Ligation von Thrombophlebitis <

Ligation von Thrombophlebitis

Ligation von Thrombophlebitis

Jul 06, Author: Although most DVT is occult and resolves spontaneously without complication, death from DVT-associated massive pulmonary embolism PE causes as many asLigation von Thrombophlebitis, deaths annually in the United States.

No single physical finding or combination of symptoms and signs is sufficiently accurate to establish the diagnosis of DVT, but physical findings in DVT may include the following:. See Clinical Presentation for more detail. Endovascular therapy is performed to reduce the severity and duration of lower-extremity symptoms, prevent PE, Ligation von Thrombophlebitis, diminish the risk of recurrent VTE, and prevent PTS.

Percutaneous transcatheter treatment of DVT includes the following:. American Heart Association AHA recommendations for inferior vena cava filters include the following [ 10 ]:. See Treatment and Medication for more detail. The earliest known reference to peripheral venous disease is found on the Eber papyrus, which dates from BC and documents the potentially fatal hemorrhage that may ensue from surgery on varicose veins.

InSchenk first observed venous thrombosis when he described an occlusion in the inferior vena cava. InVirchow recognized the association between venous thrombosis in the legs and PE. DVT is the presence of coagulated blood, a thrombus, in one of the deep venous conduits that return blood to the heart. The clinical conundrum is that symptoms pain and swelling are often nonspecific or absent. However, if left untreated, the thrombus may become fragmented or dislodged and migrate to obstruct the arterial supply to the lung, causing potentially life-threatening PE See the images below.

DVT most commonly involves the deep veins of the leg or arm, often resulting in potentially life-threatening emboli to the lungs or debilitating valvular dysfunction and chronic leg swelling. Over the past 25 years, the pathophysiology of DVT has become much better understood, and considerable progress has been made in Ligation von Thrombophlebitis diagnosis and treatment. DVT is one of the most prevalent medical problems today, with an annual incidence of 80 cases perEach year in the United States, more thanpeople develop venous thrombosis; of those, 50, cases are complicated by PE.

Conclusive diagnosis has historically required invasive Ligation von Thrombophlebitis expensive venography, which is still considered the criterion standard. The diagnosis may also be obtained noninvasively by means of ultrasonographic examination. Early recognition and appropriate treatment of DVT and its complications can save many lives. See Treatment and Management. The primary agents include anticoagulants and thrombolytics.

Other than the immediate threat of PE, the risk of long-term major disability from postthrombotic syndrome is high. The peripheral venous system functions both as a reservoir to hold extra blood and as a conduit to return blood from the Ligation von Thrombophlebitis to the heart and lungs.

Unlike arteries, which Ligation von Thrombophlebitis 3 well-defined layers a thin intima, a well-developed muscular media, and a fibrous adventitiamost veins are composed of a single tissue layer. Only the largest veins possess internal elastic membranes, and this layer is thin and unevenly distributed, providing little buttress against high internal pressures. The correct functioning of the venous Ligation von Thrombophlebitis depends on a complex series of valves and pumps that are individually frail and prone to malfunction, yet the system as a whole performs remarkably well under extremely adverse conditions.

Primary collecting veins of the lower extremity are passive, Ligation von Thrombophlebitis, thin-walled reservoirs that are tremendously distensible. Most are suprafascial, surrounded by loosely bound alveolar and fatty tissue that is easily displaced.

These suprafascial collecting veins can dilate to accommodate large volumes of blood with little increase in back pressure so that the volume of blood sequestered within the venous system at any moment can vary by a factor of 2 or more without interfering with the normal function of the veins, Ligation von Thrombophlebitis.

Suprafascial collecting veins belong to the superficial venous system. Outflow from collecting veins is Ligation von Thrombophlebitis secondary conduit veins that have thicker walls and are less distensible.

Most of these veins are subfascial and are surrounded by tissues that are dense and tightly bound. These subfascial veins belong to the deep venous system, through which all venous blood must eventually pass through on its way back to the right atrium of the heart.

