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Chronic Venous Insufficiency

Chronic Venous Insufficiency

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Published by: fandi_cah_ganteng3367 on Feb 23, 2010
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05/16/2012

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CHRONIC VENOUS INSUFFICIENCY 
DEFINITION
When your leg veins cannot pump enough blood back to your heart, you have chronicvenous insufficiency (CVI).CVI is also sometimes called chronic venous disease, or CVD.
ETIOLOGY 
Long term blood pressure that is higher than normal inside leg veins
Deep vein thrombosis (DVT)
Phlebitis
Obstructing the free flow of blood through the veins.
Neoplastic obstruction of the pelvic veins or congenital or acquired arteriovenousfistula.
Occur in association with superficial venous reflux and varicose veins
EPIDEMIOLOGY 
Extremely common
Risk factors for chronic venous disease include
Heredity (family history of varicose veins)
Age (Women older than 50)
Female sex
Obesity
Pregnancy
Prolonged standing or sitting
Greater height
History of leg trauma
Not exercising enough
Smoking.
Symptoms
Leg fullnessAching discomfortHeavinessNocturnal leg crampsBursting pain on standing
SignsVery early 
 Tenderness to palpation
Early 
EdemaHyperpigmentationStasis dermatitisVaricose veins
Late
Venous ulcersAtrophie blancheLipodermatosclerosisAcroangiodermatitis of MaliPost-phlebitic syndrome
CLINIAL FEATURE
1.SIGN SYMPTOM
Most patients complain of leg swelling
dikasih diuretic
gak ngefek!!! Tidakseperti edema in salt-retaining states, like heart failure, cirrhosis, and nephriticsyndrome.
Ulceration may occur, biasanya di above the ankle, on the medial or anterioraspect of the leg
Venous ulcers may or may not be painful.
 
 The soft tissue injury sebelum ulceration begins in the subcutis
Appearance of petechial lesions
As the hemoglobin in the petechial lesionsbreaks down, the iron remains in the skin as hemosiderin and may lead toimpressive discoloration.
Stasis dermatitis, characterized by erythema, scaling, pruritus, erosions,oozing, crusting, and occasional vesicles.
Varicose veins, especially noticeable when the patient is standing
Althoughthey are usually asymptomatic, patients may complain of symptoms of aching,cramping, itching, fatigue, and swelling that are worse with prolonged standing.
 The skin at the ankle is usually thin, shiny, atrophic, and a brownishpigmentation often develops.
2.
DIFFERENTIAL DIAGNOSIS
Patients with
congestive heart failure, chronic renal disease, ordecompensated liver disease
may have bilateral edema of the lower extremities. Tapi edema karena penyakit itu, causes pits easily and brawny discoloration is rare.
Lymphedema
is associated with edema, usually unilateral, in thesubcutaneous tissue that does not respond readily to elevation;
varicosities areabsent
, and there is often a history of recurrent cellulitis.
Other conditions associated with chronic ulcers of the leg include
autoimmunediseases (eg. Felty's syndrome), arterial insufficiency (often very painfulwith absent pulses), sickle cell anemia, erythema induratum (bilateral andusually on the posterior aspect of the lower part of the leg), and fungalinfections (cultures specific: no chronic swelling or varicosities).
3.
HISTOPATHOLOGY of VARICOSE VEIN
Macroscopic : Veins with varicosities are
dilated, tortuous, elongated, andscarred,
with
thinning at the points of maximal dilation
.
Intraluminalthrombosis and valvular deformities
(thickening, rolling, and shortening of thecusps) are frequently discovered when these vessels are opened.
Microscopically : the changes consist of 
variations in the thickness of thevein wall caused by dilation in some areas and by compensatoryhypertrophy of the smooth muscle and subintimal fibrosis
in others.Frequently there is
elastic tissue degeneration and spotty calcifications withinthe media (phlebosclerosis).
4.IMAGING
Duplex ultrasound
 
measure the speed of blood flow and to see thestructure of your leg veins.
Venogram
 
to see the anatomy of your veins. During this test, yourphysician injects a dye, properly called contrast, which makes the blood in your veinsappear on an x-ray.
MANAGEMENT
1.MEDICAL
Aspirin
Pentoxifylline
 Topical steroids (for stasis dermatitis)
Horse chestnut seed extract
If cellulitis is suspected
empiric therapy (topical antibiotic) with coverage forS. aureus and Streptococci.2.SURGICAL
Sclerotherapy
Injects a chemical into your affected veins
The chemical scars veins from theinside
abnormal veins can then no longer fill with blood. Blood that wouldnormally return to the heart through abnormal vein returns to the heart throughother veins.
 
Long saphenous vein stripping
Makes a small incision in the groin area and calf below the knee
Disconnectsand ties off all veins associated with the saphenous vein (main superficial vein)
Removes this vein from your leg.
By Pass
Connect an artificial vein, called a graft, or a transplanted vein to a vein notaffected by CVI to help blood flow from your affected leg around the blocked vein.3.REHABILITATION
Compression stocking
Compression stockings are elastic stockings that squeeze your veins andstop excess blood from flowing backward. Wear it daily for the rest of your life.
DON’T WEAR compression stockings on edematous limbs, especiallythose that are tender.
Raising legs and avoiding standing for long periods of time to decrease thepressure in the veins.
When you do need to stand for a long period, you can flex your leg musclesoccasionally to keep the blood flowing.
Maintaining your ideal body weight or losing weight if you are overweight.
COMPLICATION
Recurrent ulceration is frequent. Any open wound provides a portal of entry forbacteria.
Many patient are predisposed to thrombi, and recurrent episodes of venousthrombosis are common.
All patients with advanced venous disease have some degree of lymphaticimpairment
Loss of lymphatic drainage from the lower leg may lead toverrucous changes and cutaneous hypertrophy, elephantiasis nostras (AcquiredLymphedema).
PREVENTION
Valvular failure may develop during pregnancy
Use of supportive stockingsthroughout maternitycan be recommended.
If one's occupation or lifestyle involves long periods of immobility
Stockings areadvisable.
Prevention of venous thrombosis prevents venous insufficiency.
PROGNOSIS

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