Vascular Surgery: Summary of A Subspecialty !

Vascular Surgery
Summary of a subspecialty !
Dr. Mahmoud W. Qandeel

Outlines
• Venous Anatomy of Lower Limb Veins
• Deep Venous Thrombosis
• Varicose veins
• Venous insufficiency
• Acute lower limb ischemia
• Chronic limb ischemia
• Acute mesenteric ischemia
• Chronic mesenteric ischemia

Venous Anatomy of Lower Limb Veins
• The venous system of lower limb consists of 3 types of veins :
• Deep veins
• Superficial veins
• Perforating / Communicating veins

Deep veins:
They lie deep to the fascia

(between the muscles)

Superficial veins:
Superficial to the deep fascia

and have valves which allow a
unidirectional blood flow , from
below upwards

Perforating / Communicating veins :
Connects the superficial to the deep veins , they

have valves which allows unidirectional blood
flow from the superficial to the deep veins.

Deep Venous Thrombosis
• Definition : Thrombosis in the deep veins.

Causes:
1. Change in vessel wall: Endothelial damage leads to adherence of platelets

to the intima which leads to activation of clotting mechanism.
– Example: Trauma , inflammation and tourniquet.
2. Change in blood flow: –> Stasis : As heart failure , shock , prolonged

embolization.
3. Change in blood composition: Hypercoagulability

Risk factors :
• Common after major operations , old age , malignancy , obesity , delivery and
contraceptive pills , female during pregnancy and perperium. Previous history
of DVT is a strong risk factor .
Clinical picture : Most cases are silent

• May be 1st manifestation -→ pulmonary embolism.
• Suspected if unexplained fever, tachycardia early postoperatively ( day 7-10 )

Symptoms and signs depend on the level of thrombosis:
1) Deep calf thrombosis : ( most common )

Pain , tenderness and tense edema affects the calf ( best detected by measuring tape )
NEVER CHECK FOR Homan’s sign : which is sudden dorsiflexion of the foot ( Positive :
Severe pain )
– Should not be done as it may lead to PE !
2) Femoral vein thrombosis : Affects the leg and distal thigh in a more severe way .
Femoral vein may be felt as tender firm cord in the femoral triangle.
3) I.V.C thrombosis : manifestations affect both legs.

4) Iliofemoral thrombosis : ( The worst )
• It affects all the lower limb and produce the worst manifestation.
• 2 subtypes according to the severity :

1.Phlegmasia Alba Dolens : Painful white swelling
- Partial obstruction of the vein
- With total arterial spasm
2. Phlegmasia Cerulae Dolens: Painful blue swelling

- Total obstruction of the vein
- With partial arterial spasm
Phlegmasia Cerulae Dolens

Complications
Early complications :
1. Pulmonary Embolism
2. Venous gangrene ( in case of phlegmasia cerulae dolens)
Late complications:
1. Secondary varicose vein
2. Chronic venous insufficiency ( post-plebitic syndrome )

Investigations :
1.Doppler US :
Accurate in 85% of cases
2.Colored duplex scan :

The standard for diagnosis of DVT
3.D-dimer :
not specific , so it’s a good negative test.

Diagnostic approach
If a patient presents with signs or symptoms of DVT, carry out the

following to exclude other causes:
• An assessment of their general medical history and
• A physical examination.
If DVT is suspected, use the two-level DVT Wells score.

