THE KURSK STATE MEDICAL UNIVERSITY
DEPARTMENT OF SURGICAL DISEASES № 1
ACUTE SUPERFICIAL AND DEEP VEIN THROMBOPHLEBITIS
Information for self-training of English-speaking students
The chair of surgical diseases N 1 (Chair-head - prof. S.V.Ivanov)
BY ASS. PROFESSOR I.S. IVANOV
KURSK-2010

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I. INTRODUCTION
Venous disorders are associated with a high morbidity and a significant mortality.
Twenty per cent of the population suffer with varicose veins. Two per cent of the population have skin changes associated with venous ulceration and, at any one time,
100 000 people in the UK have active venous ulceration. The cost in dressings alone runs to £200 million per annum. Deep veins thrombosis is one of the most serious problem in industrial countries .
II. GENERAL AIM OF THE SESSION
General aim of the session includes acquisition the following by students:
1. Knowledges on clinical signs, diagnose, medicine treatment and surgical management of deep veins thrombosis
2. Practical skills of disease anamnesis accumulation and objective examination of the patients.
3. Opportunity to create plan of laboratory and instrumental investigation, ability to create and to prove clinical diagnosis, to make indications and contra-indication for surgical treatment and to choose the mode of it or conservative therapy in patient with deep veins thrombosis.
III. TRAINING-AIM TASKS FOR SELF-TRAINING
After individual studying of the material every student have to:
A/ to know:
• Classification of this diseases
• Pathogenesis of more spread forms of the diseases
• Clinical picture of this diseases
• Diagnostic value of different instrumental methods.
• Indications and contra-indication for surgical treatment
•Complex conservative treatment
•Principles of surgical treatment and technics of operation.

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B / be able
• To find main complains, symptoms and signs of the deep veins thrombosis, accumulate anamnesis in cases and staging this disease.
• To realize objective examination of patients with this diseases.
• Be able to assess received datas of US-scanning, X-Ray examination, angiography, CT-examination, laboratory datas
• To create indications and contra-indication for surgical treatment.
III. INITIAL LEVEL OF KNOWLEDGES
Anatomo-physiological datas about the deep veins thrombosis have been studied on 3-4-th courses. Different modes of surgical procedures have been studied on course of operative surgery. You should restore this study material.
IV. MATERIAL, IS OBL1GATIVE FOR TOPIC MASTERING
The venous system of the lower limb can be conveniently classified into three groups:

The superficial veins, external to deep fascia and therefore, unsupported

The deep veins deep to deep fascia and

Communicating (Perforating) system of veins connecting the superficial and deep veins.
The superficial venous system consists of :

Dorsal venous arch lying beyond the heads of the metatarsals.

Lone saphenous veins —Formed at the medial end of the dorsal venous arch, ascends up the high and finally through the saphenous opening to empty into the femoral vein. At this end, the long saphenous vein receives the following tributaries : superficial external iliac, superficial epigastric and superficial external pudendal. The saphenofemoral junction is always guarded by a valve.

Short saphenous vein
—Formed at the lateral end of the dorsal venous arch, passes upwards behind the lateral malleolus to reach the midline of the calf

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(accompanied by sural nerve) to open into the popliteal vein. The short saphendpopliteal junction is also guarded by a valve.
Deep venous system : This high pressure system accompanying the main arteries lies deep to deep fascia and is well supported by powerful muscles (muscle or calf pump). Deep venous system consists of the following veins : 1) Posterior tibial vein
(lateral+medial plantar veins) which joins the 2) Anterior tibial veins (upward continuation of the venae comitantes of the dorsalis pedis artery) to form 3) Popliteal vein at the lower border of the popliteus muscle. It courses up from the opening in the adductor magnus as femoral vein to run up as the external iliac vein as it passes under the inguinal ligament. Valves in the deep venous system help to direct the blood flow upwards towards the heart.
Communicating or perforating veins : The perforating veins pass through the deep fascial layer at numerous anatomical sites in the foot, leg and thigh to connect the superficial and deep venous systems. The junctions between the superficial and deep venous systems are guarded by unidirectional strategic valves (see below).
Constant medial perforating veins (lateral perforators being inconstant) are situated behind the medial border of tibia at 5 cm.. 10 cm. and 15 cm. above the medial malleolus. This area is susceptible to venous hypertension and development of venous ulcers.
Functional valve mechanism. Valvular mechanism is situated at the level of deep fascia. The valves (veil—like bicuspid valve) in the perforating veins permit unidirectional flow of blood from the superficial to deep venous system. Valves are generally located just proximal to the entry of a tributary. The retrograde How of blood from the high pressure deep veins to the low pressure superficial veins is prevented by this valvular mechanism. Normally, this one-way flow mechanism is guided by valves which are kept closed by the pressure of the muscles against the deep fascia and a pinch cock mechanism at the deep fascial opening.

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The venous (calf-muscles) Pump
—Venous blood from the lower limb is returned to the heart by pumping action of call muscles within strong fascial cover.
Contraction of the muscles within strict confines of the encircling deep fascia (venous or calf-muscle pump) squcey.e the blood and its flow is directed to heart by unidirectional strategic valves. During momentary phase (diastolic phase of calf pump) blood flows from the superficial venous system to the deep venous syslcm via the perforating veins under the guidance of valves.
Classification
Clinical forms:
1. Edematous
2. Painful
3. Ulcerative
4. Varicose
5. Mixed
Localization of process
1. Tibia-femoral segment
2. Tibia-femoral + popliteal segment
3. Ileal
4. Vena cava inferior syndrom
INVESTIGATION
A full history and clinical examination should be undertaken. Patients presenting with arterial disease may have coexisting varicose veins and are inappropriately referred to a venous clinic. Venous symptoms include tiredness, aching, tingling and cramps which get progressively worse towards the end of the day and are relieved by elevating the leg. Ankle swelling and skin changes may also occur.

