Treatment for Varicose Veins
Chronic venous insufficiency is a significant problem in the United States, affecting as much as a quarter of the population. Venous valve incompetence is central to the venous hypertension that appears to underlie most or all signs of chronic venous disease. Chronic venous disease afflicts a younger segment of the population, and the morbidity of edema, leg pain, and ulceration may result in lifestyle alterations, loss of work, and frequent hospitalizations. The prevalence of venous ulcerations is not restricted to the elderly but certainly increases with age.1 It has been estimated that venous ulcers have a major negative economic impact, with the loss of approximately swelling, itching, cramps, and restless legs. Chronic venous disease can be graded according to the descriptive clinical, etiologic, anatomic, and pathophysio-logic (CEAP) classification, which provides an orderly framework for communication and decision-making (Table 45-1).34 The pathophysiology of chronic venous...
There are a number of techniques that can be used to treat varicose veins. The veins can be injected with a chemical agent which causes them to collapse permanently. This is called sclerothera-py, which is a relatively simple and effective way to treat varicose veins. Some of the risks of sclerotherapy include brown spots at the injection sites, clot development in the superficial veins, and a reaction to the injected chemicals. Sometimes, new bursts of small red or purple veins called spider veins occur as a result of the chemical injections. Spider veins can often be removed with laser therapy. In some cases, varicose veins may have to be removed through a surgical procedure, which is referred to as vein stripping. Fortunately, the procedure is straightforward and low in risk.
The use of androgen therapy in acute or chronic venous disease arises from their fibrinolytic effect, which may reduce venous fibrin plugging. One study of chronic venous insufficiency aiming to test whether androgen therapy would reduce the rate of venous ulceration involved 60 patients with venous skin changes but no ulceration being treated with below-knee compression stockings as standard therapy (McMullin et al. 1991). They were randomised to receive either stanozolol (10 mg daily) or placebo tablets for six months and androgen therapy produced a significant but modest reduction in the area of venous skin changes but no change Another prospective two-centre study examined the role of androgen therapy in prevention of post-operative deep venous thrombosis (DVT). In this study 200 patients scheduled for elective major abdominal surgery were randomised into three groups (Zawilska etal. 1990). The first received inhaled heparin (800 units kg) one day prior to surgery alone, a second...
Patient safety is paramount and the patient should be positioned carefully, taking into account requirement for both surgical and anaesthetic access. The anaesthetist must be aware of the varying effects of different positions. Local pressure effects on nerves can result in postoperative morbidity. Intraoperatively, the head-down or prone positions will make abdominal breathing difficult. The sitting position requires careful support of the head and can result in cardiovascular instability from pooling of blood in the leg veins. The supine position is used for the majority of surgery. Aortocaval compression in pregnant patients or those with large abdominal masses can result in hypotension.
Some obvious precautions are in order. Acupressure should not be used as the only treatment for a chronic problem or for serious injury or illness. In these cases, a licensed physician should be consulted. Acupressure should be avoided near the abdominal area in pregnant women and near varicose veins, wounds, sores or bones that may be broken.
RLS and PLMs may be induced or aggravated by a variety of conditions, including iron deficiency, anemia, and chronic renal failure. Peripheral neuropathy may be a factor in some cases, although peripheral nerve function is clinically normal in most affected patients. Symptoms occur in 10 to 20 percent of pregnant women and usually resolve postpartum. Other disorders that may be associated with PLMs or RLS include venous disease, degenerative CNS disorders, and vitamin deficiency.
Oral anticoagulation with warfarin is indicated for a variable period. Patients who are unable to comply with or tolerate warfarin anticoagulation, or those who continue to have PEs despite a therapeutic dose of warfarin as monitored by the international normalized ratio (INR), might be suitable for a caval filter. This is a mechanical filter placed percutaneously through a neck vein into the inferior vena cava, which 'catches' emboli from the leg veins en route to the right side of the heart.