The lower limb deep venous system is typically thought of as 2 separate systems, one below the knee and one above. The calf has 3 groups of paired deep veins: Venous sinusoids within the calf muscle coalesce to form soleal and gastrocnemius intramuscular venous plexuses, which join the peroneal veins in the mid calf. These veins play an important role in the muscle pump function of the calf. Just below the knee, these tibial veins join to become the popliteal vein, which too can be paired on occasion.

The calf-muscle pump is analogous to the common hand-pump bulb of a sphygmomanometer filling a blood pressure cuff. Before pumping has started, the pressure is neutral and equal everywhere throughout the system and the calf fills with blood, typically mL. When the calf contracts, the feeding perforator vein valves are forced closed and the outflow valves are forced open driving the blood proximally.

When the calf is allowed to relax, the veins and sinusoids refill Wie eine Salbe von Krampfadern vorzubereiten the superficial venous system via perforating veins, and the outflow valve is then forced shut, preventing retrograde flow. The deep veins of the thigh begin distally with the popliteal vein as it courses proximally behind the knee and then passes through the adductor canal, at which point its name changes to the femoral vein.

The term superficial femoral vein should never be used, because the femoral vein is in fact a deep vein and is not part of the superficial venous system. This incorrect term does not appear in any definitive anatomic atlas, yet it has come into common use in vascular laboratory practice.

Confusion arising from use of the inappropriate name has been responsible for many cases of clinical mismanagement and death, Ligation von Thrombophlebitis. In theproximal thigh,the femoral vein and the deep femoral vein Ligation von Thrombophlebitis to form the common femoral vein, which passes upwards above the groin crease to become the iliac vein.

The external iliac vein is the continuation of the femoral vein as it passes upward behind the inguinal ligament.

At the level of the sacroiliac joint, it unites with the hypogastric vein to form the common iliac vein. Ligation von Thrombophlebitis left common iliac is longer than the right and more oblique in its course, passing behind the right common iliac artery. This anatomic asymmetry sometimes results in compression of the left common iliac vein by the right common iliac artery to produce May-Thurner syndrome, a left-sided iliac outflow obstruction with localized adventitial fibrosis and intimal proliferation, often with associated deep venous thrombosis.

At the level of the fifth lumbar vertebra, the 2 common iliac veins come together at an acute angle to form the inferior vena cava.

Please go to the main article on Inferior Vena Caval Thrombosis for more information, Ligation von Thrombophlebitis. Over a century ago, Ligation von Thrombophlebitis Virchow described 3 factors that are critically important in the development of venous thrombosis: These factors have come to be known as the Virchow triad.

Venous stasis can occur as a result of anything that slows or obstructs the flow of venous blood. This results in an increase in viscosity and the formation of microthrombi, which are not washed away by fluid movement; the thrombus that forms may then grow and propagate.

Endothelial intimal damage in the blood vessel may be intrinsic or secondary to external Ligation von Thrombophlebitis. It may result from accidental injury or surgical insult, Ligation von Thrombophlebitis.

A hypercoagulable state can occur due to a biochemical imbalance between circulating factors. This may result from an increase in circulating tissue activation factor, Ligation von Thrombophlebitis, combined with a decrease in circulating plasma antithrombin and fibrinolysins, Ligation von Thrombophlebitis.

Over time, Ligation von Thrombophlebitis have been made in the description of these Ligation von Thrombophlebitis and their relative importance to the development of venous thrombosis. The origin of venous thrombosis is frequently multifactorial, with components of the Virchow triad assuming variable importance in individual patients, Ligation von Thrombophlebitis, but the end result is early thrombus interaction with the endothelium.

This interaction stimulates local cytokine production and facilitates leukocyte adhesion to the endothelium, both of which promote venous thrombosis. Depending on the relative balance between activated coagulation and thrombolysis, thrombus propagation occurs.

Decreased vein wall contractility and vein valve dysfunction contribute to the development of chronic venous insufficiency. The rise in ambulatory venous pressure causes a variety of clinical symptoms of varicose veins, lower extremity edema, and venous ulceration. Thrombosis is the homeostatic mechanism whereby blood coagulates or clots, a process crucial to the establishment of hemostasis after a wound, Ligation von Thrombophlebitis.