Two-level DVT Wells score
Clinical feature Points
Active cancer (treatment ongoing, within 6 months, or palliative) 1
Paralysis, paresis or recent plaster immobilisation of the lower extremities 1
Recently bedridden for 3 days or more or major surgery within 12 weeks requiring
1
general or regional anaesthesia
Localised tenderness along the distribution of the deep
1
venous system
Entire leg swollen 1
Calf swelling at least 3 cm larger than asymptomatic side 1
Pitting oedema confined to the symptomatic leg 1
Collateral superficial veins (non-varicose) 1
Previously documented DVT 1
An alternative diagnosis is at least as likely as DVT −2
Clinical probability simplified score
DVT likely 2 points or more
DVT unlikely 1 point or less
aAdapted with permission from Wells PS et al. (2003) Evaluation of D-dimer in the diagnosis of suspected deep-vein thrombosis. New England Journal of
Medicine 349: 1227–35

Wells score = DVT unlikely
Offer a D-dimer test and if the result is positive, offer either:

• Proximal leg vein ultrasound scan (within 4 hours of request) or
• If proximal leg vein scan not available within 4 hours, interim 24-hour dose of a
parenteral anticoagulant followed by proximal leg vein ultrasound within
24 hours of request.

Wells score = DVT likely
Offer either:
• Proximal leg vein ultrasound scan (within 4 hours of request),
• If proximal leg vein scan not available within 4 hours, D-dimer test and
an interim 24-hour dose of a parenteral followed by proximal leg vein
ultrasound within 24 hours of request
Repeat proximal leg vein ultrasound scan 6–8 days later for all patients
with positive D-dimer test and negative proximal leg vein ultrasound scan.

CBC
ECG (PE most common tachycardia. RBBB .RV strain .S1Q3T3 rare).
Chest X-ray
Electrolyte

D-dimers: what is the role?
• D-dimer: degradation product of cross-linked fibrin

• The appeal: a simple blood test
• High sensitivity, low specificity
• Quantitative D-dimer < 500 ng/ml makes PE less likely
• Elevated d-dimer common w/o clot - especially
• Cancer
• Post-op
• Pregnancy
• Inpatients
• Prior DVT

D-dimers: use selectively
• Goal: high negative predictive value

• To rule out clot
• Use D-dimers with clinical suspicion or other testing

– In outpatients, ED

Treatment
Prophylactic treatment :
1) Before operations :
Stop contraceptive pills ( if taken) and good hydration .
2) Intraoperative : ( in major operations with long duration)

- Avoid hypovolemia
- Galvanic stimulation of the calf
- Pneumatic trousers
- Elevation of lower limbs by pads under the heal
3) After operation :
- Adequate hydration by IV or oral fluids
- Leg elevation
- Early ambulation from bed
With moderate and high risk patients prophylactic small doses of heparin or
low molecular weight heparin are given.

Curative treatment :
Conservative :
1) Bed rest : and leg elevation to improve venous return.
2)Thrombolytic/Fibrinolytics : Should be given within 24 hours only , not

effective if administrated after that.
3)Anticoagulants ( to prevent progression of the thrombus)

Heparin or warfarin , but remember warfarin has a delayed onset of action.

Surgical :
Venous thrombectomy by Fogarty’s catheter.
IVC filter : inserted through jugular vein.
Indication :
• Recurrent showers of PE
• DVT with contraindication of heparin
• DVT with high risk cardiac patient

Varicose veins
• Definition : dilated , elongated and tortuous veins .
• Its twice common in women .

Primary varicose vein Secondary varicose vein
• Causes : unknown but there’s 2 • Causes :

theories : 1) DVT
1) Congenital incompetence of valves of
superficial veins and perforators . 2) Deep vein compression in upper
2) Congenital weakness of vein wall due thigh and pelvic by tumors.. etc.
to generalized elastic tissue deficiency
3) Congenital arterio-venous fistula.
Precipitating factors : prolonged standing
, weak muscle pump , in pregnant women
due to increase venous pressure due to
uterus compression.
• Usually found in : Adult male or female • Patient : older female with repeated
with the causes mentioned . pregnancies , history of OCPs ,
obesity. Child with A-V fistula.
• Symptoms :
• Symptoms :
-Marked leg pain (bursting)
-Mild leg pain aggravated by long aggravated by walking.
standing, relieved by walking except if
associated incompetent perforators . -Persistent diffuse edema not relived
by leg elevation or walking.
-Evening ankle edema
-Presence of skin complications.
-Minimal skin complications

• Past history : • Past history :

50% family history of weak mesenchyme. DVT after operation
Trauma ( A-V fistula)
• General examination :
Flat foot , piles, hernia, varicocele = • General examination:
generalized weak mesenchyme. Pelvic or abdominal masses , scars
of pelvic operation.
Pulse and BP changes in A-V fistula.

