CHRONIC VENOUS INSUFFICIENCY AND DEEP VEIN THROMBOSIS
The causes for chronic venous insufficiency are attributed to three types of abnormalities. First one being the varicosity of veins second is the incompetence of the valves which are responsible for a unidirectional flow in the veins and third is the deep vein abnormalities. Formerly it was also known as post phlebitic syndrome post thrombotic syndrome depending on its remote cause (Weiss, n. a). However in some patients the cause could be attributed to congenital absence of the valves.
Varicose veins are dilatation, tortuosity and elongation of the veins. It can occur as a result of occupational hazard, prolonged standing may cause a temporary dilatation of the veins of legs.
The perforators between the deep and superficial veins have valves in them which ensure a unidirectional flow proximally from the legs, when these valves lose their competency, they become dilated and leads to a localised dilatation at their junction with the superficial veins. Due to the incompetency, during exercising, very high ambulatory pressure seems to be developing in the deep veins. This elevated pressure is the transmitted through the perforators to the superficial veins. This persistent rise in the pressure results in oedema, necrosis and ultimately ulcer formation.
On the other hand, deep vein thrombosis is a leading cause of chronic venous insufficiency. It is a result of stasis, hypercoagulability of blood and trauma to the vessel wall. Other causes can be taking oral contraceptive pills, post puerperal, and post surgical, any chronic debilitating disease or lack of mobility for a considerable period of time (Das, 2010). The symptoms will be pain, swelling and tenderness of the affected area ( Mayoclinic.org, 2014)
Venous thrombosis is a disease of veins whereas arterial thrombosis is a disease of the arteries. Damage to the arteries causes formation of thrombus which is classically called as “white clot” due its superimposition over the atherosclerotic plaque with active inflammation, rich in platelets, giving it a whitish appearance. On the contrary, venous thrombosis is called as “red clot” due to its association with red blood cells and being rich in fibrin (Jerjes-Sanchez, 2004, pp. 3-4)
The risk of both chronic venous insufficiency and deep vein thrombosis increases substantially with age. More is the age; more is the proneness to these diseases due to weakening of the valves with age, effects of senility on veins and relative immobility.
The diagnostics for both the conditions are almost same. On physical examination, selling, tenderness and Homan’s sign will be positive in both the cases. Homan’s sign is elicited by passive dorsiflexion of the foot with the knee kept extended. On dorsiflexion the patient will experience intense pain. Specifically in deep vein thrombosis Mose’s sign will be positive; that is, on squeezing the calf muscles from side to side pain will b elicited. For further distinguishing between the two conditions invasive procedures may be required, like phlebography, radioactive fibrinogen test, Doppler ultrasonography, plethysmography, venous pressure measurement or duplex ultrasound imaging.
Till date, no medication has proved to be successful in the treatment of chronic venous insufficiency or deep vein thrombosis. Surgical intervention can be considered, but it also runs a high risk of post operative deep vein thrombosis. In aged patients, the complications are further worse. Some conservative treatments can prove to be beneficial, like elevation of legs above the heart level while lying. Taking up active exercises with elastic stockings can help. The elastic stockings should be kept handy and used whenever stepping out of bed. Surgical treatment would include ligation and stripping of long or short saphenous veins in the presence of moderate to severe venous incompetency or presence of ulcers. One may opt for ligation of the incompetent perforators or a by-pass procedure, where the saphenous vein is used to by-pass the segment of venous occlusion (Das, 2010).
While undergoing the operative procedure, use of anti coagulants greatly reduces the chances of deep vein thrombosis. Infusion of 5000 units of heparin subcutaneously 2 hours prior to operation and 8 hours after the procedure reduces the risk of DVT significantly. Prevention of venous stasis in the soleal vein can be brought about by intermittent pneumatic compression, electrical calf stimulation or by active plantar flexion. Post surgically, low molecular weight dextran can be used to prevent venous thrombosis; adequate care should be taken during administration of dextran as its indiscriminate use may lead to pulmonary oedema or formation of haematomas along with increased bleeding. The dosage should not exceed 1.5g/kg body weight of the patient. Special care needs to be taken in elderly patients as they are at a higher risk of fluid overload. Usage of aspirin has been seen to be successful both in reducing the post operative pain due to its analgesic actions, and reduction in chances of deep vein thrombosis. In already established cases, coumarin derivatives can be useful in reduction of plasma concentration of prothrombin. Fibrinolytic drugs like streptokinase can lyse the clots in the deep veins. Urokinase can also perform a similar function.
CHRONIC VENOUS INSUFFICIENCY
DEEP VEIN THROMBOSIS
DEEP VEIN THROMBOSIS
REFERENCES
Das, S. (2010). A concise textbook of surgery (6th ed.). Kolkata: Dr. S. Das.
Deep Vein Thrombosis (July 3, 2014)
Retrieved: http://www.mayoclinic.org/diseases-conditions/deep-vein-
thrombosis/basics/definition/con-20031922. Accessed on December 28, 2014.
Jerjes-Sanchez, C. (2004). Venous and arterial thrombosis: A continuous spectrum of the
same disease? European Heart Journal, 26(1), 3-4. Retrieved from:
http://eurheartj.oxfordjournals.org/content/26/1/3
Weiss, R. Venous Insufficiency (W. James, Ed.)(n. a)
Retrieved from: http://emedicine.medscape.com/article/1085412-overview. Accessed on
December 28, 2014)
