DOCSLIB.ORG

Treatment of Superficial Vein Thrombosis: Role of Anticoagulation

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Treatment of Superficial Vein Thrombosis: Role of Anticoagulation 4/14/2016 Suman Rathbun MD, MS No relevant disclosures Professor of Medicine Director, Vascular Medicine University of Oklahoma Health Sciences Center Epidemiology More common than DVT 1:1000 Clinical Presentation Estimated 3 to 8% of the general population Diagnosis Risk factors: varicose veins, immobilization, trauma, surgery, Treatment pregnancy and post-partum, hormonal contraception or -Medical replacement therapy, increasing age, obesity, history of VTE, -Surgical malignancy, autoimmune disease, thrombophilia, IV catheter -Topical Females>Males -Clinical trials Varicose vein SVT • Most common risk factor for SVT • Lower risk of progression to DVT Varicose veins • May be precipitated by trauma • Tender nodules Traumatic • Localized induration Septic and Suppurative • More common after foam sclera vs. thermal ablation Migratory Mondor’s Disease Small saphenous Upper extremity Post endovascular vein treatment 1 4/14/2016 Septic thrombophlebitis • Infusion therapy • IV lines with septicemia • Direct endothelial injury of irritating solutions • Leukocytosis • Pain, tenderness and erythema at catheter insertion • Intense pain • Vein may contract rather than recanalize • Staph aureus, Pseudomonas, Klebsiella, Candida • Removal of catheter; IV antibiotics • Excision of vein in rare cases Great/Small Saphenous Vein SVT Mondor’s disease • Can progress to common femoral or popliteal DVT • Similar morbidity with GSV or SSV SVT • Thoracoepigastric vein of the breast/chest wall • Breast carcinoma or hypercoagulable states • Benign and self limited • NSAIDs At presentation 3 month follow-up Upper extremity IV line related SVT • Caustic substance with direct injury to endothelium • Basilic or cephalic veins Compression ultrasound • Rare progression to DVT • Catheter removal; occasional anticoagulation 2 4/14/2016 Reduce or ameliorate symptoms Prevent progression to DVT Prevent PE Prevent recurrence/QOL Treatment Options: Topical Pharmacological systemic: Anticoagulation, NSAID Surgical SVT TREATMENT — Treatment differs depending upon whether the thrombosis affects the tributaries (superficial thrombophlebitis) or axial veins (ie, great or small saphenous veins) indicative of superficial vein thrombosis (SVT), and whether or not there are complications. Approach to treatment — Treatment of superficial phlebitis is primarily aimed at alleviating symptoms and preventing propagation of thrombus into the deep venous system. LMWH Uncomplicated — Initial management of uncomplicated thrombophlebitis and less extensive SVT (ie, affected vein segment <5 cm, remote from saphenofemoral/saphenopopliteal junction, no medical risk factors) is supportive and -Titon consists of extremity elevation (ie, waist level), warm or cool compresses, nonsteroidal anti-inflammatory drugs (NSAIDs), and possibly compression therapy [46]. The patient should be encouraged to remain ambulatory if possible. Antibiotic treatment is not indicated -VESALIO in the absence of signs of infection (eg, high fever, purulent drainage) [47]. (See 'Symptomatic care' below.) -CALISTO Anticoagulation is suggested for patients with more extensive superficial thrombophlebitis, particularly those with SVT approaching the deep venous system via the saphenofemoral junction, because of a higher risk for developing a deep vein thrombosis (DVT) [21,37,41,48-50]. A decision to anticoagulate the -STEFLUX patient when thrombus approaches the deep venous system at other sites (ie, saphenopopliteal junction, perforator veins) should be individualized; either anticoagulation or serial duplex ultrasound may be appropriate. Anticoagulation is also appropriate for those patients who demonstrate propagation. (See 'Anticoagulation' below.) An exception to the need for anticoagulation is the patient with superficial vein thrombosis following endovenous ablation