1
MINISTRY OF HELTHCARE OF THE REPUBLIC OF UZBEKISTAN
TASKENT MEDICAL ACADEMY
APPROVED
Vice-rector for studying process
Senior Prof.
Teshaev O.R.
«_________» __________2011y
Uniform tutorial
Theme: Ischemic
simtomokompleks upper and lower extremities
(Lesson 10)
Tashkent - 2011
2
APPROVED
On conference in department of surgical diseases for general practitioners
Head of department___________________senior prof Teshaev O.R.
Text of lecture accepted by CMC for GP of Tashkent Medical Academy
Report №___________from____________2011 y
Moderator
senior professor Rustamova M.T.
3
Edematous-pain syndrome in diseases of the veins
Syndromes in the pathology of venous
Subject: Edematous-pain syndrome in diseases of the veins. Varicose veins of the lower
extremity. The inferior vena cava syndrome, and thrombophlebitis phlebemphraxis.
Postthrombophlebitic syndrome. Superior vena cava syndrome and syndrome of PedzhettaShrettera. Etiology, clinical syndrome, diagnosis and differential diagnosis, treatment
strategy. Complications, pulmonary embolism (PE). Prevention, clinical examination of
patients. The tasks of GDs.
1. Venue activities and equipment: Hospital, school room, dressing room, operating. By
category patients, outpatient and hospital cards and medical history of patients, clinical and
biochemical analysis, the conclusion of instrumental methods of examination, radiographs,
guidelines, case studies, tests, algorithms for the implementation of practical exercises, the
scenario of interactive teaching methods, protocols, standards, materials on the subject Taken
from the Internet, slides, videos, training aids: slaydoskop, TV and video.
2. Duration of training - 327 minutes
3. Session Purpose
3.1. Learning objectives: to complement and consolidate students' knowledge of anatomy,
topographic anatomy of veins and lymphatic system.
-Provide students with contemporary issues of pain in edematous diseases of veins,
particularly highlighting the relevance of topics for GPs.
- Consolidate and extend students' knowledge of clinical topographic anatomy of venous
system.
- Provide students with existing diseases leading to edema, pain.
- Know the etiopathogenesis, diagnosis, venous diseases difdiagnostiku.
- Provide students with clinical features of different edema syndrome of the inferior vena
cava, depending on the location.
- Know the methods of sampling for diseases of the veins of the lower extremity.
- Be able to diagnose the syndrome posttrombeflebitichesky, Pedzhetta-Shrattera
- To know the complications of varicose veins of the lower extremities.
- The acquisition of practical skills in overlapping elastic bandage, applying knowledge and
skills in practice.
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- To acquaint students with modern methods of treating varicose veins of the lower limbs,
and the optimal organization of health care and rehabilitation of the population.
- Define the indications for phlebectomy.
3.2 The student should know:
- Anatomical and physiological features of the structure of the veins of the
extremities.
-Etiology and pathogenesis of superficial varicose veins, thrombophlebitis deep leg
Prince of treatment of edematous syndrome of the lower extremities
-The role of direct and oposredstvennyh factors (local and general) in the development of the
disease and complications
-Diagnostics and difdiagnostiku postromboflebiticheskogo sindromai syndrome PedzhettaShrattera.
-Basic principles of treatment of chronic venous insufficiency
-Organization of optimal health profilaktichekskih activities among the population.
3.3 The student should be able to do:
- Collection of complaints and medical history of patients
- Survey of patients, palpation, percussion, auscultation of vessels
- To carry out functional tests
- Interpret the data of functional tests, surveys
patients, lab tests
- Identify the indications for hospitalization and surgical treatment.
- Formulate and justify the clinical diagnosis.
- Maintain a surveillance card.
- Diagnose varicose superficial thrombophlebitis and deep vein
- Proper conduct tests reflecting functional state of different parts of the venous system.
- Elastic bandaging limbs.
- Principles of conservative treatment.
- Prevention of varicose superficial and deep vein thrombophlebitis.
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4. Motivation.
Diseases of the leg veins are still one of the leading causes of disability and disability. In the
United States and Western Europe, the frequency of varicose veins is 25%. In Russia, various
forms of varicose disease affects more than 30 million people, 15% of which are trophic
disorders. Today, for varicose veins are characterized not only is the number of cases, but
also to the appearance of varicose veins trend in young adults.
Deep vein thrombosis and pulmonary embolism may be concomitant to meet a doctor in any
specialty. Diagnosis and treatment of vein diseases often cause difficulties and baffled doctor.
The ability of a general practitioner to diagnose, provide the necessary assistance and be
treated effectively early in the disease of the lower limb veins is of great importance in
preventing complications.
Putting into practice the new modern methods of investigation and a deeper knowledge of the
pathogenesis of venous diseases can significantly increase the effectiveness of treatment.
5. Interdisciplinary communication and vnutripredmetnye. Anatomy, pathological anatomy,
pathophysiology.
Blood flow to the lower extremities by the veins of three types: superficial, deep and
perforating (communicating).
1. Superficial veins are systems of the great saphenous and small saphenous veins.
• Large subcutaneous Vienna originates in the medial malleolus, runs along the anteromedial
surface of the feet and empties into the femoral vein at the level of the oval fossa.
• Small subcutaneous Vienna begins at the lateral border of the foot near the lateral malleolus
and empties into the popliteal vein between the heads of the gastrocnemius muscle.
