pulmonary embolism

1. Disease of veins of theDisease of veins of the
extremities.extremities.
Pulmonary embolismPulmonary embolism

2. PLAN OF LECTURE
1. Actuality of theme.
2. Acute deep vein thrombosis of the lower
extremities and pelvis.
3. Paget-Schroetter Syndrome
4. Thrombophlebitis of superficial veins of the
lower extremities.
5. Varicose veins of the lower extremities.
i. 6. Postthrombotic syndrome (disease) of the
lower extremities.
7. Pulmonary embolism.

3. Venous thromboembolic complications (deep
vein thrombosis, thrombophlebitis of superficial
veins, pulmonary embolism) are among the main
causes of postoperative mortality !!!

4. Deep Vein Thrombosis of the lower limbs
(phlebothrombosis, DVT)
Wirkhov Rudolf
Creation of blood clot in the deep
veins - PHLEBOTHROMBOSIS
PATHOGENESIS:
Virchow’s triad:
•The changes of the vascular wall
•Slower flow
•Increased blood coagulation
properties

5. Factors causing phlebothrombosis

6. “ECONOMY CLASS” SYNDROM

7. Pathogenesis of phlebothrombosis

8. DVT is distinguished
depending on their
localization in the
extremities
Anatomical (Proximal or Distal)
Lower Extremity Thrombosis
(LET)
- LET 1 (Calf veins AT , PT, PER)
- LET 2 (POPV, SFV, DFV)
- LET3 (Ilio - femoral)
LET4 ( Caval)

9. Thrombosis of inferior vena cava
Inferior vena cava filter
for the prevention of
pulmonary embolism

10. Lower extremity DVT - Clinic
The main complaints of patients:
•Swelling of the extremities (shin, hip - depending
on the height thrombosis)
•Pain in the calf muscles when walking, perhaps in
the hip and inguinal region during movements
•Cyanosis of the skin in distal extremities
•Asymptomatic course in immobilized patients is
possible
•Sometimes pulmonary embolism may be the first
symptom of DVT

11. Typical symptoms during examination
of the patients with DVT
•Swelling of the extremities
(measuring a circumference shins
and thighs on 3 levels must be done)
•Pain in according to the location of
the vascular trunk at the hips and
groin is present during palpation
•Change the color of the skin on
cyanotic (in case of arteries spasm -
pallor)
•Intensified picture of the
subcutaneous veins on the lower limb

12. The Homans' Sign for DVT
1. In the supine position, the knee of
the suspected leg of the patient
should be flexed
2. The examiner should then forcibly
and abruptly dorsiflex the patient's
ankle
3. The examiner observes whether or
not the patient reports pain in this
calf and popliteal region
* Pain indicates a positive sign.

13. Lowenberg’s test
A cuff from the
sphygmomanometer
is imposed on the leg.
If at pressure of 80-
100 mmHg a pain
arises in the tibia
muscle, then this test
is considered to be
positive.

14. Moses Test: tenderness over calf
muscles on squeezing the muscles
from side to side. Not done now for
the fear of embolism

15. Clinic of DVT of the upper extremity
Paget-Schroetter
Syndrome - thrombosis
of subclavian vein

16. DVT diagnostic algorithm
ULTRASOUND DIAGNOSIS is the main!
Possible CT, MRI, phlebography too.

17. Complications of DVT
Ppulmonary
embolism
Phlegmasia alba dolens
Phlegmasia cerulea
dolens, and venous
gangrene.

18. DVT Treatment
 IMMEDIATE START of entering of direct
anticoagulants intravenously or
subcutaneously (Heparin, preferably -
LMWH)
 It is possible begin to appointment the
tablets of new modern oral anticoagulants
(RIVAROXABAN, DABIGATRAN)
 Immobilization because of the risk of
pulmonary embolism
 Elevated limbs position
 Elastic compression
 Duration of Anticoagulation - more than 3
months

19. DVT Treatment
In the case of phlegmasia cerulea dolens or DVT in
young people it is possible:
•systemic or catheter thrombolysis;
•opened thrombectomy from the veins of the thigh
and pelvis;
•fasciotomia or even amputation!