It may be initiated via several pathways, Ligation von Thrombophlebitis, usually consisting of cascading activation of enzymes that magnify the effect of an initial trigger event.

A similar complex of events results in fibrinolysis, or the dissolution of thrombi, Ligation von Thrombophlebitis. The balance Ligation von Thrombophlebitis trigger factors and enzymes Ligation von Thrombophlebitis complex. Microscopic thrombus formation and thrombolysis dissolution are continuous events, but with increased stasis, Ligation von Thrombophlebitis, procoagulant factors, or endothelial injury, the coagulation-fibrinolysis balance may favor the pathologic formation of an obstructive thrombus.

Clinically relevant deep venous thrombosis is the persistent formation of macroscopic thrombus in the deep proximal veins. For the most part, the coagulation mechanism consists of a series of self-regulating steps that result in the production of a fibrin clot. These steps are controlled by a number of relatively inactive cofactors or zymogens, which, when activated, promote or accelerate the clotting process.

These reactions usually occur at the phospholipid surface of platelets, Ligation von Thrombophlebitis, endothelial cells, or macrophages. Generally, the initiation of the coagulation process can be divided into 2 distinct pathways, an intrinsic system and an extrinsic system see the image below.

The extrinsic system operates as the result of activation by tissue lipoprotein, usually released as the result of some mechanical injury or trauma. The intrinsic system usually involves circulating plasma factors, Ligation von Thrombophlebitis. Both of these pathways come together at the level of factor Ligation von Thrombophlebitis, which is activated to form factor Xa. This in turn promotes the conversion of prothrombin to thrombin factor II.

This is the key step in clot formation, for active thrombin is necessary for the transformation of fibrinogen to a fibrin clot. Once a fibrin clot is formed and has performed its function of hemostasis, mechanisms exist in the body to restore the normal blood flow by lysing the fibrin deposit, Ligation von Thrombophlebitis. Circulating fibrinolysins perform this function.

Three naturally occurring anticoagulant mechanisms exist to prevent inadvertent activation of the clotting process. This has the effect of potentiating the coagulation process. Studies have demonstrated that levels of circulating ATIII is decreased more, and stay reduced longer, after total hip replacement THR than after general surgical cases see the image below. Furthermore, patients who have positive venograms postoperatively tend to be those in whom Ligation von Thrombophlebitis levels of ATIII are diminished see the image below, Ligation von Thrombophlebitis.

Under normal circumstances, a physiologic balance is present between factors that promote and retard coagulation. A disturbance in this equilibrium may result in the coagulation process occurring at an inopportune time or location or in an excessive manor.

Alternatively, failure of the normal coagulation mechanisms may lead to hemorrhage. Thrombus usually forms behind valve cusps or at venous branch points, most of which begin in the calf.

Venodilation may disrupt the endothelial cell barrier and expose the subendothelium. Platelets adhere to the subendothelial surface by means of von Willebrand factor or fibrinogen in the vessel wall. Neutrophils and platelets are activated, releasing procoagulant and inflammatory mediators, Ligation von Thrombophlebitis.

Neutrophils also adhere to the basement membrane and migrate into the subendothelium. Complexes form of the surface of platelets and increase the rate of thrombin generation Ligation von Thrombophlebitis fibrin formation.

Ligation von Thrombophlebitis

Individuals Suitable for Ligation von Thrombophlebitis. Test Selection - Figure. Test Interpretation - Table 4 - Table 5 - Table 6. Almost 2 Ligation von Thrombophlebitis Americans succumb annually to a thromboembolic event, Ligation von Thrombophlebitis, 1 with venous thrombosis the third most common cardiovascular disease after ischemic heart disease and stroke.

