Peripheral vascular diseases
Classification
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Venous diseases；
Arterial diseases；
Arterio-venous diseases；
Congenital vascular malformation (CVM)；
Vascular injury.
Hemodynamics
1. The contraction function muscular pump in calf;
2. The negative pressure caused during thoracic inspiration and diastole;
3. Up-ward one-way direction opening of venous valve.
Venous diseases
1. Venous reflux diseases：
⑴ Simple superficial varicosities in lower limbs
⑵ Primary deep venous insufficiency (PDVI)
2. Venous obstructive diseases：
Deep venous thrombosis (DVT)
Lower extremity varicose veins
Etiology
1. Weakness of venous wall;
2. Defect of venous valve；
3. Augmentation in superficial venous pressure.
Pathophysiology
Venous hypertension in lower extremity → Clinical symptoms
 Ectasia of superficial vein
 Enlargement of capillary bed
 Increased permeability in capillary
Pathophysiology
Skin malnutrition：
Large-molecular substances (fibrinogen, red blood cells) infiltrate to tissue
interspaces;
 Lowering fibrinolytic activity in blood and tissue, fail to disintegrate
fibrin.
 Deposition of fibrin around capillary bed;
 Lack of oxygen & nutrition in cells of dermis and subcutaneous tissue,
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lowering of metabolic rate.
Pathophysiology
Mechanisms of skin malnutrition in gaiter area:
 Partial venous backflow passes by saphenous vein, but mainly direct
through deep vein by perforators.
 Blood gravity of deep vein is highest;
 Perforators locate below muscular pump, and suffer the highest inverse
pressure during pump contraction, finally result in valve insufficiency.
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Clinical manifestations
Superficial varicosities in lower extremity (great/lesser saphenous vein);
Discomfortable;
Mild edema around ankle;
Skin alteration at gaiter area (skin pigmentation, pruritus, eczema, ulcer).
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Diagnosis
History：course, inducible factors;
Clinical manifestations;
Physical examinations: special vascular examinations;
Auxillary examinations: non-invasive & invasive tests
Doppler;
Peripheral vascular laboratories (venous pressure measurement in
lower limbs…)；
Venography.
Differential diagnosis
1. Primary deep venous insufficiency, DVI
 Clinical symptoms are relatively more severe;
 Decreased lowering rate of superficial venous pressure after
mobilization;
 Venography helps to confirm.
2. Deep venous thrombosis sequela, DVTs
 Edema of lower limb occur before superficial varicosities;
 Superficial varicosities are compensative, not along courses of
great/lesser saphenous veous & their tributaries;
 Limb edema;
 Venography helps to confirm.
3. Arterio-venous fistula, AVF)
Increased skin temperature in affected limb；
 Local thrill during palpation / blood murmur during auscultation;
 Increased superficial venous pressure & superficial varicosities
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around fistulae;
Increased blood oxygen content in veins around fistulae;
Arteriography helps to confirm.
★ Therapy
 Non-operative treatment：improve symptoms；
 Minimally-invasive treatment ： sclerotherapy, compressive treatment,
endovenous laser treatment (EVLT)
 Surgery treatment
Non-operative treatment
Indication:
⑴ local lesion, mild symptoms
⑵ Pregnant；
⑶ With predominant symptoms, but poor surgical tolerance.
Methods：
 Compression ： elastic compression bandage / elastic compression
stockings
 Avoid long-time standing & sitting, intermittent elevate affected limb.
Sclerotherapy & compressive treatment
Indication:
⑴ few, local lesion;
⑵ auxillary methods to surgery.
Commonly-used sclero-agent：
⑴ 5% sodium morrhuate
⑵ phenol-glycerin solution
⑶ others
Surgical treatment
Indication: with symptoms, no contra-indications for operation.
Methods:
 High ligation of great/lesser saphenous vein;
 Ablation of great/lesser saphenous vein & superficial varicosities.
 Ligation of perforators;
 Management of ulcer.
Deep venous thrombosis DVT
Definition
Abnormal blood coagulation in deep vein causes venous obstruction,
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which affect venous blood back-flow. It occurs in venous main trunk all over
the body, esp. in lower extremities.
▲ Etiology & pathology
Virchow theory(1856)：
 Venous injury;
 Venous stasis;
 Hypercoagulation.
▲ Clinical manifestations
DVT in upper limb
Limited to axillary vein → swelling & pain in forearm & hand, finger
movement limitation;
Confluence of axillary-subclavian vein
→ swelling in upper limb + superficial varicosities in above-elbow,
shoulder, upper clavicle, affected part of anterior chest wall.
Symptoms worsen while lowering limb
Thrombosis in superior vena cava (Diastinum/pulmonary neoplasm)
 Symptoms of venous obstruction in upper limb
 Swelling in face & neck, conjunctive congestion, blepharon swelling
 Superficial varicosities in neck, anterior chest wall & shoulder (flow
direction is down-ward)
 Symptoms of nervous system
 Symptoms of primary diseases
Thrombosis in inferior vena cava
(mainly caused by propagation of DVT in lower limb)
 Symptoms of venous obstruction in lower limb
 Superficial varicosities in trunk (flow direction is up-ward)
• Budd-Chiari syndrome: Stenosis / total occlusion of post-hepatic IVC &/
hepatic vein. Pt. Has hepatomegaly, progressive hepatic failure & ascites,
complicates hepatic cirrhosis at late stage.
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Diagnosis
Detailed history;
Clinical manifestations;
Physical examinations: special vascular examinations;
Auxillary examinations: non-invasive & invasive methods
Doppler；
Venography
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▲ Therapy
 Non-operative treatment
 Operative treatment
▲ Non-operative treatment
 General management: absolutely lie in bed, elevate affected limb,
properly use diuretics at acute stage; elastic compression at chronic
stage.
 Thrombolytic therapy: courses < 72 h，urokinase.
 Aanti-coagulate therapy: heparin & dicoumarin (warfarin).
 Anti-platelet therapy: aspirin, persentin.
▲ Operative treatment
 thrombectomy：
Indication：①Thrombosis in ilio-femoral vein, courses <48 h;
②Limb salvage
 Bypass operation:
① Palma-Dale procedure (supra-pubic autograft / synthetic graft
cross-over);
② Husini procedure
 Palliative operation:
Ablation of superficial varicosities & ligation of perforators around
ulcer.
Fatal complication
Pulmonary embolism, PE
Questions
1. Try to depict the pathophysiology and clinical manifestations of simple
superficial varicosities in lower limbs.
2. What are Trendelenburg and Perthes tests?
3. Try to depict the diagnostic basis of simple superficial varicosities in
lower limbs.
4. Try to depict the preventive and therapeutic measures of simple
superficial varicosities in lower limbs.
5. Try to depict the etiology of deep venous thrombosis (DVT) in lower
limbs.
6. Try to depict the diagnostic basis of deep venous thrombosis (DVT).
7. Try to depict the therapeutic measures of deep venous thrombosis (DVT),
which include non-operative and operative treatment.
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