20. Acute thrombophlebitis
Blood clots formation
in the saphenous
veins of lower
extremities is called
thrombophlebitis.

21. Etiology of acute thrombophlebitis
 Most common it is on
base of varicose disease
 Post Traumatic
 Infection
 Migratory
thrombophlebitis in the
patients with Buerger's
disease
 Hypercoagulation
 After vein catheterization

22. Acute thrombophlebitis - RISKS
Migration of
thrombus through
the femoral-
saphenous
junction or
through the veins-
perforators in deep
veins and
development of
phlebothrombosis
Festering of
the inflamed
varicose
nodule
PE

23. Acute thrombophlebitis - clinic
 Painful SEALS on
surface of saphenous vein
 Local signs of
inflammation
 Low-grade fever
 Swelling of the part of
extremity
 Differentiation (cellulitis,
erysipelas, lymphangitis,
nodulus erythema,
allergic reaction)

24. Acute thrombophlebitis - DIAGNOSIS
ULTRASOUND
DIAGNOSTICS with
"Compression test"
gives 100%
confirmation of the
diagnosis and it is the
main method of
diagnosis prevalence
of thrombotic
process!!!

25. Acute thrombophlebitis
algorithm of actions

26. Acute thrombophlebitis
TREATMENT
 If there is a local proces: anti-
inflammatory, anticoagulant, elastic
bandaging, active mode; locally -
application of semi-alcohol
bandages, anti-inflammatory gel.
 If process is ascending and
thrombus is located about 3-5 cm to
the femoral-saphenous and
popliteal-saphenous junctions:
emergency operation (cross-ectomy,
vein-stripping) for the prevention of
transition of thrombotic process into
the deep veins and development of
pulmonary embolism.

27. Pulmonary embolism (PE)
PE remains one
of the most
frequent causes
of death in
surgical
hospitals in all
world!!!

29. Thrombus gets into the
Pulmonary artery from
the venous system
(phlebothrombosis -
DVT; thrombophlebitis -
subcutaneous veins)

30. Pulmonary embolism - Clinic
1. Pain syndrome
2. The syndrome of acute respiratory failure
3. The syndrome of acute circulatory failure
(collaptoid)
4. The syndrome of acute right-ventriculus
failure
5. The syndrome of acute cardiac arrhythmias
6. syndrome acute coronary insufficiency
7. Cerebral syndrome
8. Abdominal syndrome

31. Pulmonary embolism - Clinic
The classic presentation of pulmonary
embolism is the abrupt onset of pleuritic chest
pain, shortness of breath, and hypoxia.
However, most patients with pulmonary
embolism have no obvious symptoms at
presentation. Rather, symptoms may vary from
sudden catastrophic hemodynamic collapse to
gradually progressive dyspnea. The diagnosis
of pulmonary embolism should be suspected in
patients with respiratory symptoms
unexplained by an alternative diagnosis.

32. PE
Signs and Symptoms
Patients with pulmonary embolism may present with atypical
symptoms, such as the following:
 Seizures
 Syncope
 Abdominal pain
 Fever
 Productive cough
 Wheezing
 Decreasing level of consciousness
 New onset of atrial fibrillation
 Hemoptysis
 Flank pain
 Delirium (in elderly patients)

33. PE
Signs and Symptoms
Physical signs of pulmonary embolism include the
following:
 Tachypnea (respiratory rate >16/min): 96%
 Rales: 58%
 Accentuated second heart sound: 53%
 Tachycardia (heart rate >100/min): 44%
 Fever (temperature >37.8°C): 43%
 Diaphoresis: 36%
 S 3 or S 4 gallop: 34%
 Clinical signs and symptoms suggesting thrombophlebitis: 32%
 Lower extremity edema: 24%
 Cardiac murmur: 23%
 Cyanosis: 19%

34. Diagnostic algorithm of PE

35. Pulmonary embolism - the basis of
instrumental diagnostics
CT angiography Pulmonary
scintigraphy
PULMONOGRAPHY
Overload in the right
heart on ECG and
Ultrasound

