Peripheral Vascular Disease and

Varicose Veins
Peripheral Arterial Disease

Nur jannah roslan

Supervisor: Dr Ainuddin
Anatomy
 Case 1
• A 70 years old female came to ED complaining of sudden onset of pain in the left leg
started 1 hour ago.
• On examination there were absent popliteal and lower pulsation and decreased
sensation of left leg and it was cold and pale compared to left leg
• Patient had history of heart disease and known case of Dm and hypertension
• there was no recent history of trauma / claudication / fever
• contralateral leg pulses were felt
• Patient sent for urgent Doppler ultrasound
• Ultrasound revealed large clot in left common iliac artery
• Further History ?
• Investigations?
• Differential Diagnosis?
Acute limb ischemia
Acute occlusion of a peripheral artery that often threatens limb
viability, usually occurs less than 14 days
• Risk factors
• embolism
• thrombosis
• trauma
clinical features
6 Ps - all may not be present

• pain
• pallor
• paresthesia
• paralysis
• poikilothermia
• pulselessness
• History and physical examination
• Determine Rutherford classification based on physical findings and doppler signals
• Blood investigation
• ABI ( ankle brachial index )
• Ecg
• Echo
• Ct angiogram
• Angiography
Rutherford classification
Treatment

• Immediate care
• Thrombolytics
• surgical Intervention
Immediate care

• anticoagulation
• analgesia
• treatment of associated cardiac condition
Thrombolysis

• Agents used : streptokinase , urokinase , tissue plasminogen activator

• Indications :
• viable or marginally treatened limb ( class 1 , 2a)
• recent acute thrombosis
Surgical intervention

• Embolectomy
• Mechanical Thrombectomy
• Amputation
• symptomatic relief
• Immediate heparanization with weight based bolus and continuous titration
• if impaired neurovascular status : emergent revascularization ( rutherford category 2
B)
• if intact neurovascular status may have time for workup : ct angio
• identify and treat underlying cause
• continue heparin post operatively , start oral anti coagulant post operatively when
stable.
complication

• local compartment syndrome

• heart
• kidneys
• metachronous embolism
Venous Disorders
Venous Hypertension
 Clinical Features of Venous Hypertension

Haemosiderosis
and eczema

Saphena varix
Telangiectasia and
reticular veins

Varicose veins Venous ulcer

Lipodermatosclerosis,
eczema and
atrophie blanche
Classification of Chronic Venous Disorders
 VARICOSE VEINS
Dilated, tortous, elongated superficial veins of lower limb
Surgical pathology

• Arise from incompetent valves, which permit blood flow from the
deep venous system to the superficial venous system (at the sapheno-
femoral junction and sapheno-popliteal junction, but other perforating
veins exist).
• This results in venous hypertension and dilatation of the superficial
venous system
ATIEOLOGY
PRIMARY SECONDARY CONGENITAL

Venous obstruction
-pregnancy
-pelvic tumor -arterio venous fistula
Defect in valves -DVT -cavernous (venous) hemangioma
-hormonal causes
-retroperitoneal lymphadenopathy
Predisposing factors
• Prolonged standing
• Obesity
• Pregnant
• Old age
• Athletes
Clinical features
• Majority of the patients come with dilated veins in the leg.
• They are minimal to start with and at the end of the day they are sufficiently
large because of venous engorgement.
• Symptoms:
1. Dragging pain in the leg or dull ache is due to heaviness
2. Night cramps occur due to change in the diameter of veins.
3. Sudden pain in the calf region with fever and oedema of the ankle region
suggests DVT.
4. Patients can present with ulceration, eczema, dermatitis and bleeding.
5. A generalised swelling of the leg may be present which is due to DVT
• Signs:
1. Dilated veins are present in the medial aspect of the leg and the
knee some times they are visible in the thigh also.
2. Single dilated varix at the SF junction called “SAPHENA VARIX”.
3. A group of veins near the medial malleolus is ANKLE FLARE.
4. A localised, dilated segment of the vein, if present is an indication of
blow out. It signifies underlying perforator
Tests for varicose veins
(1) Cough impulse or Morrissey’s test – Saphenofemoral incompetence.
(2) Brodie - Trendelenburg – A. Saphenofemoral incompetence.
B. Perforator in competence.
(3) Multiple tourniquet test – Site for perforator in competence.
(4) Schwartz test – Superficial column of blood.
(5) Modified Perthes test – Deep vein thrombosis.
(6) Fegan’s Test – To locate the perforators in the deep fascia.
(7) Pratt’s test – To know the position of the leg perforators.
 Treatment
Conservative Injection Surgery

- Elastic crepe bandage - Sclerotherapy: the most commonly used - Ligation: Trendelenburg’s operation
- Elevation of leg sclerosant used is sodium tetradecyl sulphate - Ligation with stripping

- Ultrasound guided foam sclerotherapy: Others:

alternative to the blind sclerotherapy 1. Subfascial endoscopic perforator surgery
practiced in the past. 2. Multiple Cosmetic Phebectomy
3. Subfascial ligation of Cockett and Dodd
4. Radical surgery approach
Venous Thromboembolism
(VTE)
 Venous Thromboembolism (VTE)
Aetiology

THROMBOSIS
T - Trauma
H - Hormones (esp OCPs)
R - Road traffic accidents
O - Operations (esp
cholecystectomy)
M - Malignancy
B - Blood disorders (esp
polycythaemia)
O - Obesity, old age
S - Serious illness
I - Immobilisation
S - Splenectomy
 Clinical Features of VTE

