By: abdulkrim al-kharashi naif alsikan

1
Byabdulkrim al-kharashinaif alsikan

• Presentation and management of a Swollen Leg

2
Differential Diagnosis of a swollen leg

• Vascular vs Non vascular

3
Vascular

• Venous causes
• DVT
• Varicose veins
• Post-thrombotic syndrome
• Klippel-Trenaunay syndrome
• External venous compression
• Pelvic or abdominal tumors including gravid
  uterus and Retroperitoneal fibrosis

4
Vascular

• Arterial causes
• Arteriovenous fistula
• AV malformation
• Aneurysm
• - Popliteal
• - Femoral
• - False aneurysm following (iatrogenic) trauma

5
Non vascular

• Systemic diseases
• Cardiac (congestive heart failure)
• renal (nephrotic)
• liver failure
• Thyrotoxicosis (myxedema)
• Allergic disorder
• Immobility and lower limb dependency

6
Non vascular

• Local disease
• Arthritis
• Bony or soft tissue tumors
• Heamarthrosis
• Calf muscle hematoma
• bone dislocations or fractures

7
Others

• Trauma
• Steroids
• Lymphedema

8
Chronic Venous Insufficiency
9
Anatomy

• Lower Limb Veins

10
Anatomy

• Superficial system
• Great saphenous vein
• Short saphenous vein
• Deep system
• posterior tibial , anterior tibial veins, and
  peroneal veins

11

• Communicating veins
• between 2 superficial veins or 2 deep veins.
• Perforated veins
• between 1 superficial 1 deep vein

12
Pathophysiology

• Normally, when the leg muscles contract, they
  squeeze the deep veins of the legs, aiding in
  circulation.
• Chronic venous insufficiency (CVI) results when
  the veins in the legs no longer pump blood back
  to the heart effectively.

13
Pathophysiology

• Veins contain one-way valves that keep the blood
  from flowing in the opposite direction, toward
  the foot.
• These valves can wear out over time, leading to
  blood leaking backward and pooling in the veins
  of the leg

14
Causes

• Primary causes
• Due to inherent structural weakness of the
• veins themselves, most common cause,often
  familial.

15

• Secondary causes
• Obstruction to venous flow
• Pregnancy, fibroids, ovarian cysts, pelvic
  cancer, abdominal lymphadenopathy
• Valve destruction( Deep Vein Thrombosis)
• High Flow and pressure (AV fistula )

16
(No Transcript)
17
Classes
18
Varicose veins 

• Veins that have become enlarged and tortuous

19
Signs and symptoms

• Aching, heavy legs (often worse at night and
  after exercise).
• Appearance of spider veins (telangiectasia) in
  the affected leg.
• Ankle swelling.
• A brownish-blue shiny skin discoloration near the
  affected veins.
• Redness, dryness, and itchiness of areas of skin
  - termed stasis dermatitis or venous eczema,
  because of waste products building up in the leg.
• Cramps may develop especially when making a
  sudden move as standing up.
• Minor injuries to the area may bleed more than
  normal and/or take a long time to heal.
• Restless legs syndrome appears to be a common
  overlapping clinical syndrome in patients with
  varicose veins and other chronic venous
  insufficiency

20
Complaction

• Pain, heaviness, inability to walk or stand for
  long hours.
• Dermatitis.
• Venous ulcers.
• Carcinoma or sarcoma in longstanding venous
  ulcers.
• Severe bleeding from minor trauma.
• superficial thrombophlebitis , but can extend
  into deep veins becoming a more serious problem
• Acute fat necrosis can occur ( Females gt Males).