• Local examination: • Local examination :
- Usually bilateral - Usually unilateral

- Never cross the groin - Always cross the groin
- Affects saphenous veins - Affects any superficial vein
- Mainly tubular varicosity - Serpentine and spider
- Minimal ankle edema - Diffuse ankle edema
- No or minimal skin - Skin complications
complications - May see local enlargement in
- Normal limb congenital A-V fistula and
pulsating varicosities

Complications
• Vein complications :
1) Superficial thrombophlebitis.
2) Hemorrhage from minor trauma or ulceration.
• Skin complications: ( mainly in 2ry varicose vein)

1) Brown pigmentation
2) Dermatitis
3) Edema
4) Ulcerations : above medial malleolus
5) Malignancy ( Marjolin’s ulcer )
6) Inverted Champaign bottle leg
Venous Ulcer

Inverted Champaign bottle leg
• The combination of swollen calf and narrow ankle from lipodermatosclerosis.

Investigations :
• Doppler or duplex ( investigation of choice)
• Arteriography for A-V fistula
• Abdominal and pelvic CT for pelvic masses.
Treatment:
➢ Conservative : avoid prolonged standing or sitting , below knee elastic
stocking and decongestive drugs.
➢ injection sclerotherapy : for minor varicosities or cosmetic purpose
➢ Surgery : ( IF deep system is patent)

Trendelenburg operation and subcutaneous stripping is commonly used if
surgery is indicated.
Venous insufficiency
• DVT
• Varicose veins
• Venous stasis
• Venous ulcer

Signs of venous insufficiency
• Venous lipodermatosclerosis
• Ankle-flare or corona phlebectatica
• Atrophie blanche
• Venous ulcer
• Subcutaneous fibrosis
• Browse’ 4th edition Page 204/205

Arterial Disease

Acute Lower Limb ischemia
• Sudden interference with the blood flow to the limb ( may lead to extensive
tissue necrosis within 6 hours unless the limbs surgically re-vascularised )
• Aetiology :
1) Embolism
2) Causes in the wall
1. Arterial injury .
2. Acute thrombosis on top of atherosclerosis.
3. Vasospastic disorder leading to sudden vasoconstriction.
4. As a complication of aortic dissection.
3) Prolonged compression of the artery.
4) Phlegmasia alba dolens.

Clinical picture :
1. Pain : sudden and severe in 80% of cases. Pain may be absent because
of rapid onset.
2. Pallor: replaced by mottled cyanosis after few hours due to the
accumulation of deoxygenated blood.
3. Paresis : passing to paralysis.
4. Paresthesia : hypoesthesia progresses slowly to anesthesia.
5. Pulselessness
6. Progressive coldness

Urgent investigations :
• Imaging studies :
1) Duplex scan
2) Arteriography
3) ECG and Echo : for the source of embolism
• Laboratory studies :
Hemoglobin , urea and creatinine
Acidosis and raised WBCs ---< extensive muscle necrosis

Treatment :
(Urgent Heparin and embolization )
1) IV heparin
2) IV fluid to correct dehydration if present
3) Morphine for pain
4) Care for cardiac conditions:
– Oxygen if needed
– Lasix for heart failure
– Digoxin for rapid AF
Urgent embolectomy:
Under anesthesia using Fogarty catheter
Should be carried within 6-8 hours to avoid muscle necrosis and secondary
thrombus formation .
Complications of embolectomy :
1) Compartments compression
2) Reperfusion injury
3) Sudden death ( due to possibility of pulmonary embolism from
detachment of large thrombus)