• Unilateral calf swelling and pain (although 30% of DVTs are bilateral, however have to rule
out other causes of systemic oedema - hypoproteinaemia, renal failure or heart failure)
• May present with symptoms of PE instead : chest pain, SOB, haemoptysis
• Mild pitting oedema, dilated veins, stiff calf and tenderness over the course of deep veins
• Low grade pyrexia
• Clinical signs of PE = TOO LATE (cyanosis, dilated neck veins, split S2, pleural rub)
 Investigations

• Well’s score
• Blood ix :
D-dimer - if raised, provides supportive evidence of PE
• Imaging
- Venous duplex scan along the superficial and deep venous
system (reduced / absent signal, popliteal and common
femoral vein unable to compress)
- Ascending venography / MR venography
 Management
Anticoagulants available
1) Unfractionated heparin
2) Fondaparinux
• Prophylaxis : TED stocking and LMWH 3) Warfarin
4) NOAC - Rivaroxaban

• Confirmed VTE : Treatment dose of anticoagulant

• Consider 3 months of anticoagulant for provoked VTE, or longer for unprovoked VTE
• Thrombolytic therapy in DVT can be considered if patient is symptomatic with low risk of
bleeding, symptoms < 14 days with good functional status. In PE, it is offered to patients with
haemodynamic instability. (Manage with medical team)
• Patients will need follow up in medical / haematological clinic
• Thrombophilia screening should be offered to UNPROVOKED VTE patients on treatment if
planned to stop treatment
 Ulcers

Arterial, venous, neuropathic,

malignant
Features Venous Arterial Neuropathic Malignant
Clinical assessment of leg ulcer
Below knee Feet: heels, tips of toes
Medial aspect Increased pressure
Between toes
Site Proximal to medial points Face , lips , tongue
Protrusion/ rubbing
malleolus Trauma
Nail bed
Unilateral or bilateral

Borders Irregular Punched out Punched out

Discoloured +/- oedema & erythema

Edge Calloused Everted/rolled
Oedematous if infection/ imitation

Erythematous
+/- covered with yellow Yellow, brown, grey or Pink/red or
Floor fibrous tissue +/- green black Black mass
brown/black
or yelow discharge if Rarely bleeds
infected
 Features Venous Arterial Neuropathic Malignant

Depth Shallow Deep Deep to bone Shallow

Tender Painless Painful Painless Painless

Thin skin/ dec hair

Edema/ eczema/ growth/ loss of sc fat/
Skin pigmentation/ varicose loss of shiness/ brittle Callus/ loss of sensation Fix to underlying skin
vein nails

Lymph node Absent Absent Absent Present except BCC

History of SVT/DVT Diabetics

Affected population Varicose veins Poor circulation Impaired sensation
Oedema
 Management
• Venous ulcer- compression and mobilisation,
treatment of associated varicosities
• Neuropathic- reduce pressure, orthotics and
foot care, glucose control, visual monitoring of
at risk areas
• Arterial- endovascular or vessel replacemtn
theraphy
Lymphatic Disorders
Amirah binti Mohd Nur
Lymphatic disorders
Lymphoedema
Lymphatic
vessels
Acute
lymphangitis

Acute
lymphadenitis
Lymph nodes Specific TB
Chronic
lymphadenitis
Non specific Syphilis

Hodgkin

Sarcoidosis

Lymphoma Non-Hodgkin

Burkitt
Acute lymphangitis
• Def : Acute inflammation of lymphatic vessels
(usually secondary to infected wounds)

• Causative organism :
▫ Strept. Pyogenes (commonest)
▫ Staph. Aureus

• Clinical picture :
▫ Fever, headache, malaise, anorexia
▫ Tender and hot lines, pus discharge
• Complications : recurrent infection,
lymphoedema

• Investigation
▫ FBC, CRP, Blood C&S

• Management :
▫ Rest, elevate affected part
▫ IV Antibiotics, eg : IV Augmentin
▫ Care of primary wound
▫ if suppuration -> I&D
Lymphoedema
• Def : accumulation of fluid in interstitial space
due to defective lymphatic drainage.
• Types
▫ Primary : congenita, precox, tarda
▫ Secondary :
● Trauma – injury, operation, burn, irradiation
● Inflammation – chronic specific or non-specific
● Neoplasm (primary or metastatic)
• Clinical picture
▫ Swelling, heaviness of limb, ache or discomfort,
recurrent infections, skin changes
• Burner’s classification
• Complication : infection, elephantiasis,
lymphangiosarcoma (rare)

• Investigation
▫ Lymphangiography (for obstruction), dupplex (for
venous insufficiency)
▫ CT, MRI
▫ TRO cause, eg: blood film for filaria, TB workup

• Treatment :
▫ Mainly conservative
▫ Surgery is indicated only in disability, but results are not
promising
● Bypass, liposuction, limb reduction surgeries
Differentials of limb swelling
• Arterial : ischemia, AV malformation, aneurysm
• Venous : DVT, post-thrombotic syndrome,
varicose veins
• Non-vascular/ lymphatics
▫ General : heart failure, liver failure, allergic,
prolonged immobility
▫ Local : hematoma, ruptured Baker’s cyst, arthritis
▫ Fibrosis, gigantism, drugs, trauma, obesity