therapy. The natural history of endovenous LMWH vs. NSAID heat-induced thrombus (EHIT) appears to be more benign than spontaneous thrombus with less of a propensity for embolization [7]. EHIT is generally managed conservatively. (See "Radiofrequency ablation for the treatment of lower extremity chronic venous disease", section on 'Deep venous thrombosis' and 'Anticoagulation' below.) -STENOX -Rathbun Up to Date Sept 29,2015 LMWH vs. NSAID for Prevention of VTE Study Patients Intervention Outcome Titon 117 RCT Nadro 6150 IU 2.6% STP 1994 + compress Nadro 31.5 IU/kg 5% STP 6 days Naprox 500 mg 2.6% STP No DVT,PE, bleed STENOX 436 RCT Enox 40 qd 0.9/8.3% DVT/STP, 0 PE 2003 STP > 5 cm Enox 1.5mg/kg 0.9/5.7 % DVT/STP, 0 PE + compress Tenoxicam 20 2.0/13.1% DVT/STP, 1 PE 8-12 days Placebo 3.6/29.5% DVT/STP, 0 PE Vesalio 164 RCT Nadroparin 2850 2005 STP >3cm Nadro from jx Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004982. DOI: 10.1002/14651858.CD004982.pub5. Titon J. Annales de cardiologie et d’angeiologie 1994;43:160-6 STENOX study group. Arch Intern Med 2003;163:157-63 3 4/14/2016 LMWH and NSAIDs reduced the incidence of extension or recurrence of SVT but no effect on VTE Topical treatments relieved local symptoms but trials did not report progression to VTE Surgical treatments and wearing elastic stockings were associated with lower VTE and VTE compared to stockings alone Methodological quality of the 30 studies assessed was poor overall. No differences in major bleeding but NSAID with increased gastrointestinal side effects Di Nisio M, Wichers IM, Middeldorp S. Treatment for superficial thrombophlebitis of the leg. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD004982. DOI: 10.1002/14651858.CD004982.pub5. Double-blind RCT 3002 received either fondaparinux (2.5mg/day) or placebo X 45 days Primary efficacy outcome: composite of death from any cause or symptomatic pulmonary embolism, symptomatic deep- vein thrombosis, or symptomatic, extension to the saphenofemoral junction or symptomatic recurrence of STP at day 47 Main safety outcome - major bleeding Follow up to day 77 Major bleeding occurred in one patient in each group Incidence of serious adverse events was 0.7% with fondaparinux and 1.1% with placebo A=parnaparin 8500 IU qd X 10 days + placebo 20 days B=parnaparin 8500 IU qd X 10 days + 6400 IU 20 days C=parnaparin 4250 qd for 30 days 4 4/14/2016 Low-Molecular-Weight Heparin Versus Saphenofemoral Disconnection for the Treatment of Above-Knee Greater Saphenous Thrombophlebitis: A Prospective Study Francisco S. Lozano, MD, PhD and Arturo Almazan, MD, PhD, Salamanca, Sp The objective of this study was to assess the efficacy, safety, and cost of low-molecularweight heparin compared to saphenofemoral disconnection for the treatment of internal saphenous proximal thrombophlebitis (SPT). Eighty-four consecutive patients diagnosed as presenting SPT alone (symptoms/echo-Doppler) were divided into 2 comparable groups treated with (1) saphenofemoral disconnection under local anesthesia with a short hospital stay (n=45) or (2) prospective enoxaparin on an outpatient basis for 4 weeks (n=39). Informed consent was obtained and inclusion, exclusion, and withdrawal criteria were established. Patients were followed up at 1, 3, and 6 months. Thirty patients per group completed the study requirements. In the disconnection group, 2 patients (6.7%) presented complications of the surgical wound, 1 (3.3%) had SPT recurrence (however, there was no deep venous thrombosis), and 2 (6.7%) had nonfatal pulmonary embolism confirmed by radionuclide scan. In the enoxaparin group, there were 2 cases (6.7%) of minor bleeding (epistaxis and rectal bleeding) and 3 (10%) recurrences of SPT. In the enoxaparin group there was no case of progression of the thrombosis to the deep venous system or pulmonary embolism. The study found no statistically significant differences between saphenofemoral disconnection and enoxaparin in the treatment of SPT, but the low-molecular-weight heparin group had socioeconomic