Peripheral Venous And Lymphatic Disorders

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arteriovenous fistula

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is an abnormal communication between an artery and a vein.

An arteriovenous fistula may be congenital (usually affecting smaller vessels) or acquired as a result of trauma (eg, a bullet or stab wound) or erosion of an arterial aneurysm into an adjacent vein.

The fistula may cause symptoms and signs of arterial insufficiency (eg, extremity ulceration due to reduced arterial flow, embolization, or ischemia) or chronic venous insufficiency due to high-pressure arterial flow in the affected veins (eg, peripheral edema, varicose veins, stasis pigmentation). If the fistula is near the surface, a mass can be felt, and the affected area is usually swollen and warm with distended, often pulsating superficial veins. A thrill can be palpated over the fistula, and a continuous loud, to-and-fro (machinery) murmur with accentuation during systole can be heard during auscultation. Rarely, if a significant portion of cardiac output is diverted through the fistula to the right heart, high-output heart failure develops.

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Chronic venous insufficiency

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is impaired venous return, sometimes causing lower extremity discomfort, edema, and skin changes. Postphlebitic (postthrombotic) syndrome is symptomatic chronic venous insufficiency. Causes are disorders that result in venous hypertension, usually through venous damage or incompetence of venous valves, as occurs after deep venous thrombosis (DVT). Diagnosis is by history, physical examination, and duplex ultrasonography. Treatment is compression, wound care, and, rarely, surgery. Prevention requires adequate treatment of DVT and compression stockings.

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Deep venous thrombosis (DVT)

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is clotting of blood in a deep vein of an extremity (usually calf or thigh) or the pelvis. DVT is the primary cause of pulmonary embolism. DVT results from conditions that impair venous return, lead to endothelial injury or dysfunction, or cause hypercoagulability. DVT may be asymptomatic or cause pain and swelling in an extremity. Diagnosis is by history, physical examination, and duplex ultrasonography, with d-dimer or other testing as necessary. Treatment is with anticoagulants. Prognosis is generally good with prompt, adequate treatment; common long-term complications include venous insufficiency with or without postphlebitic syndrome.

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Idiopathic telangiectasias

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are fine, dilated intracutaneous veins that are not clinically significant but may be extensive and unsightly.

Telangiectasias are usually asymptomatic. However, some patients report a burning sensation or pain, and many women consider even the smallest telangiectasias cosmetically unacceptable.

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Lymphedema

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is edema of a limb due to lymphatic hypoplasia (primary) or to obstruction or disruption (secondary) of lymphatic vessels. Symptoms and signs are brawny, fibrous, nonpitting edema in one or more limbs. Diagnosis is by physical examination. Treatment consists of exercise, pressure gradient dressings, massage, and sometimes surgery. Cure is unusual, but treatment may lessen symptoms and slow or halt progression. Patients are at risk of cellulitis, lymphangitis, and, rarely, lymphangiosarcoma.

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Superficial venous thrombosis

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is a blood clot in a superficial vein of the upper or lower extremities or, less commonly, in one or more veins of the chest or breast (Mondor's disease).

Superficial venous thrombosis in the upper extremity most commonly results from IV catheterization; varicose veins seem to be the main risk factor for the lower extremity, especially among women. Superficial venous thrombi rarely cause serious complications and rarely embolize.

Typically, patients present with a superficial, often painful or tender indurated cord contiguous with a palpable normal superficial vein. The overlying skin is usually warm and erythematous. Migratory superficial venous thrombosis, which develops, resolves, and recurs in normal veins of the arms, legs, and torso at various times, is a possible harbinger of pancreatic cancer and other adenocarcinomas (Trousseau's syndrome).

Diagnosis is based on history and physical examination. Treatment traditionally involves warm compresses and NSAIDs, but local thrombectomy with a local anesthetic is very effective.

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Varicose veins

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are dilated superficial veins in the lower extremities. Usually, no cause is obvious. Varicose veins are typically asymptomatic but may cause a sense of fullness, pressure, and pain or hyperesthesia in the legs. Diagnosis is by physical examination. Treatment is compression, wound care, sclerotherapy, and surgery.