2. Deep veins - thin-walled blood vessels that accompany the artery of the same name in pairs
and their major branches, represented by systems of veins of the foot, shin, thigh and iliac
veins. Venous network triceps legs consist of calf veins draining into the popliteal vein, and
soleus veins draining into the posterior tibial and fibular veins.
3. Perforating (communicating) veins connect the superficial and deep venous network
among themselves. On these vessels the blood is sent from the superficial veins into the deep.
In the thigh are usually 2.1 perforating veins, and the rest are located on the lower leg.
For venous plexus characterized by the presence and abundance of connections between
different systems of veins, which provide great opportunities for the development of
collateral blood outflow tract in occlusion of the main veins.
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Physiology
All leg veins are equipped with folding flaps, which provide blood flow in one direction:
from the superficial veins - in the deep, from the distal sites - to proximal. Under the
influence of retrograde flow valve closes, which contributes to the centripetal advance and
protect the blood capillaries and venules by a sharp increase in pressure at the time of the
muscle pump. When a person is, the hydrostatic pressure of the blood makes it difficult to
venous outflow from the lower extremities. However, any reduction in the hip and thigh
muscles drives blood through the veins in the proximal direction, and the venous valves, as
discussed above, preventing retrograde blood flow. This mechanism is called the musclevenous pump or "peripheral heart". Full leaf valves are durable and can withstand pressures
up to 3 atm. While walking the pressure in the veins of legs is reduced by more than twice.
All veins carry blood flow from the muscles, are equipped with valves. There are no valves
hollow veins, portal vein, the veins of the liver, lungs and brain veins.
The transition from a prone position to standing position leads to increased hydrostatic
pressure in the veins of the lower extremities. However, in the arteries of the hydrostatic
pressure increases in the same range. Therefore, the change in body position is not
accompanied by changes in the ratio of pressure in the veins and arteries at the appropriate
levels.
Above the inguinal ligament deoxygenated blood goes to the heart through the breath the
diaphragm and the difference between intraabdominal and intrathoracic pressure.
Pathological and pathophysiological basis of varicose veins
Most varicose happening in the great saphenous vein, at least in the short saphenous and
tributaries of the stem begins with the veins in the calf. So why do veins suddenly begin to
expand?
The main reason for developing varicose leg veins, is that of the venous wall is not muscle
tissue, which could provide the tone of blood vessels and promote blood in the right
direction, that is, to the heart. On the contrary, in the arteries of the muscular layer is,
therefore, a disease like varicose veins of the arteries, does not exist.
Vienna pushes the blood through valves through which blood can only move in one direction.
Promotion of blood through the veins also contribute to the leg muscles, the fibers are located
and veins. Muscle motion contributes to a better blood flow to the legs.
When sedentary muscles are not able to fully compress the veins and to ensure normal blood
flow. At this point, and is stretching thin vein wall. Blood collects in the veins of the weakest
areas, expanding and stretching them to the state of varices.
Pathological anatomy. At the beginning of the disease is hypertrophy and growth of cellular
elements, resulting in significant thickening of the vein wall. In the future along with
hypertrophy of the muscular elements is their loss of connection with the further propagation
of the cells. Venous wall tension resulting from the death of muscle cells of subcutaneous
7
veins, stimulates production of collagen by fibroblasts. Neural elements located in the wall of
the veins are in the process again and create a new negative factor leading to loss of function
of smooth muscles of the venous wall - atony. The wall of varicose veins abruptly thickens,
but it is uneven thickening and thinning alternating with large walls in some places. Vienna is
extended, is tortuous, it formed multiple protrusions, sometimes reaching a diameter of 2-3
cm In addition, the vast majority of patients (85%) with varicose veins of the lower
extremities have a pronounced lack of valves around the trunk of the great saphenous vein.
Deterioration of blood flow through the veins leads to malnutrition of the skin and
subcutaneous tissue, which is manifested on the skin the appearance of dark brown spots, and
then venous ulcers.
Physiopathology. The pressure in the veins of the lower extremities varies significantly with
changes in body position during movement. In the initial stages of varicose veins, where there
are no signs of failure of valves, venous pressure determined by the vertical position of the
patient, in line with normal numbers - 75-120 mm water column In the further course of the
disease, and especially when there are signs of valvular insufficiency in varicose veins the
pressure increases to 500-800 mm water column and more. Increased venous pressure in
superficial veins leading to the further unfolding of the physiologically inactive precapillary
arteriovenous anastomoses through which resets the arterial blood in the veins, which in turn
further increases venous pressure. In the standing position and walking in these patients arises
violation of the outflow of blood from the veins of the lower extremities, congestion in the
veins of the number to 500-1000, or even 2000 ml. The pressure in the veins of the legs and
feet can be higher blood pressure. This leads to difficulties of transition from the blood
capillaries of the skin and subcutaneous tissue in the venules and veins with the development
of stasis in the arterioles and capillaries, and the transition of the liquid part of blood into the
tissues, skin and subcutaneous tissue with subsequent development of trophic changes in the
legs and feet.
