULATES Arteries carry freshly oxygenated blood from the heart to the rest of the body, starting in the central trunk artery, the aorta, which leads from the heart's main pumping chamber (the left ventricle). From the aorta, the arteries branch and divide into successively smaller vessels, and finally into tiny arterioles and capillaries that deliver oxygen to the body’s tissues. Arteries are thick-walled and muscular Arterial blood is scarlet,because it carries richly oxygenated red cells

7. HOW BLOOD CIRCULATES Veins carry blood that has left much of its oxygen in the tissues back to the right side of the heart. It is then pumped into the lungs to pick up more oxygen. Compared to the flow of arterial blood, which is driven by the heart's powerful pumping, the flow of venous blood is relatively slow, returning from the lower body against the force of gravity. (A series of one-way valves inside the veins helps keep the blood from pooling or moving backward.)

8. HOW BLOOD CIRCULATES The flow of blood from a cut vein is slow and steady. Veins are thinner than arteries, and they appear bluish, because the blood they carry is low in oxygen.

9. The veins, which send blood from the limbs and other tissues back to the heart, are also vulnerable to a variety of disorders that can cause blood clots to form or inflammation to develop. The veins, which send blood from the limbs and other tissues back to the heart, are also vulnerable to a variety of disorders that can cause blood clots to form or inflammation to develop,

10. Diseases of the Veins Varicose Veins Varicose veins are dilated, turtous superficial vessels that often develop in the lower extremities. Clinically apparent varicose veins occur in 10 – 20 % of general population. They affect women 2-3 times more frequently than men, and roughly half of patiens have a family history of this condition.

11. Varicose veins Can occur in any vein in the body but are most common in the saphenous veins of the leg. They may also develop in the anorectal area (hemorrhoids), in the lower esophageal veins (esophageal varices), and the spermatic cord (varicocele).

12. Extensive venous varicosities of the right leg.

13. Varicose veins Causes : Varicosity is thought to result from intrinsic weakness of the vessel wall, or increased intraluminal pressure from standing too long or hormonal changes during pregnancy,or from congenital defects in the structure and fuction of the valves that severely impair flow toward to the heart, that dilate and relax veins.

14. Varicose veins Symptoms : Sometimes asymptomatic ; sometimes pain; dull ache or pressure sensation in the leg after prolonged standing. Can cause swelling and skin ulceration that is particulary severe near the ankle. Stasis of blood within varicose veins can promote superficial vein thrombosis.

15. Varicose veins Treatment : Elevate the leg while supine,avoiding prolonged standing; wearing elastic or support stockings,surgical removal for patiens who are very symptomatic.

16. Diseases of the Veins Venous thrombosis / thrombophlebitis. = Thrombus within superficial or deep veins.and the inflamatory response in the vessel that it incites. Causes: - Sluggish movement of blood (stasis) - Damage to the lining of the vein - Inflammation of the vein (phlebitis) - Abnormal tendency to form clots (hypercoagulable state).

17. Deep Vein Thrombosis The presence of a thrombus in a deep vein. The incidence of deep vein thrombosis increases with age. Deep vein thrombosis usually occurs in the leg, regardless of cause.

18. Deep Vein Thrombosis Etiology: Immobilization, Prolonged sitting (as may occur during long drives or air travel), or Relatively sedentary existence can lead to venous stasis and predisposes to thrombosis, because the emptying of veins in the extremities depends entirely on skeletal muscles that pump blood and on one-way venous valves that inhibit retrograde flow.

19. Deep Vein Thrombosis. Incompetent venous valves lead to deep vein thrombosis. Thrombosis also damages the intima of the vein; may lead to decreased local production of antithrombotic factors (eg, antithrombin III, prostacyclin).

20. Deep Vein Thrombosis Any condition that increases the Hct increases blood viscosity and results in a higher incidence of clotting. Dehydration, pulmonary disorders, smoking, and polycythemia are common causes of a high Hct in the elderly. The two most common known hypercoagulable states are hyperhomocysteinemia and protein C resistance, which is genetically determined.

21. Deep Vein Thrombosis Symptoms : Sometime asymptomatic; Generally, patients first note swelling when they awaken. In ambulatory patients, swelling is maximal at the ankle and lower leg, usually developing over 1 or 2 days. Pain may be present but is usually not severe.. Shortness of breath; coughing up blood-tinged phlegm if clot moves to the lung (pulmonary embolism); marked pain and swelling in one leg.

22. Deep Vein Thrombosis Physical examination often reveals pitting edema and a mild to moderate increase in skin temperature over the calf or thigh. A gap always occurs between the level of thrombosis and the location of edema.

23. Deep Vein Thrombosis With popliteal and lower femoral vein thrombosis, edema occurs only in the lower leg and ankle. With thrombosis in the mid femoral vein area, most or all of the leg is swollen. With upper femoral and external iliac vein thrombosis, the thigh is also swollen.. Calf vein thrombosis may produce no symptoms or mild tenderness and mild edema.

24. Deep vein thrombosis (DVT) and pulmonary embolism represent different manifestations of the same clinical entity, which is referred to as venous thromboembolism. A proximal DVT in the leg is one that is located within the popliteal, femoral (including the superficial femoral), or iliac veins.

25. A pulmonary embolism occurs when a segment of a thrombus within the deep venous system detaches from the vessel, travels to the lungs, and lodges within the pulmonary arteries The pelvic and deep veins of the lower extremities are the source of more than 70% of all pulmonary emboli. The superior vena cava, upper extremity veins, and right chambers of the heart are less common sources.

26. Deep Vein Thrombosis Diagnosis The “gold standard” for diagnosing deep- vein thrombosis is contrast venography, also called a venogram, a dye visible on an X-ray is injected into the veins of the feet; the patient is then tilted in various positions to facilitate blood flow from the lower veins to the heart, providing an X- ray image of the vein network.

27. Laboratory test : Serum D- Dimer level. D-Dimer is a byproduct of fibrin degradation. Impedance plethysmography,. Doppler ultrasonography,

28. Diagnostic Imaging /Venogram of deep venous thrombosis A.Normal B.Extensive Thrombosis of deep calf vein

29. Deep Vein Thrombosis Treatment Anticoagulant such as warfarin (Coumadin) and heparin. In repeated cases,insertion of a filtering device to prevent pulmonary embolism. Bedrest for 3 to 5 days with legs elevated. Elastic stockings worn below the knee.. Anti-inflammatory drugs such as aspirin or indomethacin (Indocin)

30. Pulmonary embolism Causes : Deep-vein thrombosis moved to lungs. Symptoms : Some times chest pain that worsens upon inhaling; sandpaper-like sound heard through stethoscope; shortness of breath; coughing up blood.

32. Pulmonary embolism Angiogram Arteri Pulmonal.

33. Pulmonary embolism. Treatment : - Thrombolytic drugs such urokinase (Abbokinase), streptokinase (Kabikinase or Streptase). - Anticoagulants such as warfarin (Coumadin) or heparin. - In rare cases, surgery to remove the clot.

34. Superficial veins thrombophlebitis Much less serious than DVT(deep veins thrombosis) does not lead to pulmonary embolism. Causes : Infection or injury as a complication of indwelling intravenous catheter. Symptoms : Pain; redness; tenderness,and edema over the involved vein.. Treatment : Anti-inflammatory drugs such as indomethacin (Indocin); analgesics such as aspirin.

35. Chronic venous Insufficiency Causes : Complication following deep-vein thrombosis. Symptoms: Swelling and discoloration of one or both legs. Treatment Knee-length elastic stocking indefinitely to prevent swelling.

36. Chronic venous Insufficiency

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