VENOUS DISORDERS

 DEFINATION:
- When a vein become dilated, elongated and tortuous, the vein is
said to be “varicose veins”.
- Varicosity is the penalty for verticality against gravity.
The blood has to flow from the lower limbs into the heart against
gravity because of the upright posture of human beings.

 Sites
- The common sites of varicosity are
I) Superficial venous system of the lower limb affecting either
the long saphenous or the short saphenous vein or the both.
II) Esophageal varix (affecting vein of the gastro-esophageal
junction)
III) Varicosity of the haemorrhoidal veins (piles)
IV) Varicosity of the spermatic veins (varicocele)
- The return of the venous blood from the lower limb to the heart
requires a pump, equipped with non return valves.
- The pumping action is provided by the muscle
- If the valves are absent or become incompetent there is only a
high back pressure on standing but an even higher back pressure
on walking and running.
- The blood is squeezed out of the veins in the deep compartment
into the superficial vein.

 Surgical anatomy
 Venous drainage of the lower limbs can be conveniently described
Under 3 heads
- Deep vain
- Superficial veins
- Perforating or communicating veins, which connect the
superficial with deep veins.

1) Deep veins
- The deep veins of the lower limb accompany the arteries
and their branches. These veins possess numerous valves.
- The main veins are – the posterior tibial vein and its
tributaries, the peroneal vein and the femoral vein.
- The characteristic features of the deep veins are:
I) There are numerous valves in there veins. These
valves direct the flow of the blood upwards and
prevents regurgitation of flow downwards.
II) Within the soleus muscle , which is the most powerful
muscle of the calf there are venous plexuses or
sinuses. These are devoid of valves. These veins
empty is segments into the posterior tibial and the
peroneal veins.
These posterior tibial veins and the peroneal veins also
receive perforating or communicating veins from the
superficial veins and both these perforating veins and
soleus venous plexuses or sinuses may enter the sites of
these veins.
2) Superficial veins
- These veins lie in the subcutaneous fat between the skin
and the deep fascia. These superficial veins of the lower
limb are the
 Long (Great) saphenous vein
 It is the longest vein in the body. It begins in the
medial marginal vein of the foot and ends in the
femoral vein about 3cm below the inguinal
ligament
 Short (small) saphenous vein
This vein begins behind the lateral malleolus as
a continuation of the lateral marginal vein of
the foot.

3) Perforating or communicating veins

- These veins communicate between the superficial and
deep veins.
- These always pierce the deep fascia. There are valves
within these veins which under normal conditions allow
blood to flow from the superficial to the veins.

 Surgical pathology
- Under normal condition the blood from the superficial venous
system is passed to the deep veins through the competent
perforators and from the deep veins, the blood is pumped up to
the heart by the muscle pump, competent valves and negative
intrathoracic pressure.
- But, if this mechanism breaks down , either due to destruction of
the valves of the deep veins [ following deep vein thrombosis], or
of the perforators or of the superficial venous system, the blood
become stagnated in the superficial veins which become pray of
“high pressure leaks” and thus becomes distended and tortuous
to become varicose veins.
- If an individual stands motionless for a long period of time,
venous pressure at the ankle may rise to 80 to 100 mm hg ; and
gradually swelling appears.
- Even this modest activity of calf muscles and with competent
venous valves, this pressure is reduced to 20 or 30mm hg.

 Pathogenesis and complication

Pooling of blood in the superficial veins

Rise in intraluminal pressure

Excessive dilatation due to loss of elasticity sacculation and

elongation

When an elongated structure is placed between shorter length it

becomes tortuous

Thinning of vessel wall and exudation

Edema of the leg , stasis in the posterior arch veins produce a

localized edema around the ankle called “ankle flare”.

Pigmentation – this is due to break down of hemoglobin into

various pigments [ hemotodin – bilirubin containing= yellow in
colour , hemosiderin= iron containing= black in colour].

Itching this is due to breakdown products of hemoglobin

Dermatitis weeping or stasis

 Aetiology
1. Morphological factors
- Varicose veins of the lower limbs are the penalty the man
has to pay for its erect posture.
 - The veins have to drain against gravity. The superficial
veins have loose fatty tissue to support them and thus
suffer varicosity
2. Primary varicose veins
- These are more common, this condition is mainly due to
defect in the valves
- The defects may be congenital or acquired [ either due to
thrombosis or due to inflammation in the veins]
I) Defect in the saphenofemoral valve leads to varicosity
of the long saphenous vain.
II) Defect in the saphenopopliteal valve leads to
3. Secondary varicose veins
- It occur due to venous obstruction e.g.
I) Mechanical factors e.g. pregnancy or tumours in
the pelvis [ e.g. uterine fibroids, ovarian, cyst,
cancers of the cervix, uterus, ovary or rectum]
II) Deep vein thrombosis leading to damage of the
valves.
III) Hormonal cause- progesterone may cause
varicosity in multiparous females.
IV) Acquired arteriovenous fistula [ due to trauma or
deliberate shunting for dialysis].
V) Extensive cavernous (venous) haemangioma.
VI) Retroperitoneal lymphadenopathy or
retroperitoneal fibrosis.
VII) Iliac vein thrombosis.
4. Congenital varicose veins
- Occasionally varicose veins may develop below 20 years
of age
 - These cares are mostly due to either congenital
arteriovenous fistula or cavernous (venous)
haemangioma.
Examples of varicose veins
 Long saphenous varicosity
 Short saphenous varicosity
 Esophageal varices and fundal varices
 Hemorrhoids
 Varicocele
 Vulval varix and ovarian varix.

