clinical aspects of vein

Clinical aspects of vein

Presented by:
ANKITA MISHRA
16

Clinical anatomy of vein
Anatomy of the venous system of the leg
DEEP VEINS

POSTERIOR TIBIAL

ANTERIOR TIBIAL

PERONEAL

`
SOLEAL

GASTROC NEMIUS

POPLITEAL

FEMORAL

ILIAC

SUPERFICIAL VEINS

LONG SAPHENOUS (LSV)

SHORT SAPHENOUS (SSV)

PHYSIOLOGY OF VENOUS BLOOD FLOW

VENOUS RETURN FROM LEG IS GOVERNED BY:

Arterial pressure

Calf musculovenous pump

Gravity

Thoracic pump

Vis a tergo of adjoining muscles

Valves in veins

MUSCULOVENOUS PUMP

Foot and calf muscles act to
squeeze blood out of deep
veins.

One way valve allow only
upward and inward flow.

During muscle relaxation
blood is drawn inward thru
perforating veins.

VENOUS VALVULAR FUNCTION

VALVE LEAFLETS ALLOW
UNIDIRECTIONAL FLOW UPWARD
OR INWARD.

“NONREFLUXING OF VALVES”

MAJOR VALVES-OSTIAL VALVE

PRETERMINAL VALVE

PATHOPHYSIOLOGY

Primary muscle pump failure

Venous obstruction

Venous valvular incompetance:

1.perforator incompetence-hydrodynamic reflux

2.sup.vein incompetence- hydrostatic reflux

3.deep vein incompetence- isolated/2°

Vein Disorders
Venous Thrombosis (Superficial and Deep Vein
Thrombosis),

Thrombophlebitis

Chronic Venous Insufficiency

Varicose Veins

Chronic Venous Insufficiency
Results from obstruction of venous valves in legs or
reflux of blood back through valves

Venous ulceration is serious complication

Pharmacological therapy is antibiotics for infections

Debridement to promote healing

Topical Therapy may be used with cleansing and
debridement

Stages of chronic venous insufficiency

0 - no symptoms;

1 - heavy feet syndrome;

2 - intermittent edema;

3 - persistent edema, hyper- or hypopigmentation,
lipodermatosclerosis, eczema;

4 - venous ulcer.

Causes
Primary

Theories of Aetiology:
• Weak wall theory
• Congenital valvular incompetence

Aggravating factors:
• Female sex
• High parity
• Occupation requiring prolonged standing
• Marked obesity
• Constricting clothes
• Estrogen intake
• Deep venous thrombosis

Secondary
Anything that raises intra-abdominal pressure or raises pressure in
superficial/deep venous system
so…:

•Pregnancy
•Abdominal/pelvic mass
•Ascites
•obesity
•constipation
•thrombosis of leg veins (DVT)
•AV fistula
•Vena cava thrombose
•Large liver cysts

Varicose disease

Varicose disease of
subcutaneous veins is
their irreversible
dilation and elongation
occurring due to crude
pathological change of
venous walls and
valvular apparatus.

ANY RISK FACTOR INCREASED VENOUS PRESSURE

DILATION OF VEIN WALLS

STRECHING OF VALVES-VALVULAR INCOMPETENCE

REVERSAL OF BLOOD FLOW

FAILURE OF MUSCLES TO PUMP BLOOD

VEINS DISTEND,ELONGATE,TORTOUS,POUCHED,INELASTIC
AND FRIABLE

Surgical Intervention

INDICATED OR DONE FOR PREVENTION OR RELIEF OF EDEMA, FOR
RECURRENT LEG ULCERS OR PAIN OR FOR COSMETIC PURPOSES

VEIN LIGATION AND STRIPPING

THE GREAT SAPHENEOUS VEIN IS LIGATED (TIED) CLOSE TO THE
FEMORAL JUNCTION

THE VEINS ARE STRIPPED OUT THROUGH SMALL INCISIONS AT THE
GROIN, ABOVE & BELOW THE KNEE AND AT THE ANKLES.