21
Approach to varicose veins

• History
• History of venous insufficiency
• Presence or absence of predisposing factors
• History of edema
• History of any prior evaluation of or treatment
  for venous disease

22
Approach to varicose veins

• History of superficial or deep thrombophlebitis
• History of any other vascular disease
• Family history of vascular disease of any type

23

• Physical examination
• 1.Inspection from distal to proximal and from
  front to back.
• Surgical scars
• Pigmentations and skin changes
• Ulcers ( mostly in the medial aspect)

24
inspection
Telangiectases
Varicose veins
25
Reticular veins
Lipodermatosclerosis
26

• Palpation
• Distal and proximal arterial pulses
• Entire skin surface
• Greater saphenous vein
• Anteromedial surface
• Posterior surface
• Short saphenous vein

27
investigation

• Doppler bidirectional-flow studies

28

• Doppler color-flow

29
Management

• Conservative management
• Non-surgical management
• Surgical management

30

• Elevating the legs.
• The wearing of graduated compression stocking
  with a pressure of 3040 mmHg.
• has been shown to
• Correct the swelling.
• Improve nutritional exchange.
• Improve the microcirculation.
• Provide relief.

31
Non-Surgical Management

• Sclerotherapy injection of a substance into the
  vein shows greater benefits than surgery in the
  short term but surgery has greater benefits in
  the longer term.
• Complications
• Blood clots and ulceration.
• Anaphylactic reactions are very rare.
• Stinging or pain at the sites of injection

32
(No Transcript)
33
Sclerotherapy

• Schlerotherapy
• its not a good Rx for varicose veins because it
  can cause superficial thrombosis. It can be used
  in small sized veins pathologies such as
  telengectasia, spiders veins. NOT for varicose
  veins gt 3mm
• Sclerosing agents Sodium Tetradecyl Sulfate and
  Polidocanol .
• You aspirate FIRST then inject the substance

34
Non-Surgical Management

• Endovenous laser And radiofrequency ablation.
• Appears to be more effective in the
• short term.
• Complications
• minor skin burns (0.4)
• temporary paraesthesia (2.1).

35
Endovenous laser And radiofrequency ablation.
36
Surgical management

• Surgical ligation and stripping
• High ligation of the long saphenous vein at
  the saphenofemoral junction together with
  ligation of all tributeries.
•  
• Complications of stripping-
• DVT(5.3).
• PE(0.06).
• Wound complications including infection (2.2).

37
Surgical ligation and stripping
38
(No Transcript)
39
Deep vein thrombosis
40
Deep vein thrombosis

• Is the formation of a blood clot (thrombus) in a
  deep vein. It is a form of thrombophlebitis.

41
Deep vein thrombosis

• Risk factors
• immobility
• hypercoagulability
• trauma to vein
• age
• drugs
• orthopedic surgeries

42
hypercoaguble state includes antithrombin 3
deficiency, protein C and S deficiency, factor V
leiden deficiency
43
Signs and symptoms

• Asymptomatic
• Symptomatic
• Pain
• redness,
• warmth,
• tenderness and dilation of the surface veins
• swelling.
• PE symptoms

44
Massive DVT

• Phlegmasia alba dolens the leg is pale and cool
  with a diminished arterial pulse due to spasm.
• Phlegmasia cerulea dolens The leg is usually
  painful, cyanosed and oedematous. Venous gangrene
  may supervene.
• They need surgical intervention usually at the
  iliofemoral junction

45

• Physicians and healthcare providers, must regard
  DVT as a life-threatening condition because more
  people die each year from PE than motor vehicle
  accidents, breast cancer or AIDS.

46
management

• History
• Physical examination
• Measuring the circumference of the affected and
  the contralateral limb at a fixed point(edema).
• Palpating the venous tract, for tenderness.
• Homans' test Dorsiflexion of foot elicits pain
  in posterior calf.
• Pratt's sign Squeezing of posterior calf elicits
  pain.

47
Wells scor for DVT probability
Criterion Score If Present
Lower limb trauma or surgery or immobilization in a plaster cast  1
Bedridden for more than three days or surgery within the last four weeks  1
Tenderness along deep venous system  1
Entire limb swollen  1
Calf more than 3cm bigger circumference,10cm below tibial tuberosity  1
Pitting oedema  1
Dilated collateral superficial veins (non-varicose)  1
Malignancy (including treatment up to six months previously) 1
History of DVT 1
48

• gt 2 or higher DVT is likely? Consider imaging
  the leg veins.
• lt2 DVT is unlikely. Consider blood test such as
  d-dimer test to further rule out deep vein
  thrombosis.