 Predisposing factors
a) Prolonged standing
- During prolonged standing long column of blood along
with gravity, puts pressure on the weekend valves of the
veins
- This causes failure of the valves quickly giving rise to
varicosity of the long or short saphenous vein
- During prolonged standing, the muscles also do not work
quite often so the calf pump mechanism also cannot push
venous blood upwards.
b) Obesity
- Excessive fatty tissue in the subcutaneous tissue offer
poor support to the veins
- This leads to the formation of varicosity
c) Pregnancy
- Pregnancy is said to predispose the formation of varicose
veins.
- Varicose veins are often noticed in multiparous women.
- Pregnancy acts in various ways
 I) Progesterone causes dilatation and relaxation of the
veins of the lower limb.
- This may make the valves incompetent
- This hormonal effect is maximum in the first
trimester of pregnancy.
II) Pregnant uterus causes pressure on the inferior
venacava thus causing obstruction to the venous
flow.
- This effect is mostly seen in the last trimester of
pregnancy
- After each pregnancy, both hormonal and
mechanical effects are removed and there is
improvement of varicosity.
- During the subsequent pregnancy, these factors
again cause the varicosities to develop in a bigger
way.
- That is why varicose veins are commonly seen in
multiparous women.

d) Old age
- This cause atrophy and weakness of the vein wall. At the
same time with aging the valves in the veins are commonly
become gradually incompetent.

e) Athletes
- Sometimes varicose veins are noticed among athletes
- Forcible contraction of the calf muscles may force
blood through the perforating veins in reverse
direction.
- This will cause destruction of the valves of the
perforating veins and ultimately lead to
formation of varicose veins
 - Similarly, rickshawpullers often suffer from
varicose veins.

 Clinical features
Symptoms
a) The commonest symptom is tired and aching sensation in
the affected lower limb, particularly in the calf muscles, at
the end of the day.
The severity of symptoms depends mostly on the extent of
the high back pressure.
b) Sharp pains may be complained of in grossly dilated veins.
c) Some patients may suffer from cramp in the calf muscles
shortly after retiring to bed.
Such cramp is usually due to sudden change in the caliber
of communicating veins which stimulates the muscles
through which they pass.
d) Pain may be bursting or severe in nature and may be
particularly localized to the site of the incompetent
perforating veins.
Such bursting pain while walking indicates deep vein
deficiency.
e) Patients may present with no other symptom except
dilated and tortuous veins of the leg.
These dilated veins may or may not be associated with the
following complications.
f) There may be other complaints or complication of the
dilated and tortuous veins such as
I) Ankle swelling towards evening
II) The skin over the varicosities may itch may be
pigmented.
III) Eczema of the affected skin
 IV) Venous ulceration
g) In the personal history , one may find that the patient is
involved in a job of prolonged standing.
E.g. bus or train conductors.

 Local & clinical examinations

I) Inspection
1. When the patient stands up, the veins become
prominent. The varicosities may be either widespread
or restricted to a single varix.
- When such single varix is situated at the
saphenous opening. It is called a “saphena varix”
- It must be distinguished from a femoral hernia.
One can feel characteristic thrill when the patient
lies down.
- When this varix is tapped with a finger, a fluid
thrill may be obtained in the long saphenous vein
lower down in the limb.
2. One must assess in inspection whether varicosity has
affected the long saphenous vein or the short
saphenous vein or the bath.
3. The skin of the lower part of the leg should be
particularly inspected to exclude edema,
pigmentation, eczema or ulceration.
II) Palpation
1. Cough impulse test [Morrissey’s test]
- Test should be done in the standing position
- In this test, limb is elevated to empty the veins
- The patient is asked to cough forcibly, an
exapansile impulse if felt in the long saphenous
 varicose vein , it may be presumed that the
sapheno – femoral valve is incompetent
- Similarly if the patient cough and the sapheno-
femoral junction is incompetent , a bruit may be
heard on auscultation.
2. Brodie – trendelenburg test
- This test is performed to determine
incompetency of the sapheno – femoral valve
and other communicating system.
- This test can be performed in two ways.
- In both the methods, the patient is first placed in
the recumbent position and legs are raised to
empty the veins.
- The sapheno- femoral [SF] junction is now
compressed with the thumb of the clinician and
the patient is asked to stand up quickly.
I) In first method, the pressure is released. If the
varices fill very quickly by a (column) of blood
from above, it indicated incompetency of the
sapheno – femoral valve.
This is called a positive +ve “Trendelenburg test”
II) To test the communicating system, mostly
situated on the medial side of the lower half of
the leg allowing the blood to flow from the
deep to the superficial veins.
This is also considered as a positive +ve
“trendelenburg test” and the positive tests are
indication for operation.