Chronic limb ischemia
• Definition : slowly progressive arterial obstruction mostly caused by
atherosclerosis.
• Causes :
Above the age of 45 : atherosclerosis (mcc)
Below the age of 45:
a. In diabetics : pre-senile atherosclerosis is the main cause.
b. In non diabetics :
In females: Raynaud’s disease in the upper limb .
In males : Burger’s disease in the lower limb .
Arteritis may be a cause , it can occur in both upper and lower limbs .
Other causes :
1) Vasospastic disorders
2) Aneurysm
3) Incomplete recovery after treatment of acute ischemia
4) Vascular compression :
- Thoracic outlet syndrome ( in the upper limb )
- Compression by tumour

Risk factors :
– Hypertension ,
– Hypercholesterolemia ,
– Smoking ,
– Diabetes ,
– Obesity ,
– Sedentary or stressful lifestyle, and
– Positive family history.

Symptoms of Chronic lower limb ischemia
• Intermittent claudication
• Rest pain
• Ulceration
• Gangrene

Intermittent claudication
• Intermittent claudication is a cramp-like pain felt in the muscles due to
poor blood supply that is brought on by exertion and relieved by rest
• The pain of claudication is most commonly felt in the calf but

it can affect the thigh or buttock.

• The pain of intermittent claudication is quite specific and must fulfil
three criteria:
– The patient must experience the pain in a muscle, usually the calf.
– The pain should only develop when the muscle is exercised.
– The pain must disappear when the exercise stops.
Claudication distance
• The distance that a patient is able to walk without stopping before
beginning of claudication.
• It varies only slightly from day to day.

• Claudication time: the time which the patient can walk until pain occur.
• Mechanism of pain : accumulation of metabolites due to muscle

ischemia during walking.
– These metabolites are gradually washed away during the rest ( time of rest)
• ( Claudication = to the limb ) It comes from the Romanian emperor

Claudis, walked with a limb due to polio.

Note which muscle groups are affected to correlate which vascular beds are
affected.
• Iliac occlusive disease often produces hip, buttock, and thigh pain.
• Femoral and popliteal disease causes calf pain.
• Tibial disease often causes calf pain but also foot numbness and pain.
Leriche syndrome: aortoiliac disease that causes the triad of buttock claudication,
sexual impotence, and muscular atrophy.
• Arm claudication is unusual but may be caused by subclavian, axillary or brachial

artery obstruction

You must differentiate between different causes of
claudication
• Intermittent claudication is not present on taking the first step unlike
osteoarthrosis
• it is relieved by standing still unlike lumbar intervertebral disc nerve

compression.
• Venous claudication
• Neurogenic claudication

Rest pain
• ‘Rest pain’ is a term used to describe the continuous, unremitting

burning pain caused by severe ischemia.
• In contrast to the pain of intermittent claudication, which only appears

during exercise, this pain is present at rest throughout the day and night.
• It can stop them sleeping.
• Rest pain is usually experienced in the most distal part of the limb,
namely the toes and forefoot.

• If any gangrene is present, the patient feels the pain at the junction of the
living and dead tissues.
• Rest pain is often relieved by putting the leg below the level of the heart, so
patients hang their legs over the side of the bed or prefer to sleep sitting in
a chair.
• The painful part is very sensitive.
• Movement or pressure exacerbates the pain.
• Strong analgesic drugs are the only means of providing relief.
• Rest pain is unremitting and gets steadily worse.

Intermittent claudication Rest pain
Ischemia of the muscles Ischemia of the nerves
Cramping pain Burning pain
Level according to the artery Foot

occluded
The leg is bluish Swollen red
Relived by rest Present at rest

Ulceration
• Leg ulcers are common in the population in general.

• Vascular pathology is associated with the majority of leg ulcers.
• Almost 70% of leg ulcers have a venous etiology; approximately 20–25%
are due to arterial insufficiency; and some of these have a mixed vascular
etiology.
• The remaining leg ulcers have a variety of less common causes, including
infection, malignancy, vasculitis and other conditions.

