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VARICOSE VEINS-THROMBOPHLEBITIS-OBLITERATIVE ARTERITIS-OBLITERATIVE THROMBANGEITIS

Varicose veins are veins that have become enlarged and twisted. The term commonly refers to the veins on the leg,although varicose veins can occur elsewhere. Veins have pairs of leaflet valves to prevent blood from flowing backwards (retrograde flow or venous reflux).Leg muscles pump the veins to return blood to the heart (the skeletal-muscle pump), against the effects of gravity. When veins become varicose, the leaflets of the valves no longer meet properly, and the valves do not work (valvular incompetence). This allows blood to flow backwards and they enlarge even more. Varicose veins are most common in the superficial veins of the legs, which are subject to high pressure when standing. Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening (lipodermatosclerosis) and ulceration. Life-threatening complications are uncommon, but varicose veins may be confused with deep vein thrombosis, which may be life-threatening.

Symptoms and signs

Aching, heavy legs (often worse at night and after exercise).

Appearance of spider veins (telangiectasia) in the affected leg.

Ankle swelling, especially in the evening.

A brownish-yellow shiny skin discoloration near the affected veins.

Redness, dryness, and itchiness of areas of skin, termed stasis dermatitis or venous eczema, because of waste products building up in the leg.

Cramps may develop especially when making a sudden move as standing up.

Minor injuries to the area may bleed more than normal or take a long time to heal.

In some people the skin above the ankle may shrink (lipodermatosclerosis) because the fat underneath the skin becomes hard.

Restless legs syndrome appears to be a common overlapping clinical syndrome in patients with varicose veins and other chronic venous insufficiency.

Whitened, irregular scar-like patches can appear at the ankles. This is known as atrophie blanche.

 

Complications

Most varicose veins are reasonably benign, but severe varicosities can lead to major complications, due to the poor circulation through the affected limb.

Pain, tenderness, heaviness, inability to walk or stand for long hours, thus hindering work

Skin conditions / Dermatitis which could predispose skin loss

Skin ulcers especially near the ankle, usually referred to as venous ulcers.

Development of carcinoma or sarcoma in longstanding venous ulcers. Over 100 reported cases of malignant transformation have been reported at a rate reported as 0.4% to 1%.

Severe bleeding from minor trauma, of particular concern in the elderly.

Blood clotting within affected veins, termed superficial thrombophlebitis. These are frequently isolated to the superficial veins, but can extend into deep veins, becoming a more serious problem.

Acute fat necrosis can occur, especially at the ankle of overweight patients with varicose veins. Females are more frequently affected than males.

Trendelenburg test–to determine the site of venous reflux and the nature of the saphenofemoral junction

Traditionally, varicose veins were investigated using imaging techniques only if there was a clinical suspicion of deep venous insufficiency, if they were recurrent, or if they involved the saphenopopliteal junction. This practice is not now widely accepted. Patients with varicose veins should now be investigated using lower limbs venous ultrasonography. The results from a randomised controlled trial on patients with and without routine ultrasound has shown a significant difference in recurrence rate and reoperation rate at 2 and 7 years of follow

Obliterating endarteritis also called “obliterating arteritis” is severe proliferating endarteritis (inflammation of the intima or inner lining of an artery) that results in an occlusion of the lumen of the artery. Obliterating endarteritis can occur due to a variety of medical conditions such as a complication of radiation poisoning,TB meningitis or a syphilis infection. Thromboangiitis obliterans (also known as Buerger’s disease, Buerger or presenile gangrene is a recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. It is strongly associated with use of tobacco products, primarily from smoking, but is also associated with smokeless tobacco

There is a recurrent acute and chronic inflammation and thrombosis of arteries and veins of the hands and feet. The main symptom is pain in the affected areas, at rest and while walking (claudication).The impaired circulation increases sensitivity to cold. Peripheral pulses are diminished or absent. There are color changes in the extremities. The colour may range from cyanotic blue to reddish blue. Skin becomes thin and shiny. Hair growth is reduced. Ulcerations and gangrene in the extremities are common complications, often resulting in the need for amputation of the involved extremities

A concrete diagnosis of thromboangiitis obliterans is often difficult as it relies heavily on exclusion of other conditions. The commonly followed diagnostic criteria are outlined below although the criteria tend to differ slightly from author to author.

Typically between 20–40 years old and male, although recently females have been diagnosed.

Current (or recent) history of tobacco use.

Presence of distal extremity ischemia (indicated by claudication, pain at rest, ischemic ulcers or gangrene) documented by noninvasive vascular testing such as ultrasound.

Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests.

Exclusion of a proximal source of emboli by echocardiography and arteriography.

Consistent arteriographic findings in the clinically involved and noninvolved limbs.

 

Buerger’s disease can be mimicked by a wide variety of other diseases that cause diminished blood flow to the extremities. These other disorders must be ruled out with an aggressive evaluation, because their treatments differ substantially from that of Buerger’s disease, for which there is no treatment known to be effective.

 

Diseases with which Buerger’s disease may be confused include atherosclerosis (build-up of cholesterol plaques in the arteries), endocarditis (an infection of the lining of the heart), other types of vasculitis, severe Raynaud’s phenomenon associated with connective tissue disorders (e.g., lupus or scleroderma), clotting disorders of the blood, and others.[further explanation needed]

CT angiogram showing segmental stenosis of arteries of the lower leg (indicated by arrows). The changes are particularly apparent in the blood vessels in the lower right hand portion of the picture (the femoral artery distribution).

 

Angiograms of the upper and lower extremities can be helpful in making the diagnosis of Buerger’s disease. In the proper clinical setting, certain angiographic findings are diagnostic of Buerger’s. These findings include a “corkscrew” appearance of arteries that result from vascular damage, particularly the arteries in the region of the wrists and ankles. Collateral circulation gives “tree root” or “spider leg” appearance. Angiograms may also show occlusions (blockages) or stenosis (narrowings) in multiple areas of both the arms and legs. Distal plethysmography also yields useful information about circulatory status in digits. To rule out other forms of vasculitis (by excluding involvement of vascular regions atypical for Buerger’s), it is sometimes necessary to perform angiograms of other body regions (e.g., a mesenteric angiogram).Skin biopsies of affected extremities are rarely performed because of the frequent concern that a biopsy site near an area poorly perfused with blood will not heal well.