3. Tourniquet test
- It can be called a variant of “trendelenburg test”.
- In this test the tourniquet is tied around the thigh
or the leg at different levels after the superficial
 veins have been made empty by raising the leg in
recumbent position.
- The position is now asked to stand up
- If the veins above the tourniquet fill up and those
below it remain collapsed, it indicates presence
of incompetent communicating vein above the
tourniquet.
- Similarly, if the vein below the tourniquet fill
rapidly whereas veins above the tourniquet
remain empty , the incompetent communicating
veins must be below the tourniquet.
- Thus by moving the tourniquet down the leg in
steps one can determine the position of the
incompetent communicating vein.
4. Perthes’ test [modified]
- This test is primarily intended to know whether
the deep veins are normal or nat.
- A tourniquet is tied round the upper part of the
thigh tight enough to prevent any reflux down
the vein.
- The patient is asked to walk quickly with the
tourniquet in place.
- If the communicating and the deep veins are
normal, the varicose veins will shrink whereas if
they are blocked the varicose vein will be more
distended.
5. Schwartz’s test
- In a long standing case if a tap is made on the
long saphenous varicose veins, In the lower part
of the leg
- The patient feels an impulse at the saphenous
opening with the other hand of doctor.
 Investigation
- Various special investigation may be performed
e.g. Ascending phlebography
Thermography
Radioisotope scanning
Radioactive fibrinogen studies
And ultrasonics to know the condition of the deep vein.
And
- Position of the thrombus and position of the
incompetent perforators.
- Of the above mentioned methods “ascending
phlebography” is the most practical and valuable in
the average hospitals.
“Doppler ultrasound” is the most important,
minimum level investigation to be done before
treating a patient with venous disease.
- This investigation is carried out with the patient
standing.
- Incompetence of SFJ and saphenopopliteal junction
[SPJ] can be assessed by this method.
- Gentle squeezing of calf muscles helps in [defect]
detecting the incompetence.
- It also helps to rule out arterial disease.
- It can detect patency of veins.
Duplex ultrasound imaging:
- In this investigation high resolution B-mode
ultrasound imaging and Doppler ultrasound are
used.
- It helps in getting image of veins
- It can also measure flow in these vessel.
 - All lower limb veins can be imaged.
- Origin of venous ulcers and varicose veins also is
assessed.
- Importantly it can detect a thrombus
Venography:
- Both ascending and descending venography can be
done as in case of deep vein thrombosis(DVT)
- Duplex ultrasonography has largely replaced this
investigation

 Complication of varicose veins

- Thrombophlebitis
- Pigmentation
- Eczema (chronic dermatitis)
- Ankle flare
- Venous ulcer
- Hemorrhage
- Periostitis
- Calcification
- Equines deformity
 Treatment
- Three modes of treatment are available
A. Palliative treatment
B. Operative treatment
C. Fegan’s injection and compression treatment

A. Palliative treatment
The treatment has a limited scope and its indication are
1. These who are pregnant
2. These who don’t want operation
3. These who are waiting for operation
 4. Very early cases of varicosity.
- This treatment consists of:
I) Avoidance of prolonged standing
II) A crepe bandage or elastic stockings are applied from
the toss to the thigh.
- This should be applied before getting out of the in the
morning and should be kept till after getting into the
bed at night.
- So, it should be worn all through out the day and is
only taken off during sleep.
III) Whenever the patient site or sleeps, the limb should be
preferably above the heart level
- At least, it should be always raised.
IV) Exercise like “ bicycle riding” in the air while lying on
the back, walking etc. should be performed to
strengthen the calf muscles.
B. Operative treatment
- Indication of operative treatment are:
1. Positive trendelenburg test
2. Particularly sapheno – femoral incompetence
- Contraindication are:
a. Pregnancy
b. Women taking contraceptive pills
c. Thrombophlebitis
- These cases should be treated first and operation for
varicose veins is postponed till the above complication are
got rid of.
- There are two types of operation
I) Ligation
II) Ligation with stripping

I) Ligation
a. Sapheno-femoral incompetence
 - The operation is performed under general anesthesia.
- An oblique incision is made just below the grain
crease starting from the femoral artery pulsation to
5cm medially.
- All the tributaries of the long saphenous vein are
lighted and divided.
- The long saphenous vein is now lighted flush with
femoral vein.
- Particular care is taken to see that there is no
intervening tributary of the long saphenous vein
between the ligature and sapheno- femoral junction.
- In the process, the superficial epigastric, the
superficial circumflex iliac , the superficial and deep
external pudendal tributaries are ligated and divided.
- The long saphenous vein is now ligated distal to the
flush ligature and it is divided between the ligatures.
b. In case of sapheno popliteal incompetence
- A ligature is applied at the short saphenous vein ‘flish’
with the popliteal vein and another ligature distal to
it.
- The short saphenous vein is divided between the
ligatures.
 Past operative treatment
At the end of the operation compression bandage is applied to
the limb to prevent excessive bruising
This bandage may be replaced after 1 or 2 days with a thigh-
length high-compression stock.
The advantage of this stocking is that it can be easily removed
before taking bath and can then be reapplied.
 Complication after surgery
Bruising and discomfort are the main complication
 Slight pain is often complained of which requires mild analgesic.