Henry is a 65-year-old man in no acute distress. Physical examination reveals systolic hypertension, retinal changes suggestive of sustained hypertension, a mild cataract in his right eye, a conductive hearing loss in his right ear, tonsillopharyngitis, and gynecomastia. Cardiac examination reveals aortic insufficiency. Peripheral vascular examination reveals possible atherosclerotic disease of the right carotid artery and mild venous disease of the lower extremities. The patient has a right, easily reducible inguinal hernia. A left-sided varicocele is present. Mild osteoarthritis of the hands is also present.
Ask the patient to stand, and inspect the lower extremities for varicosities. Look at the area of the proximal femoral ring, as well as in the distal portion of the legs. Varicose veins in these locations may not have been visible when the patient was lying down. Figure 15-4 Chronic venous insufficiency. Figure 15-4 Chronic venous insufficiency.
SYMPTOMS There is aching or sharp pain around the medial part of the foot and ankle joint, often radiating along the medial or the lateral part of the foot, or towards the plantar fascia insertion. AETIOLOGY This syndrome is caused by trapping of the posterior tibia nerve or any of its branches in the tarsal tunnel, most often after scarring from trauma. Other non-traumatic aetiology, such as varicose veins, neuroma or tumours, may also trap the nerve. CLINICAL FINDINGS There is tenderness on palpation over the tarsal tunnel and a positive Tinel's sign is typical. Dysaestesia along the nerve branch distribution is also a common finding. INVESTIGATIONS X-ray is usually normal. MRI may show localised oedema in or around the tarsal tunnel and may, if present, identify some causes for the entrapment such as varicose veins or tumours. Nerve conduction tests can show decreased nerve conduction in chronic cases but can be normal in early cases.
Affected children have small, firm testes, and adult patients have azoospermia. y This disorder is a common cause of primary hypogonadism and male infertility. Although a male phenotype is typical, delayed or poorly developed secondary sex characteristics are present, and about half the patients have varying degrees of gynecomastia, androgen deficiency, and eunuchoid features. These patients tend to be tall and have long legs, and adults have an increased incidence of pulmonary disease, varicose veins, diabetes mellitus, and breast cancer. y Serum levels of follicle-stimulating hormone and luteinizing hormone are increased early in the second decade, whereas testosterone concentrations are normal to low. Plasma levels of estradiol are normal or high. Affected individuals have cognitive abnormalities including impaired auditory sequential memory with delayed language development and associated learning disorders. y There is a slight lowering of the mean IQ and an increased incidence of...
When an individual is in the upright posture, the venous pressure in the lower extremity is the highest. Over many years, the veins dilate as a result of weakening of their walls. As the walls dilate, the veins are unable to close adequately, and reflux of blood occurs. In addition, the venous pump becomes less efficient in returning blood to the heart. Both of these factors are responsible for the venous stasis seen in patients with chronic venous insufficiency. Complications from venous stasis include pigmentation, dermatitis, cellulitis, ulceration, and thrombus formation.
Blood clots in the leg veins, which can dislodge and move to the heart and lungs. Riskfactors Surgery, obesity, cancer, previous episode of DVT, recent childbirth, use of oral contraceptive and hormone replacement therapy, long periods of immobility, for example while travelling, high homocysteine levels in the blood.
Some patients may report a history of cortisone injections to treat the symptoms. This history needs to be taken into consideration when planning the reconstruction as it may have contributed to tendon degeneration. Other problematic conditions include systemic diseases (diabetes mellitus, seronegative inflammatory disease, spondyloarthropathies, or sarcoidosis) and previous infections in the area. The surgeon needs to assess all risk factors very carefully so as not to put the result of his intervention at risk. This is also the case for patients with tobacco use or chronic arterial or venous disease. Patients with severe vascular disease and with sensorimotor deficits, such as peripheral neuropathy or Parkinson's disease, should be excluded from surgical treatment.
These conflicting changes are difficult to reconcile and are further complicated by changes in platelet activity before and after delivery. However, there are indications that an inflammatory response arises at the placental bed after placental delivery22. Such a response would promote local coagulation. This finding is important in terms of evolutionary advantage, because it allows prevention of hemorrhage at the pla-cental site, while elsewhere (particularly in deep pelvic and leg veins) thrombi are less likely to persist, due to the increased fibrinolysis.