49
Work up

• Blood tests
• CBC , PT , APTT , fibrinogen , LFT , U and E
• D-dimer testing

50
imaging

• Plethysmography, (Used in research not clinical
  practice)
• Doppler US.( Gold standard BUT Operator
  dependent, if the operator wasnt good do
  venography)
• Compression US scanning of the leg combined with
  duplex US .
• Venography
• MRI

51

• Doppler findings of DVT
• Decrease blood flow in vein.
• Non-compressible vein.
• Heterogenicity.

52
(No Transcript)
53
Treatment and mediations

• Anticoagulation
• Patients are initiated on a brief course (3
  week) of heparin treatment while they started on
  a 3-6 month course of Warfarin.
• Anticoagulants heparin unfractionated ?bolus 100
  unit /kg ? monitoring by PTT, can be used in
  pregnancy.
• LMWH ? can be given twice daily 1 mg/Kg
• Warafarin monitoring by INR
• Length of Rx w/ anticoagulant
• below common femoral vein ? 3 months
• at Common femoral, PE, iliac vein ? 6 months

54

• Thrombolytic Therapy
• Is generally reserved for extensive clot, e.g. an
  iliofemoral thrombosis.

55

• Inferior vena cava filter-
• Indication
• anticoagulant therapy is ineffective, unsafe, or
  contraindicated.
• to prevent PE.
• Contraindications
• Uncorrectable, severe coagulopathy.
• Extensive IVC thrombosis such that placement of a
  filter above the thrombus is not possible.
• Bacteremia.

56
(No Transcript)
57
Cont.

• Compression stockings (routinely recommended)
• Venous thrombectomy. In very rare cases

58
complications

• Pulmonary embolism
• Post-phlebitic syndrome
• signs and symptoms, including
• Swelling of your legs (edema)
• Leg pain
• Skin discoloration

59
prevention

• Patients for surgery, LMWH are routinely
  administered to prevent thrombosis.
• Prophylaxis for pregnant women who have a history
  of thrombosis may be limited to LMWH injections.
• Early and regular walking

60

• Intermittent pneumatic compression (IPC) machines
  have proven protective in bed- or chair-ridden
  patients at very high risk or with
  contraindications to heparins.
• wearing compression socks or compression tights
  while travelling
• In a long trip , Exercise your calf and foot
  muscles regularly

61
lymphoedema
62

• Regional swelling due to failure of lymph
  drainage.
• Causes-
• Primary
• congenital, underdevelopment and decreased
  function of lymphatic system.
• -congenital in first year of life
• -precox if after one year
• -tarda if after 35 yrs of age

63

• Secondary
• Cancer breast, cervix, uterus, melanoma, etc.
• Lymph node dissection.
• Surgery or trauma.
• Radiotherapy.
• Cancer Rx esp. breast cancer.
• Infection (filariasis, in tropical areas).
• Recurrent cellulites.
• more common than 1ry happens after breast surgery
  in the upper limb.

64
Sings symptoms

• Severe fatigue, pain.
• A heavy swollen limb, reduced mobility.
• Discoloration of the skin.
• Eventually deformity (elephantiasis).

65

• Diagnosis is clinical then lymphoscintigraphy
  (nuclear study)
• Duplex to check if there is varicose veins

66
treatment

• Treat the underlying cause . However, medical
  treatment doesnot always cure the underlying
  condition or the cause is wholly or partially
  lifestyle aspects. Therefore various measures of
  the edema are useful.
• -Non-operative
• -operative

67

• This is a complete set of edema treatment.
• The techniques used are
• Manual lymphatic drainage,
• compression bandaging
• therapeutic exercise
• skin care.

68
complications

• Infections cellulitis, lymphangitis,
  lymphadenitis, and in severe cases, skin ulcers.
• Lymphangiosarcoma (rare)