C. Fegan’s injection and compression treatment

The indication are:
I) When varicose veins are mostly confined to below
knee and are caused by incompetent perforators.
II) Recurrent varicosity after operation
III) A probable alternative to surgery when the patient
refuse it.
 Contraindication are:
Deep vein thrombosis – this must be excluded before injection
treatment
Sapheno-femoral incompetence – in this technique, sclerasant
like ethanolamine oleate 5% [ethanolamine B.P.C] or sodium
tetradecyl sulphate 3% ( thrombovar ) is used to damage the
intima of the vein and to produce sclerosis later on.
no doubt that intima damage will take place only when sufficient
concentration of sclerosant is injected,
yet only one should be cautions not to inject more than sufficient
concentration of the sclerosant lest it may reach the deep veins
and should initiate thrombosis there.
The maximum dose at one time in one points is 1ml.
The injection should be given into an empty vein so that its walls
adhere without any intervening blood clot thrombosis to yield a
lasting result.

Technique:
- The patient is made to stand
- The position of incompetent perforators are marked
with ink.
- The needles of small syringes containing 1ml
sclerosant solution are inserted into the ink marked
points
- The position of the syringes are slightly withdrawn to
see if the venous blood is entering the syringes freely
indicating that the ends of the needles are inside the
incompetent perforators
- The patient is now asked to lie down on a bed
- He is directed to lift the leg concerned
- Thus the veins are made empty.
- Now the solution is injected
- Rubber pads are pressed on the sites of injection
while the needles are withdrawn.
- A crepe bandage is applied from the toes to the grain
keeping equal pressure through out over the rubber
pads.

Post operatively
- The patient is encouraged to walk as usual.
- Importance of walking immediately after
sclerotherapy and subsequent extra walking each day
cannot be over imphasized.
- Such walking is important to discourage (clotting)
from spreading into the veins.
- If the veins patient remains comfortable with
compressive bandage it should be not be disturbed for
at least 3 weeks
- The patient must attend the out patient every week.
- After 3 weeks , a new bandage is applied with less
compression for another 3 weeks , after which the
bandages are taken off.
 - Later on, the patient will always be asked to attend
out patient at regular intervals , so that further
injection may be carried out to any returning
varicosities
- So, sclerotherapy is a long term policy of maintenance
rather than the one time cure intended with surgery.

II - VENOUS THROMBOSIS

 Venous thrombosis is a very common surgical problem, which

has great influence on the morbidity and mortality of surgical
patients.

 AETIOLOGY:

 Three factors play major role in aetiology of venous thrombosis –

These are:
(1) Stasis
(2) Injury to vessel wall and
(3) Hypercoagulability
 Stasis is probably the most important clinical factor to cause
venous thrombosis.
 A reduction of blood flow in the major veins by half has been
shown immediately following induction of general anesthesia
and in debilitating diseases.
 This decrease in flow persists for the duration of anesthesia.
 Clinically, coagulability is raised from the overactivity of the
normal blood clotting mechanism.
 The increased clotting tendency encountered post-operatively
may be the result of several factors including altered blood
elements associated with blood dyscrasias or polycythemia or
may be secondary to dehydration.
 This hypercoagulability of the blood most frequently occurs in
infection, after hemorrhage and in visceral carcinoma which may
cause “THROMBOPHLEBITIS” migrans.
 Injury to the vein wall is mainly due to trauma or infection.

 PREDISPOSING FACTORS :

I. Major injuries
II. Following operation
III. Visceral cancer
IV. Tobacco smoking
V. Diabetes mellitus
VI. Congestive heart failure
VII. Shock
VIII. Polycythemia vera
IX. Long period of sitting or bed rest
X. Pregnancy
 XI. Infection
XII. Varicose vein
XIII. Obesity
XIV. Using of contraceptive pills

 Now a days, great stress is being led on the hypercoagulability

factor.
 Damage to the endothelium leads to platelets adherence which is
the start of the thrombotic process with fibrin deposition.
 Results of thrombosis are as follows :

a) Proximally, thrombosis extends into larger veins where

portions of clot may detach as emboli to cause pulmonary
embolism and infarction which is fatal.
b) Locally , the clot ultimately organize into fibrous tissue .
 While a few veins remain obstructed following
thrombosis ,others may recanalise.
 In both these cases the venous valves are destroyed
leading to chronic venous valvular insufficiency.
 Occasionally calcification may be seen in the thrombus
in pelvic veins which are known as “PHLEBOLITH”.

c) Distally , thrombus causes venous obstruction which

increases distal venous pressure.
 This leads to edema.
 Venous collateral circulation may open up by the
appearance of tortuous superficial veins.
 If venous pressure increases to such an extent that it
exceeds local arterial pressure, blood flow ceases and
venous gangrene.

 TYPES OF VENOUS THROMBOSIS :

 Mainly two types of venous thrombosis are seen –

1. Thrombophlebitis :
 Also known as superficial vein thrombosis.
 This is mainly seen in the superficial veins, particularly in
varicose veins or in veins which have been cannulated for
infusion.
 In these cases venous thrombosis is associated with acute
inflammatory response giving rise to pain , local swelling ,
redness and tenderness.
 Although, acute inflammatory changes occur in the vein
wall, so that bacteria are rarely present.