36. Pulmonary embolism - Treatment
1. Anticoagulation
(immediate 10 000 IU of
heparin intravenously),
followed by a choice of
anticoagulant (LMWH,
indirect oral
anticoagulants).
2. Thrombolytic therapy
(when there is decrise of
blood pressure and threat of
overload right heart).
3. Symptom therapy
(antibiotics, oxygen
therapy, monitoring ABP).
4. Surgical treatment
(embolectomy)

37. Varicose veins (varicose disease)
of the lower extremities
Varicose disease belongs to
chronic diseases of the veins
- suffer up to 60% of people

39.  The disease begins at an early age:The disease begins at an early age:
 An examination of students Bochum High SchoolAn examination of students Bochum High School
(England) 10% reported that in age of 10 to 12 years they(England) 10% reported that in age of 10 to 12 years they
have found the first varicose veins andhave found the first varicose veins and
 4 years later, 30% of these same young people were already4 years later, 30% of these same young people were already
had the signs of varicose veinshad the signs of varicose veins
 The incidence depends on the age and sex:The incidence depends on the age and sex:
 Men from 3% at age 30 years to 20%-50% aged over 70Men from 3% at age 30 years to 20%-50% aged over 70
yearsyears
 Women from 20% at the age of 30 years to 50% aged over 70Women from 20% at the age of 30 years to 50% aged over 70
Varicose disease of the lower extremities

40. Varicose disease of the lower extremities -
etiology and pathogenesis
• They are placed throughout
the length of the veins of the
lower extremities
•The normal outflow of venous
blood flow is always
unidirectional and rising
•Venous valves prevent reverse
blood flow down
Normal venous outflow

41. Risk factors of development of the HVD
Favorable factors
 Heredity
 Female gender
 Old age
 Deep vein thrombosis
 Adiposity
Hormonal factors
Pregnancy

The use of oral contraceptives
Lifestyle
Long-term stay in a standing or
sitting position
Sedentary lifestyle
The food is poor in fiber

42. Change of blood flow
Genetic predisposition, risk factors
Chronic inflammation in the wall of the veins and valves
Remodeling of the walls of veins and valves
Incompetence of the valves anf blood reflux
HVD
Adapted from JJ Bergan et al. N Engl J Med 2006 355:488-498
Venous hypertension and inflammation are the base ofVenous hypertension and inflammation are the base of
all symptoms and signs HVDall symptoms and signs HVD

43. 1. Failure of
saphenous-femoral
anastomosis
2. Reflux in
perforating veins
3. Failure of
saphenous-popliteal
anastomosis
4. Blood reflux
through the varicose
veins
Blood reflux through the varicose veins
Varicose disease of the lower extremities -
etiology and pathogenesis

44. Varicose disease of the lower extremities - symptoms
 PainPain
 ItchinessItchiness
 Feeling of heaviness in legsFeeling of heaviness in legs
 Night crampsNight cramps
 Feeling of edemaFeeling of edema
 The symptom of Restless LegsThe symptom of Restless Legs
 ParesthesiaParesthesia
 Foot fatigueFoot fatigue
 PulsationPulsation
Symptoms
They appear and / or amplified after prolonged stay in a
sitting position or standing in the heat, in the premenstrual
period, when taking a hot bath

45. CEAP classification
C0а The lack of visible or palpable signs of venous disease
C1а Reticulate veins and telangiectasia
Telangiectasia: conglomerate of the constantly dilated
subcutaneous veins less than 1 mm in diameter
Veins are like a net, cyanotic constantly dilated
subcutaneous veins, usually more than 1mm and less than 3
mm in diameter
C2а
Varicose veins
Permanently dilated subcutaneous vein
3 mm in diameter, standing
C0s The lack of visible or palpable signs of venous disease + symptoms
(pain, fullness, heaviness, itching, cramps)
C1s Telangiectasia or veins like a net +
symptoms
C2s
Varicose vein + symptoms
Clinical manifestations