advantages. Vascular and Endovascular Surgery Volume 37, Number 6, 2003 DVT Thrombus at 21 days DOI: 10.1002/14651858.CD004982.pub5 Superficial Vein Thrombosis (SVT) Treated With Rivaroxaban Rivaroxaban Anticoagulation for Superficial Vein Versus Fondaparinux Thrombosis (RASET) This study is currently recruiting participants. (see Contacts and Locations) This study is currently recruiting participants. (see Contacts and Locations) Verified December 2015 by GWT-TUD GmbH Verified January 2016 by McMaster University Sponsor: Sponsor: GWT-TUD GmbH McMaster University Collaborator: Collaborator: Bayer Bayer Information provided by (Responsible Party): Information provided by (Responsible Party): GWT-TUD GmbH McMaster University ClinicalTrials.gov Identifier: ClinicalTrials.gov Identifier: NCT01499953 NCT02123524 First received: December 19, 2011 First received: April 23, 2014 Last updated: December 3, 2015 Last updated: January 19, 2016 Last verified: December 2015 Last verified: January 2016 History of Changes History of Changes 5 4/14/2016 Efficacy and Tolerability of Hirudoid Cream in Prophylaxis and Treatment Infusion Phlebitis This study is currently recruiting participants. (see Contacts and Locations) Verified September 2015 by Medinova AG Sponsor: Medinova AG Information provided by (Responsible Party): Medinova AG ClinicalTrials.gov Identifier: NCT01943006 First received: September 6, 2013 Last updated: September 23, 2015 Last verified: September 2015 History of Changes LMWH or NSAID effective for reducing pain and extension/VTE but risk stratification model not available Compression alone not effective for preventing extension Surgery provides symptom relief but may not reduce extension ACCP 2012 recommendation (no change 2016): Superficial thrombosis ≥ 5 cm in length should receive prophylactic dose fondaparinux or LMWH for 45 days (2B). Fondaparinux 2.5 mg is preferred over LMWH (2C). Goals of treatment met by LMWH but dose and duration of LMWH not clear 6 .
Load more

Recommended publications
  • Clinical Case: Post-Procedure Thrombophlebitis
    Clinical Case: Post-procedure Thrombophlebitis A 46 year old female presented with long-standing history of right lower limb fatigue and aching with prolonged standing. Symptoms –Aching, cramping, heavy, tired right lower limb –Tenderness over bulging veins –Symptoms get worse at end of the day –She feels better with lower limb elevation and application of elastic compression stockings (ECS) History Medical and Surgical history: Sjogren syndrome, mixed connective tissue disease, GERD, IBS G2P2 with C-section x2, left breast biopsy No history of venous thrombosis Social history: non-smoker Family history: HTN, CAD Allergies: None Current medications: Pantoprazole Physical exam Both lower limbs were warm and well perfused Palpable distal pulses Motor and sensory were intact Prominent varicosities Right proximal posterior-lateral thigh and medial thigh No ulcers No edema Duplex ultrasound right lower limb GSV diameter was 6.4mm and had reflux from the SFJ to the distal thigh No deep venous reflux No deep vein thrombosis Duplex ultrasound right lower limb GSV tributary diameter 4.6mm Anterior thigh varicose veins diameter 1.5mm-2.6mm with reflux No superficial vein thrombosis What is the next step? –Conservative treatment – Phlebectomies –Sclerotherapy –Thermal ablation –Thermal ablation, phlebectomies and sclerotherapy Treatment Right GSV radiofrequency ablation Right leg ultrasound guided foam sclerotherapy with 0.5% sodium tetradecyl sulfate (STS) Right leg ambulatory phlebectomies x19 A compression dressing and ECS were applied to the right lower limb after the procedure. Follow-up 1 week post-procedure –The right limb was warm and well perfused –There was mild bruising, no infection and signs of mild thrombophlebitis –Right limb venous duplex revealed no deep vein thrombosis and the GSV was occluded 2 weeks post-procedure –Tender palpable cord was found in the right thigh extending into the calf with overlying hyperpigmentation.