6. The order of activities:
6.1 The theoretical part;
Research Methods
1. Duplex ultrasound. Use sensors with a frequency of 4 MHz radiation and 8 MHz to
combine study with Doppler imaging of blood vessels. Access to any study of the deep veins
below the iliac crest. In the diagnosis of deep vein thrombosis duplex ultrasound is the
method of choice and gradually replacing phlebography. Signs of a blood clot: intractability
wall veins, increased echogenicity compared with the moving blood, the lack of blood flow in
the affected segment. Duplex ultrasound to differentiate fresh thrombus from growing old
organized. Study of iliac vein is often difficult due to gas accumulation in the intestine. The
diagnostic accuracy of the method is 95%, sensitivity - 94%.
2. Doppler study can confirm the presence of venous flow, to register changes in blood flow
during the phases of the respiratory cycle, an increase in blood flow during compression of
8
the leg distal to the test segment, the appearance of retrograde flow during compression of the
leg proximal to the test segment. The method is simple and often used in the diagnosis of
deep venous thrombosis and insufficiency of venous valves, but requires high skills of the
researcher.
3. Plethysmography to determine changes in the volume of the limb.
i. Impedance plethysmography. The method is based registration of the total electrical
resistance, which reflects blood flow to the limb. Impedance plethysmography - a highly
sensitive method for diagnosis of obstruction of the iliac, femoral and popliteal veins.
However, any state, accompanied by an increase in venous pressure (postromboflebitichesky
syndrome, heart failure, mechanical ventilation) increases the number of false positive
results. With partial occlusion of the vein, double leg veins and local calf vein thrombosis
may be false negative results.
ii. Photoplethysmography is based on recording the optical density of the skin, which
depends on its blood supply. The volume of blood in the vessels of the skin is greater the
higher the pressure in the superficial veins. The rapid filling of superficial veins after exercise
indicates failure of venous valves. Failure of venous valves can be quantified - to reduce the
filling time previously emptied veins. Or a pneumatic tourniquet cuff to recompress the
superficial veins can distinguish an isolated insufficiency of valves of superficial veins of
insolvency valvular deep veins.
iii. When mechanical plethysmography study segment extremity is placed in a sealed
vessel, and the fluctuations in recorded using hydraulic or pneumatic transmission. Evaluate
changes in blood flow during the phases of the respiratory cycle and after compression of the
limb cuff. The method used in the diagnosis of deep vein thrombosis trunk.
. Flebotonometriya. Measurement of venous pressure by catheterization of a vein of the
foot performed at rest and after exercise. The method is considered the reference to
quantification of valvular insufficiency of functional veins. Nevertheless, it has significantly
pushed the noninvasive tests such as photoplethysmography. For suspected iliac vein
obstruction measure the pressure in the femoral vein.
5. Scintigraphy with 125I-fibrinogen based on the inclusion of radioactive iodine in the blood
clot. The method gives satisfactory results only at the stage of active growth and formation of
thrombus and can not distinguish thrombosis from phlebitis. In addition, because of high
background radioactivity in it malospetsifichen vein thrombosis of the upper thigh and pelvis.
If you use drugs fibrinogen is always the risk of transmission of viral infections.
6. Venography - a common standard method for studying diseases of the veins.
1) Ascending venography. Rentgenkontrastnoe substance injected into one of the distal veins
and get the image of proximal venous network. Thrombi appear as filling defects are
rounded. The absence of staining for visualization of arterial venous collaterals of the set another sign of venous thrombosis.
9
2) The descending phlebography. Radiopaque substance injected into the femoral vein.
Retrograde spread of contrast medium to evaluate the degree of venous insufficiency:
I st. Slight reflux during the Valsalva maneuver.
II with Art. Antegrade blood flow in the iliac venous segment reflux to the distal femur.
III Art. Reflux through the popliteal vein to vein leg.
IV with Art. Landslide reflux venous leg up, antegrade blood flow in the iliac segment is
missing.
7. Function tests can detect failure valve surface and perforating veins, patency and
functional status of the deep veins of the lower extremities.
Sample Brodie-Trendelenburg Troyanov is designed to detect valvular insufficiency of
superficial veins. For her performance in patients in the supine position to raise the
investigated limb emptying varicose superficial veins. Next, place the confluence of the great
saphenous vein in the thigh pressed with your finger or on the upper third of thigh tourniquet
impose. The patient is on his feet. After a while the tourniquet is removed, and the varicose
veins collapsed on top quickly and tightly filled with reverse flow of blood. This is a positive
test, indicating the lack of valvular mouth of the barrel and the great saphenous vein. With a
negative result of the superficial veins quickly (within 5-10 s) filled with blood prior to
removal of the compression in the oval fossa, and their content is not increased by removal of
compression.
Sample Pratt - the most commonly used test to detect failure of perforating veins. In the
patient lying down after emptying of varicose veins in the upper thigh rubber band is applied,
compressing a large subcutaneous vein. Then the limb imposed crepe bandage from the toes
up to the tow, and the patient is on his feet. Crepe bandage starting to take off the top, turn
over a loop. When the formed between the tourniquet and bandage in 10 - 15 cm above
impose a second crepe bandage, which gradually encircle limb down after contracting rounds
first bandage. The appearance of a busy segment of the varicose veins between the two
bandages indicates failure valvular perforating veins through which is filled from the deep
venous network of the segment saphenous vein.
Sample Barrow-Cooper-Sheinis or trehzhgutovaya sample based on the same principle as the
sample Pratt. To impose a three investigated limb tourniquet: the upper thigh, above knee and
below knee. Filling the segment between the bundles of the superficial veins in the transfer of
a patient in a vertical position indicates the failure of perforating veins in this segment. The
displacement of wire harnesses to meet each other can be more precisely determine the
localization of perforating veins untenable.