2. Phlebothrombosis :

 Also known as deep vein thrombosis (DVT).

 Here, the thrombus produces little local
signs or symptoms and may be loosely
attached to the vein wall so that emboli
may be dislodged from this thrombus to
cause fatal pulmonary embolism.

Superficial vein thrombosis

[THROMBOPHLEBITIS]
- As mentioned earlier such thromobophlebitis occurs
more often in varicose veins or after intravenous
infusion.
- This is also seen in association with polycythemia,
polyarthritis , buerger’s disease and visceral cancer.
- In both buerger’s disease and visceral cancer,
thrombophlebitis may affect one vein after the other
and is typically known as “thrombophlebitis migrans”.
- This is known as ‘trousseau’s sign’ [this sign is also
used to indicated muscular spasm or pressure over
nerve , seen in tetany].

 Clinical features
- The patients usually complain of painful cord-like
inflamed area, the inflamed vein.
- Careful palpation until reveal a firm cord along the
course of a nonsuperficial vein.
- There may be associated redness, tenderness and
local induration
- Veins of the lower extremity should be best examined
in the standing position.

 Treatment
- Operation is almost never required as embolization
never occurs.
- However, thrombophlebitis may be present with deep
vein thrombosis, when there will be significant distal
swelling and a phlebogram will diagnose deep vein
thrombosis.
A) Hot baths or compress may be helpful in relieving
discomfort. It may also prevent propagation of
thrombus by preventing venous stasis.
B) Elastic support or crepe bandage should be applied to
the part.
- When it affects the leg, walking is advised with elastic
support.
- The patient may lie down in bed with legs elevated
above the level of the heart.
 - However, sitting or standing should be discouraged
though walking is encouraged.
C) Anticoagulants or enzymatic clot dissolves have little
effect on the outcome.
D) Aspirin is quite effective in this condition , though
there is hardly any place of expensive and potentially
dangerous “anti-inflammatory” drugs.
E) The role of antibiotic is debateable.
- While many surgeons prefer to give a short course of
penicillin or cotrimoxazole, others rule out may
benefit which may be achieved due to administration
of antibiotic unless a definite septic cause is obvious.
- But, antibiotic has got a definite role to play in case of
thrombophlebitis due to intravenous infusion

 Operative treatment
- Only when there is evidence of ascent of thrombi into
the more proximal vein, ligation of the vein is justified.
- Ligation of the long saphenous vein at the
saphenofemoral junction using local anesthesia or
short saphenous vein in the popliteal fossa may be
indicated if there is fear of propagation of thrombi
proximally.
- Such ligation is also required when the vein is
becoming recurrent phlebitis.

Deep vein thrombosis [PHLEBOTHROMBOSIS]

(DVT)
- It is also called “phlebothrombosis”.
- It is an acute thrombosis of deep veins .
 Follows child birth, operations muscular violence, local
trauma , immobility and any debilitating illness.
Spontaneous thrombosis occurs in the presence of a
visceral neoplasm.

 Cause of DVT ( deep vein thrombosis)

T = trauma , injury to the vessel wall
H = hormones , increased coagulability
R = road traffic accidents
O = operation, cholecystectomy
M = malignancy, sluggish blood flow
B = blood disorders- polycythemia
O = Orthopedic surgery, obesity, old age
S = serious illness, stoke, MI , stasis
I = Immobilization
S = splenectomy

- The thrombus may commence in a venous tributary of

a main vein.
- The calf is the mast frequent site of thrombosis.
- From here , thrombus extends in a serpentine fashion
into the main deep vein , where a portion may break
off to cause pulmonary embolus.
- Other veins are also involved less frequently.

 Clinical features
- Patients with suspected deep venous thrombosis
should be evaluated and treated promptly in order to
lessen the propagation of the thrombus , to limit the
damage to the venous valves and to reduce the
potential for pulmonary embolism.
- Venous thrombosis after is asymptomatic and clinical
indication are present in only 40% or less of patients
with venous thrombosis.
- Swelling is another symptom , which is noticeable at
the dependent part.
- This swelling is usually minimal and only occasionally
it may be marked.
- Low grade fever with increased pulse rate.
- Dull aching or nagging pain in the calf muscles.

 Physical sings or findings

- The three 3 most important signs which may be
present in a case of deep vein thrombosis(DVT) are
 Swelling
 Tenderness
 Homan’s sign

- Swelling should be searched for with the aid of a

measuring tape.
- In majority of cases there is so slight swelling that it
may be missed by the naked eyes.
- The other extremity should always be placed side by
side to compare and to exclude swelling on the
affected side.
- Tenderness over the thrombosed vein can be
detected by carful palpation of the calf, popliteal
space, and thigh (particularly the adductor canal).
- Homan’s signs homans was the first physician to
emphasize the importance of venous thrombosis in
the legs as source of pulmonary emboli.
- He described a test which is known as “homan’s sign”.
- In this test , passive forceful dorsiflexion of the foot
with the knee extended will elicit pain in the calf.
- Passive elongation f the gastrocnemius and soleus
muscles cause irritative pain the calf when the calf
veins are thrombosed.
- Gentle pressure directly on the calf muscles in the
relaxed position will also elicit pain.
- Care must be taken to be gentle in manipulation test it
should dislodged emboli to cause pulmonary
embolism.
- Mose’s sign- squeezing of the calf muscle from side is
painful in case of deep vein thrombosis

 Various sites of involvement

- Calf – vein thrombosis
- Femoral vein thrombosis
- Iliofemoral venous thrombosis
- Pelvic vein thrombosis
 Investigation
I) Doppler study: it is ideal for femoral vein
thrombosis or when thrombus extends into
popliteal vein.
- Normal femoral vein given a wind storm sound
which completely disappears at the end of
inspiration.
- No sound is heard if there is femoral thrombosis.