    [Show full text]
  • Pulmonary Veno-Occlusive Disease
    Arch Dis Child: first published as 10.1136/adc.42.223.322 on 1 June 1967. Downloaded from Arch. Dis. Childh., 1967, 42, 322. Pulmonary Veno-occlusive Disease K. WEISSER, F. WYLER, and F. GLOOR From the Departments of Paediatrics and Pathology, University of Basle, Switzerland Pulmonary venous congestion with or without time. She gradually became more dyspnoeic, with 'reactive' or 'protective' pulmonary arterial hyper- increasing weakness and fatigue, and her weight fell. tension (Wood, 1954; Wood, Besterman, Towers, In October 1961 she developed jaundice with acholic and McIlroy, 1957) is most commonly caused by stools and dark urine. Infective hepatitis was diagnosed, and she was put on a diet and, 2 weeks later, on corti- left heart disease. The obstruction to blood flow costeroids. She had had no known contact with a case may, however, also be located upstream to the left of hepatitis. Again, except for her dyspnoea, no cardiac atrium. Among the known causes of such obstruc- or pulmonary abnormality was found. The icterus tion are compression of the pulmonary veins by a decreased very slowly, but never disappeared entirely. mediastinal mass (Edwards and Burchell, 1951; In the following months her general condition deteriora- Andrews, 1957; Evans, 1959); congenital stenosis of ted and she was breathless even at rest. On two occasions the pulmonary veins at the veno-atrial junction she had syncopal attacks lasting a few minutes. She lost (Lucas, Woolfrey, Anderson, Lester, and Edwards, 12 kg. within one year. In January 1962 the parents finally consented to her being admitted to hospital. 1962); or thrombus formation in the pulmonary On admission she was obviously ill, wasted, jaundiced, veins due to greatly reduced blood flow associated cyanotic, and severely dyspnoeic and orthopnoeic.
    [Show full text]
  • Byoung Chan Kang, MD, Da Jeong Nam, MD*, Eun Kyoung Ahn, MD*, Duck Mi Yoon, MD, and Joung Goo Cho, MD*
    Korean J Pain 2013 July; Vol. 26, No. 3: 299-302 pISSN 2005-9159 eISSN 2093-0569 http://dx.doi.org/10.3344/kjp.2013.26.3.299 |Case Report| Secondary Erythromelalgia - A Case Report - Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, *National Health Insurance Service Ilsan Hospital, Goyang, Korea Byoung Chan Kang, MD, Da Jeong Nam, MD*, Eun Kyoung Ahn, MD*, Duck Mi Yoon, MD, and Joung Goo Cho, MD* Erythromelalgia is a rare neurovascular pain syndrome characterized by a triad of redness, increased temperature, and burning pain primarily in the extremities. Erythromelalgia can present as a primary or secondary form, and secondary erythromelalgia associated with a myeloproliferative disease such as essential thrombocythemia often responds dramatically to aspirin therapy, as in the present case. Herein, we describe a typical case of a 48-year-old woman with secondary erythromelalgia linked to essential thrombocythemia in the unilateral hand. As this case demonstrates, detecting and visualizing the hyperthermal area through infrared thermography of an erythromelalgic patient can assist in diagnosing the patient, assessing the therapeutic results, and understanding the disease course of erythromelalgia. (Korean J Pain 2013; 26: 299-302) Key Words: aspirin, erythromelalgia, infrared thermography, neuropathic pain. Erythromelalgia is a rare clinical syndrome charac- Adults are more commonly involved than children and are terized by a triad of redness, increased temperature, and more likely to have the secondary form. Secondary eryth- burning pain primarily in the extremities. The term eryth- romelalgia is usually associated with myeloproliferative romelalgia, derived from the Greek words for redness and disorders such as essential thrombocythemia (ET) and pol- pain in the extremities, was coined in 1878 by Mitchell [1].
