Deep Vein Thrombosis (DVT) & Varicose Veins, Lymphangioma + Lymphedema😊

Deep Vein Thrombosis (DVT)

Virchow’s Triad (RF)

• Stasis: Immobility, Obesity, Puerperium, Pregnancy, Malignancy

• Endothelial Injury: Trauma, Surgery

• Hypercoagulable State

Clinical Features

• Pain → earliest

• Limb Edema (Constant Sign):
• Mostly Unilateral Lower Limb

• Homan’s Sign:
• Dorsiflexion of Foot → Resistance in Calf
• Hooman → dog language → Dorsiflexion of foot

• Perthes sign/Moses Sign:
• Squeeze Calf → Pain

Investigations

• IOC: Doppler/Duplex Scan

• CT Angiography: If Suspecting Pulmonary Embolism

Well’s Criteria

Probability Category	Score Range
Low Probability	-2 to 0
Moderate Probability	1 to 2
High Probability	>2

Treatment

• Presents Within 6-8 Hours:
• Direct Thrombolysis

• Anticoagulants
• First 5 Days:
• LMWH + Warfarin
• Warfarin takes 3-4 days to show effect
• After 5 Days:
• Only Warfarin

• INR Target
• PT Patient / PT Control
• Target INR: 2-3
• Normal = < 1.4
• Pregnancy: #LMWH

• Heparin Sensitive Options
• NOAC (DOC): Rivaroxaban, Apixaban
• Fondaparinux
• Bivalirudin

Greenfield Filter

• Indications
• Recurrent Thromboembolism Despite Anticoagulation
• Complications of Recurrent Pulmonary Embolism (PE):
• Pulmonary Hypertension
• C/I to Anticoagulation (E.g., Brain Hemorrhage)
• Complications of Anticoagulation

Complications

Post-Thrombotic Leg (PTL)

• Prevalence: 
• Occurs in 2/3 of patients following DVT

• Pathophysiology: 
• Maximum blood flow shifts from the deep to the superficial venous system.

• Clinical Features (C/F):
• secondary Varicose veins
• Pigmentation changes
• Lipodermatosclerosis

• Management Consideration: 
• Varicose vein surgery is contraindicated.

DVT Prophylaxis

High-Risk Patients

• Patients who require DVT prophylaxis include those undergoing:
• Major Orthopedic Surgery:
• Fractures of hip, pelvis, or lower limb.
• Major Abdominal/Pelvic Surgery.
• Major Surgery with History of:
• DVT
• Pulmonary Embolism (PE)
• Patients with:
• Lower limb paralysis
• Lower limb amputation

Prophylaxis for High-Risk Patients (Dual Prophylaxis)

• Combination of:
1. Pharmacological Prophylaxis:
• LMWH +
2. Mechanical Prophylaxis:
• Early ambulation +
• Pneumatic compression stockings

Varicose Veins

Anatomy

• Vein of Giacomini
• Upward extension of SSV after SPJ
• Connect with GSV
• ↑↑ recurrence rate in venous disease.
 

• Perforator Veins (Superficial to Deep flow)

Perforator Vein	Anatomical Location
Hunterian	Thigh
Dodd	Above knee
Boyd	Below knee
Cockett	Medial malleolus area (5, 10, 15 cm above)
May Kuster	Heel

Clinical Features

• Vein Appearance

Vein Type	Diameter	Alternate Names
Varicose Veins	3 mm	ㅤ
Reticular Veins	1–3 mm	-
Thread Veins	<1 mm	Dermal flares / Telangiectatic veins

Skin Changes (Advanced Disease Signs)

 

CEAP Classification (Severity)

• Reticular

• Varicose

• Edema

• Pigmentation

• Ulcer

Most Accepted theory regarding evolution of venous ulcers :

Investigations

• IOC:
• Doppler Ultrasound.

USG DVT

• Distended vein which is non compressible

• Normal vein is compressed

Mickey Mouse Sign

• In the groin region - saphenofemoral junction:
• Femoral vein.
• Femoral artery.
• Great saphenous vein.
• Note: Profunda femoris not part.

Clinical Tests

Management

Foam Sclerotherapy

• Perforator

• Technique: Tessari.

• Sclerosant: Sodium tetradecyl sulphate.

• Air : Sclerosant Ratio: 3:1 or 4:1.

• Used for: Thread veins/dermal flares.

TRIVEX

• Full form: Transilluminated Powered Phlebectomy

• Minimally invasive technique for removal of varicose veins

• Uses transillumination + irrigation + suction

• Performed under tumescent anesthesia

• TRIVEX = Transilluminated + Tumescent + Powered phlebectomy;
• Costly and largely obsolete now

Complications

Cystic Hygroma

Management

• Initial: Aspiration.

• Definitive: Surgery.

• Nerve at Risk during Surgery:
• Spinal accessory nerve.

Features

• A/w in Turners

• Nature: Sequestered lymphatic tissue.

• Most Common Site:
• Posterior triangle of neck.
• Hygroma → Hide Posteriorly

• Characteristics:
• Fluctuant, brilliantly transilluminant
• partly compressible swelling.

Lymphedema

• Brenners, Stemmers, Charlies limb reduction Sx

Definition

• Excessive interstitial fluid accumulation.

Classification: Primary (Hereditary)

• General Primary Features:
• Can affect multiple limbs, face, genitalia;
• often unilateral initially to knee.

Classification: Secondary (Most Common)

• Upper Limb Most Common Cause:
• Post-mastectomy or post-lymph node clearance.

• Lower Limb Most Common Cause:
• Filariasis / Elephantiasis.

Brunners Classification (Stages)

• Leg become Bun (B Runners) like

• Subclinical (Latent):
• Excess interstitial fluid
• no visible signs.

• Stage I:
• Pitting edema.

• Stage II:
• Non-pitting edema.

• Stage III:
• Edema with irreversible skin changes.
• Stemmer’s Sign:
• Inability to pinch skin (diagnostic).
• Hard like stem → cannot pinch
• Buffalo Hump:
• Loss of ankle contour.

Investigations

• Gold Standard:
• Water plethysmography (measures limb volume).
• Mild: < 20% volume increase.
• Moderate: 20-40% volume increase.
• Severe: > 40% volume increase.

Management

• Skin Care:
• Protect skin during activities (chopping, gardening).
• Never walk barefoot.
• Use electric razors for hair removal.
• Prevent dry skin.
• Treat cuts promptly with antibiotics.
• No blood sampling from affected limb.
• Use sunscreen.

• Decongestive Lymphedema Therapy (DLT):
• Phase 1 (Intensive):
• Supervised
• MLD: manual lymphatic drainage
• MLLB: multilayer bandaging
• Phase 2 (Maintenance):
• Self-care.

• Exercises:
• Beneficial: Slow, rhythmic isotonic (e.g., swimming).
• Worsens with: Vigorous, anaerobic, isometric exercise.

• Surgery:
• TOC
• Lymphovenous anastomosis (creates bypass).
• Debulking (reduction procedures):
• Not done

Stewart-Treves Syndrome/Lymphangiosarcoma

• Development:
• Angiosarcoma
• Long Standing (8-10 years) Lymphedema

• Features:
• Bluish/reddish skin nodules.

• Increased Incidence: 
• LN removed above axillary vein
• RT given to axilla after clearance