II) Contrast Venography is done by injection radio

opaque dye into dorsal venous arch with an
inflatable calf both above the ankle and above
the knee.
- Clot appears as a filling defect
- However venography is not routinely done
because it is expensive and invasive.
III) Phlebography
 IV) Venous pressure measurement
V) Duplex ultrasound imaging
- Due to direct visualization , both functional and
anatomical information can be obtained.

 Prevention:-
- Every care should be taken to prevent formation
of deep vein thrombosis is
a) To minimize venous stasis
b) To avoid venous intimal injury and
c) To reduce hypercoagulability.

 Treatment:-
 Conservative treatment:
I) Bed rest – bed rest is indicated for about 7 days
after the diagnosis established.
- This is to allow thrombi to become adherent to
the vein wall.
- It also prevents formation of pulmonary
embolus.
II) Elevation of legs above the level of the heart
decreased the pressure in the veins.
- It relieves edema and pain
- It also increases rate of blood flow in the non-
affected veins there by preventing venous stasis
and formation of new thrombi.
III) When walking is started, an elastic stocking
should be used.
- With this rate of flow in the vein is increased.
 - Standing and sitting idle should be prohibited
this prohibition should be for no less than 6
months period.
IV) Heparin = this drug prevents thrombus formation
inhibiting the formation of thromboplastin and
also acts as antithrombin to inactivate thrombin.
V) Coumarin derivatives = there derivatives interfere
4 factors in the clotting mechanism, but their
main effect is reduction of plasma concentration
of prothrombin.
VI) Fibrinolytic drugs e.g. streptokinase indirectly
converts plasminogen to plasmin, which can lyses
clots in deep veins.

 Operative / surgical treatment

- By pass procedure = simple by pass with vein or
prosthetic material may be used in larger vessels
e.g. vena cava and iliac veins.
- In this techniques, veins of larger caliber are
difficult to get , so some sort of prosthetic
material is more often used.
- “palma operation” may be carried out which
involves mobilizing the long saphenous vein of
the opposite leg, the distal end is tunneled
across suprapublically and inserted into the
affected femoral vein below the obstruction.
- Blood drains from the affected leg via the long
saphenous vein into the femoral vein of the
opposite side.
- In case of obstruction of the superficial femoral
vein, the long saphenous vein is connected to
the popliteal vein of the same leg.
 - This is known as “ May Husni procedure”.
- In majority of patients with chronic superficial
femoral vein obstruction , the blood flows along
the long saphenous vein to reach the ( common)
femoral vein, so no operation is required.

 Valvular repair:
- When the venous valves in the deep veins are
damaged valve repair is possible to make them
competent.
- This valve repair was described by “Kistner”.
- He described two types of repair – internal
(incision) incising, open the vein and suturing the
valve to make incompetent valve competent.
- The other type is external suturing i.e., the
valves are sutured from outside the vein without
opening it.
 Thrombectomy in case of venous gangrene.
 Complications
- Permanent edema of the limb. The limb has an
inverted beer bottle appearance.
- Pulmonary embolism because the thrombus is
not attached to vessel wall.
- Secondary varicosity and non healing ulcer.

III venous ulcer

- Venous ulceration has two main etiologies.

- Firstly, ulceration may be associate with demonstrable
varicose veins and ,
- Secondly ,such ulceration may follow thrombosis and
phlebitis in the deep and perforating veins.
- This second group presents as an ulcerated edematous leg
with demonstrable superficial veins in only about 1/3 of
cases.
- In all cases of this ,second group there will be history of long
standing edema of the leg.

 pathogenesis-

- After the deep vein thrombosis, if the deep venous system

is allowed to eventually recanalise itself, the delicated
valves will remain impregnated laterally in organized
thrombosis.
- The result is patent but valveless deep venous system
,which transmits the gravitational pressure of the blood
column unimpeded from the level of the heart to the
ankles.
- This is the main predisposing feature in the pathophysiology
of the past phlebitis state .
- However ,valvular incompetence alone is not enough to
produce serious stasis sequels.
- It must occur through (serious) incompletent perforator
veins through which the high deep venous pressure is
transmitted to the superficial veins.
- The location of these perforating veins determines the
predilection of ulcer formation.
Extending from the malleolus upto the lower half of the
leg
- These perforators may have been involved in the initial
thrombosis or may become incompetent by dilatation
 resulting from the back pressure of the valveless deep
venous system.
- Within 10 years of untreated thrombophlebitis , 50% will
have venous ulcers.
- Fibrinogen escapes through large pores in the veins of these
patients with venous hypertension secondary to venous
insufficiency.
- This fibrinogen accumulation acts as a barrier to diffusion of
oxygen and other nutrients and thus develops thick, hard
subcutaneous tissue.
- ‘stasis dermatitis’ develops with browny edema,
pigmentation and cutaneous atrophy.
- Fat necrosis, tissue death and ulceration follow.
- It is not until some minor trauma which leads to a skin break
that an actual venous ulcer develops.