Gangrene

Fontaine classification of chronic limb ischemia:
• Stage 1 : Asymptomatic
• Stage 2: Intermittent claudication
• Stage 3 : Ischemic rest pain
• Stage 4 : Ulceration or gangrene or both

Other features
Trophic changes:
a) Skin : atrophic , dry , scaly with loss of hair.
b) Nails : brittle , deformed and loss of lustre.
c) Loss of subcutaneous fat, thin tapering toes.

• Arterial pulsation : weak or absent pulsation.
Pulses blocks

• Sensory changes : parasthesia or hyperesthesia
• Skin temperature : coldness indicates the level of ischemia
• Color changes :
- Mild ischemia : may be normal
- Moderate ischemia : postural color changes ( sunset sign : pallor on
elevation and rubor on dependency )
- Severe ischemia : fixed color changes pallor, cyanosis and redness.

• Functional changes :
• Muscle weakness
• Possible gangrene in severe ischemia
• Impotence in aortic bifurcation block (Leriche’s Syndrome)

Critical lower limb ischemia
• Stage of impending limb loss or pre-gangerous stage!

• Denotes severe ischemia
• Revascularization is essential
• There’s a role for primary limb amputation in advanced non-reconstructable
limb.

Critical lower limb ischemia
• It is a pre-gangrenous limb threatening condition

• It includes one or more of the following:
1. Incapacitating intermittent claudication
2. Rest pain for more than 2 weeks not relived by analgesia
3. Tissue loss ( Ulcer or Gangrene)
4. Burger’s angle less than 20
5. Venous return time more than 120 seconds
6. ABI less than 0.3

Buerger’s Angle
• The vascular angle, which is also called Buerger’s angle, is the angle to which
the leg has to be raised before it becomes white.
• In a limb with a normal circulation, the toes stay pink even when the limb is
raised by 90°.
• In an ischemic leg, elevation to 15° or 30° for 30–60 seconds may cause pallor
• A vascular angle of less than 20° indicates severe ischemia. This test is useful
as a comparator.
• When both limbs are raised together, the ischemic foot goes white, while the
normal foot remains pink.

• After elevating the legs, patients should be asked to sit up and dangle
their feet over the side of the couch.
• A normal leg and foot will remain a healthy pink color, whereas an
ischemic leg will slowly turn from white (after elevation) to pink and
then take on a suffused purple–red color

Venous return time
• The limb is elevated for 30 s and then laid flat.

• Normal venous refilling occurs within seconds and slow refilling indicates
arterial insufficiency.
• Venous return time more than 120 seconds indicate severe ischemia.
• Fast refilling and varicose veins suggest an arteriovenous fistula

Ankle Brachial Pressure Index (ABI)
• The ankle–brachial pressure index (ABPI) is the ratio of systolic pressure at

the ankle to that in the arm.
• Resting ABPI is normally about 1.0; values below 0.9 indicate some degree
of arterial obstruction and less than 0.3 suggests imminent necrosis.

➢ > 1.1 Noncompressible dorsalis pedis artery
➢ 0.9-1.1 Normal
➢ 0.7-0.9 Mild ischemia
➢ 0.5-0.7 Moderate Ischemia
➢ 0.3-0.5 Severe Ischemia
➢ < 0.3 Critical ischemia Dr. Mahmoud W. Qandeel
Critical limb ischemia management :