STERILE DRESSING ARE PLACED OVER THE INCISIONS AND AN
ELASTIC BANDAGE EXTENDING FROM THE FOOT TO THE GROIN IS
FIRMLY APPLIED

NURSING CARE AFTER VEIN LIGATION & STRIPPING

Keep pt. flat on bed for first 4 hrs. after surgery,
elevate leg to promote venous return when lying or sitting

Medicate 30 mins. before ambulation and assist patient

Keep elastic bandage snug and intact, do not remove
bandage

Monitor for signs of bleeding, esp. on 1st post-op day

if there is bleeding, elevate the leg, apply pressure over
the wound and notify the surgeon

RISK FACTORS
Age
Gender
Height
left>right
Heredity
Pregnancy
Obesity and overweight
Posture

 25-50% of adult women
 15-30% of adult men

Is it an industrialized country disease?
UK: 45 000 hospital admissions per year

Treatment complications
Major complications following VV surgery are relatively
rare
Up to 20% morbidity
Infection
Hematoma
Pain
Nerve damage
Saphenous nerve (LSV surgery)
Sural, peroneal nerve (SSV surgery)
Lymphatic leak - Venous thrombosis - Vascular injury
Recurrence

Deep Vein Thrombosis (DVT)
DVT: Blood clot in a vein
located deep in the muscles of
the legs, thighs, pelvis or
arms

DVT is the result of 3
principle factors
1. Reduce or stagnant
blood flow in deep veins
2. Injury to the blood
vessels wall
3. Increase clotting
activity (hyper-coagulability
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or thrombophilia)

Risk of DVT
1. Immobilization
2. Recent surgery or trauma

3. The use of medication
4. Inherited or acquired hypercoagulability,

Note: Approximately 75-90% of DVT have at
least one established
risk factor
: Inherited thrombophilias can be identified
in 24-37% of patients

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SIGN AND SYMPTOMS

Leg pain or tenderness

Leg swelling

Increase wormth of one leg,change in skin color (redness)

Homans sign positive

24

Medical Management
Deep vein thrombosis
REQUIRES HOSPITALIZATION
BED REST W/ LEGS ELEVATED TO 15-20 DEGREES ABOVE
HEART LEVEL ( KNEES SLIGHTLY FLEXED, TRUNK HORIZONTAL
(HEAD MAY BE RAISED) TO PROMOTE VENOUS RETURN AND
HELP PREVENT FURTHER EMBOLI AND PREVENT EDEMA
APPLICATION OF WARM MOIST HEAT TO REDUCE PAIN,
PROMOTES VENOUS RETURN
ELASTIC STOCKING OR BANDAGE
ANTICOAGULANTS, INITIALLY WITH IV HEPARIN THEN
COUMADIN
FIBRINOLYTIC TO RESOLVE THE THROMBUS
VASODILATOR IF NEEDED TO CONTROL VESSEL SPASM AND
IMPROVE CIRCULATION

Nursing Assessment
characteristic of the pain
onset & duration of symptoms
history of thrombophlebitis or venous disorders
color & temp. of extremity
edema of calf of thigh - use a tape measure,
measure both legs for comparison
Identify areas of tenderness and any thrombosis

SURGERY
if the thrombus is recurrent and extensive or if
the pt. is at high risk for pulmonary embolism
Thrombectomy – incising the common femoral vein
in the groin and extracting the clots
Vena caval interruption – transvenous placement
of a grid or umbrella filter in the vena cava to block
the passage of emboli

Thrombophlebitis
inflammation of the veins caused by thrombus or
blood clot
Factors assoc. with the devt. of Thrombophlebitis
venous stasis
damage to the vessel wall
hypercoagulability of the blood – oral
contraceptive use
common to hospitalized pts. , undergone major
surgery (pelvic or hip surgery), MI
Pathophysiology
develops in both the deep and superficial veins of
the lower extremity
deep veins – femoral, popliteal, small calf veins
superficial veins – saphenous vein
Thrombus – form in the veins from accumulation
of platelets, fibrin, WBC and RBC

Thrombophlebitis
•Thrombosis with infammation of superfiacial
veins

•Occur spontaneously/due to minor trauma

•Can occur durin injection of sclerosing fluid
for treatment

Main symptoms of thrombophlebitis

Edema of the extremity
The pains are localised in the
gastrocnemius muscles as a rule,
along the course of vascular
bundles
The skin of the extremity becomes
cyanotic.

Medical Management
Thrombophlebitis

bed rest with legs elevated
apply moist heat
NSAID’s ( Non – steroidal
anti-inflammatory drugs) -
aspirin

Homans' sign
• Pains in gastrocnemius muscle upon
dorsal flexing of the foot is
characteristic of thrombophlebitis of
profound veins of the extremity.

Classification of functional tests
1. Test enable one to judge the
condition of valvular apparatus
Trendelenburg-Trojanov's tests
Hackenbruch's
2. Test enable of insufficient
perforating veins
Pratt's test II
Scheins' test
Thalmann's test
3. Test enable the patency of
profound veins
Delbe-Pertez test (marching test)
Pratt-I test

Trendelenburg-Trojanov's test.

Delbe-Pertez test (marching test)

Thrombectomy from femoral vein

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