Phlebology

Sommaire et contenu du livre "Phlebology"

Contents Abbreviations V Foreword VII 1. BASIC KNOWLEDGE 1 Definitions -classifications 3 Chron? venous disorders -Definitions 3 Chronic venous disorders and chronic venous disease 3 Venous insufllciency 3 Posr-rhromboric syndrome 4 Varicose veins 4 Telangiecrasias 5 Trophic changes 5 Leg ulcer 5 New CEAP definirions (2004) 5 Classificarions of CVD 6 Widmer Classificarion 7 CEAP c1assificarion 7 Superficial Thrombophlebitis (STP) -Definition Il Deep Vein Thrombosis (DVT) -Definition 12 2 Anatomy and pathology of the limb veins 15 Anatomy of the limb veins 15 Structure of rhe venous wall 15 Valve srructure 15 Descriptive anaromy 16 Pathologica1 anatomy 32 Telangiecrasias 33 Varicose veins 33 Perforaring veins 38 Primary deep valvular insufficiency (PDYl) 40 Deep vein compression 40 Free edge of the leaRers' valve sinus 40 Posr-rhromboric syndrome 43 Thoraco-brachial ourler syndrome 43 Superior vena cava (SVe) syndrome 43 Venous aneurysms 44 Congeniral venous malformarions 44 Vein tumours 46 Sequelae oflimb vein trauma 46 Venous lesions in rhe pelvic syndrome 47 Microangioparhy of chronic venous insufficiency (CYl) 47 3 Venous physiology 49 Venous physiology of the lower Iimb 49 Veins 49 Blood pressure and velociry in rhe venous and capillary companmenr 51 Venous relUrn 54 amers mechanisms 56 Environmenral facrors 58 Venous physiology of the upper Iimb . 58 4 Pathophysiology of chronic venous disease 61 Venous pathophysiology of the lower Iimb 61 Pamophysiological mechanisms 61 Consequences 70 Aggravaring facrors 74 Consequences of cIuonic LL venous disease 79 Venous pathophysiology of the upper Iimb 79 Pathophysiology of tdangiectasias 79 Walilesions 80 Aneriovenous anasromoses 80 Hormones 80 5 Epidemiology and costs 83 Prevalence and incidence ofvenous disorders 83 Venous symproms in lhe absence of dinical signs (Cos) or analomo-pamophysiological abnormaliries (~ and PN) of CVD 83 C" Telangiecrasias and rericuiar varicose veins 83 C• Varicose veins 84 2 C3 • Oedema 85 C,. Sl?changes ofvenous origin (pigmenrarion, eczema, lipodermarosclerosis) 85 Cs~' Healed uicer -unhealed ulcer 85 Posr-mromboric syndrome 86 Risk factors for telangiectasias, varicose veins, CVI, u1cer and the post-tbrombotic syndrome 87 Risk facrors for relangiecrasias. varicose veins and CYl 87 Risk facrors for rhe posr-rhromboric syndrome 90 Cast of venous disorders 90 Posr-mrombo?yndrome 91 Venous Jeg uicer 91 Conclusions 91 II. CHRONIC VENOUS DISEASE 6 Symptoms 97 Symptoms 97 Impression of Swelling 98 Heavy Legs 98 Prurilus 98 Pain 98 Nighr Cramps 100 ResrJess Legs 100 Evaluation and quantification of the symptoms 101 Evaluation and quantification of the symptoms 102 Evaluation of disability 102 7 Signs 105 Telangiectasias 105 Definition of telangiectasias (C,) 106 Significance of telangiectasias 106 Development of telangiectasias 106 Clinical presentation 107 Topography of telangiectasias 108 Venous drainage of the skin 109 Differential diagnosis of telangiectasias III Clinical course and recurrence III Reticu1ar varicose veins (CI) III Clinical appearance III Differential diagnosis of reticular varicose veins 112 Complications 112 z Varicose veins (C) 112 Saphenous varicose veins (truncal varicose veins) 112 Collateral saphenous varicose veins (accessory truncal varicose veins) 113 Non saphenous varicose veins 114 Varicose veins and pregnancy 114 Differential diagnosis ofvaricose veins 114 Complications 116 Œdema (C) 117 Causes of oedema 117 Venous oedema 117 Traveller's oedema 118 Lipoedema and Iymphoedema 118 Trophic changes (C4) 118 Pigmentation ("dermite ocre", purpuric and pigmented angiodermatitis of Favre and Chaix) 119 ~ma 120 Lipodermatosclerosis 124 Atrophie blanche 127 Calcification (cutaneous calcinosis) 128 Healed venous ulœr (CJ 129 Active ulœr(CJ 130 Definitions 130 Epidemiology 130 Diagnosis 131 Differential diagnosis 131 Ulcers in Practice -clinical aspects 132 Complications 139 Progression 142 Venous signs not considered in the CFAP 143 Corona phlebectatica 143 Congenital venous malformations 144 "Deœptive" signs or signs "associated" with CVD 144 Eryrhema 144 Purpura 145 Ecchymosis and haematoma 147 Infections 147 Livedo 149 Lipoedema 150 Lymphatic disotdets of CVD 152 Lymphoedema 152 Other curaneous disorders associaœd with CVD 155 Relationship berween drug injection and CVD 157 Cutaneous complications occuring during CVD and its treatment 157 Complications of local treatmems 157 Complications of systemic treatments 158 Rare complicarions foliowing surgery 159 Parricular complications following sc!erotherapy 161 J Clinical forms 167 Primary varicose veins 167 Uncomplicared varicose veins 167 Incompetence of perforating veins 171 Parricular c!inical appearances 172 Parricular anaromo-clinical forms of varicose veins and telangiectasias 172 Secondary varicose veins 180 Superficial venous insufliciency in the context of a post-thrombotic syndrome 180 Ehlers-Danlos syndrome 182 Particular venous disorders 185 Venous aneurysms 185 Background 185 Definition, pathology, parhophysiology 185 Clinical presentation and complememary investigations 185 Venous tumours 186 Background 186 Clinical presemation and complementary investigations 186 Sequelae of injury 187 Compression of deep veins in the legs 187 Chronic obstruction and compression ofveins in the arms 189 AxiJJary-subclavian venous obstructive syndrome 189 Superior vena cava syndrome 190 Pelvic congestion syndrome 190 Symproms 190 Clinical presentation 190 Diagnosis 190 Congenital venous malformations 191 KJippel-Trenaunay syndrome 191 Parlœs-Weber syndrome 192 Differentiai diagnosis of venous malformations 192 Approach -Patient association 193 Agenesis, hypoplasia and valvular dysplasia 193 Valvular agenesis 193 Hypoplasia and valvular dysplasia 193 DifferentiaI diagnosis 194 Clinicat repercussions 194 Arteriovenous fistulae 194 Symproms 194 Clinical presemation 194 Diagnosis 195 10 Quality of life and CVD Complaints voiced Evaluation questionnaires Results of a few studies Conclusions III INVESTIGATIONS 11 History and c1inical examination Reason for the consultation Clinical history Symproms Pasr hisrory Risk facrors Furcher c1inical hisrory Prognosis Patient examination Chronic venous disease Acure venous disease Upper limbs Phlebological tests Tap sign (Schwarrz's resr, wave resr) Cough resr Trendelenburg resr Perches resr Grher resrs Validation of the clinical examination Chronic venous disease Acure venous disease 12 Ultrasonography Doppler principle Continuous wave doppler (CWD) Duplex ultrasound (DU) B mode ulrrasound Pulsed Doppler Colour mode Doppler energy or power B-Aow 3D 20 MHz probe Conrrasr media Ulrrasound-guided rechniques Grher ulrrasound rechniques Technique Invesrigarion Choice of probe and machine serring Parienr prepararion and complicarions DU orCWD? Conclusion 197 197 198 198 199 203 203 203 204 205 205 205 206 206 206 211 211 211 212 212 212 215 216 218 218 218 221 222 222 223 223 223 223 224 225 225 225 226 226 226 226 226 230 231 231 235 13 Vascular investigations in venous disease exduding ultrasound techniques 241 General details 241 Non-invasive methods 241 Plerhysmography 241 Static volumetry 245 Dynamic volumetry 245 Thermography 246 Measurement of transcutaneous oxygen pressure (TcP02) 246 Laser Doppler 246 Capillaroscopy 247 Measurement of the systolic index (SI) 247 Invasive methods 248 Venous pressures 248 Phlebography 250 Other radiological techniques 254 Skin biopsy 257 Measurement of interstirial