 Investigations
- ‘Ascending functional phlebography’ or venography is
highly important to formulate treatment in difficult cases.
- It will show the size of the lumen of the deep veins , the
presence of valves and existence of high pressure leaks in
the calf.
- ‘Doppler apparatus’ may be adopted to indicate the
direction of flow in veins.

 Treatment
A. Conservative treatment
(i) Elevation of the affected limb is important.
(ii) Passive movements to maintain the mobility of the
foot and ankle.
(iii) Active movements of the calf muscles.
 (iv) A firm elastic ‘blue line’ bandage is applied spirally
from the base of the tees upto the knee joint.
While walking this bandage will alternatively stretch
and relax and thus help in venous pumping.
(v) Effective antibiotic from the culture report should
be prescribed immediately. Analgesic may also be
given.

B. Surgical treatment
- Along with the previous conservative regimen,
incompetent perforators and varicose veins may be
treated by ‘surgery’ or sclerotherapy’ following which
the ulcer will heal completely.
- ‘Subfascial ligation’ of cockett and dodd
- A ‘By-pass operation’ may be performed.
- ‘valvular repair’ may be performed.
- ‘valve transplant’ by autograph.

IV - Pulmonary Embolism
- Thrombi break loose from the deep vein thrombosis, pass through
the right atrium and ventricle and lodge in the pulmonary arteries.
This is known as “pulmonary embolism”
- Small emboli lodging in a lobar or segmental artery may cause
death. But the mechanism is not clearly known.
- It may be , that intense reflex broncho constriction and
vasoconstriction may lead to such death.
- Single small embolism may also result in infarction followed by
infection, abscess and emphysema.
- Multiple small emboli may produce arterial obstruction to such an
extent as to cause pulmonary hypertension and right ventricular
failure.
- Large thrombus which lodges in major pulmonary artery may
cause immediate death due to vasovagal shock , right ventricular
failure and inadequate transfer of oxygen and carbon-dioxide in
the pulmonary circulation.
- Majority of pulmonary emboli originate in the lower extremity
[85%].
- 5% come from pelvic vein, venacava or upper extremities.
- 10% of emboli originate from the right atrium.
- Obviously there will be more risk of loosening of thrombus at the
upper limit of a long femoroiliac occlusion, where both the force
of venous flow and turbulence will be greater.

 Clinical features
 - Patients usually complain of dyspnoea, chestpain,
haemoptysis and hypotension.
- Dyspnoea is first to appear, followed by pain which
becomes more severe in the presence of a massive
embolus lodged in the main pulmonary artery.
- The pain is usually substernal and sharp, stabbing in
nature, which occurs during breathing.
- In case of peripheral embolus there may ne pleuritic
pain.
- Occasionally pain may be epigastric.
- Haemoptysis is due to presence of infarction of
segments of lung.

 Physical examinations
- Most consisting finding is
 Tachycardia
 Tachypnoea
- Shock and cyanosis are ominous signs and only seen in
massive embolus.
- Pleural friction trubs are heard in case of peripheral
infarcts.
- Rales may be heard due to secondary pulmonary
edema.
- Small pleural effusion are not uncommon.
- Dilatation of the cervical veins are due to right
ventricular failure.
- There may be accentuation of second pulmonary
sound.

 Investigations
(I) Chest X-ray
(II) ECG [electrocardiography]
(III) Pulmonary arteriography
 (IV) Pulmonary radio isotope scanning.
(V) Chemical test – LDH activity
SGOT
CBC

 Treatment
A) Conservative treatment
1. Anticoagulants
- Anticoagulant therapy is the primary method in
the majority of patients once a diagnosis of
pulmonary embolism is established.
- Heparin is administered in large doses – 40000
units or more daily till the clotting time is
brought down to atleast twice the normal.
- In acute stages a continuous intravenous drip of
heparin is a reliable method for maintaining
stable and sustained deviation of clotting time.
- Heparin also acts against reflex
bronchoconstriction in pulmonary embolism.
- It should be followed by oral anticoagulants for 3
to 6 months or even longer.
2. Fibrinolytic agents
- Although much work has been done on the use
of fibrinolytic agents to lyses pulmonary emboli ,
there is little clear evidence about its usefulness.
- Streptokinase is infused through the pulmonary
angiogram cannula in an intial dose of upto
6,00,000 units, followed by 1,00,000 units hourly
for upto 3 days.
- it is important to maintain the treatment for a
sufficient length of time.
 - The pulmonary arteriogram can be repeated to
check the progress of the condition.
- Streptokinase or more recently urokinase has
been used but its effectibility is still controversial.
3. Essential supportive treatment in the form correction
of metabolic acidosis by infusion of sodium
bicarbonate and improvement of heart function by the
use of intropic drugs should be considered.