Investigations and treatment :
Radiological investigations :
• Doppler ultrasound
• Duplex scan
• Arteriography
Treatment :
Conservative methods in :
- Mild ischemia or moderate that doesn’t affect the life style.
- If the general condition is poor.
Conservative methods include :
1) Mild exercise ( help collateral circulation )
2) Stop smoking, control DM , HTN and Hyperlipidemia.
3) Drugs : ( can improve peripheral circulation) :
• Clopidogrel ( prevent platelet aggregation)
• Small dose of aspirin
• Pentoxiphylline ( increase RBC elasticity )
• PGE2 ( peripheral vasodilator )
4) Protection and care for ischemic parts:
Carefully washed , dried . Cautious measures and if infection occurred must
be treated properly.
Interventional Radiological procedures ( Endo-vascular) :
Indications: localized obstruction in large or medium sized arteries.
Methods:
1. Percutaneous transmural angioplasty( PTA): a special balloon catheter in
introduced percutaneously until the balloon reaches the stenosed or
occluded segment , then inflated.
2. Application of stent : after balloon angioplasty.(+/-)
3. Destruction of the atheroma by laser( angioplasty ).

Surgical treatment :
1) Arterial reconstruction :
Salvage procedures and shouldn’t be preformed in early or mild cases .
Indications:
1. Severe ischemia
2. Proximal arterial occlusion
3. Good general condition
Methods:
1. Thromboendarterectomy : large artery with localized lesion.
2. Bypass grafting.
2) Amputation :
Conservative amputation or urgent high amputation.
Acute mesenteric ischemia

I. Epidemiology: Patients tend to be elderly with significant comorbidities.
II. Etiology
A. Cardiac source (atrial fibrillation): Acute embolic mesenteric ischemia
Most common cause of embolic occlusion of mesenteric vessels.
The emboli usually lodge distal to the origin of proximal jejunal branches and middle colic
artery, which spares the proximal jejunum and ascending colon.
B. Acute thrombosis: Acute thrombotic mesenteric ischemia

20% of cases, pre-existing severe atherosclerotic stenotic lesion thrombosis is seen.
The entire small and large bowel supplied by SMA is affected, as the origin of vessel is
occluded.

C. Nonocclusive mesenteric ischemia:
– Due to diffuse mesenteric vasospasm in absence of arterial or venous
occlusion.
– Most commonly seen in patients with severe cardiopulmonary
insufficiency and shock.
D. Mesenteric venous thrombosis:

– Involves thrombosis of superior mesenteric vein with or without
extension into portal or splenic vein.
– It can be spontaneous or secondary to abdominal injury, hypercoaguable
states, inflammation, or infection.

Diagnosis :
High index of suspicion along with prompt treatment before bowel infarction
sets in is key to prevent mortality.
A. Plain abdominal x-rays: may show ileus in early cases of mesenteric ischemia
or pneumatosis in advanced cases.
B. Duplex ultrasound of mesenteric vessels: Useful in identifying stenosis of celiac

and SMA. It is mostly used in chronic mesenteric ischemia.
C. CTA: good to assess the patency of mesenteric arteries and vein and also
useful in assessing the state of the bowel and other intra-abdominal pathology.
D. Mesenteric angiogram: provides diagnosis and potential treatment such as

angioplasty and stent, thrombolysis, or injection of vasodilator agents.
Treatment: depends on the aetiology of acute mesenteric ischemia
A. Bowel infarction: All patients need exploratory laparotomy and resection of
nonviable bowel. Usually, a second look laparotomy is performed within 24 hours to
ensure viability of residual bowel.
B. Embolism: Embolectomy is performed; postprocedure, therapeutic anticoagulation

is mandatory.
C. Acute arterial thrombosis: Aortomesenteric bypass is performed.
D. Nonocclusive mesenteric Ischemia: usually treated with supportive care including

bowel rest, antibiotics, and fluid resuscitation. Surgical exploration is indicated if
peritonitis develops.
E. Mesenteric venous thrombosis: systemic anticoagulation; operation if bowel

necrosis occurs Dr. Mahmoud W. Qandeel
Chronic Mesenteric Ischemia

Etiology: Seen in patients with slowly progressive stenosis/occlusion of origin
of mesenteric vessels.
Atherosclerosis is the most common etiology.
Pathophysiology: In normal individuals, blood flow to intestine increases 30–

90 minutes after food ingestion.
This increased blood flow is required for metabolism and absorption.