    [Show full text]
  • Why Are Spider Veins of the Legs a Serious and a Dangerous Medical
    1 Anti-aging Therapeutics Volume 9–2007 Prevention or Reversal of Deep Venous Insufficiency and Treatment: Why Are Spider Veins of the Legs a Serious and A Dangerous Medical Condition? Imtiaz Ahmad M.D., F.A.C.S a, b, Waheed Ahmad M.D., F.A.C.S c, d a Cardiothoracic and Vascular Associates (Comprehensive Vein Treatment Center), Hamilton, NJ, USA b Robert Wood Johnson University Hospital, Hamilton, NJ, USA. c Comprehensive Vein Treatment Center of Kentuckiana, New Albany, IN 47150, USA. d Clinical professor of surgery, University of Louisville, Louisville, KY, USA. ABSTRACT Spider veins (also known as spider hemangiomas) unlike varicose veins (dilated pre-existing veins) are acquired lesions caused by venous hypertension leading to proliferation of blood vessels in the skin and subcutaneous tissues due to the release of endothelial growth factors causing vascular neogenesis. More than 60% of the patients with spider veins of the legs have significant symptoms including pain, itching, burning, swelling, phlebitis, cellulites, bleeding, and ulceration. Untreated spider veins may lead to serious medical complications including superficial and deep venous thrombosis, aggravation of the already established venous insufficiency, hemorrhage, postphlebitic syndrome, chronic leg ulceration, and pulmonary embolism. Untreated spider vein clusters are also responsible for persistent low-grade inflammation; many recent peer- reviewed medical studies have shown a definite association of chronic inflammation with obesity, cardiovascular disease, arthritis, Alzheimer’s disease, and cancer. Clusters of spider veins have one or more incompetent perforator veins connected to the deeper veins causing reflux overflow of blood that is responsible for their dilatation and eventual incompetence.
    [Show full text]
  • Venous Symposium: Overview
    5/30/2017 1 5/30/2017 VENOUS SYMPOSIUM: OVERVIEW Robert W. Vorhies, M.D., F.A.C.S. Vascular and Endovascular Surgery Endovenous Therapy and Vein Aesthetics Ferrell-Duncan Clinic, Cox Health Systems WHY DO WE CARE? • Epidemiology • Disability • Historical experience • Opportunity 2 5/30/2017 EPIDEMIOLOGY QUESTION #1 Which state has nearly the same population as all the people in the US with venous disease? • A. New York • B. Florida • C. California • D. Missouri EPIDEMIOLOGY QUESTION #1 Which state has nearly the population as all the people in the US with venous disease? • A. New York • B. Florida • C. California • More than 11 million men and 22 million women between the ages of 40 and 80 years in the United States have varicose veins. • Prevalence of 20% (range, 21.8%-29.4%) • D. Missouri Peter Gloviczki, Anthony J. Comerota, Michael C. Dalsing, Bo G. Eklof, David L. Gillespie, Monika L. Gloviczki, Joann M. Lohr, Robert B. McLafferty, Mark H. Meissner, M. Hassan Murad, Frank T. Padberg, Peter J. Pappas, Marc A. Passman Joseph D. Raffetto, Michael A. Vasquez, and Thomas W. Wakefield. “The care of patients with varicose veins and associated chronic venous diseases: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum.” J Vasc Surg . 2011;53:2S-48S. 3 5/30/2017 EPIDEMIOLOGY QUESTION #2 • Which mid western metropolitan area has about the same number of people as those with severe chronic venous insufficiency including ulcers and skin changes? • A. Minneapolis • B. Chicago • C. St. Louis • D. Kansas City. EPIDEMIOLOGY QUESTION #2 • Which mid western city has about the same number of people as those with severe chronic venous insufficiency including ulcers and skin changes? • A.