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Doppler ultrasonography is now the minimum level of investigation required before treating venous disease. Students should know physical bases of Doppler effect.
Photoplethysmography is the technique which measures the amount of blood in the skin. On dorsiflexion of the ankle the blood is pumped from the skin.
Strain gauge plethysmography measures volume changes in the leg in response to a tourniquet applied around the thigh. It provides useful information on venous outflow and can be used to diagnose iliofemoral venous thrombosis.
Duplex imaging involves the use of B-mode ultrasound and a coupled Doppler probe. It allows direct visualisation of the veins and provides functional as well as anatomical information.
Venography.
A fine tourniquet is applied just above the malleoli and an injection of nomonic contrast material given to outline the veins. The technique provides anatomical information and is now only indicated in the absence of good duplex ultrasonography facilities.
Prevention
All patients admitted to hospital or being treated for a serious illness should be assessed for the risk of deep vein thrombosis. These patients mav be considered at low, moderate or high risk. Exist 3 stages of the risks: low, moderate and high risk.
Treatment
1.Conservative
1) Elevation
2) Elastic stocking

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3) Massage as described under lymphodema
4) Anticoagulant therapy—Heparin I.V. for 7-10 days followed by warfarin orally tor 3 months
5) Analgesics
6) Fibrinolytic therapy e.g. streptokinase or urokinase may cause serious bleeding at the site of operation if used in about 10 days after operation.
7) If fever persists, blood culture should be performed and antibiotics given for fear of septicaemia & pyaemia
8) Patients with extensive thrombosis are often very anaemic and urgent blood transfusion should be considered.
Operative—When conservative treatment fails .
2.Operative
1) Thrombectomy: Deserves consideration if, there is evidence of venous gangrene.
2) Venous interruption may be called for extension of life-threatening thrombus.
Palma operation —Iliac vein obstruction is bypassed by long saphenous vein of the good leg. The vein is rerouted across the pubis through a subcutaneous tunnel and anastomosed to a vein below the iliac vein obstructin.
Valve repair or replacement —Not much in practice because the incidence of post-operative thrombosis is too high.
V. LITERATURE
1. Short Practice of Surgery by Charles v. Mann and al.
2. Lections
VI. APPROXIMATE ACTIONS BASE
1. Introduction /5 min/
Teacher short characterizes topic actuality, meets students with main aims of

8 the study and its plan.
2. Initial knowledges control /15 min/
3. Individual students work with patients. /30 min/ The teacher explains some more difficult and important parts of problem. The choice is realized by asking of students and their answers correction.
4. Clinical analisys of topical patients. /100 min/
Students observe topical patients under teacher control. After it finishing, the students report about receiving results.
Work in dressing-room and operational theater.
Teacher and students change the dressings of patients after different surgical procedures on the pancreas
Study of X-Ray pictures, US- and CT-scanns, laboratory datas
5. Final knowledge control. Solution of test-questions /25 min/
6. Conclusion /5min/
The teacher concludes the session and gives new task for the next once.
VII. TEST QUESTION
1. What is the main used operations in surgical treatment of deep veins trombosis?.

Thrombectomy from the vein

Resection of the pulmonary arteria

Palma operation

Thrombectomy from the arteria

Valve repair or replacement
2.Some clinical forms of deep veins thrombosis are known, except:

Edematous

Phlegmonous

Painful

Ulcerative

Suppurative

Varicose

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
Mixed
3. The venous system of the lower limb classified into three groups, except:

Mixed veins

The superficial veins

Palpebral veins

The deep veins

Communicating (Perforating) system of veins

Scrotal veins
4.What is the main important methods of deep venous thrombosis investigating?

Doppler ultrasonography of veins

Photoplethysmograph

Duplex imaging of veins

Venography

Arteriography

Endoscopic methods of investigation
5. Conservative treatment will consist from some methods of examination, except:

Elevation

Elastic stocking

Nonelastic stocking

Coagulant therapy

Anticoagulant therapy

Analgesics

Antifibrinolytic therapy

Fibrinolytic therapy
6.The signs and symptoms of deep vein thrombosis are:

Heartburn

Swelling

Pain

Redness

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
Dilated superficial veins

Low grade pyrexia

Sleepiness
7.
The triad of Virchov will consist of three components, except :

Change in the vessel wall, namely endothetial damage by trauma or inflammation.

Normocoagulability of blood.

Stasis due to sluggish blood flow during or after operation, prolonged convalescence and in debilitating conditions such as typhoid fever.

Change in the lymphatic wall, namely endothetial damage by trauma or inflammation.

Hypercoagulability of blood.

High temperature of the blood.

Hypocoagulability of blood.
VIII. CORRECT ANSWERS
1. 1, 3, 5
2. 2, 5
3. 1, 3, 6
4. 5, 6
5. 3, 4, 6, 8
6. 1, 7
7. 2, 4, 6, 7