Deep Vein Thrombosis

The leg contains superficial veins, located in the fatty layers under the skin, and deep veins, located in the muscles. Short veins, called connecting veins link the superficial and deep veins. The deep veins play a major role in propelling blood upwards. The one-way valves in deep veins prevent blood from flowing back-ward, and the muscles surrounding the deep vein compress them helping force the blood upwards just squeezing a toothpaste tube eject tooth-paste. The powerful calf muscles are particularly important, forcefully compressing the deep veins with every step. The deep veins carry 90 per cent or more of the blood from the legs toward the heart.

Superficial veins play only a miner role in carrying blood to the heart. They have the same type of valves as deep veins, but they are not surrounded by muscle. Thus blood in the superficial veins is not forced upward by the squeezing action of muscles, and it flows more slowly than blood in the deep veins. Much of the blood that flows up the superficial veins into the deep veins but not vice versa.

Deep Vein Thrombosis : Thrombus can occur either in the deep leg veins, causing deep vein thrombosis, or in the superficial leg veins causing superficial thrombophlebitis.

Thrombophlebitis is a disorder in which the blood clots (thrombsis) and inflammation of the vein (Phlebitis) occur together.

Because thrombosis is almost always accompanied by phlebitis, some doctors use thrombosis and thrombophlebitis interchangeably. Deep vein thrombosis is, then, the formation of blood clots (thrombi) in the deep vein. Deep vein thrombosis causes only a little inflammation.

The less inflammation around a thrombus, the less tightly the thrombus adheres to the vein wall and the more likely it will break loose (becoming an embolus), travel trough the blood stream, and lodge in an artery down stream, blocking blood flow. In addition, the squeezing action of the calf muscles can dislodge a thrombus in a deep vein, especially when a convalescing person becomes more active. Thus a thrombi in the deep veins are potentially dangerous.

Because blood in the leg veins travels to the heart and then to the lungs, emboli originating in the leg veins usually pass trough the heart and block one or more arteries in the lungs, a condition called pulmonary embolism.

Causes of DVI : Three main factors ie, the Virchow's triad can contribute to deep vein thrombosis : injury to the vein's lining, and increased tendency for blood to clot, and slowing of the blood flow.

Veins may be injured during surgery by injection or irritating substances, or by certain disorders like Buerger's disease. Some disorders, such as disseminated intravascular coagulation, cause blood to clot when it should not. Some cancers and rarely oral contraceptives can cause blood to clot. Sometimes blood colts more readily after childbirth or surgery. Among older people, dehydration and smoking are common causes of this tendency.

During prolonged bed rest, blood flow slows, because the calf muscles are not contracting and squeezing the blood toward the heart. Thrombosis can even occur in healthy people who sit for long periods, for example during long drives or airplane flights.

Symptoms : Because DVT usually cause little inflammation, pain and redness of the skin over the vein are usually minimal. About half of the people with DVT have no symptoms at all.

In these people, chest pain caused by pulmonary embolism may be the first indication that something is wrong. When DVT blocks blood flow in a large leg vein, the calf swells and may be painful, tender to the touch, and warm. The ankle, foot, or thigh may also swell, depending on which veins are involved.

Some thrombi heal by being converted to scar tissue, which may damage the valves in the veins. Because the damaged valves prevent the veins from functioning normally, fluid accumulates resulting in oedema and ankle swells.

The edema can extend up the leg and even affect the thigh if the blockage is high enough in the vein. Complications such as chronic deep vein insufficiency occurs late in the course of deep vein thrombosis. The valves in the leg veins and the connecting veins of the legs are destroyed, consequently, blood is not adequately returned to the heart from the legs. Eventually, the affected veins may be obliterated.

Edema is always present in the leg, generally worsening at the end of the day. The skin on the inside of the ankle becomes scaly and itchy and may turn a reddis brown. The discolouration is caused by red blood cells that escape from swollen (distended) veins into the skin. The discoloured skin is vulnerable, and even a minor injury, such as that from scratching or a bump, can break it open, resulting in an ulcer. In addition to ulcer, there may be throbbing pain when standing or walking.

Diagnosis : DVT may be difficult to detect, especially when pain and swelling are absent or very slight. When this disorder is suspected, colour Doppler Ultra-sonography can confirm the diagnosis. If the person has symptoms of pulmonary embolism chest scanning using a radioactive marker is performed to confirm the diagnosis of pulmonary embolism and colour dopper USG done to check the legs for clot- collapse of a person suggests massive pulmonary embolism and requires immediate treatment.

Prevention and Treatment : Deep vein thrombosis may be difficult for a doctor to detect because there's a lack of pain and often either no swelling or only very slight swelling. When this disorder is suspected then investigations like colour dopper may be done.

Although the risk of deep vein thrombosis can't be entirely eliminated, it can be reduced in several ways. People at risk for deep vein thrombosis - people who have just had major surgery or those taking long trips, for example - should flex and extend the ankles about 10 times every 30 minutes.

Wearing elastic stockings (support hose) continuously makes the veins narrow, slightly and the blood flow more rapidly, making clotting less likely. However, elastic stockings provide minimal protection and may give a false sensation of security, discouraging more effective methods of prevention. If not worn correctly, they may bunch up and aggravate the problem by obstructing blood flow in the legs.