    [Show full text]
  • Cardiovascular System 9
    Chapter Cardiovascular System 9 Learning Outcomes On completion of this chapter, you will be able to: 1. State the description and primary functions of the organs/structures of the car- diovascular system. 2. Explain the circulation of blood through the chambers of the heart. 3. Identify and locate the commonly used sites for taking a pulse. 4. Explain blood pressure. 5. Recognize terminology included in the ICD-10-CM. 6. Analyze, build, spell, and pronounce medical words. 7. Comprehend the drugs highlighted in this chapter. 8. Describe diagnostic and laboratory tests related to the cardiovascular system. 9. Identify and define selected abbreviations. 10. Apply your acquired knowledge of medical terms by successfully completing the Practical Application exercise. 255 Anatomy and Physiology The cardiovascular (CV) system, also called the circulatory system, circulates blood to all parts of the body by the action of the heart. This process provides the body’s cells with oxygen and nutritive ele- ments and removes waste materials and carbon dioxide. The heart, a muscular pump, is the central organ of the system. It beats approximately 100,000 times each day, pumping roughly 8,000 liters of blood, enough to fill about 8,500 quart-sized milk cartons. Arteries, veins, and capillaries comprise the network of vessels that transport blood (fluid consisting of blood cells and plasma) throughout the body. Blood flows through the heart, to the lungs, back to the heart, and on to the various body parts. Table 9.1 provides an at-a-glance look at the cardiovascular system. Figure 9.1 shows a schematic overview of the cardiovascular system.
    [Show full text]
  • Hemorrhoids Information, Pictures, Treatments, and Cures by Rick Shacket DO, 1989 ©
    Hemorrhoids Information, Pictures, Treatments, and Cures By Rick Shacket DO, 1989 © Hemorrhoids are cushions of tissue and varicose veins located in and around the rectal area. When they become inflamed, hemorrhoids can itch, bleed, and cause pain. Unfortunately a hemorrhoidal condition only tends to get worse over the years. That is why safe, gentle, and effective treatment for hemorrhoids is recommended as soon as they occur. Hemorrhoids bother about 89% of all Americans at some time in their lives. Hemorrhoids caused Napoleon to sit side-saddle, sent President Jimmy Carter to the operating room, and benched baseball star George Brett during the 1980 World Series. Over two thirds of all healthy people reporting for physical examinations have hemorrhoids. For more information about Hemorrhoids visit the links below: • Pictures: Hemorrhoids and Anal Fissure • Stapled Hemorrhoidopexy (PPH Procedure) • What Are Hemorrhoids? • Harmonic Scalpel Hemorrhoid surgery • What Are the Symptoms of Hemorrhoids? • Laser Surgery for Hemorrhoids • How Common Are Hemorrhoids? • Atomizing Hemorrhoids • How Are Hemorrhoids Diagnosed? • Complications of Hemorrhoid Surgery • What Is the Treatment? • Knowing What to Ask Your Surgeon • How Are Hemorrhoids Prevented? • Allopathic Hemorrhoid Medications • Painless Treatment of Hemorrhoids • Herbal Hemorrhoid Medications • HAL-RAR Method Hemorrhoidectomy • Homeopathic Hemorrhoid Medications • Hemorrhoids Grades 1 to 4 • References • Surgical Classification of Hemorrhoids • Video References • Traditional Surgery for Hemorrhoids Pictures: Hemorrhoids and Anal Fissure Internal hemorrhoids occur higher up in the anal canal, out of sight. Bleeding is the most common symptom of internal hemorrhoids, and often the only one in mild cases. View hemorrhoid gallery for detailed photos. Hemorrhoids Information, Pictures, Treatments, and Cures Page 1 of 21 External hemorrhoids are visible-occurring out side the anus.
