By:By:abdulkrim al-kharashiabdulkrim al-kharashi

naif alsikannaif alsikan

Presentation and management of a Swollen

Leg

Differential Diagnosis of a Differential Diagnosis of a swollen legswollen leg

Vascular vs Non vascular

VascularVascular

Venous causes: DVT

Varicose veins

Post-thrombotic syndrome

Klippel-Trenaunay syndrome

External venous compression: Pelvic or abdominal tumors including gravid uterus and Retroperitoneal fibrosis

VascularVascular

Arterial causes Arteriovenous fistula

AV malformation

Aneurysm: - Popliteal - Femoral - False aneurysm following (iatrogenic)

trauma

Non vascularNon vascularSystemic diseases: Cardiac (congestive heart failure)

renal (nephrotic)

liver failure

Thyrotoxicosis (myxedema)

Allergic disorder

Immobility and lower limb dependency

Non vascularNon vascularLocal disease :

Arthritis

Bony or soft tissue tumors

Heamarthrosis

Calf muscle hematoma

bone dislocations or fractures

OthersOthers

TraumaSteroidsLymphedema

Chronic Venous Chronic Venous InsufficiencyInsufficiency

AnatomyAnatomyLower Limb Veins :

AnatomyAnatomySuperficial system :Great saphenous veinShort saphenous vein

Deep system:posterior tibial , anterior tibial veins, and

peroneal veins

Communicating veins:between 2 superficial veins or 2 deep veins.

Perforated veins : between 1 superficial & 1 deep vein

Pathophysiology: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.

Pathophysiology: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

Causes:Causes:Primary causes:

Due to inherent structural weakness of the

veins themselves, most common cause,often familial.

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 )

Classes:Classes:

Varicose veinsVaricose veins  Veins that have become enlarged

and tortuous

Signs and symptomsSigns 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

ComplactionComplaction

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 > Males).

Approach to varicose Approach to varicose veinsveins

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

Approach to varicose Approach to varicose veinsveins

History of superficial or deep thrombophlebitis

History of any other vascular disease

Family history of vascular disease of any type

Physical examination:

1.Inspection: from distal to proximal and from front to back.

Surgical scarsPigmentations and skin changesUlcers ( mostly in the medial aspect)

inspectioninspection

Varicose veins Telangiectases

Reticular veins Lipodermatosclerosis

Palpation:

Distal and proximal arterial pulses Entire skin surface:

• Greater saphenous vein :Anteromedial surface

• Posterior surface:Short saphenous vein

investigationinvestigationDoppler bidirectional-flow studies

Doppler color-flow

ManagementManagement

Conservative management

Non-surgical management

Surgical management

Elevating the legs.

The wearing of graduated compression stocking with a pressure of 30–40 mmHg.

has been shown to:

Correct the swelling. Improve nutritional exchange.

Improve the microcirculation. Provide relief.

Non-Surgical Management: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

SclerotherapySclerotherapySchlerotherapy: it’s 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 > 3mm

Sclerosing agents: Sodium Tetradecyl Sulfate and Polidocanol .

You aspirate FIRST then inject the substance

Non-Surgical Non-Surgical Management: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%).

Endovenous laser And Endovenous laser And radiofrequency ablationradiofrequency ablation..

Surgical managementSurgical managementSurgical 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%).

Surgical ligation and Surgical ligation and strippingstripping

Deep vein thrombosisDeep vein thrombosis

Deep vein thrombosisIs the formation of a blood clot (thrombus) in a

deep vein. It is a form of thrombophlebitis.

Deep vein thrombosis

Risk factors :

immobility

hypercoagulability

trauma to vein

age

drugs

orthopedic surgeries

hypercoaguble state includes: antithrombin 3 deficiency, protein C and S deficiency, factor V leiden deficiency

Signs and symptomsAsymptomatic

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

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

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.

managementHistory

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.

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

> 2 or higher :DVT is likely Consider imaging the leg veins.

<2 :DVT is unlikely. Consider blood test such as d-dimer test to further rule out deep vein thrombosis.

Work upBlood tests :

CBC , PT , APTT , fibrinogen , LFT , U and E

D-dimer testing

imaging

Plethysmography, (Used in research not clinical practice)

Doppler US.( Gold standard BUT Operator

dependent, if the operator wasn’t good do venography)

Compression US scanning of the leg combined with duplex US .

Venography

MRI

Doppler findings of DVT: Decrease blood flow in vein.

Non-compressible vein. Heterogenicity.

Treatment and mediationsAnticoagulation 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 INRLength of Rx w/ anticoagulant :

below common femoral vein 3 months at Common femoral, PE, iliac vein 6

months

Thrombolytic TherapyIs generally reserved for extensive clot,

e.g. an iliofemoral thrombosis.

Inferior vena cava filter:-Indication:1. anticoagulant therapy is ineffective, unsafe, or

contraindicated. 2. to prevent PE.

Contraindications: Uncorrectable, severe coagulopathy. Extensive IVC thrombosis such that placement of a filter

above the thrombus is not possible. Bacteremia.

Cont. Compression stockings (routinely

recommended)

Venous thrombectomy. In very rare cases

complications

1. Pulmonary embolism

2. Post-phlebitic syndrome:signs and symptoms, including:

Swelling of your legs (edema) Leg pain Skin discoloration

preventionPatients 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

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

lymphoedema

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

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.

Sings & symptoms

Severe fatigue, pain.

A heavy swollen limb, reduced mobility.

Discoloration of the skin.

Eventually deformity (elephantiasis).

Diagnosis is clinical then lymphoscintigraphy (nuclear study)

Duplex to check if there is varicose veins

treatment

Treat the underlying cause . However, medical treatment does’not 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

This is a complete set of edema treatment.

The techniques used are: 1.Manual lymphatic drainage,

2. compression bandaging

3. therapeutic exercise

4. skin care.

complicationsInfections: cellulitis, lymphangitis,

lymphadenitis, and in severe cases, skin ulcers.

Lymphangiosarcoma (rare)