Anticoagulant therapy before, during and sometimes after surgery reduces blood clotting much far effectively.

Low molecular weight heparin (LMWH) is best for such treatment and is practised widely at present.

Pneumatic stockings are another effective way to prevent clots. Usually made of plastic, these stockings are automatically pumped up and emptied by an electric pump, thereby repeatedly squeezing the calves and emptying the veins.

Swelling of the legs can be eliminated either by resting in bed and elevating the legs on by wearing compression bandages. These bandages must be applied by an experienced doctor or nurse.

The veins never recover after deep vein thrombosis develops and surgery to correct the problem is experimental. If painful skin ulcers develop, properly applied compression bandages can help. Applied ones or thrice a weak, these bandages almost always heal the ulcer by improving the blood flow in the veins. Once the blood flow in the veins has improved, the ulcers will heal by itself.

Balm, ointments or skin medications are of little use. The ulcers are almost always infected, and pus and a foul- swelling discharge appear on the bandages each time it's changed.

The pus and discharge can be washed off the skin with soap and water; they don't substantially delay healing. After it has healed, wearing an elastic stocking daily can prevent a recurrence.

Rarely, ulcers that don't heal require skin grafting.

DVT : Additional Information

The incidence of DVT is not known in Bangladesh as it is not looked for but this does not mean that it does not exist. In fact, the best way to avoid the fate of DVT is, prevention by using prophylactic medicines.

In the last decade, major advancement has taken plae in this field especially with the development of new anti thrombotic drugs. In the era of evidence based medical practice each of the drugs has undergone multiple trials and by their use it has become possible to prevent the development of DVT/thrombus formation in medical and surgical practice especially in cardiovascular system, orthopaedic and general surgery.

As we all know that the activation of clotting system is one of the three factors for formation of thrombus; aspirin which is usually prescribed, prevents only platelet aggregation and that to prevent clotting, anti thrombin has to be prescribed.

By using single dose ASPIRIN against platelet aggregation it has been observed that incidence of thrombus fatality was reduced almost by 50% and that when it is combined with Heparin the result was even better. But the traditional Heparin had some important limitations, especially with regard to its safety, monitoring and efficacy. And this lead to the discovery and use of Low Molecular Weight Heparins (LMWH).

Many studies were carried out, where comparative trials of LMWH vs Heparin showed that LMWH had superior outcome in terms of safety, monitoring and efficacy. Some of these studies and their result, clearly showed the superiority of LMWH over Unfractionated Heparin. Thus the American College of Chest Physicians through a consensus conference recommended Low Molecular Weight Heparin as medication in fixed weight doses subcutaneously twice daily in place of Heparin.

At-Home Remedies

You can minimize the discomfort of varicose veins in your legs. To ease painful swelling and inflammation, rest frequently, wear support stockings, and take one or two aspirin or ibuprofen tablets daily until the condition clears. If you like to sit with your legs crossed, cross them at the ankles rather than the knees for better circulation. Better yet, take a break and put your feet up; periods of rest with your feet a few inches above your heart level let gravity work in your favor, helping pooled blood drain from your legs. To further improve circulation, women should avoid high heels in favor of flat shoes and should wear loose clothing.

Nutrition And Diet

Diet plays a critical role in any varicose vein treatment program. Your goals are to promote better circulation and keep weight in check. Extra body fat increases water retention and puts pressure on the legs and abdomen, aggravating varicosity. To decrease body fat, eat foods that are low in fat, sugar, and salt, and high in fiber. To promote a healthy flow of nutrients and waste through the body, make fruits, vegetables, and whole grains the mainstays of your diet, and drink plenty of fluids, especially water.

Certain vitamins and bioflavonoids-natural substances found in many fruits and vegetables-may improve varicose veins; try 500 mg of vita-min C and 400 IU of vitamin E daily. Bioflavonoids are beneficial because they promote the absorption of vitamin E. Among bioflavonoids,

Prevention

Exercise regularly! Staying fit is the best way to keep your leg muscles toned, your blood flowing, and your weight under control.

Eat foods low in fat, sugar, and salt. Drink plenty of water. Take supplements of vitamins C and E, both critical to blood-vessel health.

If your daily routine requires you to be on your feet constantly, stretch and exercise your legs as often as possible to increase circulation and reduce pressure buildup.

If you smoke, quit. Studies show that smoking may contribute to elevated blood pressure, which in turn can aggravate varicosity.

If you're pregnant, be sure to sleep on your left side rather than on your back to minimize pressure from the uterus on the veins in your pelvic area. This position will also improve blood flow to the fetus.

Switch Your Bed

Varicose vein sufferers are told to elevate their teat when resting or sleeping. But before you rush to the bedroom armed with pillows and bricks-or start building a makeshift ramp at the end of your bed- consider changing the bed itself. By switching to a hospital-style adjustable bed, you can keep your feet raised all through the night and you'll have the added benefit of low back pain relief. Another option-perhaps more attractive to the home decorator - is a well-designed waterbed. Waterbeds adapt their contour to fit your body minimizing the discomfort to tender veins where they come in contact with the mattress.

Submitted By:
DR. MASWOODUR RAHMAN PRINCE

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