    [Show full text]
  • Microlymphatic Surgery for the Treatment of Iatrogenic Lymphedema
    Microlymphatic Surgery for the Treatment of Iatrogenic Lymphedema Corinne Becker, MDa, Julie V. Vasile, MDb,*, Joshua L. Levine, MDb, Bernardo N. Batista, MDa, Rebecca M. Studinger, MDb, Constance M. Chen, MDb, Marc Riquet, MDc KEYWORDS Lymphedema Treatment Autologous lymph node transplantation (ALNT) Microsurgical vascularized lymph node transfer Iatrogenic Secondary Brachial plexus neuropathy Infection KEY POINTS Autologous lymph node transplant or microsurgical vascularized lymph node transfer (ALNT) is a surgical treatment option for lymphedema, which brings vascularized, VEGF-C producing tissue into the previously operated field to promote lymphangiogenesis and bridge the distal obstructed lymphatic system with the proximal lymphatic system. Additionally, lymph nodes with important immunologic function are brought into the fibrotic and damaged tissue. ALNT can cure lymphedema, reduce the risk of infection and cellulitis, and improve brachial plexus neuropathies. ALNT can also be combined with breast reconstruction flaps to be an elegant treatment for a breast cancer patient. OVERVIEW: NATURE OF THE PROBLEM Clinically, patients develop firm subcutaneous tissue, progressing to overgrowth and fibrosis. Lymphedema is a result of disruption to the Lymphedema is a common chronic and progres- lymphatic transport system, leading to accumula- sive condition that can occur after cancer treat- tion of protein-rich lymph fluid in the interstitial ment. The reported incidence of lymphedema space. The accumulation of edematous fluid mani- varies because of varying methods of assess- fests as soft and pitting edema seen in early ment,1–3 the long follow-up required for diagnosing lymphedema. Progression to nonpitting and irre- lymphedema, and the lack of patient education versible enlargement of the extremity is thought regarding lymphedema.4 In one 20-year follow-up to be the result of 2 mechanisms: of patients with breast cancer treated with mastec- 1.
    [Show full text]
  • Portal Hypertensionand Its Radiological Investigation
    Postgrad Med J: first published as 10.1136/pgmj.39.451.299 on 1 May 1963. Downloaded from POSTGRAD. MED. J. (I963), 39, 299 PORTAL HYPERTENSION AND ITS RADIOLOGICAL INVESTIGATION J. H. MIDDLEMISS, M.D., F.F.R., D.M.R.D. F. G. M. Ross, M.B., B.Ch., B.A.O., F.F.R., D.M.R.D. From the Department of Radiodiagnosis, United Bristol Hospitals PORTAL hypertension is a condition in which there branch of the portal vein but may drain into the right is an blood in the branch. abnormally high pressure Small veins which are present on the serosal surface portal system of veins which eventually leads to of the liver and in the surrounding peritoneal folds splenomegaly and in chronic cases, to haematem- draining the diaphragm and stomach are known as esis and melaena. accessory portal veins. They may unite with the portal The circulation is in that it vein or enter the liver independently. portal unique The hepatic artery arises normally from the coeliac exists between two sets of capillaries, i.e. the axis but it may arise as a separate trunk from the aorta. capillaries of the spleen, pancreas, gall-bladder It runs upwards and to the right and divides into a and most of the gastro-intestinal tract on the left and right branch before entering the liver at the one hand and the sinusoids of the liver on the porta hepatis. The venous return starts as small thin-walled branches other hand. The liver parallels the lungs in that in the centre of the lobules in the liver.
    [Show full text]
  • Reprint Of: Why Are Hemorrhoids Symptomatic? the Pathophysiology and Etiology of Hemorrhoids
    Seminars in Colon and Rectal Surgery 29 (2018) 160 166 À Contents lists available at ScienceDirect Seminars in Colon and Rectal Surgery journal homepage: www.elsevier.com/locate/yscrs Reprint of: Why are hemorrhoids symptomatic? the pathophysiology and etiology of hemorrhoids WilliamD1X X C. Cirocco, MD,D2X X FACS, FASCRS* Department of Surgery, University of Missouri Kansas City, Kansas City, Missouri. À ABSTRACT Hemorrhoids are a normal component of the anorectum and contribute to the mechanism of anal closure, thus providing fine adjustment of anal continence. There are numerous myths and legends associated with the disordered and diseased state of hemorrhoids. Fortunately, information obtained from modern technolo- gies including microscopic histopathology defined first the actual substance and makeup of hemorrhoids and was later combined with anorectal physiology to provide evidence establishing the underlying pathophysiol- ogy of this universal finding of the human anorectum. The sliding anal canal theory of Gass and Adams has held up and is further supported by other anatomic studies including the work of WHF Thomson, who popu- larized the term “cushions” to describe the complex intertwining of muscle, connective tissue, veins, arteries, and arteriovenous communications which constitute hemorrhoids. A loss of muscle mass in favor of connec- tive tissue over time helps explain the role of aging as a predisposing factor for symptomatic hemorrhoids. Other factors include the modern “rich” or low-residue diet leading to constipation and straining which con- tributes to prolapsing cushions. Pathologic studies also demonstrated arteriovenous communications explain- ing why hemorrhoid bleeding is typically bright red or arterial in nature as opposed to dark or venous bleeding.