Venous thrombosis affects 1 to 2 in individuals every year and is associated with life-threatening conditions such as pulmonary embolism PE, Ligation von Thrombophlebitis. Conditions associated with an increased risk of venous thrombosis can be either inherited or acquired Tables 1 and 2. Deficiency of antithrombin, protein C, and protein S may also be acquired. Individuals at high risk for venous thrombosis include those with a personal or family history of thrombosis, inherited coagulation disorders, homocystinuria, paroxysmal nocturnal hemoglobinuria, essential thrombocythemia, polycythemia vera, recurrent spontaneous abortion and stillbirth, and malignancy.

Additional risk factors include surgery, trauma, physical inactivity bed confinement or paralysisLigation von Thrombophlebitis, warfarin induced skin necrosis, diabetes, hyperlipidemia, vasculitis, thrombocytopenia, sepsis, congestive heart failure, and use of purified prothrombin complex concentrates. Other factors that may be associated with increased thrombotic risk include plasminogen deficiency and elevations of plasminogen activator inhibitor-1, lipoprotein aD-dimer, and thrombin-activatable fibrinolysis inhibitor.

The risk of thrombosis increases with the number of defects or risk factors present; ie, individuals with multiple conditions associated with thrombosis are at greater risk than those with only one condition, Ligation von Thrombophlebitis. The identification of thrombotic risk factors and diagnosis of thrombophilia contributes to patient management in multiple ways Table 3.

Such diagnosis is based on personal and family history of thrombosis especially during adolescence and young adult yearsclinical manifestations, Ligation von Thrombophlebitis, and laboratory testing. Clear guidelines how to best manage individuals with a family or personal history of documented risk factors and who have not experienced a thrombotic episode have not been established.

Prophylactic treatment is provided to diagnosed patients when in high-risk situations, eg, surgery, prolonged immobilization, and pregnancy and puerperium. Lifelong prophylactic therapy may be considered for those with recurrent thrombotic episodes, high-risk disorders, or with multiple-risk factors and may include plasma transfusions eg, antithrombin concentratesoral anticoagulants, low dose aspirin, and heparin.

Individuals with hyperhomocysteinemia may be treated with vitamin supplementation folic acid, cobalamin, pyridoxine. Individuals Suitable for Testing [ return to contents ] Symptomatic individuals. High-risk individuals predisposed by surgery, trauma, immobility, pregnancy, oral contraceptives, etc.

Test Availability [ return to contents ] Tests available to assist in diagnosis and management of thrombophilia disorders are listed in Appendix 2.

Additionally, Quest Diagnostics offers panels that include multiple tests, thereby simplifying the test ordering process. Refer to the Quest Diagnostics Directory of Services for information on these panels, which are typically named according to the medical condition. Test Selection [ return to contents ] Diagnosis. A venous thrombosis laboratory work-up for high-risk or symptomatic individuals begins with a personal and family history. For example, venous thrombosis in a pediatric patient suggests the likelihood of an inherited disorder; in an individual with SLE, antiphospholipid syndrome should be considered; and in an older individual, malignancy.

Testing for multiple etiologies is recommended since venous thrombosis is a polyfactorial disorder, and presence of multiple etiologies increases the risk for thrombosis.

Likewise, if a first thrombotic event occurs after the age of 50, testing for protein C, S, Ligation von Thrombophlebitis, and antithrombin deficiency may be postponed as hypercoagulability due to these disorders usually manifests as Ligation von Thrombophlebitis earlier than the fifth decade. Additional testing directed toward diagnosis of other causes of acquired thrombophilia such as systemic lupus erythematosus, liver disease, nephrotic syndrome, polycythemia vera JAK2 mutationschronic myelogenous leukemia BCR-ABL1 gene rearrangementdiabetes mellitus, Cushing syndrome, etc.

Positive functional assays can be confirmed by genetic testing in some cases or by demonstration of the abnormality in another family member. Such analysis differentiates homozygous and heterozygous states, providing additional prognostic information.

Factor V HR2 allele mutation analysis provides even more prognostic information in factor V Leiden carriers, Ligation von Thrombophlebitis. Homocysteine elevations may Ligation von Thrombophlebitis due to an acquired nutritional deficiency vitamin B 12B 6or folate.