pressure 257 Endovenous ultrasound 257 14 Choice of investigations in chronic limb venous disease 259 Venous symptoms of the liwithout visible or palpable sign ofvenous disease (Cos) 259 LL pain, LL venous pain, with no visible or palpable sign of venous disease 259 Other LL venous symptoms without visible or palpable sign of venous disease 260 Cl -Presence of tdang?tasias or reticulu varicose veins 261 Telangieetasias 261 Reticu1ar varicose veins 262 Varicoseveins(C) 262 Saphenous varicose veins 262 Recurrence of varicose veins 263 Non-saphenous varicose veins 263 Venous malformations or varicose veins in the context of a congenital venous malformation 264 Secondary varicose veins 264 Oedema (C,) 264 Trophic changes (C~) 264 Active venous u1cer (CJ 265 Post-thrombotic syndrome (PTS) 265 Primary deep valvulu insufficiency 265 Venous claudication 265 Other situations 266 Venous disease of the upper Iimb 266 IV PREVENTION AND TREATMENT 15 lifestyle, physiotherapy, prevention 269 L?styte 269 Background 269 Principles and objectives of treatment 269 Princip1es and methods 269 Sports and spare rime 274 Background 274 Principles and objectives of sports rraining 274 Principles and merhods 274 Parricular aspecrs 275 Physiotherapy 276 Background 276 Principles and objecrives of rrearmenr 276 Examinarions before rrearmenr 277 Principles and merhods 277 Crenotherapy -thermalism 278 Ortheses 279 Compression 280 Prevention 280 Chronic venous disease (CVD) 280 Pregnancy 280 Prevenrion of recurrence of ulcers 280 16 Compression therapy 285 Background 285 Acrive and passive compression 285 Compression 285 SuPPOrt 286 Acrive or passive compression 286 Principles and objectives of treatment 286 Pressure 286 Pressure variations 287 Effecrs of compression 287 Objecrives of compression 288 Pre-treatment examinations 288 Principle and methods 289 Marerials 289 Elasric bandages 289 Compression srockings (medical srockings) 294 Indications 298 Contraindications 298 Results 300 Classes Cos and C" 301 Trearmenr for varicose veins (C) 301 Trearmenr for oedemas (C3) 302 Trearmenr for rrophic changes (C.) 302 Prevenrion of recurrence of ulcers (Cs) 302 Trearmenr of leg ulcers (CG) 303 Prevenrion of rhe progression of CVD 304 Prophylaxis for DVT 304 Trearmenr for superficial rhrombophlebiris 304 Trearmenr for DVT 304 Prevention and rrearment of posr-rhromboric syndromes 304 Pregnancy 305 Prevenrion of oedemas and DVT during Jong-disrance f1ighrs or long trips 305 Orher indicarions 305 Compression and sports 305 Compression and qualiry of life 305 Economy of compression 305 Complications 306 Consequences ofexcessive pressure 306 Infectious complications 306 Allergies and irrirarion 306 Injury during applicarion 306 Conclusions 306 17 Drug treatment of CVD 309 Venoactive drugs 309 Definition 309 Objecrives, mode of action and evaluarion 310 Classification and pharmacology ofVAD 311 Indications for VAD, dosage, parricular siruarions 320 Side effecrs 323 Resulrs 323 Conclusion 327 Other medicinal products 327 Quinine sulphare 327 Fibrinolyric anabolic agems 327 Non-sreroidal ami-inAarrunarory drugs 328 Diuretics 328 Plare/er ami-aggregams 328 18 Sclerotherapy 335 Background 335 Principles and objectives of treatment 335 Pre-treatment exarns 335 Principle and methods 336 Sclerosing agems 336 Techniques 338 Indications 343 Indicarions for rhe rrearmem of varicose veins and relangiecrasias 343 Advamages of sclerorherapy 344 Orher indicarions 344 Contraindications 344 Results 345 Te/angiecrasias 345 Reticular varicose veins 345 Accessory saphenous varicose veins 345 Varicose veins of rhe saphenous rrunks 345 Perforaring veins 346 Complications 346 Early complicarions 347 Lare complications 348 Conclusions 351 Information for the patient 355 