Sample Mayo Pratt - the most common test for detecting and evaluating cross-functional state
of the deep veins. The patient is in a horizontal position to impose a rubber band the top third
of the thigh. Then this finite tight bandage crepe bandage from the toes to the upper thigh.
Patient walks 20-30 minutes. If the trouble and pain it does not, then it shows good patency
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of deep veins, and, conversely, the appearance of arching pain in the shin alleges a violation
of patency of deep veins.
Sample Delbe-Perthes. In the upright position at the maximum filling of superficial veins on
the upper third of thigh tourniquet impose. Then the patient walks for 5-10 minutes. Rapid (12 min), emptying of superficial veins indicates good patency of deep venous valvular and
usefulness of perforating veins. If walking does not decrease the superficial veins, and,
conversely, their content increases, there are arching pain, it indicates the deep venous system
obstruction.
Special methods of diagnosis.
Before proceeding to the treatment of varicose veins doctor should make a very clear idea
about the state of deep and perforating veins of the limb. To date, no one can leave the patient
without Phlebology ultrasound. It is this study, non-invasive, highly informative in
experienced hands, a short time and quite burdensome for the patient, was the main diagnosis
in venous insufficiency. The most modern technique is duplex scanning with color Doppler
mapping, which allows to identify and cross-state valves of deep veins, from tibia to the
inferior vena, the direction of blood flow in the perforating and superficial veins. After the
widespread introduction of ultrasound techniques in practice the role of classical venography
greatly diminished. Today this technique is used infrequently, mainly in need of
reconstructive surgery (shunt or plastic) on the deep veins of the legs, and that every year the
frequency is reduced by venography performed learning and improving opportunities for
ultrasound.
Differential diagnosis
CVI
venous
lymph
thrombos
is
unilateral deme
ly
"Nephro
tic
edema"
always
"Cardiac
sided
primary
Nye,
often
bilateral;
Applyin
g
Swelling
of the
entire hip
and thigh
slightly
cyanotic
H\3
legs,
over
and
Swelling
n / a not
expresse
d
unilateral
localizati more
on of
often
lesions
two
localizati parties
on of
edema
Hue of
the skin
in the
area of
edema
The
nature of
swelling
Secondar
y - more
edema
edema "
orthostat "Articul
ic
ar
edema
always
edema "
Two
hundred
sided
always
duplex
In both
duplex
Shin,
okololol
odyzhec
hnyaa
area
pale
Shin,
okolololo
dyzhechn
yaa area
H\3
shin
okololo
dyzhek,
edema
edema
may rear
foot
pinkish
pale
more
often
duplex
In the
area of
the
affected
joint
normal
pregnant
lower
limbs
The
lower
third of
tibia
11
Sutoch
okololo
dyzhek,
Nye
dynamic
edema
rarely
limb
volume
in the
acute
period is
not
changed
ka
From
ordinar
y to
cyanoti
c
not
character
ized
indicators
pain
pulse
women,
increased
muscle
size
Swelling soft
of the feet
of the
rear leg +
thigh +
pale
no
Soft,
soft
dense
with
long-term
NC
no
associat
ed with
immobil
ity,
disappea
rs from
the east.
activity
not
not
typical
typical
Soft at
not
first, in
typical
the later
periods
dense
Differential Diagnosis
Chronic arterial insufficiency
(late stage)
Manifested as claudication,
pain in the future join in
peace
Loose or missing
color
The skin is pale, especially
when lifting his feet with his
feet sveshivanii skin becomes
dark red
temperature
edema
Reduced
Absent or insignificant, could
be due to the frequent mixing
of feet to relieve pain.
Atrophic skin, glossy, marked
loss of hair on feet and
fingers, thickening and
deformation of the nail
trophic changes
ulcers
gangrene
soft
pale
no
soft
not
typical
transient
Chronic venous insufficiency
(late stage)
Either not available or is
aching in nature and occurs
in an upright position
Normal, although its
definition due to swelling can
be difficult
Normal skin color. In the
vertical position of the
patient skin becomes
cyanotic hue. Over time,
there are petechiae and
brown pigmentation.
normal
As a rule, there is often
considerable and.
Often in the ankles
pigmented skin, there are
signs of stagnation
dermatitis, may decrease the
circumference of lower leg
with the development of scar
tissue
Usually formed on the fingers If formed, localized in the
and in places subject to
ankle, often in the medial
frequent injury.
malleolus
High risk of developing
do not develop
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Classification of venous disorders of lower limbs
A general classification of venous diseases not currently exist. Many of the proposed
classification [Kuzin MI, Vasyutka VJ, 1966 Askerkhanov RP, 1969 Klioner LI, 1969,
Saveliev VS et al, 1972; Klimov, VN et al, 1979; Shalimov AA, Sukharev II, 1984] reflect
some aspects of the pathological process in acute and chronic diseases of various levels of the
venous system. VI Bourakovsky and LA Bokeria (1989) proposed a generic classification in
which the entire venous system is divided into two parts - the system of the superior vena
cava and its main tributaries and the inferior vena cava system.