Acquired causes for antithrombin, protein C, and protein S deficiencies can be ruled out by liver function testing, a disseminated intravascular coagulation screen D-dimer, fibrin degradation product, PT, aPTT, fibrinogen, platelet countand a proteinuria test urine albumin.

If all of the aforementioned testing is negative, the patient may have a rare disorder that can be identified by testing for factors IX and XI, lipoprotein a [Lp a ], plasminogen activity functionplasminogen activator inhibitor-1 PAI-1and tissue plasminogen activator TPA ; evaluation Ligation von Thrombophlebitis dysfibrinogenemia may also be helpful Figure.

Testing for rare disorders is only recommended for individuals with a strong personal and family history of thrombosis and negative first line tests or in whom clinical suspicion is high.

Since all thrombophilia etiologies are not yet known, it is possible for all of these tests to be negative. Since individuals with variations in the CYP2C9 and VKORC1 genes may require lower warfarin doses, mutation analysis should be performed to assist in selecting the initial dosage and to prevent over anticoagulating the patient.

Warfarin therapy can be monitored using the prothrombin time test, Ligation von Thrombophlebitis, reported as INR, except in 1 some patients with a strong lupus anticoagulant and 2 patients receiving direct thrombin inhibitors.

For these patients, monitoring with chromogenic factor X is preferred. When injectible anticoagulants are used, Ligation von Thrombophlebitis, patients can be monitored using a Xa inhibition assay. See Appendix 2 under Heparin and Fondaparinux for test details. Additional interpretive information, Ligation von Thrombophlebitis, specific to each test, is provided below.

Increases homocysteine Oral contraceptives. Increases homocysteine Acute phase reaction, inflammation, infection. The cytochrome P enzyme CYP2C9 participates in the metabolism of a number of important drugs, including warfarin.

Prolongation is also seen in individuals with lupus anticoagulant. A decreased ratio of clotting times obtained with and without exogenous activated protein C is suggestive of activated protein C APC resistance and increased risk of deep vein thrombosis. Such cases are also associated with increased venous thrombosis risk.

Decreased levels of antithrombin are associated with an increased risk of both arterial and venous thrombosis and are seen in individuals with hereditary antithrombin deficiency, nephrotic syndrome, colitis, liver disease, active thrombosis, disseminated intravascular coagulation DICthose receiving l -asparaginase therapy or oral contraceptives, and individuals who are pregnant or have undergone surgery.

Levels are also decreased in individuals receiving heparin. Levels in neonates are approximately half of the adult level, which is reached by 6 months of age. Low levels in both the activity and antigen assays indicate type I deficiency, whereas low activity levels in the presence of normal antigen levels indicate type II deficiency dysproteinemia.

Increased levels may be due to oral anticoagulants or heparin cofactor II. Increased levels of C4 binding protein may cause decreased levels of free protein S, and subsequent increased risk of thrombosis, and are associated with inflammation, pregnancy, diabetes mellitus, SLE, AIDS, allograft rejection, estrogen and progesterone administration, and smoking.

IgG antibodies appear to be more predictive of disease activity, while IgM antibody occurs more often in drug-induced disorders and infectious disease eg, syphilis.

Higher antibody titers are generally correlated with greater thrombotic risk see Appendix 1, Ligation von Thrombophlebitis. Elevated levels are associated with myocardial infarction, deep vein thrombosis, pulmonary embolism, DIC and other coagulation disorders, surgery, trauma, sickle cell disease, liver disease, severe infection, sepsis, inflammation, malignancy, pregnancy, and hyperfibrinolysis.

When clinical probability is low, a negative result normal level essentially rules out DVT. An uncorrected dRVVT in the mixing study rules out factor deficiencies, specifically those induced by warfarin therapy. A false-negative dRVVT test may be due to platelet contamination of the plasma. Samples with moderate or severe icterus or lipemia are contraindicated. Ligation von Thrombophlebitis co-inheritance increases the risk of venous thromboembolism 3- to 4-fold when compared with factor V Leiden alone, Ligation von Thrombophlebitis.