Sc1erorherapy of small varicose veins and relangiecrasias 355 Before rrearmem 355 Afcer sc!erorherapy 355 Risks and complicarions 355 Resulrs 356 Information for the patient 356 Ulrrasound-guided sc1erorherapy for varicose veins 356 Advantages and drawbacks 356 Before treatment 356 After ultrasound-guided sclerotherapy 356 Risks and complications 357 19 Lasers, electro-coagulation, curetting and other treatments for telangiectasias 359 ScJerotherapy of telangiectasias 359 Lasers and flash lamps 359 Background 359 Definitions 360 Principles and objectives of the therapeutic method 361 Equipment and parameters 361 Patient examination and information 362 Indications 362 Contraindications and safety measures 362 Post-procedure care 363 Posr-procedure complications 363 Results 363 Electrocoagulation 365 Background 365 Principles of the method 365 Methods 365 Conrraindications 366 Complications 366 Results 366 Phlebectomy and curetting of telangiectasias 366 Background 366 Principles of rhe method 366 Methods 367 Follow-up and post-operative care 367 Complications 368 Results 368 ~ouflage 369 Background 369 Principles of the method 369 Methods 369 Complications 370 Results 370 20 Surgical methods for the treatment of chronic venous disease 373 21 Surgical methods for the treatment of superficial venous insufficiency 375 Ba~ound 375 Principles and objectives of varicose vein surgery 375 ln theory 375 In practice 375 Simplification of the aims of treatment 376 Principles of surgery and methods 377 Excision surgery 377 Endovenous ablation 382 So-called conservative haemodynamic techniques for saphenous rrunks 384 Anaesthesia and hospitalisation 386 Post-operative care 387 Drug treatment 387 Posr-operative elastic compression 387 Recovery 387 Complications of surgery 388 Peroperative complications 388 Postoperative complications 388 Tests before surgery for SV! 390 Results 390 Information for the patient 394 Sutgery for varicose veins in the legs 394 Varicose veins 394 Symptoms and risks of progression 394 Therapeutic possibilities 394 Surgical procedures 395 Posroperative period 395 Possible complications 396 Declaration 397 22 Surgical methods for the treatment of perforating vein insufficiency (Pel) 399 Background 399 Objective ofsurgery 399 Principles and methods 400 Point surgery on perforating veins 400 Extensive su rgery on perforating veins 400 Fasciotomy 402 Follow-up and postoperative care 402 Complications ofsurgery 402 Results 402 23 Surgical methods for the treatment of lower limb deep vein insufficiency 405 Background 405 Principles and objectives ofsurgery 405 Venous obstruction 405 Reflux 406 Principles and methods ofsurgery 406 Obstruction 406 Reflux 408 Specifie complications 412 Preoperative investigations 412 Results 412 Obstruction 412 Reflux 415 24 Particular cases: surgical methods and results 419 Venous aneurysms 419 fum of surgery 419 Preoperative investigations 419 Surgical methods 420 Results 421 Venous tumours Principle of surgery Surgical merhods Invesrigations Resu!rs SequeIae of venous trauma Aim of surgery Merhods Invesrigations Resuhs Compression of deep veins in the Iower limb Aim of surgery Investigarions Chronie obstruction and compression ofveins in the arms Axillary-subdavian vein Superior vena cava Pe1vie congestion syndromes and pelvie varicose veins Aim of surgery Invesrigarions Classification of rhe surgical merhods Resuhs ofsurgical rrearmem Congenital venous malformations Invesrigarions Merhods Resulrs 25 Treatment of venous ulcers Introduction Aim of treatment Treatment methods Reducrion of the venous hypertension and of ifS consequences Local rrearmem of ulcers Improvemem in rhe effect?eness of rhe muscle pump Adjuvant rrearmenfS Trearment of ulcer complications Monitoring the