With regard to the inferior vena cava and its main tributaries, the disease of which differ
considerably large number of occurrences, the most common pathology in the range of the
venous system is a varicose superficial veins of the lower extremity with the most likely
outcome in chronic venous insufficiency. Another very common disease of the inferior vena
cava thrombosis are acute. The latter have a tendency to transform into
postromboflebitichesky syndrome (PTFS) - a chronic stage. At the same time are affected and
the deep and superficial segments of the system, which again leads to the development of
chronic venous insufficiency of the lower extremities. In addition, acute thrombosis of deep
inferior vena cava system in some cases can cause serious complications, which primarily
include pulmonary embolism and venous gangrene, so-called blue flegmaziya.
Treatment. Existing methods for treating varicose veins of the lower extremities can be
divided into four groups: 1) conservative and 2) sclerosing (injection), 3) surgical and 4)
combined. Surgery is indicated in cases where the primary varicose veins is accompanied by
chronic venous insufficiency, and with symptoms of circulatory disorders and lower
extremity varicose accession to various complications - eczema, dermatitis, ulcers, varicose
veins thrombophlebitis.
Control questions:
1. anatomical features of the veins of the lower extremity.
2. mechanism of the musculo-venous pump.
3. Varicose leg veins.
4. Thrombophlebitis of veins.
5. Postromboflebitichesky syndrome
6. chronic venous nedostatochnocht.
7. Syndrome Pedzhetta-Shrettera (acute subclavian vein thrombosis)
8. superior vena cava syndrome.
The answers to these questions:
13
1. Blood flow to the lower extremities by the veins of three types: superficial, deep and
perforatnym (communicating).
1. Superficial veins
and. Large subcutaneous Vienna originates in the medial malleolus, runs along the
anteromedial surface of the feet and empties into the femoral vein at the level of the oval
fossa.
b. Small subcutaneous Vienna starts at the lateral margin of the foot near the lateral malleolus
and runs into the popliteal vein between the heads of the gastrocnemius muscle.
2. Deep veins - thin-walled blood vessels that accompany the artery of the same name in pairs
and their major branches. Venous network triceps legs consist of calf veins draining into the
popliteal vein, and soleus veins draining into the posterior tibial and fibular veins.
3. Perforating veins connect the superficial and deep venous network among themselves. On
these vessels the blood is sent from the superficial veins into the deep. In the thigh are usually
2.1 perforating veins, and the rest are located on the lower leg.
2. All leg veins are equipped with folding flaps, which provide blood flow in one direction:
from the superficial veins - in the deep, from the distal sites - to proximal. When a person is,
the hydrostatic pressure of the blood makes it difficult to venous outflow from the lower
extremities. However, any reduction in the hip and thigh muscles drives blood through the
veins in the proximal direction, and the venous valves prevent the retrograde flow of blood.
This mechanism is called the muscle-venous pump or "peripheral heart". Above the inguinal
ligament deoxygenated blood goes to the heart through the breath the diaphragm and the
difference between intraabdominal and intrathoracic pressure.
3. "Varicose" is derived from the Latin. "Varix, varicis" - bloating. When the disease is
swelling of the subcutaneous veins, impaired outflow of blood on them with the development
of congestive changes in the lower extremities. Varicose veins are characterized by the
appearance feet saccular protrusion - varicose veins, tortuosity and increase in the length of
the surface of leg veins.
1. Primary varicose veins - the most common disease of the leg veins, occurs in 10-20% of
the population. The main reason, apparently, is a hereditary connective tissue weakness and
educated her vein walls and valves of venous valves. Risk factors: family history, profession,
associated with prolonged stay on his feet, pregnancy, age-related changes; obesity.
2. Secondary varicose veins due to increased venous pressure.
4. Thrombophlebitis - inflammation of the vein wall, accompanied by the formation of a
blood clot in the lumen of her. May be affected by any superficial Vienna. The main
complaint - the pain, along the vein is palpated a painful cord tight. To eliminate the
associated deep vein thrombosis are shown non-invasive study. Deep vein patency was
14
determined by non-invasive methods (duplex ultrasonography, Doppler study) rarely used
phlebography. For the differential diagnosis is used:
1. A sample of the Trendelenburg
2. Photoplethysmography. Superficial veins are pinched or pneumatic tourniquet cuff: an
increase in venous filling time means that only affected the subcutaneous veins.
5. Postromboflebitichesky syndrome develops after suffering deep vein thrombosis and is
characterized by failure of venous valves and occasionally - a violation of the venous
outflow. Small clots can completely dissolve under the action of the fibrinolytic system of
blood. But more is organizing a blood clot, that is, its replacement by connective tissue and
sewerage - germination thrombus capillaries. As a result, cross-veins is restored. However,
this process is accompanied by damage to the valves of venous valves, leading to their
inferiority. As a result, disturbed function of musculo-venous pump and develops a persistent
increase in venous pressure.
6. Chronic venous insufficiency develops in varicose veins or postthrombophlebitic diseases
of the lower extremities. Despite the similarity of many of the clinical symptoms, especially
edema syndrome manifestations in these diseases are different.
7. Development of the disease contribute to the topographic features of the subclavian vein,
located in the circumference of the bone and tendon-muscle formation. With strong stresses
the shoulder girdle muscles, combined with the movements of the shoulder joint, eliminates
the subclavian space and Vienna is squeezed between the clavicle and a rib.
8. A group of symptoms arising from impaired blood flow in the trunk of the superior vena
cava and venous hypertension caused by regional upper body is called "the superior vena
cava syndrome." According to the literature men suffer 3-4 times more often than women.