B) Surgical treatment
I. Ligation or division
- An analysis has shown that femoral vein
ligation is less effective in the prevention of
emboli than the use of anticoagulants.
- Ligation or division of the inferior venacava
just distal to the right renal vein has been
performed to prevent passage of thrombi.
- The operation required general or spinal
anesthesia.
- The incidence of pulmonary embolism
following this procedure is generally lower
than the reported incidence following femoral
vein ligation.
- However this technique cannot be used is
desperate ill patients.
- The ligation of a vein however results in
propagation of the thrombus to the site of the
ligature from its origin.
- It is also complication by edema , pain ,
recurrent phlebitis and ulceration of lower
limbs.
II. Venous interruption
 - Interruption of the veins of the lower
extremity is indicated if pulmonary embolus
occurs in a patient receiving adequate
anticoagulant therapy or in patients in whom
anticoagulant therapy is contraindicated.
- Phlebography is routinely used to localize the
thrombi.
- Interruption should always be performed
proximal to the site of embolus.
- It should be done at the venacava level in the
presence of pelvic vein and iliac vein
thrombosis.
- Interrupted arterial sutures are placed
through the vena cava or a plastic clip
(moretz) is placed across, it.
- A plastic umbrella grid may also be placed
into the inferior vena cava by means of a
venous catheter under radiological control.

III. Pulmonary embolectomy

- It should be used in the event of failure of
thrombolytic treatment.
V – CHRONIC VENOUS INSUFFICIENCY
 AETIOLOGY
- There are mainly 3 three causes of chronic venous
insufficiency these are:
I) Varicose veins
II) Incompetent perforators
III) Deep vein abnormalities
I) Varicose veins
- It is discussed in detail previously.
II) Incompetent perforators
- There are many perforators between the
superficial and deep veins of the inferior
extremity , which are also discussed in the
section of “varicose veins”
- When the valves of these perforators become
incompetent, they become dilated and produce
localized dilatations at their junction with the
superficial vein which can be detected both by
inspection and palpation.
- Defects in the deep fascia through which these
dilated perforators pass may also be palpated.
- When these perforators become incompetent,
high ambulatory venous pressure developing
within the deep veins of the calf during exercise
is directly transmitted through these perforators
to the superficial venous system.
- Ultimately there is sustained rise in capillary
pressure in the surrounding skin with the
development of edema, induration , fat necrosis,
and ulceration.
 III) Deep vein abnormalities
a) Deep vein thrombosis (DVT) is the main deep vein
abnormality which often causes chronic venous
insufficiency.
- Following thrombosis, major deep veins may
become patent by recanalization , however
the delicate valves will remain imprisoned
laterally in organized thrombosis.
- The result is the patent and valveless deep
venous system which transmits the
gravitational pressure of the blood column
unimpeded from the level of the heart to the
ankles.
- This is the main predisposing feature in the
pathophysiology of the chronic venous
insufficiency.

b) Occasionally the congenital or familial causes of

varicosities may also cause deep vein abnormalities.

 Clinical features
- An aching discomfort in the lower limb is frequently
complained of.
- Edema is also seen.
- There may be associated varicose veins, but this
condition is mainly due to deep vein abnormalities and
incompetent perforators.
- There may be night cramps in the muscles of the calf
and fat.
Physical findings
- Edema , browny induration , brownish
pigmentation and dermatitis are seen followed
by the development of venous ulcers.
 - All these are usually seen on the medial aspect of
the leg just above the ankle posterior and
superior to medial malleolus.
- Various types of “Dermatitis” may be seen.
- The venous ulcers are characteristically shallow
with surrounding rims of bluish discolouration
and erythema.
- These may be as deep as the deep fascia but
cannot be deeper than that.
- The ulcers may appear spontaneously or follow
trivial trauma.

 Investigation
- Like those described in “deep venous thrombosis”

 Treatment
 Conservative treatment
(I) Elevation of leg
- The frequency of daily leg elevation should
be charted according to the edema of the
leg of the individual.
(II) Active exercise
- Active exercise , particularly walking with
elastic stockings
- Elastic stocking should be used whenever
out of bed.
(III) Those who have already developed venous ulcer,
the treatment of venous ulcer as described in the
section of “venous ulcer” should be followed.

 Surgical management
1. Ligation and stripping of long or short saphenous vein
 - This can only be performed when its incompetecncy
has been demonstrated by “trendelenburg test”.
- Indication for this operation are:
a. Severe varicosities
b. Moderate to severe symptoms of varicosities
c. Presence of venous ulcers even with aggressive
conservative management
- The operative procedure has been discussed under
“varicose veins”.

2. Fegan’s injection of veins

- Followed by 6 weeks of continuous elastic
compression, is also discussed in ‘varicose veins’.

3. By - pass operation
- Saphenous vein has been used to by pass
segmental venous occlusion of the iliofemoral or
femoropoliteal veins.
- For iliofemoral occlusion the contra lateral
saphenous vein is passed suprapubically and
anastomosed to the affected side.
- A temporary arteriovenous fistula distal to the
anastomosis may ensure patency.
- For femoropopliteal occlusion the obstructed
segment can be by passed by anastomosis of
saphenous vein to the popliteal tibial trunk at the
level of the knee.