    [Show full text]
  • Treatment for Superficial Thrombophlebitis of The
    Treatment for superficial thrombophlebitis of the leg (Review) Di Nisio M, Wichers IM, Middeldorp S This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2012, Issue 3 http://www.thecochranelibrary.com Treatment for superficial thrombophlebitis of the leg (Review) Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. TABLE OF CONTENTS HEADER....................................... 1 ABSTRACT ...................................... 1 PLAINLANGUAGESUMMARY . 2 BACKGROUND .................................... 2 OBJECTIVES ..................................... 3 METHODS ...................................... 3 RESULTS....................................... 5 Figure1. ..................................... 7 Figure2. ..................................... 8 DISCUSSION ..................................... 11 AUTHORS’CONCLUSIONS . 12 ACKNOWLEDGEMENTS . 12 REFERENCES ..................................... 12 CHARACTERISTICSOFSTUDIES . 17 DATAANDANALYSES. 42 Analysis 1.1. Comparison 1 Fondaparinux versus placebo, Outcome 1 Pulmonary embolism. 51 Analysis 1.2. Comparison 1 Fondaparinux versus placebo, Outcome 2 Deep vein thrombosis. 51 Analysis 1.3. Comparison 1 Fondaparinux versus placebo, Outcome 3 Deep vein thrombosis and pulmonary embolism. 52 Analysis 1.4. Comparison 1 Fondaparinux versus placebo, Outcome 4 Extension of ST. 52 Analysis 1.5. Comparison 1 Fondaparinux versus placebo, Outcome 5 Recurrence of ST. 53 Analysis 1.6. Comparison 1 Fondaparinux
    [Show full text]
  • Lower Limb Venous Drainage
    Vascular Anatomy of Lower Limb Dr. Gitanjali Khorwal Arteries of Lower Limb Medial and Lateral malleolar arteries Lower Limb Venous Drainage Superficial veins : Great Saphenous Vein and Short Saphenous Vein Deep veins: Tibial, Peroneal, Popliteal, Femoral veins Perforators: Blood flow deep veins in the sole superficial veins in the dorsum But In leg and thigh from superficial to deep veins. Factors helping venous return • Negative intra-thoracic pressure. • Transmitted pulsations from adjacent arteries. • Valves maintain uni-directional flow. • Valves in perforating veins prevent reflux into low pressure superficial veins. • Calf Pump—Peripheral Heart. • Vis-a –tergo produced by contraction of heart. • Suction action of diaphragm during inspiration. Dorsal venous arch of Foot • It lies in the subcutaneous tissue over the heads of metatarsals with convexity directed distally. • It is formed by union of 4 dorsal metatarsal veins. Each dorsal metatarsal vein recieves blood in the clefts from • dorsal digital veins. • and proximal and distal perforating veins conveying blood from plantar surface of sole. Great saphenous Vein Begins from the medial side of dorsal venous arch. Supplemented by medial marginal vein Ascends 2.5 cm anterior to medial malleolus. Passes posterior to medial border of patella. Ascends along medial thigh. Penetrates deep fascia of femoral triangle: Pierces the Cribriform fascia. Saphenous opening. Drains into femoral vein. superficial epigastric v. superficial circumflex iliac v. superficial ext. pudendal v. posteromedial vein anterolateral vein GREAT SAPHENOUS VEIN anterior leg vein posterior arch vein dorsal venous arch medial marginal vein Thoraco-epigastric vein Deep external pudendal v. Tributaries of Great Saphenous vein Tributaries of Great Saphenous vein saphenous opening superficial epigastric superficial circumflex iliac superficial external pudendal posteromedial vein anterolateral vein adductor c.
    [Show full text]