6.2. The analytical part.
The case dealt with the problem consistently, emphasizing the diagnostic and tactical features
in a particular case.
situational problems
Problem number 1.
Patient 65, a number of years suffering from BPB lower extremities. 3 days ago there was
pain along the posteromedial veins of the left tibia. Morbidity increased, the patient began to
experience difficulty in moving, the temperature rose to 37.8 * C. On examination, along the
vein is determined by the sudden flushing. Vienna thickened, sometimes chetkiobraznaya,
palpable in the form of a sharply painful pinch. The skin around a few infiltrated, hyperemic
and painful. Swelling in the foot and lower leg almost none.
Diagnosis? Survey:? Tactics?
15
The standard answer:
№
Replies
Max. ball
Full answer
Неуд. answer
1
Acute thrombophlebitis of greater
saphenous vein
5
5
0
2
Doppler ultrasound study of venous
5
5
0
3
Strict bed rest
5
5
0
4
Exalted position of limb
5
5
0
5
Appointment antikoogulyantov,
ointment bandages, antibiotics
5
5
0
Objective number 2.
In patient 70, a secondary varicose veins left leg and thigh, which gradually emerged after
suffering 10 years ago, deep vein thrombosis. In addition to the medial surface of the tibia has
a trophic ulcer size 10x5 cm, which has no tendency to heal. When flebograficheskom study
found that deep vein femur and tibia rekanalizirovany, there are a lot of communicating
veins.
Diagnosis? Tactics?
The standard answer:
№
replies
Max. ball
Full answer
Неуд. answer
1
PTFS, the mixed form
5
5
0
2
Hospitalization in the surgical
department
5
5
0
3
Treatment of trophic ulcers
5
5
0
4
Appointment of improving the blood
supply, antibiotics
5
5
0
5
Operations on fleboektomiya Babcock
and ligation komunikantnyh veins in
Linton
5
5
0
16
Task number 3
The patient's 62 years on the 8th day after hysterectomy appeared suddenly choking, chest
pain, loss of consciousness. Effective resuscitation to restore consciousness. The patient's
condition is extremely serious. Determined by cyanosis of face and upper body. In the lungs,
breathing auscultated on both sides. Ps-120 beats per minute. AD-80 / 50 mm Hg. determined
by the moderate right lower limb edema, increased vascular pattern in the groin area, pain on
palpation of the projection zone of the vascular bundle hip. Angiography (APG) revealed a
symptom of "stump" left branch pulmonary artery.
The development of the disease complicated the postoperative period? What was his reason?
The tactics of a doctor?
The standard answer:
№
Replies
Max. ball
Full anwer
Неуд.
answer
1
Postoperative femoral vein
phlebemphraxis
5
5
0
2
Thromboembolism left branch
pulmonary artery
5
5
0
3
Appointment of thrombolytics and
antigogulyantov after installing cava
filter
5
5
0
4
Local appointment to the finiteness of
ointment dressings
5
5
0
5
If failure of therapy, surgery
5
5
0
Objective number four
The patient aged 53 complained of sharp pain, numbness, itching in the right lower limb,
fever, 37.8. OBJECTIVE: tibia thickened, cyanotic, edematous. Determined by the
threadlike, compacted surface veins, right limb, the skin over the vein giperemiya. There is
tenderness on palpation of the vein.
The diagnosis of the patient. What complications are possible in this situation?
№
replies
Max. ball
Full anwer
Неуд. answer
1
Varicose veins in the right lower limb
5
5
0
17
decompensated
2
Acute saphenous vein
thrombophlebitis right leg
5
5
0
3
Pulmonary embolism
5
5
0
4
ascending thrombosis
5
5
0
5
venous gangrene
5
5
0
Interactive game "question ball"
Write questions about the little pieces of paper and stick on the ball with a ribbon molding so
that it is possible to read the questions completely and remove the following response.
Throws the ball to one of the students. A student who receives the ball detaches one of the
questions and answers the question written on a piece of paper. If the answer is correct the
game continues and the student who answered the question, throws the ball to another
student. Thus, the game continues until you have answers to all questions.
Questions and answers:
1. - The value of duplex ultrasound in the diagnosis of venous diseases of lower limbs.
Use sensors with a frequency of radiation 4 and 8 MHz to combine study with Doppler
imaging of blood vessels. Access to any study of the deep veins below the iliac crest. In the
diagnosis of deep vein thrombosis duplex ultrasound is the method of choice and gradually
replacing phlebography. Signs of a blood clot: intractability wall veins, increased
echogenicity compared with the moving blood, the lack of blood flow in the affected
segment. Duplex ultrasound to differentiate fresh thrombus from growing old organized.
Study of iliac vein is often difficult due to gas accumulation in the intestine. The diagnostic
accuracy of the method is 95%, sensitivity - 94%.
2. Venous malformations
A venous malformations - a relatively rare and heterogeneous group of diseases, including
aplasia, hypoplasia, a doubling of the veins and the presence of vestigial veins. Congenital
diseases of veins can be combined with arteriovenous malformations.