Clinical presentation:
• Most commonly seen in middle-aged women with a long history of
smoking.
• Patients are usually cachectic with typical symptoms of postprandial
epigastric pain, fear of food, and weight loss.

Diagnosis :
A. Mesenteric duplex ultrasound: screening tool with greater than 80%

sensitivity and specificity.
B. CTA: diagnostic modality of choice for chronic mesenteric ischemia.
C. Mesenteric angiogram: Gold standard diagnostic tool. If a stenosis is

amenable to endovascular intervention, it can be performed at same time.

Treatment: All patients with chronic mesenteric ischemia must undergo
revascularization to prevent bowel infarction and to improve nutritional status.
A. Endovascular revascularization: involves balloon angioplasty and stent

placement across the area of stenosis.
B. Open revascularization: performed either by transaortic mesenteric

endarterectomy or by aortomesenteric bypass
1. Conduit or bypass procedure: can be prosthetic graft or greater saphenous vein
2. Infow or bypass: Can be supraceliac aorta (antegrade bypass) or infrarenal aorta or
iliacs (retrograde bypass). Usually both celiac and SMA are bypassed beyond the area
o occlusion.

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Vascular Surgery

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• The venous system of lower limb consists of 3 types of veins :

Dr. Mahmoud W. Qandeel

They lie deep to the fascia

Dr. Mahmoud W. Qandeel

Superficial to the deep fascia

Dr. Mahmoud W. Qandeel

Connects the superficial to the deep veins , they

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

1. Change in vessel wall: Endothelial damage leads to adherence of platelets

2. Change in blood flow: –> Stasis : As heart failure , shock , prolonged

3. Change in blood composition: Hypercoagulability

Dr. Mahmoud W. Qandeel

Clinical picture : Most cases are silent

Dr. Mahmoud W. Qandeel

1) Deep calf thrombosis : ( most common )

3) I.V.C thrombosis : manifestations affect both legs.

Dr. Mahmoud W. Qandeel

• 2 subtypes according to the severity :

2. Phlegmasia Cerulae Dolens: Painful blue swelling

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

2.Colored duplex scan :

Dr. Mahmoud W. Qandeel

If a patient presents with signs or symptoms of DVT, carry out the

If DVT is suspected, use the two-level DVT Wells score.

Dr. Mahmoud W. Qandeel

Paralysis, paresis or recent plaster immobilisation of the lower extremities 1

Dr. Mahmoud W. Qandeel

Offer a D-dimer test and if the result is positive, offer either:

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• D-dimer: degradation product of cross-linked fibrin

Dr. Mahmoud W. Qandeel

• Goal: high negative predictive value

• Use D-dimers with clinical suspicion or other testing

Dr. Mahmoud W. Qandeel

2) Intraoperative : ( in major operations with long duration)

Dr. Mahmoud W. Qandeel

2)Thrombolytic/Fibrinolytics : Should be given within 24 hours only , not

3)Anticoagulants ( to prevent progression of the thrombus)

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

Dr. Mahmoud W. Qandeel

• Causes : unknown but there’s 2 • Causes :

Dr. Mahmoud W. Qandeel

• Past history : • Past history :

Dr. Mahmoud W. Qandeel

- Usually bilateral - Usually unilateral

Dr. Mahmoud W. Qandeel

• Skin complications: ( mainly in 2ry varicose vein)

Dr. Mahmoud W. Qandeel

• The combination of swollen calf and narrow ankle from lipodermatosclerosis.

Dr. Mahmoud W. Qandeel

➢ injection sclerotherapy : for minor varicosities or cosmetic purpose

➢ Surgery : ( IF deep system is patent)

Dr. Mahmoud W. Qandeel

• Browse’ 4th edition Page 204/205

Dr. Mahmoud W. Qandeel