Thrombophlebitis and DVT lecture

Deep venous thrombosis

differentiate from gout image : HERE

Several different terms are used for the chronic symptoms that can occur after a deep vein thrombosis:
1. Venous stasis syndrome
2. Postthrombotic syndrome.................

Read more...............>>

May-Thurner syndrome

The May-Thurner syndrome is the symptomatic compression of the left common iliac vein between the right common iliac artery and the lumbar vertebrae.

The normal anatomy is that the artery which runs to the right leg (= right common iliac artery) lies on top of the vein coming from the left leg (= left common iliac vein). This close proximity leads, in some people, to pressure of the artery onto the vein and to varying degrees of narrowing of the vein. This is referred to as "May Thurner syndrome". It is not a disease but a congenital anatomic variant. Mild and moderate degrees of narrowing are typically asymptomatic. More severe degrees can lead to obstruction of blood flow from the leg and thus to leg swelling and pain. The narrowed vein can also clot, resulting in left leg DVT.

The syndrome is named after the authors R. May and J. Thurner, who first described this phenomenon in 1957. It has also been termed the iliac compression syndrome. It is probably the reason why more DVTs occur in the left than in the right leg.

Compression of the iliac vein has been documented in approximately 50% of patients with left iliac vein thrombosis.

Several surgical treatment strategies have been employed in the past:

1. venous bypass surgery of the narrowed area;
2. cutting of the iliac artery and repositioning of the artery behind the iliac vein;
3. construction of a tissue sling or flap to lift it off the iliac vein;

Since 1995 venous stents have been placed into the narrowed area, to pry them open . Unfortunately, there are no large studies that
(a) investigate the long-term success of the procedure, i.e. how often the stents improve symptoms and remain patent.
(b) whether patients should remain on long-term (lifelong) coumadin (warfarin) or not. Stents appear beneficial at least in the short-term improvement of symptoms, within the first 1-2 years of stent placement .

Algorithm for the therapeutic management of patients with venous ulcer

Algorithm for the diagnostic management of patients with chronic ulcer of L.L.

Kienbock's Disease (Lunatomalacia)

.Avascular necrosis of lunate bone

· Predisposed in individuals engaged in manual labor with repeated or single episode of trauma

· Frequency
o Usually affects men aged 20-40 yrs.
o Mostly unilateral
o More often in right wrist

· Pathophysiology
o Vascular impairment due to acute or chronic injury
( Exact cause is unknown)
o Lunate develops osteonecrosis due to loss of blood supply, causing pain and stiffness in the wrist
o In late stages, the bone collapses eventually leading to degenerative changes and osteoarthritis in the radiocarpal joint

· Clinical findings
o Progressive pain
o Soft-tissue swelling of wrist


Imaging findings
o The disease can be staged based on radiographic findings

** Lichtman's Radiographic Classification of Kienbock's Disease
· Stage I - Normal radiograph
· Stage II - Sclerosis of lunate with possible decrease of lunate height on radial side only
· Stage IIIa - Lunate collapse, no scaphoid rotation
· Stage IIIb - Lunate collapse, fixed scaphoid rotation
· Stage IV - Degenerative changes around the lunate

§ The disease may also be associated with negative ulnar variance

Frontal view of the hand and wrist demonstrates sclerosis, irregularity
and collapse of the lunate (blue arrows) in Kienbock's Disease (Kienbock's Osteomalacia)

o Bone scan and MRI may be helpful early in the course of the disease when there are minimal radiographic findings.

Treatment:
** Initial therapy is conservative management
** Anti-inflammatory medications and splinting or casting
** Operative treatment is based on the stage of the disease and may involve
1-Revascularization procedures
2-Ulnar lengthening or radial shortening
3-Fusion or excision of carpal bones

Deep venous thrombosis

Several different terms are used for the chronic symptoms that can occur after a deep vein thrombosis:
1. Venous stasis syndrome
2. Postthrombotic syndrome
3. Venous insufficiency syndrome
4. Postphlebitic syndrome

Symptoms:

* chronic leg swelling
* chronic (or waxing) pain
* diffuse aching
* leg heaviness
* leg tiredness
* leg cramping
* dark skin pigmentation (=postthrombotic pigmentation; figure)
* hardening of the skin
* skin dryness
* formation of varicose veins
* skin ulcer (stasis ulcer)

Complications of DVT:
- Pulmonary embolism (the most important) WATCH VIDEO
- Post thrombotic syndrome
- Limb ischaemia

Investigation:
* A blood test called a D-Dimer. This measures a substance which develops when a
blood clot breaks down. If this is negative it's unlikely that you have a DVT.
* A Doppler ultrasound. This is a test that uses sound waves to look at your
blood as it flows through your blood vessels. It's the best test to detect
blood clots above your knee.
* A venogram. In this test, a special dye is injected into your vein, which shows
up the vein on X-ray. This is the best way of showing clots below your knee.


Prevention:
There are a number of things you may be able to do to reduce your risk, such as stopping smoking if you smoke, or losing weight if you're overweight. Regular walking can help to improve the blood circulation in your legs and help to prevent another DVT from developing.

There is no good evidence that taking aspirin reduces your risk of developing DVT.

Treatment of DVT:
The treatment for deep venous thrombosis above the knee is anticoagulation, unless a contraindication exists (recent major surgery or abnormal reactions).Anticoagulation prevents further growth of the blood clot and prevents it from forming an embolus that can travel to the lung.

. Warfarin (Coumadin) is the drug of choice. It is begun immediately, but unfortunately it may take a week or more for the blood to be appropriately thinned. Therefore, low molecular weight heparin [enoxaparin (Lovenox)] is administered at the same time. It thins the blood via a different mechanism and is used as a bridge therapy until the warfarin has reached its therapeutic level.

The dosage of warfarin is monitored by blood tests measuring the prothrombin time or INR (international normalized ratio). For an uncomplicated deep vein thrombosis, the recommended length of therapy with warfarin is three to six months.

Some patients may have contraindications for warfarin therapy, for example a patient with bleeding in the brain, major trauma, or recent significant surgery. An alternative may be to place a filter in the inferior vena cava to prevent emboli from reaching the heart and lungs. These filters may be effective but also may be the source of new clot formation.

Compression stockings
These are also called graduated compression stockings.It eases pain and reduce swelling, and to prevent post-thrombotic syndrome. You may need to wear them for two years or more after having a DVT.

In rare cases, surgery may be needed if medicines do not work. Surgery may involve:

* Placement of a filter in the body's largest vein to prevent blood clots from
traveling to the lungs
* Removal of a large blood clot from the vein or injection of clot-busting
medicines.

Axillofemoral bypass graft

This elderly female patient underwent an axillofemoral graft (also called axillofemoral bypass graft) for loss of blood flow in the right femoral artery. The procedure involved connecting the right femoral artery and right axillary artery using an artificial graft tube, which was placed along the subcutaneous plane of the chest and abdomen. This patient underwent Color Doppler imaging to assess the condition and flow in the graft tube. The color Doppler image above shows the artificial axillofemoral graft tube with normal flow through it.
Note the large diameter of the graft tube and location in the subcutaneous plane of the chest wall.

NEJM Procedure: Thrombus Aspiration

n an occluded infarct-related artery, reperfusion can be achieved by the standard means of primary percutaneous coronary intervention or by the new method of thrombus aspiration, followed by stenting, as depicted in this video.

The Closure Procedure for Varicose Veins

DVT & Pulmonary Embolism animation