B. Klippel-Trenaunay syndrome - a congenital disease of the major veins. Characterized by a
triad of signs: a vascular nevus, congenital varicose veins, soft tissue hypertrophy of one or
more limbs. In addition, common hypoplasia or absence of deep vein thrombosis and,
consequently, the secondary increase in venous pressure. Develop a network of collaterals
around the missing segment of the vein can lead to the formation of large thin-walled varices
in the pelvic veins, which often are the cause of rectal and vaginal bleeding. To eliminate the
18
need angiography arteriovenous malformation. Treatment is conservative: the exalted
position of the legs, wearing elastic stockings.
3. Pulmonary embolism.
One of the serious complications of deep vein thrombosis of lower extremities is a pulmonary
embolism (PE). Clinically observed sudden severe chest pain, shortness of breath and
tsianogz (face, neck, upper half of the thorax), lower blood pressure. In cases of hemoptysis
associated infavrkta light, the temperature rises.
In the treatment of heparin administered in large doses (30-50 thousand units.) Selectively
into the pulmonary artery or intravenously streptazu (500 thousand-1 million. ED), avelizin
(250 thousand - 1.5 million units per day). Occasionally, emergency surgery is shown, the
pulmonary artery embolectomy.
4. Methods venography
Venography - a common standard method for studying diseases of the veins.
and. Rising phlebography. Radiopaque substance injected into one of the distal veins and get
the image of proximal venous network. Thrombi appear as filling defects are rounded. The
absence of staining for visualization of arterial venous collaterals of the set - another sign of
venous thrombosis.
b. Descending phlebography. Radiopaque substance injected into the femoral vein.
Retrograde spread of contrast medium to evaluate the degree of venous insufficiency:
1) Slight reflux during the Valsalva maneuver.
2) anterograde venous blood flow in the iliac segment reflux to the distal femur.
3) reflux in popliteal vein to vein leg.
4) to venous reflux landslide tibia; anterograde blood flow in the iliac segment is missing.
5. Treatments for varicose veins varikonogo limb
1. Conservative: the sublime position of the feet, wearing stockings, creating a pressure
gradient from foot to thigh. These measures are most effective when postflebiticheskom
syndrome, varicose veins, caused congenital arteriovenous malformation.
2. Sclerotherapy is used to remove small varicose veins and residual varicose after surgery.
3. Surgery. The most frequent indication for surgery - removal of a cosmetic defect feet.
Other indications: failure of conservative therapy, continuous pain, complications (bleeding,
ulcers, thrombophlebitis of superficial veins). Acquired arteriovenous fistulas also require
surgical intervention
6.Tromboz deep vein
19
A. Incidence. Deep vein thrombosis is often asymptomatic and go unrecognized, so that the
overall incidence of disease is unknown. According scintigraphy with 125I-fibrinogen, deep
vein thrombosis complicating the postoperative period in 30% of patients older than 40 years.
Deep vein thrombosis is diagnosed in more than half of patients with paralysis of lower limbs
and more than half of patients, long-term bedridden.
B. Etiology and pathogenesis. The main causes of deep vein thrombosis coincide with
thrombotic pathogenetic factors (Virchow's triad):
1) endothelial damage;
2) slowing of venous flow;
3) increased blood clotting.
Risk factors include heart failure, advanced age, malignancy, trauma, obesity, prolonged
immobilization of the limb, prolonged bed rest, oral contraceptives, erythremia,
thrombocytosis
7. What are the contraindications for phlebectomy.
Contraindications to the removal of saphenous veins: limb arterial insufficiency, pregnancy,
infections of skin and soft tissues, lymphedema, hemorrhagic diathesis, a high anesthetic risk,
as well as thrombotic occlusion of the main deep veins and deep vein hypoplasia. Major
complications: hematoma formation and ecchymosis, subcutaneous, or damage to the sural
nerve, necrosis of wound edges and long nezazhivlenie. Known erroneous ligation and
removal of the femoral artery and femoral vein.
8. thrombosis prophylaxis
Prevention of thrombosis is important because it saves the patients with deep vein thrombosis
of lower extremities from serious complications such as pulmonary embolism and
posttromboflebetichesky syndrome. The need for measures to prevent thrombosis is greatest
in elderly patients, patients with severe diseases of the cardiovascular system in the
postoperative period. Specified quota of patients should be prescribed drugs which improve
blood rheology and microcirculation, which have inhibitory effects on adhesively-aggregative
function of platelets, reducing the potential for coagulation of blood. Non-specific prevention
of thrombosis: limb bandaging elastic bandages, electrical muscle stimulation shins,
gymnastic exercises, which improve the venous outflow, getting up early in the postoperative
period, prompt correction of fluid and electrolyte disturbances, anemia, removal, control of
the cardiovascular and respiratory disorders.
6.3 The practical part
Definition of symptoms with pain for edematous limbs venous disorders, conduct
fuktsionalnyh samples venogram reading.
20
Identification of symptoms in edematous limb pain syndrome
skills
№
Not doing
(0 ball)
Definition of ripple on the vessels
1
2
3
15
palpation of the limb
Auscultation limb vessels
Perform functional tests for deep vein
thrombophlebitis
Perform functional tests
reading venogram
Total:
4
5
6
Doing
(10 ball)
15
20
20
15
15
100
7. Forms of control knowledge, skills and abilities:
• oral;
• writing;
• testing;
• addressing situational problems;
• demonstration of skills mastered
8.Assessment criteries of the current control
№
%
evaluation
Criteria
1
96-100
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational problems applies
unconventional approaches grounded in the
responses.