eifectiveness of treatment Ulcer measuremem Teleconsu1rarion Praet?I approaeh Making the diagnosis Venous ulcer Refractory ulcer Prevemion of recurrences Results of the treatment of venous uleers Healing Prevemion of recurrence Specifie features of the treatment of Ieg ulcers of other causes Mixed ulcers Necrotising angiodermatitis (Martorell's ulcer) AIterial ulcers Ulcers in atrophie blanche Ulcers associated with connective tissue disease Other ulcers 422 422 422 422 422 425 425 425 425 425 425 425 425 427 427 428 429 429 429 429 431 431 431 432 432 435 435 435 436 436 439 453 454 458 460 460 462 462 462 462 464 465 465 466 470 471 472 474 474 474 475 475 26 Therapeutic indications 481 Symptoms 481 Impression of sweJling 482 Prurirus 482 Heavy legs 483 Pain 483 Nighr cramps 483 Resrless legs 483 Sympramarology due ra rhe female hormone cycle 484 Venous LL symprams wirhour visible or palpable signs of venous disorders 484 Venous changes and complications from CVD 484 TeJangiecrasias (C,) 484 Rericular varicose veins (C,) 485 Primary varicose veins (C" Ep) 485 Secondary varicose veins (C" Es) 492 Perforaring veins 492 Posr-rhromboric syndrome 493 Signs due to or associated with CVD 494 Oedema 494 Lipoedema 494 Lymphoedema 494 Pigmenrarion 495 Srasis dermariris and conracr eczema 495 Lipodermarosclerosis 496 Atrophie blanche 496 Leg ulcer and ulcer scar 496 ?r ehronic venous disorders 496 SequeJae ofinjuries 496 Pelvic congesrive syndrome 497 Congeniral venous malformarions 497 Primary deep venous insufficiency -Valvular agenesis 497 v; ACUTE VENOUS DISEASE 27 Definitions SOI Superficial thrombophlebitis (STP) SOI Deep vein thrombosis (DVD SOI Pulmonary embolism (PE) 502 Post thrombotic syndrome (PTS) 502 28 Superficial thrombophlebitis 503 EpidemioIogy 503 Pathophysiology and aetiopathogenesis 504 Clinical presentation 504 Diagnosis 505 Superficial thrombophlebitis ofvaricose veins (varicophlebitis) 506 Superficial thrombophlebitis in a non-varieose vein 506 Specifie presentations 507 Superficial thrombophlebitis and deep vein thrombosis 508 Treaunent of superficial thrombophlebitis 508 Compression 509 Mobilisarion 509 Anri-inflammaroryagenrs 509 Thrombecromy 510 Anricoagularion 511 Plare!er anri-aggreganrs 512 Surgery 512 Prevention of recurrences 513 STP in varicose veins 513 STP in a non-varicose vein 513 29 Deep vein thrombosis 517 Epidemiology, pathophysiology and natural history 517 Epidemiology 517 Parhophysiology and aerioparhogenes? 517 Narural hisrory 519 Clinical sympthoms and signs 519 Main symproms and signs 519 Clinical examinarion 519 ClinicaJ assessmenr scores 520 Differenria! diagnosis 521 Specifie c1inical forms oflower Iimb DVf 522 Phlegmasia alba dolens and coerulea dolens 522 Trousseau's syndrome 522 DYT and pregnaney 522 DYT from a venous spur 522 Traveller's DYT 523 Upper limb DYT 523 Pulmonary embolism 524 Paraclinical diagnostic investigations 524 Ascending phlebography 525 Ulrrasound 526 D-dimer measuremenr 527 Diagnostics strategies 528 Pharmacology of anticoagulants 528 Heparins 528 Viramin K anragonisrs 530 Specifie facror Xa inhibirors 531 Specifie rhrombin inhibirors 531 Prevention ofvenous thromboembolic disease 532 Posr-operarive prevenrion 532 Prevenrion in non-surgica! deparrmenrs 533 Prevenrion of rraveller's DYT 533 Medical treatment of deep vein thrombosis 534 Therapeuric measures 534 Ambularory or hospiral rrearmenr) 537 Trearmenr of DYT in pregnaney and in rhe posr-parrum period 538 Parrial inferior vena cavaI inrerruprion 538 Antagonism of anticoagulant effeet 539 30 Thrombolysis and the surgical treatment of acute venous disorders 543 Venous thrombectomy 543 Fibrinolysis 543 Acute venous trauma 545 Surgical techniques 545 Indicarions 545 VI. CONCLUSIONS Conclusions 549 Index 551