46. CEAP classification
C4а Skin changes
a) Pigmentation: brown pigment darkening of the skin that
usually develops in the ankle, but may extend to the entire
foot and leg;
b) eczema, erythema, with bubbles, wet or scale-like skin
inflammation on legs;
c Lipodermatosclerosis: it is localized seal of skin sometimes
with contracture of the scar;
d) White atrophy: white colored and atrophic part of the skin,
often circular, that is surrounded by the spots of enlarged
capillaries and sometimes hyperpigmentation.
C3а Edema
Significant increasing the volume
of fluid in the subcutaneous tissue
C3s
Edema + symptoms
C4s
Skin changes + symptoms

47. CEAP classification
C5а Skin changes with healed ulcer
C6а
Skin changes
with opened ulcer
C5s
Skin changes with healed ulcer
+ symptoms C6s
Skin changes with opened
ulcer + symptoms

48. Etiological classification
Ес – congenital, congenital vein dysfunction
Ep – primary, acquired dysfunction of the veins
Es – secondary, dysfunction of the veins are secondary (PTS)
En – dysfunction veins are absent

49. Anatomical classification
As - superficial, damaged superficial veins
Ad - deep, deep veins damaged
Ap - perforating, perforating veins damaged
An - are not damaged veins

50. Pathophysiology Classification
Pr - reflux, clinical symptoms coursed by reflux of the blood
Po - obstruction, the clinical symptoms caused by occlusion
Pr, o - clinical symptoms caused by the both reasons
Pn - the lack of venous disorders

51. Varicose diseases - Treatment
Conservative therapyConservative therapy
- Compression therapy- Compression therapy
- Drug treatment- Drug treatment
Surgical treatmentSurgical treatment
- Open surgery- Open surgery
- Intravenously thermal radiofrequency ablation,- Intravenously thermal radiofrequency ablation,
sclerotherapysclerotherapy

52. Varicose diseases - Treatment
С1 С2 С3 С4 С5 С6С0
Зміна способу
життя
Консервативна
терапія
Компресійна
терапія
Місцеве
лікування
Склеротерапія,
хірургічне
лікування

53.  Elastic crepe bandage – stockings
 20-30 mm Hg
 Elevation of limbs
 Above the level of heart
 Graded compression stockings

54. Varicose veins - compression therapy

55.  Calcium dobesilate monohydrate
500mg
 Improves lymph flow, reduce
edema;
 1 capsule twice in a day for 3
weeks and followed by 1 capsule
once a day at least for a month
after meals.
 Diosmin + hesperidin (phlebotropic
drug)
 Protects venous valves / anti
inflammatory

56. Sclerotherapy

57. Varicose diseae - operative therapy, aimed at the
elimination of vertical and horizontal reflux of blood
flow
Small-traumatic
procedure of laser
ablation
Traditional venous
extraction

58. POST THROMBOTIC DISEASE (SYNDROME) - PTS
PTS, PTFS, PTFS -
severe pathology of
venous system caused
by the lesions of deep,
perforating and
saphenous veins of the
lower limbs as a result
of deep vein
thrombosis

59. PTS - pathogenesis

60. PTS - classification
CVI - chronic venous insufficiency,
appearance of edema (degree 1),
induration and hyperpigmentation
of skin (degree 2 ), trophic ulcers
(degree 3)
Affected venous segment is
indicated

61. PTS - Classification (Clinic)
Varicose form
Oedema form
Ulcer form

62. PTS
diagnostics (the main - Ultrasound)
Occluded
Femoral vein
Insufficient
perforant vein
Phlebography with partly recanalized deep veins

63. PTS - treatment
С1 С2 С3 С4 С5 С6С0
Зміна способу
життя
Консервативна
терапія
Компресійна
терапія
Місцеве
лікування
Склеротерапія,
хірургічне
лікування

64. PTS - treatment
1. Surgical interventions
aimed at the elimination
of vertical and horizontal
refluxes of blood flow
2. In case of deep vein
obstruction -
reconstructive operations
3. If there is a valvular
insufficiency into the
large veins - correction of
valves

65. TREATMENT OF THE ULCERS
If ulcer is good
granulating, there is
no any signs of
infection, large size
ulcers - dermatoplasty
must be performed

66. My veins have disappeared!!!