An individual heterozygous positive for the HR2 allele and negative for factor V Leiden is not at increased risk of thrombosis compared to factor V Leiden alone. However, homozygosity for factor V HR2 is associated with increased risk of thrombosis even in the absence of a factor V Leiden mutation.

Factor V Leiden Mutation Ligation von Thrombophlebitis. Factor V Leiden confers an approximately 7-fold increase in venous thromboembolic events in heterozygous individuals and an fold increase in homozygous subjects. Although this wenn die geschwollene Bein und Krampfadern, die zu tun haben is highly specific, identification of a mutation may occur in the absence of APCR in rare cases.

A negative result Ligation von Thrombophlebitis not rule out APCR or an increased risk of venous Blut, ob Sie mit Krampfadern annehmen kann. Factor VIII is an acute phase reactant and increased levels are found during periods of stress, postoperatively, and in inflammatory conditions.

Elevated levels are also found at birth and during pregnancy. Increased levels are associated with increased risk for venous thrombosis, 31 whereas decreased levels are associated with hemophilia A. The presence of soluble fibrin monomer complexes in plasma indicates intravascular thrombin generation.

It can be used to support diagnosis of DIC in the context of other laboratory and clinical findings. Increased levels are associated with acute phase reactions, Ligation von Thrombophlebitis, pregnancy, and an increased risk of thrombosis. Low fibrinogen activity levels are associated with afibrinogenemia, hypofibrinogenemia, or dysfibrinogenemia which may be associated with thrombophilia in rare instancesas well as with DIC, systemic fibrinolysis, pancreatitis, severe hepatic dysfunction, and l -asparaginase or valproate treatment.

Individuals with afibrinogenemia or hypofibrinogenemia will have decreased activity and antigen levels. Individuals with dysfibrinogenemia will typically have decreased activity levels and normal or decreased antigen levels. FDP result from the breakdown of fibrinogen, as Ligation von Thrombophlebitis as fibrin, by plasmin. Normally, the fibrinolytic process Ligation von Thrombophlebitis localized to fibrin, however, during conditions such as DIC, Ligation von Thrombophlebitis, fibrinolysis spreads and becomes systemic.

Persistent elevations indicate that abnormal fibrinolysis and fibrinogenolysis are occurring. Fondaparinux Sodium Xa Inhibition. Fondaparinux is a synthetic pentasaccharide administered subcutaneously and used to prevent or treat thromboembolic conditions. Measurement is used to monitor therapeutic levels. The therapeutic range is 1. These ranges are applicable to samples collected approximately 3 hours after administration of the drug.

LMWH are prepared by the chemical or enzymatic degradation of unfractionated heparin, and are used in the prevention Ligation von Thrombophlebitis treatment of thromboembolic conditions. Measurement of LMWH in plasma is used to monitor therapeutic levels. The therapeutic and prophylactic ranges for samples collected 4 hours after subcutaneous administration are shown in Table 6. Heparin Anti-Xa Unfractionated Heparin.

Unfractionated heparin is used for the prevention and treatment of thromboembolic conditions and measurement is used to monitor therapeutic levels. When administered as an intravenous infusion, the therapeutic range is 0. Levels are increased in the following: When coupled with the factor V Leiden mutation, venous thrombosis risk increases synergistically. Homocysteine is decreased in pregnancy except in some women carrying a fetus with a neural tube defectLigation von Thrombophlebitis, individuals less than 15 years of age, and individuals taking oral contraceptives or hormone replacement therapy.

Human Ligation von Thrombophlebitis Antigen 1 HPA-1 Genotype The HPA-1b platelet antigen polymorphism is associated with increased platelet thrombogenecity, neonatal alloimmune thrombocytopenia, and post-transfusion purpura.

Lipoprotein a [Lp a ]. Increased levels of Lp a are observed in patients with coronary artery disease, stroke, cerebrovascular and peripheral vascular disease, and venous thrombosis. Substantial increases are secondarily not genetically related observed in nephrotic syndrome and end-stage renal disease. Decreased Lp a levels may be seen in several rare disorders lecithin:

Lernfeld 1.3 - Venenerkrankungen (Varizen, Thrombophlebitis, Phlebothrombose)

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