The formation of blood clots can be a good thing or a bad thing. When blood clots prevent further bleeding from a surgical incision, this is a good thing. But when blood clots form in the large veins in your pelvis and legs after surgery (deep vein thrombosis), this is a bad thing. If these large blood clots dislodge from the pelvic and leg veins and travel to the lungs (pulmonary embolism), this is a very bad thing. Such clots can obstruct blood flow to the lungs, which can be deadly following major surgery. Prevention of this complication has been an area of focus for all major surgery.
The physical examination in patients with PVD should consist of inspection, palpation, auscultation, and even percussion. Observations should note any asymmetry between the limbs, joint deformities, varicose veins, skin discoloration, absence of hair, swelling, ulcerations, tissue loss, and gangrene. Acute CLI from embolism or thrombosis typically causes pallor with decreased capillary refill that eventually leads to mottling unless adequate collateral flow can be recruited. Chronic ischemia may have a normal skin color with relatively normal or slightly delayed capillary refill, particularly if collateral flow has developed. Chronic advanced CLI can lead to dependent rubor due to chronic dilation of the postcapillary venules. The toes of the dependent limbs can become red with brisk capillary refill. This is often mistaken for hyperemia rather than a sign of severe ischemia. A cadaveric pallor on elevating the limb to greater than 45 degrees above the horizontal for 1 to 2 minutes,...
However, there is a tendency to be more aggressive with thrombolytic therapy and catheter-based throm-bectomy in individual cases, especially in younger patients who are at risk for chronic venous insufficiency, or in an effort to minimize long-term morbidity and optimize functionality. A structured physical therapy program to loosen muscles compressing the subclavian vein and weight loss, if appropriate, are other important adjuncts to complete therapy. DVT is a process that can affect each one of the deep veins of the body but is more frequently present in the deep veins of the lower extremity. Venous thrombus formation is initiated by intravascular clotting and is increased in the presence of risk factors. These risk factors were postulated more than 100 years ago by Virchow and are summarized by his classic triad of coagulation abnormalities, endothelial damage, and stasis. The main conditions contributing to the formation of venous thrombus in the deep veins of the legs are...
Pain relief, biostimulation, tooth whitening Tumour removal In oral surgery, gynaecology, bleeding peptic ulcers, fissure sealing, caries, dentine hypersensitivity, dentine, enamel and bone cutting, varicose veins (long pulse), analgesia (low power laser) Ureter and bladder surgery, lithotripsy, myocardial revascularisation, dacrocystorhinostomy Skin resurfacing, caries removal, enamel, dentine and bone cutting Tumour removal in gynaecology, ENT and oral surgery, denture-induced hyperplasia, skin resurfacing, gingival surgery, implant exposure, fissure sealing, caries, scaling of root surfaces, dentine, enamel and bone cutting_
Skin examination is an important step in the search for a cause. It should be performed with the patient naked, and requires the advice of a dermatologist when necessary. The examination should focus on the search for features of abnormal skin elasticity, varicose veins, spontaneous ecchymosis, abnormal scars (in favor of Ehlers-Danlos disease) papulosis (in favour of malignant atrophic papulosis, so-called Degos disease) livedo racemosa (in favor of Sneddon disease) neurofibromas and taches caf -au-lait (in favor of von Recklinghausen disease)
Skin color changes are common with vascular disease. In chronic arterial insufficiency, the affected extremity is cool and pale. In chronic venous insufficiency, the extremity is warmer than normal. The leg becomes erythematous, and erosions produced by excoriation result. With chronic insufficiency, stasis changes produce increased pigmentation, swelling, and an ''aching'' or ''heaviness'' in the legs. These changes characteristically occur in the lower third of the extremity and are more prominent medially. When venous insufficiency occurs, edema of dependent areas results.
Stasis dermatitis occurs on the lower extremities in patients with chronic venous insufficiency (Fig. 33-32). Impaired function of the venous valves permits backflow of the blood from the deep venous system to the superficial system, causing increased venous hydrostatic pressure and increased permeability of dermal capillaries. The condition typically affects middle-aged and older-adult patients, except for patients with acquired venous insufficiency resulting from surgery, trauma, or thrombosis.
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