2
91-95
Excellent "5"
In full view of a syndrome of limb ischemia,
classification, diagnosis, and treatment methods
21
dif.diagnostike. The questions gives a correct
and comprehensive answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies. Independently, with
knowledge of the facts involved in the choice of
treatment. Actively involved in conducting
intraktivnyh games. In solving the situational
problems applies unconventional approaches
grounded in the responses. When interpreting
the data biochemistry made one mistake
3
86-94
Excellent "5"
The full presentation is on the edematous limb
pain syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions gives a correct and comprehensive
answer. To think independently and draw
conclusions. Self-supervised patients and
skillfully applies the practical skills. Interprets
the data of clinical and instrumental studies.
Independently, with knowledge of the facts
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
4
81-85%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. Selfsupervised patients and skillfully applies the
practical skills. Interprets the data of clinical
and instrumental studies, but not fully aware of
the value of individual data. Knowingly
involved in the choice of treatment. Actively
involved in conducting intraktivnyh games. In
solving the situational tasks made some errors
5
76-80%
"Good"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently. Self-supervised patients and
skillfully applies the practical skills. Interprets
22
the data of clinical and instrumental studies, but
not fully aware of the value of individual data.
Knowingly involved in the choice of treatment.
Actively involved in conducting intraktivnyh
games. In solving the situational tasks and skills
made a few inaccuracies
6
7
8
Good "4"
A student has full understanding of edematous
limb pain syndrome, classification, diagnosis,
and treatment methods dif.diagnostike. The
questions gives the correct answer. To think
independently and draw conclusions. Selfsupervised patients and skillfully applies the
practical skills. Independently, with knowledge
of the facts involved in the choice of treatment
tactics, but admits mistakes. In carrying out the
practical skills makes a grave error. Situational
problems decides not to complete.
Satisfactory "3"
The student is aware of the edematous limb pain
syndrome, classification, diagnosis, and
treatment methods dif.diagnostike. The
questions do not give a complete answer. Make
mistakes in presenting the classification and
dif.diagnostike. The answers are not confident.
Practical skills and case studies serves correctly.
71-75%
66-70%
Satisfactory "3"
At half the questions gives the correct answer.
Answers are not confident. Poor knowledge of
the classification of ischemia. To individual
questions knows the answers, but to present
their idea can not.
Satisfactory "3"
Half the questions asked gave the correct
answer. In presenting the essence of the
syndrome, diagnosis, diff. Diagnostic algorithm
for the interpretation of medical mistakes.
Uncertain poses a problem. Practical skills are
difficult to perform. Situational tasks executes
correctly.
Unsatisfactory "2"
The student has no idea about the syndrome,
classification, diagnosis of the disease, does not
know diff.diagnostike treatment policy and is
61-65%
9
55-60%
10
under
54%
66-70%
23
not able to perform practical skills.
9. Chronological map of activities:
stages of training
form class
№
Duration
of activity
(327min)
1
Introductory speech teacher, study subjects
5
2
Discussion of homework. Interactive game "lottery"
The survey, discussion
(Annex № 1)
30
3
Admission of patients in the clinic, dispensary
work. Study dispensary cards.
Reception questioning,
examination of patients.
Primary surgical treatment
of wounds.
60
4
Improvement of practical skills, interpretation of
laboratory data, radiographs.
The algorithm of
60
break
30
5
Discussion of the practical lessons with the teacher.
A poll debate
35
6
Hearing the abstract of the report the student,
followed by discussion as a group
Abstract messages,
discussion threads
32
7
Group discussion as interactive games. The solution Working in small groups,
of case problems on the wound, securing the
interactive game
students' knowledge
8
Conclusion lecturer on the topic. Evaluation of each
student on a 100 ballnoy system and announces it.
Distributes tasks for self-training.
(Annex № 2,3)
9
Independent work in the library
Magazine, the work
program, questions for
self-training.
0. Control questions:
1. The main diseases are manifested edematous pain.
65
10
24
2. Diagnosis and difdiagnostika varicose veins and superficial thrombophlebitis of deep veins
of the lower extremity.
3. Anatomical features of the structure of veins of the extremities.
4. theoretical basis of sampling, reflecting the functional state of different parts of the venous
system.
5. Mechanisms phase of chronic venous insufficiency
6. Classification of varicose superficial veins;
7.Postromboflebitichesky syndrome;
8.Sindrom superior vena cava and Pedzhetta-Shrettera;
9. phlebemphraxis and thrombophlebitis;
10.Oslozhnenie (PE);
11.Osnovnye types of surgery;
12.printsipy prevention of complications.
11. References:
Summary:
1. Gostischev VK, General Surgery. Moscow. 2003
2. Savel'ev VS, Surgical Diseases, Moscow, 2006.
3. Karimov SH.I. Surgical diseases, Tashkent, 2005
MORE:
4. Murtagh, J., Handbook of general practice, 1998
5. Shevchenko YL, Private Surgery, St Petersburg, 2000
6. AV Gavrilenko, SI Disappeared, FA Radkevich. Surgical methods of correction of valvular
insufficiency of deep veins of the lower extremities. - Angiology and Vascular Surgery. 1997. - № 2. - S. 27 - 34.
7. GD Konstantinova, T. V. Alekperov, ED Don. Outpatient treatment of varicose veins of
the lower extremities. - Annals of Surgery. - 1996. - № 2. - S. 52 - 55.